Term Drug Therapy Research Articles

Serum vitamin D status in children with epilepsy on antiepileptic drugs and its relation to the frequency of breakthrough seizures

Background: Epilepsy is the most common neurological disorder in children requiring long term drug therapy which are associated with vitamin D deficiency. Antiepileptic actions of vitamin D deficiency have been extensively studied in animal models but human data, particularly in children is lacking. Objectives were to study the levels of serum vitamin D in children with epilepsy on antiepileptic drugs and to study the correlation between levels of vitamin D and frequency of breakthrough seizures. Methods: hospital-based cross-sectional study. Participants: A total of 94 children with epilepsy were included in the study. Intervention: The patients were on a minimum of 6 months of antiepileptic drug therapy. Anthropometric measurements were taken and blood samples were analysed for vitamin D, serum calcium, phosphate, complete blood counts and renal profile. Results: The present study showed a statistically significant relationship between serum vitamin D deficiency and antiepileptic drugs (p value <0.001), the number of AEDs with patients on polytherapy ≥2 AEDs having lower vitamin D levels (p value <0.001) and the duration of antiepileptic drugs (p value of 0.016). Linear regression analysis also showed a statistically significant relationship between serum vitamin D deficiency and seizure frequency (p value of <0.001, 95% confidence interval: -3.465, -2.275). Conclusions: Case studies and epidemiological data also support the evidence of connection between levels of serum vitamin D and epilepsy and the use of vitamin D3 as a potential therapy for human epilepsy. This study is conducted with an aim to highlight the role of vitamin D in children with epilepsy in seizure control.

A PROSPECTIVE RANDOMIZED OPEN-LABELED PARALLEL GROUP STUDY TO COMPARE THE EFFICACY OF ORAL TERBINAFINE VERSUS ORAL TERBINAFINE PLUS ORAL FLUCONAZOLE IN DERMATOPHYTE INFECTIONS

Objectives: The objectives of this study were to assess the efficacy of oral monotherapy (Terbinafine) as compared to combination of oral drugs (Terbinafine and fluconazole) in treatment of dermatophyte infections. Methods: Patients of clinically diagnosed, potassium hydroxide (KOH) confirmed dermatophyte infections (n=235), were recruited as per inclusion criteria and randomized into Group A (Tab. Terbinafine 6 mg/kg body weight daily) and Group B (Tab. Terbinafine 6 mg/kg daily+Tab Fluconazole 3 mg/kg twice per week) treatment for 2 weeks. Assessment was done in beginning, after week 1 and after week 2 using visual analog scale (VAS) and global physician assessment (GPA). At the end of 4 weeks, they were again called back to assess the residual disease activity. Results: VAS scoring at week 1 and week 2 showed a significant reduction of scores in both the groups as compared to basal score of 0 week. Inter-group comparison showed decrease in mean-VAS itch scores in Group B as compared to Group A. Week 1 reduction in the Group B was statistically significant (p<0.001). GPA reflected a gradual but significant improvement in GPA scores end of week 1 and week 2 in both groups. The improvement seemed robust in Group B reflecting the stronger clinical response. The inter-group comparison showed statistically significant improvement in Group B over Group A in both 1stweek (p<0.001) and 2nd week (p=0.021). Conclusion: Dermatophyte infections treated with either terbinafine alone or terbinafine and fluconazole combination is clinically effective. Combination therapy is better than single drug therapy in terms of treatment response.

Еволюція тактик лікування пацієнтів зі стовбуровими ураженнями коронарних артерій

Damage to the trunk of the left coronary artery is the most dangerous manifestation of coronary atherosclerosis. Mortality with this type of lesions occurs by 3–4 times more often compared to lesions of other segments of coronary arteries. On the basis of previous clinical studies demonstrating advantages of coronary artery bypass grafting over drug therapy in terms of patient survival, coronary artery bypass grafting has long been considered the gold standard for the treatment of these lesions. The purpose of the work was to study the literature data on the evolution and peculiarities of the choice of methods of surgical treatment of coronary heart disease in patients with severe lesions of the trunk of the left coronary artery. Results and discussion. Along with the improvement of endovascular instrumentation, stenting procedures, antithrombotic agents, as well as concomitant drug therapy, percutaneous coronary interventions for lesions of the left trunk are becoming more and more widespread and show favorable clinical results in these patients. This is evidenced by the data of many randomized multicenter studies (SYNTAX, EXCEL). Based on the results of these studies, ESC/EACTS approved the following guidelines for myocardial revascularization in 2018. Percutaneous coronary interventions are indicated in the case of damage to the left trunk with scores on the SYNTAX scale less than 22 – class I, scores on the SYNTAX scale 23–32 – class IIa, and scores on the SYNTAX scale greater than 32 – class III. However, it is worth noting that both the American and the European guidelines recommend a discussion by a team of endovascular surgeons, cardiologists and cardiac surgeons (Heart Team) when choosing a treatment strategy for coronary artery disease patients with lesions of the trunk of the left coronary artery. Since the data of many studies on the treatment of patients with lesions of the trunk of the left coronary artery remain quite contradictory and ambiguous. Conclusion. Current literature data have shown that left coronary artery stenting is a fairly safe procedure, with a high rate of immediate success, low mortality, and few complications, especially in low-risk surgical patients. The use of stents with medical coating made it possible to reduce the frequency of repeated interventions to 10–12%. A number of issues remain, the solution of which would allow optimizing the application of this technique. These include: development of indications for surgical or endovascular treatment of lesions of the left coronary artery trunk, optimization of stenting techniques, assessment of the significance of concomitant pathology in the effectiveness of treatment of patients with lesions of the left coronary artery trunk

A randomized clinical trial: Comparison of group acceptance and commitment therapy with drug on quality of life and depression in patients with obsessive-compulsive disorder.

Background:Acceptance and commitment therapy (ACT) is one of the newest treatment strategies that has been developed rapidly to improve the treatment of patients with obsessive–compulsive disorder (OCD). The aim of this study was to evaluate and compare the effect of ACT and selective serotonin reuptake inhibitors (SSRIs) drugs on the severity of depression symptoms and quality of life (QOL) in obsessive–compulsive patients.Materials and Methods:A randomized clinical trial with a control group was conducted including 27 patients with OCD. Based on the Diagnostic and Statistical Manual of Mental Disorders-5 criteria for OCD diagnosis, participants were recruited from Tamasha Counseling Center and obsessive–compulsive clinic in the Psychosomatic Research Center in Isfahan, Iran. Selected patients were allocated to two groups (14 in ACT the group and 13 in the drug group with SSRI with a simple random sampling method. ACT group was treated by an ACT therapist in eight 1-h sessions. Data were collected by the World Health Organization QOL Questionnaire (WHOQOL-BREF) and Depression subscale of DASS-42 at admission, after the intervention, and 3 months thereafter. Therapists and evaluators were blind to each other's work. Data were analyzed using analysis of variance with repeated measures method using IBM SPSS Statistics software (V 23, IBM Corporation, Armonk, NY, USA).Results:Results revealed that both treatments (ACT and SSRIs drug therapy) had significant impacts on reducing depression subscales scores and increasing WHOQOL-BREF scores at posttreatment (P < 0.05). There were no significant differences in QOL scores between the two groups after the intervention and follow-up (P > 0.05). Nevertheless, drug therapy presented a significantly greater improvement in depression scores of patients than those resulting from ACT (P = 0.005). The persistence of treatment effects continued after 3 months (follow-up) in both groups.Conclusion:ACT is equal to SSRIs drug therapy in terms of improving QOL in patients with OCD. However, SSRIs are more effective in treating depression in obsessive–compulsive patients. It may be presumed that ACT without any chemical side effect is equal to drug and is preferred for patients who either cannot use drugs or prefer not to have a drug treatment.

Clinical effect of the combination therapy of hydroxychloroquine, azithromycin and ivermectin in patients with COVID-19

Background: The ongoing pandemic has highlighted the need for an effective treatment of COVID-19 patients and prevention of SARS-CoV-2 community transmission.Methods: We conducted a prospective observational study on a cohort of 85 COVID-19 patients (80% males, median age 46 years, range 18–80 years). Patients were treated with a triple drug therapy: ivermectin 12 mg once a week, hydroxychloroquine 400 mg twice a day on the first day and 200 mg twice a day for the next 4 days, and azithromycin 500 mg once a day for 5 days. Endpoints were assessed by clinical outcomes, death, negative SARS-CoV-2 RNA-PCR test on the tenth day, and length of the hospital stay.Results: All patients improved except one 70-year-old female, who died on the third day of admission. The clinical outcome was considered good as 95.24% (80/84) of patients presented a negative SARS-CoV-2 RNA-PCR test on the tenth day of admission and 90.48% (76/84) were discharged in stable condition.Conclusions: The response must focus on immediate isolation of COVID-19 patients and their early treatment to prevent irreversible severe respiratory injury. Our study shows the beneficial effect of triple drug therapy in terms of clinical recovery, shorter duration of viral carriage, community spread prevention, and minimal cost of therapy.

Demographic, Clinical and Hormonal Characteristics as Predicting Factors Affecting the Outcome of Laparoscopic Ovarian Drilling in Women with Poly Cystic Ovary Syndrome

Background: Laparoscopic ovarian drilling as a second line of treatment modality for those PCOS patients failed to respond to clomophine citrate they may have the benefit of avoiding the side effects of long term drug therapy, lower costs and less time for successful ovulation and conceprtion compared to medical treatment. Objectives: Before doing LOD recognize factors that affect the outcome of the procedure for selecting patients to avoid unnecessary or unbeneficial intervention. Method: 143 anovulatory infertile PCOS patients followed up for 6 months after LOD for ovulation with pre-operative assessment for demographic characters and serum hormone levels (LH, FSH, free testosterone, AMH and prolactin). Results: Ovulation was demonstrated in 59.4%. Regression analysis showed significantly higher rates of ovulation among women 12 mIU/ml (OR = 4.18, 95% CI = 1.28-13.63) and free testosterone <4.5 ng/ml (OR = 3.22, 95% CI = 1.08-9.59). No significant (p = 0.078) association was detected between the ovulation rate and the AMH level, but it is evident that the OR was around 2 among women with AMH level of less than 7.7 ng/ml.Conclusion: preoperative LH, free testosterone and duration of infertility regarded as 3 important predicting factor for success of LOD

Protective effects of dantrolene and methylprednisolone against spinal cord injury-induced early oxidative damage in rabbit bladder: A comparative experimental study.

Spinal cord injury (SCI) may cause dysfunction in the bladder and many distal organs due to systemic inflammatory response and oxidative stress-related injury. We investigated the preventive effects of dantrolene (DNT) and methylprednisolone (MP) on stress-induced tissue damage in rabbit bladder with SCI. A total of 35 rabbits were included in this study and they were divided into 5 groups: group 1 - control, group 2 - SCI only, group 3 - SCI and DNT, group 4 - SCI and MP, and group 5 - SCI and DNT+MP. Twenty-four hours after SCI, the bladders of these rabbits were removed and the histopathologic changes in the bladder were examined under a light microscope. Additionally, malondialdehyde (MDA), glutathione (GSH), and nitric oxide (NO) levels were evaluated as antioxidant agents both in bladder tissue and in blood. Compared to the control group, there was an increase in edema and congestion in all groups. The least amount of edema was observed in the group receiving DNT and the least amount of congestion was observed in the group receiving combined treatment (group 5). No superiority was found between the drug-receiving groups in terms of reducing MDA level in blood and tissue after SCI. The most successful group was the group receiving combined drug therapy in terms of increasing the blood GSH level, which was significantly decreased after SCI. After SCI, blood NO level increased significantly in all groups. Nitric oxide levels in the bladder tissue significantly decreased in the groups receiving DNT and combination therapy and fell in the control group. Dantrolene and MP may have potential benefits against oxidative damage in the bladder after SCIs because of their anti-inflammatory and antioxidant effects. In particular, the combined use of DNT and MP at different doses can be considered a treatment strategy.

Annals for Educators - 2 July 2019.

Annals for Educators - 2 July 2019.

ДИНАМИЧЕСКОЕ НАБЛЮДЕНИЕ НЕ СОЗДАЁТ УСЛОВИЙ ПОВЫШЕНИЯ ПРИВЕРЖЕННОСТИ ЛЕЧЕНИЮ И ЭФФЕКТИВНОСТИ ФАРМАКОТЕРАПИИ У БОЛЬНЫХ ГИПЕРТОНИЧЕСКОЙ БОЛЕЗНЬЮ ПЕНСИОННОГО ВОЗРАСТА

Цель работы – обосновать необходимость вовлечения и формат участия провизора в процессе формирования у пациентов приверженности лекарственной терапии, назначенной врачом, с целью повышения эффективности лечения больных гипертонической болезнью пожилого возраста.Материал и методыВ данной статье представлены результаты, полученные в ходе реализации этапа динамического наблюдения, который является частью трехэтапного исследования приверженности лечению больных гипертонической болезнью пожилого возраста, и не предусматривает проведения специальных мероприятий по повышению комплаентности пациентов.Набор больных гипертонической болезнью пожилого возраста в этапе динамического наблюдения осуществлялся в аптеке, где была организована специальная комната (центр фармацевтической опеки). Провизор предлагал пожилым посетителям аптеки участие в исследовании по самостоятельному контролю лечения.После подписания информированного согласия определяли уровень комплаентности по тесту Мориски-Грина. В дальнейшем пациентам было предложено посетить врача-кардиолога с целью уточнения диагноза и оценки принимаемой антигипертензивной лекарственной терапии соответствию клиническому статусу больного.Все участники программы динамического наблюдения были консультированы провизором по вопросу приобретения АГЛП, прописанных врачом. Врач-кардиолог назначал препараты, согласно международным названиям. Провизор разъяснял возможность взаимозаменяемости препаратов разных производителей, обсуждал стоимость приобретаемых препаратов.В дальнейшем визиты больных к провизору в центр осуществлялась на 4-ой и 8-ой неделях участия в программе динамического наблюдения. Во время визитов определяли уровень приверженности лечению по тесту Мориски-Грина и оценивали эффективность проводимой антигипертензивной терапии (измерение артериального давления).Результаты и обсуждениеБольные (n=51), принявшие участие в этапе динамического наблюдения, были представлены мужчинами (n=25; 49,0%) и женщинами (n=26 человек; 51,0%) в возрасте от 62 до 75 лет (средний возраст мужчин 67,2±0,9; женщин – 67,7+0,9).Полученные результаты демонстрируют исходно низкую приверженность лечению больных гипертонической болезнью пожилого возраста: результат по тесту Мориски-Грина составлял 2,4±0,1. Антигипертензивная фармакотерапия у данного контингента больных неэффективна: уровень систолического артериального давления равен 168,9±1,5 мм рт. ст. и диастолического – 106,6±1,5 мм рт. ст. Динамическое наблюдение пациентов не обеспечивает улучшение анализируемых показателей, которые через восемь недель остаются на прежнем уровне: результат по тесту Мориски-Грина – 2,4±0,1; уровень систолического артериального давления равен 167,0±1,4 мм рт. ст. и диастолического – 105,0±1,4 мм рт. ст. ЗаключениеДинамическое наблюдение пациентов не обеспечивает улучшение показателей приверженности лечению больных гипертонической болезнью и эффективности антигипертензивной фармакотерапии. Для достижения надлежащей приверженности лечению больных гипертонической болезнью пожилого возраста необходимо проведение дополнительных бесед о важности соблюдения режима приёма антигипертензивных препаратов больными, постоянного контроля эффективности лекарственной терапии по уровню артериального давления. Такую работу с больными может проводить провизор в созданном нами центре фармацевтической опеки.

The spine instability neoplastic score (SINS) in the assessment of response to radiotherapy for bone metastases.

Vertebral metastases are often causing pain and spine instability. Radiotherapy is of significant benefit for painful spine metastases but the response can be very variable. The spine instability neoplastic score (SINS) is a recent classification system for diagnosis of spinal instability caused by vertebral metastases. We analysed the degree of pain relief, the need of drug therapy and the imaging features and the SINS before and after radiotherapy. In particular, we investigated the possible correlation of spine instability defined by pre-treatment SINS with pretreatment pain and with response to radiotherapy. This study included 121 patients with spine metastases treated with palliative 3D conformal radiotherapy. Pain "at rest" and "breakthrough pain", need for drug therapy in terms of "anti-inflammatory", "weak opioid", "strong opioid", imaging studies and SINS were assessed before and after radiotherapy. Statistical analysis was performed by the correlation coefficient of Spearman and Kruskal-Wallis test. Pain relief after radiotherapy was observed in 50.4 and 57.8% of patients in terms of pain at rest and breakthrough pain, respectively. The correlation between pain before radiotherapy and SINS was not statistically significant for both pain at rest (p=0.4) and breakthrough pain (p=0.49). The correlation between pain response after radiotherapy and SINS was statistically significant for both pain at rest (p=0.007) and breakthrough pain (p=0.047). The degree of instability, classified according to SINS, resulted to be predictive factor for pain response after radiotherapy. SINS might become a valid tool to identify those patients who can benefit the most from radiotherapy.

Study of drug utilization pattern in emergency medicine ward at a tertiary care teaching hospital

Background: The emergency department represents an important platform for conducting drug utilization studies as patients present with a wide spectrum of diseases in acute form. An irrational prescription adversely affects the prognosis and recovery of patients. Hence, the objective of our study was to evaluate the drug utilization pattern and to determine the rationality of prescription using WHO prescribing indicators in emergency medicine ward.Methods: After obtaining Institutional Ethical Committee approval, a prospective observational study was conducted over 2 months. The case records of 150 patients admitted to the emergency medicine ward, with a hospital stay of more than 24hrs were reviewed to analyze the prescription pattern during the initial 48hrs of admission. Case records of patients irrespective of age, sex and diagnosis were included in the study. Descriptive statistics were used to analyze the results (SPSS version 20).Results: A total of 1014 drugs were prescribed from 150 case records with a mean age of 47±18 years. An average of 6.76 drugs was prescribed per prescription; percentage of encounters with at least an antimicrobial was 115 (76.66%). Injections were prescribed in all patients (100%) and only 416 (41.02%) drugs were prescribed by generic name and 657 (64.79%) drugs abided to the WHO essential drug list. Majority of patients received anti-ulcerogenic drugs followed by antimicrobials.Conclusions: There was a tendency of polypharmacy with overuse of PPIs and antimicrobials. There is need to rationalize the drug therapy in terms of increasing prescription of drugs from essential drug list by generic name.

1793 - The spine instability neoplastic score (SINS) in the assessment of response to radiotherapy for bone metastases

Vertebral metastases are often causing pain and spine instability. Radiotherapy is of significant benefit for painful spine metastases but the response can be very variable. The spine instability neoplastic score (SINS) is a recent classification system for diagnosis of spinal instability caused by vertebral metastases. We analysed the degree of pain relief, the need of drug therapy and the imaging features and the SINS before and after radiotherapy. In particular, we investigated the possible correlation of spine instability defined by pre-treatment SINS with pretreatment pain and with response to radiotherapy. This study included 121 patients with spine metastases treated with palliative 3D conformal radiotherapy. Pain “at rest” and “breakthrough pain”, need for drug therapy in terms of “anti-inflammatory”, “weak opioid”, “strong opioid”, imaging studies and SINS were assessed before and after radiotherapy. Statistical analysis was performed by the correlation coefficient of Spearman and Kruskal–Wallis test. Pain relief after radiotherapy was observed in 50.4 and 57.8% of patients in terms of pain at rest and breakthrough pain, respectively. The correlation between pain before radiotherapy and SINS was not statistically significant for both pain at rest (p = 0.4) and breakthrough pain (p = 0.49). The correlation between pain response after radiotherapy and SINS was statistically significant for both pain at rest (p = 0.007) and breakthrough pain (p = 0.047). The degree of instability, classified according to SINS, resulted to be predictive factor for pain response after radiotherapy. SINS might become a valid tool to identify those patients who can benefit the most from radiotherapy.

Drug utilization study in medical emergency unit of a tertiary care hospital in north India.

Objective. To generate data on the drug utilization pattern and cost of drug treatment and to determine the rationality of prescriptions. Methods. A retrospective cross-sectional drug utilization study was conducted in the medical emergency unit of our hospital. Patient case records were reviewed to extract data on the pattern of drug use. Cost of drug treatment for the emergency visit was calculated by referring to the cost mentioned in Monthly Index of Medical Specialties and the rationality of prescriptions was evaluated using WHO core indicators of drug utilization. Results. 1100 case records were reviewed. Majority of patients received proton pump inhibitors followed by multivitamins. The median cost per prescription was 119.23$ (7.32$–7663.46$). Majority (49.9%) of drug cost was driven by antibiotics alone. An average of 4.9 drugs was prescribed per prescription. There were 14.89% encounters with antibiotics. 75.17% of the drugs were given as injectables and only 29.27% of the drugs were prescribed as generics. Conclusion. There is need to rationalize the drug therapy in terms of increasing prescribing of drugs by generic name and to avoid overuse of PPIs and multivitamins in emergency unit. Also the hospital pharmacy should be encouraged to procure more cost effective alternative antibiotics in future.

Reforming Pharmaceutical Education to Enhance the Global Uptake of Pharmacogenomics and Personalized Medicine

Personalized medicine has been defined as the tailoring of medical treatment based on individual patient characteristics. In practice, personalized medicine generally involves the stratifying of patient populations based on biomarkers, most frequently genetic in nature. This results in patient subpopulations likely to show differential responses to drug therapy in terms of efficacy and toxicity. While the potential for personalized medicine to positively impact on drug discovery and therapeutics has been widely hyped, clinical uptake has been markedly limited. Over the recent years, a number of potential barriers to the more widespread uptake of personalized medicine have been identified. These include technical, economic and social factors. One such barrier is the need for the significant up-skilling of health professionals in order to harness the potential of personalized medicine and ensure adequate information flow to consumers. Pharmacists are ideally positioned to be active participants in personalized medicine but to date, their role has been minimal. While the reasons are multifactorial, we argue that there is a clear need for significant reforming of current pharmacy curricula. Here we review progress in worldwide pharmaceutical education and practice relevant to global personalized medicine and public health pharmacogenomics and highlight salient points for future consideration.

Atrial Fibrillation Ablation

Atrial fibrillation is the commonest cardiac arrhythmia, with significant morbidity related to symptoms, heart failure, and thromboembolism, which is associated with excess mortality. Over the past 10 years, many centers worldwide have reported high success rates and few complications after a single ablation procedure in patients with paroxysmal atrial fibrillation. Recent studies indicate a short-term and long-term superiority of catheter ablation as compared with conventional antiarrhythmic drug therapy in terms of arrhythmia recurrence, quality of life, and arrhythmia progression. As a result, catheter ablation is evolving to a front-line therapy in many patients with atrial fibrillation. However, in patients with persistent long-standing atrial fibrillation catheter ablation strategy is more complex and time-consuming, frequently requiring repeat procedures to achieve success rates as high as in paroxysmal atrial fibrillation. In the near future, however, with growing experience and evolving technology, catheter ablation of atrial fibrillation may be extended also to patients with long-standing atrial fibrillation.

Tratamiento ablativo de la fibrilación auricular

Atrial fibrillation is the commonest cardiac arrhythmia, with significant morbidity related to symptoms, heart failure, and thromboembolism, which is associated with excess mortality. Over the past 10 years, many centers worldwide have reported high success rates and few complications after a single ablation procedure in patients with paroxysmal atrial fibrillation. Recent studies indicate a short-term and long-term superiority of catheter ablation as compared with conventional antiarrhythmic drug therapy in terms of arrhythmia recurrence, quality of life, and arrhythmia progression. As a result, catheter ablation is evolving to a front-line therapy in many patients with atrial fibrillation. However, in patients with persistent long-standing atrial fibrillation catheter ablation strategy is more complex and time-consuming, frequently requiring repeat procedures to achieve success rates as high as in paroxysmal atrial fibrillation. In the near future, however, with growing experience and evolving technology, catheter ablation of atrial fibrillation may be extended also to patients with long-standing atrial fibrillation.Full English text available from:www.revespcardiol.org

Spironolactone in the treatment of portal hypertension in liver cirrhosis. A new therapeutic principle?

Five patients with liver cirrhosis, portal hypertension and oesophageal varices received spironolactone in daily doses of 50-200 mg. Measurements of hepatic vein occlusion pressure at intervals of 1 to 5 months showed a pressure reduction of between 9 and 11 mm Hg. Thus the pressure lowering effect of spironolactone is about the same as that of beta-blockers. Since spironolactone is without the well known side effects of beta-blockers this therapeutic approach has wide application in the long term drug therapy of portal hypertension.

Clinical Photo: Angioedema by N-Acetylcysteine and Angiotensin-Converting Enzyme Inhibitor

Ruttonjee Hospital, Accident and Emergency Department, 266 Queen’s Road East, Wanchai, Hong Kong Sia Yin Shan, Jacky, FHKCEM, FHKAM(Emergency Medicine) An 87-year-old man with hypertension, ischaemic heart disease and heart failure, on long term drug therapy including enalapril, attended our emergency department 12 hours after an intentional overdose of 15 g of paracetamol. N-acetylcysteine (NAC) intravenous infusion was started empirically with the initial loading dose of 150 mg/kg in 15 minutes. The paracetamol level was later confirmed to be above the treatment line in the nomogram.

Bromide as a marker to measure adherence to drug therapy

Several methods have been described to measure adherence to prescribed drug therapy. However, most of these have been shown to be inaccurate. Bromide is an anion that is readily absorbed in the gut and has an elimination half-life of about 12 days. In the present study, we investigated the pharmacokinetic properties of bromide with the objective to use it as a measure of drug adherence. Three groups of each 8 healthy volunteers took 15, 24 or 30 mg potassium bromide, respectively, daily for 20 weeks. Serum concentrations of bromide were measured every two weeks. There was a linear relationship between the daily dosage taken and the mean increase of bromide concentration. In every group considerable inter-individual variability was seen. Correction for body weight resulted in an improved correlation between daily bromide dose and increase in concentration (r=0.78, p<0.01). Unfortunately, the inter-individual variability in clearance of bromide was considerable. This limits the use of bromide to primarily measuring adherence in individual patients during long term follow-up. Bromide appears to be a potentially useful marker to be added to drugs for assessment of individual adherence to long term drug therapy. This needs to be investigated in various patients, particularly for patients with relatively asymptomatic diseases (e.g. hypertension).

Changes in the usage of antihypertensive drugs: implications and prospects

In their paper [1], Cheung and colleagues describe changes in antihypertensive drug usage over 8 years at a university hospital in Hong Kong. The quantitative analysis of usage frequency is supplemented by estimates of the percentage of patients with blood pressure at target levels. Their findings prompt a number of questions, about patterns of drug usage in different populations worldwide, the possible influences on these patterns and how these might change over the next few years. Of course, such detailed information is not available everywhere, so some comparisons are likely to remain speculative. In this particular case there are apparently no specific Hong Kong or Chinese national guidelines which are applicable, unlike the USA or Europe [2–4]: it would indeed be very interesting to establish how far such guidelines do actually modify prescribing practice in countries where they are supposed to be applicable. Regardless of that, Cheung's paper can serve as a focus for several current issues of interest and debate.