Term Drug Therapy Research Articles

Review: antibiotics have a slight beneficial effect on acute bronchitis

Bent S, Saint S, Vittinghoff E , et al. Antibiotics in acute bronchitis: a meta-analysis. Am J Med1999 Jul; 107 : 62 –7 [OpenUrl][1][PubMed][2][Web of Science][3] QUESTION: In patients with...

Review: antibiotics have a slight beneficial effect on acute bronchitis

(1999) Am J Med 107, 62. Bent S, Saint S, Vittinghoff E, et al. . Antibiotics in acute bronchitis: a meta-analysis. . Jul; . : . –7 . [OpenUrl][1][PubMed][2][Web of...

Pharmacoeconomics of antimicrobial therapy

Switch therapy, sequential therapy, and step-down therapy are discussed in terms of their contribution to reducing antimicrobial expenditures. Pharmacoeconomics is the science used to identify and compare the costs and consequences of drug therapy in terms of efficacy, safety, and overall health care. Pharmacoeconomic studies of antimicrobials for respiratory-tract infections have identified significant cost savings associated with regimens that are optimized for a particular patient on the basis of a drug's pharmacokinetic profile. For fluoroquinolones, optimal therapy has been associated with targeting the specific pharmacodynamic variable known as the ratio of the area under the serum concentration-time curve from 0 to 24 hours (AUC) to the minimum inhibitory concentration, also referred to as the area under the inhibitory curve (AUIC). Several studies have shown that regimens that achieve targeted AUIC values of 125 to 250 against gram-negative aerobic bacteria are cost-effective; cost savings are linked to decreased time to bacterial eradication and higher AUICs. Additional cost-effective measures for hospitals and health care institutions include the implementation of formalized i.v.-to-oral conversions and streamlining programs. Pharmacoeconomic analysis of therapies for respiratory-tract and other infections demonstrates that reducing health care costs may best be achieved by curing the infection in the shortest possible time through dosage optimization individualized to the patient.

Correspondence

Radiofrequency ablation is a technique that can deliver a high chance of cure with a low incidence of complication for many cardiac arrhythmias. As Dr Marshall has indicated (Vol 60(5), 1999, p. 320), this technique is currently routinely applicable to re-entrant arrhythmias that involve the atrioventricular node as well as the Wolff-Parkinson-White syndrome and many atrial tachycardias. These arrhythmias often present in younger patients and a definitive and curative procedure is often preferable to long term drug therapy.

Efficacy and safety measures for low density lipoprotein apheresis treatment using dextran sulfate cellulose columns.

Long-term low density lipoprotein (LDL) apheresis using dextran sulfate cellulose (DSC) columns is a well tolerated treatment for drug refractory hypercholesterolemia with coronary heart disease (CHD). Hypercholesterolemic patients may benefit from LDL apheresis combined with cholesterol lowering drug therapy in terms of the prevention of the progression of atherosclerosis, stabilization of atheromatous plaque, and reduction of cardiac events. The major adverse reaction of LDL apheresis is temporal hypotension caused by hypovolemia or vasovagal reactions due to extracorporeal circulation. Anaphylactoid reactions in patients administered angiotensin converting enzyme inhibitors (ACE-I) are other dextran sulfate cellulose column related adverse reactions, which must be carefully prevented by ceasing the administration of ACE-I before LDL apheresis treatment. ACE-I must not be administered to patients undergoing LDL apheresis.

Selected B Vitamin Intakes from Diet and Supplements in Adults

While frank deficiencies are rare without contributing factors such as alcohol or long term drug therapy, even among well educated, presumably well nourished Americans, diets may not provide adequate amounts of some B vitamins. Older men and women may be susceptible to the effects of chronic marginal intakes. Because these effects may be completely reversible if diagnosed and treated in the early stages, it is essential to develop strategies to recognize those at risk and identify and treat them. Five hundred sixty-four subjects (20-95 yrs.) of the Baltimore Longitudinal Study of Aging were assessed with respect to intakes of folacin, vitamins Bg and B12. Substantial numbers of men and women consumed less than adequate folacin and vitamin Bg from diet. Women were at greater risk of low intakes than men.

Fulminant hepatic failure caused by ecarazine hydrochloride (a hydralazine derivative)

The cause of fulminant hepatic failure is reported to be unknown in more than half the cases in Japan. We recently reviewed 23 cases of fulminant hepatic failure that had been treated at our hospital. The cause of disease had been regarded as unknown before this study. It was found that seven of these patients had been under ecarazine hydrochloride therapy when they developed fulminant hepatic failure. We examined the reasons why fulminant hepatic failure in these seven patients had not been previously attributed to ecarazine, and found that it could be explained by the following factors: (1) the time from the start of ecarazine therapy to the onset of hepatic failure was long; (2) in all cases, hepatic failure developed more than 10 days after the clinical recognition of hepatitis; and (3) characteristic signs of drug-induced hepatic failure such as a skin rash and positive lymphocytes stimulation test with the drug were absent in all cases. Fulminant hepatic failure in these cases could be characterized by: (1) rapid decrease in serum alanine transaminase (ALT) level after discontinuation of ecarazine, (2) prolonged jaundice despite discontinuation of ecarazine, (3) high incidence of anti-nuclear antibody (ANA) (57%), and (4) histological findings of extensive hepatocellular necrosis ranging from bridging necrosis to massive necrosis. Of the seven patients, four died of fulminant hepatic failure. These four patients had received high doses of ecarazine hydrochloride for prolonged periods. Our data suggest that there may be many cases in which the cause of fulminant hepatic failure or acute hepatitis was not previously determined that can be attributed to long- term drug therapy for chronic diseases.

Fulminant hepatic failure caused by ecarazine hydrochloride (a hydralazine derivative)

The cause of fulminant hepatic failure is reported to be unknown in more than half the cases in Japan. We recently reviewed 23 cases of fulminant hepatic failure that had been treated at our hospital. The cause of disease had been regarded as unknown before this study. It was found that seven of these patients had been under ecarazine hydrochloride therapy when they developed fulminant hepatic failure. We examined the reasons why fulminant hepatic failure in these seven patients had not been previously attributed to ecarazine, and found that it could be explained by the following factors: (1) the time from the start of ecarazine therapy to the onset of hepatic failure was long; (2) in all cases, hepatic failure developed more than 10 days after the clinical recognition of hepatitis; and (3) characteristic signs of drug-induced hepatic failure such as a skin rash and positive lymphocytes stimulation test with the drug were absent in all cases. Fulminant hepatic failure in these cases could be characterized by: (1) rapid decrease in serum alanine transaminase (ALT) level after discontinuation of ecarazine, (2) prolonged jaundice despite discontinuation of ecarazine, (3) high incidence of anti-nuclear antibody (ANA) (57%), and (4) histological findings of extensive hepatocellular necrosis ranging from bridging necrosis to massive necrosis. Of the seven patients, four died of fulminant hepatic failure. These four patients had received high doses of ecarazine hydrochloride for prolonged periods. Our data suggest that there may be many cases in which the cause of fulminant hepatic failure or acute hepatitis was not previously determined that can be attributed to long- term drug therapy for chronic diseases. (Hepatology 1996 Mar;23(3):465-70)

Non-pharmacological therapy of hypertension.

Weight reduction, moderate sodium restriction and alcohol reduction all lower blood pressure significantly in the short-term, and appear feasible in the long-term. Dynamic exercise may have a useful role in selected patients. Cessation of cigarette smoking has no important effect on blood pressure itself but is likely to improve the prognosis. No other non-pharmacological intervention warrants a place in routine management on present evidence. Regimens involving combined reduction in weight, salt and alcohol have proved less effective than drug therapy in terms of blood pressure reduction. Hypertensive patients may be shifted from just above some arbitrary intervention level to just below it by non-pharmacological treatment, and the perceived benefits of non-pharmacological management may be offset by an increased risk of vascular complications related to suboptimal blood pressure control. Moreover even simple measures such as moderate sodium restriction may affect some aspects of quality of life adversely. Non-pharmacological measures should generally be regarded as useful adjuncts to antihypertensive drug therapy rather than alternatives to it.

Cost effectiveness of radiofrequency catheter ablation in the treatment of symptomatic supraventricular tachyarrhythmias.

The recent advent of radiofrequency (RF) catheter ablation as a curative therapy for supraventricular tachyarrhythmias has challenged the role of long term drug treatment, which is essentially a palliative therapy. To date, however, no data have been published on the cost-effectiveness of RF ablation as compared with drug treatment in the Australian setting. The study aimed to compare actual and projected costs of these two treatment options in a consecutive group of patients having RF ablation as treatment for symptomatic tachyarrhythmias. The cost effectiveness of RF catheter ablation was assessed in 26 patients having RF ablation, using a hypothetical model of continued drug therapy in the same group of patients. A 'cost saving' criterion was used for cost effectiveness. Actual costs for the RF ablation and for continued drug therapy were based on data from medical records and from the answers to a detailed patient questionnaire. Analysis included costs of prior diagnostic electrophysiology (EP) study (17/26 patients), general anaesthesia (GA: 20/26 patients), post-ablation echocardiography (10/26 patients), and late follow-up EP study (7/26 patients). The in-hospital stay for the RF ablation was two days in all cases, and no patient required implantation of a permanent pacemaker. The RF ablation procedure was successful in 23/26 patients (88.5%) with late recurrence of tachycardia in one patient. After a median follow-up of nine months, 22/26 patients no longer require antiarrhythmic drug therapy. The mean per patient cost of RF ablation was $4067 in the study group. This reduces to $2546 if prior EP study and GA are excluded. The mean per patient cost of continued medical therapy was $700 per year. Extrapolating over 20 years and allowing for an annual 5% inflation factor, RF ablation becomes cost saving in 5.5 years (3.8 years if prior EP and GA are excluded). Over 20 years, continued drug therapy would be four to five times more expensive than RF ablation in the patient study group. We consider RF ablation to be a cost-effective alternative to long term drug therapy in patients with supraventricular tachyarrhythmias.

Cardiac Arrhythmias in Childhood

Determining safe and effective antiarrhythmic therapy in paediatric patients requires definition of the mechanism of the arrhythmia, determination of associated risk factors for treatment (such as the presence of congenital cardiac defects, myocarditis or cardiomyopathy), and monitoring for potential drug side effects related to the treatment. A number of modalities for non-invasive evaluation of arrhythmias is available, including ECG, 24-hour ambulatory Holter monitoring, and transtelephonic ECG transmission. Arrhythmias requiring medical treatment in children with normal cardiac anatomy and function include supraventricular tachycardia (SVT), ventricular tachycardia (VT) and primary atrial tachycardias. SVT is treated acutely with vagal manoeuvres or drugs which slow AV conduction [adenosine (adenine riboside), edrophonium, phenylephrine or verapamil]. When medical conversion is not achieved, transoesophageal overdrive pacing or direct current (DC) cardioversion may be required. Long term drug therapy for SVT includes first-line treatment with digoxin, verapamil or propranolol. Ventricular tachycardia is managed acutely with DC cardioversion and intravenous lidocaine (lignocaine). Chronic drug regimens include mexiletine, propranolol or amiodarone. In children with structural congenital heart disease or myocardial dysfunction, hazards of drug therapy for arrhythmias include depression of cardiac function, proarrhythmia (drug-induced worsening of arrhythmias), and conduction abnormalities. Care must be taken to choose medication regimens which are likely to be effective with minimum risk of potentiating abnormal haemodynamics or conduction.

Measurement of radiographic changes occurring in rheumatoid arthritis by image analysis techniques.

We have applied image analysis techniques to serial measurements of bone contour in standard radiographs of single small joints of the hands in subjects with rheumatoid arthritis (RA) and controls. Adequate reproducibility was shown in 20 controls radiographed twice over a six month period. The technique showed significant changes in a proximal interphalangeal joint of 13 of 15 patients with RA studied over periods of three to 10 months. In further serial studies in selected small joints of RA hands significant changes could be shown as early as four months. These results justify further development of these techniques to allow their full scale evaluation in multiple joints in patients with RA receiving long term drug therapy.

Pemoline pharmacokinetics and long term therapy in children with attention deficit disorder and hyperactivity.

The pharmacokinetic behaviour of pemoline was studied in 28 children, aged 5 to 12 years, diagnosed as having the attention deficit disorder with hyperactivity. The mean elimination half-life of pemoline in these children was approximately 7 hours, which is considerably shorter than the half-life of 11 to 13 hours previously reported in adults. The tendency of the half-life to increase with age may be explained by the statistically significant decrease in total body clearance with age. The increasing half-life of pemoline with age should be considered during long term drug therapy. In this study no tolerance to the beneficial effects of pemoline was observed over 6 months. The apparent therapeutic serum concentration range for these children was attained after doses of 37.5 to 131.25 mg pemoline daily. Since the optimum serum concentration shows wide variation, the dosing regimen must be determined individually. Routine monitoring of the pemoline serum concentrations is not useful because of this apparent variation in optimum serum concentration and because of the linear relationship between dose and concentration.

Drug treatment and obesity

1. (1) The initial treatment of obesity must include an attempt to modify previous eating pattern and may involve group therapy or behavioral modification. Drug treatment is not indicated unless this dietary approach is shown to be ineffective. 2. (2) Since antiobesity drugs do not help to establish a new and permanent eating habit, they should never be prescribed except as part of an overall management plan. 3. (3) The potential for abuse with amphetamine and phenmetrazine is such that their use cannot be justified as anorectic agents. 4. (4) Phenmetrazine, diethylpropion, mazindol and fenfluramine will all produce an additional mean weight loss of approximately 0.2 kg per week. They are contraindicated if there is a history of drug misuse, drug dependence or psychiatric illness. They should always be prescribed with caution. With the exception of fenfluramine, they are best given intermittently on the grounds of efficacy, safety and cost benefit. 5. (5) The individual response to drug therapy is extremely variable and may reflect differences in drug pharmacokinetics, metabolic adaptation or, less frequently, drug tolerance. 6. (6) Following drug withdrawal, weight regain is the rule. It follows that therapy can most easily be justified if there is a short term need for weight loss, e.g. prior to elective surgery. 7. (7) The safety and efficacy of long term drug therapy has yet to be established. It may prove justifiable in patients most at risk from obesity or from obesity associated disorders such as diabetes and hypertension. However, at present the only established indication for prolonged administration of the currently available drugs is the use of metformin in insulin independent diabetics. 8. (8) The indications for the pharmacological treatment of obesity remain poorly defined. A number of new approaches are being evalued, and the future may lie in the development of drugs which enhance thermogenesis or primarily act upon the gastrointestinal tract.

Treatment of pyoderma with radiant energy of artificial light sources

Pyoderma diseases often lead to disability. The use of the most effective methods, which shorten the time of treatment of pyoderma diseases, will improve the health of workers, save many working days and give great savings in public funds. In recent years, the KSMI skin clinic has been successfully using topically solutions (water, alcohol) of aniline dyes and manganese peroxide for pyoderma. Of the negative aspects of this treatment, it should be noted that aniline dyes stain linen and have a weak effect in forms of deep dermal pyoderma (furuncle, carbuncle, hydradenitis). The simultaneous use of phototherapy with aniline dyes and manganese peroxide, as observations have shown, did not give us special advantages over conventional drug therapy in terms of shortening the treatment time.