Indication For Long-term Therapy Research Articles

Deprescribing proton pump inhibitors.

Proton pump inhibitors (PPIs) are indicated for disorders including peptic ulcer disease and gastro-oesophageal reflux disease; however, they are often used for longer and at higher doses than recommended, or for indications that are not supported by evidence. The aim of this article is to outline evidence-based approaches to deprescribing PPIs. PPIs are generally well tolerated; however, use beyond eight weeks is rarely indicated and increases the risk of adverse events. PPI deprescribing should be considered when there is no indication for long-term therapy. Evidence supports a patient-centred approach to PPI deprescribing involving stepping down the dose before ceasing or switching to pro re nata (PRN; 'as needed') use. Abrupt PPI discontinuation may result in short-term rebound acid hypersecretion that can mimic symptom return. This can be minimised with gradual dose tapering prior to discontinuation and managed with PRN treatment. Prescribers should discuss the rationale for PPI deprescribing and involve patients indeveloping the deprescribing plan.

Is There Still a Need for Medical Antiarrhythmic Therapy?

The use of medical antiarrhythmic therapy apart from beta-blockers has been steadily decreasing in the recent past. This can partly be attributed to technological progress that has rendered the ablation of complex cardiac arrhythmias like atrial fibrillation, focal atrial tachycardias and ventricular arrhythmias feasible and efficacious. Furthermore, an awareness regarding pro-arrhythmic and toxic side-effects of antiarrhythmic medication has evolved. Nevertheless, medical antiarrhythmic therapy still plays a fundamental role in acute therapy of arrythmias as well as certain indications for long-term therapy. This review comprehensively summarizes the current role of medical antiarrhythmic therapy in daily clinical practice focusing on mechanisms and therapies of the most common cardiac arrythmias.

Assessment of the mean time in the therapeutic INR range and the SAME-TT2R2 score in patients with atrial fibrillation and cognitive impairment.

INTRODUCTION Most patients with atrial fibrillation (AF) are elderly and may have an increased risk of cognitive disorders. Low mean values of the therapeutic international normalized ratio (INR) range (TTR) (≤60%) are associated with increased risk of stroke, vascular events, and bleeding complications. OBJECTIVES The aim of the study was to evaluate the efficacy of long-term anticoagulant therapy in patients treated with vitamin K antagonists (VKAs), depending on their cognitive functions. In addition, we used the SAMe-TT2R2 risk score to predict the risk of ineffective anticoagulation. PATIENTS AND METHODS The analysis comprised 154 patients (68 men and 86 women; mean age, 76 ±10 years) with AF and indications for long-term therapy with VKA (CHA2DS2-VASc score ≥1, HAS-BLED score <3). Cognitive functions were evaluated using the Mini-Mental State Examination (MMSE) score. The efficacy of VKA therapy was determined by the TTR values from the preceding 6 months of treatment. We used the SAMe-TT2R2 score to identify patients who were likely to have poor INR control. RESULTS Depending on the number of MMSE points, patients treated with VKAs were divided into 2 groups: patients with normal cognitive functions (MMSE score ≥27; n = 62) and those with cognitive impairment (MMSE score <27; n = 42). Despite the fact that all patients had indications for anticoagulant therapy, 50 patients (32%) received no VKAs on admission. The mean TTR value exceeded 60% in 61% of patients with an MMSE score of 27 points or higher, whereas mean TTR value was 28% in patients with an MMSE score of less than 27 (P <0.0001). Patients with a SAMe-TT2R2 score of 0 to 1 had higher TTR values than those with a SAMe-TT2R2 score of 2 or higher (r = -0.24; P <0.05 ). The cognitive status was significantly more impaired in patients with persistent and permanent AF compared with patients with paroxysmal AF (MMSE score, 25.8 ±3.7 vs 28.6 ±2; P <0.0001). CONCLUSIONS Cognitive disorders in patients with AF significantly reduce the efficacy of VKA therapy. The decision to administer VKA treatment should be based not only on the CHA2DS2-VASc and HAS-BLED scores, but also on the SAMe-TT2R2 score and the evaluation of the patient's cognitive functions.

The clinical and therapeutical aspects of schizo-affective psychosis.

According to our three series of examinations, we have found a way of differentiating between nuclear schizophrenics and manic-depressives in schizo-affective disorders. Only a very small amount of all people diagnosed as schizophrenics (about 3%) have to be put under the category of schizo-affective disorders (Legierungspsychose) sensu strictiori. But in this well-defined group, there is a relation between the symptomatology of the acute stage and the long-term course of the disorder. There is also a better indication for long-term therapy in schizo-affective disorders, because the differentiation in psychopathology also means a better-differentiated therapy with better long-term results.

Practical aspects of long-term anticoagulant therapy.

The clinician is more and more frequently confronted with the decision as to whether or not to give a patient anticoagulants beyond his hospital stay. Indications for longterm therapy are quite definite in some conditions and less so in others. Once the decision is made to continue such therapy over a period of months or years the burden on both patient and physician may be materially eased if certain principles are understood and practices followed. Since long-term therapy with heparin is for the most part impractical, it is the prothrombin depressants with which the clinician is chiefly concerned in prolonged anticoagulant administration. It is the purpose of this paper to discuss briefly certain principles of such therapy and to emphasize the practical aspects of their application. Methods of Control Despite recent advances in our knowledge of the mechanism by which blood clots, our assays for clotting factors are still not