Terms Of Pharmacotherapy Research Articles

ADP-receptor blockade: A case for personalised pharmacotherapy?

The dual antiplatelet therapy consisting of aspirin and the ADP-receptor blocker clopidogrel is the current standard medication after acute coronary events. However, clopidogrel is characterised by a high interindividual response variability, insufficient inhibition of platelet aggregation in a significant number of patients, relatively slow onset of efficacy and potential interaction with different co-medication via diverse hepatic cytochrome enzymes. In various trials, response variability of clopidogrel was translated into a higher rate of recurrent cardiovascular events. Different clinical and non-genetic factors contribute to the phenomenon of clopidogrel response variability. An individualised antithrombotic pharmacotherapy taking these factors into account, including the definition of status of response, verification of the efficacy by standardised platelet function testing, intensified or alternative platelet inhibition would be the ultimate goal for patients treated with clopidogrel. Currently, new drugs are on the way and promise a more consistent efficacy and smaller amount of response variability. However, the bleeding risk in subgroups of patients and further side effect profile remains to be clearly defined. Therefore, risk stratification models are warranted to identify patients who benefit from personalised pharmacotherapy in terms of improved clinical net benefit. In this review, we discuss treatment failure of clopidogrel based on platelet function testing, the mechanism of established and new ADP-blockers as well as new therapeutic principles.

UP-3.074: A Simplified TURP Especially for the Third World

The current standard of care of BPO requires an assessment of the prostate symptom score and thereafter the use of long term pharmacotherapy. In the Third World patients present later with higher symptom scores. Many will present in acute urinary retention. Most of these patients are best offered TURP. TURP provides a one-off cure. It also provides tissue for microscopic analysis. The patient can then be safely returned to his local community. Pharmacotherapy requires repeated follow-up. This can be challenging in many parts of the poorer world.

P01-179 Does psychoeducatioanal approach could reach the target patients with bipolar disorder?

The recurrent nature of bipolar disorder needs an optimum compliance with long term pharmacotherapy, however the poor adherence is common. Adjunctive psychoeducation seems favorable effects on adherence during the long term pharmacotherapy. Even strong benefits were showed, setting a psychoeducation in clinical practice is still novel and recruiting the patients with long history of bipolar disorder may not be feasible. In literature, recruitment rate, motivation and attitudes of patients for participation in psychoeducation is not studied. The present study was conducted to clarify the intends of patients with bipolar disorder to participate in psychoeducation and the factors that contribute.The euthymic patients with diagnosis of bipolar disorder I or II, were invited to the 6 week psychoeducation program in prospective study. The demographic and clinical data were obtained from life charts and updated with a clinical interview. The blood levels of mood stabilizers, adherence, response to prophylactic treatment, relapses and hospitalization rates between the participants and non-participants were compared.84 patients were attended the program, 71 patients were considered as unwilling to attend. The motivation of patients to attend a psychoeducation is limited. The participation rate was only 54.2%. The patients who refused attending to this program have fewer adherences to medication and irregular follow up visits, insufficient blood levels of mood stabilizers, poor response to long term treatment, more likely have mood episodes. Education level between attendees and non-attendees were not different.Optimum methods are required for recruitment of bipolar patients to a psychoeducation program.

Interventions for treating depression after stroke

Depression is an important consequence of stroke that impacts on recovery yet is often not detected or inadequately treated. This is an update of a Cochrane review first published in 2004. To determine whether pharmaceutical, psychological, or electroconvulsive treatment (ECT) of depression in patients with stroke can improve outcome. We searched the trials registers of the Cochrane Stroke Group (last searched October 2007) and the Cochrane Depression Anxiety and Neurosis Group (last searched February 2008). In addition, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2008), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), CINAHL (1982 to May 2006), PsycINFO (1967 to May 2006) and other databases. We also searched reference lists, clinical trials registers, conference proceedings and dissertation abstracts, and contacted authors, researchers and pharmaceutical companies. Randomised controlled trials comparing pharmaceutical agents with placebo, or various forms of psychotherapy or ECT with standard care (or attention control), in patients with stroke, with the intention of treating depression. Two review authors selected trials for inclusion and assessed methodological quality; three review authors extracted, cross-checked and entered data. Primary analyses were the prevalence of diagnosable depressive disorder at the end of treatment. Secondary outcomes included depression scores on standard scales, physical function, death, recurrent stroke and adverse effects. Sixteen trials (17 interventions), with 1655 participants, were included in the review. Data were available for 13 pharmaceutical agents, and four trials of psychotherapy. There were no trials of ECT. The analyses were complicated by the lack of standardised diagnostic and outcome criteria, and differing analytic methods. There was some evidence of benefit of pharmacotherapy in terms of a complete remission of depression and a reduction (improvement) in scores on depression rating scales, but there was also evidence of an associated increase in adverse events. There was no evidence of benefit of psychotherapy. A small but significant effect of pharmacotherapy (not psychotherapy) on treating depression and reducing depressive symptoms was found, as was a significant increase in adverse events. More research is required before recommendations can be made about the routine use of such treatments.

Long term pharmacotherapy for obesity and overweight: updated meta-analysis

Long term pharmacotherapy for obesity and overweight: updated meta-analysis

Long term pharmacotherapy for obesity and overweight: updated meta-analysis

Objective To summarise the long term efficacy of anti-obesity drugs in reducing weight and improving health status.Design Updated meta-analysis of randomised trials.Data sources Medline, Embase, the Cochrane controlled trials register,...

Psychotherapy in psychiatry

The relationship between psychotherapy and psychiatry has become a beleagured one in recent years. The swing of the pendulum in the direction of biological psychiatry has led to a marginalization of psychotherapy within the discipline of psychiatry as a whole. However, psychotherapy continues to be a basic science of psychiatry with application in all clinical settings. It must be regarded as a biological treatment that works by changing the brain and is therefore just as important as pharmacotherapy in terms of overall treatment planning. The combined treatment of medication and psychotherapy has become the most common mode of psychiatric treatment planning in current practice. Both the two-treater model and the single-treater model have a set of advantages and disadvantages that are explicated. Further research is needed to identify clinical situations in which psychotherapy is essential, whether alone or in combination with medication. Moreover, as greater insights are gained into the brain mechanisms responsible for therapeutic changes, more specifically targeted psychotherapies can be developed.

Disordered gambling in adolescents : epidemiology, diagnosis, and treatment.

Rapid expansion of legalized gambling has been associated with increased rates of gambling disorders among adults and adolescents worldwide. Epidemiologic studies suggest that, in North America, up to 6% of adults and 20% of adolescents have a gambling problem. Despite increasing prevalence rates of gambling disorders, little research is available on how to treat such disorders in adolescents. Much of what is known about how to treat adolescent problem and pathological gambling comes from research on psychosocial and psychopharmacologic treatments for adult pathological gambling. Risk factors for adolescent gambling disorders include male gender, alcohol and drug use, deviant peers, family history of gambling, and impulsive behavior. While several risk factors characterize disordered gambling among adolescents, the extent to which these characteristics are related remains to be determined. In terms of screening for adolescent problem and pathological gambling, several instruments designed to reflect the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for pathological gambling are available. Psychosocial approaches used to treat adult pathological gambling include Gamblers Anonymous, cognitive-behavioral therapy (CBT), and motivational enhancement therapy (MET). Among adolescents, CBT as well as an eclectic therapy have been helpful in reducing problematic gambling behavior. In terms of pharmacotherapy, three classes of psychotropic drugs have been used to treat adult pathological gambling - serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers. While some of these pharmacotherapies have been efficacious in treating adult pathological gambling, additional double-blind, placebo-controlled studies are needed to determine the long-term effectiveness of these treatments. No known study has evaluated the use of psychopharmacologic agents in treating adolescent pathological gambling. Possible reasons for the lack of research on treatment for adolescent gambling disorders include lack of motivation to pursue treatment, feelings of self-control, and negative perception of therapy. Referrals from parents, teachers, and peers of adolescents, as well as community outreach programs, may be useful in successfully deriving a treatment population. Clinicians are advised to be sensitive to behavioral risk factors and to screen for disordered gambling in high risk adolescents. A combination of CBT and MET, as well as medication for any comorbid psychiatric condition, is recommended.

Empirically supported treatments for panic disorder: Costs, benefits, and stepped care.

Treatment outcome findings suggest that cognitive-behavioral therapy (CBT) and pharmacotherapy offer similar short-term treatment gains for panic disorder and that CBT may afford more optimal maintenance of treatment gains without the need for ongoing treatment. However, efficacy is not the only consideration for patients, and because of limited health care resources, evaluation of the cost-benefit ratio of these treatments is important. In this article, the authors review estimates of the relative efficacy, acceptability, tolerability, and costs of these treatments; empirically examine the costs and outcome of cognitive-behavioral and pharmacologic interventions as they are delivered in an outpatient clinic specializing in these treatments; and comment on how these data inform a stepped care model of treatment. Analysis of the "services" data indicated that CBT was at least equal to pharmacotherapy in terms of pretreatment severity and acute treatment outcome and that CBT is an especially cost-effective treatment option.

Obsessive-Compulsive Disorder

Obsessions, compulsions and rituals have been recognised as abnormal cognitions and behaviours for several centuries. These symptoms and signs, which have been variously referred to in different ages and cultures, are encompassed under the present diagnosis of obsessive-compulsive disorder (OCD). OCD has been an elusive nosological entity, resistant to treatment until the last 30 years. In 1966, two distinct treatment modalities, a potent serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitor (SRI) and behavioural therapy, were introduced. Today, SRIs and behavioural therapy remain important interventions in modern OCD management, underscoring the fact that more effective modes of treatment have not been developed. Despite recent advances in understanding the underlying neurobiology of OCD, its treatment remains a challenge. At present, the mainstay of treatment is a combination of pharmacotherapy and behavioural therapy. In terms of pharmacotherapy, the most effective class of medication remains the SRIs. Clomipramine and the selective SRIs fluoxetine, fluvoxamine, paroxetine and sertraline have all demonstrated efficacy and are regarded as first-line agents for monotherapy. If multiple trials of SRIs do not result in improvement, alternative monotherapy may be attempted with monoamine oxidase inhibitors, buspirone or clonazepam. If monotherapy achieves partial response, augmentation of SRIs or combinations of agents may be considered. Only haloperidol has demonstrated efficacy as an augmentation of an SRI in a controlled trial and only in patients with comorbid tic disorders. There is support from noncontrolled trials for some other augmenting agents. Of the psychotherapeutic techniques, only behavioural therapy in the form of exposure and response prevention (ERP) has demonstrated significant effectiveness. Optimal results in the management of OCD are often realised through a combination of ERP and pharmacological therapy, although the availability of behavioural therapy is limited. For the small proportion of patients who are severely disabled by prolonged treatment-resistant OCD, neurosurgery may be an effective treatment option.

Patient Outcome and the Future Practice of Pharmacy

The societal move to focus on patient healthcare outcomes as a measure of provider performance is discussed. Recent steps taken by the Joint Commission on Accreditation of Healthcare Organizations to include outcome criteria as part of its accreditation process represent one such example. Pharmacists must define and defend their role in patients' pharmacotherapy in terms of patient outcomes. Collective actions needed by pharmacists are recommended.