Treatment Of Comorbid Conditions Research Articles

EL14 - Drugs Interaction of Anticancer Agents

ABSTRACT Cancer patients are increasingly benefiting from new treatment strategies and advances in supportive care. However, adverse drug interactions of anticancer agents are a major cause of morbidity and mortality, and cancer patients are at particularly high risk of such interactions because they commonly receive multiple medications. In addition, the majority of cancer patients are elderly, and the ages-related decline in hepatic and renal function reduces their ability to metabolize and clear drugs and increase the potential for toxicity. Drugs interaction can be categorized as pharmaceutical, pharmacodynamic, or pharmacokinetic. Pharmaceutical interactions may occur when two compounds interact because they are incompatible either physically or chemically. These may also occur as the modulating effect of a vehicle on the pharmacokinetic and pharmacodynamic properties of drugs. Pharmacodynamic interactions may occur when two or more drugs have mechanisms of action that influence the same physical process. Excessive response and increased toxic effects are seen if the interaction is additive or agonistic. When drugs have an antagonistic effect, the drug can decrease and the patient's response to the drug can be reduced. Pharmacokinetic interactions may occur when one drug influences the absorption, distribution, metabolism, and/or excretion of another. Metabolizing enzyme or drug transporters are often involved in these processes. The hepatic CYP system is the major site of drug metabolism, and most drug interactions take place at this site. P-glycoprotein is a membrane-bound protein, and has an important influence on the management of cancer patients due to this ability to transport antineoplastic agents out of cancer cells. Drugs interactions of antineoplastic agents, supportive car medications, and/or drugs to treat co-morbid conditions will be introduced in this session. The adverse drugs interaction should be minimized by considering the potential for interactions of all the drugs that cancer patients are receiving.

Pharmacological management of co-morbid conditions at the end of life: is less more?

Co-morbid conditions (CMCs) are present in over half of patients with cancer over 50 years of age. As life-limiting illnesses progress, the benefits and burdens of treatments for CMCs become unclear. Relevant issues include physiological changes in advanced illness, time-to-benefit of medications, burden of medications, and psychological impact of discontinuing medications. Optimal prescribing is unclear due to lack of evidence. The objectives are to determine prescribing practice, for CMCs, in a single SPC service. Patients referred to a single specialist palliative care (SPC) service, who died between 1/8/2010 and 30/9/2012, were identified. Medical notes were reviewed, and data collected on prescribing at 3 months, 1 month, and 1 week prior to death. Fifty-two patients with a median age of 74.5 years were identified; 41 patients (79%) had a malignant condition. 50% died in hospital. Patients had a mean of three CMCs. A mean of 4.6 medications for CMCs were prescribed to patients over 65. A mean of 10 medications in total were prescribed at 1 week before death. One week before death, one-third of patients continued to be prescribed aspirin, and over one-quarter a statin. Total medication burden increases as time to death shortens, due to continuation of medications for CMCs, and addition of medications for symptom control. There is a need for research to demonstrate the impact of polypharmacy at the end of life, in order to formulate a framework to guide practice.

Neurocognitive problems in epilepsy

SummaryCognitive dysfunction is one of the major contributors to the burden of epilepsy. It can significantly disrupt intellectual development in children and functional status and quality of life in adults. Epilepsy affects cognition through a number of mechanisms in complex interrelationship. Cognitive deficits in epilepsy may be treated indirectly through aggressive seizure control using anti-epileptic drugs or surgery, and by treating comorbid conditions such as depression. The beneficial effects of reducing seizures may offset the adverse cognitive side-effects of these therapies. Direct treatment of cognitive impairment in epilepsy mainly involves memory rehabilitation. Other direct treatments are mostly experimental and their evidence base is currently poor.

Achieving symptom control in patients with moderate asthma.

Disease severity in asthma can be classified as mild, moderate or severe based upon the frequency of symptoms or the severity of airflow obstruction. This review will focus on the treatment of youths greater than 12 years of age and adults with moderate persistent asthma. Moderate asthmatics may have daily symptoms that cause some limitation with normal daily activities and require use of a rescue inhaled short-acting beta2-agonist inhaler or experience nocturnal awakenings secondary to asthma that occur more than once per week. Furthermore, spirometry may reveal airflow obstruction with a reduction in FEV1 to between 60% and 80% of predicted. Although inhaled corticosteroids (ICS) are the primary controller medication used to modify symptoms in moderate asthmatics, additional controller medications, such as inhaled long-acting beta2-agonists (LABA), leukotriene receptor antagonists (LTRA) or theophylline, are often needed to obtain optimal disease control. While the addition of an inhaled LABA to an ICS is very effective at improving disease control in moderate asthma, concerns have arisen over the safety of LABAs, in particular the risk of asthma-related death. Therefore, consideration may be given to initially adding a LTRA, rather than a LABA, to ICS when asthma symptoms are not adequately controlled by ICS alone. Furthermore, individualization of medication regimens, treatment of co-morbid conditions, and patient education are crucial to optimizing compliance with therapy, improving disease control, and reducing the risk of exacerbations. Lastly, the development of new asthma treatments, perhaps based upon personalized medicine, may revolutionize the future treatment of moderate asthma.

The Impact of Frailty on Health Related Quality of Life in Heart Failure

Most heart failure (HF) hospital discharges involve people >65years, many frail. The purpose of this study was to determine if frailty explains variability in health related quality of life (HRQOL) in older adults with HF over and above known correlates. A frailty index score was developed by weighting age, number of comorbid conditions, and symptom severity. A multivariate hierarchical regression analysis of known predictors of HRQOLgender, income, ethnicity, health perception, NYHA class - were entered first and then the frailty index was entered and regressed on HRQOL in 2 unique samples. When known predictors were tested on a sample they explained 11% (p 0.14) of the variance in HRQOL; when the frailty index score was added 24% (p 0.001) was explained. When the index was validated in a second sample, known predictors explained 15% (p 0.04) of the variance; with the frailty index score 40% (p 0.000) was explained. Frailty explains significant amounts of variance in HRQOL in HF. Treating comorbid conditions and controlling symptoms may improve HRQOL in HF patients. These findings support the need for further research into the impact of frailty on HRQOL in HF patients.

Bipolar disorder: new perspectives in health care and prevention.

High rates of misdiagnosis, delayed diagnosis, and lack of recognition and treatment of comorbid conditions often lead patients with bipolar illness to have a chronic course with high disability, unemployment rates, and mortality. Despite the recognition that long-term outcome of bipolar disorder depends on systematic assessment of both interepisodic dysfunctional domains and comorbid psychiatric and medical conditions, treatment of bipolar disorder still focuses primarily on alleviation of acute symptoms and prevention of future recurrences. We propose here to review the evidence offering a modern view of bipolar disorder defined as a chronic and progressive multisystem disorder, taking into account characteristics of each patient as well as biosignatures in order to help design personalized treatments. We conducted a systematic PubMed search of all English-language articles, published between 2000 and 2010, focusing on the English and French literature with bipolar disorder cross-referenced with the following search terms: emotional dysregulation, sleep and circadian rhythm disturbances, cognitive impairment, age at onset, comorbid medical and psychiatric conditions, psychosocial and medical interventions, outcome, remission, and personalized medicine. The search was conducted between July 2009 and July 2010. The literature on bipolar disorder was reviewed to provide supporting evidence that the assessment of various symptom domains that are dysfunctional between episodes should all be considered as core dimensions of the disorder. Forty-one articles were identified through the PubMed search described above and selected on the basis of addressing any combination of the search terms in conjunction with bipolar disorder. Current guidelines advocate the use of more or less similar treatment algorithms for all patients, ignoring the clinical, pathophysiological, and lifetime heterogeneity of bipolar disorder. Systematic assessment of interepisodic dimensions, along with comorbid medical and psychiatric risk factors, should be performed along the life cycle in order to plan specific and personalized pharmacologic, medical, and psychosocial interventions tailored to the needs of each patient and ready-to-test biosignatures to serve as risk factors or diagnostic or prognostic tools. Medical and research findings, along with health economic data, support a more modern view of bipolar disorder as a chronic, progressive, multisystem disorder. This new comprehensive framework should guide the search to identify biomarkers and etiologic factors and should help design a new policy for health care, including prevention, diagnosis, treatment, and training.

Dasatinib (Versus Imatinib) In Patients (Pts) with Newly Diagnosed Chronic Myeloid Leukemia In Chronic Phase (CML-CP): Analysis of Safety and Efficacy by Use of Baseline Medications In the DASISION Trial

AbstractAbstract 2295 Background:During first-line BCR-ABL inhibitor therapy for CML-CP, concomitant medication use is associated with worse adherence to CML therapy, which may detrimentally affect efficacy (St Charles, ASH 2009; Marin, J Clin Oncol 2010). Medications may include adjuvants to anti-CML therapy or treatments for comorbid conditions. Depending on posology, the number of medications may affect BCR-ABL inhibitor efficacy and safety. Dasatinib is a BCR-ABL inhibitor 325-fold more potent than imatinib at inhibiting BCR-ABL in vitro and is taken once daily (QD) at any time of day with or without food. Medications that prolong QTc, or increase or decrease dasatinib levels (CYP3A4 substrates/inhibitors/inducers, PPIs and H2 antagonists) should be avoided. In the phase 3 DASISION trial, first-line dasatinib 100 mg QD had superior efficacy vs imatinib 400 mg QD in pts with newly diagnosed CML-CP, including significantly higher complete cytogenetic response (CCyR) and major molecular response (MMR) rates. Here, efficacy and safety of dasatinib (and imatinib) by number and type of baseline medications were analyzed. Methods:519 pts with newly diagnosed CML-CP were randomized to dasatinib 100 mg QD (n=259) or imatinib 400 mg QD (n=260) arms. Exclusion criteria included prior interferon or systemic anti-CML therapy (except anagrelide, hydroxyurea, or ≤28 days of imatinib), and baseline pleural effusion, cardiovascular disease, or bleeding disorder unrelated to CML. Efficacy and safety were assessed using rates of CCyR/MMR or drug-related adverse events (AE), respectively. Baseline medications were defined as any additional medication taken prior to initiating study therapy, as reported by individual investigators. Results:189/259 pts (73%) in the dasatinib arm and 194/260 pts (75%) in the imatinib arm were receiving ≥1 baseline medication (median 2, range 1–7). Medications taken by ≥5% of pts were prophylactic allopurinol therapy for tumor lysis syndrome (51%); alimentary tract or metabolism therapies, eg, antacids or PPIs (33%: omeprazole 6%, famotidine <1%); nervous system therapies, eg, NSAIDs or other analgesics (22%); cardiovascular therapies, eg, calcium channel blockers, loop diuretics, β blockers, and ACE inhibitors (21%); agents for blood or blood-forming organs, eg, folic acid or statins (15%); systemic antibiotics/antifungals/vaccines (7%); and respiratory system therapies, eg, antihistamines or inhaled steroids (7%). 12-month CCyR and MMR rates were unaffected by the number of baseline medications. Pts in the dasatinib arm receiving 0, 1–3, or ≥4 medications (27%, 56%, and 17%, respectively) had CCyR rates of 79%, 85%, and 87% and MMR rates of 43%, 49%, and 42%, respectively. Pts in the imatinib arm receiving 0, 1–3, or ≥4 medications had CCyR rates of 76%, 70%, and 71% and MMR rates of 35%, 26%, and 23%, respectively. In pts receiving baseline medications, safety was similar irrespective of the number received. Respective grade 3/4 thrombocytopenia rates for pts receiving 0, 1–3, or ≥4 medications were 28%, 17%, and 13% in the dasatinib arm and 9%, 9%, and 17% in the imatinib arm; grade 3/4 neutropenia rates were 29%, 13%, and 31% in the dasatinib arm and 31%, 18%, and 11% in the imatinib arm. Nonhematologic AEs of any grade occurring in ≥10% of pts receiving dasatinib and 0, 1–3, or ≥4 medications, respectively, were diarrhea in 17% vs 19% vs 13% (13% vs 19% vs 17% with imatinib), nausea/vomiting in 12% vs 9% vs 18% (25% vs 23% vs 23% with imatinib), arthralgia/myalgia in 12% vs 10% vs 11% (28% vs 13% vs 14% with imatinib), rash in 6% vs 12% vs 18% (19% vs 16% vs 20% with imatinib), fluid retention in 9% vs 23% vs 24% (41% vs 44% vs 37% with imatinib), pleural effusion in 1% vs 13% vs 13% (0% with imatinib) and superficial edema in 7% vs 8% vs 16% (25% vs 41% vs 31% with imatinib). Efficacy and safety patterns were generally comparable in pts receiving various baseline medication categories. Additional analyses of on-study medication characteristics and effects on efficacy or safety will be presented. Conclusions:Although occurrence of pleural effusion and fluid retention appeared higher in patients receiving ≥1 medication with dasatinib, overall, the number of medications administered at baseline in the DASISION trial did not appear to affect efficacy or safety of dasatinib (or imatinib) in pts with newly diagnosed CML-CP. Disclosures:Guilhot: Bristol-Myers Squibb: Honoraria, Research Funding; Novartis: Honoraria, Research Funding. Off Label Use: This abstract discusses the use of first-line dasatininb in CML-CP. Kantarjian: Bristol-Myers Squibb: Research Funding; Novartis: Consultancy, Research Funding; Wyeth: Research Funding. Shah: Bristol-Myers Squibb: Consultancy; Novartis: Consultancy; Ariad: Consultancy. Hochhaus: Bristol-Myers Squibb: Consultancy, Research Funding; Novartis: Consultancy, Research Funding. Bradley-Garelik: Bristol-Myers Squibb: Employment. Dejardin: Bristol-Myers Squibb: Employment, Equity Ownership. Cortes: Bristol-Myers Squibb: Research Funding.

Systematische Literaturanalyse zur rehabilitativen Behandlung von Kindern und Jugendlichen mit Asthma bronchiale

Relevant data bases were used to collect and evaluate guidelines, meta-analyses, and reviews as well as primary studies dealing with asthma therapy for children and adolescents. Treatment approaches whose effectiveness with regard to bronchial asthma was empirically verified (i. e., evidence-based) were identified (medical and diagnostic procedures as well as drug trials were excluded from the analysis). 152 methodically sound studies referring to asthma treatment of children and adolescents were selected. Strong evidence was found for patient education, parent education, exercise therapy, inhalation, and tobacco withdrawal. Nutritional counseling and avoidance of allergens showed limited evidence. Psychotherapy, relaxation techniques, breathing exercises, climate therapy, clinical social work (social and legal counseling services, vocational reintegration counseling, aftercare) and integration counseling showed inconsistent evidence. No evidence was found for alternative medicine. Challenges regarding the development of treatment standards for children and adolescent rehabilitation are highlighted; these refer to limitations in report quality in some of the studies, the validity of treatments for comorbid conditions, a lack of differentiation for different age groups, and transferability of outpatient or international study results to inpatient rehabilitation.

Treatment of Pulmonary Exacerbations in Adult Cystic Fibrosis Patients: A Review

Cystic fibrosis (CF) is a complex multisystemic disease requiring specialized care. It is characterized by progressive pulmonary decline, with intermittent worsening of lung function, often called pulmonary exacerbations. Eighty-five percent of all deaths from CF are a result of pulmonary disease, and pulmonary exacerbations are associated with decline in lung function. Treating pulmonary exacerbations requires a multifaceted approach and includes a multidisciplinary team composed of a physician, nurse, respiratory therapist, physical therapist, and nutritionist. Recently, the Cystic Fibrosis Foundation published guidelines addressing the comprehensive treatment of pulmonary exacerbations. This article outlines the treatment goals established by these guidelines, including the evaluation and treatment of comorbid conditions (eg, CF-related diabetes) and serious complications associated with CF exacerbations (eg, pneumothorax). Proper treatment of pulmonary exacerbations in CF patients will continue to improve their health and quality of life.

Long-term maintenance of pediatric asthma: focus on budesonide/formoterol inhalation aerosol.

Current national and international asthma guidelines recommend treatment of children with asthma towards achieving and maintaining asthma control. These guidelines provide more stringent recommendations to increase therapy for patients with uncontrolled asthma in order to reduce asthma-related morbidity and mortality. Newer combination agents such as budesonide and formoterol have been shown to be safe and effective in treatment of asthma in children. Use of long-term controller agents like this in combination with improved compliance and treatment of co-morbid conditions have been successful in this endeavor. This review discusses control of pediatric asthma with focus on the use of budesonide in combination with formoterol.

Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival

osteoporosis is a common disease, and the incidence of osteoporotic fractures is expected to rise with the growing elderly population. Immediately following, and probably several years after a hip fracture, patients, both men and women, have a higher risk of dying compared to the general population regardless of age. The aim of this study was to assess excess mortality following hip fracture and, if possible, identify reasons for the difference between mortality for the two genders. this is a nationwide register-based cohort study presenting data from the National Hospital Discharge Register on mortality, comorbidity and medication for all Danish patients (more than 41,000 persons) experiencing a hip fracture between 1 January 1999 and 31 December 2002. Follow-up period was until 31 December 2005. we found a substantially higher mortality among male hip fracture patients than female hip fracture patients despite men being 4 years younger at the time of fracture. Both male and female hip fracture patients were found to have an excess mortality rate compared to the general population. The cumulative mortality at 12 months among hip fracture patients compared to the general population was 37.1% (9.9%) in men and 26.4% (9.3%) in women. In the first year, the risk of death significantly increased for women with increasing age (hazard ratio, HR: 1.06, 95% confidence interval, CI: 1.06-1.07), the number of comedications (HR 1.04, 95% CI 1.03-1.05) and the presence of specific Charlson index components and medications described below. For men, age (HR 1.07, 95% CI 1.07-1.08), number of comedications (HR 1.06, 95% CI 1.04-1.07) and presence of different specific Charlson index components and medications increased the risk. Long-term survival analyses revealed that excess mortality for men compared with women remained strongly significant (HR 1.70, 95% CI 1.65-1.75, P < 0.001), even when controlled for age, fracture site, the number of medications, exposure to drug classes A, C, D, G, J, M, N, P, S and for chronic comorbidities. excess mortality among male patients cannot be explained by controlling for known comorbidity and medications. Besides gender, we found higher age and multimorbidity to be related to an increased risk of dying within the first year after fracture; acute complications might be one of the explanations. This study emphasises the need for particular rigorous postoperative diagnostic evaluation and treatment of comorbid conditions in the male hip fracture patient.

Managing Outpatient Asthma Exacerbations

Asthma is a chronic inflammatory disease that renders individuals vulnerable to acute exacerbations. A wide variety of allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, avoidance of relapses, and prevention of future episodes. A written asthma home management plan is essential to minimize the severity of exacerbations. Short-acting beta-agonists, oxygen, and corticosteroids remain fundamental to early intervention in acute asthma exacerbations. Anticholinergics and magnesium sulfate can help nonresponders. Combination inhalers of the long-acting beta-agonist formoterol and inhaled steroid budesonide have been effective in flexible dosing in treating early acute exacerbations and as a daily controller medication outside the United States. Initiation or intensification of long-term controller therapy, treatment of comorbid conditions, trigger avoidance, and prompt follow-up can help prevent relapses. Listening to patient preferences and concerns enhances adherence, and regular follow-up care can help prevent future episodes.

Parkinson disease and comorbid cerebrovascular disease

Optimal management of chronic diseases not only requires tackling of the primary disease processes, but also necessitates timely recognition and treatment of comorbid conditions. In this article, we illustrate this two-pronged approach for two common age-related disorders: Parkinson disease (PD) and cerebrovascular disease (CVD). We first discuss the pathophysiological mechanisms that could provide a link between PD and CVD. Patients with PD have a series of risk factors that could promote development of CVD, but also have several protective factors. We then review the available clinical, radiological and neuropathological evidence to support an association between these two conditions. We conclude by discussing the potential implications for clinical practice, highlighting how comorbid CVD could alter the clinical presentation of PD and reviewing the possibilities for prevention and secondary prophylaxis. Additional research will be needed to fully evaluate the prevalence and clinical relevance of comorbid CVD in PD. Pending further evidence, we recommend that cerebral neuroimaging should be considered if patients with initially uncomplicated PD develop-either acutely or chronically-prominent and/or treatment-resistant gait impairment, postural instability, depression, cognitive decline, or urinary incontinence. Finding comorbid CVD in such patients could have prognostic implications, and could necessitate treatment to arrest further progression of CVD.

Getting to the Meat of the Matter: Beyond Protein Supplementation in Maintenance Dialysis

Until recently, patients on dialysis with low serum albumin levels were characterized as suffering from protein malnutrition suggesting that the cause of this malady was due to an inadequate intake of protein. In fact, these patients tend to suffer from a wasting syndrome similar to cachexia commonly associated with inflammation in which there is loss of lean body mass and fat mass is underutilized. The term protein energy wasting has been used to characterize this syndrome and suggests that the simple addition of protein supplements to the dietary regimen of hemodialysis patients will not cure this malady. Correction of the underlying inflammatory disorder which drives losses of body protein and fuel reserves is far more important and is the single most effective therapy. Protein supplements which may promote albumin synthesis and synthesis of liver-related proteins tend to increase muscle catabolism. Muscle growth is not fostered by increasing dietary protein above recommended goals for dialysis patients, but can be promoted by the addition of protein of high biological value that is rich in leucine and other essential amino acids in tandem with repetitive exercises. Ultimately, correction of PEW hinges on the diagnosis and treatment of co-morbid conditions in combination with strategies to replenish caloric and protein stores. A supplementary exercise program would allow recovery of lean body mass. Given the multiple co-morbidities that exist in this population, therapy would have to be individualized.

Psychiatric and General Medical Conditions Comorbid With Schizophrenia in the National Hospital Discharge Survey

Morbidity and mortality from general medical conditions are elevated among patients with schizophrenia compared with the general U.S. population. More than 50% of patients with schizophrenia have one or more comorbid psychiatric or general medical conditions. This study determined types of comorbid disorders and their prevalence among hospitalized patients with and without schizophrenia. Data from the National Hospital Discharge Survey, a nationally representative sample, were analyzed for 1979-2003 (N=5,733,781 discharges). For discharges of patients aged 15 to 64 with at least one comorbid condition, the conditions of those with a primary diagnosis of schizophrenia (N=26,279) were compared with those with other primary diagnoses (N=1,936,876). Proportional morbidity ratios (PMRs) were calculated. The proportion of discharges listing schizophrenia, particularly schizoaffective disorder, increased significantly over time among both males and females. The proportion was higher among males, blacks, and discharges in the Northeast. Discharge records with a primary diagnosis of schizophrenia showed higher proportions of all comorbid psychiatric conditions examined and of some general medical conditions, including acquired hypothyroidism (PMR=2.9), contact dermatitis and other eczema (PMR=2.9), obesity (PMR=2.0), epilepsy (PMR=2.0), viral hepatitis (PMR=1.4), diabetes type II (PMR=1.2), essential hypertension (PMR=1.2), and various chronic obstructive pulmonary diseases (PMR range 1.2-1.5). Knowledge of the risks of comorbid psychiatric and general medical conditions is critical both for clinicians and for patients with schizophrenia. Closer attention to prevention, early diagnosis, and treatment of comorbid conditions may decrease associated morbidity and mortality and improve prognosis among patients with schizophrenia.

The burden and extent of comorbid conditions in patients with erectile dysfunction

Erectile dysfunction (ED) is a common sexual problem in men. Under-reporting of ED is widespread, largely because of the embarrassing nature of the condition. This paper reviews the comorbid conditions that are commonly found in patients with ED patients and discusses the implications. Erectile dysfunction is often associated with other disorders such as diabetes, cardiovascular disease, hypertension, dyslipidaemia, obesity, depression, chronic obstructive pulmonary disease and lower urinary tract symptoms. Although the aetiology of ED is multifactorial, some of the associated comorbid conditions, including diabetes, cardiovascular disease and hypertension, can be a primary cause of ED. Similarly, ED could be a useful marker for comorbid conditions such as cardiovascular disease and diabetes. Effective treatments for ED are available, including the three phosphodiesterase type 5 inhibitors sildenafil citrate, tadalafil and vardenafil HCl. Thorough medical screening of patients with ED is advisable, as this could lead to earlier diagnosis and treatment of comorbid conditions. Conversely, men with conditions such as cardiovascular disease, diabetes, obesity and depression may have undiagnosed ED and should be questioned appropriately to ascertain any erectile problems and initiate appropriate treatment.

Implications of recent epidemiology studies for the clinical management of lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) include storage, voiding, and postmicturition symptoms, and occur commonly in both men and women. Findings from two recent epidemiological studies, the Epidemiology of LUTS study and the Boston Area Community Health survey, further extend the understanding of the prevalence of individual LUTS, the overlap of LUTS in men and women, the associations of LUTS with other comorbid conditions, the impact of LUTS on health-related quality of life (HRQL), and the relationships between frequency and bother of LUTS and treatment-seeking behaviour. Examining the clinical implications of these findings might provide directions to physicians for managing their patients with LUTS. For example, common findings of separate patient groups spanning a spectrum from those with typically one urinary symptom of mild to moderate severity to those with multiple more severe LUTS and frequent comorbidities might further encourage the diagnosis and treatment of comorbid conditions as a standard part of the management of patients with LUTS. Likewise, understanding that the impact of LUTS on HRQL and the degree of bother, rather than the frequency of LUTS, are significant drivers for treatment seeking might aid in assisting patients to make decisions about treatment.

Healthcare costs associated with treatment of bipolar disorder using a mood stabilizer plus adjunctive aripiprazole, quetiapine, risperidone, olanzapine or ziprasidone

Objective: Bipolar disorder has an associated economic burden due to its treatment, including medication and hospitalization costs as well as costs associated with treatment of comorbid conditions. This study compared healthcare costs in patients treated with a mood stabilizer and adjunctive aripiprazole versus adjunctive olanzapine, quetiapine, risperidone or ziprasidone.Research design and methods: A retrospective propensity score-matched cohort study was conducted in the LabRx integrated claims database from January 2003 to December 2006. Patients (18–65 years) with bipolar disorder and 180 days of pre-index enrolment without atypical treatment and 90 days post-index enrolment were eligible. Mood stabilizer therapy was initiated prior to index atypical prescription. Generalized gamma regressions were used to compare the total healthcare costs of adjunctive aripiprazole treatment and treatment with adjunctive olanzapine, quetiapine, risperidone or ziprasidone.Results: After controlling for differences in baseline characteristics and pre-index cost, psychiatric costs and subtotal psychiatric and general medical costs were higher for all adjunctive atypicals than adjunctive aripiprazole (p<0.001). Based on gamma regressions cost ratios, there was no significant difference in general medical costs between aripiprazole and ziprasidone, olanzapine, or quetiapine; risperidone general medical costs were 18% higher versus aripiprazole (p=0.041). Aripiprazole pharmacy costs were higher than quetiapine and risperidone (p<0.001) but not olanzapine or ziprasidone. Total healthcare costs were higher for ziprasidone, olanzapine, or risperidone (p<0.001) but not quetiapine.Limitations: Methodological restriction of patients to those newly initiated on an atypical antipsychotic and incomplete medication history limit the generalizability of the findings.Conclusion: Adjunctive aripiprazole may have economic benefits over other atypicals in terms of lower psychiatric treatment costs than adjunctive olanzapine, quetiapine, risperidone or ziprasidone, and lower total healthcare costs than adjunctive olanzapine, risperidone or ziprasidone.

Comorbidity, health screening, and quality of life among persons with a history of epilepsy

Previous population surveys outside the United States have found an increased prevalence of comorbid conditions in persons with epilepsy. However, the effect of comorbid conditions on health-related quality of life (HRQOL) has not been previously examined in the epilepsy literature from the United States. Results from the California Health Interview Survey (CHIS) indicate an increased prevalence of comorbid conditions in persons with a history of epilepsy compared to those without epilepsy. After controlling for demographics and comorbid conditions, persons with a history of epilepsy were significantly more likely to report poor HRQOL. Although seizure freedom should continue to be a primary clinical goal, optimal care should also include primary and secondary prevention of comorbid conditions, especially cardiovascular and pulmonary diseases. Prevention, early identification, and treatment of comorbid conditions may reduce mortality risk and improve health outcomes in persons with epilepsy.

Importance of allergic rhinitis management in achieving asthma control: ARIA update

Asthma continues to be a major burden for the health and healthcare of people worldwide. The recent updates of the Global Initiative for Asthma and the National Heart, Lung and Blood Institute asthma guidelines stress the need for achieving and monitoring asthma ‘control’, emphasizing the importance of identifying, assessing and treating comorbid conditions. Allergic rhinitis (AR) is a major comorbid condition in people with asthma and is related to inflammation of the upper portions of the airway. Recognizing and treating AR has been shown to improve asthma control, specifically by decreasing rates of asthma attacks or asthma exacerbations. In 2008, updated Allergic Rhinitis in Asthma (ARIA) guidelines were published. The updated version of the guidelines has a familiar look, with classification systems and care algorithms that are similar to those presented in other asthma guidelines. The new ARIA guidelines make one major change that should affect the care of adults and children with asthma: everyone with asthma should be assessed for AR. In addition, AR should be considered a risk factor for asthma, and all children and adults with AR, especially persistent AR, should be assessed for asthma, including testing lung function for reversible obstruction whenever feasible. Treatment for AR follows a similar format to that for asthma, including symptom management, treatment of chronic inflammation, identification and management of triggers, including allergens, and ongoing education for self-management. Pharmacotherapies that address both asthma and AR include corticosteroids (intranasal and inhaled), leukotriene receptor antagonists, immunomodulation or immunotherapy. Too often, pharmacotherapy is not supplemented by the necessary education and evaluation related to allergen, trigger identification and management.