摘要:

Many different drugs are used for sedation of patients in the intensive care unit (ICU). The vast majority of the agents used are administered intravenously; however, for the purposes of sedation, inhalational anaesthetic agents have some advantages, and potential disadvantages, over intravenous drugs. There has been some published work on the use of isoflurane as a sedative agent in this situation, with favourable comparisons with the currently used intravenous drugs. Ultimately, the role of inhalational agents as sedatives in the ICU will depend on the development of appropriate equipment and the enthusiasm of the clinicians involved.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Breakthrough pain is the relatively new term applied to describe acute episodes of severe pain superimposed upon a background of otherwise well controlled chronic pain. Surveys of patients with cancer who have pain suggest that breakthrough pain is very common, affecting the majority of patients several times a day on average. The cause of breakthrough pain is tumour related in most cases, and is fairly evenly distributed among somatic, visceral, neuropathic and mixed aetiologies. Not unexpectedly, the incidence and prevalence of breakthrough pain increase with advancing disease. About half of all breakthrough pain episodes are attributable to a specific inciting event or activity, and so these types of pains have been categorised as incident pain. Another subcategory of breakthrough pain is end-of-dose failure, caused by pain that ‘breaks through’ around-the-clock medication because of declining blood concentrations of analgesic near the end of the administration interval. The remainder of breakthrough pain episodes, classified as spontaneous pain, are unpredictable in occurrence.The treatment of breakthrough pain needs to be preventative and active. Immediate release opioid analgesics are the mainstay of therapy in most cases. Few techniques and interventions have consistently been shown to ameliorate breakthrough pain, with the exception of oral transmucosal fentanyl citrate. This novel formulation of the potent opioid fentanyl is a hard candied matrix on a handle that is dissolved in the patient's mouth yielding a rapid onset of symptom relief. Although safety and efficacy have been well demonstrated in controlled clinical trials, this product has not been available for prescription long enough to determine its overall impact on this very common distressing symptom which is experienced by most cancer patients.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

This review discusses the potential role of sildenafil in managing antidepressant-induced sexual dysfunction, with a focus on that associated with selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs). To provide a context, the epidemiology, assessment, prevalence with comparative agents and management strategies for SSRI/antidepressant-induced sexual dysfunction are reviewed.Sexual dysfunction is a frequent adverse effect of many therapeutic agents; it is prominently associated with SSRIs, and may be an important factor contributing to discontinuation of and noncompliance with antidepressants. However, a significant number of patients spontaneously develop tolerance to this reversible adverse effect over time.Sildenafil is an important addition to the therapeutic armamentarium for treating erectile dysfunction in men. Preliminary data suggest that it also has potential for treating antidepressant-induced sexual dysfunction in men and women, particularly in patients who do not have sexual dysfunction prior to becoming ill. The effective management of SSRI treatment emergent sexual dysfunction can have an important impact on improving the effectiveness and clinical outcomes of treatment by reducing switching and premature discontinuation of medication, and reducing the related morbidity/mortality of major depression and other disorders for which these drugs are prescribed.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Individuals with epilepsy have a mortality rate 2 to 3 times that of the general population, attributable both to any underlying disease that may be causing epilepsy and to the epilepsy itself. The commonest category of seizure-related death is sudden unexpected death in epilepsy (SUDEP).The epidemiology of SUDEP has been extensively studied and a number of such studies have taken anticonvulsant drug usage as an indicator of epilepsy, although obviously this may lead to inaccuracies. Epidemiological work has also yielded information about possible risk factors for SUDEP. At present there is no evidence that any particular anticonvulsant influences this risk, although there are anecdotal reports of sinus arrest and arrhythmias occurring in individuals receiving carbamazepine. A recent case-control study found that the risk of SUDEP increased with increasing number of concomitant anticonvulsants. In many cases of SUDEP, subtherapeutic anticonvulsant concentrations have been found at postmortem which may reflect noncompliance with medication, although the relationship between ante- and postmortem drug concentrations is unclear.The mechanism of SUDEP is unknown, although a possible role for anticonvulsants in its aetiology must be considered. Some anticonvulsants, by blocking sodium channels, have a direct effect on cardiac conduction, but studies examining the association between anticonvulsants and cardiac arrhythmia are lacking.As there is evidence to suggest an association between seizures and sudden death, the judicious use of anticonvulsants in optimising seizure control may be important in the prevention of these deaths.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Parkinson’s disease is primarily characterised by degeneration of the nigrostriatal dopaminergic pathways in the basal ganglia. However, non-dopaminergic neurotransmission is also affected in Parkinson’s disease. The dysfunction of non-dopaminergic systems explains the principal non-dopaminergic symptoms, such as ‘axial’ signs and cognitive impairment.The non-dopaminergic neurotransmitters affected in Parkinson’s disease are noradrenaline (norepinephrine), serotonin (5-hydroxytryptamine; 5-HT), glutamate, γ-aminobutyric acid (GABA), acetylcholine and neuropeptides. Dysfunction of these systems can lead to some of the motor symptoms of the disease and may provide targets for pharmacological interventions to treat these symptoms. For example, antagonists of certain glutamate receptors have been found to improve parkinsonian symptoms when given in associated with levodopa, although adverse effects may limit their use.The dysfunction of non-dopaminergic neurotransmitter systems in Parkinson’s disease is also important because it can lead to non-motor symptoms that are not responsive to dopaminergic therapy and can be a major cause of disability during disease evolution. Dysautonomia is not infrequent in individuals with Parkinson’s disease and is characterised by constipation, urinary disorders and orthostatic hypotension, the latter resulting from deficits in adrenergic and noradrenergic neurotransmission. Postural instability is caused by abnormalities in both dopaminergic and non-dopaminergic pathways. Depression is partially a result of dopaminergic denervation, but also of a decrease of serotonergic transmission. Cognitive impairment with frontal lobe−like symptomatology is a result of the dopaminergic deficit but also, at least in part, a cholinergic and noradrenergic deficit.Long term use of levodopa can be associated with complications such as dyskinesias. Although these are treated initially with other dopaminergic treatments, including changes in the levodopa administration schedule and dopamine receptor agonists, there have been attempts to treat dyskinesias with non-dopaminergic drugs. Agents such as glutamate antagonists and opioid antagonists have been found to be useful.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Depression is a common and serious mental illness which is treated mainly in primary care settings. The most common treatment modality is antidepressant medication. Controlled clinical trials have found antidepressants to be effective in the treatment of the acute symptoms of depression and in the prevention of relapse and recurrence of the disorder.To be effective, antidepressants need to be taken in sufficient doses for adequate periods of time. Many attempts have been made to ensure that the treatments available for depression are applied effectively in clinical practice, mainly through the development and promulgation of consensus guidelines. The various guidelines are consistent in recommending that antidepressants be administered at adequate doses both during the acute phase of treatment and for 4 to 6 months after a response is achieved.However, optimal use of antidepressants appears to be the exception rather than the rule. Patients who are treated with older tricyclic antidepressants (TCAs) rarely receive doses which have clear evidence of efficacy. Patients taking TCAs or newer antidepressants such as the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) commonly stop treatment prematurely. As few as 1 patient in 17 on TCAs, and 1 in 3 on SSRIs, continues treatment at an effective dose for the minimum recommended period of 4 consecutive months.The patterns of treatment with antidepressants are completely incongruous with the magnitude of burden and risk associated with major depression. This is reflected in evidence of poor outcomes in both the short and longer terms. Failure to treat depression at an early stage contributes to the development of chronic depressive illness. Inadequate doses of antidepressants result in a failure to respond and premature discontinuation increases the risk of relapse; both these patterns of treatment seem to contribute to the development of recurrent depressive episodes.Despite these findings, suboptimal use of antidepressants in the treatment of depression appears to be universal. It seems that clinicians require clear guidance regarding the crucial importance of recognising depression and initiating effective treatment without delay. They also need information that they regard as credible regarding the vital necessity for patients to receive an effective antidepressant dose for an adequate period of time. There is compelling evidence that this is less likely to be achieved with a TCA than with an SSRI. Given the morbidity and burden caused by depression, centrally coordinated naturalistic studies to investigate the outcomes of suboptimal antidepressant use should be a key priority for government research initiatives.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS