摘要:

Despite two recent negative trials, most controlled clinical studies have found that when naltrexone is added to substance abuse treatment or counselling, significantly less heavy drinking is done by the patients who are willing to take most of the prescribed naltrexone. Naltrexone also reduces urges to drink and makes any slips back into drinking less pleasant. Therefore, naltrexone can be a useful adjunct to substance abuse counselling or rehabilitation programmes, as one of many tools that clinicians and patients use. However, beneficial effects are limited in scope. Naltrexone mostly does not increase the chance of staying completely abstinent but rather reduces the intensity or frequency of any drinking that does occur. Many alcohol-dependent individuals are medically ineligible or are unwilling to take naltrexone, many who start naltrexone do not continue with it and many who comply with it do not benefit. Compliance is greater for individuals who experience fewer adverse effects and who have stronger beliefs in the benefits of naltrexone, suggesting that clinicians can increase compliance by helping patients to manage adverse effects and by bolstering patients’ beliefs in the benefits of naltrexone. Alcohol-dependent individuals who are most likely to benefit from naltrexone seem to be those with close relatives who also had alcohol problems, or who have stronger urges to drink or who are more limited in cognitive abilities. Some individuals may benefit from a higher dose, particularly people with lower blood concentrations of the medication, and individuals who achieve good results may benefit from a longer course of treatment with naltrexone. In these ways, treatment can be targeted to increase the likelihood of beneficial outcomes with naltrexone.

ISSN:1172-7047    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Multiple sclerosis (MS) is one of the most common causes of neurological disability in young and middle-aged adults. The full economic cost of MS is substantial given that MS patients experience a major perturbation in their daily activities and the disease affects mainly young people who are obliged to restrict their levels of economic activity, either temporarily or permanently. A positive relationship exists between the direct and indirect costs of MS and its severity. Cost variations between countries exist because of differences in the costs of inpatient care, the number of ambulatory visits, drug usage and the extent and type of informal care.The development and availability of new agents has been accompanied by an increased optimism that treatment regimens for MS would be more effective. However, doubts have been expressed about the effectiveness of these treatments, which have compounded the problems associated with estimating the relative cost effectiveness of such interventions.In addition, variations in the utility scores associated with disease categories, the impact of relapses and the resulting utility losses, plus the speed of disease progression have all contributed to the difficulty of estimating the quality-adjusted life year (QALY) losses for a patient experiencing MS. Differences between studies with respect to the costs associated with each disability level, the timescale of the disease and the period over which costs and QALYs are to be measured, and the perspective employed in relation to costing have also resulted in a wide range of estimates being produced for the cost effectiveness of interferons and glatiramer acetate in the management of MS. These range from situations of cost savings, to over $US1.6 million (euro1.85 million) per QALY gained. Recent cost-effectiveness studies have benefited from more relevant and up-to-date data relating to disease progression and have generally produced more favourable cost-effectiveness ratios. However, the lack of homogeneity in the design of the studies partly accounts for the extent of variation in the estimates of cost effectiveness, and the difficulty of arriving at a consensus.The UK Department of Health has introduced a scheme that provides disease-modifying agents in the National Health Service for those patients with clinically active relapsing disease. Patients are monitored annually and payments to manufacturers are dependent on outcomes achieved. This initiative, although not without its detractors, will hopefully enhance the quantity and quality of evidence on the impact of drugs on disease progression and address some of the current difficulties with estimating the relative cost effectiveness of disease-modifying drugs in the treatment of patients with MS.

ISSN:1172-7047    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

By some estimates moderate-to-severe Alzheimer’s disease accounts for 50% of all patients with Alzheimer’s disease.However, there are numerous issues that remain to be resolved in the management of patients with more advanced Alzheimer’s disease. The first prospective, randomised, controlled trial of the cholinesterase inhibitor donepezil in more advanced Alzheimer’s disease has reported quite encouraging results, with further studies being undertaken.Post-hocanalyses of rivastigmine and galantamine in patients with more advanced Alzheimer’s disease have supported the hypothesis that acetylcholinesterase inhibitors are likely be efficacious in this subgroup. Memantine, a glutamate NMDA receptor antagonist, is newly licensed in Europe for the treatment of more advanced Alzheimer’s disease and will provide the first non-cholinesterase inhibitor option for the treatment of Alzheimer’s disease. The combination of donepezil and memantine has been shown to have superior efficacy than donepezil alone in this severe Alzheimer’s disease subgroup, potentially supporting a role for dual treatment in more advanced Alzheimer’s disease.Further studies of all aspects of more advanced Alzheimer’s disease are clearly needed. The problems of translating clinical trial results to routine clinical practice are even more complex and challenging in this patient group, with the true impact of any one given treatment ranging over a spectrum of clinical domains from improved cognition to reduced caregiver burden. Increased attentiveness by clinicians to treatment response across this multidisciplinary spectrum in more advanced Alzheimer’s disease is warranted.

ISSN:1172-7047    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Bipolar patients with comorbid substance abuse or dependence (‘dual diagnosis’ patients) represent a major public health problem. Substance abuse generally predicts poor outcome and higher morbidity/mortality in bipolar disorder. For the purposes of this review, open and controlled studies of dual diagnosis assessment and treatment were located through electronic searches of several databases. Pertinent case reports were also evaluated. The results of the search were evaluated in light of the authors’ own research on dual diagnosis patients.Literature searching revealed few controlled studies to guide pharmacotherapy of bipolar patients with comorbid substance abuse or dependence. However, preliminary evidence suggests that the best outcomes are usually achieved with antiepileptic mood stabilisers and/or atypical antipsychotics, combined with appropriate psychosocial interventions. The latter may include classical 12-step groups, integrated group therapy or individual psychotherapy. While it is often difficult to determine the precise pathway to comorbid bipolar disorder/substance abuse, it is clear that both disorders must be vigorously treated. This requires a carefully integrated biopsychosocial approach, involving appropriate mood stabilisers and psychosocial interventions. Many more controlled studies of these combined treatment approaches are needed.

ISSN:1172-7047    

出版商:ADIS    

年代:2004

数据来源: ADIS

摘要:

Based on information from clinical trials, both the efficacy and adverse effects of conventional antipsychotics in the treatment of schizophrenia are dose related. The overlapping nature of these dose-response profiles limits the use of these agents. Atypical antipsychotics provide greater relief across the comorbid symptom domains of schizophrenia, but dose-response studies and clinical experience have revealed that some of these drugs also have dose limitations. This article reviews the dose-response relationships of the atypical antipsychotics as presented predominantly in pivotal, randomised studies (double-blind and otherwise).Limited data indicate that clozapine shows dose-related efficacy up to 600 mg/day in patients with treatment-resistant schizophrenia. However, higher dosages of clozapine may be associated with the risk of seizures. Risperidone demonstrates dose-related adverse events that compromise efficacy. The dose-response relationships for ziprasidone, quetiapine and aripiprazole are less well established. The efficacy of olanzapine appears to be dose related within the recommended dosage range of 10–20 mg/day, but clinical trials that have explored higher dosages suggest improved efficacy. Furthermore, the higher doses are not associated with a significantly increased incidence of adverse events.Further studies are clearly needed to fully characterise the dose-response relationships of atypical antipsychotics.

ISSN:1172-7047    

出版商:ADIS    

年代:2004

数据来源: ADIS