摘要:

Atypical antipsychotics offer significant improvements over older, conventional antipsychotic agents. However, recently the newer agents have been linked to medical morbidity including hyperglycaemia, diabetes mellitus, bodyweight gain and abnormal lipid levels. Even more concerning, because of a significant risk of death, there have been numerous case reports of patients treated with clozapine or olanzapine developing diabetic ketoacidosis shortly after initiation of the drug.Much of the information concerning the medical morbidity of diabetes mellitus is based on case reports, retrospective chart reviews, naturalistic studies and cross-sectional studies. While definitive studies have yet to be reported, mounting evidence suggests that the atypical antipsychotic agents, particularly clozapine and olanzapine, may significantly impair glucose metabolism and increase the risk of diabetes in patients with schizophrenia. Diabetic ketoacidosis, although it appears to be uncommon, is of great concern secondary to the risk of death.Patients treated with atypical antipsychotic agents should be routinely screened for diabetes and other metabolic abnormalities including raised lipid levels. Patients with risk factors for diabetes should be monitored more closely. Reports and clinical experience suggest that in a case of atypical antipsychotic−associated diabetes or diabetic ketoacidosis, discontinuation of the antipsychotic agent may result in complete resolution of the hyperglycaemia and diabetes.

ISSN:1172-7047    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Seizures are a relatively common occurrence in patients with HIV infection. They may be a result of HIV infection of the CNS or a manifestation of an opportunistic infection. Because seizures are likely to recur in patients infected with HIV and because they are a poor prognostic indicator, it is generally recommended that all HIV-seropositive patients experiencing a first seizure without a recognisable and reversible cause be treated. Clinicians faced with treating seizures in HIV-seropositive patients often encounter a therapeutic dilemma since few data exist in this area. In selecting appropriate anticonvulsant therapy, clinicians must consider both therapy-compromising drug-drug and drug-disease interactions. Ideal anticonvulsants for this setting are those that do not effect viral replication, have limited protein binding and have no effects on the cytochrome P450 system, such as gabapentin, topiramate and tiagabine. Unless the benefits outweigh the risks, valproic acid (sodium valproate) should be avoided as it has been shown to stimulate HIV replication. Since few data exist, controlled trials examining pharmacokinetic and pharmacodynamic interactions between anticonvulsants and antiretrovirals are needed. Until such time, clinicians caring for these patients should examine existing data carefully and employ vigilant monitoring.

ISSN:1172-7047    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern.In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate.Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists’ clinical services.Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention.More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.

ISSN:1172-7047    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Over several decades, a large body of evidence has emerged to suggest that depressive disorder is a risk factor for heart diseases, both aetiologically and prognostically. Several large, prospective, longitudinal studies have examined the relationship between depression and the development of coronary artery disease (CAD); they reveal that the relationship is significant and independent of conventional risk factors. Prognostic studies have shown that depression is associated with two to three times higher mortality after myocardial infarction, unstable angina or coronary artery bypass grafting, and in patients with stable CAD compared with such patients without depression. Depression also has been found to increase mortality and morbidity in patients with heart failure, regardless of its aetiology. Such adverse associations persist after adjustment for conventional prognostic risk factors.Despite all of these findings, depressed patients with heart disease are less likely to be recognised clinically as being depressed than those patients who have depression but no heart disease. The very limited evidence available from pharmacological clinical trials raises concern about the safety of antidepressants in CAD and heart failure. In addition, no research has addressed whether the treatment of depression in patients with heart disease will improve their prognosis.

ISSN:1172-7047    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

ObjectiveTo use a single national data source to discern trends in the prevalence of office-based visits resulting in a diagnosis of attention deficit hyperactivity disorder (ADHD) among girls, and trends in the prescribing of stimulant pharmacotherapy (including methylphenidate) for its treatment in the US.MethodsData from the US National Ambulatory Medical Care Survey were utilised for this analysis. The number and rate of office-based physician visits resulting in a diagnosis of ADHD (International Classification of Diseases, 9th Revision, Clinical Modificationcode 314.00 or 314.01) were discerned from the beginning of 1990 to the end of 1998, for children aged 5 to 18 years. Gender-specific trend analyses were conducted using four time intervals: 1991 to 1992, 1993 to 1994, 1995 to 1996, and 1997 to 1998.ResultsThe estimated number of office-based visits documenting a diagnosis of ADHD among children increased from 947 208 in 1990 to 3 234 180 in 1998. The rate of office-based visits documenting a diagnosis of ADHD among children increased from 19.4 per 1000 of the US population aged 5 to 18 years in 1990 to 59.0 per 1000 in 1998, a 3-fold increase (p < 0.05). The annualised mean number of office-based visits documenting a diagnosis of ADHD among girls tripled between 1991 to 1992 and 1997 to 1998 (from 296 389 to 886 798), whereas the number for boys increased 2.2-fold (from 1 006 243 to 2 200 021). The US population-adjusted rate of office-based visits documenting a diagnosis of ADHD among girls increased 2.7-fold between 1991 to 1992 and 1997 to 1998 (from 12.3 per 1000 girls to 33.4 per 1000; p < 0.05), whereas the rate among boys doubled (from 39.5 per 1000 boys to 78.7 per 1000; p < 0.05). Documentation of a diagnosis of ADHD and the prescribing of stimulant pharmacotherapy increased 2.8-fold for girls, from 7.5 per 1000 girls in 1991 to 1992 to 21.1 per 1000 in 1997 to 1998 (p < 0.05), as compared with a 2.2-fold increase among boys (from 25.5 per 1000 boys to 57.0 per 1000; p < 0.05).ConclusionOver the time frame 1990 to 1998, the rate of ADHD as well as the prescribing of stimulant medications for its treatment increased significantly among children aged 5 to 18 years. Between 1991 to 1992 and 1997 to 1998, the increased rate of diagnosis of ADHD among girls contributed to the overall upward trend. The rapidly increasing rate of ADHD among girls, and the prolonged nature of the disorder, represent significant public health problems. There exists a need for additional research examining both the aetiology and treatment of ADHD by gender.

ISSN:1172-7047    

出版商:ADIS    

年代:2002

数据来源: ADIS

摘要:

Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) which may be used for the management of anxiety disorders in children and adolescents. Absorption of fluvoxamine was similar in adolescents to that in adults, which suggests that the maximum dosage of the drug for patients aged between 12 and 17 years can be as high as 300 mg/day. However, steady-state plasma fluvoxamine concentrations were 2 to 3 times higher in children (aged between 6 and 11 years) than in adolescents; thus, the maximum fluvoxamine dosage recommended for children is 200 mg/day.Fluvoxamine (50 to 300 mg/day) for 8 to 16 weeks significantly reduced symptoms of obsessive-compulsive disorder (OCD) [measured across multiple assessment scales] compared with placebo in a well controlled trial in paediatric patients (n = 120) or from baseline in noncomparative trials in adolescent (n = 20) or paediatric (n = 16) patients. Improvements with fluvoxamine (up to 200 mg/day) were observed for up to 1 year in 98 patients with OCD in a noncomparative trial. The drug (up to 250 or 300 mg/day) also improved symptoms of anxiety compared with placebo in an 8-week well controlled trial in 128 paediatric patients with social phobia, separation anxiety disorder or generalised anxiety disorder (GAD).Fluvoxamine (50 to 300 mg/day) appears to be well tolerated in paediatric patients, with most adverse events with the drug (except abdominal discomfort, which occurred more often in patients receiving fluvoxamine) occurring with a similar incidence to those with placebo. The most common adverse events involved the CNS or gastrointestinal system. Most adverse events reported by paediatric patients with OCD were similar to those reported by adults.In conclusion, fluvoxamine is generally well tolerated and has demonstrated short-term efficacy compared with placebo in the treatment of OCD, and social phobia, separation anxiety disorder or GAD in well controlled trials in paediatric patients. Reductions in symptoms of anxiety with fluvoxamine have been observed for up to 1 year in children and adolescents with OCD. However, there are currently no comparative trials of fluvoxamine with other pharmacological agents. In the absence of such trials, current consensus opinion recommends that when pharmacotherapy is indicated, fluvoxamine, like other SSRIs, can be used as first-line treatment for anxiety disorders, particularly OCD, in paediatric patients. However, direct comparisons are required to assess the relative efficacy and tolerability of pharmacological agents in order to make firm recommendations for the treatment of anxiety disorders in this patient group.

ISSN:1172-7047    

出版商:ADIS    

年代:2002

数据来源: ADIS