Cns Drugs
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Ziconotide (Prialt(®)) is a synthetic conopeptide analgesic that acts by selectively antagonizing N-type voltage-gated calcium channels. Intrathecal ziconotide is the only non-opioid intrathecal analgesic that is FDA-approved for use in patients with treatment-refractory, chronic pain. The efficacy of intrathecal ziconotide was demonstrated in randomized, double-blind, placebo-controlled trials in patients with treatment-refractory noncancer-related pain or cancer- or AIDS-related pain. ⋯ In general, clinically important non-CNS adverse events were infrequent, and during the ziconotide titration phase, relatively few patients discontinued treatment because of adverse events. Ongoing research will assess various strategies for selecting patients for ziconotide treatment and for enhancing its efficacy and tolerability. At the present time, intrathecal ziconotide provides a treatment option for patients with severe, unremitting pain who have failed to respond to other intensive analgesic regimens.
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Dexmedetomidine is currently used in the US in the treatment of alcohol withdrawal syndrome (AWS) in the intensive care unit (ICU) setting, although data to support this practice are limited. Dexmedetomidine targets the noradrenergic system, an important but frequently overlooked secondary mechanism in the development of AWS, and, in doing so, may reduce the need for excessive benzodiazepine use which can increase the risk of γ-aminobutyric acid (GABA)-mediated deliriogenesis and respiratory depression. The purpose of this narrative review is to evaluate available literature reporting on the safety and efficacy of dexmedetomidine for AWS in the ICU setting. ⋯ Eight published case studies and case series were identified. Based on a limited body of evidence, dexmedetomidine shows promise as a potentially safe and possibly effective adjuvant treatment for AWS in the ICU. Prospective, well-controlled studies are needed to confirm the safety and efficacy of the use of dexmedetomidine in AWS.
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Medication overuse headache (MOH) is a daily, or almost daily, headache form that arises from overuse of one or more classes of migraine-abortive or analgesic medication. The main classes of drugs that cause MOH are opioids, butalbital-containing mixed analgesics, triptans, ergotamine tartrate derivatives, simple analgesics (except for plain aspirin), and perhaps non-steroidal anti-inflammatory drugs. MOH can be debilitating and results from biochemical and functional brain changes induced by certain medications taken too frequently. ⋯ Other primary headache disorders are not currently believed to be vulnerable. The treatment of MOH consists of discontinuation of the offending drug(s), acute treatment of the withdrawal symptoms and escalating pain, establishing a preventive treatment when necessary, and the implementation of educational and behavioral programs to prevent recidivism. In most patients, MOH can be treated in the outpatient setting but, for the most difficult cases, including those with opioid or butalbital overuse, or in patients with serious medical or behavioral disturbances, effective treatment requires a multidisciplinary, comprehensive headache program, either day-hospital with infusion or an inpatient hospital setting.
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No head-to-head clinical trials have been published comparing guanfacine extended release (GXR) and atomoxetine (ATX): two nonstimulants approved for the treatment of attention-deficit/hyperactivity disorder (ADHD). However, other study designs or methods could be used to indirectly compare these two medications. Matching-adjusted indirect comparison (MAIC) is a recent methodology that utilizes individual patient data (IPD) from clinical trials for one treatment and published aggregate data from another treatment to estimate the relative efficacy of both, providing rapid, reliable comparative efficacy results. ⋯ After adjusting for difference in baseline trial characteristics using MAIC, GXR appears to be more efficacious than ATX for the treatment of ADHD. Results were consistent in a variety of dosage range comparisons and within increasingly heterogeneous trial populations.