Postgraduate medicine
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Until recently, warfarin had been one of the only treatment options for long-term anticoagulation of patients with atrial fibrillation, venous thromboembolism, or other medical conditions that require chronic anticoagulation. A main concern when treating patients with anticoagulants is balancing the benefits of preventing a thromboembolic event with the risks of bleeding events. The US Food and Drug Administration recently approved 2 new oral anticoagulants, dabigatran and rivaroxaban, for stroke prevention in patients with atrial fibrillation, and is currently reviewing a drug application for a third new oral anticoagulant, apixaban. ⋯ The 2012 American College of Chest Physicians Evidence-Based Clinical Practice Guidelines for antithrombotic therapy and prevention of thrombosis include recommendations for dabigatran, rivaroxaban, and apixaban for certain indications. Each of the 3 novel oral anticoagulants has specific pharmacokinetic and pharmacodynamic properties that may make them suitable agents for use in specific patient populations. Knowledge of dosing, drug-drug interactions, monitoring parameters, and clinical considerations for each of these new medications will help clinicians decide for which patients they may be best suited to replace conventional therapy with warfarin.
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Chronic pain, whether localized or generalized, is a widespread, often debilitating condition affecting > 25% of adults in the United States. Oral agents are the cornerstone of chronic pain treatment, but their use may be limited in certain patients, particularly the elderly. Topical therapies offer advantages over systemically administered medications, including the requirement of a lower total systemic daily dose for patients to achieve pain relief, site-specific drug delivery, and avoidance of first-pass metabolism, major drug interactions, infections, and systemic side effects. ⋯ In patients with neuropathic pain, topical forms of both capsaicin and lidocaine have been shown to be useful in the treatment of postherpetic neuralgia and diabetic peripheral neuropathic pain. Lidocaine has also demonstrated efficacy in relieving patient pain due to complex regional pain syndrome and may be useful in the treatment of patients with neuropathic pain who have cancer, although clinical trial results have not been consistent. Data suggest that topical therapies may offer a safe, well-tolerated, and effective alternative to systemic therapies in the treatment of patients with chronic, localized musculoskeletal and neuropathic pain.
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Postgraduate medicine · Jul 2013
ReviewChallenges in the transition of care for adolescents with attention-deficit/hyperactivity disorder.
Attention-deficit/hyperactivity disorder (ADHD) is often considered a childhood disorder. However, in those diagnosed with ADHD as children, inattention, impulsivity, and hyperactivity can persist into adulthood, causing significant functional impairment and emotional distress, even if the condition no longer meets diagnostic criteria. This review examines the developmental and psychosocial factors to consider in adolescents with ADHD and the strategies that facilitate the transition from pediatric to adult care. ⋯ Although recommendations for planning initiatives have been developed by a variety of professional organizations, they do not seem to be routinely implemented for the transition of ADHD care. Such careful advanced transition planning can ensure continuity of treatment, encourage treatment adherence, and help young individuals adjust to new life circumstances and avoid negative educational, social, and vocational results. Guidelines designed to facilitate this transition of care may be helpful.
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Postgraduate medicine · Jul 2013
ReviewClopidogrel, prasugrel, or ticagrelor? a practical guide to use of antiplatelet agents in patients with acute coronary syndromes.
Aspirin is a cornerstone of therapy in the treatment of patients with acute coronary syndromes (ACS). However, dual antiplatelet therapy reduces the risk of stent thrombosis and cardiovascular events compared with aspirin alone in the treatment of patients with ACS. Recently, there has been debate as to which antiplatelet agent should be added to aspirin in the ACS treatment regimen. This review summarizes the pharmacologic and clinical data comparing clopidogrel, prasugrel, and ticagrelor, and provides a practical guide to clinicians for determining which antiplatelet to use for patients with ACS.