Drugs & aging
-
Postherpetic neuralgia (PHN) represents a potentially debilitating and often undertreated form of neuropathic pain that disproportionately affects vulnerable populations, including the elderly and the immunocompromised. Varicella zoster infection is almost universally prevalent, making prevention of acute herpes zoster (AHZ) infection and prompt diagnosis and aggressive management of PHN of critical importance. Despite the recent development of a herpes zoster vaccine, prevention of AHZ is not yet widespread or discussed in PHN treatment guidelines. ⋯ Given the low systemic drug exposure, adverse events with topical therapies are generally limited to application-site reactions, which are typically mild and transient with lidocaine 5 % patch, but may involve treatment-limiting discomfort with capsaicin cream or 8 % patch. Based on available clinical data, clinicians should consider administering the herpes zoster vaccine to all patients aged 60 years and older. Clinicians treating patients with PHN may consider a trial of lidocaine 5 % patch monotherapy before resorting to a systemic therapy, or alternatively, may consider administering the lidocaine 5 % patch in combination with a tricyclic antidepressant or a gabapentinoid to provide more rapid analgesic response and lower the dose requirement of systemic therapies.
-
Comparative Study Clinical Trial
Comparison of intranasal ketorolac tromethamine pharmacokinetics in younger and older adults.
The nonsteroidal anti-inflammatory drug (NSAID) ketorolac tromethamine shows higher plasma concentrations and a longer plasma half-life in adults ≥65 years of age than in subjects aged <65 years, after intramuscular administration. An intranasal formulation of ketorolac tromethamine is approved for short-term treatment of moderate to moderately severe pain requiring analgesia at the opioid level. ⋯ The increased systemic exposure to ketorolac following intranasal administration in adults ≥65 years of age warrants reduction of the intranasal ketorolac tromethamine dose, and halving the dose to 15.75 mg (one spray to one nostril) in this patient population is recommended based on similar dosing adjustments made for intramuscular ketorolac tromethamine.
-
Clinical Trial
Optimal remifentanil dosage for intubation without muscle relaxants in elderly patients.
Remifentanil used in combination with propofol provides adequate conditions for tracheal intubation without muscle relaxants. Delivery of the optimal dose is important to prevent poor intubation conditions and drug-related complications. No previous study has investigated the use of a remifentanil-propofol combination in elderly patients. ⋯ Combined with 1 mg/kg propofol, 1.39 (95 % CI 1.27, 2.13) µg/kg remifentanil resulted in acceptable intubation conditions within 60 s in 95 % of elderly patients without major complications.
-
In patients with dementia, undertreatment of pain, irrespective of its aetiology, is widely recognized; the risk for undertreatment increases with the severity of dementia. We argue, however, that central neuropathic pain is by far the most undertreated type of pain in patients with dementia. Central pain is a type of neuropathic pain that is known to occur in stroke patients and is caused by white matter lesions. ⋯ Antidepressants and antiepileptic drugs appear to have a positive effect on central neuropathic pain. In the review, advantages and disadvantages of amitriptyline, carbamazepine, lamotrigine, gabapentin and pregabalin are discussed; a negative effect of these drugs on liver and kidney functions, as well as on cognitive functions in patients who already suffer from cognitive impairment is highlighted. Next to pharmacotherapy, non-pharmacological treatment strategies such as transcutaneous electrical nerve stimulation may be effective as long as afferent pathways transmitting the electrical stimulus are still intact.