Prescrire international
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(1) Osteodensitometry is the standard method for measuring bone mineral density. Since the 1990s, diagnosis of osteoporosis has been defined, by convention, by a bone density T score cut-off of less than -2.5. This threshold, based on population statistics, is appropriate for the diagnosis of osteoporosis in Caucasian postmenopausal women in Europe and North America but may not be suitable for other populations. (2) To determine whether measurement of bone mineral density is useful in the prevention of fractures in postmenopausal women, we reviewed the relevant literature using our established in-house methodology. (3) Two meta-analyses of cohort follow-up studies involving tens of thousands of women showed a statistically increased risk of fracture in women with low bone density, especially in those with osteoporosis diagnosed by means of osteodensitometry. ⋯ The screening for osteoporosis in postmenopausal women, or exposing large numbers of women to the adverse effects of these drugs. (6) Severe osteoporosis in postmenopausal women is defined by the presence of both low bone mineral density and a history of fragility fractures following low-energy trauma. Alendronic acid is the best-assessed drug in these women, preventing about 3 symptomatic vertebral fractures and 1 hip fracture when 100 patients are treated for 3 years. After a first fracture, women should be asked questions designed to assess the severity of the trauma, and should undergo osteodensitometry to document osteoporosis before exposure to the potential adverse effects of bisphosphonates.
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Prescrire international · Apr 2008
0.4% glyceryl trinitrate ointment: new drug. Not useful for anal fissures.
(1) Anal fissures are very painful but often heal spontaneously. After eliminating other diagnoses, various treatments can be tried while waiting for fissures to heal: warm seat baths, local anaesthetics, and adequate fibre and fluid intake. (2) Clinical evaluation of glyceryl trinitrate 0.4% ointment, a nitrate derivative, is mainly based on a double-blind trial versus excipient in 193 adults with "chronic" fissures. ⋯ Abrupt-onset hypotension is a risk during concomitant use of other vasodilatory drugs. (5) There are no data on pregnant women exposed to glyceryl trinitrate. (6) In summary, glyceryl trinitrate 0.4% ointment does not reduce the pain linked to chronic anal fissures, but it does carry a risk of sometimes severe headache. It is best to continue using simple, non-aggressive treatments.
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Prescrire international · Dec 2007
Ibuprofen: new indication. Migraine attacks: don't begin with 400 mg!
Ibuprofen, initially at a dose of 200 mg, is a second-line option for treating migraine attacks after paracetamol fails.
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Prescrire international · Dec 2007
Buprenorphine + naloxone: new combination. Opiate dependence: no proof of reduced risk of self-administered injection.
(1) Two drugs with similar efficacy are available in France for heroin replacement therapy: methadone and buprenorphine. (2) Buprenorphine is sold in the form of sublingual tablets, but some patients dissolve and inject them. Methadone is the main alternative for these patients. Other intravenous opiate derivatives can also be tried, although they have not been approved for this indication. (3) In order to help prevent patients from injecting themselves with buprenorphine, a sublingual combination of buprenorphine + naloxone is to be marketed in France. (4) From a pharmacological point of view, this combination makes sense. ⋯ However, clinical studies are needed to determine whether or not this prevents injection. (5) A double-blind trial in 326 patients compared replacement therapy with buprenorphine 16 mg + naloxone 4 mg/day versus buprenorphine 16 mg + placebo. The addition of naloxone did not reduce the efficacy of sublingual buprenorphine, but the frequency with which patients injected the drugs was not studied in this trial. (6) This combination of buprenorphine + naloxone has not been directly compared with methadone. (7) In addition to the classical adverse effects of opiates, buprenorphine can cause hepatic adverse effects. (8) Little evidence is available on the effects of intravenous injection of buprenorphine + naloxone. According to an epidemiological survey conducted in Finland, where the combination is also marketed, about 8% of patients regularly inject it intravenously. (9) Patients who are likely to inject buprenorphine should be switched to methadone.