Prescrire international
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Prescrire international · Feb 1999
Comparative StudyModafinil: a second look. Confirmed efficacy in narcolepsy.
(1) Modafinil, a psychostimulant, has been available in France for the treatment of narcolepsy and idiopathic hypersomnia since 1994. (2) The initial clinical file was inadequate to judge its possible clinical value. (3) In narcolepsy three new short-term clinical trials have compared modafinil with a placebo (nearly 500 patients treated with modafinil). (4) These trials show that the effects of modafinil on daytime drowsiness are only moderate (average reduction of one unwanted sleep episode a day) but are subjectively better than those of a placebo. In all, 84% of patients preferred the modafinil period to the placebo period during a cross-over trial. In contrast, modafinil does not improve cataplexy. (5) No new trials have been done in idiopathic hypersomnia. (6) The effects of modafinil persist for at least four months according to a double-blind placebo-controlled trial. (7) The safety profile of modafinil appears to be similar to that of non amphetamine psychostimulants. (8) There is currently no evidence of dependence leading to withdrawal symptoms after abrupt treatment cessation, or of a risk of abuse.
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Drugs are rarely the cause but should be screened for in cases of persistent hiccups.
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Prescrire international · Oct 1998
Transdermal fentanyl: new preparation. An alternative to morphine.
(1) Fentanyl, an opiate agonist, was previously available in injectable form for use in anaesthesia. The new patch form is indicated for the treatment of chronic cancer pain. (2) The clinical assessment mainly involved non comparative trials showing good analgesic efficacy on chronic pain. (3) Given the long time-lag before the effect of fentanyl is felt, a short-acting analgesic should be given when the first patch is applied. ⋯ It must be replaced every three days. (4) Fentanyl patches have similar adverse effects to opiate agonists, i.e. gastrointestinal and neuropsychological disorders. However, the adverse effects of morphine and fentanyl are not always identical in a given patient. (5) Fentanyl patches carry a risk of misuse by opiate addicts and of acute intoxication.
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A meta-analysis published in the Lancet in September 1997 cautiously concluded that homeopathic drug activity is not fully explained by the placebo effect. A thorough examination of this meta-analysis reveals design errors that make the results untrustworthy. There is still nothing to suggest that homeopathic drugs are any more effective than a placebo.
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Prescrire international · Feb 1998
Comparative StudyTramadol: new preparation. Capsules: central analgesic; step 2 on the WHO scale.
The clinical assessment file on tramadol is of low quality. In acute postoperative pain and chronic pain there is no proof that tramadol has a better risk-benefit ratio than the paracetamol + codeine combination or other step 2 analgesics in the World Health Organisation classification. Like all other central analgesics, tramadol can have neuropsychological adverse effects, especially a risk of dependence and misuse.