Expert opinion on pharmacotherapy
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Chronic obstructive pulmonary disease (COPD), which affects approximately 14 million Americans, is the fourth leading cause of death in the United States and is responsible for an estimated US$6.5 billion in direct and indirect costs per year [1,2]. Its usual course is a slow deterioration of lung function and progressive breathlessness with activities. The age-adjusted death rate for COPD rose 71% from 1967 to 1987, and the 10 year mortality rate is about 50%. ⋯ Patients often experience a reduction in symptoms and improvement in their quality of life. There are several classes of bronchodilators available for the treatment of COPD, each with specific clinical benefits: anticholinergics, short-acting beta 2 agonists, combination anticholinergic and short-acting beta 2 agonist, long-acting beta 2 agonists and methylxanthines. This chapter reviews the use of an anticholinergic (ipratropium bromide) concomitantly with other bronchodilators, focusing on patients with COPD.
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Expert Opin Pharmacother · Dec 2000
ReviewInterferon-gamma 1b: impact of new indications (idiopathic pulmonary fibrosis).
Idiopathic pulmonary fibrosis (IPF) is a relentlessly progressive disease with inadequate response to conventional treatment with corticosteroids and/or immunosuppressive agents in most patients. Interferon-gamma (IFN-gamma), an antifibrotic agent, has been proposed as a novel therapeutic approach. ⋯ Clinical experience is, however, limited to a single clinical trial that showed objective functional improvement in a small number of patients treated with IFN-gamma and low-dose corticosteroids. Further research is needed to characterise the efficacy, safety and optimum route of administration of this agent before it can be recommended for use in routine clinical practice.
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This article reviews the new criteria for selecting the proper antimicrobial agent and dosage regimen for standard treatment of severe sepsis, with the intention of preventing septic shock. After introducing new concepts on the pathogenesis of sepsis and septic shock, the authors analyse the parameters of beta-lactam antibacterial activity, the antibiotic-induced release of bacterial endotoxin and the interrelationships between pharmacokinetics and pharmacodynamics of antibiotics in the search for an optimum dosage regimen of antimicrobial mono- or polytherapy for severely ill septic patients admitted to the intensive care unit. The mortality rate resulting from severe bacterial sepsis, particularly that associated with shock, still approaches 50% in spite of appropriate antimicrobial therapy and optimum supportive care. ⋯ Not all antimicrobial agents are equally capable of inducing septic shock; this is dependent on their mechanism of action rather than on the causative pathogen species. The quantity of endotoxin released depends on the drug dose and whether filaments or spheroplast formation predominate. Some antibiotics, such as carbapenems, ceftriaxone, cefepime, glycopeptides, aminoglycosides and quinolones, do not have the propensity to provoke septic shock because their rapid bacterial activity induces mainly spheroplast or fragile spheroplast-like bacterial forms.
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Expert Opin Pharmacother · May 2000
GuidelineCritical appraisal of the JNC VI, WHO/ISH and BHS guidelines for essential hypertension.
Three guidelines have been selected for this review: The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI), the 1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension (WHO/ISH) and the Guidelines for management of hypertension: report of the third working party of the British Hypertension Society (BHS). The guidelines are generally in accordance on the principles of drug prescribing. There is, however, a serious divergence of opinion between JNC VI and BHS, and WHO/ISH on the levels of blood pressure chosen for defining hypertension and the level to which blood pressure should be reduced. ⋯ Using conventional measurement WHO/ISH recommends lowering systolic blood pressure with treatment by 10-20/5-10 mmHg more than JNC VI and BHS depending on whether 'normal' or 'optimal' pressures are to be achieved. Using average daytime ABPM pressure, WHO/ISH recommends lowering the average daytime blood pressure with treatment by 10-30/5-10 mmHg more than JNC VI and BHS depending on whether 'normal' or 'optimal' blood pressures are chosen. These differing recommendations between JNC VI and BHS, and WHO/ISH cannot be reconciled and they are of such magnitude as to carry serious implications for clinical practice, not least among which is that acceptance of the WHO/ISH levels of 'normality' for blood pressure would result in some 45% of the population of all ages and nearly 60% of elderly people being classified as 'hypertensive'.
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Prior to 1993, there were only six major drugs available in the US for the treatment of patients with epilepsy. These included phenobarbital (PB), phenytoin (PHT), carbamazepine (CBZ), primidone (PRIM), valproic acid/sodium valproate (VPA) and ethosuximide (ESX). Of these drugs, VPA has the broadest spectrum of activity and ESX the most limited. ⋯ Since 1993, ten new drugs have entered the worldwide market (not all in the US). Those released include felbamate (FBM), gabapentin (GBP), lamotrigine (LTG), topiramate (TPM), tiagabine (TGB), oxcarbazepine (OXC), levetiracetam (LVT), zonisamide (ZNS), clobazam (CLB) and vigabatrin (VGB). The purpose of this article is to review each of the above drugs, looking at efficacy, safety, tolerability and where they may play a role in the current treatment of epilepsy.