Drug Safety
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Depression is a serious condition, associated with considerable morbidity and mortality; selective serotonin reuptake inhibitors (SSRIs) were commonly used in its treatment in child and adolescent psychiatry until recently. In the wake of the recent UK Committee on Safety of Medicines (CSM) advice, we conducted a rapid review of current available information on SSRIs and suicidality (suicidal ideation, self-harm and suicide attempt) in children and adolescents from clinical trials and epidemiological studies. There is insufficient safety information from the randomised controlled trials to confirm a definite association between SSRIs and suicidality. ⋯ Local bodies of clinicians or peer groups should agree protocols and acceptable guidelines, taking into consideration the type of patients being assessed, the availability of nonpharmacological intervention, and the benefit-risk ratio of the pharmacological intervention. It is important that parents (and patients when possible) be given accurate information regarding the current controversy over SSRI prescribing. More research into the use of SSRIs in childhood depression is urgently required.
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Review Comparative Study
A benefit-risk assessment of inhaled long-acting beta2-agonists in the management of obstructive pulmonary disease.
The two inhaled long-acting beta2-adrenoceptor agonists, salmeterol and formoterol, have been studied extensively since their introduction in the early 1990s. In this review we consider the evidence for their efficacy and safety in adults with asthma and chronic obstructive pulmonary disease (COPD), by reviewing long-term prospective studies in which these drugs have been compared with placebo or an alternative bronchodilator. We have also assessed safety, including data from postmarketing surveillance studies and case-control studies using large databases. ⋯ There is some evidence that serious adverse events including dysrhythmias and life-threatening asthma episodes can occur; however, the incidence of such events is very low but may be increased in patients not taking an inhaled corticosteroid. Salmeterol 50 microg twice daily and formoterol 12 microg twice daily are effective and safe in treating patients with asthma and COPD. Higher doses cause more adverse effects, although serious adverse events are rare.
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Ropivacaine is a long-acting amide-type local anaesthetic, released for clinical use in 1996. In comparison with bupivacaine, ropivacaine is equally effective for subcutaneous infiltration, epidural and peripheral nerve block for surgery, obstetric procedures and postoperative analgesia. Nevertheless, ropivacaine differs from bupivacaine in several aspects: firstly, it is marketed as a pure S(-)-enantiomer and not as a racemate, and secondly, its lipid solubility is markedly lower. ⋯ Ropivacaine shows an identical efficacy and potency to that of bupivacaine, with similar analgesic duration over hours using single shot or continuous catheter techniques. In summary, ropivacaine, a newer long-acting local anaesthetic, has an efficacy generally similar to that of the same dose of bupivacaine with regard to postoperative pain relief, but causes less motor blockade and stronger vasoconstriction at low concentrations. Despite a significantly better safety profile of the pure S(-)-isomer of ropivacaine, the increased cost of ropivacaine may presently limit its clinical utility in postoperative pain therapy.
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Although screening tests to prevent anaphylaxis during anaesthesia have been advocated, such tests are unlikely to have significant impact on reducing the incidence of anaphylaxis during anaesthesia. This is due to the low prevalence of the disease, the diversity of drugs used in anaesthesia and the incidence of false positive and negative tests. The suggested risk factors of allergy, i.e. atopy, asthma, family history, female sex, previous exposure, vasectomy, use of zinc protamine sulfate insulin and allergy to cosmetics, eggs, fish and non-anaesthetic drugs are not valid. ⋯ Determining the cause of an adverse event and the drug responsible, and adequately communicating those findings can reduce second reactions. Avoiding neuromuscular blocking drugs (NMBDs) in patients who have reacted to an NMBD, and use of non-intravenous techniques should also reduce the incidence of second reactions. Desensitisation, and blocking with monovalent quaternary ammonium compounds may allow improved safety of NMBDs and pretreatment with antihistamines and corticosteroids may block or ameliorate the severity of reactions, but there is currently little evidence to support their routine use.
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Review Comparative Study
Tolerability of treatments for postherpetic neuralgia.
Herpes zoster occurs in up to 20% of people infected with varicella-zoster virus, due to reactivation of the virus from latently infected sensory ganglia. Although pain is a typical feature of acute zoster, pain persisting for more than a month after resolution of the rash is less common and is termed postherpetic neuralgia (PHN). The pain associated with PHN is neuropathic in origin and is notoriously difficult to treat. ⋯ Although effective, the relatively common adverse effects of opioids and ketamine limit their usefulness in treating PHN. Topical treatment with 5% lidocaine patch or capsaicin is of benefit in some patients and is generally well tolerated. Intrathecal methyl prednisolone may be considered for intractable pain but efficacy and safety have not been confirmed.