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PubMed1988

Age-related effects of antihypertensive therapy with alpha-blockers.

Currently, the most important alpha-blockers used in treating hypertension are prazosin and its long-acting congeners, doxazosin and terazosin. Although there are minor age-related changes in the pharmacokinetics of these compounds, they result in no appreciable alteration in dose requirements. Overall, published evidence does not indicate any loss of responsiveness to alpha-blockade in the elderly. Despite the potential risks of first-dose hypotension and of postural hypotension, long-acting alpha-blockers may warrant further consideration as possible first-line therapy in elderly hypertensive patients. These agents allow the simplicity of once-daily dosing, and their cardiac and metabolic effects offer potential advantages.

Adrenergic alpha-Antagonists↗

PubMed1989

An overview of integration of therapy for congestive heart failure.

Patients with symptoms of congestive heart failure look to treatment to relieve symptoms, improve the quality of life, and prolong life. They prefer a convenient dosing schedule, with minimal side effects and low cost. A wide variety of agents are available to treat patients with congestive heart failure. The three major classes of drugs that improve heart failure include the diuretics, inotropic drugs, and vasodilators. It appears that any one of these three classes are potential first-line candidates for treating patients with congestive heart failure. Patients with edema usually require long-term therapy with diuretic agents. Since the vasodilators are the only class of drugs which have been shown to prolong life, they should be used routinely in the management of patients with congestive heart failure. Since all three classes of drugs have additive beneficial hemodynamic effects, it makes sense to consider the use of all three in patients with at least moderate to severe heart failure. At the moment unanswered questions include the role of antiarrhythmic agents in reducing the incidence of sudden death, and the use of potent new inotropic vasodilators. Overall, the current therapeutic approach to patients with heart failure is effective in relieving symptoms, improving exercise tolerance and in prolonging life.

Heart Failure↗

PubMed1989

The effect of dihydropyridine calcium antagonists in hypertensive patients with impaired renal function.

Dihydropyridine calcium antagonists play an important role in the treatment of arterial hypertension. In many centers, they are used as first-line treatment. Since impaired renal function can be a complication of long-standing blood pressure elevation, the usefulness of dihydropyridine calcium antagonists in hypertensive patients with reduced glomerular filtration rate is an important clinical issue. Several studies of the pharmacokinetics of calcium antagonists, such as nifedipine and related compounds, clearly show that the important pharmacokinetic variables are not affected by impaired renal function. Moreover, the antihypertensive efficacy is not reduced in patients with reduced glomerular filtration rate. A matter of potentially great clinical importance is the fact that several studies have shown that treatment with dihydropyridine calcium antagonists in patients with impaired renal function has reduced the rate of deterioration in filtration rate, leading to a preservation of renal function. It can therefore be concluded that dihydropyridine calcium antagonists are useful in the treatment of hypertensive patients with impaired renal function, that the major pharmacokinetic and pharmacodynamic variables are not negatively affected, in particular that the antihypertensive effect is maintained in such patients, and that there is no retention of metabolites. Finally, the observation that the decline in renal function can be slowed down suggests that dihydropyridine calcium antagonists may be the preferential treatment in hypertensive patients with reduced renal function.

Aged↗

PubMed1989

The polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is a multifaceted clinical entity the hallmark of which is ovulatory dysfunction associated with a relative luteinizing hormone excess and follicle-stimulating hormone (FSH) deficiency. Clomiphene citrate has been the first-line drug for ovulation induction in women with PCOS: because it is an attenuated estrogen, its action blocks the acyclic estrone effect in PCOS. However, many women fail to ovulate or conceive on clomiphene, and an appropriate agent for them was unavailable until relatively recently. The use of a "pure" FSH preparation, Metrodin, provides physiologic replacement of the deficient gonadotropin in PCOS; thus, Metrodin is the ideal second-line drug. Its use with a low-dose regimen should avoid the hyperstimulation seen with human menopausal gonadotropin in PCOS; spontaneous ovulation is an end point. Thus, PCOS patients who do not achieve pregnancy with clomiphene citrate have available a new, more physiologic approach to ovulation induction.

Clomiphene↗

PubMed1989

[Implantation of endoprostheses in aortocoronary bypass. Preliminary experience at the Thoraxcenter of Rotterdam].

An intraluminal stent was implanted in 5 patients after dilatation of an aorto-coronary venous graft. In the first 4 patients the procedure was motivated by restenosis after angioplasty. In the 5th patient the stent was implanted as a first-line measure in a case of dilated venous bypass stenosis. Stent implantation carries a risk of thrombosis and requires effective anticoagulation. Thus, one of our patients had to be reoperated upon for prosthetic thrombosis facilitated by the withdrawal of anticoagulants owing to a gastrointestinal haemorrhage. After a 3-month follow-up, the results seem to be encouraging in spite of a case of restenosis located at the proximal end of the tutor. However, more time will be needed to determine precisely the effectiveness of stents in the prevention of restenosis after venous graft dilatation.

Aged↗

PubMed1989

Percutaneous transluminal angioplasty of failing arteriovenous dialysis fistulae.

Percutaneous transluminal angioplasty (PTA), a method combining diagnostic and therapeutic procedures, was studied prospectively in 40 patients with clinically failing a-v fistulae. Forty-seven procedures were performed in 40 patients with a variety of a-v fistulae (26 Cimino, five saphenous loops, five goretex grafts, and four upper-arm fistulae). In 43 cases the procedure was initially successful. The mean time of fistula patency after first PTA was 10.06 +/- 2.10 months. Primary failures were due either to technical inability to pass the stenosis (two patients) or to vessel perforation during the attempt (two patients). Surgical intervention had to follow both perforations. Restenosis at the dilatation site occurred in six patients, and in one a new stenosis at a different site occurred; the mean time of fistula patency in these patients was 5.8 months. Our results suggest that PTA is a highly effective therapy for the majority of cases of shunt stenosis. The success rate of the method is excellent and the complication rate low. The combination of this interventional approach with the mandatory angiographic procedure if stenosis of a fistula is suspected makes PTA a favourable first-line treatment and appears to save a considerable number of surgical interventions.

Adult↗

PubMed1989

[Treatment of achalasia by pneumatic dilatation].

Between 1979 and 1988, 60 patients with achalasia were treated by pneumatic dilatation under general anaesthesia, using the Rider-Moeller apparatus. The diagnosis rested on clinical, radiological, manometric and endoscopic criteria. These 60 patients underwent a total of 99 dilatations: 63.3 per cent were dilated once and 37.7 per cent were dilated several times. Forty seven of the 60 patients were followed up for more than 12 months (mean: 44 months): 2 of them (4.2 per cent) had to be operated upon, while 45 (95.7 per cent) are asymptomatic. Immediate complications were perforation in one case and cardial fissure in another; both were treated medically and cured. There was no oesophagitis or peptic stenosis, and no patient died. These results are compared with those found in the literature. The authors underline the simplicity, safety and effectiveness of pneumatic dilatation and suggest that it should be used as first-line treatment of achalasia, surgery being performed only when dilatation fails.

Adolescent↗

PubMed1989

Therapeutic focus. Minocycline in the treatment of acne.

Minocycline has an established place in the oral therapy of acne. Prolonged courses of therapy have an acceptable safety profile. Where therapy with oxytetracycline has failed, minocycline is still likely to prove effective. The twice-daily dosage and ease of absorption from the gastrointestinal tract offer significant advantages over other tetracyclines. The simpler minocycline regime and early onset of clinical improvement are likely to result in better patient compliance, and hence optimise therapeutic response. There is therefore justification for the use of minocycline as first-line oral therapy, but, whether as a first- or second-line therapy, minocycline is a valuable drug in the treatment of this very distressing disorder. The earlier effective therapy is used in a patient with acne, the less physical and psychological scarring will remain thereafter.

Acne Vulgaris↗

PubMed1989

Percutaneous automated lumbar nucleotomy.

The results of percutaneous automated lumbar nucleotomy in the treatment of lumbar disc herniation were assessed in a series of 39 patients. The technique consists of mechanical decompression of the herniated intervertebral disc without total excision. Only one-space discs were treated by this method. Sciatica was the predominant clinical symptom in 30 cases, and lumbar pain in 9 cases. Good to very good results were obtained in 70% of patients with sciatica and in 55% of patients with lumbar pain. After 4 cases of nucleotomy performed after failure of nucleolysis were excluded, the proportion of very good results rose to 77% in sciatica. Conversely, it seems that a number of failed nucleotomies can be treated by nucleolysis. Nucleotomy is very well tolerated and deserves to be used as first-line treatment of single and radiologically well documented lumbar disc herniations.

Adult↗

PubMed1989

Ifosfamide in small cell lung cancer.

Ifosfamide, an analogue of cyclophosphamide, has been proven to be of value in numerous malignancies, including testicular cancer, sarcoma, and lymphoma. Furthermore, ifosfamide is more suitable for combination chemotherapy than its parent compound because it causes less myelosuppression than cyclophosphamide. There have been only a few studies evaluating single-agent ifosfamide in small cell lung cancer (SCLC). In patients who have had little or no prior chemotherapy, ifosfamide appears as active as any single agent. Combination chemotherapy regimens employing cisplatin (or carboplatin) plus etoposide plus ifosfamide are currently under way on both sides of the Atlantic. A Hoosier Oncology Group (HOG) study will evaluate this three-drug regimen v cisplatin plus etoposide, and this protocol will establish or refute the value of ifosfamide as first-line therapy in extensive SCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1989

[Recent trends of chemotherapy in small cell lung cancer: a slow but steady progress].

The author reviewed some distinct findings concerning chemotherapy of small cell lung cancer (SCLC) which had appeared recently in the articles of journals and proceedings. Of new drugs, teniposide and carboplatin have a significant activity against SCLC, however, the usefulness of these drugs must be determined in the comparative fashion with their mother compounds. Cisplatin plus etoposide (PVP), which was demonstrated to have a distinct activity in previously treated SCLC and to be not fully cross-resistant to CAV, has recently been incorporated into the first-line treatment. PVP has been evaluated as either induction chemotherapy or consolidation therapy, as alternating chemotherapy with CAV and as a chemotherapy regimen in the combined modality treatment with chest irradiation. The data obtained provide results comparable or rather superior to those achieved with CAV or other conventional regimens when used as induction chemotherapy, and provide some encouraging results when used as consolidation chemotherapy and in combination with chest irradiation. Four trials have been conducted to test the usefulness of CAV-PVP alternation, however, the results is still controversial. Recently, two institutions reported the results of pilot study of an intensive weekly chemotherapy. Although the complete response rate of the weekly regimens appears superior to that of conventional regimens, the survival benefit is still obscure because of an inadequate follow-up time. The pace of therapeutic advances in SCLC has slowed and appears to reach a plateau, however, recent articles indicate a slow but steady progress in the treatment of SCLC.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1989

Drug therapy for juvenile arthritis.

Juvenile arthritis includes a variety of rheumatic disorders with varied articular and extraarticular manifestations. The heterogeneity of JA cannot be overemphasized in a rational approach to therapy. Fortunately, most children with JA improve significantly with first-line treatment, especially those with pauciarticular disease. Only a small number of these patients go on to require second-line treatment, usually because of the evolution of their condition into the polyarticular type. Patients with polyarticular, RF-positive disease and patients with early-onset polyarthritis in association with systemic-onset disease both have poor prognoses in terms of ultimate joint function, and should receive second-line treatment early in their therapy. Injectable gold is the drug of choice for the former patients, if an initial trial of NSAIDs has failed. Patients with polyarticular onset, RF-negative disease generally have a better prognosis than other patients with polyarticular involvement. One may wait considerably longer before introducing a second-line agent for these patients. An antimalarial agent may be a reasonable choice for these patients, especially those with limited polyarticular involvement (5 to 10 active joints). This latter principle may also be applied to patients who evolve from pauciarticular to polyarticular involvement. In all such cases, penicillamine is almost never used as first choice. If the patient is a young child, the difficulty with injecting gold and the hazards of antimalarial agents may limit the use of these treatments. In situations such as this, auranofin or sulfasalazine may be the drug of choice. Cytotoxic/antimetabolic therapy should be reserved for those children who have continued active disease despite full courses of two SAARDs, or for those who have been unable to take SAARDs because of their side effects. Corticosteroid therapy should be used only when specifically indicated, and every attempt should be made to wean the patient from it as soon as feasible. The aim of therapy is to ensure that patients enter their remission in the best condition possible. For this to be assured, a sensible approach to drug therapy is mandatory.

Adolescent↗

PubMed1989

[Combination of anti-angina drugs].

Within the last decade it became obvious that the treatment of angina pectoris alone is not sufficient. Modern goals include the optimization of anti-ischemic treatment ("silent myocardial ischemia") without compromising quality of life, as well as the reduction of fatal and non-fatal cardiac events. The failure of nitrates to continuously protect from myocardial ischemia ("nitrate tolerance") requires a modification of the current step-care recommendations for medical treatment. Numerous combinations of nitrates, betablockers and calcium channel blockers compensate for each other regarding their effects on heart rate, contractility, peripheral resistance and coronary blood flow. Recommendations for combination therapy decisively depend on the choice of the first-line drug. Only nitrates reduce myocardial preload by venodilation and substitute for EDRF-deficiency. After headaches disappear, nitrates do not affect quality of life and they are cheap. The nitrate-induced acceleration of heart rate should be compensated by the addition of beta-blockers or heart rate-decreasing calcium channel blockers. Therefore, the combination of nitrates with heart-rate-increasing calcium channel blockers, such as nifedipine, should be avoided. Many studies have proven the superiority of different double and triple therapies, as compared to their single components. A few reports, however, did not confirm this increase of anti-ischemic efficacy with combination therapy. The improvement of prognosis is proven for beta blockers without ISA in subgroups of patients with acute or post myocardial infarction and can be assumed for nitrates as well. With regard to prognosis, calcium channel blockers were inferior to nitrates and beta blockers. The combination of nitrates with a non-ISA betablocker should be preferred in post myocardial infarction patients with ventricular arrhythmias, whereas the combination of nitrates with a heart rate decreasing calcium channel blocker should be preferred in patients with COPD, severe peripheral arterial disease or severe diabetes. The combination of nitrates with a heart-rate-increasing calcium channel blocker should be considered in patients with sinus bradycardia, first degree AV-block, or proven coronary spasm. In patients with congestive heart failure, betablockers and calcium channel blockers should be avoided. To optimize medical treatment of ischemic heart disease, intermittent high dosage ISDN plus a beta blocker without ISA or ISDN plus a calcium channel blocker like verapamil are recommended. Frequently, however, the patient decides by himself, based on unacceptable side effects.

Adrenergic beta-Antagonists↗

PubMed1977

Drug prescribing in rheumatoid arthritis in Otago.

The drug therapy prescribed for a group of 50 patients with rheumatoid arthritis in Otago prior to specialist referral was examined. Thirty-two patients were receiving some first-line anti-inflammatory drugs and six were receiving no therapy at the time of their first hospital clinic visit. Salicylates had been prescribed first in only 16 of the 50 patients while this drug had been withdrawn because of side effects in about one-third of the patients who had been treated with it prior to specialist referral. Seven patients had received phenylbutazone and six corticosteroids as the first treatment for their rheumatoid arthritis. About one-third of the patients were receiving more than one anti-inflammatory drug at the time of their initial clinic visit.

Adult↗

PubMed1979

Bretylium tosylate: a review.

The chemistry, pharmacology, pharmacokinetics, clinical uses, adverse effects, drug interactions and dosage of bretylium tosylate, a recently approved antiarrhythmic agent, are reviewed. Bretylium tosylate is used to treat life-threatening ventricular arrhythmias, principally ventricular fibrillation and ventricular tachycardia, that have not responded to treatment with first-line antiarrhythmic agents. The drug has a direct positive inotropic effect on the myocardium and blocking effect on postganglionic sympathetic nerve transmission. The drug is poorly absorbed orally, requiring either i.m. or i.v. administration. Drug excretion occurs primarily through the kidney, necessitating dosage modification in renal disease. Hypotension is the most commonly observed adverse reaction to bretylium tosylate. Rapid i.v. administration may cause severe nausea and vomiting, and i.m. injection at the same site may cause atrophy and necrosis of muscle tissue. Quinidine and procainamide may potentiate the hypotensive effects of bretylium. Bretylium will aggravate digitalis-induced arrhythmias. Bretylium's use in resistant ventricular tachyarrhythmias requires close clinical monitoring.

Arrhythmias, Cardiac↗

PubMed1979

[Current chemotherapy of pulmonary tuberculosis].

Tuberculosis has today lost much of its dread for mankind: in 1976, 1823 persons contracted tuberculosis and 182 died of pulmonary tuberculosis in Switzerland. In contrast, 1375 died of pneumonia, 1309 of non-specific airway disease and 2202 of bronchial cancer in the same year. The present data on morbidity and mortality in Switzerland resemble those of the other industrial European countries or the USA. The decrease in morbidity and mortality of pulmonary tuberculosis was caused-among other factors-by chemotherapy. Chemotherapy not only profoundly changed the infectivity of tuberculous patients and made ambulatory, domiciliary treatment possible, but cured pulmonary tuberculosis. The introduction of the bactericidal rifampicin led to the latest major landmark in the chemotherapy of tuberculosis in the past 20 years: namely, short-course chemotherapy. Together with the other first-line drugs (isoniazid, streptomycin, ethambutol), rifampicin shortened the duration of chemotherapy from 18--24 to 9--12 months. Short-course chemotherapy is today the therapy of choice for most patients with pulmonary tuberculosis.

BCG Vaccine↗

PubMed2026

[Tics and Tourette Syndrome].

Tics disorders and Tourette syndrome (TS) are neurodevelopmental conditions characterized by motor and/or vocal tics with onset in childhood. Their clinical presentation is heterogeneous and fluctuating over time, with exacerbations related to emotional, environmental, and medical factors. Diagnosis is clinical and based on medical history and neurological examination, following DSM-5-TR criteria, with ancillary testing rarely required. The prevalence of TS is estimated at 0.7%, while transient tic disorders affect up to 10% of children. The natural history is generally favorable, with symptom improvement during adolescence, although a subset of patients continues to experience tics into adulthood. Most individuals with TS present psychiatric comorbidities, particularly attention-deficit/hyperactivity disorder and obsessive-compulsive disorder, which significantly impact quality of life and should be prioritized in management decisions. Treatment is recommended only when tics cause functional impairment and follows a stepwise approach including psychoeducation, behavioral interventions, and individualized pharmacological therapy. Comprehensive behavioral intervention for tics is considered first-line treatment when available. Alpha-2 adrenergic agonists and dopamine antagonists are the most commonly used pharmacological options. Neuromodulation therapies are reserved for severe, refractory cases. These recommendations from the Ibero-American Academy of Pediatric Neurology summarize current evidence and provide a practical, updated framework for the diagnosis and management of tic disorders and Tourette syndrome in pediatric patients.

Humans↗

PubMed1978

Rheumatoid arthritis.

Management should help relieve symptoms, increase or maintain function, produce few side effects and keep the cost to a minimum. Aspirin remains the first-line drug; other nonsteroidal anti-inflammatory drugs may be useful when aspirin cannot be tolerated. Symptoms and signs of rheumatoid disease may be suppressed by corticosteroids, but only gold compounds, penicillamine and cytotoxic therapy have been shown to decrease disease activity and lessen permanent joint damage.

Adrenal Cortex Hormones↗