Related Articles

Which parameters differ in very old patients with chronic atrial fibrillation treated by anticoagulant or aspirin? Antithrombotic treatment of atrial fibrillation in the elderly.

Fundam Clin Pharmacol. 2008 Oct;22(5):569-74

Authors: Doucet J, Gréboval-Furstenfeld E, Tavildari A, M'bello L, Delaunay O, Pesqué T, Moirot P, Mouton-Schleifer D

The objective was to determine the main parameters taken into account for the decision of antithrombotic treatment of atrial fibrillation (AF) by vitamin K antagonist or aspirin. This was a prospective clinical study of four clinical services of geriatric medicine. Two hundred and nine inpatients, 84.7 +/- 7 years (women 60.8%), with chronic AF were included. The patients were distributed into two groups (anticoagulant or aspirin) according to medical decision. All the decision criteria for treatment were recorded: cardiopathy, conditions of life, clinical examination (nutrition and autonomy, mini-mental state examination (MMSE), walking evaluation, comorbidity), subjective evaluation of risk of falls and glomerular filtration rate. The thromboembolic risk and the bleeding risk, evaluated subjectively for each patient, were compared with two scores of thrombo-embolic risk and bleeding risk. The evolution of the patients was recorded after 3 months. Student’s t-test and chi-squared tests were used for statistical analysis. One hundred and two patients (48.8%) received anticoagulant and 107 patients received aspirin. Patients in the aspirin group were significantly older (86.5 +/- 6.5 vs. 82.9 +/- 7.1 years), with more frequent social isolation, higher systolic blood pressure, and had more important subjective bleeding risk and risk of falls. Patients in the anticoagulant group had significantly more valvulopathies and a more important subjective thromboembolic risk. Thrombo-phlebitis antecedents, dementia, denutrition and walking alterations were only slightly more frequent in patients in the aspirin group. Physicians underestimated thromboembolic risk (one-third of patients) and they overestimated bleeding risk (half of the patients). After 3 months, the two groups did not significantly differ for death, bleeding or ischaemic events. In common practice, the decision of antithrombotic treatment for AF should take into account not only cardiovascular but also geriatric criteria.

PMID: 18844728 [PubMed - indexed for MEDLINE]

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Association Between Mortality and Persistent Use of Beta Blockers and Angiotensin-Converting Enzyme Inhibitors in Patients With Left Ventricular Systolic Dysfunction and Coronary Artery Disease.

Am J Cardiol. 2009 Jun 1;103(11):1518-1524

Authors: Allen Lapointe NM, Zhou Y, Stafford JA, Hernandez AF, Kramer JM, Anstrom KJ

Beta blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) are evidence-based medications for chronic heart failure, but little is known about the persistent use and clinical effectiveness of these medications. We evaluated the longer-term use of beta blockers and ACEIs/ARBs in patients with left ventricular systolic dysfunction and coronary artery disease. Patients with an ejection fraction <40% and coronary artery disease who had a cardiac catheterization from April 1994 through December 2005 were identified. Long-term patterns of beta-blocker and ACEI/ARB use were categorized as persistent, new, previous, or no use based on information from routine follow-up surveys. Characteristics among medication-use groups were explored, and survival associated with persistent use was determined. Of 3,187 patients identified for the beta-blocker analysis, 1,339 (42.0%) had persistent use. Conditional on surviving for >/=2 follow-up surveys, the adjusted risk of death was statistically significantly lower with persistent use versus no use (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.65 to 0.82) and new use versus no use (HR 0.81, 95% CI 0.68 to 0.97). Adjusted risk of death was not statistically significantly different between persistent or new use of an evidence-based beta blocker and persistent use of a nonevidence-based beta blocker (HR 0.96, 95% CI 0.78 to 1.17). Of 3,166 patients identified for the ACEI/ARB analysis, 1,347 (42.5%) had persistent use. There was no statistically significant association between adjusted mortality and persistent use (HR 0.93, 95% CI 0.81 to 1.05), new use (HR 0.86, 95% CI 0.71 to 1.03), or previous use (HR 0.88, 95% CI 0.73 to 1.07) compared with no ACEI/ARB use. In conclusion, persistent and new use of beta blockers was associated with survival, but evidence-based beta blockers did not appear superior to nonevidence-based beta blockers. We were unable to demonstrate a statistically significant association between persistent ACEI/ARB use and survival.

PMID: 19463509 [PubMed - as supplied by publisher]

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Use of non-invasive ventilation to wean critically ill adults off invasive ventilation: meta-analysis and systematic review.

BMJ. 2009;338:b1574

Authors: Burns KE, Adhikari NK, Keenan SP, Meade M

OBJECTIVE: To summarise the evidence for early extubation with immediate application of non-invasive ventilation compared with continued invasive weaning on important outcomes in intubated adults with respiratory failure. DESIGN: Systematic review and meta-analysis of randomised and quasi-randomised controlled trials. SETTING: Intensive care units. PARTICIPANTS: Critically ill adults receiving invasive ventilation. Study selection criteria We searched Medline, Embase, and CENTRAL, proceedings from four conferences, and reference lists of relevant studies to identify relevant trials. Two reviewers independently selected trials, assessed trial quality, and abstracted data. RESULTS: We identified 12 trials enrolling 530 participants, mostly with chronic obstructive pulmonary disease. Compared with invasive weaning, non-invasive weaning was significantly associated with reduced mortality (relative risk 0.55, 95% confidence interval 0.38 to 0.79), ventilator associated pneumonia (0.29, 95% 0.19 to 0.45), length of stay in intensive care unit (weighted mean difference -6.27 days, -8.77 to -3.78) and hospital (-7.19 days, -10.80 to -3.58), total duration of ventilation, and duration of invasive ventilation. Non-invasive weaning had no effect on weaning failures or weaning time. Benefits on mortality and weaning failures were non-significantly greater in trials that exclusively enrolled patients with chronic obstructive pulmonary disease versus mixed populations. CONCLUSIONS: Current trials in critically ill adults show a consistent positive effect of non-invasive weaning on mortality and ventilator associated pneumonia, though the net clinical benefits remain to be fully elucidated. Non-invasive ventilation should preferentially be used in patients with chronic obstructive pulmonary disease in a highly monitored environment.

PMID: 19460803 [PubMed - in process]

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Gastrointestinal lesions associated with spondyloarthropathies.

World J Gastroenterol. 2009 May 28;15(20):2443-8

Authors: Orlando A, Renna S, Perricone G, Cottone M

Subclinical gut inflammation has been described in up to two-thirds of patients with spondyloarthropathies (SpA). Arthritis represents an extra-intestinal manifestation of several gastrointestinal diseases, including inflammatory bowel disease (IBD), Whipple’s disease, Behcet’s disease, celiac disease, intestinal bypass surgery, parasitic infections of the gut and pseudomembranous colitis. Moreover about two-thirds of nonsteroidal anti-inflammatory drug users demonstrate intestinal inflammation. Arthritis may manifest as a peripheral or axial arthritis. The spondyloarthropathy family consists of the following entities: ankylosing spondylitis, undifferentiated spondyloarthritis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with IBD, juvenile onset spondyloarthritis. This topic reviews the major gastrointestinal manifestations that can occur in patients with SpA and in nonsteroidal anti-inflammatory drugs users.

PMID: 19468992 [PubMed - in process]

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Discussions with physicians about hospice among patients with metastatic lung cancer.

Arch Intern Med. 2009 May 25;169(10):954-62

Authors: Huskamp HA, Keating NL, Malin JL, Zaslavsky AM, Weeks JC, Earle CC, Teno JM, Virnig BA, Kahn KL, He Y, Ayanian JZ

BACKGROUND: Many terminally ill patients enroll in hospice only in the final days before death or not at all. Discussing hospice with a health care provider could increase awareness of hospice and possibly result in earlier use. METHODS: We used data on 1517 patients diagnosed as having stage IV lung cancer from a multiregional study. We estimated logistic regression models for the probability that a patient discussed hospice with a physician or other health care provider before an interview 4 to 7 months after diagnosis as reported by either the patient or surrogate or documented in the medical record. RESULTS: Half (53%) of the patients had discussed hospice with a provider. Patients who were black, Hispanic, non-English speaking, married or living with a partner, Medicaid beneficiaries, or had received chemotherapy were less likely to have discussed hospice. Only 53% of individuals who died within 2 months after the interview had discussed hospice, and rates were lower among those who lived longer. Patients who reported that they expected to live less than 2 years had much higher rates of discussion than those expecting to live longer. Patients reporting the most severe pain or dyspnea were no more likely to have discussed hospice than those reporting less severe or no symptoms. A third of patients who reported discussing do-not-resuscitate preferences with a physician had also discussed hospice. CONCLUSIONS: Many patients diagnosed as having metastatic lung cancer had not discussed hospice with a provider within 4 to 7 months after diagnosis. Increased communication with physicians could address patients’ lack of awareness about hospice and misunderstandings about prognosis.

PMID: 19468089 [PubMed - in process]

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Anemia: An independent predictor of death and hospitalizations among elderly patients with atrial fibrillation.

Am Heart J. 2009 Jun;157(6):1057-1063

Authors: Sharma S, Gage BF, Deych E, Rich MW

BACKGROUND: Anemia and atrial fibrillation (AF) are common among the elderly. Anemia is an independent predictor of mortality and morbidity for numerous cardiovascular and noncardiovascular diseases, but the association of anemia with mortality and hospitalizations in patients with AF requires clarification. METHODS: Subjects were 13,067 Medicare beneficiaries hospitalized with AF and included in the National Registry of Atrial Fibrillation II data set. Index hospitalization hematocrit (Hct) was obtained by structured chart abstraction. Cox proportional hazards models quantified the association of Hct with mortality and re-hospitalizations during a median follow-up period of 12 months. RESULTS: The mean age was 79.8 years, 58% were women, and the mean Hct was 39.2%. Hematocrit was significantly (P < .0001) associated with risk of death and of rehospitalization even after adjustment for demographic information, comorbid conditions, and use of cardiovascular medications. As compared to a Hct of 40% to 44.9%, the adjusted hazard ratios for mortality were 1.66 for Hct <25%, 1.50 for 25% to 29.9%, 1.28 for 30% to 34.9%, 1.07 for 35% to 39.9%, 1.03 for 45% to 49.9%, and 1.10 for >/=50%. The association between anemia and mortality was significant in men and women but stronger in men (P = .006 for interaction). Compared to the category 40% to 44.9%, the risk of rehospitalization was increased to 28% (adjusted hazard ratio 1.28, 95% CI 1.15-1.43) in the Hct category 25% to 29.9%. CONCLUSION: Anemia is an independent predictor of mortality and of hospitalizations in elderly patients with AF. Studies are needed to assess the effect of treatment of anemia on clinical outcomes.

PMID: 19464417 [PubMed - as supplied by publisher]

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Cost-effectiveness of warfarin: Trial versus “real-world” stroke prevention in atrial fibrillation.

Am Heart J. 2009 Jun;157(6):1064-1073

Authors: Sorensen SV, Dewilde S, Singer DE, Goldhaber SZ, Monz BU, Plumb JM

BACKGROUND AND PURPOSE: Previous cost-effectiveness analyses analyzed warfarin for stroke prevention in randomized trial settings. Given the complexities of warfarin treatment, cost-effectiveness should be examined within a real-world setting. METHODS: Our model followed patients with atrial fibrillation at moderate to high risk of stroke through primary and recurrent ischemic stroke, hemorrhages-intracranial and extracranial, and the resulting disability. Four scenarios were examined: (1) all patients start on warfarin with perfect control, that is, international normalized ratio (INR) values always within range; (2) all patients start on warfarin with trial-like control, where INR can fall outside the recommended range; (3) all patients start on warfarin with real-world INR control; and (4) real-world prescription (and control) of warfarin, aspirin, or neither for warfarin-eligible patients. Reported warfarin discontinuation rates were used. Main outcomes were total number of events, quality adjusted life years, and costs in a US setting. RESULTS: The total number of primary and recurrent ischemic strokes in a 1,000-patient cohort (age 70 years, lifetime analysis) was 626, 832, 984, and 1,171 in scenarios 1 to 4, respectively. The corresponding mean quality adjusted life years per patient were 7.21, 6.92, 6.75, and 6.67 for scenarios 1 to 4, respectively. Costs per patient were $68,039, $77,764, $84,518, and $87,248 in scenarios 1 to 4, respectively. If “perfect” adherence to warfarin was assumed, except for discontinuations for clinical reasons, strokes would decrease to 503, 737, 909, and 1,120 in scenarios 1 to 4, respectively. CONCLUSIONS: Clinical and cost outcomes are strongly dependent on the quality of anticoagulation and rates of warfarin discontinuation. Clinicians should work to improve both. Policy makers should use real-world INR control and warfarin discontinuation rates when assessing cost-effectiveness.

PMID: 19464418 [PubMed - as supplied by publisher]

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Epidemiology and Outcomes of Clostridium difficile-Associated Disease Among Patients on Prolonged Acute Mechanical Ventilation.

Chest. 2009 May 22;

Authors: Zilberberg MD, Nathanson BH, Sadigov S, Higgins TL, Kollef MH, Shorr AF

Purpose Patients on prolonged acute mechanical ventilation (PAMV), though comprising one third of all MV patients, consume two thirds of all the resources allocated to MV, and their numbers are projected to double by year 2020. By virtue of their prolonged hospital length of stay (LOS, median 17 days), they are subject to such nosocomial infections as Clostridium difficile-associated disease (CDAD), whose incidence and age-adjusted case fatality rate have doubled between 2000 and 2005. We examined the rates and outcomes of CDAD among adult PAMV patients. Methods We analyzed 2005 data from the Health Care Utilization Project (HCUP)/Nationwide Inpatient Sample (NIS) from the Agency for Healthcare Research and Quality (AHRQ). PAMV and CDAD were identified using the ICD-9-CM codes 96.72 and 008.45, respectively. Results Among 64,910 adult PAMV discharges in 2005, 3,468 (5.34%) had a concurrent diagnosis of CDAD. CDAD+ discharges were older (66.7 +/- 15.9 vs 63.7 +/- 16.9 years, p < 0.001), and more likely to be admitted from a long-term facility (5.7%vs 2.9%, p < 0.001) than CDAD-. While crude hospital mortality did not differ among PAMV discharges by CDAD status (32.6%CDAD+ and 33.0%CDAD-, p = 0.598), both unadjusted calculations and propensity-score adjustment showed a substantial increase in LOS (6.1 days; 95%CI 4.9-7.4) and total costs ($10,355; 95%CI $7,540-$13,170) among CDAD+ discharges. Conclusions PAMV patients have an order of magnitude higher risk of CDAD than other hospitalized patients. Concurrent CDAD infection is associated with increased hospital LOS and costs. PAMV population is an attractive target for aggressive measures aimed at CDAD prevention.

PMID: 19465510 [PubMed - as supplied by publisher]

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Troponin-Based Risk Stratification of Patients With Acute Nonmassive Pulmonary Embolism: Systematic Review and Metaanalysis.

Chest. 2009 May 22;

Authors: Jiménez D, Uresandi F, Otero R, Lobo JL, Monreal M, Martí D, Zamora J, Muriel A, Aujesky D, Yusen RD

Data synthesis From the literature search, 596 publications were screened. Nine studies that consisted of 1366 normotensive patients with acute symptomatic PE were deemed eligible. Pooled results showed that elevated troponin levels were associated with a 4.26-fold increased odds of overall mortality [95%confidence interval (CI) 2.13 to 8.50, heterogeneity chi = 12.64, df = 8, p = 0.125]. Summary receiver operating characteristic (SROC) curve analysis showed a relationship between sensitivity and specificity of troponin levels to predict overall mortality [Spearman rank correlation coefficient = 0.68 (p = 0.046)]. Pooled likelihood ratios were not extreme [negative likelihood ratio 0.59 (95%CI 0.39 to 0.88), and positive likelihood ratio 2.26 (95%CI 1.66 to 3.07)]. The Begg rank correlation method did not detect evidence of publication bias. Conclusions This metaanalysis indicates that elevated troponin levels do not adequately discern normotensive patients with acute symptomatic PE at high from those at low-risk for death.

PMID: 19465511 [PubMed - as supplied by publisher]

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Validity of a risk-prediction tool for hospital mortality: The Global Registry of Acute Coronary Events.

Am Heart J. 2009 Jun;157(6):1097-1105

Authors: Pieper KS, Gore JM, Fitzgerald G, Granger CB, Goldberg RJ, Steg G, Eagle KA, Anderson FA, Budaj A, Fox KA,

BACKGROUND: The Global Registry of Acute Coronary Events (GRACE) risk model provides a simple method for determining the probability of hospital death in acute coronary syndrome (ACS). The aim of this study was to explore the impact of modeling techniques on the risk model when generating predictions. METHODS: Patients with ACS (n = 48,023) with or without ST-segment elevation myocardial infarction (STEMI) were enrolled (123 hospitals, 14 countries) between April 1999 and June 2006. The original GRACE model did not include terms to account for possible differences in outcomes between patients with STEMI, non-STEMI, and unstable angina, nor did it account for changing risk across continuous measures. RESULTS: In this cohort, the influence on outcome of region of hospitalization and cardiac arrest at presentation changed over the 7-year study. Other interactions included previous percutaneous coronary intervention and age with type of ACS. However, these interactions were insufficient to affect the final risk score. The same variables as in the original score comprise the new score. Inclusion of nonlinearity and differential effects did little to change the model’s discrimination but influenced predictions for patients at extremes of risk. CONCLUSIONS: Irrespective of the inclusion of nonlinear and interaction terms, the updated GRACE risk model provides an excellent means to discriminate risk of death in patients with ACS and can be used as a simple nomogram to estimate risk in patients seen in clinical practice.

PMID: 19464422 [PubMed - as supplied by publisher]

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Comparison of one-week and two-week empirical trial with a high-dose rabeprazole in non-cardiac chest pain patients.

J Gastroenterol Hepatol. 2009 May 10;

Authors: Kim JH, Sinn DH, Son HJ, Kim JJ, Rhee JC, Rhee PL

Background: In patients with non-cardiac chest pain (NCCP), the optimal duration of an empirical trial with a high-dose proton pump inhibitor (PPI) is unclear. We aimed to compare the efficacy of one-week and two-week PPI trial in patients with weekly or more than weekly NCCP and to determine its optimal duration for diagnosing gastroesophageal reflux disease (GERD)-related NCCP. Methods: Forty-two patients with at least weekly NCCP were enrolled. The baseline symptoms were assessed using a daily symptom diary for seven days. Also, esophago-gastro-duodenoscopy and 24 h esophageal pH monitoring were performed for the diagnosis of GERD. Then, patients were treated with rabeprazole 20 mg twice daily for 14 days. To assess NCCP improvement during the PPI trial, the first week and the second week symptom diary were kept for 1-7 and 8-14 days. The PPI test was considered positive if a symptom score improved (50% compared to the baseline. Results: There was no significant difference for a positive PPI test between GERD-related NCCP group (n = 8, 50%) and non GERD-related NCCP group (n = 6, 23%) during the first week of the PPI test. However, during the second week, GERD-related NCCP had a higher positive PPI test (n = 13, 81%) than non GERD-related NCCP (n = 7, 27%) (P = 0.001) with a sensitivity and specificity of 81% and 62%, respectively. Conclusions: The rabeprazole empirical trial was diagnostic for patients with GERD-related NCCP, and its optimal duration was determined to be at least two weeks.

PMID: 19467139 [PubMed - as supplied by publisher]

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Related Articles

Anti-inflammatory effects and clinical efficacy of theophylline and tulobuterol in mild-to-moderate chronic obstructive pulmonary disease.

Pulm Pharmacol Ther. 2008 Dec;21(6):874-8

Authors: Kanehara M, Yokoyama A, Tomoda Y, Shiota N, Iwamoto H, Ishikawa N, Taooka Y, Haruta Y, Hattori N, Kohno N

BACKGROUND: The airway inflammation of chronic obstructive pulmonary disease (COPD) demonstrates a poor response to the anti-inflammatory actions of corticosteroids. However, long-acting beta(2)-agonists and low-dose theophylline are reported to have a possible anti-inflammatory effect in COPD. The aim of this study was to compare the effects of treatment between theophylline and the tulobuterol patch (transdermal patch preparation designed to yield sustained beta(2)-agonistic effects for 24h) on airway inflammation in addition to quality of life (QOL) and pulmonary function in mild-to-moderate COPD. METHODS: The study subjects consisted of 26 patients with COPD who were treated with theophylline or tulobuterol for 8 weeks with a wash-out period of 4 weeks in a randomized open-label crossover study. We prospectively investigated the differential cell counts and levels of inflammatory markers in induced sputum before and after treatment with theophylline and tulobuterol. We also examined pulmonary function and quality of life (QOL) as assessed by St. George’s Respiratory Questionnaire. RESULTS: In the induced sputum, the total inflammatory cell count and number of neutrophils were significantly reduced by treatment with low-dose theophylline. Neither of these parameters was significantly changed by treatment with tulobuterol. Pulmonary function measurements such as FEV(1), FEV(1) % pred, FVC, PEF, MEF(50), and MEF(25) were significantly improved by the treatment with low-dose theophylline but not tulobuterol. The total QOL scores, levels of interleukin 8 and myeloperoxidase in the supernatants of induced sputum, and serum levels of hypersensitive C-reactive protein were not significantly changed by either of the treatments. CONCLUSION: These results suggest that treatment with low-dose theophylline but not the tulobuterol patch may have anti-inflammatory effects and improve pulmonary function in mild-to-moderate COPD.

PMID: 18983928 [PubMed - indexed for MEDLINE]

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Combined prolonged-release oxycodone and naloxone improves bowel function in patients receiving opioids for moderate-to-severe non-malignant chronic pain: a randomised controlled trial.

Expert Opin Pharmacother. 2009 Mar;10(4):531-43

Authors: Löwenstein O, Leyendecker P, Hopp M, Schutter U, Rogers PD, Uhl R, Bond S, Kremers W, Nichols T, Krain B, Reimer K

BACKGROUND: This randomised, double-blind, double-dummy, parallel-group multicentre study assessed the impact of a total daily dose of 60-80 mg oral oxycodone prolonged-release (PR)/naloxone PR (OXN PR) as fixed-ratio combination for patients with opioid-induced constipation (OIC) having moderate-to-severe, non-malignant pain. METHODS: During pre-randomisation patients receiving opioids for moderate-to-severe non-malignant pain were converted to oxycodone PR (OXY PR) and titrated to an effective analgesic dose. During randomisation 265 patients on a stable OXY PR dose (60-80 mg/day) and with OIC were included in the full analysis population to receive OXN PR or OXY PR alone. Primary outcome was improvement in symptoms of constipation as measured by the Bowel Function Index (BFI). Secondary/exploratory outcomes examined analgesic efficacy and other bowel function parameters. RESULTS: After 4 weeks of treatment, patients receiving OXN PR showed a significant improvement in bowel function compared with those in the OXY PR group (-14.9; 95% CI: -17.9, -11.9; p<0.0001) as measured by BFI which was seen after only 1 week of treatment continuing to the end of the study. After 4 weeks of treatment, patients receiving OXN PR had a median number of 3.0 complete spontaneous bowel movements (CSBM) per week compared with only 1.0 for OXY PR alone. Laxative intake was lower in the OXN PR than the OXY PR group. Furthermore, improvements in bowel function were achieved without loss of analgesic efficacy; pain intensity scores were comparable between the groups and consistent for duration of the study. Most frequently reported adverse events were consistent with those reported for opioid analgesics; no new or unexpected adverse reactions attributable to OXN PR used in higher doses were observed. CONCLUSION: This study shows that the fixed-ratio combination of OXN PR is superior to OXY PR alone in terms of bowel function, while providing effective equivalent analgesia.

PMID: 19243306 [PubMed - indexed for MEDLINE]

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Insulin Glargine: a review 8 years after its introduction.

Expert Opin Pharmacother. 2009 Mar;10(4):705-18

Authors: Goykhman S, Drincic A, Desmangles JC, Rendell M

Insulin Glargine was the first long-acting insulin analog produced by recombinant DNA technology, approved for use by the US FDA in April 2000 and by the European Agency for the Evaluation of Medicinal Products in June, 2000. It has become the most widely used insulin in the USA owing to its long duration of action without a pronounced peak. The principal advantage of insulin Glargine over neutral protamine Hagedorn (NPH) insulin is in a lower frequency of hypoglycemic reactions, thus affording improved safety. It is used in both type 1 and type 2 diabetes, usually as a single daily dose. In type 2 patients, it is often the first insulin introduced as a single daily dose. Although insulin Glargine is typically administered as a single nighttime dose, it can be given in the morning or at any other time convenient for the patient. In labile type 1 diabetes, it is often most effective given as two daily injections. In obese, insulin-resistant patients, it may be best to administer insulin Glargine in two separate doses, owing to the high volumes of injected insulin required. Insulin Glargine does not treat postprandial hyperglycemia. It is necessary to supplement with short-acting insulin at mealtimes to control glucose surges after meals. Insulin Glargine is effective in hospitalized and postsurgical patients on account of its lack of pronounced insulin peaks and long duration of action. Although there is considerable use of Glargine in pregnant diabetic women, there is no definitive study to confirm its benefits. Insulin Glargine is thought to coprecipitate supplementary short-acting insulins when co-administered in the same syringe. Therefore, more injections are typically needed in the usual treatment regimen for insulin requiring diabetes. In many cases, constant basal insulin levels may be achieved with multiple overlapping doses of NPH insulin given together with short-acting insulin at mealtimes. Such a therapy may be less costly, but the major advantage of insulin Glargine remains the greater safety of a lower frequency of hypoglycemic reactions.

PMID: 19284367 [PubMed - indexed for MEDLINE]

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Randomized evaluation of octreotide vs prochlorperazine for ED treatment of migraine headache.

Am J Emerg Med. 2009 Feb;27(2):160-4

Authors: Miller MA, Levsky ME, Enslow W, Rosin A

Patients with headaches account for approximately 2% of all ED visits, with migraines being the most common defined primary headache syndrome. Our goals were to evaluate the efficacy of intravenous octreotide (OC) for the treatment of migraines, when compared to standard therapy with prochlorperazine. METHODS: The study was conducted as a double-blinded, randomized controlled trial. Each subject received either 100 microg of octreotide or 10 mg of prochlorperazine intravenously for a 2-minute period. RESULTS: Comparison of the change in median visual analog scale scores for 60 minutes demonstrated that octreotide was less effective at reducing pain (P = .03) and producing clinical success (P < .01). Restlessness consistent with akathisia was noted by 35% of the PC group and 8% of the OC group (P < .01). At 60 minutes, rescue medication was required by 48% of the patients in the OC group, whereas 10% of the PC group required such therapy (P < .01). All 44 patients were contacted for follow-up at 48 to 72 hours after enrollment. At that time, 10% of the prochlorperazine and 25% of the octreotide patients had experienced some headache recurrence (P = .1). CONCLUSION: Prochlorperazine was statistically superior to octreotide in clinical success rate and decrease in pain in migraine patients but caused more restlessness and sedation.

PMID: 19371522 [PubMed - indexed for MEDLINE]

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