The role of pharmacotherapy in the treatment of patients with borderline personality disorder

Most patients with borderline personality disorder (BPD), especially early in their treatment, will need pharmacotherapy along with supportive or exploratory psychotherapy. A benzodiazepine anxiolytic will suffice for some. Many require more definitive treatment with an antidepressant or a neuroleptic in low dosage. Those with bipolar II comorbidity may benefit from lithium or, if the irritability component is pronounced, from carbamazepine. In practice, a variety of personality factors and comorbid conditions, over-represented in populations of BPD patients, often complicate the clinical picture. Depending upon the mix of these factors, drugs may have to be avoided, nonstandard combinations of drugs may be necessary, or a safer but less effective drug may have to be substituted for a generally more effective drug whose abuse in a suicidal patient might have more dangerous consequences. Examples of complicating factors, namely premenstrual syndrome (PMS), bulimia, agoraphobia, major affective (including bipolar II manic-depressive) disorder, hypersomnia, and so forth are discussed.     

Predictors of non-adherence to pharmacotherapy in patients with type 2 diabetes

Background The prevalence of diabetes in Jordan is among the highest in the world, making it a particularly alarming health problem there. It has been indicated that poor adherence to the prescribed therapy lead to poor glycemic control and enhance the development of diabetes complications and unnecessary hospitalization. Objective To explore factors associated with medication nonadherence in patients with type 2 diabetes in Jordan. Findings would help guide the development of future pharmaceutical care interventions for patients with type 2 diabetes. Setting This study was conducted in an outpatient diabetes clinic at the Royal Medical Services Hospital. Method Variables including sociodemographics, disease and therapy factors, diabetes knowledge, health-related quality of life in addition to adherence assessment were collected for 171 patients with type 2 diabetes using medical records, custom-designed and validated questionnaires. Logistic regression was performed to develop a model with variables that best predicted medication non-adherence in patients with type 2 diabetes in Jordan. Main outcome measure Variables which significantly and independently associated with medication nonadherence in patients with type 2 diabetes in Jordan. Results Patients were found four times less likely to adhere to their medications with each unit increase in the number of prescribed medications (OR = 0.244, CI = 0.08–0.63) and nine times less likely to adhere to their medications if they received more than once daily dosing of diabetic medication (OR = 0.111, CI = 0.04–2.01). Patients in the present study were also approximately three times less likely (OR = 0.362, CI = 0.24–0.87) and twice less likely (OR = 0.537, CI = 0.07–1.31) to adhere to their medications if they reported having concerns about side effects and if they were taking metformin therapy respectively. Finally, participants were found twice more likely to adhere to medications if they had one or more Microvascular complication (OR = 0.493, CI = 0.08–1.16). Conclusion Simplifying dosage regimen, selecting treatments with lower side effects along with an emphasis on diabetes complications should be taken into account in future interventions designed to improve health outcomes for patients with type 2 diabetes.     

The effects of alcoholism pharmacotherapy on immune responses in alcohol-dependent patients

Chronic alcohol use has profound modulatory effects on the immune system. Both the innate and the acquired immunity are compromised. The use of pharmacotherapy is increasingly applied to enhance the percentage of success in maintaining alcoholic patients in remission. Disulfiram, naltrexone and gamma hydroxybutiric acid are the drugs used for this purpose in Italian Addiction Services. In this study we analyze the effect of pharmacotherapy of alcohol dependence on immune responses in alcoholics. Six groups were studied. Group A included 10 patients who were still using alcohol. Group B consisted of 10 patients abstinent from alcohol in treatment only with group therapy. Groups C, D and E were composed of 10 patients each, treated for at least 6 months with oral doses of gamma hydroxybutiric acid, naltrexone or disulfiram respectively. Ten age- and sex-matched healthy volunteers who never misused alcohol were included as a control group. Lymphoproliferation and peripheral mononuclear cell production of the Th1 cytokines IL-2 and IFN-gamma, the Th2 cytokine IL-4, and of the pro-inflammatory cytokines IL-1 and TNF-alpha were evaluated in all the patients and controls. The level of activity of the hypothalamus pituitary adrenal axis was assessed. Both ACTH and cortisol levels in plasma were elevated in alcoholic patients with no treatment. In this group a significant alteration of cytokine production was observed. TNF and IFN-gamma were lower than controls, while the Th2 cytokine IL-4 was increased. These altered levels state for a Th1/Th2 unbalance characterized by decreased Th1 response in the presence of Th2 predominance. In patients undergoing pharmacological treatment, none of the immune parameters were different from those observed in healthy controls, independently of the type of drug administered. These data indicate that pharmacotherapy more than group therapy treatment is able to ameliorate the immune system functioning in alcoholic patients.     

精神心理干预在功能性消化不良的药物治疗中的作用

目的：探讨功能性消化不良（FD）药物治疗与精神心理干预的临床疗效。方法：将348例FD门诊病人随机分为对照组和心理干预组各174例，对照组为单纯药物治疗组[兰索拉唑、莫沙必利、地西泮或氟哌噻吨／美利曲辛（黛力新）]；心理干预组在药物治疗的基础上采用精神心理疏导（启发开导和精神支持）及生活指导（生活饮食习惯），观察其疗效。结呆：对照组中显效60例（34．5％），有效72例（41．4％），总有效率75．9％；心理干预组中显效114例（65．5％），有效48例（27．6％），总有效率93．1％，两组总有效率差异具有显著性（P〈0．05）。结论：在抑酸药、促胃动力药及抗焦虑抑郁药治疗FD病人的基础上，加以精神心理疏导及生活指导能取得更好的治疗效果。     

The pharmacotherapy of overactive bladder

Urinary urgency is the key symptom of overactive bladder (OAB) and often forces patients to modify their lifestyle or daily routine. The impact of OAB on quality of life is significant. Antimuscarinics, an established pharmaceutical treatment for OAB, were originally thought to affect parasympathetic efferents to the bladder; however, there is increasing evidence of an important effect on afferent pathways. Dry mouth and constipation are the most common undesirable events resulting from the use of these agents. Imipramine, a tricyclic antidepressant, is a useful drug for the treatment of OAB, especially when combined with antimuscarinic agents, although this has not been adequately assessed as yet. One result of research in this field is the upcoming introduction of beta-3 agonists in the treatment of OAB. Botulinum toxin, a minimally invasive medical treatment, represents a new era for the treatment of refractory OAB. Despite the fact that this is currently an off-label treatment, it actually represents a widespread alternative method of therapy when conventional medical treatment fails. Pharmacotherapy will continue to play a major role in the treatment of OAB in the future.     

The pharmacotherapy of overactive bladder

Urinary urgency is the key symptom of overactive bladder (OAB) and often forces patients to modify their lifestyle or daily routine. The impact of OAB on quality of life is significant. Antimuscarinics, an established pharmaceutical treatment for OAB, were originally thought to affect parasympathetic efferents to the bladder; however, there is increasing evidence of an important effect on afferent pathways. Dry mouth and constipation are the most common undesirable events resulting from the use of these agents. Imipramine, a tricyclic antidepressant, is a useful drug for the treatment of OAB, especially when combined with antimuscarinic agents, although this has not been adequately assessed as yet. One result of research in this field is the upcoming introduction of beta-3 agonists in the treatment of OAB. Botulinum toxin, a minimally invasive medical treatment, represents a new era for the treatment of refractory OAB. Despite the fact that this is currently an off-label treatment, it actually represents a widespread alternative method of therapy when conventional medical treatment fails. Pharmacotherapy will continue to play a major role in the treatment of OAB in the future.     

New approaches to the pharmacotherapy of neuropathic pain

Pain is one of the most debilitating symptoms that presents with neuropathy. Neuropathic pain syndrome is a challenge to treat and, even with appropriate evidence-based treatment, only a 40% reduction of symptoms can be achieved in approximately half of patients. Furthermore, efficient doses are often difficult to obtain because of adverse effects. These observations underline that the treatment of neuropathic pain is still an unmet medical need. New approaches to the pharmacotherapy of neuropathy embrace different lines of work, including a fundamental mechanism-based approach, a clinical mechanism-based approach and an evidence-based approach. Moreover, interindividual variability in drug response, and genetic polymorphism in particular, is an emerging aspect to consider. Together with reviewing recent evidence-based guidelines as well as briefly discussing genetic polymorphisms that may influence the individual responses to treatments, this article will focus on what a mechanism-based approach is bringing to the clinical setting, on the perspective in fundamental research and on the difficulty of bridging the gap between fundamental notions and positive clinical outcomes.     

Antibiotic therapy: what to consider when treating geriatric patients

The epidemiology, etiology, clinical manifestations, diagnostic approach, and therapeutic choices may be quite different for infections that occur in elderly patients compared with those that occur in younger adults. Given these variables, it is essential for clinicians who care for older patients to understand how to prescribe antibiotics appropriately for this population. This article examines the unique characteristics of infections in the elderly as well as provides recommendations on the use of specific antibiotic agents commonly used to treat infections in geriatric patients.     

Pharmacokinetics of temazepam in geriatric patients

Summary A single dose of temazepam 10 mg, as a solution in soft gelatin capsules, was given to 10 fasting geriatric in-patients (mean age 83 years) in a stable clinical condition. The mean peak plasma concentration was 306 ng/ml, with a median time of 0.75 h to peak concentration. Temazepam was eliminated from plasma in a biexponential manner, with a distribution phase (mean t_1/2=0.7 h) predominating for 3 h. The drug had a mean elimination half-life of 8.7 h. In a chronic study, in which temazepam 10 mg p.o. was given nightly to 13 patients, the plasma concentrations on Days 3, 5, 8, 12 and 15 were not significantly different from each other, showing rapid attainment of steady state levels and the lack of drug accumulation.     

Metabolism of methaqualone in geriatric patients

Summary The urinary excretion of fiveC-monohydroxy metabolites and theN-oxide of methaqualone has been measured in a group of eleven geriatric patients aged 71–90 years. The total excretion of the six metabolites in 24 h after the oral administration of a single dose was approximately one-half of that in a group of young healthy adults. The relative importance of the six metabolites was 4-hydroxy N-oxide> 2-hydroxymethyl = 3-hydroxy > 6-hydroxy = 2-hydroxymethyl which was the same order as that in young adults. The ratio ofC-toN-oxidation was also the same in the two groups. There was no impairment of conjugation of theC-hydroxy metabolites with glucuronic acid in the geriatric group but there was greater interindividual variation in metabolite excretion. There was also evidence for delayed metabolism in the geriatric patients.     

Pharmacokinetics of triazolam in geriatric patients

Serum triazolam levels were determined in eight geriatric patients (average age 80 years) on Days 1 and 7 of administration of triazolam 0.25 mg once daily, 1 h after a standard breakfast. Triazolam was rapidly absorbed reaching average peak concentrations of 2.0 and 2.04 ng/ml, 1.5 and 1.38 h after administration on Days 1 and 7, respectively. The mean apparent elimination half-life was 1.41 h (range 0.73-4.13 h) on Day 1 and 1.37 h (range 0.69-3.36 h) on Day 7. There was no significant difference between mean serum triazolam concentrations or pharmacokinetic parameters on Days 1 and 7 of the treatment. Serum samples were also assayed for alpha-hydroxytriazolam, an active metabolite of triazolam, but none could be detected in any of the samples from Days 1 or 7, assay sensitivity 0.09 ng/2 ml serum. The range of half-lives of triazolam in the patients in the present study is in close agreement with that previously reported in elderly subjects. The study provides further evidence of the lack of change in pharmacokinetic parameters on multiple dosing and that drug accumulation did not occur.     

Assessing the appropriateness of physician prescribing for geriatric outpatients. Development and testing of an instrument.

OBJECTIVE: In a randomized, controlled trial evaluating the impact of clinical pharmacists' consultations on physicians' prescribing decisions, a seven-member physician/pharmacist panel developed an instrument to characterize and quantify the full range of drug-prescribing problems. The instrument was tested for validity and reliability. SAMPLE: The instrument was applied in reviewing prescribing for 236 geriatric outpatients. METHODS: To ensure internal validity of the instrument, five panel meetings were devoted to reaching a consensus on procedures, categories, criteria, and scoring. Each case was evaluated independently by two reviewers and each drug in the regimen was evaluated for drug-drug interactions, dosage, schedule, allergic reactions, therapeutic duplication, use of drugs without established diagnoses, and inappropriate drugs for the patient's clinical conditions; discrepancies were adjudicated by the panel chairperson. Self-reported adverse effects of 60 study patients who were interviewed, and hospital readmissions of all study patients were used to test the external validity of the instrument. RESULTS: Inter-rater reliability improved over time, reaching a high of 97.1 percent after six months. A positive association was determined between the prescribing scores and the number of reported adverse effects (rho = 0.28, p = 0.02). Although the number of patients with drug-related hospital readmissions was too few to establish a significant association between the prescribing scores and readmissions, the findings were expected. CONCLUSIONS: Given current requirements for drug utilization reviews in hospitals, health maintenance organizations, and Medicaid programs, this instrument may prove to be very useful.