Practical use of dabigatran etexilate for stroke prevention in atrial fibrillation

Atrial fibrillation (AF) is associated with an increased risk of thromboembolism, and is the most prevalent factor for cardioembolic stroke. Vitamin K antagonists (VKAs) have been the standard of care for stroke prevention in patients with AF since the early 1990s. They are very effective for the prevention of cardioembolic stroke, but are limited by factors such as drug-drug interactions, food interactions, slow onset and offset of action, haemorrhage and need for routine anticoagulation monitoring to maintain a therapeutic international normalised ratio (INR). Multiple new oral anticoagulants have been developed as potential replacements for VKAs for stroke prevention in AF. Most are small synthetic molecules that target thrombin (e.g. dabigatran etexilate) or factor Xa (e.g. rivaroxaban, apixaban, edoxaban, betrixaban, YM150). These drugs have predictable pharmacokinetics that allow fixed dosing without routine laboratory monitoring. Dabigatran etexilate, the first of these new oral anticoagulants to be approved by the United States Food and Drug Administration and the European Medicines Agency for stroke prevention in patients with non-valvular AF, represents an effective and safe alternative to VKAs. Under the auspices of the Regional Anticoagulation Working Group, a multidisciplinary group of experts in thrombosis and haemostasis from Central and Eastern Europe, an expert panel with expertise in AF convened to discuss practical, clinically important issues related to the long-term use of dabigatran for stroke prevention in non-valvular AF. The practical information reviewed in this article will help clinicians make appropriate use of this new therapeutic option in daily clinical practice.

Chronic administration of methylphenidate produces neurophysiological and behavioral sensitization.

The electrophysiological properties of acute and chronic methylphenidate (MPD) on neurons of the prefrontal cortex (PFC) and caudate nucleus (CN) have not been studied in awake, freely behaving animals. The present study was designed to investigate the dose-response effects of MPD on sensory evoked potentials recorded from the PFC and CN in freely behaving rats previously implanted with permanent electrodes, as well as their behavioral (locomotor) activities. On experimental day 1, locomotor behavior of rats was recorded for 2 h post-saline injection, and sensory evoked field potentials were recorded before and after saline and 0.6, 2.5, and 10 mg/kg, i.p., MPD administration. Animals were injected for the next five days with daily 2.5 mg/kg MPD to elicit behavioral sensitization. Locomotor recording was resumed on experimental days 2 and 6 after the MPD maintenance dose followed by 3 days of washout. On experimental day 10, rats were connected again to the electrophysiological recording system and rechallenged with saline and the identical MPD doses as on experimental day 1. On experimental day 11, rat's locomotor recording was resumed before and after 2.5 mg/kg MPD administration. Behavioral results showed that repeated administration of MPD induced behavioral sensitization. Challenge doses (0.6, 2.5, and 10.0 mg/kg) of MPD on experimental day 1 elicited dose-response attenuation in the response amplitude of the average sensory evoked field potential components recorded from the PFC and CN. Chronic MPD administration resulted in attenuation of the PFC's baseline recorded on experimental day 10, while the same treatment did not modulate the baseline recorded from the CN. Treatment of MPD on experimental day 10 resulted in further decrease of the average sensory evoked response compared to that obtained on experimental day 1. This observation of further decrease in the electrophysiological responses after chronic administration of MPD suggests that the sensory evoked responses on experimental day 10 represent neurophysiological sensitization. Moreover, two different response patterns were obtained from PFC and CN following chronic methylphenidate administration. In PFC, the baseline and effect of methylphenidate expressed electrophysiological sensitization on experimental day 10, while recording from CN did not exhibit any electrophysiological sensitization.

Modulating bioreductive drug activity with antivascular agents

Modulation of tumor hypoxia to increase bioreductive drug antitumor activity was investigated. The antivascular agent 5,6-dimethylxanthenone acetic acid (DMXAA) was used in combination studies with the bioreductive drugs Tirapazamine (TPZ) and Mitomycin C (MMC). Blood perfusion studies with DMXAA showed a maximal reduction of 66% in tumor blood flow 4 hours post drug administration. This tumor specific decrease in perfusion was also found to be dose-dependent, with 25 and 30 mg/kg DMXAA yielding greater than 50% reduction in tumor blood flow. Increases in antitumor activity with combination therapy (bioreductive drugs $+$ DMXAA) were significant over individual therapies, suggesting an increased activity due to increased hypoxia induced by DMXAA. Combination studies yielded the following significant tumor growth delays over control: MMC (5mg/kg) $+$ DMXAA (25mg/kg) = 20 days, MMC (2.5mg/kg) $+$ DMXAA (25 mg/kg) = 8 days, TPZ (21.4mg/kg) $+$ DMXAA (17.5mg/kg) = 4 days. The mechanism of interaction of these drugs was investigated by measuring metabolite production and DNA damage. 'Real time' microdialysis studies indicated maximal metabolite production at 20-30 minutes post injection for individual and combination therapies. DNA double strand breaks induced by TPZ $\pm$ DMXAA (20 minutes post injection) were analyzed by pulsed field gel electrophoresis (PFGE). Southern blot analyses and quantification showed TPZ induced DNA double strand breaks, but this effect was not evident in combination studies with DMXAA. Based on these data, combination studies of TPZ $+$ DMXAA showed increased antitumor activity over individual drug therapies. The mechanism of this increased activity, however, does not appear to be due to an increase in TPZ bioreduction at this time point. ^

Voluntary ingestion of antiparasitic drugs emulsified in honey represents an alternative to gavage in mice

The oral route is the most frequently used method of drug intake in humans. Oral administration of drugs to laboratory animals such as mice typically is achieved through gavage, in which a feeding needle is introduced into the esophagus and the drug is delivered directly into the stomach. This method requires technical skill, is stressful for animals, and introduces risk of injury, pain and morbidity. Here we investigated another method of drug administration. The benzimidazole derivative albendazole was emulsified in commercially available honey and administered to mice by voluntary feeding or gavage. Mice that received albendazole by either gavage or honey ingestion had virtually identical levels of serum albendazole sulfoxide, indicating that uptake and metabolism of albendazole was similar for both administration techniques. In addition, dosing mice with the albendazole-honey mixture for 8 wk had antiparasitic activity comparable to earlier studies using gavage for drug administration. Compared with gavage, voluntary ingestion of a drug in honey is more rapid, less stressful to the animal, and less technically demanding for the administrator. Because of its low cost and ready availability, honey presents a viable vehicle for drug delivery.

Linking altered central pain processing and genetic polymorphism to drug efficacy in chronic low back pain.

BACKGROUND Inability to predict the therapeutic effect of a drug in individual pain patients prolongs the process of drug and dose finding until satisfactory pharmacotherapy can be achieved. Many chronic pain conditions are associated with hypersensitivity of the nervous system or impaired endogenous pain modulation. Pharmacotherapy often aims at influencing these disturbed nociceptive processes. Its effect might therefore depend on the extent to which they are altered. Quantitative sensory testing (QST) can evaluate various aspects of pain processing and might therefore be able to predict the analgesic efficacy of a given drug. In the present study three drugs commonly used in the pharmacological management of chronic low back pain are investigated. The primary objective is to examine the ability of QST to predict pain reduction. As a secondary objective, the analgesic effects of these drugs and their effect on QST are evaluated. METHODS/DESIGN In this randomized, double blinded, placebo controlled cross-over study, patients with chronic low back pain are randomly assigned to imipramine, oxycodone or clobazam versus active placebo. QST is assessed at baseline, 1 and 2 h after drug administration. Pain intensity, side effects and patients' global impression of change are assessed in intervals of 30 min up to two hours after drug intake. Baseline QST is used as explanatory variable to predict drug effect. The change in QST over time is analyzed to describe the pharmacodynamic effects of each drug on experimental pain modalities. Genetic polymorphisms are analyzed as co-variables. DISCUSSION Pharmacotherapy is a mainstay in chronic pain treatment. Antidepressants, anticonvulsants and opioids are frequently prescribed in a "trial and error" fashion, without knowledge however, which drug suits best which patient. The present study addresses the important need to translate recent advances in pain research to clinical practice. Assessing the predictive value of central hypersensitivity and endogenous pain modulation could allow for the implementation of a mechanism-based treatment strategy in individual patients. TRIAL REGISTRATION Clinicaltrials.gov, NCT01179828.

Report from the National Institute of Allergy and Infectious Diseases workshop on drug allergy

Allergic reactions to drugs are a serious public health concern. In 2013, the Division of Allergy, Immunology, and Transplantation of the National Institute of Allergy and Infectious Diseases sponsored a workshop on drug allergy. International experts in the field of drug allergy with backgrounds in allergy, immunology, infectious diseases, dermatology, clinical pharmacology, and pharmacogenomics discussed the current state of drug allergy research. These experts were joined by representatives from several National Institutes of Health institutes and the US Food and Drug Administration. The participants identified important advances that make new research directions feasible and made suggestions for research priorities and for development of infrastructure to advance our knowledge of the mechanisms, diagnosis, management, and prevention of drug allergy. The workshop summary and recommendations are presented herein.

Interazione di nanoparticelle metalliche con menbrane biologiche: risultati di studi in vitro su cute, mucosa del cavo orale e meningi ed implicazioni per la salute

L’utilizzo di nanomateriali, ovvero una nuova classe di sostanze composte da particelle ultrafini con dimensioni comprese fra 1 e 100 nm (American Society for Testing Materials - ASTM), è in costante aumento a livello globale. La particolarità di tali sostanze è rappresentata da un alto rapporto tra la superficie e il volume delle particelle, che determina caratteristiche chimico-fisiche completamente differenti rispetto alle omologhe macrosostanze di riferimento. Tali caratteristiche sono tali da imporre una loro classificazione come nuovi agenti chimici (Royal Society & Royal Academy of Engineering report 2004). Gli impieghi attuali dei nanomateriali risultano in continua evoluzione, spaziando in diversi ambiti, dall’industria farmaceutica e cosmetica, all’industria tessile, elettronica, aerospaziale ed informatica. Diversi sono anche gli impieghi in campo biomedico; tra questi la diagnostica e la farmacoterapia. È quindi prevedibile che in futuro una quota sempre maggiore di lavoratori e consumatori risulteranno esposti a tali sostanze. Allo stato attuale non vi è una completa conoscenza degli effetti tossicologici ed ambientali di queste sostanze, pertanto, al fine di un loro utilizzo in totale sicurezza, risulta necessario capirne meglio l’impatto sulla salute, le vie di penetrazione nel corpo umano e il rischio per i lavoratori conseguente al loro utilizzo o lavorazione. La cute rappresenta la prima barriera nei confronti delle sostanze tossiche che possono entrare in contatto con l’organismo umano. Successivamente agli anni ‘60, quando si riteneva che la cute rappresentasse una barriera totalmente impermeabile, è stato dimostrato come essa presenti differenti gradi di permeabilità nei confronti di alcuni xenobiotici, dipendente dalle caratteristiche delle sostanze in esame, dal sito anatomico di penetrazione, dal grado di integrità della barriera stessa e dall’eventuale presenza di patologie della cute. La mucosa del cavo orale funge da primo filtro nei confronti delle sostanze che entrano in contatto con il tratto digestivo e può venir coinvolta in contaminazioni di superficie determinate da esposizioni occupazionali e/o ambientali. È noto che, rispetto alla cute, presenti una permeabilità all’acqua quattro volte maggiore, e, per tale motivo, è stata studiata come via di somministrazione di farmaci, ma, ad oggi, pochi sono gli studi che ne hanno valutato le caratteristiche di permeazione nei confronti delle nanoparticelle (NPs). Una terza importante barriera biologica è quella che ricopre il sistema nervoso centrale, essa è rappresentata da tre foglietti di tessuto connettivo, che assieme costituiscono le meningi. Questi tre foglietti rivestono completamente l’encefalo permettendone un isolamento, tradizionalmente ritenuto completo, nei confronti degli xenobiotici. L’unica via di assorbimento diretto, in questo contesto, è rappresentata dalla via intranasale. Essa permette un passaggio diretto di sostanze dall’epitelio olfattivo all’encefalo, eludendo la selettiva barriera emato-encefalica. Negli ultimi anni la letteratura scientifica si è arricchita di studi che hanno indagato le caratteristiche di assorbimento di farmaci attraverso questa via, ma pochissimi sono gli studi che hanno indagato la possibile penetrazione di nanoparticelle attraverso questa via, e nessuno, in particolar modo, ha indagato le caratteristiche di permeazione delle meningi. L’attività di ricerca svolta nell’ambito del presente dottorato ha avuto per finalità l’indagine delle caratteristiche di permeabilità e di assorbimento della cute, della mucosa del cavo orale e delle meningi nei confronti di alcune nanoparticelle, scelte fra quelle più rappresentative in relazione alla diffusione d’utilizzo a livello globale. I risultati degli esperimenti condotti hanno dimostrato, in vitro, che l’esposizione cutanea a Pt, Rh, Co3O4 e Ni NPs determinano permeazione in tracce dei medesimi metalli attraverso la cute, mentre per le TiO2 NPs tale permeazione non è stata dimostrata. È stato riscontrato, inoltre, che la mucosa del cavo orale e le meningi sono permeabili nei confronti dell’Ag in forma nanoparticellare.

Estudo observacional do uso da hipodermóclise em cuidados paliativos oncológicos

Hipodermóclise (HDC) é uma importante técnica alternativa para a administração de medicamentos e fluidos pela via subcutânea. É usada com frequência para o controle dos sintomas em pacientes em cuidados paliativos com dificuldade de acesso venoso e que são incapazes de tolerar medicação oral. No entanto, raros estudos abordaram o uso da HDC de uma forma global, para reposição hidroeletrolítica e terapia medicamentosa, tanto na forma contínua quanto intermitente, observando detalhes e complicações do seu uso. Os objetivos deste estudo incluíram caracterizar o uso da HDC para administração de medicamentos, soluções e eletrólitos e avaliar as possíveis complicações locais, identificando também outros fatores que influenciam sua ocorrência. Estudo observacional prospectivo com coleta de dados em prontuário e acompanhamento diário de pacientes internados com câncer avançado, da equipe de Cuidados Paliativos do Instituto do Câncer do Estado de São Paulo (ICESP) em uso de HDC, verificando local de punção, medicamentos administrados e possíveis complicações, acompanhando os detalhes de seu uso. A análise estatística não-paramétrica e método de regressão logística foram realizados. Foram acompanhados 99 pacientes com 243 punções, das quais 166 (68,3%) em coxa e 46 (18,9%) em abdome. Os medicamentos mais utilizados foram morfina em 122 (50,2%) punções, seguido de dipirona em 118 (48,6%) e dexametasona em 86 (35,4%). A solução mais prescrita foi a glicofisiológica em 38 (15,6%) punções, pelo seu aporte calórico. 13,6% das punções (33 de 243) tiveram complicações, sendo apenas seis casos maiores (edema). Complicações ocorreram mais frequentemente até o segundo dia da punção e foram associadas com o número (p=0,007) e o volume (p=0,042) de medicamentos administrados e também com a solução glicofisiológica (p=0,003) e os eletrólitos cloreto de potássio (p=0,037) e cloreto de sódio (p=0,013). Este estudo permitiu o conhecimento de fatores associados a complicações e propõe algumas recomendações, como: individualização da terapia, especialmente relacionada com o volume de escolha, número de medicamentos administrados e evitar a adição de eletrólitos na solução glicofisiológica

Alergia a beta-lactâmicos : uma revisão sistemática

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Drug registration and listing instruction booklet.

Mode of access: Internet.

From test tube to patient : new drug development in the United States.

Mode of access: Internet.

FDA drug bulletin April 1970 through October 1990 ; FDA medical bulletin March 1991 through June 1993 : index by subject and title.

Mode of access: Internet.

FDA drug bulletin.

Title from cover.

Pesticide chemicals: regulations under the Federal food, drug, and cosmetic act.

Kept up-to-date by revised pages which are inserted.

Drugs--current good manufacturing practice in manufacture, processing, packing, or holding. : regulations under the Federal Food, Drug, and Cosmetic Act, Part 133, Title 21, Code of Federal Regulations. Part 191, Hazardous substances.

Mode of access: Internet.