BackgroundRespiratory syncytial virus (RSV) is a common infection among children, with nearly 70% of children affected by 2 years, 22% developing symptomatology and 2–5% requiring hospitalisation.National Clinical Practice guidelines and Paediatric Consensus Conference on acute bronchiolitis (AB) support the lack of effectiveness of most therapeutic interventions in AB caused by RSV.PurposeTo evaluate the suitability of therapeutic management in AB patients, in comparison with reference patterns, and to propose the establishment of corrective measures.Reference protocols make the following recommendations: contraindicate corticoids; not systematically indicate bronchodilator therapy and adrenaline; indicate palivizumab and ribavirine only in risk patients; indicate aerosolised 3% saline solution (SS); and supportive therapy (ST).Material and methodsRetrospective study including patients (≤2 years old) admitted to the paediatric unit from January to May 2015 with a diagnosis of AB.Variables were: diagnosis, RSV test, concomitant infection, antibiotherapy, risk factors (RF) (prematurity and complications), ST and palivizumab administration.Adequacy between established therapy and reference protocols was evaluated.Results250 patients ≤ 2 years old with AB were admitted to the paediatric unit during the above mentioned period. When admitted, 22 (9%) patients presented moderate to severe bronchiolitis and 60 (24%) presented RF (57% respiratory complications at birth, 27% prematurity and 17% other). Only one patient received palivizumab.RSV test results were: 205 (82%) positive, 40 (16%) negative.Only 13 (5%) patients presented concomitant infection when admitted, with 4 (80%) receiving antibiotics. The remaining 16 prescriptions were unjustified.Corticoids were prescribed in 97 (40%) patients, despite recommendations against its use in protocols.Bronchodilator therapy with salbutamol was prescribed in 144 (57%) patients, although data on its potential benefit in AB are conflicting and it is not systematically suggested.Adrenaline aerosols were conditionally prescribed in 16 (6%) patients, in concordance with not routinely recommended prescription.92 (36%) patients received aerosolised 3% SS alone or associated with a bronchodilator or adrenaline, recommended measure in protocols. ST was established in 100% of our patients, as recommended.ConclusionIn our population, the therapeutic approach in AB was far from the reference patterns, with usual establishment of non-effective measures. Elaboration and validation of a protocol between clinicians and pharmacists should be assssed as a corrective measure, in order to optimise AB management.No conflict of interest.
registers compiled and updated on the AIFA (Italian Drugs Agency) web monitoring platform. Patient data such as age, sex, smoking, diabetes, hypertension and adherence were extracted and processed using Microsoft Access. In the same way, lipid ratios were calculated, and factors and percentage cardiovascular risk at 10 years were calculated using the Framingham Heart Study algorithm. Results Average age was 63 years and 68% were men. About 60% of 120 patients had arterial hypertension and 22% had diabetes mellitus. Concomitant therapy with statins (evolocumab-alirocumab) was present in 42% and 56% of patients, respectively, while intolerance was found in 52% and 47% of cases, respectively. Adherence to therapy was 100%. LDL and triglyceride concentrations decreased (LDL À60%) while HDL values remained constant over the study period. The percentage risk of a 10 year cardiovascular event was reduced from about 35% to 15% in 6 months and remained stable at 12 months. Conclusion and relevance The results confirmed a reduction in LDL cholesterol levels. These drugs represent treatment for patients subject to therapeutic failure. Alirocumab and evolocumab are innovative drugs with high costs. Their use should be limited to patient categories who have no real feedback with conventional drugs used in hypercholesterolaemia.
BackgroundMultiple Sclerosis (MS) is the most common demyelinating disorder. Still today its pathogenesis is not well known, but there are several drugs to slow down disease progression. Interferon-B (IFN-B) drugs are useful to initiate treatment quickly after diagnosis. But treatment response to IFN-B is highly variable between individuals. There are recent investigations demonstrating genetic polymorphisms associated with the response to INF-B.PurposeTo determine the main genetic polymorphisms evaluated for possible clinical utility in MS.Material and methodsA literature review focused on genetic polymorphisms associated with IFN-B treatment responses in MS published in 2004 or later.ResultsTwenty-seven articles were reviewed. Different genes have been studied as a possible cause of inter-individual response. HLA genes have been associated with development of neutralising antibodies (NAbs) to interferon: rs4961252-GG, rs9272105-GG, HLA-DRB1*04:01, DRB1*04:08 and DRB1*16:01 polymorphisms were associated with higher risk of appearance of NAbs. In the CD46 gene the polymorphism rs2724385-AT was significantly lower and the TT genotype was higher in responders to interferon compared to non-responding patients. Other genes for pro and anti-inflammatory cytokines (IFNG, TNF, IFNB1, TGFB1) and receptors (IFNAR1, CCR5 and IL7RA) have been studied due to the inflammatory component of MS; Only the single alleles TGFB1*C and CCR5*d were associated with optimal IFN-B response. Another study associated one polymorphism (rs2542109-AA) from the ubiquitin-specific peptidase-18 gene with a better response to IFN-B. Another important gene studied was myxovirus resistance A (MXA) because previous studies demonstrated different gene expression in IFN-B patients treated. But in one study of two promoter region single nucleotide polymorphisms (rs2071430; rs17000900) no association was found with the clinical course.ConclusionAlthough individual genetic polymorphisms are relatively poor predictors, combinations of these will possibly be useful to guide therapeutic decision-making given the variety of different treatments now available with varying mechanisms of action and risks.ReferenceBaranzini SE, Madireddy LR, Cromer A, et al. Prognostic biomarkers of IFNb treatment in multiple sclerosis patients. Mult Scler 2014No conflict of interest.
BackgroundBiological agents are used to treat rheumatic diseases. Patients are initially treated at the recommended dose according to the results of clinical trials but there is no current consensus on what attitude to take following remission. The practice of dose optimisation (DO) is spreading among professionals, resulting in an effective strategy.PurposeTo evaluate the impact of etanercept DO in patients with chronic rheumatic diseases, in a real world setting.Material and methodsDescriptive, cross-sectional study between January and July 2015. Data were collected by reviewing patient’s clinical records. DO was defined as a treatment regimen with a reduced amount of drug than recommended in the product labelling, either by using lower doses or by spacing the intervals of administration. Measured parameters were: Disease Activity Score of 28 joints (DAS28) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) before and after DO, therapeutic regimens and reasons for withdrawal.Results193 patients received treatment with etanercept. Optimisation was started in 53 (27.5%) patients by spacing the dose interval: rheumatoid arthritis (43%), psoriatic arthritis (32%) and ankylosing spondylitis (25%).55% were women, and mean age was 49 years.At the standard dose, average values for DAS28 and BASDAI were 2.1 and 2.1, respectively, versus 2.0 and 2.6 at DO. In 11 patients, data were not available.30% of patients showed a reduction in clinical parameters considered (54% of DAS28 and BASDAI 10%), 22% presented no differences (8% DAS28 and BASDAI 40%) and 48% showed an increase (46% of DAS28 and BASDAI 50%) although they were not clinically relevant.The most common therapeutic regimens used were: 25 mg/week (70%), 25 mg/2 weeks (11%) and 25 mg/10 days (7%).3 (5.6%) returned to the recommended label dose, having good disease control to date.ConclusionIn our clinical practice, 27.5% of chronic rheumatic patients received DO of etanercept, showing a risk of relapse in 5.6% of cases but reinstatement of the recommended label dose seemed to reinstate disease control. Optimisation of biological treatment in rheumatic diseases could be effective resulting in less exposure. However, well designed studies are needed to establish the best optimisation strategy.No conflict of interest.
Background Pirfenidone is currently the only agent approved for mild to moderate idiopathic pulmonary fibrosis (IPF) in adults. Purpose To evaluate the effect of pirfenidone in two patients who met the criteria for use. Materials and methods Follow-up of two cases of IPF in a Spanish hospital. The most common parameters used when monitoring IPF are functional vital capacity (FVC) and diffusing capacity or Transfer Factor of the Lung for Carbon Monoxide (TLCO). Results Patient 1 was diagnosed in 2008. Initial treatment: 20 months of prednisone. Changed treatment in 2009 to triple therapy with azathioprine, N-acetylcysteine (NAC) and prednisone. This regimen lasted 11 months, after which NAC was used in monotherapy. In 2012 a new regimen was started: pirfenidone, NAC and prednisone. This lasted until the end of the observation period. During treatment with corticosteroids, TLCO decreased from 83 to 41%, and FVC from 68 to 52%. With the triple therapy, TLCO changed from 41 to 32% and FVC increased slightly from 52 to 57%. During the treatment with NAC in monotherapy, TLCO values remained at 35% and FVC at 58%. Finally, with pirfenidone, TLCO stabilised between 31% and 34% and FVC remained between 50% and 51%. Patient 2 was diagnosed in 2007. Initial treatment: 19 months with triple therapy after which NAC remained in monotherapy for 24 months. Treatment with pirfenidone, NAC and prednisone began in 2012 and continued until the end of the observation period. With the triple therapy regimen, TLCO decreased from 50 to 44% and FVC remained constant (80%). During the NAC monotherapy period, TLCO values fluctuated around 43 to 42%, with a minimum of 31%. With pirfenidone TLCO ranged from 37 to 39%, and FVC remained at 91%. Conclusions Although the two patients clearly stabilised in breathing patterns, in both cases this stability had been reached previously with NAC monotherapy. The results indicated that pirfenidone did not provide evident benefits in the treatment of IPF and its use may not be cost effective. No conflict of interest.
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