In elderly patients, the risks associated with polypharmacy are due to drug interactions, adverse effects, and poor compliance with complex treatment plans, leading to worsening of underlying conditions. Deprescribing is the cessation of therapy supervised by a clinician. Drugs that should be considered for cessation are those responsible for side effects, those not clinically indicated, drugs used to treat side effects of another drug that has already been stopped, or drugs used for the treatment of a situation that has resolved. There are few studies of the best method of deprescribing. The decision to stop a drug arises from the balance between therapeutic goals and the risk/benefit ratio of treatment.
Melatonin in primary insomnia: what is the evidence?Objetivos: rever as evidências existentes sobre o uso da melatonina no alívio da sintomatologia da Insônia Primária e na melhoria da qualidade de vida em doentes com ≥55 anos de idade. Métodos: pesquisa bibliográfica na base de dados Pubmed e sites de Medicina Baseada de meta-análises (MA), revisões sistemáticas (RS), ensaios clínicos aleatorizados e controlados (ECAC) e normas de orientação clínicas (NOC) utilizando os termos MeSH Melatonin e Sleep Initiation and Maintenance Disorders, publicados entre março de 2007 e janeiro de 2013 nas línguas inglesa, portuguesa e espanhola. Para atribuição de níveis de evidência e forças de recomendação, foi utilizada a escala Strenght of Recommendation Taxonomy (SORT) da American Family Physician. Resultados: foram encontrados 72 artigos; destes, foram incluídos seis: cinco ECAC e uma NOC. Os ECAC referem que a melatonina melhora de forma estatisticamente significativa a qualidade de sono, o estado de alerta matinal e a qualidade de vida comparativamente com o placebo. Também se verificou uma diminuição significativa da latência de sono. Nestes ECAC não se verificaram efeitos de privação após a descontinuação do tratamento. A NOC recomenda que o uso de melatonina em pacientes maiores de 55 anos de idade é preferencial ao uso de um hipnótico no tratamento da insônia. Conclusão: existe evidência suficiente para aconselhar a utilização da melatonina no alívio sintomático da Insônia Primária (SOR A), e na melhoria da qualidade de vida (SOR B). Contudo, são necessários mais estudos, com metodologias rigorosas e seguimento a longo prazo, para a obtenção de resultados mais consistentes. (38)845 www.rbmfc.org.br ARTIGOS DE REVISÃO La melatonina en insomnio primario: ¿ qué evidencias?Objectives: to review the existing evidence on the use of melatonin for relieving symptoms of primary insomnia and improving quality of life in patients ≥55 years of age. Methods: bibliographic search of the PubMed Database and evidence based medicine websites for meta-analyses, systematic reviews, randomized controlled trials (RCTs), and clinical guidelines published between March 2007 and January 2013 in English, Portuguese, or Spanish, using the MeSH terms "melatonin" and "sleep initiation and maintenance disorders". The American Family Physician's Strength of Recommendation (SOR) Taxonomy was used to establish the quality of the studies and define the strength of the recommendation. Results: of the 72 articles identified, six were selected: five RCTs and one clinical guideline. The RCTs reported that melatonin significantly improved quality of sleep, morning alertness, and quality of life compared with placebo. There was also a significant reduction in sleep latency. In these trials there were no withdrawal effects after discontinuation of treatment. The clinical guideline recommends the use of melatonin instead of a hypnotic in the treatment of insomnia in patients >55 years of age. Conclusion: there is sufficient evidence to recommend the use o...
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