Education and decision making at the time of triptan prescribing: patient expectations vs actual practice.

BACKGROUND: Optimizing patient satisfaction with their medical care and maximizing patient adherence with treatment plans requires an understanding of patient preferences regarding education and their role in decision making when treatments are prescribed. OBJECTIVE: To assess the congruence between patient expectations and actual practice regarding education and decision making at the time a triptan is prescribed. METHODS: This multicenter cross-sectional survey was performed by headache fellow members of the American Headache Society Headache Fellows Research Consortium at their respective tertiary care headache clinics. Migraine patients who were new patients to the headache clinic and who were current triptan users (use within prior 3 months and for ≥1 year) or past triptan users (no use within 6 months; prior use within 2 years) completed questionnaires that assessed the education they received and their role in decision making at the time a triptan was first prescribed as well as their desire for education and participation in decision making when a triptan is prescribed. RESULTS: Consistent with patient preference, most participants received the majority of their education about the triptan from the prescriber's office (70.2%). In descending rank order, participants most desired to be informed about how to decide if a triptan should be taken, when during the course of migraine a triptan should be taken, possible side effects, cost, and how to obtain refills. Regarding side effects, most participants preferred to receive education about the most common side effects of a triptan rather than addressing all possible side effects. Regarding triptan dosing, participants desired to be informed in descending order of importance about taking other medications with triptans, how many doses can be taken for each migraine, how many doses can be taken each week/month, what to do if the triptan does not work, and the triptan mechanism of action. The vast majority of participants (92%) preferred that the decision to prescribe a triptan be a joint decision between the patient and the provider. In actual practice, participants were not as involved in decision making as they would like to be, with patients reporting that the prescriber was the sole decision maker 55.1% of the time. Participants had confidence in their providers (87.7%) and generally felt they did a good job educating them about the triptan (71.1%). CONCLUSIONS: Based on this study, it is clear that patients prefer the shared model approach to medical decision making in regards to the prescription of triptans. The majority of patients received education that was generally consistent with their desires. Patients preferred that the prescribing provider be the primary source of information. The most desired educational topics included when/if a triptan should be taken, the number of times a triptan can be taken for a single migraine, co-administration with other acute medications, and the most common side effects. Focusing on these topics should enhance patient satisfaction and may improve compliance.

Triptan education and improving knowledge for optimal migraine treatment: an observational study.

BACKGROUND: It is generally felt that patient education and patient knowledge regarding triptan use for acute migraine management are important for successful and safe treatment. It is unclear how knowledgeable triptan users are regarding their triptan, how much education occurs when triptans are prescribed, and the impact patient education has on actual patient knowledge regarding triptan use. OBJECTIVE: The primary objective was to compare triptan users' self-perceived knowledge and actual knowledge about triptans in patients who report having received triptan education vs patients who report not having received triptan education. METHODS: This was a multicenter prospective observational study of 207 migraine patients who were using triptans for abortive therapy and who were being evaluated as new patients at academic headache specialty clinics in the United States. Patients completed standardized questionnaires regarding their self-perceived knowledge about triptans, their actual knowledge regarding triptans, and the perceived education about the triptan that they had received at the time of prescription. RESULTS: Although greater than 80% of the subjects reported receiving education about when to take the triptan and the number of doses they could take for headache, only 71.5% reported receiving education about triptan side effects, 64% for the number of triptan doses they could take each week/month, 64% for taking other medications with the triptan, and 49% for medical contraindications to triptan use. Compared with subjects who did not recall receiving education about when to take their triptan, subjects who recalled such education had a statistically significant greater actual knowledge for taking the triptan immediately after a headache begins (91% vs 77%, P = .049; confidence interval [CI]: 0.00-0.33), treating when pain is mild (75% vs 50%, P = .009; CI: 0.04-0.45), understanding that they do not need to fail treatment with over-the-counter medications before taking a triptan (74% vs 42%, P = .001; CI: 0.11-0.51), and recognizing that coronary artery disease is a contraindication to triptan use (40% vs 19%, P = .001; CI: 0.09-0.34). CONCLUSION: This study provides evidence that patients who recall having received education at the time of triptan prescribing have greater knowledge regarding optimal triptan use. Triptan users who recalled having received this education had greater recognition of the importance of taking the triptan immediately at the onset of a headache, treating when pain is mild, not needing to fail treatment with over-the-counter medications before taking a triptan, and understanding that coronary artery disease is a contraindication to triptan use.

Alpha-conotoxin residues that interact at close range with gamma-tyrosine-111 and mutant delta-tyrosine-113 on the Torpedo nicotinic acetylcholine receptor.

The alpha-conotoxins MI and GI display stronger affinities for the alphagamma agonist site on the Torpedo californica electrocyte nicotinic acetylcholine receptor (ACHR) than for the alphadelta agonist site, while alpha-conotoxin SI binds with the same affinity to both sites. Prior studies reported that the arginine at position 9 on GI and the tyrosine at position 111 on the receptor gamma subunit were responsible for the stronger alphagamma affinities of GI and MI, respectively. This study was undertaken to determine if the alpha-conotoxin midchain cationic residues interact with Torpedo gammaY111. The findings show that lysine 10 on MI is responsible for the alphagamma selectivity of MI and confirm the previously reported importance of R9 on GI and on the SI analogue, SIP9R. The results also show that gammaY111 contributes substantially to the selective alphagamma high affinity of all three peptides. Double-mutant cycle analyses reveal that, in the alphagamma site, K10 on MI and R9 on SIP9R interact with the aromatic ring of gammaY111 to stabilize the high-affinity complex, while in contrast, R9 on GI does not. The substitution of Y for R at position 113 on the delta subunit converts the alphadelta site into a high-affinity site for MI, GI, and SIP9R through the interacting of deltaY113 with K10 on MI and with R9 on both GI and SIP9R. The overall data show that the residues in the two sites with which MI interacts, other than at gamma111/delta113, are either the same or similar enough to exert equivalent effects on MI, indicating that MI binds in the same orientation at the alphagamma and alphadelta sites. Similar findings show that SIP9R probably also binds in the same orientation at the wild-type alphagamma and alphadelta sites. The finding that R9 on GI interacts closely with deltaR113Y but not with gammaY111 means that GI binds in different orientations at the alphagamma and alphadelta sites. This report also discusses the molecular basis of the difference in the MI high-affinity sites on Torpedo and embryonic mouse muscle ACHRs.