Climate-conscious inhaler prescribing for family physicians.

OBJECTIVE: To provide family physicians with prescribing and diagnostic strategies that can reduce carbon emissions associated with inhalers. SOURCES OF INFORMATION: This review is based on the authors' experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed. MAIN MESSAGE: There is growing acknowledgment of the substantial impact that inhalers have on climate emissions generated by the health sector. Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available. Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care and enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions. Family physicians may reduce carbon emissions associated with inhalers by reducing unnecessary inhaler prescribing; ensuring patients' control of asthma and COPD is optimized; considering whether a more sustainable inhaler may be appropriate; optimizing dosing technique to reduce emissions and waste; and disposing of inhalers appropriately if possible. CONCLUSION: Family physicians may reduce carbon emissions associated with inhalers through the following strategies: confirming diagnosis, controlling disease, considering inhaler type, optimizing dosing technique, and encouraging appropriate disposal.

Effect of the UGT1A1*28 allele on unconjugated hyperbilirubinemia in HIV-positive patients receiving Atazanavir: a systematic review.

OBJECTIVE: To systematically examine the literature assessing the effect of uridine 5'-diphospho-glucuronosyltransferase (UGT)1A1*28 genetic polymorphisms on atazanavir-associated hyperbilirubinemia. DATA SOURCES: MEDLINE (1948-November 2012), EMBASE (1980-November 2012), International Pharmaceutical Abstracts (1970-November 2012), Google, and Google Scholar were searched using combinations of the following terms: glucuronosyltransferase, glucuronosyltransferase 1A1, atazanavir, atazanavir plus ritonavir, or polymorph$. The reference lists of all identified articles were manually searched. STUDY SELECTION AND DATA EXTRACTION: Studies were included if at least 1 group of patients received atazanavir therapy and assessed the effect of UGT1A1*28 variants on bilirubin concentrations or atazanavir discontinuation rates. The quality of each study was ranked according to the US Preventive Services Task Force 1996 classification system. Information extracted included study design, baseline characteristics, treatment regimens, UGT1A1*28 genotype frequencies, bilirubin concentrations, incidence of hyperbilirubinemia, and atazanavir discontinuation rates. DATA SYNTHESIS: Our search produced 12 studies, of which 9 were included (6 full manuscripts [level II-2], 2 abstracts, and 1 letter to the editor [level III]). Reported UGT1A1*28 homozygote genotype frequencies (0.8-23.8%) were in general agreement with the literature for the diverse ethnic population captured in the 9 studies. An association between the incidence of hyperbilirubinemia and UGT1A1*28 genotype (homozygotes > heterozygotes > wild-type) was demonstrated in all studies that reported such data (6 of 9 studies). However, the calculated positive predictive value for homozygosity and hyperbilirubinemia from pooled data was low (40.3%). Only 2 studies (levels II-2 and III) reported rates of atazanavir discontinuation due to hyperbilirubinemia and showed some positive correlation with presence of the UGT1A1*28 allele. CONCLUSIONS: Based on the available evidence, homozygosity of the UGT1A1*28 allele does not strongly predict the incidence of severe hyperbilirubinemia. Thus, until large, prospective trials demonstrate otherwise, UGT1A1*28 testing does not appear to provide additional information to aid clinical decision-making when initiating atazanavir treatment in HIV-infected patients.

Patient preferences regarding atrial fibrillation stroke prophylaxis in patients at potential risk of atrial fibrillation.

Background With an increasing number of options for atrial fibrillation (AF) stroke prophylaxis, there are several medication-related factors to consider. This study aimed to gain a better understanding of which preference factors influence patient decisions when selecting AF stroke prophylaxis. Objective To determine the factors that influence patient stroke prophylaxis decisions and preferred therapeutic options. Methods A questionnaire about AF stroke prophylaxis medication options was distributed to participants at risk of AF. Preferences were elicited through ranking and rating medication preference factor statements, then selecting most and least preferred treatment options. Results Reduced stroke risk and lowest risk of an intracranial haemorrhage (ICH) had the highest median preference factor ranking of 2 (IQR, 1-3.5 for stroke reduction; 2-4 for ICH risk). Reducing stroke risk, availability of a lab test to assess drug effect, and availability of an antidote were the preference factors with the highest ratings. Apixaban was the most preferred treatment option (44% blinded to drug name, 37% unblinded) while 'No treatment' was the least preferred option (48% blinded, 52% unblinded). Conclusions Reducing stroke risk and limiting ICH risk were the most important medication factors to participants. High inter-participant preference variability suggests the importance of including the patient in decision-making when selecting AF stroke prophylaxis.

Lacosamide as adjunctive therapy in refractory epilepsy in adults: a systematic review.

PURPOSE: To review the evidence for efficacy and safety of lacosamide in adult patients with refractory epilepsy and refractory status epilepticus (RSE). METHODS: A systematic literature search of MEDLINE, PubMed, EMBASE, IPA, Google and Google Scholar (through October 2014) was performed. RESULTS: Fourteen studies assessing lacosamide in 3509 refractory epilepsy patients were included. In 3 RCTs, more patients had at least 50% reduction in seizure frequency with lacosamide compared to placebo with 38.3-41.1%, 38.1-41.2%, and 18.3-25.8%, in the 400 mg/day, 600 mg/day, and placebo groups, respectively. In non-comparative trials, 18-69% of patients achieved at least 50% reduction in seizure frequency, and 1.7-26.2% achieved seizure freedom. Non-responders were documented in two trials, with 26.2-34% having no response. Thirteen studies assessing lacosamide in 390 RSE patients were included. When assessing lacosamide's ability to terminate RSE, one comparative cohort study found no improvement in SE duration or seizure control with addition of lacosamide. Another study documented no difference compared to use of phenytoin. Eleven descriptive studies using lacosamide as add-on RSE therapy revealed seizure termination rates of 0-100% (median 64.7%). In all patients receiving lacosamide, dizziness (21.8%), vision disturbances (10.4%), drowsiness (7.4%), headache (7.0%), nausea (6.5%), and coordination problems (5.8%) were the most common adverse effects. CONCLUSION: Based on evidence to date, adjunctive lacosamide is a treatment option to reduce seizure frequency in patients with refractory epilepsy and terminate seizures in patients with RSE. The safety information summary can be used to advise patients of potential adverse effects.

Alcohol exposure among pregnant women in sub-saharan Africa: a systematic review.

BACKGROUND: The prevalence of general alcohol use in many countries of sub-Saharan Africa (SSA) is high. However, research examining alcohol use in among pregnant women within this population is limited. A review of the current status of research examining the prevalence of alcohol exposed pregnancies (AEP) is required to inform future research aiming to decrease this occurrence and its subsequent socio-economic complications. OBJECTIVE: The primary objective was to identify all published papers estimating prevalence and risk-factors of alcohol use among pregnant women in SSA. A secondary objective was to determine changes in alcohol use following pregnancy recognition. METHODS: PubMed/Medline, Embase, IPA, CINAHL were systematically searched using MeSH terms and keywords from inception date to March 2013. Studies from SSA reporting prevalence of alcohol use among pregnant women were included. RESULTS: Twelve studies were identified. Studies varied significantly according to design and study population. Prevalence of alcohol use during pregnancy ranged from 2.2%-87%. The most important risk-factors for alcohol use included tobacco use, partner violence, urban living, and having a male partner who drank alcohol. Only three studies examined changes in alcohol use prior to and following pregnancy recognition with absolute reductions of between 9% and 15%. CONCLUSIONS: Although the burden of alcohol use during pregnancy is likely a significant problem, limited data currently exist for the majority of SSA countries. Furthermore, significant variation likely exists within various populations. Further research is required to explore alcohol use in pregnancy. Strategies to decrease AEP must be developed and implemented in standard pre-natal care.