The Headache Pipeline: Excitement and Uncertainty.

There are many new treatment options available for migraine and more are coming. Three calcitonin gene-related peptide (CGRP) antagonist monoclonal antibodies have been approved and a 4th is due in early 2020. Small molecule CGRP receptor-blocking oral compounds, both for acute care and prevention, are also coming. Four neurostimulators are available, with others on the way. New acute treatments coming soon include the 5HT1F agonist lasmiditan, a zolmitriptan intradermal micro-needle patch, and a nasal mist sumatriptan with a permeability enhancer. Farther out, three novel dihydroergotamine delivery systems, and a liquid-filled capsule of celecoxib show early promise. A new, safer form of methysergide is in the works, as is a longer-duration onabotulinumtoxinA. As always with new products, questions regarding safety, tolerability, cost, and insurance coverage will need to be addressed. Despite these concerns and uncertainties, a robust headache treatment pipeline is good for patients who are not satisfied with the results of their treatment and/or cannot tolerate existing treatments.

Intravenous acetaminophen: a review of pharmacoeconomic science for perioperative use.

Hospitals are subject to more economic pressures than ever before. On the one hand, cost containment or cost reduction is paramount, particularly in relation to costly branded pharmaceuticals. On the other hand, quality measures and value-based reimbursement penalizes poor patient care. Multimodal analgesia sits squarely in this quandary, since its very nature requires use of multiple drugs with their associated costs, though this approach has the potential to improve quality of care. We undertook a comprehensive review of the pharmacoeconomics of IV acetaminophen, a new drug useful as part of a multimodal analgesic approach. While this new branded drug adds to direct drug costs, there is clear potential for IV acetaminophen to reduce the incidence of opioid-related adverse events and, in so doing, result in net hospital savings. This review describes many clinical studies showing significant improvements in postoperative nausea and vomiting, excessive sedation and pruritus. In addition, we describe studies demonstrating faster recovery times in the post-anesthesia care unit, intensive care unit and total hospital length of stay. Lastly, we summarize many studies demonstrating the robust effect of IV acetaminophen on patient satisfaction. A holistic view of total hospital performance should be adopted when reviewing drugs rather than a silo mentality within the pharmacy. While IV acetaminophen adds to drug costs, the body of evidence indicates this drug has the potential to improve outcomes and hospital efficiency.

Oral acetaminophen (paracetamol) for additional analgesia in phacoemulsification cataract surgery performed using topical anesthesia Randomized double-masked placebo-controlled trial.

PURPOSE: To evaluate the clinical analgesic efficacy of 1.0 g oral acetaminophen (paracetamol) given in addition to topical anesthesia before phacoemulsification cataract surgery. SETTING: Inpatient and outpatient ophthalmology clinics, Bydgoszcz, Poland. METHODS: Consecutive patients with age-related cataract having phacoemulsification under topical anesthesia (tetracaine 0.5%) were enrolled in a prospective double-blind randomized placebo-controlled study. Patients were randomly assigned to preoperative oral administration of a placebo medication or to oral administration of 1.0 g acetaminophen. The main outcome measure was intensity of pain during and after surgery. Pain intensity was measured using a 10 cm baseline visual analog scale and a discrete 5-category verbal rating scale. RESULTS: The study comprised 160 consecutive patients (80 in each group). Intraoperatively, the mean visual analog scale pain intensity score was 2.17 +/- 1.81 in the placebo group and 1.45 +/- 1.17 in the acetaminophen group and the mean verbal rating scale score, 1.11 +/- 0.73 and 0.67 +/- 0.66, respectively (P<.01). Postoperatively, the mean visual analog scale score for pain was 1.47 +/- 1.39 in the placebo group and 0.56 +/- 0.61 in the acetaminophen group and the mean verbal rating scale score, 0.94 +/- 0.79 and 0.28 +/- 0.41, respectively (P<.01). There was no significant difference in patient behavior during surgery and no significant adverse effects of acetaminophen use. CONCLUSION: Preoperative oral administration of acetaminophen 1.0 g was effective, convenient, safe, and cost effective in reducing intraoperative and postoperative pain in phacoemulsification performed using topical anesthesia.

Treatment modalities, health care resource utilization, and costs in patients diagnosed with interstitial cystitis.

OBJECTIVE: The aim of this study was to examine treatment modalities, health care resource utilization, and costs in patients diagnosed with interstitial cystitis (IC). STUDY DESIGN: Patients with a diagnosis of IC were identified from a national managed care administration claims database and classified into treatment cohorts. All-cause health care resource utilization and costs were calculated by treatment cohort. RESULTS: Patients treated with narcotics plus nonnarcotic analgesics were associated with higher mean health care costs. Patient cohorts treated with some of the more common oral therapies for interstitial cystitis, including pentosan polysulfate sodium, amitriptyline, and hydroxyzine, were associated with lower costs. Physician visits were fewest among patients treated with pentosan polysulfate sodium plus amitriptyline and hydroxyzine. Physician visits were higher for cohorts that included dimethyl sulfoxide plus cystoscopy or bladder irrigation, or narcotics plus nonnarcotic analgesics. CONCLUSION: Interstitial cystitis is associated with substantial costs and health care resource utilization.

[Drugs for postoperative analgesia: routine and new aspects: Part 2: opioids, ketamine and gabapentinoids]. / Medikamente zur postoperativen schmerztherapie: bewährtes und neues : Teil 2: Opioide, ketamin und gabapentinoide.

In part 1 of this review, perioperative aspects of the use of non-opioids (acetaminophene, dipyrone, traditional NSAR, coxibs) were discussed. In part 2 the perioperative aspects of opioids (weak opioids: tramadol, tilidine with naloxone, strong opioids: morphine, piritramide, oxycodone, hydromorphone, fentanyl, methadone, buprenorphine) and coanalgesics (gabapentinoids; ketamine) will now be presented. The main aim of the review is to describe the use, risks and cost of some substances to facilitate the differential indication. New aspects concerning the use of gabapentinoids and ketamine are discussed.

Economic evaluation alongside n-of-1 trials: getting closer to the margin.

The n-of-1 trial is a particularly flexible form of randomized controlled trial that involves a single patient receiving multiple episodes of alternative therapies. Although n-of-1 trials are only applicable in certain treatment areas, the collection of economic data within such trials may provide unique advantages. This paper illustrates the issues around the use of economic n-of-1 trials with a hypothetical example, and discusses their potential for the estimation of individualized cost-effectiveness.