RESUMO
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.
Assuntos
Analgésicos não Narcóticos/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/uso terapêutico , Inibidores de Ciclo-Oxigenase 2/uso terapêutico , Terapia por Estimulação Elétrica , Transtornos de Enxaqueca/terapia , Agonistas do Receptor 5-HT1 de Serotonina/uso terapêutico , Estimulação Magnética Transcraniana , Vasoconstritores/uso terapêutico , Analgésicos não Narcóticos/administração & dosagem , Analgésicos não Narcóticos/efeitos adversos , Analgésicos não Narcóticos/economia , Anticorpos Monoclonais/administração & dosagem , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais/economia , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/administração & dosagem , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/efeitos adversos , Antagonistas do Receptor do Peptídeo Relacionado ao Gene de Calcitonina/economia , Inibidores de Ciclo-Oxigenase 2/administração & dosagem , Inibidores de Ciclo-Oxigenase 2/efeitos adversos , Inibidores de Ciclo-Oxigenase 2/economia , Humanos , Transtornos de Enxaqueca/tratamento farmacológico , Agonistas do Receptor 5-HT1 de Serotonina/administração & dosagem , Agonistas do Receptor 5-HT1 de Serotonina/efeitos adversos , Agonistas do Receptor 5-HT1 de Serotonina/economia , Vasoconstritores/administração & dosagem , Vasoconstritores/efeitos adversos , Vasoconstritores/economiaRESUMO
Wide awake hand surgery employs local-only anesthesia with low-dose epinephrine to create a bloodless field without the use of an arm tourniquet. Despite traditional teaching, evidence-based medicine suggests epinephrine is safe for use in hand and digital anesthesia. Eliminating an arm tourniquet reduces the requirement for sedation and general anesthetic. This confers particular advantage in surgeries such as tendon repairs, tendon transfers, and soft tissue releases in which intraoperative active motion can used to optimize outcomes. The wide awake approach also confers significant benefit to patients, providers, and health care systems alike due to efficiencies and cost savings.
Assuntos
Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Procedimentos Médicos e Cirúrgicos sem Sangue/métodos , Epinefrina/administração & dosagem , Mãos/irrigação sanguínea , Mãos/cirurgia , Procedimentos Ortopédicos/métodos , Vasoconstritores/administração & dosagem , Vigília , Anestesia Local/efeitos adversos , Anestesia Local/economia , Anestésicos Locais/efeitos adversos , Anestésicos Locais/economia , Procedimentos Médicos e Cirúrgicos sem Sangue/efeitos adversos , Procedimentos Médicos e Cirúrgicos sem Sangue/economia , Redução de Custos , Análise Custo-Benefício , Epinefrina/efeitos adversos , Epinefrina/economia , Custos de Cuidados de Saúde , Humanos , Injeções , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/economia , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Fluxo Sanguíneo Regional , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vasoconstritores/economiaRESUMO
In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these circumstances, steroids and triptans are frequently employed leading to fearful side effects in one and high costs in the other. The direct costs of drug-resistant chronic CH are mainly due to frequent medical consultations and frequent use of expensive drugs. In recent years, hypothalamic stimulation has been employed to treat drug-resistant chronic CH patients suffering multiple daily attacks and long-term results from different centres show a 60% overall benefit. Nine years since the introduction of this technique, we attempt a preliminary analysis of the direct costs of hypothalamic stimulation based on patients treated at our centre. We estimated the following direct costs as follows: cost of neurosurgery plus cost of equipment (electrode, connection and impulse generator = 25,000 euro), cost of hospital admissions in long-term follow-up (2,000 euro per admission), cost of single sumatriptan injection (25 euro). Number of daily sumatriptan injections in the year before and for each year after hypothalamic implantation was obtained from headache diaries. To estimate the saving due to the reduction in sumatriptan consumption following hypothalamic stimulation, we calculated the following for each year of follow-up after surgery: number of sumatriptan injections in the year before surgery minus number of sumatriptan injections in each year, updated to December 2008. In our 19 implanted patients, the costs of neurosurgery plus cost of equipment were 475,000 euro; the costs of hospital admissions during follow up were 250,000 euro. Reduction in sumatriptan consumption resulted in a total saving of 3,573,125 euro. Hence, in our 19 patients, the sumatriptan saving (3,573,125 euro) minus the direct costs due to operation and follow up hospitalisations (475,000 + 250,000) euro is equal to 2,848,125 euro. These preliminary results indicate that hypothalamic stimulation is associated with marked reduction of direct costs in the management of complete drug-resistant chronic CH.
Assuntos
Cefaleia Histamínica/economia , Cefaleia Histamínica/terapia , Estimulação Encefálica Profunda/economia , Hipotálamo , Adulto , Cefaleia Histamínica/cirurgia , Resistência a Medicamentos , Eletrônica Médica/economia , Feminino , Seguimentos , Custos de Cuidados de Saúde , Hospitalização/economia , Humanos , Masculino , Procedimentos Neurocirúrgicos/economia , Sumatriptana/economia , Sumatriptana/uso terapêutico , Vasoconstritores/economia , Vasoconstritores/uso terapêuticoRESUMO
Flexible nasendoscopy is now an integral part of the diagnostic process in Otorhinolaryngology. Topical local anaesthesia is generally recommended and cocaine is usually the drug of choice in view of its concurrent vasoconstrictor action. However, it is expensive, a controlled drug and serious side effects have been reported. Co-phenylcaine forte is a new preparation which also has both local anaesthetic and vasoconstrictor properties. This study compares the efficacy of cocaine and Co-phenylcaine in flexible nasendoscopy and concludes that they provide similar local anaesthesia and vasoconstriction of the nasal mucosa. Co-phenylcaine forte can therefore be used as an alternative to cocaine in flexible nasendoscopy.