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West Indian med. j ; 49(Suppl 2): 21, Apr. 2000.
Artigo em Inglês | MedCarib | ID: med-998


OBJECTIVE: To audit anti-epileptic drug monitoring in tertiary hospitals in Trinidad. METHODS: Epileptic patients, from hospital clinics, who were receiving maintenance therapy and were referred for plasma drug level monitoring, gave informed consent and were enrolled. Blood collection was at trough levels of drug and coded plasma samples were analysed by competitive immunoassay on the TDx Monitoring system. RESULTS: All 93 patients consented to participate. Phenytoin and carbamazepine were the two major drugs prescribed. The use of multiple drugs did not influence the occurrence of seizures in the patients; (31 percent) receiving polytherapy. Phenobarbital was the most frequent agent added to the drug regime in 24/9 patients (83 percent). Low plasma levels of drugs were detected in 58 percent and 36 percent of patients receiving polytherapy with phenytoin and carbamazepine respectively; but an association was not found between the range of drug levels and the frequency of seizures. Seventy-seven (83 percent) patients reported good compliance. Plasma drug levels were significantly below normal (p=0.004) in patients who reported poor compliance. CONCLUSIONS: Multiple drug therapy did not influence the prognosis of seizure control in this study. Suspected non-compliance, drug toxicity and failure to individualize dosing are considerations for plasma level drug monitoring in the protocol for management of epilepsy.(Au)

Humanos , Anticonvulsivantes/análise , Monitoramento de Medicamentos , Epilepsia/tratamento farmacológico , Epilepsia/prevenção & controle , Fenitoína/uso terapêutico , Carbamazepina/uso terapêutico , Trinidad e Tobago
West Indian med. j ; 43(Suppl. 2): 4, July, 1994.
Artigo em Inglês | MedCarib | ID: med-6506


Over 50 percent of diabetics have measuable neuropathy, but only about 15 percent have symptoms (Dyck et al, 1993), of which pain is the most distressing. The pain of diabetic neuropathy (DN) is thought to arise from regenerating axons and spontaneously firing small nociceptive fibres. In addition, poor diabetic control (hyperglycaemia) may reduce the individual pain threshold. Ordinary analgesics are usually ineffective and opiates should be used cautiously because both in the depressed and non-depressed but side effects are common, especially in the elderly patient. The starting dose should be 10 - 25 mg given at night to controlnocturnal exacerbations of pain. Imipramine, another tricyclic anti-depressant with less anticholinergic inhibitor, are alternatives to amitriptyline. Pain which is lancinating in quality may repond better to carbamazepine at a starting dose of 200 mg daily. Mexilitene has also been shown to be effective in painful DN. Topical capsaicin which depletes nociceptive C fibres of their neurotransmitter, substance P, may be used as an adjunct to oral therapy. The patient with painless symmetrical polyneuropathy is at risk for the development of foot ulceration at areas of abnormally high pressure which arise as a result of destruction of the small joints of the foot. Patienst education regarding daily obsessive foot care is essential. Specific strategies for the management of plantar foot ulceration include non-weight bearing, redistribution of foot pressure by the use of various plaster-of Paris walking devices, treatment of infection with appropriate antibiotics, and the use of hyperbaric oxygen where available. Some complications of autonomic neuropathy which may respond to pharmacotherapy include gastroparesis (metoclopamide, erthromycin, domperidone), nocturnal diarrhoea (tetracycline), gustatory sweating (preprandial propantheline) and postural hypotension (fludrocortisone). The results of the recently reported multicentre trial (DCCI) clearly show that risk of developing neuropathy can be significantly reduced by intensive glycaemic control. Physicians need to be aware of the various syndromes of DN in order to advise and treat complications if and when they arise (AU)

Diabetes Mellitus/complicações , Neuropatias Diabéticas/terapia , Amitriptilina/uso terapêutico , Analgésicos/uso terapêutico , Entorpecentes/uso terapêutico , Imipramina/uso terapêutico , Carbamazepina/uso terapêutico , Capsaicina/uso terapêutico
West Indian med. j ; 33(Suppl): 38, 1984.
Artigo em Inglês | MedCarib | ID: med-6066


Twelve patients with complex partial epilepsy (CPE) are reviewed. The diagnosis was delayed from two to 43 years of 16.1 ñ 11.6 years (mean ñ S.D.) after fits began. The previous diagnoses had been: petit mal (1), petit mal and grand mal (2), grand mal and bad behaviour (1), "not classical grand mal", (1), chronic epilepsy, retardation and tantrums (1), epilepsy and cerbral palsy (1), fits and strange feelings (1) and "epilepsy" (2). Nine patients were referred because of poor control. In three others the diagnosis was suspected from information on the drug-assay request form that control was poor and a phenothiazine was being prescribed. Control was poor in spite of three anti-epileptics in one patient and two in eight patients (various combinations of five different drugs.) Of these nine patients, five were also receiving a phenothiazine. Two patients were receiving one anti-epileptic and a phenothiazine and one patient a single anti-epileptic. Three patients had clinical toxicity and toxic blood levels at the time of referral. Four had subtherapeutic and two therapeutic levels. Three came to attention before therapeutic drug monitoring was available. Perfect or near perfect control was achieved in two patients, good control in seven and improved control in two. Nine patients were controlled on a single drug (carbamazepine in seven and phentoin in two). The others required both drugs. Phenothiazines were discontinued in all. There is little attempt to type seizures in Barbados and most CPE is undiagnosed. Greater awareness of CPE and more assiduous history-taking would obviate costly diagnostic errors. Seizure control can be dramatically improved by appropriate drug selection (preferably carbamazepine) and meticulous dose titration, with the aid of therapeutic drug monitoring (AU)

Humanos , Epilepsia Parcial Complexa/diagnóstico , Epilepsia do Lobo Temporal/diagnóstico , Carbamazepina/uso terapêutico , Barbados
West Indian med. j ; 37(Suppl. 2): 22-3,
Artigo em Inglês | MedCarib | ID: med-5838


For many drugs there is a close relationship between plasma concentration and biological/therapeutic effects. Laboratory services for estimating plasma drug concentrations (Therapeutic Drug Monitoring or TDM) are now provided in most major hospitals of the developing world, including most of the Caribbean, for three major reasons: 1) the variable but generally long lag period in the transfer of new technology, 2) the perceived cost of the new technology, 3) the dearth of clinical pharmacologists, the specialists most closely involved in the provision and interpretation of plasma drug levels. A TDM service was set up in Barbados in 1982, in the Clinical Pharmacology Laboratory at the Queen Elizabeth Hospital using the Syva Enzyme Mediated Immuno Assay/spectophotometric system. Eight drugs are now routinely assayed, using (since January 1987) a flourescence polarisation immuno assay (Abbott), which permits rapid estimation and a same day service, facilitating immediate feedback of emergency and out-patient results. Drugs assayed include the top four anti-epileptics (phenytoin, phenobarbitone, carbamazepine and valproate), two cardiac drugs (digoxin and quinidine), theophylline and gentamycin. Assay services (including pharmacokinetic interpretation and advice on dose regimes) are provided for hospital in-and out-patients, private and polyclinic patients and, on request, to other Caribbean countries, i.e. countries of the Organisation of Eastern Caribbean States (OECS) and occasionally Jamaica. In Trinidad TDM services are provided for anti-epileptics at the Port-of-Spain General Hospital. Review of anti-epileptic TDM in Barbados indicates that drug management is usually far less than optimal. Because of its saturation kinetics, phenytoin is particularly difficult to achieve correct therapeutic levels and good results with, only 25 percent of assays falling in the recommended therapeutic range. Improved patient compliance and doctor education both require the concerted attention of the health services if the present poor epilepsy management is to be improved. TDM is less costly than perceived if the service: 1) uses a system where equipment is provided by the Company, with a contract for purchase of a minimal number of kits, rather than purchase of equipment, at high capital costs, and having to pay for service; 2) is centralised, providing large runs and minimising cost of controls, etc. Current costs per test for anti-epileptics to our lab (e.g. carbamazepine US$3.50) are comparable with basic cost to QEH of hormone assays (e.g. prolactin US$2.50, testosterone US$3.50, cortisol US$2.30). These costs are, however, multiplied by about four for private patients, or six or more by the commercial labs, where routine assays, e.g. amylase and blood count costs US$6.00 and $15.00 respectively. Since most other lab test costing must include capital equipment and service costs, the comparisons become even more favourable. Finally, assay costs are negligible compared to annual Drug costs for all relevant drugs except phenobarbitone. A select number of drug assays provide invaluable guidance in treating difficult patients with drugs which have a narrow therapeutic/toxic ratio. Anti-epileptic assays in particular are increasingly recognised to be as valuable in treating epilepsy as blood sugars in treating diabetics. No major hospital in the Caribbean or elsewhere should be without a Clinical Pharmacologist or a TDM service, providing assays for anti-epileptics, gentamycin and digoxin at least (AU)

Humanos , Monitoramento de Medicamentos/economia , Epilepsia/tratamento farmacológico , Educação de Pacientes como Assunto , Digoxina , Carbamazepina/farmacologia , Índias Ocidentais