The Sequential Therapy in Osteoporosis.

Background: Osteoporosis management often involves a sequential treatment approach to optimize patient outcomes and minimize fracture risks. This strategy is tailored to individual patient characteristics, treatment responses, and fracture risk profiles. Methods: A thorough literature review was systematically executed using prominent databases, including PubMed and EMBASE. The primary aim was to identify original articles and clinical trials evaluating the effectiveness of sequential therapy with anti-osteoporosis drugs, focusing on the period from 1995 to 2023. The analysis encompassed an in-depth examination of osteoporosis drugs, delineating their mechanisms of action, side effects, and current trends as elucidated in the literature. Results and Discussion: Our study yielded noteworthy insights into the optimal sequencing of pharmacologic agents for the long-term treatment of patients necessitating multiple drugs. Notably, the achievement of optimal improvements in bone mass is observed when commencing treatment with an anabolic medication, followed by the subsequent utilization of an antiresorptive drug. This stands in contrast to initiating therapy with a bisphosphonate, which may potentially diminish outcomes in the post-anabolic intervention period. Furthermore, it has been discerned that caution should be exercised against transitioning from denosumab to PTH homologs due to the adverse effects of heightened bone turnover and sustained weakening of bone structure. Despite the absence of fracture data substantiating the implementation of integrated anabolic/antiresorptive pharmacotherapy, the incorporation of denosumab and teriparatide presents a potential avenue worthy of consideration for individuals at a heightened vulnerability to fragility fractures. Conclusions: A judiciously implemented sequential treatment strategy in osteoporosis offers a flexible and tailored approach to address diverse clinical scenarios, optimizing fracture prevention and patient outcomes.

Great occipital nerve long-acting steroid injections in cluster headache therapy: an observational prospective study.

BACKGROUND: Injections targeting the occipital nerve are used to reduce headache attacks and abort cluster bouts in cluster headache patients. There is no widely accepted agreement over the optimal technique of injection, type and doses of steroids and/or anesthetics to use, as well as injection regimens. The aim of this study was to verify the effectiveness and safety of greater occipital nerve long-acting steroid injections in the management of episodic and chronic cluster headache. METHODS: We conducted a prospective observational cohort study on episodic (ECH) and chronic cluster headache patients (CCH). ECH were included in the study at the beginning of a cluster period. Three injections with 60 mg methylprednisolone were performed on alternate days. We registered the frequency and intensity of attacks three days before and 3, 7 and 30 days after the treatment, the latency of cluster relapse, adverse events, scores evaluating anxiety (Zung scale), depression (Beck's Depression Scale) and quality of life (Disability Assessment Schedule II, 12-Item Self-Administered Version). Primary outcome was the interruption of the cluster after the three injections. Responders conducted a follow-up period of 12 months. RESULTS: We enrolled 60 patients, 47 with ECH and 13 with CCH. We observed a complete response in 47.8% (22/46) of episodic and 33.3% (4/12) of chronic patients. Moreover, a partial response (reduction of at least 50% of attacks) was obtained in further 10.8% (5/46) of episodic and in 33.3% (4/12) of chronic patients at 1 month. Median pain-free period was of 3 months for CCH responders. Only mild adverse events were reported in 38.3% (23/58) cases. CONCLUSIONS: We suggest three greater occipital nerve injections of 60 mg methylprednisolone on alternate days as useful therapy in episodic and chronic cluster headache. This leads to a long pain-free period in chronic forms. Adverse effects are mild and support its use as first choice. TRIAL REGISTRATION: The study was inserted in AIFA observational studies register.

Pain Relief Effects and Safety of Transitional Therapy in the Treatment of Posterior Teeth of Pregnant Women with Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis.

Purpose: To assess the pain relief effects and safety of transitional therapy (TT) in the treatment of posterior teeth of pregnant women with symptomatic irreversible pulpitis and symptomatic apical periodontitis. Methods: A prospective cohort clinical study was conducted in the Department of Stomatology at Shenzhen Maternity & Child Healthcare Hospital, China, from January 2017 to December 2019. We enrolled 62 pregnant women with acute dental pain caused by posterior teeth with symptomatic irreversible pulpitis or symptomatic apical periodontitis. Among the 62 participants, 34 received TT, and 28 chose nontreatment during pregnancy. We evaluated the pain relief with the verbal numerical rating scale (VNRS) scores of pain perception in the clinical study, as well as the anti-bacterial medicament filling conditions of canals of in vitro models. Moreover, we investigated the safety outcomes, such as gestational age, neonatal head circumstance, birth weight, and body length. Results: The VNRS scores of the participants treated with TT were significantly lower than those of the nontreatment group 2 days after treatment (P<0.001). TT treated pregnant women experienced significantly more pain decreases in VNRS scores than their counterparts(P<0.05). The optimal anti-bacterial medicament filling conditions of canals of in vitro models by TT method were comparable with those of canals instrumented with traditional RCT method. Moreover, no significant differences of safety outcomes were observed between pregnant women of these two groups. Conclusion: The transitional therapy is efficient in alleviating acute dental pain of posterior teeth of pregnant women with symptomatic irreversible pulpitis and symptomatic apical periodontitis, and maintaining painless chains throughout pregnancy with no adverse effects on neonatal birth outcomes.

OnabotulinumtoxinA Wear-off Phenomenon in the Treatment of Chronic Migraine.

OBJECTIVE: To evaluate the frequency and features of onabotulinumtoxinA (onabotA) wear-off in chronic migraine (CM). BACKGROUND: Clinical experience suggests that patients with CM frequently perceive onabotA treatment duration <12 weeks, but this phenomenon has not been well explored. METHODS: This study was a retrospective chart review of patients (n = 143) with CM initiated on onabotA over a 2-year period. Wear-off was considered present with the phrase documented, a quantitative headache day increase, or increased use of abortive medications, bridging therapies or emergency department visits in the 6 weeks preceding the subsequent administration. RESULTS: Wear-off was present in 90/143 patients (62.9%). Age, sex, medication overuse, psychiatric comorbidity, injector training level, and mean days between injections did not differ between the wear-off and no wear-off groups. Mean units injected per session in the wear-off group until first documented wear-off were significantly less vs no wear-off group (166.0 ± 13.1 vs 173.4 ± 10.3, P = .0005). Wear-off most commonly occurred 2-4 weeks before the next injection (43.3%) and after the very first injection (40.0%). Intramuscular ketorolac injections (33.3%) and peripheral nerve blocks (25.6%) were the most common bridge therapies used in the wear-off period. CONCLUSIONS: Most patients with CM receiving onabotA experience wear-off. Clinicians may consider increasing the units used from the treatment onset to reduce the frequent need for bridging therapies.

Greater Occipital Nerve Injection versus Oral Steroids for Short Term Prophylaxis of Cluster Headache: A Retrospective Comparative Study.

OBJECTIVE: To investigate our experience with oral steroid and greater occipital nerve (GON) injection with steroid as transitional treatments for cluster headache. BACKGROUND: Cluster headache is a primary headache disorder characterized by multiple episodes of intense unilateral pain with autonomic features. During cluster headache attacks, transitional therapies are useful while prophylactic dosages are initiated or increased. There are limited data comparing the efficacy of oral versus injected transitional treatments. METHODS: We retrospectively reviewed charts for patients evaluated with cluster headache at our center and captured episodes of transitional therapy utilized from 1995 to 2014. Treatment benefit was categorized into complete, partial, or no response. RESULTS: Forty-three patients received transitional therapy over a total of 151 encounters, of which 140 were available for analysis. Encounters featured oral steroids (81, 57.9%) and GON injection (59, 42.1%). Of the 40 patients with treatment response data available, 24 patients received only one type of transitional therapy and 16 patients received both therapies. More encounters featuring oral steroids versus GON injections led to at least a partial response (82.7% vs 64.4%) and to a lesser extent a complete response (50.6% vs 35.6%). Among 16 patients treated with both therapies, 8 (50%) responded to both and 6 (37.5%) responded only to oral steroids. CONCLUSIONS: Our single-center, retrospective data suggest the majority of patients with cluster headache responded to both prednisone and GON injections for transitional treatment, with a higher response to oral steroids. Our results may inform study design for a randomized trial, which is warranted.

[Basic Principles of Periprocedural Management of Patients With Nonvalvular Atrial Fibrillation Receiving Anticoagulant Therapy: the Consensus Document of Experts of the American College of Cardiology].

The article contains an outline of the 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. This document considers in detail problems of necessity and safety of temporary interrupting of anticoagulation for the period of procedure, main principles of interruption and restarting anticoagulant therapy after procedure, indications to the transitional (bridging) therapy in the periprocedural period, as well as possible strategies of periprocedural management of patients in dependence of risk of bleeding and thromboembolic complications. This Expert Consensus Decision Pathway refer to the periprocedural use of both oral (vitamin K antagonists, new oral anticoagulants) and parenteral (unfractionated and low-molecular-weight heparins) anticoagulants.

Efficacy and safety of a single occipital nerve blockade in episodic and chronic cluster headache: A prospective observational study.

Background Treatment options for cluster headache (CH) include acute, transitional and prophylactic strategies. We assessed the efficacy and safety of a single occipital nerve block (ONB) in patients with episodic (eCH) and chronic CH (cCH). Methods In this prospective, observational study 101 CH were treated with a single ONB using triamcinolone 10 mg and bupivacaine. Attack frequency, pain intensity and side effects were assessed at days 1 and 7 after ONB and thereafter weekly for 60 days until recurrence of attacks. Results Baseline mean daily attack frequency was 2.9 ± 2.5 (eCH) and 3.3 ± 2.9 (cCH), which was reduced to 0.7 ± 1.2 (eCH) and 1.1 ± 1.4 (cCH) after one day ( p = 0.08 for group difference) and to 1.1 ± 1.6 (eCH) and 1.9 ± 2.3 (cCH) after seven days ( p = 0.01 for group difference). In patients with eCH the pain-free period lasted longer compared to cCH ( p = 0.004). There was no association between the presence of local anesthesia and treatment response ( p = 0.88). No serious adverse events occurred. Conclusion ONB is an easy, safe and effective transitional treatment option in case of insufficient response of CH to treatment both in patients with eCH and cCH. Patients with eCH have a better and more sustainable treatment response.

Acute, transitional and long-term cluster headache treatment: pharmacokinetic issues.

INTRODUCTION: The cornerstones of cluster headache therapy are based on the tripod of acute, transitional and preventative treatments that respectively aim to the control of the bouts, the transitional suppression of the relapse and the prevention of the entire cluster period. Particularly in chronic cluster headache, where a long-term preventative therapy is necessary, multiple drug regimens increase the risk of drug-drug interactions leading to variability in the clinical efficacy and to potentially harmful adverse effects. AREAS COVERED: We focused on how clinically significant pharmacokinetic drug-drug and food-drug interactions can be carefully managed both in cluster headache patients with a progressive frequency of bouts and in chronic cluster headache sufferers. In fact, in these cases a long-term preventive therapy is indicated, increasing the possibility of interactions both with other transitional and acute cluster headache medications and with other foods or xenobiotics. EXPERT OPINION: Pharmacokinetic interactions for both preventive, transitional and acute drugs are significant with a number of xenobiotics and other medications. Therefore, the pharmacokinetic issues knowledge is advisable for a safe and effective cluster headache management.