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1.
Ned Tijdschr Geneeskd ; 1652021 01 19.
Artigo em Holandês | MEDLINE | ID: mdl-33560612

RESUMO

Obesity is a complex endocrine disease, mainly caused by environmental, behavioral and biological factors. Maintaining weight loss is extremely difficult due to the neuro-endocrine dysregulations that stimulate the body to return to the previous, increased, weight. Identifying underlying weight-gaining factors is needed, including medication-related, psychological and endocrine factors, as well as monogenic obesity. The cornerstone of treatment is optimization of lifestyle and all other contributing factors. Achieving at least 5% weight loss already has important health benefits. If combined lifestyle intervention (CLI) alone is not successful, pharmacotherapy or bariatric surgery can be added for patients with increased weight-related health risks. Recently, novel pharmacotherapy became available, among which, liraglutide 3 mg and the combination therapy naltrexone/bupropion, which leads to an additional 5-6% mean weight loss compared to CLI alone. For rare forms of obesity there are specific drugs that target defects in the regulation of hunger and satiety. Promising new pharmacotherapy for obesity is under development.


Assuntos
Fármacos Antiobesidade/uso terapêutico , Obesidade/terapia , Cirurgia Bariátrica , Bupropiona/uso terapêutico , Terapia Combinada , Combinação de Medicamentos , Quimioterapia Combinada , Humanos , Fome/efeitos dos fármacos , Estilo de Vida , Liraglutida/uso terapêutico , Naltrexona/uso terapêutico , Saciação/efeitos dos fármacos , Resultado do Tratamento , Perda de Peso/efeitos dos fármacos
2.
Pediatrics ; 147(2)2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33504611

RESUMO

Serotonergic medications are used for the prevention and treatment of depression during pregnancy. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRIs) can cause poor neonatal adaptation, which has been attributed to withdrawal versus toxicity. Bupropion, a norepinephrine-dopamine reuptake inhibitor, is often used as an adjunctive agent to selective serotonin reuptake inhibitors or SNRIs for refractory depression. Quetiapine, an atypical antipsychotic, may also be used in more complex cases. When combined with serotonergic drugs, bupropion and quetiapine are associated with increased risk of serotonin syndrome in adults. We describe a neonate exposed to venlafaxine (an SNRI), bupropion, and quetiapine in utero who presented nearly immediately after birth with encephalopathy and abnormal movements. The severity and rapidity of symptoms may be attributable to potentiation of venlafaxine's serotonergic effects by bupropion and quetiapine. Neonatal providers should be aware of maternal medications and prepare for possible adverse effects, particularly from common psychotropic exposures.


Assuntos
Antidepressivos/efeitos adversos , Transtorno Bipolar/tratamento farmacológico , Encefalopatias/induzido quimicamente , Discinesia Induzida por Medicamentos/etiologia , Inibidores da Captação de Neurotransmissores/efeitos adversos , Complicações na Gravidez/tratamento farmacológico , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Antidepressivos/uso terapêutico , Encefalopatias/congênito , Encefalopatias/diagnóstico , Bupropiona/efeitos adversos , Bupropiona/uso terapêutico , Quimioterapia Combinada , Discinesia Induzida por Medicamentos/congênito , Discinesia Induzida por Medicamentos/diagnóstico , Feminino , Humanos , Recém-Nascido , Masculino , Inibidores da Captação de Neurotransmissores/uso terapêutico , Gravidez , Fumarato de Quetiapina/efeitos adversos , Fumarato de Quetiapina/uso terapêutico , Cloridrato de Venlafaxina/efeitos adversos , Cloridrato de Venlafaxina/uso terapêutico
3.
Cochrane Database Syst Rev ; 1: CD007654, 2021 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-33454957

RESUMO

BACKGROUND: This is the third update of this review, first published in July 2009. All major guidelines on treatment of hypertension recommend weight loss; anti-obesity drugs may be able to help in this respect. OBJECTIVES: Primary objectives: To assess the long-term effects of pharmacologically-induced reduction in body weight in adults with essential hypertension on all-cause mortality, cardiovascular morbidity, and adverse events (including total serious adverse events, withdrawal due to adverse events, and total non-serious adverse events).. Secondary objectives: To assess the long-term effects of pharmacologically-induced reduction in body weight in adults with essential hypertension on change from baseline in systolic and diastolic blood pressure, and on body weight reduction. SEARCH METHODS: For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to March 2020: the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. The searches had no language restrictions. We contacted authors of relevant papers about further published and unpublished work. SELECTION CRITERIA: Randomised controlled trials of at least 24 weeks' duration in adults with hypertension that compared approved long-term weight-loss medications to placebo.  DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risks of bias, and extracted data. Where appropriate and in the absence of significant heterogeneity between studies (P > 0.1), we pooled studies using a fixed-effect meta-analysis. When heterogeneity was present, we used the random-effects method and investigated the cause of the heterogeneity. MAIN RESULTS: This third update of the review added one new trial, investigating the combination of naltrexone/bupropion versus placebo. Two medications, which were included in the previous versions of this review (rimonabant and sibutramine) are no longer considered relevant for this update, since their marketing approval was withdrawn in 2010 and 2009, respectively. The number of included studies in this review update is therefore six (12,724 participants in total): four RCTs comparing orlistat to placebo, involving a total of 3132 participants with high blood pressure and a mean age of 46 to 55 years; one trial comparing phentermine/topiramate to placebo, involving 1305 participants with high blood pressure and a mean age of 53 years; and one trial comparing naltrexone/bupropion to placebo, involving 8283 participants with hypertension and a mean age of 62 years. We judged the risks of bias to be unclear for the trials investigating orlistat or naltrexone/bupropion. and low for the trial investigating phentermine/topiramate. Only the study of naltrexone/bupropion included cardiovascular mortality and morbidity as predefined outcomes. There were no differences in the rates of all-cause or cardiovascular mortality, major cardiovascular events, or serious adverse events between naltrexone/bupropion and placebo. The incidence of overall adverse events was significantly higher in participants treated with naltrexone/bupropion. For orlistat, the incidence of gastrointestinal side effects was consistently higher compared to placebo. The most frequent side effects with phentermine/topiramate were dry mouth and paraesthesia. After six to 12 months, orlistat reduced systolic blood pressure compared to placebo by mean difference (MD) -2.6 mm Hg (95% confidence interval (CI) -3.8 to -1.4 mm Hg; 4 trials, 2058 participants) and diastolic blood pressure by MD -2.0 mm Hg (95% CI -2.7 to -1.2 mm Hg; 4 trials, 2058 participants). After 13 months of follow-up, phentermine/topiramate decreased systolic blood pressure compared to placebo by -2.0 to -4.2 mm Hg (1 trial, 1030 participants) (depending on drug dosage), and diastolic blood pressure by -1.3 to -1.9 mm Hg (1 trial, 1030 participants) (depending on drug dosage). There was no difference in the change in systolic or diastolic blood pressure between naltrexone/bupropion and placebo (1 trial, 8283 participants). We identified no relevant studies investigating liraglutide or lorcaserin in people with hypertension. AUTHORS' CONCLUSIONS: In people with elevated blood pressure, orlistat, phentermine/topiramate and naltrexone/bupropion reduced body weight; the magnitude of the effect was greatest with phentermine/topiramate. In the same trials, orlistat and phentermine/topiramate, but not naltrexone/bupropion, reduced blood pressure. One RCT of naltrexone/bupropion versus placebo showed no differences in all-cause mortality or cardiovascular mortality or morbidity after two years. The European Medicines Agency refused marketing authorisation for phentermine/topiramate due to safety concerns, while for lorcaserin the application for European marketing authorisation was withdrawn due to a negative overall benefit/risk balance. In 2020 lorcaserin was also withdrawn from the US market. Two other medications (rimonabant and sibutramine) had already been withdrawn from the market in 2009 and 2010, respectively.


Assuntos
Fármacos Antiobesidade/efeitos adversos , Depressores do Apetite/efeitos adversos , Hipertensão/tratamento farmacológico , Adulto , Fármacos Antiobesidade/uso terapêutico , Depressores do Apetite/uso terapêutico , Viés , Pressão Sanguínea/efeitos dos fármacos , Peso Corporal/efeitos dos fármacos , Bupropiona/efeitos adversos , Bupropiona/uso terapêutico , Dieta Redutora , Combinação de Medicamentos , Feminino , Frutose/efeitos adversos , Frutose/análogos & derivados , Frutose/uso terapêutico , Humanos , Hipertensão/mortalidade , Lactonas/efeitos adversos , Lactonas/uso terapêutico , Masculino , Pessoa de Meia-Idade , Naltrexona/efeitos adversos , Naltrexona/uso terapêutico , Orlistate/efeitos adversos , Orlistate/uso terapêutico , Fentermina/efeitos adversos , Fentermina/uso terapêutico , Piperidinas/efeitos adversos , Piperidinas/uso terapêutico , Pirazóis/efeitos adversos , Pirazóis/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Retirada de Medicamento Baseada em Segurança , Tempo , Topiramato/efeitos adversos , Topiramato/uso terapêutico
4.
JAMA Netw Open ; 4(1): e2032053, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33464316

RESUMO

Importance: Understanding Black vs White differences in pharmacotherapy efficacy and the underlying reasons is critically important to reducing tobacco-related health disparities. Objective: To compare pharmacotherapy efficacy and examine variables to explain Black vs White differences in smoking abstinence. Design, Setting, and Participants: This study is a secondary analysis of the Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES) double-blind, placebo-controlled, randomized clinical trial, which took place at clinical trial centers, academic centers, and outpatient clinics in 29 states in the US. US Black and White smokers who smoked 10 or more cigarettes per day with and without psychiatric comorbidity were enrolled between November 2011 and January 2015. Data analysis was performed from July 2019 to January 2020. Interventions: Participants were randomized (1:1:1:1) in a double-blind, triple-dummy, placebo- and active-controlled (nicotine patch) trial of varenicline and bupropion for 12 weeks with follow-up through week 24. Main Outcomes and Measures: Biochemically verified continuous cigarette abstinence rate (CAR) from weeks 9 to 24. Baseline, postbaseline treatment, and safety characteristics were examined as variables to explain race differences in abstinence. Results: Of the 1065 Black smokers enrolled, 255 were randomized to receive varenicline, 259 received bupropion, 286 received nicotine replacement therapy (NRT [ie, nicotine patch]), and 265 received placebo. Among the 3044 White smokers enrolled, 778 were randomized to receive varenicline, 769 received bupropion, 738 received NRT, and 759 received placebo. Participants were predominantly female (614 Black [57.7%] and 1786 White [58.7%] women) and heavy smokers (mean [SD] cigarettes per day, 18.2 [7.9] for Black and 20.0 [7.5] for White smokers), with a mean (SD) age of 47.2 (11.2) years for Black and 46.5 (12.7) years for White participants. Treatment and race were associated with CAR for weeks 9 to 24. The CAR was 4.9% lower for Black vs White participants (odds ratio [OR], 0.53; 95% CI, 0.41-0.69; P < .001); differences were found across all treatments. Pooling psychiatric and nonpsychiatric cohorts, varenicline (OR, 2.63; 95% CI, 1.90-3.63; P < .001), bupropion (OR, 1.75; 95% CI, 1.25-2.46; P = .001), and NRT (OR, 1.52; 95% CI, 1.07-2.16; P = .02) had greater efficacy than placebo for White participants. Only varenicline (OR, 2.63; 95% CI, 1.26-5.48; P = .01) had greater efficacy than placebo for Black participants. Baseline, postbaseline, and safety characteristics differed by race, but these variables did not eliminate the association of race with CAR. Black participants had 49% reduced odds of CAR for weeks 9 to 24 compared with White participants in the adjusted model (OR, 0.51; 95% CI, 0.39-0.66; P < .001). Conclusions and Relevance: Black and White smokers achieved the highest rate of abstinence while taking varenicline, suggesting that it is the best first-line therapy for these groups. However, Black smokers were less responsive to all therapies, including placebo. Understanding variables (eg, socioeconomic or biological) beyond those may lead to improved treatment outcomes for Black smokers. Trial Registration: ClinicalTrials.gov Identifier: NCT01456936.


Assuntos
Bupropiona/uso terapêutico , Agonistas Nicotínicos/uso terapêutico , Fatores Raciais , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Abandono do Hábito de Fumar/etnologia , Vareniclina/uso terapêutico , Grupo com Ancestrais do Continente Africano , Método Duplo-Cego , Grupo com Ancestrais do Continente Europeu , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dispositivos para o Abandono do Uso de Tabaco
5.
Expert Opin Pharmacother ; 22(7): 835-847, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33372557

RESUMO

Introduction: Chronic obstructive pulmonary disease (COPD) is progressive inflammatory disease of the lungs in which smoking plays a significant pathogenic role. Smoking cessation is the only therapeutic intervention which was demonstrated to interfere with disease progression. Smoking cessation intervention can benefit from pharmacological therapies such as nicotine replacement therapies, bupropion, or varenicline which can be given individually or in combination, their effectiveness being demonstrated in various clinical trials enrolling COPD patients.Areas covered: The authors provide a pragmatic discussion of the clinical data of the main studies evaluating therapies for smoking cessation within COPD starting with the seminal Lung Health Study and continuing with more recent ones.Expert opinion: Smoking cessation is one of the most difficult therapeutic interventions in COPD, despite having the highest impact on disease progression and despite the demonstrated benefit of the discussed pharmacological therapies. Potential approaches to maximize its chance of success might be represented by prolonging the time of administration, combinational options, or sequential pharmacotherapy.


Assuntos
Doença Pulmonar Obstrutiva Crônica , Abandono do Hábito de Fumar , Benzazepinas , Bupropiona/uso terapêutico , Humanos , Nicotina , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Quinoxalinas , Dispositivos para o Abandono do Uso de Tabaco , Vareniclina/uso terapêutico
6.
JAMA ; 324(14): 1406-1418, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33048154

RESUMO

Importance: Persistent smoking may cause adverse outcomes among patients with cancer. Many cancer centers have not fully implemented evidence-based tobacco treatment into routine care. Objective: To determine the effectiveness of sustained telephone counseling and medication (intensive treatment) compared with shorter-term telephone counseling and medication advice (standard treatment) to assist patients recently diagnosed with cancer to quit smoking. Design, Setting, and Participants: This unblinded randomized clinical trial was conducted at Massachusetts General Hospital/Dana-Farber/Harvard Cancer Center and Memorial Sloan Kettering Cancer Center. Adults who had smoked 1 cigarette or more within 30 days, spoke English or Spanish, and had recently diagnosed breast, gastrointestinal, genitourinary, gynecological, head and neck, lung, lymphoma, or melanoma cancers were eligible. Enrollment occurred between November 2013 and July 2017; assessments were completed by the end of February 2018. Interventions: Participants randomized to the intensive treatment (n = 153) and the standard treatment (n = 150) received 4 weekly telephone counseling sessions and medication advice. The intensive treatment group also received 4 biweekly and 3 monthly telephone counseling sessions and choice of Food and Drug Administration-approved cessation medication (nicotine replacement therapy, bupropion, or varenicline). Main Outcome and Measures: The primary outcome was biochemically confirmed 7-day point prevalence tobacco abstinence at 6-month follow-up. Secondary outcomes were treatment utilization rates. Results: Among 303 patients who were randomized (mean age, 58.3 years; 170 women [56.1%]), 221 (78.1%) completed the trial. Six-month biochemically confirmed quit rates were 34.5% (n = 51 in the intensive treatment group) vs 21.5% (n = 29 in the standard treatment group) (difference, 13.0% [95% CI, 3.0%-23.3%]; odds ratio, 1.92 [95% CI, 1.13-3.27]; P < .02). The median number of counseling sessions completed was 8 (interquartile range, 4-11) in the intensive treatment group. A total of 97 intensive treatment participants (77.0%) vs 68 standard treatment participants (59.1%) reported cessation medication use (difference, 17.9% [95% CI, 6.3%-29.5%]; odds ratio, 2.31 [95% CI, 1.32-4.04]; P = .003). The most common adverse events in the intensive treatment and standard treatment groups, respectively, were nausea (n = 13 and n = 6), rash (n = 4 and n = 1), hiccups (n = 4 and n = 1), mouth irritation (n = 4 and n = 0), difficulty sleeping (n = 3 and n = 2), and vivid dreams (n = 3 and n = 2). Conclusions and Relevance: Among smokers recently diagnosed with cancer in 2 National Cancer Institute-designated Comprehensive Cancer Centers, sustained counseling and provision of free cessation medication compared with 4-week counseling and medication advice resulted in higher 6-month biochemically confirmed quit rates. However, the generalizability of the study findings is uncertain and requires further research. Trial Registration: ClinicalTrials.gov Identifier: NCT01871506.


Assuntos
Aconselhamento/métodos , Neoplasias/diagnóstico , Abandono do Hábito de Fumar/psicologia , Temperança/psicologia , Dispositivos para o Abandono do Uso de Tabaco , Idoso , Bupropiona/efeitos adversos , Bupropiona/uso terapêutico , Cotinina/análise , Aconselhamento/estatística & dados numéricos , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Entrevista Motivacional , Satisfação do Paciente , Seleção de Pacientes , Saliva/química , Fumar/tratamento farmacológico , Fumar/epidemiologia , Fumar/psicologia , Agentes de Cessação do Hábito de Fumar/efeitos adversos , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Telefone , Dispositivos para o Abandono do Uso de Tabaco/efeitos adversos , Vareniclina/efeitos adversos , Vareniclina/uso terapêutico
7.
J Clin Psychiatry ; 81(5)2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32780949

RESUMO

OBJECTIVE: An antidepressant medication switch often follows a failed initial trial with selective serotonin reuptake inhibitors (SSRIs). When, for whom, and how often second-step response and remission occur are unclear, as is preferred second-step trial duration. As more treatments are approved for use following 2 failed "adequate" trials, researchers and clinicians require an evidence-based definition of "adequate." METHODS: Following citalopram in the randomized Sequenced Treatment Alternatives to Relieve Depression (STAR*D) clinical trial (which ran July 2001-September 2006), participants with score ≥ 11 on the 16-item Quick Inventory of Depressive Symptomatology-Self-Rated (QIDS-SR16) were randomized to bupropion sustained release, sertraline, or venlafaxine extended release (up to 14 weeks). The QIDS-SR16 defined response, remission, and no clinically meaningful benefit based on the modified intent-to-treat sample. RESULTS: About 80% of 438 participants completed ≥ 6 weeks of treatment with the switch medication. All treatments had comparable outcomes. Overall, 21% (91/438) remitted, 9% (40/438) responded without remission, and 58% (255/438) had no meaningful benefit. Half of the responses and two-thirds of remissions occurred after 6 weeks of treatment. Overall, 33% of responses (43/131) occurred after ≥ 9 weeks of treatment. No baseline features differentiated early from later responders or remitters. No early triage point was found, but those with at least 20% reduction from baseline in QIDS-SR16 score around week 2 were 6 times more likely to respond or remit than those without this reduction. CONCLUSIONS: Following nonefficacy with an initial SSRI, only about 20% remit and more than half achieve no meaningful benefit with a second-step switch to another monoaminergic antidepressant. A 12-week trial duration seems necessary to capture as many second-step switch responders as possible. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00021528.


Assuntos
Antidepressivos/uso terapêutico , Bupropiona/uso terapêutico , Transtorno Depressivo Maior/tratamento farmacológico , Substituição de Medicamentos , Inibidores de Captação de Serotonina/uso terapêutico , Sertralina/uso terapêutico , Cloridrato de Venlafaxina/uso terapêutico , Adulto , Bupropiona/administração & dosagem , Preparações de Ação Retardada , Feminino , Humanos , Masculino , Escalas de Graduação Psiquiátrica , Resultado do Tratamento
8.
Lancet Psychiatry ; 7(9): 762-774, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32828166

RESUMO

BACKGROUND: People with schizophrenia have higher rates of smoking than the general population, and lower quit rates. Several randomised controlled trials have investigated the effectiveness of pharmacological interventions for smoking cessation over the past 20 years. We did a systematic review and pairwise and network meta-analysis of smoking abstinence to guide decision making in offering pharmacological interventions for smoking cessation for people with schizophrenia spectrum disorders. METHODS: We systematically reviewed PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and China National Knowledge Infrastructure from inception to Sept 30, 2019, for randomised controlled trials of varenicline, bupropion, and nicotine replacement therapy for smoking cessation for people with schizophrenia spectrum disorders or psychotic disorders who were smokers at the time of study recruitment. Data were extracted from published studies on smoking abstinence outcomes and psychotic symptoms. We did pairwise and network meta-analyses for the primary outcome of smoking abstinence. Sensitivity analyses were done on study inclusion criteria, duration, quality, and location. This study is registered with the international prospective register of systematic reviews PROSPERO, CRD42018102343. FINDINGS: A total of 15 111 records were identified by the database searches, and 163 full-text articles were assessed for eligibility. 145 articles were then excluded for several reasons including insufficient data, or abstracts published in later studies, and 18 studies were included in the meta-analysis. In the pairwise meta-analyses, four studies with 394 participants assessed varenicline (RR 3·75, 95% CI 1·96-7·19, p<0·0001; I2=0%), four studies with bupropion and 292 participants (RR 3·40, 95% CI 1·58-7·34, p=0·0002; I2=0%), and three studies with 561 participants assessed nicotine replacement therapy (RR 4·27, 95% CI 1·71-10·65, p=0·0002; I2=0%). All three treatments were deemed superior to placebo. In the network meta-analysis, varenicline was superior to bupropion (RR 2·02, 95% CI 1·04-3·93; p=0·038) but no significant difference was found between varenicline and nicotine replacement therapy, or bupropion and nicotine replacement therapy. No agents were associated with changes in psychiatric symptoms, but varenicline was associated with higher rates of nausea than was placebo. INTERPRETATION: We found evidence to support use of pharmacological agents for smoking cessation for people with psychosis. Varenicline might be superior to bupropion; however, additional direct testing and combination trials of pharmacological agents for smoking cessation are required to inform clinical decision making for people with psychosis. FUNDING: None.


Assuntos
Antidepressivos de Segunda Geração/uso terapêutico , Bupropiona/uso terapêutico , Esquizofrenia , Abandono do Hábito de Fumar/métodos , Humanos , Metanálise em Rede , Nicotina/administração & dosagem , Agonistas Nicotínicos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Psicologia do Esquizofrênico , Vareniclina
9.
Am J Respir Crit Care Med ; 202(2): e5-e31, 2020 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-32663106

RESUMO

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.


Assuntos
Bupropiona/normas , Guias de Prática Clínica como Assunto , Agentes de Cessação do Hábito de Fumar/normas , Tabagismo/tratamento farmacológico , Vareniclina/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Bupropiona/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Estados Unidos , Vareniclina/uso terapêutico
10.
J Clin Psychiatry ; 81(4)2020 06 23.
Artigo em Inglês | MEDLINE | ID: mdl-32603560

RESUMO

OBJECTIVE: To determine whether concurrent posttraumatic stress disorder (PTSD) should affect whether to augment or switch medications when major depressive disorder (MDD) has not responded to a prior antidepressant trial. METHODS: Patients at 35 Veterans Health Administration medical centers from December 2012 to May 2015 with nonpsychotic MDD (N = 1,522) and a suboptimal response to adequate antidepressant treatment were randomly assigned to 3 "next step" treatments: switching to bupropion, augmenting the current antidepressant with bupropion, and augmenting with the antipsychotic aripiprazole. Blinded ratings with the 16-item Quick Inventory of Depressive Symptomatology-Clinician Rated (QIDS-C16) determined remission and response by 12 weeks and relapse after remission. Survival analyses compared treatment effects in patients with concurrent PTSD diagnosed with the Mini-International Neuropsychiatric Interview (n = 717, 47.1%) and those without PTSD (n = 805, 52.9%). RESULTS: Patients diagnosed with PTSD showed more severe depressive symptoms at baseline and were less likely to achieve either remission or response by 12 weeks. Augmentation with aripiprazole was associated with greater likelihood of achieving response (68.4%) than switching to bupropion (57.7%) in patients with PTSD (relative risk [RR] = 1.26; 95% CI, 1.01-1.59) as well as in patients without PTSD (RR = 1.29; 95% CI, 1.05-1.97) (78.9% response with aripiprazole augmentation vs 66.9% with switching to bupropion). Treatment comparisons with the group receiving augmentation with bupropion were not significant. There was no significant interaction between treatment group and PTSD on remission (P = .70), response (P = .98), or relapse (P = .15). CONCLUSIONS: Although PTSD was associated with poorer overall outcomes, the presence of concurrent PTSD among Veterans in this trial did not affect the comparative effectiveness of medications on response, remission, or relapse after initial remission. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01421342.


Assuntos
Transtorno Depressivo Maior/tratamento farmacológico , Transtorno Depressivo Resistente a Tratamento/tratamento farmacológico , Transtornos de Estresse Pós-Traumáticos/tratamento farmacológico , Adolescente , Adulto , Antidepressivos/uso terapêutico , Aripiprazol/uso terapêutico , Bupropiona/uso terapêutico , Transtorno Depressivo Maior/complicações , Resistência a Medicamentos/efeitos dos fármacos , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego , Transtornos de Estresse Pós-Traumáticos/complicações , Adulto Jovem
11.
High Blood Press Cardiovasc Prev ; 27(5): 349-362, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32578165

RESUMO

Tobacco use is one of the major public health concerns and it is the most preventable cause of morbidity and mortality worldwide. Smoking cessation reduces subsequent cardiovascular events and mortality. Smoking is a real chronic disorder characterized by the development of an addiction status mainly due to nicotine. This condition makes the smokers generally unable to quit smoking without help. Different strategies are available to treat smoking dependence that include both non-pharmacological (behavioral counselling) and pharmacological therapies. Currently, it is well accepted that smoking cessation drugs are effective and safe in real-world settings. Nicotine replacement therapy (NRT), varenicline, bupropion and cytisine are the main pharmacological strategies available for smoking cessation. Their efficacy and safety have been proved even in patients with chronic cardiovascular disease. Each of these drugs has peculiar characteristics and the clinician should customize the smoking cessation strategy based on currently available scientific evidence and patient's preference, paying particular attention to those patients having specific cardiovascular and psychiatric comorbidities. The present document aims to summarize the current viable pharmacological strategies for smoking cessation, also discussing the controversial issue regarding the use of alternative tobacco products, in order to provide useful practical indications to all physicians, mainly to those involved in cardiovascular prevention.


Assuntos
Alcaloides/uso terapêutico , Bupropiona/uso terapêutico , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Abandono do Hábito de Fumar , Fumar/efeitos adversos , Tabagismo/tratamento farmacológico , Vareniclina/uso terapêutico , Alcaloides/efeitos adversos , Azocinas/efeitos adversos , Azocinas/uso terapêutico , Bupropiona/efeitos adversos , Tomada de Decisão Clínica , Sistemas Eletrônicos de Liberação de Nicotina , Humanos , Quinolizinas/efeitos adversos , Quinolizinas/uso terapêutico , Recidiva , Fatores de Risco , Agentes de Cessação do Hábito de Fumar/efeitos adversos , Dispositivos para o Abandono do Uso de Tabaco , Tabagismo/diagnóstico , Tabagismo/fisiopatologia , Tabagismo/psicologia , Resultado do Tratamento , Vareniclina/efeitos adversos
12.
Zhonghua Liu Xing Bing Xue Za Zhi ; 41(6): 890-895, 2020 Jun 10.
Artigo em Chinês | MEDLINE | ID: mdl-32564555

RESUMO

Objective: To evaluate the effect of smoking cessation project run by the Central Subsidy Smoking Cessation Clinic and to explore the related influencing factors on smoking cessation, in order to improve related services and provide better guidance to these smoking cessation clinics. Methods: Practitioners who had been trained to run smoking cessation projects were recruited to conduct face-to-face interview with the smokers. Questionnaires were completed to provide information on related psychological, social and behavioral issues. In these clinics, medications were provided to the patients by the health care takers in the clinic. One month after the first visit, smoking cessation rate (self-reported, 7-day point prevalence abstinence rate at 30-day follow-up) was counted. Results: The overall smoking cessation rate (self-reported, 7-day point prevalence abstinence rate at 30-day follow-up) appeared as 34.1%. Results from the multivariate logistic regression showed that patients over the age of 60 were the ones most likely to quit smoking. Smokers who showed higher possibility of quitting would include those: not on the daily base, intend to quit within 30 days, with other diseases, or taking varenicline and bupropion. Factors as unemployment, longer history of smoking, bigger quantity of cigarettes consumption per day, dependence on nicotine and urgency on taking up the first cigarette in the early morning etc., were related to the less likelihood of giving up smoking. However, histories of cessation did not seem to affect the possibility of quitting. Conclusions: Data from self-reported 7-day point prevalence abstinence at 30-day follow-up study showed that the smoking cessation intervention programs run by the central subsidy smoking cessation clinic project had been effectively implemented. Advocacy on quit smoking at early stage seemed to have better outcomes, thus should be called for. Since medications as varenicline tartrate and bupropion hydrochloride can increase the possibility of stop smoking, we would suggest that all the hospitals which are with smoking cessation clinics be equipped with these medicines. Professional assistance provided by practitioners is of key importance to help overcome the withdrawal symptoms during the periods of cessation, on these smokers.


Assuntos
Pacientes Ambulatoriais/psicologia , Abandono do Hábito de Fumar/estatística & dados numéricos , Bupropiona/uso terapêutico , China , Seguimentos , Humanos , Pacientes Ambulatoriais/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários , Vareniclina/uso terapêutico
13.
Prev. tab ; 22(2): 68-75, abr.-jun. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-200998

RESUMO

OBJETIVO: Evaluar diferencias de género en los pacientes que acuden a una consulta hospitalaria de deshabituación tabáquica analizando la abstinencia a seis meses. MÉTODO: Recogida retrospectiva durante dos años de los datos de una consulta de tabaco, realizándose un análisis descriptivo de la muestra. Se realizó un contraste de hipótesis para evaluar diferencias según género y un análisis de regresión logística para encontrar factores predictores de abstinencia a los seis meses. RESULTADOS: Se incluyeron 95 pacientes, 47 (49,47%) mujeres y 48 (50,53%) hombres. Solo 67 acudieron a la última visita. La edad media fue de 57,89 años. El tratamiento más utilizado fue la vareniclina (51,58%), seguido de TSN (34,74%). En 23 pacientes no se pautó medicación. El porcentaje global de éxito fue del 25,26% (n = 24). En pacientes sin medicación, del 34,78% (n = 8) y en los que se utilizó un tratamiento combinado del 36,36% (n = 4). Se dividió la muestra en dos grupos de edad, ≤ 55 y > 55 años. No se observaron diferencias significativas de género. Sí se observaron mejores tasas de abandono a mayor edad y mayor puntuación en la escala de motivación. CONCLUSIONES: · No se observan diferencias en las tasas de abandono en función del género. · El éxito en los intentos de abandono aumenta con la edad y con alta motivación


OBJECTIVE: To evaluate gender differences in patients to come to a smoking cessation hospital visit, analyzing abstinence at six months. METHOD: Retrospective collection of two years of the data from a smoking cessation consultation, carrying out a descriptive analysis of the sample. A contrast hypothesis was done to evaluate the gender differences and a logistic regression analysis to find predictor factors of abstinence at six months. RESULTS: A total of 95 patients, 47 (49.47%) women and 48 (50.53%) men were included. Only 67 came to the final visit. Mean age was 57.89 years. The treatment used most was varenicline (51.58%) followed by NRT (34.74%). No medication was prescribed in 23 patients. Overall percentage of success was 25.26% (n = 24). Success in patients without medication was 34.78% (n = 8) and those who used a combined treatment was 36.36% (n = 4). The sample was divided into two age groups ≤ 55 and > 55 years. No significant differences were observed according to gender. However, better levels of quitting were observed in the higher age and higher score on the motivation scale. CONCLUSIONS: · No differences were observed in the quitting rates based on gender. · The success of quitting attempts increases with age and with high motivation


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Tabagismo/terapia , Abandono do Uso de Tabaco/métodos , Abandono do Hábito de Fumar/métodos , Vareniclina/uso terapêutico , Bupropiona/uso terapêutico , Tabagismo/epidemiologia , Política Antifumo/tendências , Unidades Hospitalares/estatística & dados numéricos , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Estudos Retrospectivos , Dispositivos para o Abandono do Uso de Tabaco , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Distribuição por Sexo , Inquéritos e Questionários/estatística & dados numéricos
14.
JAMA Netw Open ; 3(5): e206027, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32463470

RESUMO

Importance: Apathy is a frequent neuropsychiatric symptom in dementia of Alzheimer type and negatively affects the disease course and patients' and caregivers' quality of life. Effective treatment options are needed. Objective: To examine the efficacy and safety of the dopamine and noradrenaline reuptake inhibitor bupropion in the treatment of apathy in patients with dementia of Alzheimer type. Design, Setting, and Participants: This 12-week, multicenter, double-blind, placebo-controlled, randomized clinical trial was conducted in a psychiatric and neurological outpatient setting between July 2010 and July 2014 in Germany. Patients with mild-to-moderate dementia of Alzheimer type and clinically relevant apathy were included. Patients with additional clinically relevant depressed mood were excluded. Data analyses were performed between August 2018 and August 2019. Interventions: Patients received either bupropion or placebo (150 mg for 4 weeks plus 300 mg for 8 weeks). In case of intolerability of 300 mg, patients continued to receive 150 mg throughout the study. Main Outcomes and Measures: Change on the Apathy Evaluation Scale-Clinician Version (AES-C) (score range, 18-72 points) between baseline and week 12 was the primary outcome parameter. Secondary outcome parameters included measures of neuropsychiatric symptoms, cognition, activities of daily living, and quality of life. Outcome measures were assessed at baseline and at 4, 8, and 12 weeks. Results: A total of 108 patients (mean [SD] age, 74.8 [5.9] years; 67 men [62%]) were included in the intention-to-treat analysis, with 54 randomized to receive bupropion and 54 randomized to receive placebo. The baseline AES-C score was comparable between the bupropion group and the placebo group (mean [SD], 52.2 [8.7] vs 50.4 [8.2]). After controlling for the baseline AES-C score, site, and comedication with donepezil or galantamine, the mean change in the AES-C score between the bupropion and placebo groups was not statistically significant (mean change, 2.22; 95% CI, -0.47 to 4.91; P = .11). Results on secondary outcomes showed statistically significant differences between bupropion and placebo in terms of total neuropsychiatric symptoms (mean change, 5.52; 95% CI, 2.00 to 9.04; P = .003) and health-related quality of life (uncorrected for multiple comparisons; mean change, -1.66; 95% CI, -3.01 to -0.31; P = .02) with greater improvement in the placebo group. No statistically significant changes between groups were found for activities of daily living (mean change, -2.92; 95% CI, -5.89 to 0.06; P = .05) and cognition (mean change, -0.27; 95% CI, -3.26 to 2.73; P = .86). The numbers of adverse events (bupropion group, 39 patients [72.2%]; placebo group, 33 patients [61.1%]) and serious adverse events (bupropion group, 5 patients [9.3%]; placebo group, 2 patients [3.7%]) were comparable between groups. Conclusions and Relevance: Although it is safe, bupropion was not superior to placebo for the treatment of apathy in patients with dementia of Alzheimer type in the absence of clinically relevant depressed mood. Trial Registration: EU Clinical Trials Register Identifier: 2007-005352-17.


Assuntos
Doença de Alzheimer/psicologia , Antidepressivos de Segunda Geração/uso terapêutico , Apatia/efeitos dos fármacos , Bupropiona/uso terapêutico , Idoso , Doença de Alzheimer/tratamento farmacológico , Antidepressivos de Segunda Geração/efeitos adversos , Bupropiona/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Masculino , Testes de Estado Mental e Demência
15.
Cochrane Database Syst Rev ; 4: CD000031, 2020 04 22.
Artigo em Inglês | MEDLINE | ID: mdl-32319681

RESUMO

BACKGROUND: Whilst the pharmacological profiles and mechanisms of antidepressants are varied, there are common reasons why they might help people to stop smoking tobacco. Firstly, nicotine withdrawal may produce depressive symptoms and antidepressants may relieve these. Additionally, some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction. OBJECTIVES: To assess the evidence for the efficacy, safety and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Specialized Register, which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO, clinicaltrials.gov, the ICTRP, and other reviews and meeting abstracts, in May 2019. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that recruited smokers, and compared antidepressant medications with placebo or no treatment, an alternative pharmacotherapy, or the same medication used in a different way. We excluded trials with less than six months follow-up from efficacy analyses. We included trials with any follow-up length in safety analyses. DATA COLLECTION AND ANALYSIS: We extracted data and assessed risk of bias using standard Cochrane methods. We also used GRADE to assess the certainty of the evidence. The primary outcome measure was smoking cessation after at least six months follow-up, expressed as a risk ratio (RR) and 95% confidence intervals (CIs). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model. Similarly, we presented incidence of safety and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropout due to drug, as RRs (95% CIs). MAIN RESULTS: We included 115 studies (33 new to this update) in this review; most recruited adult participants from the community or from smoking cessation clinics. We judged 28 of the studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk did not change clinical interpretation of the results. There was high-certainty evidence that bupropion increased long-term smoking cessation rates (RR 1.64, 95% CI 1.52 to 1.77; I2 = 15%; 45 studies, 17,866 participants). There was insufficient evidence to establish whether participants taking bupropion were more likely to report SAEs compared to those taking placebo. Results were imprecise and CIs encompassed no difference (RR 1.16, 95% CI 0.90 to 1.48; I2 = 0%; 21 studies, 10,625 participants; moderate-certainty evidence, downgraded one level due to imprecision). We found high-certainty evidence that use of bupropion resulted in more trial dropouts due to adverse events of the drug than placebo (RR 1.37, 95% CI 1.21 to 1.56; I2 = 19%; 25 studies, 12,340 participants). Participants randomized to bupropion were also more likely to report psychiatric AEs compared with those randomized to placebo (RR 1.25, 95% CI 1.15 to 1.37; I2 = 15%; 6 studies, 4439 participants). We also looked at the safety and efficacy of bupropion when combined with other non-antidepressant smoking cessation therapies. There was insufficient evidence to establish whether combination bupropion and nicotine replacement therapy (NRT) resulted in superior quit rates to NRT alone (RR 1.19, 95% CI 0.94 to 1.51; I2 = 52%; 12 studies, 3487 participants), or whether combination bupropion and varenicline resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I2 = 15%; 3 studies, 1057 participants). We judged the certainty of evidence to be low and moderate, respectively; in both cases due to imprecision, and also due to inconsistency in the former. Safety data were sparse for these comparisons, making it difficult to draw clear conclusions. A meta-analysis of six studies provided evidence that bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.71, 95% CI 0.64 to 0.79; I2 = 0%; 6 studies, 6286 participants), whilst there was no evidence of a difference in efficacy between bupropion and NRT (RR 0.99, 95% CI 0.91 to 1.09; I2 = 18%; 10 studies, 8230 participants). We also found some evidence that nortriptyline aided smoking cessation when compared with placebo (RR 2.03, 95% CI 1.48 to 2.78; I2 = 16%; 6 studies, 975 participants), whilst there was insufficient evidence to determine whether bupropion or nortriptyline were more effective when compared with one another (RR 1.30 (favouring bupropion), 95% CI 0.93 to 1.82; I2 = 0%; 3 studies, 417 participants). There was no evidence that any of the other antidepressants tested (including St John's Wort, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs)) had a beneficial effect on smoking cessation. Findings were sparse and inconsistent as to whether antidepressants, primarily bupropion and nortriptyline, had a particular benefit for people with current or previous depression. AUTHORS' CONCLUSIONS: There is high-certainty evidence that bupropion can aid long-term smoking cessation. However, bupropion also increases the number of adverse events, including psychiatric AEs, and there is high-certainty evidence that people taking bupropion are more likely to discontinue treatment compared with placebo. However, there is no clear evidence to suggest whether people taking bupropion experience more or fewer SAEs than those taking placebo (moderate certainty). Nortriptyline also appears to have a beneficial effect on smoking quit rates relative to placebo. Evidence suggests that bupropion may be as successful as NRT and nortriptyline in helping people to quit smoking, but that it is less effective than varenicline. There is insufficient evidence to determine whether the other antidepressants tested, such as SSRIs, aid smoking cessation, and when looking at safety and tolerance outcomes, in most cases, paucity of data made it difficult to draw conclusions. Due to the high-certainty evidence, further studies investigating the efficacy of bupropion versus placebo are unlikely to change our interpretation of the effect, providing no clear justification for pursuing bupropion for smoking cessation over front-line smoking cessation aids already available. However, it is important that where studies of antidepressants for smoking cessation are carried out they measure and report safety and tolerability clearly.


Assuntos
Ansiolíticos/uso terapêutico , Antidepressivos/uso terapêutico , Abandono do Hábito de Fumar/métodos , Fumar/tratamento farmacológico , Ansiolíticos/efeitos adversos , Antidepressivos/efeitos adversos , Bupropiona/efeitos adversos , Bupropiona/uso terapêutico , Humanos , Nortriptilina/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Inibidores de Captação de Serotonina/uso terapêutico , Fumar/psicologia , Abandono do Hábito de Fumar/psicologia , Dispositivos para o Abandono do Uso de Tabaco , Vareniclina/efeitos adversos , Vareniclina/uso terapêutico
16.
J Clin Neurosci ; 78: 236-241, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32334957

RESUMO

Data regarding the efficacy and safety of smoking-cessation pharmacotherapy after stroke are lacking. We systematically reviewed data on this topic by searching Medline, Cochrane, and Clinicaltrials.gov to identify randomized clinical trials (RCT) and observational studies that assessed the efficacy and safety of nicotine replacement therapy (NRT), varenicline, and bupropion in patients with stroke and TIA. We included studies that reported rates of smoking cessation, worsening or recurrent cerebrovascular disease, seizures, or neuropsychiatric events. We identified 2 RCTs and 6 observational studies; 3 included ischemic stroke and TIA, 2 subarachnoid hemorrhage (SAH), and 3 did not specify. Four studies assessed efficacy; cessation rates ranged from 33% to 66% with pharmacological therapy combined with behavioral interventions versus 15% to 46% without, but no individual study demonstrated a statistically significant benefit. Safety data for varenicline and buopropion in ischemic stroke were scarce. Patients with SAH who received NRT had more seizures (9% vs 2%; P = 0.024) and delirium (19% vs 7%; P = 0.006) in one study, but less frequent vasospasm in 3 studies. In conclusion, combined with behavioral interventions, smoking-cessation therapies resulted in numerically higher cessation rates. Limited safety data may prompt caution regarding seizures and delirium in patients with subarachnoid hemorrhage.


Assuntos
Ataque Isquêmico Transitório , Abandono do Hábito de Fumar , Fumar/tratamento farmacológico , Acidente Vascular Cerebral , Bupropiona/uso terapêutico , Feminino , Humanos , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Convulsões/tratamento farmacológico , Dispositivos para o Abandono do Uso de Tabaco , Vareniclina/uso terapêutico
17.
Cochrane Database Syst Rev ; 3: CD010078, 2020 03 04.
Artigo em Inglês | MEDLINE | ID: mdl-32129504

RESUMO

BACKGROUND: Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non-pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown. OBJECTIVES: To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi-randomised, cross-over, and within-participant designs, and RCTs with additional intervention components not matched between trial arms. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well-being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate. MAIN RESULTS: We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non-placebo (behavioural support only) controls, there was low-certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo-controlled and non-placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo-controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non-placebo-controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast-acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non-serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low-certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group. AUTHORS' CONCLUSIONS: NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non-placebo-controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo-controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review.


Assuntos
Complicações na Gravidez/prevenção & controle , Abandono do Hábito de Fumar , Fumar/terapia , Bupropiona/uso terapêutico , Feminino , Humanos , Agonistas Nicotínicos/uso terapêutico , Gravidez , Resultado da Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Abandono do Hábito de Fumar/métodos , Dispositivos para o Abandono do Uso de Tabaco
18.
Orthop Nurs ; 39(2): 121-127, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32218009

RESUMO

Obesity, a chronic multifactorial disease, has been on the rise in the United States in recent years. It paves a way to other chronic conditions and related morbidity and mortality. The treatment of obesity should have a chronic approach involving lifestyle modifications from the very beginning. Along with reduced calorie diet, increased physical activity, and behavior modifications, various short- and long-term pharmacological agents are available to help with the weight loss. For qualifying patients, selection of an appropriate agent based on its mechanism, efficacy, and safety profile as well as patient preference can provide desired outcomes. This medical weight management should be a multidisciplinary approach involving nurses to provide continuous patient education and motivation.


Assuntos
Tratamento Farmacológico/métodos , Obesidade/tratamento farmacológico , Programas de Redução de Peso/métodos , Benzazepinas/farmacologia , Benzazepinas/uso terapêutico , Bupropiona/farmacologia , Bupropiona/uso terapêutico , Combinação de Medicamentos , Tratamento Farmacológico/estatística & dados numéricos , Exercício Físico/fisiologia , Exercício Físico/psicologia , Frutose/análogos & derivados , Frutose/farmacologia , Frutose/uso terapêutico , Humanos , Liraglutida/farmacologia , Liraglutida/uso terapêutico , Naltrexona/farmacologia , Naltrexona/uso terapêutico , Obesidade/psicologia , Orlistate/farmacologia , Orlistate/uso terapêutico , Fentermina/farmacologia , Fentermina/uso terapêutico , Programas de Redução de Peso/normas
19.
PLoS One ; 15(3): e0230656, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32214373

RESUMO

INTRODUCTION: Smoking is a strong risk factor for disease severity in Crohn's disease (CD) and cessation improves outcomes. The nicotine metabolite ratio (NMR) predicts cessation success with pharmacotherapy: varenicline doubles cessation over nicotine replacement therapy (NRT) for "normal", but not "slow" metabolizers. Varenicline side effects are heightened in slow metabolizers. Methods using NMR to optimize cessation pharmacotherapy have not been evaluated in CD. AIMS: We aim to determine the prevalence of smoking in a CD population and then assess these smokers' attitudes toward a personalized metabolism-informed care (MIC) approach to cessation. METHODS: In this observational study, we surveyed 1098 patients visiting an inflammatory bowel disease center about their smoking history. We then evaluated a subgroup of individuals with CD (n = 32) who participated in a randomized controlled trial of smoking cessation using MIC versus usual care. For MIC, medication selection was informed by the NMR (normal ≥0.31 vs. slow <0.31). The primary outcomes were intervention satisfaction and match rates between NMR and medication choice. RESULTS: The baseline prevalence of smoking in our CD population was 13%. Intervention participants reported high rates of satisfaction (85%) and chose a medication that matched their NMR result more often in the MIC group (100% vs. 64%, p = 0.01). Six of 16 (37.5%) patients prescribed varenicline discontinued due to side effects. CONCLUSION: MIC produced high rates of satisfaction and matching between NMR and medication in CD patients, supporting patient acceptance and feasibility of precision smoking cessation in this population. To reduce smoking in CD, therapies such as MIC are needed to maximize efficacy and minimize side effects.


Assuntos
Doença de Crohn/patologia , Nicotina/metabolismo , Abandono do Hábito de Fumar/métodos , Adulto , Bupropiona/efeitos adversos , Bupropiona/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Projetos Piloto , Prevalência , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Fumar/tratamento farmacológico , Fumar/epidemiologia , Dispositivos para o Abandono do Uso de Tabaco/efeitos adversos , Resultado do Tratamento , Vareniclina/efeitos adversos , Vareniclina/uso terapêutico
20.
East Mediterr Health J ; 26(1): 110-115, 2020 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-32043553

RESUMO

The report aimed to review and assess the status of tobacco cessation services in the Eastern Mediterranean Region (EMR). Nearly 70% of people in the Region have legal access to nicotine-replacement therapy but for 77% of these people the costs of the treatment are not covered. Bupropion and Varenicline are legally available in 10 and 11 EMR countries respectively. Just under 50% of people in the Region have access to at least some cessation support in primary health care facilities. Around 32% of people have access to a national toll-free quit line. Costs for cessation services are fully covered in few EMR countries; however, cessation services in the Region must be improved. Member States should aim to increase the availability of, and financial support for, cessation treatments and support, which should be prioritized in primary health care facilities.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Agentes de Cessação do Hábito de Fumar/uso terapêutico , Abandono do Hábito de Fumar/métodos , África do Norte , Bupropiona/provisão & distribuição , Bupropiona/uso terapêutico , Humanos , Oriente Médio , Atenção Primária à Saúde/estatística & dados numéricos , Agentes de Cessação do Hábito de Fumar/economia , Agentes de Cessação do Hábito de Fumar/provisão & distribuição , Vareniclina/provisão & distribuição , Vareniclina/uso terapêutico
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