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1.
World J Gastroenterol ; 27(11): 1022-1042, 2021 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-33776370

RESUMO

Managing inflammatory bowel disease (IBD) during the coronavirus disease 2019 (COVID-19) pandemic has been a challenge faced by clinicians and their patients, especially concerning whether to proceed with biologics and immunosuppressive agents in the background of a global outbreak of a highly contagious new coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2). The knowledge about the impact of this virus on patients with IBD, although it is still scarce, is rapidly evolving. In particular, concerns surrounding medications' impact for IBD on the risk of acquiring SARS-CoV-2 infection or developing COVID-19, and potentially exacerbate viral replication and the COVID-19 course, are a current thinking of both practicing clinicians and providers caring for patients with IBD. Managing patients with IBD infected with SARS-CoV-2 depends on both the clinical activity of the IBD and the occasional development and severity of COVID-19. In this review, we summarize the current data regarding gastrointestinal involvement by SARS-CoV-2 and pharmacologic and surgical management for IBD concerning this infection, and the COVID-19 impact on both the patient's psychological functioning and endoscopy services, and we concisely summarize the telemedicine roles during the COVID-19 pandemic.


Assuntos
Produtos Biológicos/uso terapêutico , Glucocorticoides/uso terapêutico , Imunossupressores/uso terapêutico , Doenças Inflamatórias Intestinais/tratamento farmacológico , Telemedicina , Assistência Ambulatorial , Portador Sadio , Desprescrições , Gerenciamento Clínico , Endoscopia Gastrointestinal , Hospitalização , Humanos , Fatores Imunológicos/uso terapêutico , Doenças Inflamatórias Intestinais/complicações , Guias de Prática Clínica como Assunto , Fatores de Risco , Índice de Gravidade de Doença
2.
Mayo Clin Proc ; 96(1): 242-256, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33413822

RESUMO

Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.


Assuntos
Polimedicação , Idoso , Analgésicos Opioides/efeitos adversos , Antipsicóticos/efeitos adversos , Desprescrições , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Humanos , Reconciliação de Medicamentos , Instituições de Cuidados Especializados de Enfermagem
3.
Dig Liver Dis ; 53(3): 271-276, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33451910

RESUMO

BACKGROUND: Italy has been one of the most affected countries in the world by COVID-19. There has been increasing concern regarding the impact of COVID-19 on patients with inflammatory bowel disease (IBD), particularly in patients treated with immunosuppressants or biologics. The aim of our study is to understand the incidence of COVID-19 in a large cohort of patients with IBD. Furthermore, we analyzed possible risk factors for infection and severity of COVID-19. METHODS: This was an observational study evaluating the impact of COVID-19 on IBD patients in a single tertiary center. A 23 multiple-choice-question anonymous survey was administered to 1200 patients with IBD between March 10th and June 10th 2020. RESULTS: 1158 questionnaires were analyzed. The majority of patients had Crohn's disease (CD) (60%) and most of them were in clinical remission. Among the 26 patients (2.2%) who tested positive for COVID-19, only 5 (3CD) were on biological treatment and none required hospitalization. Two patients died and were on treatment with mesalazine only. Of the 1158 patients, 521 were on biological therapy, which was discontinued in 85 (16.3%) and delayed in 195 patients (37.4%). A worsening of IBD symptoms was observed in 200 patients on biological therapy (38.4%). Most of these patients, 189 (94.5%), had stopped or delayed biological treatment, while 11 (5.5%) had continued their therapy regularly (p<0.001). CONCLUSIONS: Our data are in line with the current literature and confirm a higher incidence compared to the general population. Biological therapy for IBD seems to not be a risk factor for infection and should not be discontinued in order to avoid IBD relapse.


Assuntos
/epidemiologia , Colite Ulcerativa/epidemiologia , Doença de Crohn/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados/uso terapêutico , Produtos Biológicos/uso terapêutico , Colite Ulcerativa/tratamento farmacológico , Colite Ulcerativa/fisiopatologia , Doença de Crohn/tratamento farmacológico , Doença de Crohn/fisiopatologia , Desprescrições , Feminino , Fármacos Gastrointestinais/uso terapêutico , Hospitalização/estatística & dados numéricos , Humanos , Doenças Inflamatórias Intestinais/tratamento farmacológico , Doenças Inflamatórias Intestinais/epidemiologia , Doenças Inflamatórias Intestinais/fisiopatologia , Itália/epidemiologia , Masculino , Mesalamina/uso terapêutico , Pessoa de Meia-Idade , Sulfassalazina/uso terapêutico , Centros de Atenção Terciária , Tempo para o Tratamento , Inibidores do Fator de Necrose Tumoral/uso terapêutico , Adulto Jovem
4.
Adv Chronic Kidney Dis ; 27(5): 383-389, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-33308503

RESUMO

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2, has led to the death of hundreds of thousands of people worldwide. If infected, older individuals and those with diabetes, hypertension, cardiovascular disease, and compromised immune systems are at higher risk for unfavorable outcomes. These comorbidities are prevalent in patients with kidney disease, hence the significant burden of COVID-19 on kidney transplant programs. Multiple case series of kidney transplant recipients with COVID-19 have shown increased mortality compared to nontransplant patients. To date, we do not have high-level evidence to inform immunosuppression minimization strategies in infected transplant recipients. Most centers however have adopted early antimetabolite withdrawal in addition to other interventions. This review summarizes the published COVID-19 literature as it relates to outcomes and immunosuppression management in kidney transplant recipients. It also discusses challenges pertaining to pretransplant evaluation and wait-listed patients.


Assuntos
/terapia , Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Falência Renal Crônica/cirurgia , Transplante de Rim , Telemedicina , /mortalidade , Infecção Hospitalar/prevenção & controle , Assistência à Saúde/métodos , Desprescrições , Humanos , Imunossupressão/métodos , Equipamento de Proteção Individual , Cuidados Pré-Operatórios , Listas de Espera
5.
Rev Med Suisse ; 16(714): 2169-2171, 2020 Nov 11.
Artigo em Francês | MEDLINE | ID: mdl-33174699

RESUMO

Deprescribing, in order to reduce both polypharmacy and the use of potentially inappropriate medications, remains a challenge, especially in nursing homes. Healthcare professionals perceive residents of these homes as wary of change and reluctant to take part in such endeavours. The results of two studies, one qualitative and the other quantitative, show that, on the contrary, nursing home residents and their relatives would be ready to consider a treatment reduction, provided that time is invested to explain the expected benefits of such changes.


Assuntos
Atitude Frente a Saúde , Desprescrições , Família/psicologia , Pessoal de Saúde/psicologia , Casas de Saúde , Pacientes/psicologia , Humanos , Polimedicação , Lista de Medicamentos Potencialmente Inapropriados
8.
Int Heart J ; 61(5): 1084-1087, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921661

RESUMO

Diazoxide, a drug used to treat hyperinsulinemic hypoglycemia (HH), is associated with pulmonary hypertension (PH), as reported by the US Food and Drug Administration. However, no report has detailed the association between diazoxide dose and PH development. We report a case of an infant with HH, subsequently complicated by diazoxide-induced PH. When diazoxide was introduced, PH did not appear initially, but it developed during increased dosing. We monitored PH via regular echocardiography examinations. PH gradually improved with tapering of the diazoxide dose and disappeared after drug discontinuation. Our case suggests a diazoxide dose threshold might induce PH. Therefore, close echocardiography examinations should accompany diazoxide treatment.


Assuntos
Síndrome de Beckwith-Wiedemann/diagnóstico , Hiperinsulinismo Congênito/tratamento farmacológico , Diazóxido/efeitos adversos , Hipertensão Pulmonar/induzido quimicamente , Fator Natriurético Atrial/sangue , Síndrome de Beckwith-Wiedemann/complicações , Cateterismo Cardíaco , Hiperinsulinismo Congênito/etiologia , Desprescrições , Diazóxido/administração & dosagem , Diuréticos/uso terapêutico , Relação Dose-Resposta a Droga , Ecocardiografia , Eletrocardiografia , Humanos , Hipertensão Pulmonar/sangue , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/tratamento farmacológico , Lactente , Recém-Nascido , Masculino , Peptídeo Natriurético Encefálico/sangue , Citrato de Sildenafila/uso terapêutico , Vasodilatadores/uso terapêutico
9.
PLoS One ; 15(9): e0238511, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32941462

RESUMO

INTRODUCTION: Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). METHODS: We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%). RESULTS: The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient's fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a 'security blanket'. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication. CONCLUSIONS: While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.


Assuntos
Corticosteroides/uso terapêutico , Desprescrições , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Administração por Inalação , Corticosteroides/administração & dosagem , Corticosteroides/efeitos adversos , Feminino , Humanos , Masculino , Uso Excessivo de Medicamentos Prescritos , Atenção Primária à Saúde , Inquéritos e Questionários
10.
Rev Med Suisse ; 16(706): 1690-1692, 2020 Sep 16.
Artigo em Francês | MEDLINE | ID: mdl-32936550

RESUMO

With the rise of life-expectancy, the number of comorbidities can increase and lead to polypharmacy (≥ 5 drugs/day) and excessive polypharmacy (> 9 drugs/day). In order to define suitable therapeutic targets, it is essential to take into account the heterogeneity of this population which can be classified into 3 categories : robust, vulnerable or dependent. In this context, the concept of deprescription, which englobes the process of tapering or stopping drugs, aimed at improving patient outcomes, becomes an important therapeutic tool. In the context of hypertension, this approach seems to be a safe, provided that patients can benefit from regular monitoring. It must be considered in vulnerable and dependent patients or patients institutionalized in nursing homes. Although, scientific evidence slowly accumulates, its levels remain moderate. Finally, the deprescribing process, can also be applied in specifics situations in order to prevent adverse events, such as during a heat wave.


Assuntos
Anti-Hipertensivos/administração & dosagem , Desprescrições , Humanos , Casas de Saúde , Polimedicação
11.
Clin Rheumatol ; 39(11): 3237-3244, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32892311

RESUMO

The outbreak of coronavirus in the world has led to an uncertainty about treatment of patients with autoimmune disorders because of their weakened immune system coupled with immunosuppressive agents they take which predisposes them to a host of infections. Data on COVID-19 patients with underlying rheumatological diseases has been emerging mostly in the form of small case series and one global registry. From these data, it seems like our patients, although immunosuppressed, are not particularly susceptible to the coronavirus infection and if infected, do not have significantly worse outcomes than other patients. In fact, drugs like hydroxychloroquine, dexamethasone, and tocilizumab have been studied for treatment of COVID-19. However, this is only preliminary data, and since a few parts of the world are still grappling with the pandemic at its peak, we need to be equipped on how to protect and manage our immunosuppressed patients. Published evidence to guide treatment decisions are lacking and doubts regarding continuation and initiation of immunosuppressants remain. Rheumatoid arthritis (RA) is the most common immune-mediated disorder in COVID-19 patients, and in this review, we discuss how the commonly used drugs in RA alter the patients' susceptibility to this infection. The review also summarizes the recommendations from the major bodies on how to manage this disease in these times. Key Points • Patients on immunosuppressive medications are not found to be at a greatly increased risk of acquiring COVID-19 infection. • Patients doing well on a stable dose of steroid and/or Disease-Modifying Antirheumatic Drugs (DMARDs) should be allowed to continue the same unless they get infected in which case, temporary stoppage of methotrexate and leflunomide may be considered. • Initiation of high-dose steroids, DMARDs, and biologics, if the clinical situation demands so, can be done. • Maintenance biologic therapy for stable patients should be individualized by the treating physician.


Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Infecções por Coronavirus , Glucocorticoides/uso terapêutico , Pandemias , Pneumonia Viral , Anti-Inflamatórios não Esteroides/uso terapêutico , Betacoronavirus , Produtos Biológicos/uso terapêutico , Desprescrições , Gerenciamento Clínico , Humanos , Inibidores do Fator de Necrose Tumoral/uso terapêutico
12.
Clin Rheumatol ; 39(11): 3245-3254, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32895747

RESUMO

Rheumatology practice, during Coronavirus Disease 2019 (COVID-19) pandemic, has faced multifaceted challenges. Rheumatologists routinely prescribe immunosuppressant medications to their patients with multisystem autoimmune rheumatic diseases who are concerned about the increased risk of acquiring COVID-19 infection and are anxious to know if they should continue or hold these medications. Rheumatologists are often inundated by calls from their patients and physician colleagues caring for COVID-19 patients in hospitals, about how to manage the immunosuppression. Physicians face the challenging task of keeping up with the most up-to-date information on COVID-19. There are uncertainties about the mode of spread, clinical features, management options as well as long-term complications of COVID-19. Data are rapidly evolving and different studies on treatment options are showing contradictory results. It is known that viral illnesses can trigger a flare-up of underlying rheumatic disease that was previously in remission. To further complicate the scenario, some of the immunosuppressants have shown to have antiviral properties. This has created dilemma in the light of current COVID-19 crisis, as whether to continue or stop the immunosuppressive agents which could be essential to prevent complications of the rheumatic diseases including organ failure but also there is concern about acquiring COVID-19 or developing serious infection. Until we get an effective vaccine, immunosuppressant management for rheumatic diseases as well as other autoimmune diseases and transplants will pose difficult questions. This article is an attempt to review and understand COVID-19 and its impact on the immune system with special emphasis on managing medications used for autoimmune rheumatic diseases. We have provided general guidance about decision making, in regards to the immunosuppressive agents used in rheumatology practice with an understanding that this may change in near future.


Assuntos
Antirreumáticos/uso terapêutico , Infecções por Coronavirus/imunologia , Imunossupressores/uso terapêutico , Pneumonia Viral/imunologia , Doenças Reumáticas/tratamento farmacológico , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Síndrome da Liberação de Citocina/imunologia , Desprescrições , Gerenciamento Clínico , Humanos , Pandemias , Pneumonia Viral/tratamento farmacológico
13.
Med Clin North Am ; 104(5): 751-765, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32773043

RESUMO

Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting.


Assuntos
Desprescrições , Prescrição Inadequada/prevenção & controle , Múltiplas Afecções Crônicas/tratamento farmacológico , Idoso , Humanos , Lista de Medicamentos Potencialmente Inapropriados
14.
Geriatr Gerontol Int ; 20(10): 961-966, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32812703

RESUMO

AIM: Studies of medication use in patients with a percutaneous endoscopic gastrostomy (PEG) tube have not been conducted adequately. The aim of this study was to describe medication use of care-dependent older adults with PEG and evaluate whether potential prescribing omissions (PPO) would affect the cause of death or acute illness. METHODS: In a geriatric long-term care hospital, 116 inpatients aged ≥65 years with insertion of a PEG tube because of dysphagia were enrolled and followed for 2 years: 2016-2018. The patients were divided into two groups, i.e., group A (who died between 2016 and 2018) and group B (who continued to be hospitalized in 2018). Clinical data and prescribed medications were recorded. Logistic regression models were conducted to assess the associations between survival and variables: age, gender, serum albumin level, serum creatinine level, body mass index (BMI), number of drugs and PPO. RESULTS: The patients' mean age was 85.3 ± 10.2 years, 57.8% were women and the mean number of drugs was 6.8 ± 3.5. Medications for managing symptoms, such as constipation and gastrointestinal symptoms, were commonly prescribed. The most common PPO medications were antiplatelet agents and anticoagulants. On logistic regression analysis, PPO had no influence on the cause of death or acute illness. Lower age, higher serum albumin level and body mass index were associated with survival in both univariate and multivariate models. CONCLUSIONS: Polypharmacy was prevalent in patients with PEG. Given the finding that PPO had no influence on health outcome, rational deprescribing could be warranted. Geriatr Gerontol Int 2020; 20: 961-966.


Assuntos
Causas de Morte , Desprescrições , Prescrições de Medicamentos/estatística & dados numéricos , Gastrostomia , Intubação Gastrointestinal , Idoso , Idoso de 80 Anos ou mais , Nutrição Enteral , Feminino , Humanos , Japão , Assistência de Longa Duração , Masculino , Polimedicação , Estudos Retrospectivos
15.
Am J Cardiol ; 128: 12-15, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650904

RESUMO

Although atrial fibrillation (AF) is strongly associated with stroke, previous studies have shown suboptimal use of anticoagulation (AC). In particular, there is a lack of data on the long-term use of AC after AF catheter ablation. We followed up patients 1 to 5 years out from catheter ablation at the Johns Hopkins Hospital (JHH) to assess their long-term use of AC. We sent a survey to patients from the JHH AF database who underwent an AF catheter ablation between 01/01/2014 and 03/31/2018. Patients were asked whether they were still on AC, if they thought the ablation was successful in controlling AF symptoms and whether they had follow-up rhythm monitoring. Replies were compared with risk scores and demographic data from the electronic medical record. We sent the survey to 628 patients in the database meeting our inclusion criteria, and we received 289 responses. The average age of patients was 67 ± 10 with a median CHA2DS2-VASc of 2 and a median follow-up of 3.6 years. Overall, 81.6% of patients with a CHA2DS2-VASc >2 reported taking AC. Use of AC was positively correlated with a higher CHA2DS2-VASc score (p = 0.012) and older age (p = 0.028), but negatively correlated with a successful ablation (p = 0.040). The most common reason (50.0%) for not being on AC was that doctors were recommending stopping it after a successful ablation. In general, higher risk patients (older, higher CHA2DS2-VASC score) were more likely to remain on AC. However, patients who self-reported a successful ablation were less likely to remain on AC. There may be many patients who can tolerate AC, but are recommended to stop due to a successful ablation. It is still debated how successful AF ablation affects stroke risk. In conclusion, there is considerable variation in the long-term management of AC after an ablation, but for the present, it seems prudent to continue AC based on stroke risk scores until more definite data are available.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/terapia , Ablação por Cateter/métodos , Desprescrições , Acidente Vascular Cerebral/prevenção & controle , Idoso , Fibrilação Atrial/complicações , Feminino , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Acidente Vascular Cerebral/etiologia
16.
Artigo em Inglês | MEDLINE | ID: mdl-32678526

RESUMO

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.


Assuntos
Infecções por Coronavirus/terapia , Desprescrições , Dexmedetomidina/uso terapêutico , Delírio do Despertar/diagnóstico , Hipnóticos e Sedativos/uso terapêutico , Pneumonia Viral/terapia , Respiração Artificial/métodos , Síndrome de Abstinência a Substâncias/diagnóstico , Adulto , Analgésicos Opioides/uso terapêutico , Benzodiazepinas/uso terapêutico , Betacoronavirus , Delírio do Despertar/terapia , Humanos , Masculino , Exame Neurológico , Pandemias , Guias de Prática Clínica como Assunto , Propofol/uso terapêutico , Síndrome de Abstinência a Substâncias/terapia
17.
Rheumatol Int ; 40(10): 1599-1611, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32710198

RESUMO

The aim of this work is to trace how rheumatologists all over Egypt are approaching the COVID-19 pandemic and what changes it has brought about in the patients' care with special attention to its effect on vulnerable rheumatic disease (RD) patients. This survey further aims to help inform the rheumatology community about the changes in practice during the COVID-19 pandemic. The survey included 26 questions distributed to University staff members across Egypt members of the Egyptian College of Rheumatology (ECR). It takes 5-10 min to fill out. The practice setting of participating rheumatologists included University Teaching Hospitals that are the main rheumatology and clinical immunology service providers for adults and children RD patients. There was an overall agreement across the country in the responses to the survey that took a median time of 7 min to fill in. Potential changes in rheumatology outpatient practice by staff members evolved since the COVID-19 pandemic. None of the university rheumatology staff members has prescribed chloroquine or HCQ to prevent or treat COVID-19 in a non-hospitalized patient who was not previously on it. Twenty-three recommended decrease/avoid NSAIDs if the RD patient had confirmed COVID-19 or symptoms. There is an agreement to the key emerging frontline role of rheumatologists in treating COVID-19. During the pandemic, RD cases requiring admission were dealt with by several modified strategies. The overall agreement among the different university rheumatology departments during such critical situation has provoked the ECR to consider providing provisional guidelines for dealing with RD patients during this global catastrophe.


Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Antirreumáticos/uso terapêutico , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Doenças Reumáticas/tratamento farmacológico , Reumatologistas/estatística & dados numéricos , Assistência Ambulatorial/estatística & dados numéricos , Antirreumáticos/provisão & distribução , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/prevenção & controle , Desprescrições , Egito/epidemiologia , Humanos , Hidroxicloroquina/provisão & distribução , Hidroxicloroquina/uso terapêutico , Pandemias/prevenção & controle , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/prevenção & controle , Reumatologia , Inquéritos e Questionários
18.
Clin Rheumatol ; 39(9): 2797-2802, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32562070

RESUMO

Recurrences of COVID-19 were observed in a patient with long-term usage of hydroxychloroquine, leflunomide, and glucocorticoids due to her 30-year history of rheumatoid arthritis (RA). Tocilizumab was applied and intended to target both COVID-19 and RA. However, disease of this patient aggravated after usage of tocilizumab. After the discussion of a multiple disciplinary team (MDT) including rheumatologists, antimicrobial treatments were applied to target the potential opportunistic infections (Pneumocystis jirovecii and Aspergillus fumigatus), which were authenticated several days later via high throughput sequencing. As an important cytokine in immune responses, IL-6 can be a double-edged sword: interference in the IL-6-IL-6 receptor signaling may save patients from cytokine release storm (CRS), but can also weaken the anti-infectious immunity, particularly in rheumatic patients, who may have received a long-term treatment with immunosuppressive/modulatory agents. Thus, we suggest careful considerations before and close monitoring in the administration of tocilizumab in rheumatic patients with COVID-19. Besides tocilizumab, several disease-modifying antirheumatic drugs (DMARDs) can also be applied in the treatment of COVID-19. Therefore, we also reviewed and discussed the application of these DMARDs in COVID-19 condition.


Assuntos
Antivirais/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Infecções por Coronavirus/terapia , Glucocorticoides/uso terapêutico , Pneumonia por Pneumocystis/diagnóstico , Pneumonia Viral/terapia , Aspergilose Pulmonar/diagnóstico , Idoso , Antibacterianos/uso terapêutico , Antifúngicos/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/complicações , Aspergilose , Aspergillus fumigatus , Betacoronavirus , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico por imagem , Infecções por Coronavirus/fisiopatologia , Tosse/etiologia , Síndrome da Liberação de Citocina/etiologia , Desprescrições , Progressão da Doença , Dispneia/etiologia , Feminino , Glucocorticoides/efeitos adversos , Humanos , Hidroxicloroquina/uso terapêutico , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Interleucina-6/sangue , Leflunomida/efeitos adversos , Leflunomida/uso terapêutico , Pulmão/diagnóstico por imagem , Linfo-Histiocitose Hemofagocítica/diagnóstico , Linfo-Histiocitose Hemofagocítica/etiologia , Linfo-Histiocitose Hemofagocítica/imunologia , Metilprednisolona/uso terapêutico , Oxigenoterapia , Pandemias , Pneumocystis carinii , Pneumonia por Pneumocystis/tratamento farmacológico , Pneumonia por Pneumocystis/etiologia , Pneumonia por Pneumocystis/imunologia , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico por imagem , Pneumonia Viral/fisiopatologia , Aspergilose Pulmonar/tratamento farmacológico , Aspergilose Pulmonar/etiologia , Aspergilose Pulmonar/imunologia , Recidiva , Tomografia Computadorizada por Raios X
19.
BMJ ; 369: m1822, 2020 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-32554566

RESUMO

OBJECTIVE: To evaluate the effects of a computerised decision support tool for comprehensive drug review in elderly people with polypharmacy. DESIGN: Pragmatic, multicentre, cluster randomised controlled trial. SETTING: 359 general practices in Austria, Germany, Italy, and the United Kingdom. PARTICIPANTS: 3904 adults aged 75 years and older using eight or more drugs on a regular basis, recruited by their general practitioner. INTERVENTION: A newly developed electronic decision support tool comprising a comprehensive drug review to support general practitioners in deprescribing potentially inappropriate and non-evidence based drugs. Doctors were randomly allocated to either the electronic decision support tool or to provide treatment as usual. MAIN OUTCOME MEASURES: The primary outcome was the composite of unplanned hospital admission or death by 24 months. The key secondary outcome was reduction in the number of drugs. RESULTS: 3904 adults were enrolled between January and October 2015. 181 practices and 1953 participants were assigned to electronic decision support (intervention group) and 178 practices and 1951 participants to treatment as usual (control group). The primary outcome (composite of unplanned hospital admission or death by 24 months) occurred in 871 (44.6%) participants in the intervention group and 944 (48.4%) in the control group. In an intention-to-treat analysis the odds ratio of the composite outcome was 0.88 (95% confidence interval 0.73 to 1.07; P=0.19, 997 of 1953 v 1055 of 1951). In an analysis restricted to participants attending practice according to protocol, a difference was found favouring the intervention (odds ratio 0.82, 95% confidence interval 0.68 to 0.98; 774 of 1682 v 873 of 1712, P=0.03). By 24 months the number of prescribed drugs had decreased in the intervention group compared with control group (uncontrolled mean change -0.42 v 0.06: adjusted mean difference -0.45, 95% confidence interval -0.63 to -0.26; P<0.001). CONCLUSIONS: In intention-to-treat analysis, a computerised decision support tool for comprehensive drug review of elderly people with polypharmacy showed no conclusive effects on the composite of unplanned hospital admission or death by 24 months. Nonetheless, a reduction in drugs was achieved without detriment to patient outcomes. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10137559.


Assuntos
Doença Crônica/tratamento farmacológico , Sistemas de Apoio a Decisões Clínicas , Prescrição Inadequada/prevenção & controle , Polimedicação , Idoso de 80 Anos ou mais , Áustria/epidemiologia , Doença Crônica/epidemiologia , Análise por Conglomerados , Desprescrições , Revisão de Uso de Medicamentos , Feminino , Avaliação Geriátrica , Alemanha/epidemiologia , Humanos , Itália/epidemiologia , Masculino , Reino Unido/epidemiologia
20.
Am J Cardiol ; 129: 1-4, 2020 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-32540170

RESUMO

Ranolazine is approved for patients with chronic stable angina but has not been formally studied in patients with refractory angina pectoris (RAP). Patients with RAP have limited therapeutic options and significant limitations in their quality of life. The Ranolazine Refractory Angina Registry was designed to evaluate the safety, tolerability, and effectiveness of ranolazine in RAP patients in order to expand treatment options for this challenging patient population. Using an extensive prospective database, we enrolled 158 consecutive patients evaluated in a dedicated RAP clinic. Angina class, medications, major adverse cardiac events including death, myocardial infarction, and revascularization were obtained at 12, 24, and 36 months. At 3 years, 95 (60%) patients remained on ranolazine. A ≥2 class improvement in angina was seen in 48% (38 of 80 patients with known Canadian Cardiovascular Society class) of those who remained on ranolazine. Discontinuation due to side effects, ineffectiveness, cost, and progression of disease were the principle reasons for discontinuation, but primarily occurred within the first year. In conclusion, ranolazine is an effective antianginal therapy at 3-year follow-up in patients with RAP and may reduce cardiac readmission.


Assuntos
Angina Pectoris/tratamento farmacológico , Fármacos Cardiovasculares/uso terapêutico , Ranolazina/uso terapêutico , Idoso , Angina Pectoris/epidemiologia , Angina Pectoris/fisiopatologia , Fármacos Cardiovasculares/economia , Constipação Intestinal/induzido quimicamente , Desprescrições , Diabetes Mellitus/epidemiologia , Progressão da Doença , Tontura/induzido quimicamente , Custos de Medicamentos , Dislipidemias/epidemiologia , Edema/induzido quimicamente , Feminino , Humanos , Hipertensão/epidemiologia , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio/epidemiologia , Revascularização Miocárdica/estatística & dados numéricos , Náusea/induzido quimicamente , Ranolazina/economia , Sistema de Registros , Fumar/epidemiologia , Falha de Tratamento , Resultado do Tratamento
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