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Free accessEditorialFirst published June, 2018pp. 259-261
Free accessReview articleFirst published June, 2018pp. 263-285Immune thrombocytopenia (ITP) is an autoimmune disorder that induces a decrease in the number of circulating platelets due to spleen destruction and inability of megakaryocytes to restore normal counts. Immunosuppressive therapy with glucocorticoid drugs constitutes the first line of treatment. However, lack of response to these agents is not uncommon, and the management of refractory patients is a matter of controversy. In fact, day-to-day clinical practice shows that, in spite of the current guidelines, splenectomy, which is currently considered a suitable second-choice therapy, is being replaced by treatment with thrombopoietin receptor agonists. These boost platelet production by megakaryocytes. The use of one of these, namely eltrombopag, has been permitted for ITP patients refractory to first-line drugs or splenectomy, for the last 10 years. This review summarizes the experience reported using eltrombopag in ITP, paying attention to efficacy and safety. Results from clinical trials will be discussed, and studies performed in the course of daily clinical practice will also be reviewed, as these are useful to assess the potential of the drug in real-world settings. The management of adverse events and the use of eltrombopag in particular situations will also be covered. The experience reported so far permits us to suggest that eltrombopag efficiently induces recovery of platelet counts. Furthermore, recent papers have demonstrated that a sustained response after discontinuation, initially thought to be problematic, may be possible in a nonnegligible number of cases. The safety profile is satisfactory, although patients presenting with thromboembolism risk factors should be treated with caution until the eltrombopag-associated prothrombotic risk is fully established. In summary, although larger studies are still needed to clarify some issues, eltrombopag may be a useful alternative tool for ITP patients refractory to conventional medical management or splenectomy.
Free accessReview articleFirst published June, 2018pp. 287-295
, Matthew P. Doogue, Tilenka R.J. ThynneWith the increasing prevalence of type 2 diabetes mellitus (T2DM) in women of childbearing age, prescribing antidiabetic medications in first-trimester pregnancy is becoming more common. Metformin treatment during this time is usually avoided in countries with well-resourced healthcare. This is based on historical concerns about safety to the foetus and the widespread availability of insulin. However, there is now increasing interest in the potential benefits of metformin in pregnant women with T2DM. In this commentary, the main evidence supporting metformin safety in pregnancy is summarized, with an emphasis on the first trimester. Based on a structured literature search, the recent randomized controlled trials comparing metformin and insulin are reviewed. We then show that prescribing advice for metformin in pregnancy is inconsistent and product information/package inserts (PI) are universally out of date. This causes confusion and pushes some women and their clinicians to change from metformin to insulin. The potential advantages of metformin in pregnant women with T2DM are then discussed, including oral dosing and improved acceptability, lower resource utilization and cost, decreased insulin requirements, less maternal weight gain and less risk of maternal and neonatal hypoglycaemia. The conclusion is that metformin is a cheap and efficacious antidiabetic medication for many pregnant women with T2DM, with reasonable evidence for safety. Drug information resources should be updated so that metformin can be considered more broadly in women with T2DM who present for antenatal care.
Free accessReview articleFirst published June, 2018pp. 297-308 , [...]Antidepressants are widely used medications for a range of medical conditions such as mood disorders and chronic pain in older adults. A vast body of evidence exists concerning the risks of QT interval prolongation associated with these agents and healthcare providers should critically evaluate the potential for QT prolongation when selecting antidepressant agents. Long QT syndrome is a disorder of myocardial repolarization that manifests as a prolonged QT interval on an electrocardiogram (ECG) and has been demonstrated to increase with age. The objective of this review is to present and evaluate existing literature regarding the risk of QT prolongation in older adults, age 60 years and older, and discuss the implications for clinical practice. A PubMed search was conducted to identify studies evaluating the QT prolonging effects of antidepressant medications and publications were chosen based on pertinent criteria. Depending on the antidepressant agent and patient-specific factors, clinicians should assess and monitor electrolytes and EGCs to evaluate the risks and benefits for older adults receiving agents known to prolong the QT interval.
Free accessResearch articleFirst published June, 2018pp. 309-321, Koen Boussery, Patricia van den Bemt , [...]Literature suggests a positive impact of self-administration of medication during hospitalization on medication adherence and safety, and on patient satisfaction. However, self-administration is not a common practice in Belgian hospitals. The aim of this study was to describe patients’ willingness towards self-administration of medication while in hospital.
A cross-sectional observational study was conducted in three Belgian hospitals in November and December 2015. All patients of 14 randomly selected wards were asked to participate. The structured questionnaire comprised patient characteristics, their willingness and attitude towards self-administration of medication, perceived ability to self-administer during hospitalization, and prerequisites and perceived consequences.
In total, 124 patients participated (36% of all eligible patients). The main reasons not to participate were the patients’ physical and mental condition (30%) and the absence of patients during the time of data collection (23%). The majority of the 124 participating patients had a positive attitude towards the implementation of self-administration; 83.9% were willing to self-administer their medication while in hospital. Most important prerequisites were self-administration at home before and after hospitalization, patients’ motivation, and a regular evaluation of the patients’ competences. Patients acknowledged benefits such as an increase in autonomy, independence and medication knowledge. Patients did not expect self-administration would cause important safety issues.
The majority of patients, capable of participating in the study, would want to self-administer medication during hospitalization. They had a positive attitude towards self-administration of medication. Nevertheless, patients stated important conditions which need to be considered in order to implement self-administration.
Free accessResearch articleFirst published June, 2018pp. 323-329Hyperkalemia is an electrolyte abnormality that may cause ventricular dysrhythmias and cardiac arrest. The presence of hyperkalemia may necessitate prompt treatment
This was a multicenter, retrospective, matched cohort study of patients who received intravenous insulin and dextrose for reversal of hyperkalemia. Patients received either 25 g or 50 g of dextrose in addition to 10 units of insulin. Study populations were matched based on preexisting rates of acute kidney injury, end-stage renal disease, and diabetes mellitus. Blood glucose levels were measured at 60 and 240 min following treatment.
A total of 240 patients were included in the analysis. At 60 min following treatment, 15.8% of patients who received 25 g of dextrose developed hypoglycemia, as opposed to 8.3% of patients who received 50 g of dextrose (
In the overall patient population, use of 50 g of dextrose instead of 25 g does not reduce hypoglycemia incidence. However, it may be beneficial is select patient populations, such as patients without type 2 diabetes or patients with a baseline blood glucose <110 mg/dl. Administration of 50 g of dextrose did not appear to place patients at significant risk for hyperglycemia however and could be considered during treatment of hyperkalemia.