Rise, and pronounced regional variation, in methylphenidate, amphetamine, and lisdexamfetamine distribution in the United States

Background The prescription stimulants methylphenidate, amphetamine, and lisdexamfetamine are sympathomimetic drugs with therapeutic use. They are designated in the United States as Schedule II substances, defined by the 1970 Controlled Substances Act as having a “high potential for abuse”. Changing criteria for the diagnosis of Attention Deficit Hyperactivity Disorder in 2013 and the approval of lisdexamfetamine for binge eating disorder in 2015 may have impacted usage patterns. This report compared the pharmacoepidemiology of these stimulants in the United States from 2010–2017. Methods Distribution of amphetamine, methylphenidate, lisdexamfetamine were examined via weights extracted from the Drug Enforcement Administration’s (DEA) Automated Reports and Consolidated Ordering System (ARCOS). Median stimulant Daily Dosage per patient was determined for a regional analysis. The percent of cost and prescriptions attributable to each stimulant and atomoxetine in Medicaid from the “Drug Utilization 2018 - National Total” from the Centers for Medicare and Medicaid was determined. Results There was a rise in amphetamine (+67.5%) and lisdexamfetamine (+76.7%) from 2010–2017. The change in methylphenidate (−3.0%) was modest. Persons/day stimulant usage was lower in the West than in other US regions from 2014-2017. There was a negative correlation (r(48) = −0.43 to −0.65, p < .05) between the percent Hispanic population per state and the Daily Dosage/population per stimulant. Methylphenidate formulations accounted for over half (51.7%) of the $3.8 billion reimbursed by Medicaid and the plurality (45.4%) of the 22.0 million prescriptions. Amphetamine was responsible for less than one-fifth (18.4%) of cost but one-third of prescriptions (33.6%). Lisdexamfetamine’s cost (26.0%) exceeded prescriptions (16.3%). Conclusion The rising amphetamine and lisdexamfetamine distribution may correspond with a rise in adult ADHD diagnoses. Regional analysis indicates that stimulant distribution in the West may be distinct from that in other regions. The lower stimulant distribution in areas with greater Hispanic populations may warrant further study.

Suspected Compartment Syndrome and Rhabdomyolysis after “Pseudoephedrine” Use: A Case Report

Acute compartment syndrome and rhabdomyolysis are two life threatening diagnoses that cannot be missed in the emergency room. The increased pressure in the closed compartments of extremities can eventually lead to loss of peripheral pulses, decreased tissue perfusion, and ultimately muscle necrosis. This breakdown of muscle byproducts will ultimately lead to kidney damage and rhabdomyolysis. Although the most common cause of compartment syndromes are secondary orthopedic causes such as lower extremity fractures there are known documented toxicological causes. (1,2) Pseudoephedrine, a sympathomimetic amine, is commonly used in the treatment of nasal congestion. Its primary mechanism directly acts on the adrenergic receptor system which stimulates release of stored norepinephrine from neurons. Its alpha-adrenergic effect is believed to be the cause of vasoconstriction in the body (3) Clinically, intoxication from sympathomimetic drugs have produced toxidromes with prominent features such as tachycardia, hypertension, hyperthermia, agitation, and delirium. However, it is incredibly rare to see an association with pseudoephedrine overdose and rhabdomyolysis and compartment syndrome. There are documented cases where sympathomimetic drugs have been associated with compartment syndrome (2,4,5) This case of a 29-year-old male with suspected pseudoephedrine abuse highlights the need for consideration of rhabdomyolysis and compartment syndrome being a possible complication from pseudoephedrine overdose.

Treatment of Early Allergic and Late Inflammatory Symptoms of Allergic Rhinitis with Petasites Hybridus Leaf Extract (Ze 339): Results of a Noninterventional Observational Study in Switzerland

The primary objective of this noninterventional, observational study was to assess the effectiveness of the Petasites hybridus leaf extract (Ze 339) on early allergic and late inflammatory symptoms of allergic rhinitis in Swiss outpatients. This study was conducted by general practitioners and allergologists. Data from 226 patients were collected during three documented visits. The intermediate visit was ideally made 2–4 weeks after the baseline visit, followed by the final visit approximately 2–4 months later. The mean study duration was 63 days, with 75% of patients being treated for at least 4 weeks. Of the patients, 58.5% started with Ze 339 monotherapy, and 41.5% received other antiallergic and/or sympathomimetic drugs. In both groups, the allergic total symptom score and the inflammatory total symptom scores were significantly (p < 0.001) reduced, and the scores for quality of life were improved. Both physicians and patients were very satisfied with the treatment and the concept of therapy, not only for short-term (seasonal) therapy but also for long-term therapy. The tolerability was good: only three mild gastrointestinal adverse events occurred. In summary, the effectiveness of P. hybridus leaf extract Ze 339 for the treatment of early allergic and late inflammatory symptoms of allergic rhinitis could be confirmed.

Topical decongestants in otorhinolaryngologist practice

The problem of long-term and uncontrolled use of decongestants remains one of the most relevant problems of modern otorhinolaryngology. To date vasoconstrictors are the most actively used drugs for the treatment of acute and chronic rhinitis, as well as other diseases accompanied by nasal congestion. Most of the topical decongestants are selective α2-adrenergic agonists that act on postsynaptic α2-adrenergic receptors, which perform the main function in the implementation of sympathetic stimuli in the nasal cavity. Sympathomimetic drugs in addition to the main vasoconstrictor effect also have their own anti-inflammatory and antioxidant effects. Topical decongestants are included in the treatment guidelines for acute and chronic rhinitis, rhinosinusitis, allergic rhinitis, acute and chronic otitis media, eustachitis. The recommended duration of decongestants is usually limited to 5–7 days. Longer use of this drug class can lead to paresis of the nasal mucosa vessels or an allergic reaction, to the development of rhinitis medicamentosa. Side effects that occur with the use of topical decongestants are divided into 2 groups: local symptoms and general toxic reactions. However, with strict adherence to the recommended dosing regimen of topical decongestants, to the method of use and to the duration of use, undesirable side effects are rare. The group of vasoconstrictor drugs received a new development as a result of the combination of decongestants with other drugs, which lead to the reducing local side effects and the elimination of not only nasal congestion, but also other symptoms of the common cold.

Treatment of intraoperative hypotension with cafedrine/theodrenaline versus ephedrine

Background Sympathomimetic drugs are a therapeutic cornerstone for the management of hypotensive states like intraoperative hypotension (IOH). While cafedrine/theodrenaline (C/T) is widely used in Germany to restore blood pressure in patients with IOH, more research is required to compare its effectiveness with alternatives such as ephedrine (E) that are more commonly available internationally. Methods HYPOTENS (NCT02893241, DRKS00010740) was a prospective, national, multicenter, open-label, two-armed, non-interventional study that compared C/T with E for treatment of IOH. We describe a prospectively defined cohort of patients ≥50 years old with comorbidities undergoing general anesthesia induced with propofol and fentanyl. Primary objectives were to examine treatment precision, rapidity of onset and the ability to restore blood pressure without relevant increases in heart rate. Secondary endpoints were treatment satisfaction and the number of required additional boluses or other accompanying measures. Results A total of 1496 patients were included in the per protocol analysis. Overall, effective stabilization of blood pressure was achieved with both C/T and E. Post-hoc analysis showed that blood pressure increase from baseline was more pronounced with C/T. Fewer additional boluses or other accompanying measures were required in the C/T arm. The incidence of tachycardia was comparable between groups. Post-hoc analysis showed that E produced dose-dependent elevated heart rate values. By contrast, heart rate remained stable in patients treated with C/T. Physicians reported a higher level of treatment satisfaction with C/T, with a higher proportion of anesthetists rating treatment precision and rapidity of onset as good or very good when compared with E. Conclusion Neither drug was superior in restoring blood pressure levels; however, post-hoc analyses suggested that treatment is more goal-orientated and easier to control with C/T. Heart rate was shown to be more stable with C/T and fewer additional interventions were required to restore blood pressure, which could have contributed to the increased treatment satisfaction reported by anesthetists using C/T.

Chirality of β2-agonists. An overview of pharmacological activity, stereoselective analysis, and synthesis

Abstractβ2-Agonists (β2-adrenergic agonists, bronchodilatants, and sympathomimetic drugs) are a group of drugs that are mainly used in asthma and obstructive pulmonary diseases. In practice, the substances used to contain one or more stereogenic centers in their structure and their enantiomers exhibit different pharmacological properties. In terms of bronchodilatory activity, (R)-enantiomers showed higher activity. The investigation of stereoselectivity in action and disposition of chiral drugs together with the preparation of pure enantiomer drugs calls for efficient stereoselective analytical methods. The overview focuses on the stereoselectivity in pharmacodynamics and pharmacokinetics of β2-agonists and summarizes the stereoselective analytical methods for the enantioseparation of racemic beta-agonists (HPLC, LC-MS, GC, TLC, CE). Some methods of the stereoselective synthesis for β2-agonists preparation are also presented.

Conhecimento dos enfermeiros sobre drogas vasoativas

RESUMOObjetivo: descrever o conhecimento dos enfermeiros de uma unidade de pós-operatório de cirurgia cardíaca sobre drogas vasoativas. Método: trata-se de um estudo quantitativo, descritivo, transversal, tendo como cenário a UTI de pós-operatório de cirurgia cardíaca de um hospital escola. Constituiu-se a amostra por enfermeiros. Utilizou-se um questionário para a coleta dos dados, e, para a análise as frequências absolutas e percentuais. Apresentaram-se os resultados em tabelas. Resultados: registrou-se que 75% dos pesquisados afirmaram que DVA’s são denominadas de aminas vasoativas ou drogas simpatomiméticas. Verifica-se, quanto às classificações das DVA’s como vasopressoras e vasodilatadoras, que 87,5% responderam que as drogas vasopressoras são a dopamina e a dobutamina; já em relação às drogas vasodilatadoras, todos os enfermeiros apontaram a nitroglicerina e o nitroprussiato de sódio. Conclusão: demonstram-se que as questões abordadas corroboram com outras pesquisas maiores, atuais e relevantes para o âmbito da assistência intensivista. Considera-se que o ensino de Enfermagem ainda deixa lacunas relativas ao assunto, representando um desafio para os educadores no sentido de aprimorar a didática sobre o tema. Descritores: Conhecimento; Enfermeiras e Enfermeiros; Enfermagem; Segurança do Paciente; Unidades de Terapia Intensiva; Cuidados de Enfermagem.ABSTRACT Objective: to describe the knowledge of the nurses of a postoperative unit of cardiac surgery on vasoactive drugs. Method: this is a quantitative, descriptive, cross-sectional study based on the postoperative ICU of cardiac surgery at a school hospital. The sample was composed by nurses. A questionnaire was used to collect the data and, for the analysis, the absolute and percentage frequencies. Results were presented in tables. Results: it was recorded that 75% of respondents stated that VADs are denominated vasoactive amines or sympathomimetic drugs. As regards the classifications of VADs as vasopressors and vasodilators, 87.5% answered that the vasopressor drugs are dopamine and dobutamine; already in relation to vasodilator drugs, all nurses pointed to nitroglycerin and sodium nitroprusside. Conclusion: it is shown that the issues addressed corroborate with other larger, current and relevant research in the field of intensive care. It is considered that nursing education still leaves gaps related to the subject, representing a challenge for educators to improve didactics on the subject. Descriptors: Knowledge; Nurses and Nurses; Nursing; Patient safety; Intensive Care Units; Nursing Care.RESUMEN Objetivo: describir el conocimiento de los enfermeros de una unidad de postoperatorio de cirugía cardíaca sobre las drogas vasoactivas. Método: se trata de un estudio cuantitativo, descriptivo, transversal, teniendo como escenario la UTI de postoperatorio de cirugía cardíaca de un hospital escolar. Se constituyó la muestra por enfermeros. Se utilizó un cuestionario para la recolección de los datos, y para el análisis las frecuencias absolutas y porcentuales. Se presentaron los resultados en tablas. Resultados: se registró que el 75% de los encuestados afirmó que DVA's son denominadas aminas vasoactivas o drogas simpaticomiméticas. Se observa, en cuanto a las clasificaciones de las DVA como vasopresoras y vasodilatadoras, que el 87,5% respondió que las drogas vasopresoras son la dopamina y la dobutamina; ya en relación a las drogas vasodilatadoras, todos los enfermeros señalaron la nitroglicerina y el nitroprusiato de sodio. Conclusión: se demuestra que las cuestiones abordadas corroboran con otras investigaciones más grandes, actuales y relevantes para el ámbito de la asistencia intensiva. Se considera que la enseñanza de enfermería todavía deja huecos relativos al asunto, representando un desafío para los educadores en el sentido de mejorar la didáctica sobre el tema.Descriptores: Seguridad del Paciente; Conocimiento; Enfermeros; Enfermería; Unidades de Terapia Intensiva; Vasodilatadores; Atención de Enfermería.