Much yet to learn about nondrug therapies
Patients with attention-deficithyperactivity disorder (ADHD) may be treated with medications and/or various nonpharmacologic therapies, but how these options compare is unclear. To evaluate the relative effectiveness of nonpharmacologic treatments for ADHD among pediatric patients age 17 and younger, researchers reviewed 54 studies that compared any nonpharmacologic treatment strategy with placebo, medication, or another nonpharmacologic treatment. Nonpharmacologic treatments included neurofeedback, cognitive training, cognitive behavioral therapy, child or parent training, dietary omega fatty acid supplementation, and herbal and/or dietary approaches.
The results revealed “no new guidance relating to the comparative effectiveness of nonpharmacologic treatments.” Pooled results for omega fatty acids showed no significant effects on parent or teacher ratings of ADHD symptoms. The authors concluded that despite the widespread use of nonpharmacologic therapies, “there are significant gaps in knowledge” regarding their effectiveness.
Source: Goode AP, Coeytaux RR, Maslow GR, et al. Nonpharmacologic treatments for attention-deficit/hyperactivity disorder: a systematic review. Pediatrics. 2018;141(6). pii: e20180094.
POSTPARTUM PAIN MANAGEMENT
Guidelines stress a stepwise approach
New recommendations issued by an expert committee on obstetric practice emphasize a stepwise, multimodal approach to managing postpartum pain after both cesarean and vaginal delivery, noting that untreated pain raises the risk of opioid overuse, postpartum depression, and persistent pain. Prescribing analgesics with different mechanisms of action can potentiate their analgesic effects and reduce the need for opioids in the medication regimen.
Opioid medication can be considered as an adjunct for patients with uncontrolled pain despite adequate first-line therapy, the authors say. However, “women with opioid use disorder, women who have chronic pain, and women who are using other medications or substances that may increase sedation need additional support in managing postpartum pain.”
The guidelines were developed by the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice in collaboration with the American College of Nurse-Midwives.
Source: ACOG Committee Opinion. Postpartum pain management. Obstet Gynecol. 2018;132(1).
First oral drug for moderate-to-severe disease
The FDA has expanded the indications for tofacitinib (Xeljanz) to include adults with moderately to severely active ulcerative colitis. Tofacitinib is administered orally; other FDA-approved drugs for this indication are administered via I.V. infusion or subcutaneous injection.
A Janus kinase inhibitor, tofacitinib was previously approved to treat rheumatoid arthritis and psoriatic arthritis. In clinical trials, the most common adverse reactions associated with the use of tofacitinib to treat ulcerative colitis were diarrhea, hypercholesterolemia, headache, herpes zoster, increased blood creatine phosphokinase, nasopharyngitis, rash, and upper respiratory tract infection.
Patients treated with tofacitinib are at increased risk for serious, potentially fatal infections and malignancies. These risks are the subject of a boxed warning in the labeling. Use of tofacitinib with biological therapies for ulcerative colitis or with potent immunosuppressants such as azathioprine and cyclosporine isn't recommended.
Patients with ulcerative colitis experience recurrent flares of abdominal pain and bloody diarrhea, often accompanied by fatigue, weight loss, and fever. An estimated 900,000 patients in the United States are affected.
Source: FDA approves new treatment for moderately to severely active ulcerative colitis. U.S. Food & Drug Administration. News release. May 30, 2018.
Calcium channel blockers increase risk in women
In a prospective cohort study of 145,551 postmenopausal women ages 50 to 79, researchers collected data on all medications the women were taking and analyzed four types of antihypertensive drugs: beta-blockers, diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers (CCBs). Study participants had been enrolled in the Women's Health Initiative, a long-term national health study, between 1993 and 1998.
The investigators found a 66% higher risk of incident pancreatic cancer among women who'd ever used short-acting CCBs. Women who'd used short-acting CCBs for three or more years had a 107% higher risk of pancreatic cancer than those who'd used other non-CCB antihypertensive drugs. CCBs were the only antihypertensive drug studied that was associated with an increase in pancreatic cancer risk.
“Our findings on short-acting CCB use and pancreatic cancer risk are novel and of potential broad medical and public health significance if confirmed,” said lead author Zhensheng Wang, PhD. “Short-acting CCBs are still prescribed to manage hypertension, which is one of the components of metabolic syndrome, and metabolic syndrome is a possible risk factor for pancreatic cancer.”
The study was presented at the American Association for Cancer Research annual meeting in April.
Source: Short-acting calcium channel blockers were associated with increased risk of pancreatic cancer in postmenopausal women. American Association for Cancer Research. News release. April 25, 2018.
Package inserts silent about storage and disposal
Research has shown that unused opioid analgesics are seldom safely stored or disposed of, raising the risk of drug diversion, and that providers rarely educate their patients about safe drug storage and disposal. In a recent investigation, researchers found that most package inserts offer patients and providers little or no guidance on safe storage and disposal.
The researchers examined package inserts provided with six commonly prescribed and misused types of opioid analgesics. They extracted 98 inserts from a 10% random sample of products from each type and looked for safety and/or disposal messages. They found just one message on safe storage, which appeared in 35 package inserts. It stated only that medications should be securely stored to prevent theft. Safe disposal messages recommended discarding unused medication or flushing them down the toilet or simply directed providers to instruct patients on drug disposal.
Most package inserts with safe disposal messages accompanied morphine and oxycodone products. Only 1 of 33 inserts for hydrocodone products had a storage or disposal message, and no messages were found for tramadol products. The researchers say their findings reinforce the importance of patient teaching by healthcare professionals to reduce the misuse of prescription opioids.
Sources: Doucette ML, Shields WC, Haring RS, Frattaroli S. Storing and disposing of opioid analgesics: what does our medicine tell us? Ann Intern Med. [e-pub April 17, 2018]. Opioid packaging often lacks info on safe storage, disposal. HealthDay News. April 17, 2018.