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Revista Brasileira de Anestesiologia Dec 2004Trigeminal neuralgia is a syndrome of chronic pain, characterized by paroxysms of excruciating pain which dramatically affect patients' quality of life. Systemic drug...
BACKGROUND AND OBJECTIVES
Trigeminal neuralgia is a syndrome of chronic pain, characterized by paroxysms of excruciating pain which dramatically affect patients' quality of life. Systemic drug therapy is the first line treatment for this disease. This study aimed at evaluating efficacy, safety and tolerability of several pharmacologic treatments offered to trigeminal neuralgia patients, trying to supply evidences for clinical practice recommendations and to identify the needs for further research.
METHODS
Randomized controlled clinical trials on the analgesic effects of drugs prescribed for trigeminal neuralgia were evaluated. All of them were published until July 2003. Statistical analysis was accomplished with the support of Review Manager 4.2.2 software (Cochrane Collaboration, 2003).
RESULTS
Metanalisys results suggest that carbamazepine is more efficient than placebo. In three controlled studies comparing lamotrigine, topiramate and 0.5% proparacaine hydrochloride, only lamotrigine was superior to placebo. Dextromethorphan was compared to low-dose lorazepam, with increased pain with dextromethorphan. Three studies have compared carbamazepine to tizanidine, tocainide and pimozide, and only pimozide was superior to carbamazepine.
CONCLUSIONS
Carbamazepine is still the drug of choice for treating trigeminal neuralgia, being lamotrigine and pimozide indicated for cases refractory to conventional therapy. In addition, further studies are needed to determine future therapeutic options.
PubMed: 19471799
DOI: 10.1590/s0034-70942004000600015 -
International Clinical... May 2020To collect the best available evidence and to compare the first-generation antipsychotics (FGAs) vs. the second-generation antipsychotics (SGAs) in the treatment of...
To collect the best available evidence and to compare the first-generation antipsychotics (FGAs) vs. the second-generation antipsychotics (SGAs) in the treatment of delusional disorder (DD). Systematic review including studies evaluating treatment response in DD using clinician-rated scales appearing in PubMed and Web of Science databases from inception till September 2019. Those studies meeting inclusion criteria were selected. Outcomes were summarized into two response categories: (1) response to treatment equal to or greater than 50% and (2) response less than 50%. Biases and quality of the studies were evaluated, and relevant data were extracted. Finally, both narrative review and quantitative synthesis were performed. The final sample included six studies (437 patients, 318 on treatment with SGAs). Antipsychotics achieved a good response in 32.3% of patients. Effectiveness differences between FGA and SGA were only marginal favouring the former. Among the most used antipsychotics, risperidone and olanzapine showed, respectively, 34.3 and 33.7% good response. Pimozide (n = 35) demonstrated a higher response rates compared with other antipsychotics. Inpatients showed the best treatment outcomes. Antipsychotics appeared to be an effective treatment in patients with DD. FGA were slightly superior to SGA. Pimozide does not seem to provide any advantage in most DD subtypes.
Topics: Antipsychotic Agents; Humans; Psychiatric Status Rating Scales; Schizophrenia, Paranoid; Treatment Outcome
PubMed: 32097136
DOI: 10.1097/YIC.0000000000000306 -
The Cochrane Database of Systematic... Mar 2013Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in dementia, although the literature is sceptical about their long-term use for this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Antipsychotic agents are often used to treat neuropsychiatric symptoms (NPS) in dementia, although the literature is sceptical about their long-term use for this indication. Their effectiveness is limited and there is concern about adverse effects, including higher mortality with long-term use. When behavioural strategies have failed and drug therapy is instituted, regular attempts to withdraw these drugs are recommended. Physicians, nurses and families of older people with dementia are often reluctant to try to stop antipsychotics, fearing deterioration of NPS. Strategies to reduce antipsychotic use have been proposed, but a systematic review of interventions aimed at withdrawal of antipsychotic agents in older people with dementia has not yet been performed.
OBJECTIVES
To evaluate whether withdrawal of antipsychotic agents is successful in older people with dementia in community or nursing home settings, to list the different strategies for withdrawal of antipsychotic agents in older people with dementia and NPS, and to measure the effects of withdrawal of antipsychotic agents on behaviour.
SEARCH METHODS
ALOIS, the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, clinical trials registries and grey literature sources were searched on 23 November 2012. The search included the following terms: antipsychotic* or neuroleptic* or phenothiazines or butyrophenones or risperidone or olanzapine or haloperidol or prothipendyl or methotrimeprazine or clopenthixol or flupenthixol or clothiapine or metylperon or droperidol or pipamperone or benperidol or bromperidol or fluspirilene or pimozide or penfluridol or sulpiride or veralipride or levosulpiride or sultopride or aripiprazole or clozapine or quetiapine or thioridazine combined wither terms such as discontinu* or withdraw* or cessat* or reduce* or reducing or reduct* or taper* or stop*.ALOIS contains records from all major healthcare databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS), as well as from many clinical trials registries and grey literature sources.
SELECTION CRITERIA
Randomised, placebo-controlled trials comparing an antipsychotic withdrawal strategy to continuation of antipsychotics in people with dementia.
DATA COLLECTION AND ANALYSIS
Review authors independently assessed trials for inclusion, rated their risk of bias and extracted data.
MAIN RESULTS
We included nine trials with 606 randomised participants. Seven trials were conducted in nursing homes, one trial in an outpatient setting and one in both settings. In these trials, different types of antipsychotics prescribed at different doses were withdrawn. Both abrupt and gradual withdrawal schedules were used. The risk of bias of the included studies was generally low regarding blinding and outcome reporting and unclear for randomisation procedures and recruitment of participants.There was a wide variety of outcome measures. Our primary efficacy outcomes were success of withdrawal (i.e. remaining in study off antipsychotics) and NPS. Eight of nine trials reported no overall significant difference between groups on the primary outcomes, although in one pilot study of people with psychosis and agitation that had responded to haloperidol, time to relapse was significantly shorter in the discontinuation group (Chi(2) = 4.1, P value = 0.04). The ninth trial included people with psychosis or agitation who had responded well to risperidone therapy for four to eight months and reported that discontinuation led to an increased risk of relapse, that is, increase in the Neuropsychiatric Inventory (NPI)-core score of 30% or greater (P value = 0.004, hazard ratio (HR) 1.94, 95% confidence interval (CI) 1.09 to 3.45 at four months). The only outcome that could be pooled was the full NPI-score, used in two studies. For this outcome there was no significant difference between people withdrawn from and those continuing on antipsychotics at three months (mean difference (MD) -1.49, 95% CI -5.39 to 2.40). These two studies reported subgroup analyses according to baseline NPI-score (14 or less versus > 14). In one study, those with milder symptoms at baseline were significantly less agitated at three months in the discontinuation group (NPI-agitation, Mann-Whitney U test z = 2.4, P value = 0.018). In both studies, there was evidence of significant behavioural deterioration in people with more severe baseline NPS who were withdrawn from antipsychotics (Chi(2) = 6.8; P value = 0.009 for the marked symptom score in one study).Individual studies did not report significant differences between groups on any other outcome except one trial that found a significant difference in a measure of verbal fluency, favouring discontinuation. Most trials lacked power to detect clinically important differences between groups.Adverse events were not systematically assessed. In one trial there was a non-significant increase in mortality in people who continued antipsychotic treatment (5% to 8% greater than placebo, depending on the population analysed, measured at 12 months). This trend became significant three years after randomisation, but due to dropout and uncertainty about the use of antipsychotics in this follow-up period this result should be interpreted with caution.
AUTHORS' CONCLUSIONS
Our findings suggest that many older people with Alzheimer's dementia and NPS can be withdrawn from chronic antipsychotic medication without detrimental effects on their behaviour. It remains uncertain whether withdrawal is beneficial for cognition or psychomotor status, but the results of this review suggest that discontinuation programmes could be incorporated into routine practice. However, two studies of people whose agitation or psychosis had previously responded well to antipsychotic treatment found an increased risk of relapse or shorter time to relapse after discontinuation. Two other studies suggest that people with more severe NPS at baseline could benefit from continuing their antipsychotic medication. In these people, withdrawal might not be recommended.
Topics: Aged; Antipsychotic Agents; Dementia; Humans; Mental Disorders; Psychomotor Agitation; Randomized Controlled Trials as Topic; Recurrence
PubMed: 23543555
DOI: 10.1002/14651858.CD007726.pub2