Expecting a baby and looking for professional postnatal care?
The first of its kind in Sarawak, Havilah Confinement Home has been licensed by the Ministry of Health to provide medically supervised confinement service 24/7.
Set in a quiet neighbourhood, mum and baby can stay for any duration up to 60 days post delivery. Only well mums and babies will be accepted. They will be reviewed by our doctor regularly.
Mum will be helped to establish breast feeding and learn to express and store breast milk.
Where bottle feeding is preferred, hygeinic handling of bottles will be taught.
During the stay we will help you learn how to soothe, bathe, and massage babies.
You will also learn Child Health 101 from our inhouse pediatrician and nurse, based on the book "Congratulations, You're a Mum and Dad - caring for your baby from Day One" written by Dr Tan Poh Tin.
Aesthetic pampering eg massage, facial, hair care, manicure and pedicure can also be arranged.
By the end of your stay with us, you will not only have a restful confinement recovery, we are committed to equip you with parenting skills to become more informed parents.
For more information or booking call +06 082366452 or +060168520200
or email havilahconfinement@gmail.com
Visit our website at:
http://havilah.wsiefusion.net/
Saturday, April 11, 2009
Thursday, April 9, 2009
Hypertriglyceridemia Is Common Among US Adults
Laurie Barclay, MD
http://www.medscape.com/viewarticle/590457?src=mp&spon=17&uac=71630FV
April 1, 2009 — Hypertriglyceridemia is common among US adults and should be treated with lifestyle change in most cases, according to the results of a study reported in the March 23 issue of the Archives of Internal Medicine.
"Increasing evidence supports triglyceride (TG) concentration as a risk factor for cardiovascular disease," write Earl S. Ford, MD, MPH, from the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and colleagues. "The prevalence of hypertriglyceridemia during a period of rising prevalence of obesity and its pharmacological treatment among US adults are poorly understood."
The study sample consisted of 5610 adults aged 20 years or older enrolled in the National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2004. Unadjusted prevalence rates (percentages) of TG concentration ranges in milligrams per deciliter were determined (to convert TG to millimoles per liter, multiply by 0.0113).
TG concentration of 150 mg/dL or higher occurred in 33.1% of participants (standard error [SE], 0.8%), a concentration of 200 mg/dL or higher occurred in 17.9% of participants (SE, 0.7%), a concentration of 500 mg/dL or higher occurred in 1.7% of participants (SE, 0.2%), and a concentration of 1000 mg/dL or higher occurred in 0.4% of participants (SE, 0.1%).
Use of 1 of 3 prescription medications indicated to treat hypertriglyceridemia (fenofibrate, gemfibrozil, or niacin) occurred in 1.3% of participants overall (SE, 0.2%), in 2.6% of participants with a TG concentration of 150 mg/dL or higher (SE, 0.4%), and in 3.6% of those with a TG concentration of 200 mg/dL or higher (SE, 0.7%).
"Among US adults, hypertriglyceridemia is common," the study authors write. "Until the benefits of treating hypertriglyceridemia that is not characterized by extreme elevations of TG concentration with medications are incontrovertible, therapeutic lifestyle change remains the preferred treatment."
Limitations of this study include a lack of certainty that the intended use of medications was for lowering elevated TG concentrations rather than raising high-density lipoprotein cholesterol concentrations, as well as the possible effects of oral contraceptives and hormone therapy on TG concentrations in women.
"The prevalence of hypertriglyceridemia is high among US adults, the use of pharmacologic treatment is low, and the prevalence of modifiable causes of hypertriglyceridemia, such as physical inactivity and overweight or obesity, is high," the study authors conclude. "Because measuring TG concentrations is routinely performed in clinical practice, physicians have to regularly decide on the need for treatment in many of their patients. As research clarifies uncertainties in the relation between TG concentration and cardiovascular disease, guidelines to treat hypertriglyceridemia will likely be modified."
In an accompanying commentary, Warren G. Thompson, MD, and Gerald T. Gau, MD, from the Mayo Clinic College of Medicine in Rochester, Minnesota, agree that llifestyle modification is the cornerstone of management of TG concentrations between 150 and 500 mg/dL. They note that if the patient does not make lifestyle changes in diet and exercise, it is difficult to normalize TG concentration with medication alone.
If medications are necessary, Dr. Thompson and Dr. Gau suggest trying statins first, as these have proven effects on mortality.
"Some have argued that statins reduce mortality by only 30% and that additional pharmacologic therapy to treat elevated TG concentration is warranted," Dr. Thompson and Dr. Gau write.
"However, there are no data proving that additional drug treatment will reduce mortality. If statins and lifestyle change are insufficient, then fish oil or niacin should be considered. Fibrates should be reserved for TG concentrations higher than 1000 mg/dL that do not respond to other treatments."
Arch Intern Med. 2009;169:572–578, 578–579.
-->
Laurie Barclay, MD is a freelance reviewer and writer for Medscape LLC
http://www.medscape.com/viewarticle/590457?src=mp&spon=17&uac=71630FV
April 1, 2009 — Hypertriglyceridemia is common among US adults and should be treated with lifestyle change in most cases, according to the results of a study reported in the March 23 issue of the Archives of Internal Medicine.
"Increasing evidence supports triglyceride (TG) concentration as a risk factor for cardiovascular disease," write Earl S. Ford, MD, MPH, from the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and colleagues. "The prevalence of hypertriglyceridemia during a period of rising prevalence of obesity and its pharmacological treatment among US adults are poorly understood."
The study sample consisted of 5610 adults aged 20 years or older enrolled in the National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2004. Unadjusted prevalence rates (percentages) of TG concentration ranges in milligrams per deciliter were determined (to convert TG to millimoles per liter, multiply by 0.0113).
TG concentration of 150 mg/dL or higher occurred in 33.1% of participants (standard error [SE], 0.8%), a concentration of 200 mg/dL or higher occurred in 17.9% of participants (SE, 0.7%), a concentration of 500 mg/dL or higher occurred in 1.7% of participants (SE, 0.2%), and a concentration of 1000 mg/dL or higher occurred in 0.4% of participants (SE, 0.1%).
Use of 1 of 3 prescription medications indicated to treat hypertriglyceridemia (fenofibrate, gemfibrozil, or niacin) occurred in 1.3% of participants overall (SE, 0.2%), in 2.6% of participants with a TG concentration of 150 mg/dL or higher (SE, 0.4%), and in 3.6% of those with a TG concentration of 200 mg/dL or higher (SE, 0.7%).
"Among US adults, hypertriglyceridemia is common," the study authors write. "Until the benefits of treating hypertriglyceridemia that is not characterized by extreme elevations of TG concentration with medications are incontrovertible, therapeutic lifestyle change remains the preferred treatment."
Limitations of this study include a lack of certainty that the intended use of medications was for lowering elevated TG concentrations rather than raising high-density lipoprotein cholesterol concentrations, as well as the possible effects of oral contraceptives and hormone therapy on TG concentrations in women.
"The prevalence of hypertriglyceridemia is high among US adults, the use of pharmacologic treatment is low, and the prevalence of modifiable causes of hypertriglyceridemia, such as physical inactivity and overweight or obesity, is high," the study authors conclude. "Because measuring TG concentrations is routinely performed in clinical practice, physicians have to regularly decide on the need for treatment in many of their patients. As research clarifies uncertainties in the relation between TG concentration and cardiovascular disease, guidelines to treat hypertriglyceridemia will likely be modified."
In an accompanying commentary, Warren G. Thompson, MD, and Gerald T. Gau, MD, from the Mayo Clinic College of Medicine in Rochester, Minnesota, agree that llifestyle modification is the cornerstone of management of TG concentrations between 150 and 500 mg/dL. They note that if the patient does not make lifestyle changes in diet and exercise, it is difficult to normalize TG concentration with medication alone.
If medications are necessary, Dr. Thompson and Dr. Gau suggest trying statins first, as these have proven effects on mortality.
"Some have argued that statins reduce mortality by only 30% and that additional pharmacologic therapy to treat elevated TG concentration is warranted," Dr. Thompson and Dr. Gau write.
"However, there are no data proving that additional drug treatment will reduce mortality. If statins and lifestyle change are insufficient, then fish oil or niacin should be considered. Fibrates should be reserved for TG concentrations higher than 1000 mg/dL that do not respond to other treatments."
Arch Intern Med. 2009;169:572–578, 578–579.
-->
Laurie Barclay, MD is a freelance reviewer and writer for Medscape LLC
Is Gardasil® Recommended for Young Women Already Exposed to HPV?
From Medscape Pharmacists
Ask the Experts about Pharmacotherapy
Posted 04/01/2009
Laurie L. Briceland, PharmDAuthor Information
Should Gardasil® (human papillomavirus [HPV] quadrivalent [types 6, 11, 16, and 18] vaccine) be administered to young women who test positive for oncogenic-risk HPV strains, or to those who have abnormal Papanicolaou ("Pap") smear results?
Response from Laurie L. Briceland, PharmDProfessor and Director, Experiential Education, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York
Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with an estimated 20 million people already infected and over 6 million people infected annually.[1]
Although most infections prove to be self-limiting or asymptomatic, persistent infection with oncogenic strains (such as types 16 and 18) can lead to cervical cancer.
Seventy percent of cervical cancers are attributed to HPV types 16 and 18; HPV types 6 and 11 contribute to 90% of cases of genital warts.[2]
The HPV quadrivalent (types 6, 11, 16, and 18) vaccine (Gardasil®) was approved by the US Food and Drug Administration in 2006 and is indicated for use in 9- to 26-year-old females for the prevention of diseases caused by those 4 virus strains.
These diseases include cervical, vulvar, and vaginal cancer caused by HPV types 16 and 18; cervical, vaginal, and vulvar cancer precursor and dysplastic lesions; and genital warts caused by HPV types 6 and 11.[3]
Clinical trials indicate that the vaccine is effective in preventing HPV infection and precancerous lesions in females who have not already been infected with the respective HPV type.[2]
Thus, the goal is to administer the vaccine series to females prior to their sexual activity debut, with the recommended age being 11-12 years.[2]
Vaccination is also recommended for 13- to 26-year-old females who have not been vaccinated, or who have not completed the vaccination series, even if the female is already sexually active and could have contracted HPV infection.
No evidence exists of protection against vaccine HPV types that have already infected the female at the time of vaccination.
However, females infected with fewer than all 4 of the vaccine HPV types before vaccination would likely receive protection and partial benefit against the other vaccine types upon vaccination.[2]
Vaccination is recommended for females with an abnormal Pap test in order to impart partial benefit from vaccine type(s) to which the female has not already been infected.
As Pap test results increase in severity, risk for infection with HPV 16 or 18 increases, potentially decreasing the benefit of vaccination.[2]
Patients should be counseled that the vaccine will not have any therapeutic benefit on existing HPV infection or lesions based on clinical trial data.[2]
It is important to note that patients who receive Gardasil® should continue to undergo routine cervical cancer screenings by Pap test as recommended by their physicians.[2,3]
Ask the Experts about Pharmacotherapy
Posted 04/01/2009
Laurie L. Briceland, PharmDAuthor Information
Should Gardasil® (human papillomavirus [HPV] quadrivalent [types 6, 11, 16, and 18] vaccine) be administered to young women who test positive for oncogenic-risk HPV strains, or to those who have abnormal Papanicolaou ("Pap") smear results?
Response from Laurie L. Briceland, PharmDProfessor and Director, Experiential Education, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York
Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with an estimated 20 million people already infected and over 6 million people infected annually.[1]
Although most infections prove to be self-limiting or asymptomatic, persistent infection with oncogenic strains (such as types 16 and 18) can lead to cervical cancer.
Seventy percent of cervical cancers are attributed to HPV types 16 and 18; HPV types 6 and 11 contribute to 90% of cases of genital warts.[2]
The HPV quadrivalent (types 6, 11, 16, and 18) vaccine (Gardasil®) was approved by the US Food and Drug Administration in 2006 and is indicated for use in 9- to 26-year-old females for the prevention of diseases caused by those 4 virus strains.
These diseases include cervical, vulvar, and vaginal cancer caused by HPV types 16 and 18; cervical, vaginal, and vulvar cancer precursor and dysplastic lesions; and genital warts caused by HPV types 6 and 11.[3]
Clinical trials indicate that the vaccine is effective in preventing HPV infection and precancerous lesions in females who have not already been infected with the respective HPV type.[2]
Thus, the goal is to administer the vaccine series to females prior to their sexual activity debut, with the recommended age being 11-12 years.[2]
Vaccination is also recommended for 13- to 26-year-old females who have not been vaccinated, or who have not completed the vaccination series, even if the female is already sexually active and could have contracted HPV infection.
No evidence exists of protection against vaccine HPV types that have already infected the female at the time of vaccination.
However, females infected with fewer than all 4 of the vaccine HPV types before vaccination would likely receive protection and partial benefit against the other vaccine types upon vaccination.[2]
Vaccination is recommended for females with an abnormal Pap test in order to impart partial benefit from vaccine type(s) to which the female has not already been infected.
As Pap test results increase in severity, risk for infection with HPV 16 or 18 increases, potentially decreasing the benefit of vaccination.[2]
Patients should be counseled that the vaccine will not have any therapeutic benefit on existing HPV infection or lesions based on clinical trial data.[2]
It is important to note that patients who receive Gardasil® should continue to undergo routine cervical cancer screenings by Pap test as recommended by their physicians.[2,3]
Hot Tea drinking increase Cancer esophagus
April 3, 2009 — Drinking hot tea was strongly associated with a higher risk for esophageal cancer according to the results of a northern Iranian population-based case-control study reported online first on March 27 in the British Medical Journal.
"An association between drinking hot beverages and risk of oesophageal cancer has been reported in several studies from different parts of the world," write Farhad Islami, MD, from Shariati Hospital, Tehran University of Medical Sciences in Iran, and colleagues. "In Golestan, tea and water are the only drinks commonly consumed, with comparable average intake. An ecological study showed that inhabitants of Golestan drank more tea and at a higher temperature than people living in a nearby area with a low incidence of oesophageal cancer."
The goal of this study was to evaluate the relationship between characteristics of tea drinking habits in Golestan province in northern Iran, which is an area with a high incidence of esophageal squamous cell carcinoma (SCC), and risk for that disease. Patterns of tea drinking and temperature at which tea was usually drunk were also determined for healthy persons enrolled in a cohort study.
Tea drinking among 300 patients with histologically proven esophageal SCC was compared with that in 571 matched neighborhood controls in the case-control study and in 48,582 participants in the cohort study. The primary study endpoint was the odds ratio (OR) of esophageal SCC associated with drinking hot tea.
Regular drinking of black tea was reported by 98% of the cohort participants, with mean daily volume more than 1 L. Reported temperature of tea was less than 60°C in 39.0% of participants, 60°C to 64°C in 38.9%, and 65°C or higher in 22.0%. Reported temperature agreed moderately with actual temperature measurements (weighted κ, 0.49).
In the case-control study, risk for esophageal cancer was increased for drinking hot tea (OR, 2.07; 95% confidence interval [CI], 1.28 – 3.35) or very hot tea (OR, 8.16; 95% CI, 3.93 – 16.9) vs lukewarm or warm tea. Risk was also significantly increased for drinking tea 2 to 3 minutes after pouring (OR, 2.49; 95% CI, 1.62 – 3.83) or less than 2 minutes after pouring (OR, 5.41; 95% CI, 2.63 – 11.1) vs drinking tea at least 4 minutes after being poured. Responses to the questions about temperature at which tea was drunk agreed strongly with interval from tea being poured to being drunk (weighted κ, 0.68).
"Drinking hot tea, a habit common in Golestan province, was strongly associated with a higher risk of oesophageal cancer," the study authors write.
Limitations of this study include possible information bias regarding the amount and temperature of consumed tea, validation study performed among healthy people, possible selection bias, and some missing data.
"A large proportion of Golestan inhabitants drink hot tea, so this habit may account for a substantial proportion of the cases of oesophageal cancer in this population," the study authors write. "Informing the population about the hazards of drinking hot tea may be helpful in reducing the incidence of oesophageal cancer in Golestan and in other high risk populations where similar habits are prevalent."
In an accompanying editorial, David C, Whiteman, from Queensland Institute of Medical Research at Royal Brisbane Hospital in Australia, recommends allowing tea to cool for 5 minutes before drinking.
"The mechanism through which heat promotes the development of tumours warrants further exploration and might be given renewed impetus on the basis of these findings," Dr. Whiteman writes. "These findings are not cause for alarm, however, and they should not reduce public enthusiasm for the time honoured ritual of drinking tea. Rather, we should follow the advice … [that suggests] a five to 10 minute interval between making and pouring tea, by which time the tea will be sufficiently flavoursome and unlikely to cause thermal injury."
The Digestive Disease Research Center of Tehran University of Medical Sciences, the National Cancer Institute, National Institutes of Health, and the International Agency for Research on Cancer supported this study. The study authors and Dr. Whiteman have disclosed no relevant financial relationships.
BMJ. Published online March 27, 2009.
http://www.medscape.com/viewarticle/590589?sssdmh=dm1.454091&src=nldne
"An association between drinking hot beverages and risk of oesophageal cancer has been reported in several studies from different parts of the world," write Farhad Islami, MD, from Shariati Hospital, Tehran University of Medical Sciences in Iran, and colleagues. "In Golestan, tea and water are the only drinks commonly consumed, with comparable average intake. An ecological study showed that inhabitants of Golestan drank more tea and at a higher temperature than people living in a nearby area with a low incidence of oesophageal cancer."
The goal of this study was to evaluate the relationship between characteristics of tea drinking habits in Golestan province in northern Iran, which is an area with a high incidence of esophageal squamous cell carcinoma (SCC), and risk for that disease. Patterns of tea drinking and temperature at which tea was usually drunk were also determined for healthy persons enrolled in a cohort study.
Tea drinking among 300 patients with histologically proven esophageal SCC was compared with that in 571 matched neighborhood controls in the case-control study and in 48,582 participants in the cohort study. The primary study endpoint was the odds ratio (OR) of esophageal SCC associated with drinking hot tea.
Regular drinking of black tea was reported by 98% of the cohort participants, with mean daily volume more than 1 L. Reported temperature of tea was less than 60°C in 39.0% of participants, 60°C to 64°C in 38.9%, and 65°C or higher in 22.0%. Reported temperature agreed moderately with actual temperature measurements (weighted κ, 0.49).
In the case-control study, risk for esophageal cancer was increased for drinking hot tea (OR, 2.07; 95% confidence interval [CI], 1.28 – 3.35) or very hot tea (OR, 8.16; 95% CI, 3.93 – 16.9) vs lukewarm or warm tea. Risk was also significantly increased for drinking tea 2 to 3 minutes after pouring (OR, 2.49; 95% CI, 1.62 – 3.83) or less than 2 minutes after pouring (OR, 5.41; 95% CI, 2.63 – 11.1) vs drinking tea at least 4 minutes after being poured. Responses to the questions about temperature at which tea was drunk agreed strongly with interval from tea being poured to being drunk (weighted κ, 0.68).
"Drinking hot tea, a habit common in Golestan province, was strongly associated with a higher risk of oesophageal cancer," the study authors write.
Limitations of this study include possible information bias regarding the amount and temperature of consumed tea, validation study performed among healthy people, possible selection bias, and some missing data.
"A large proportion of Golestan inhabitants drink hot tea, so this habit may account for a substantial proportion of the cases of oesophageal cancer in this population," the study authors write. "Informing the population about the hazards of drinking hot tea may be helpful in reducing the incidence of oesophageal cancer in Golestan and in other high risk populations where similar habits are prevalent."
In an accompanying editorial, David C, Whiteman, from Queensland Institute of Medical Research at Royal Brisbane Hospital in Australia, recommends allowing tea to cool for 5 minutes before drinking.
"The mechanism through which heat promotes the development of tumours warrants further exploration and might be given renewed impetus on the basis of these findings," Dr. Whiteman writes. "These findings are not cause for alarm, however, and they should not reduce public enthusiasm for the time honoured ritual of drinking tea. Rather, we should follow the advice … [that suggests] a five to 10 minute interval between making and pouring tea, by which time the tea will be sufficiently flavoursome and unlikely to cause thermal injury."
The Digestive Disease Research Center of Tehran University of Medical Sciences, the National Cancer Institute, National Institutes of Health, and the International Agency for Research on Cancer supported this study. The study authors and Dr. Whiteman have disclosed no relevant financial relationships.
BMJ. Published online March 27, 2009.
http://www.medscape.com/viewarticle/590589?sssdmh=dm1.454091&src=nldne
Wednesday, January 14, 2009
Treatment for Obesity
From Nature Clinical Practice Gastroenterology & Hepatology
Dietary Treatment for Obesity
by Peter M Clifton
Summary
In patients with obesity, low-fat diets seem to result in a weight loss of 3–4 kg at 3 years, but long-term data are limited.
Calorie-controlled diets seem to outperform low-fat diets with reported weight losses of 6–7 kg at 4 years, but, again, data are very limited; an initial very-low-calorie diet approach does not lead to greater weight loss than low-fat diets in the long term.
Use of meal replacements can lead to an 8 kg weight loss at 4 years, but this finding has been reported only in one, uncontrolled study.
High-protein, low-carbohydrate (or very-low-carbohydrate) diets have also been evaluated and seem to be superior to high-carbohydrate diets at least for up to 2 years.
Very-low-carbohydrate diets can lead to elevations in LDL cholesterol levels in some individuals.
Cognitive behavioral therapy added to diet therapy can facilitate approximately 5 kg additional weight loss, and exercise can facilitate an additional 1–1.5 kg weight loss.
Drug treatment, particularly with sibutramine and rimonabant, can increase weight loss with a mildly hypocaloric diet by an additional 3–5 kg, but weight-loss drugs are costly and have adverse effects.
If dietary and medical therapies fail, gastric banding can lead to a weight loss of ~14% at 10 years, with greater losses of up to 25% with gastric bypass and gastroplasty.
Bariatric surgery can also lead to a reduction in mortality and comorbidities but adverse effects can occur including nutritional deficiencies and gastrointestinal symptoms.
http://www.medscape.com/viewarticle/585033?src=sr
Dietary Treatment for Obesity
by Peter M Clifton
Summary
In patients with obesity, low-fat diets seem to result in a weight loss of 3–4 kg at 3 years, but long-term data are limited.
Calorie-controlled diets seem to outperform low-fat diets with reported weight losses of 6–7 kg at 4 years, but, again, data are very limited; an initial very-low-calorie diet approach does not lead to greater weight loss than low-fat diets in the long term.
Use of meal replacements can lead to an 8 kg weight loss at 4 years, but this finding has been reported only in one, uncontrolled study.
High-protein, low-carbohydrate (or very-low-carbohydrate) diets have also been evaluated and seem to be superior to high-carbohydrate diets at least for up to 2 years.
Very-low-carbohydrate diets can lead to elevations in LDL cholesterol levels in some individuals.
Cognitive behavioral therapy added to diet therapy can facilitate approximately 5 kg additional weight loss, and exercise can facilitate an additional 1–1.5 kg weight loss.
Drug treatment, particularly with sibutramine and rimonabant, can increase weight loss with a mildly hypocaloric diet by an additional 3–5 kg, but weight-loss drugs are costly and have adverse effects.
If dietary and medical therapies fail, gastric banding can lead to a weight loss of ~14% at 10 years, with greater losses of up to 25% with gastric bypass and gastroplasty.
Bariatric surgery can also lead to a reduction in mortality and comorbidities but adverse effects can occur including nutritional deficiencies and gastrointestinal symptoms.
http://www.medscape.com/viewarticle/585033?src=sr
Monday, January 12, 2009
Benefits of Probiotics Reviewed
Am Fam Physician. 2008;78:1073-1078.
Probiotics are live microorganisms that are ingested in amounts sufficient to benefit the health of the host. Although probiotics may be widely used for a variety of conditions, available evidence supports their use only for a small number of conditions.
Probiotics may have several mechanisms of action underlying their benefits. In preventing and treating gastrointestinal tract infection, probiotics may be helpful because of direct competition between pathogenic bacteria in the gut and immune modulation and enhancement. Probiotics may affect early development of immune tolerance during the first year of life, explaining their potential effect in children with atopic dermatitis.
Study Highlights
Probiotics used most widely and tested most rigorously include Lactobacillus species, Bifidobacterium species, and the nonpathogenic yeast S boulardii,
Probiotics are considered to be safe and effective for the prevention and treatment of antibiotic-associated diarrhea and infectious diarrhea.
Good evidence indicates that probiotics, especially S boulardii and L rhamnosus GG, help prevent antibiotic-related diarrhea.
Good evidence indicates that probiotic treatment of all-cause infectious diarrhea decreases both the duration of illness and the severity of symptoms.
Small studies suggest that in patients with irritable bowel syndrome, probiotic therapy may decrease the severity of pain and abdominal bloating.
Probiotics may help prevent atopic dermatitis in at-risk infants, and some preliminary evidence suggests that symptoms of atopic dermatitis may also respond to probiotic therapy.
Probiotics are sometimes used for vaginal candidiasis, stomach infection with H pylori, inflammatory bowel disease, and upper respiratory tract infections, but evidence is lacking to support these indications.
Frequently used dosages range from 5 to 10 billion colony-forming units per day for children and from 10 to 20 billion colony-forming units per day for adults, depending on the specific microorganism or combination used.
The dosages of S boulardii used in most studies range from 250 to 500 mg/day.
Common adverse effects of probiotics are mild and self-limited, including flatulence and mild abdominal discomfort.
Septicemia and other severe adverse effects of probiotics are rare.
Probiotics should be used only with caution in patients with short-gut syndrome. They should not be given to patients with conditions that severely compromise the immune system.
Available formulations of probiotics include capsules, powder, tablets, liquid, or incorporated into food. These may vary in quality and biological activity and should be obtained from a reliable supplier.
Pearls for Practice
On the basis of good evidence, probiotics are considered to be safe and effective for the prevention and treatment of antibiotic-associated diarrhea and infectious diarrhea. For prevention of antibiotic-related diarrhea, available evidence favors S boulardii and L rhamnosus GG. Probiotic treatment of all-cause infectious diarrhea decreases both the duration of illness and the severity of symptoms.
Small studies suggest that in patients with irritable bowel syndrome, probiotic therapy may decrease the severity of pain and abdominal bloating. Probiotics may help prevent atopic dermatitis in at-risk infants, and some preliminary evidence suggests that symptoms of atopic dermatitis may also respond to probiotic therapy
Probiotics are live microorganisms that are ingested in amounts sufficient to benefit the health of the host. Although probiotics may be widely used for a variety of conditions, available evidence supports their use only for a small number of conditions.
Probiotics may have several mechanisms of action underlying their benefits. In preventing and treating gastrointestinal tract infection, probiotics may be helpful because of direct competition between pathogenic bacteria in the gut and immune modulation and enhancement. Probiotics may affect early development of immune tolerance during the first year of life, explaining their potential effect in children with atopic dermatitis.
Study Highlights
Probiotics used most widely and tested most rigorously include Lactobacillus species, Bifidobacterium species, and the nonpathogenic yeast S boulardii,
Probiotics are considered to be safe and effective for the prevention and treatment of antibiotic-associated diarrhea and infectious diarrhea.
Good evidence indicates that probiotics, especially S boulardii and L rhamnosus GG, help prevent antibiotic-related diarrhea.
Good evidence indicates that probiotic treatment of all-cause infectious diarrhea decreases both the duration of illness and the severity of symptoms.
Small studies suggest that in patients with irritable bowel syndrome, probiotic therapy may decrease the severity of pain and abdominal bloating.
Probiotics may help prevent atopic dermatitis in at-risk infants, and some preliminary evidence suggests that symptoms of atopic dermatitis may also respond to probiotic therapy.
Probiotics are sometimes used for vaginal candidiasis, stomach infection with H pylori, inflammatory bowel disease, and upper respiratory tract infections, but evidence is lacking to support these indications.
Frequently used dosages range from 5 to 10 billion colony-forming units per day for children and from 10 to 20 billion colony-forming units per day for adults, depending on the specific microorganism or combination used.
The dosages of S boulardii used in most studies range from 250 to 500 mg/day.
Common adverse effects of probiotics are mild and self-limited, including flatulence and mild abdominal discomfort.
Septicemia and other severe adverse effects of probiotics are rare.
Probiotics should be used only with caution in patients with short-gut syndrome. They should not be given to patients with conditions that severely compromise the immune system.
Available formulations of probiotics include capsules, powder, tablets, liquid, or incorporated into food. These may vary in quality and biological activity and should be obtained from a reliable supplier.
Pearls for Practice
On the basis of good evidence, probiotics are considered to be safe and effective for the prevention and treatment of antibiotic-associated diarrhea and infectious diarrhea. For prevention of antibiotic-related diarrhea, available evidence favors S boulardii and L rhamnosus GG. Probiotic treatment of all-cause infectious diarrhea decreases both the duration of illness and the severity of symptoms.
Small studies suggest that in patients with irritable bowel syndrome, probiotic therapy may decrease the severity of pain and abdominal bloating. Probiotics may help prevent atopic dermatitis in at-risk infants, and some preliminary evidence suggests that symptoms of atopic dermatitis may also respond to probiotic therapy
Friday, January 9, 2009
Update on Treatment for Chronic Pain
Selection from:
Highlights of the American Academy of Pain Management 19th Annual Clinical Meeting
An Update on Chronic Pain Treatments CME/CE
Andrew N. Wilner, MD, FAAN, FACP
At the 2008 American Academy of Pain Management (AAPM) meeting in Nashville, Tennessee, experts addressed 3 problematic areas of chronic pain: chronic pelvic pain in women, headache, and fibromyalgia.
In order to treat the common problem of chronic pelvic pain in women, clinicians must focus on identifying one of the multiple causes, as many women will respond to therapy. When no cause is found, empiric treatment for unseen endometriosis may be successful.
For patients with chronic headache, the differential diagnosis is wide but severe underlying causes are rare, with most patients suffering from migraine, chronic daily headache, or cluster headache. Because of comorbidities such as bipolar and personality disorder, variability of response to medications, and other factors, algorithms are of limited usefulness and treatment must be individualized.
Fibromyalgia is a disease of multifactorial origin that is still not accepted as a "real disease" by many clinicians but can be diagnosed by specific criteria from the American College of Rheumatology (ACR). The identification and treatment of comorbidities may be even more important in fibromyalgia than in patients with migraine. In all patients with chronic pain, providers must be aware of the potential for addiction in their patients and develop safeguards for its prevention.
Chronic Pelvic Pain
Ayman Al-Hendy, MD, PhD, Director of the Center for Women's Health Research, Meharry Medical College, Nashville, Tennessee, explained that identifying and treating chronic pelvic pain represents a challenge for women's health and primary care practitioners. Up to 15% of women have chronic pelvic pain, but 75% do not consult a healthcare provider and only 10% consult a gynecologist. Chronic pelvic pain may result from a wide spectrum of disorders, including gastrointestinal, gynecologic, musculoskeletal, psychiatric, rheumatologic, and urologic.
In a laparoscopy study of 1318 women with chronic pelvic pain, the most common gynecologic cause for chronic pelvic pain was endometriosis (28%), followed by adhesions (25%) and chronic pelvic infection (6%). Less common causes included ovarian cysts, leiomyomas, pelvic varicosities, and "other." No pathology was identified in 39%, but Dr. Al-Hendy suggested that some of these patients may have had undetected endometriosis.
"Pelvic pain with a negative work-up is usually due to endometriosis when you exclude other causes of pain," advised Dr. Al-Hendy.
Evaluation of chronic pelvic pain begins with a detailed history and physical examination and may require laboratory work, imaging studies and procedures such as laparoscopy. Dr. Al-Hendy asks patients to complete a symptom questionnaire in the waiting room prior to the office examination. For successful treatment of patients with nongynecologic causes of chronic pelvic pain, such as fibromyalgia, irritable bowel syndrome, or urethral syndrome, a multidisciplinary pain clinic may be necessary.
On laparoscopy, endometriosis is characterized by a wide variety of lesions, including vesicles, polyps, "windows," diverticulae, adhesions, vascular "red" lesions, and fibrotic "white" lesions. Lesions may also be black, yellow, or clear. The gold standard for the diagnosis is histopathologic evidence of endometrial glands and stroma. Dr. Al-Hendy added that the severity of endometrial disease seen on laparoscopy doesn't correlate well with symptom severity. Further, lesions may remain hidden even from properly performed laparoscopy.
Laparoscopic laser treatment yields significant improvement in 100% of patients with severe endometriosis, 69% of patients with mild disease, and 38% of patients with minimal disease. Dr. Al-Hendy suggested that patients with minimal disease may have lesions hidden from the laparoscope, accounting for the poor treatment response.
The addition of hormonal treatment, a gonadotropin-releasing hormone (GnRH) agonist that induces a "chemical menopause," improves the results of surgical treatment. Even a GnRH agonist without surgery controls symptoms in almost 90% of patients for 1 year, with recurrence of pain symptoms in 50% of patients at 4 years. Dr. Al-Hendy recommended that patients keep a diary of their pain symptoms, which are important to separate from the menopausal symptoms that may result from GnRH therapy, such as headaches, night sweats, and hot flashes.
If there are no visible lesions of endometriosis and the pain does not respond to a GnRH agonist, the cause is probably not endometriosis, concluded Dr. Al-Hendy.
Management of Headache
Lawrence Robbins, MD, Assistant Professor of Neurology at Rush Medical College, Chicago, Illinois, and Director of the Robbins Headache Clinic, Northbrook, Illinois, was the recipient of this year's AAPM Clinical Pain Management Award. In his presentation he reviewed the treatment of chronic headache, with an emphasis on migraine. Other causes of chronic headache include chronic daily headache, cluster headache, and, more rarely, intracranial pathology.
According to Dr. Robbins, migraine affects 28 million people in the United States and is common in all age groups. In addition to head pain, symptoms characteristic of migraine headaches include nausea, photophobia, and relation to the menstrual cycle.
Dr. Robbins explained, "Migraine is like having asthma or diabetes. It's a physical problem."
Patients should be educated about possible migraine triggers. These include relation to the menstrual cycle, undersleeping, stress and daily hassles, weather changes, missing meals, bright lights, and specific foods and drinks. These triggers can be cumulative, resulting in a headache. For example, a weather change occurring on the first day of the menstrual period may trigger a migraine.
Dr. Robbins advised that people with migraine pay attention to their caffeine ingestion. Small amounts of caffeine can help headaches, and 150-200 mg, the amount in a single cup of coffee, is usually enough. However, caffeine tolerance can develop. Some people who miss their routine cups of coffee will develop headaches or depression due to caffeine withdrawal.
Medications are most effective when used early in the headache. There are many choices of triptans, which may be combined with nonsteroidal anti-inflammatory drugs (NSAIDs). Triptans are more effective when used early, before allodynia and sensitization begin. Nontriptan abortive medications include acetaminophen, aspirin, NSAIDs, caffeine, and metoclopramide, as well as dichloralphenazone alone and in combination. Dihydroergotamine (DHE) injections and dihydroergotamine and caffeine nasal spray are also options. Antiemetics include ondansetron and promethazine. Other pain medications include opioids, butalbital, and hydrocodone. Dr. Robbins uses steroids, injectable opioids, butorphanol nasal spray, and fentanyl when the usual abortives do not work. For some patients with intractable headaches, monoamine oxidase inhibitors (MAOIs), stimulants, occipital stimulators, patent foramen ovale surgery, occipital nerve blocks, and cervical injections may be helpful. Dr. Robbins objected to the use of algorithms for the treatment of headache.
"Comorbidities shape how we treat headache patients; anxiety, depression, bipolar spectrum and personality disorders, attention-deficit/hyperactivity disorder, addictions, and insomnia will all influence how we treat the headache," observed Dr. Robbins. "Medical comorbidities that affect the gastrointestinal system, irritable bowel syndrome, constipation, and diarrhea will also influence treatment choice," he added.
"For example, amitriptyline can cause weight gain, constipation, and fatigue, so we wouldn't use it in patients predisposed to these symptoms."
In addition to medical therapies, psychotherapy, biofeedback, exercise, yoga, massage, acupuncture, and other treatments may be useful. "Acceptance is very important, not resignation," advised Dr. Robbins. "However, the patient may have acceptance, but their spouse or family may not, which increases the anxiety and stress of the patient. In addition, active coping is very important compared to passive coping. We want to promote self-efficacy."
Dr. Robbins concluded, "We are not treating headaches, we are treating people and trying to enhance quality of life."
Management of Fibromyalgia
Philip Mease, MD, Chief, Division of Clinical Research, Swedish Hospital Medical Center, Seattle, Washington, described fibromyalgia as a condition characterized by heightened pain sensitivity, fatigue, sleep disturbance, and other symptoms due to dysregulation of neurophysiologic function. Fibromyalgia is not simply a condition that occurs in the developed world; it has a prevalence worldwide ranging from 0.7% (Denmark) to 10.5% (Norway). In the United States, the prevalence of fibromyalgia is 2%.
Fibromyalgia may be diagnosed by applying ACR criteria, which include a history of chronic widespread pain for at least 3 months and identification of at least 11 out of 18 tender points. The ACR diagnostic criteria are 88.4% sensitive and 81.1% specific. Fibromyalgia appears to have a multifactorial pathophysiology, which includes a strong familial predisposition, central pain amplification, psychiatric comorbid conditions, and other factors, such as immune dysregulation and the role of neurohormones such as dopamine, and growth hormone. Magnetic resonance imaging studies have provided objective evidence to show that patients with fibromyalgia have a lower threshold for pain sensitivity.
Multiple comorbid symptoms and syndromes may accompany fibromyalgia, including tension/migraine headache, affective disorders, temporomandibular joint disorder, idiopathic low back pain, irritable bowel syndrome, nondermatomal paresthesias, fatigue, memory and cognitive difficulties, and others. Tension headache is one of the most common comorbidities, occurring in over 70% of women and 50% of men with fibromyalgia.
After confirming a diagnosis, Dr. Mease recommended the identification of important symptom domains, their severity, and level of patient function. The only diagnostic instrument that has been validated for measure of function and quality of life in fibromyalgia is the Fibromyalgia Impact Questionnaire (FIQ). Patients should be evaluated for comorbid medical and psychiatric disorders, psychosocial stressors, level of fitness, and barriers to treatment. Education should be provided about fibromyalgia and treatment options should be reviewed.
Despite different modes of action, a variety of neuromodulatory agents may improve the symptoms of fibromyalgia patients. These include antidepressants, analgesics, anticonvulsants, muscle relaxants, and sedative hypnotic drugs. Only 2 drugs are FDA-approved for the specific treatment of fibromyalgia: pregabalin (Lyrica®) and duloxetine hydrochloride (Cymbalta®). However, many other medications are used off-label for the treatment of fibromyalgia.
Two pivotal phase 3 trials of the investigational drug milnacipran have been completed recently and showed favorable results for the treatment of fibromyalgia. Statistically significant durable pain relief as well as multidimensional symptom improvement lasted at least 1 year. The main adverse event was nausea (36.7%), with other adverse effects similar to those associated with duloxetine. Milnacipran has been approved in Europe and Asia for the treatment of depression.
Nonpharmacologic therapy for fibromyalgia includes aerobic exercise, cognitive-behavioral therapy, patient education, strength training, acupuncture, biofeedback, balneotherapy, and hypnotherapy. Both the patient's pain and comorbid conditions should be treated. Referral to a specialist may be necessary for complex cases.
Conclusions
The treatment of chronic pelvic pain, migraine, and fibromyalgia requires a directed history, physical examination, and laboratory evaluations to rule out other diagnoses and appreciation of multiple comorbidities that may influence the expression of symptoms and guide treatment choice. Multiple treatment modalities are available, which must be individualized for each patient.
This activity is supported by an educational grant from PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.
Highlights of the American Academy of Pain Management 19th Annual Clinical Meeting
An Update on Chronic Pain Treatments CME/CE
Andrew N. Wilner, MD, FAAN, FACP
At the 2008 American Academy of Pain Management (AAPM) meeting in Nashville, Tennessee, experts addressed 3 problematic areas of chronic pain: chronic pelvic pain in women, headache, and fibromyalgia.
In order to treat the common problem of chronic pelvic pain in women, clinicians must focus on identifying one of the multiple causes, as many women will respond to therapy. When no cause is found, empiric treatment for unseen endometriosis may be successful.
For patients with chronic headache, the differential diagnosis is wide but severe underlying causes are rare, with most patients suffering from migraine, chronic daily headache, or cluster headache. Because of comorbidities such as bipolar and personality disorder, variability of response to medications, and other factors, algorithms are of limited usefulness and treatment must be individualized.
Fibromyalgia is a disease of multifactorial origin that is still not accepted as a "real disease" by many clinicians but can be diagnosed by specific criteria from the American College of Rheumatology (ACR). The identification and treatment of comorbidities may be even more important in fibromyalgia than in patients with migraine. In all patients with chronic pain, providers must be aware of the potential for addiction in their patients and develop safeguards for its prevention.
Chronic Pelvic Pain
Ayman Al-Hendy, MD, PhD, Director of the Center for Women's Health Research, Meharry Medical College, Nashville, Tennessee, explained that identifying and treating chronic pelvic pain represents a challenge for women's health and primary care practitioners. Up to 15% of women have chronic pelvic pain, but 75% do not consult a healthcare provider and only 10% consult a gynecologist. Chronic pelvic pain may result from a wide spectrum of disorders, including gastrointestinal, gynecologic, musculoskeletal, psychiatric, rheumatologic, and urologic.
In a laparoscopy study of 1318 women with chronic pelvic pain, the most common gynecologic cause for chronic pelvic pain was endometriosis (28%), followed by adhesions (25%) and chronic pelvic infection (6%). Less common causes included ovarian cysts, leiomyomas, pelvic varicosities, and "other." No pathology was identified in 39%, but Dr. Al-Hendy suggested that some of these patients may have had undetected endometriosis.
"Pelvic pain with a negative work-up is usually due to endometriosis when you exclude other causes of pain," advised Dr. Al-Hendy.
Evaluation of chronic pelvic pain begins with a detailed history and physical examination and may require laboratory work, imaging studies and procedures such as laparoscopy. Dr. Al-Hendy asks patients to complete a symptom questionnaire in the waiting room prior to the office examination. For successful treatment of patients with nongynecologic causes of chronic pelvic pain, such as fibromyalgia, irritable bowel syndrome, or urethral syndrome, a multidisciplinary pain clinic may be necessary.
On laparoscopy, endometriosis is characterized by a wide variety of lesions, including vesicles, polyps, "windows," diverticulae, adhesions, vascular "red" lesions, and fibrotic "white" lesions. Lesions may also be black, yellow, or clear. The gold standard for the diagnosis is histopathologic evidence of endometrial glands and stroma. Dr. Al-Hendy added that the severity of endometrial disease seen on laparoscopy doesn't correlate well with symptom severity. Further, lesions may remain hidden even from properly performed laparoscopy.
Laparoscopic laser treatment yields significant improvement in 100% of patients with severe endometriosis, 69% of patients with mild disease, and 38% of patients with minimal disease. Dr. Al-Hendy suggested that patients with minimal disease may have lesions hidden from the laparoscope, accounting for the poor treatment response.
The addition of hormonal treatment, a gonadotropin-releasing hormone (GnRH) agonist that induces a "chemical menopause," improves the results of surgical treatment. Even a GnRH agonist without surgery controls symptoms in almost 90% of patients for 1 year, with recurrence of pain symptoms in 50% of patients at 4 years. Dr. Al-Hendy recommended that patients keep a diary of their pain symptoms, which are important to separate from the menopausal symptoms that may result from GnRH therapy, such as headaches, night sweats, and hot flashes.
If there are no visible lesions of endometriosis and the pain does not respond to a GnRH agonist, the cause is probably not endometriosis, concluded Dr. Al-Hendy.
Management of Headache
Lawrence Robbins, MD, Assistant Professor of Neurology at Rush Medical College, Chicago, Illinois, and Director of the Robbins Headache Clinic, Northbrook, Illinois, was the recipient of this year's AAPM Clinical Pain Management Award. In his presentation he reviewed the treatment of chronic headache, with an emphasis on migraine. Other causes of chronic headache include chronic daily headache, cluster headache, and, more rarely, intracranial pathology.
According to Dr. Robbins, migraine affects 28 million people in the United States and is common in all age groups. In addition to head pain, symptoms characteristic of migraine headaches include nausea, photophobia, and relation to the menstrual cycle.
Dr. Robbins explained, "Migraine is like having asthma or diabetes. It's a physical problem."
Patients should be educated about possible migraine triggers. These include relation to the menstrual cycle, undersleeping, stress and daily hassles, weather changes, missing meals, bright lights, and specific foods and drinks. These triggers can be cumulative, resulting in a headache. For example, a weather change occurring on the first day of the menstrual period may trigger a migraine.
Dr. Robbins advised that people with migraine pay attention to their caffeine ingestion. Small amounts of caffeine can help headaches, and 150-200 mg, the amount in a single cup of coffee, is usually enough. However, caffeine tolerance can develop. Some people who miss their routine cups of coffee will develop headaches or depression due to caffeine withdrawal.
Medications are most effective when used early in the headache. There are many choices of triptans, which may be combined with nonsteroidal anti-inflammatory drugs (NSAIDs). Triptans are more effective when used early, before allodynia and sensitization begin. Nontriptan abortive medications include acetaminophen, aspirin, NSAIDs, caffeine, and metoclopramide, as well as dichloralphenazone alone and in combination. Dihydroergotamine (DHE) injections and dihydroergotamine and caffeine nasal spray are also options. Antiemetics include ondansetron and promethazine. Other pain medications include opioids, butalbital, and hydrocodone. Dr. Robbins uses steroids, injectable opioids, butorphanol nasal spray, and fentanyl when the usual abortives do not work. For some patients with intractable headaches, monoamine oxidase inhibitors (MAOIs), stimulants, occipital stimulators, patent foramen ovale surgery, occipital nerve blocks, and cervical injections may be helpful. Dr. Robbins objected to the use of algorithms for the treatment of headache.
"Comorbidities shape how we treat headache patients; anxiety, depression, bipolar spectrum and personality disorders, attention-deficit/hyperactivity disorder, addictions, and insomnia will all influence how we treat the headache," observed Dr. Robbins. "Medical comorbidities that affect the gastrointestinal system, irritable bowel syndrome, constipation, and diarrhea will also influence treatment choice," he added.
"For example, amitriptyline can cause weight gain, constipation, and fatigue, so we wouldn't use it in patients predisposed to these symptoms."
In addition to medical therapies, psychotherapy, biofeedback, exercise, yoga, massage, acupuncture, and other treatments may be useful. "Acceptance is very important, not resignation," advised Dr. Robbins. "However, the patient may have acceptance, but their spouse or family may not, which increases the anxiety and stress of the patient. In addition, active coping is very important compared to passive coping. We want to promote self-efficacy."
Dr. Robbins concluded, "We are not treating headaches, we are treating people and trying to enhance quality of life."
Management of Fibromyalgia
Philip Mease, MD, Chief, Division of Clinical Research, Swedish Hospital Medical Center, Seattle, Washington, described fibromyalgia as a condition characterized by heightened pain sensitivity, fatigue, sleep disturbance, and other symptoms due to dysregulation of neurophysiologic function. Fibromyalgia is not simply a condition that occurs in the developed world; it has a prevalence worldwide ranging from 0.7% (Denmark) to 10.5% (Norway). In the United States, the prevalence of fibromyalgia is 2%.
Fibromyalgia may be diagnosed by applying ACR criteria, which include a history of chronic widespread pain for at least 3 months and identification of at least 11 out of 18 tender points. The ACR diagnostic criteria are 88.4% sensitive and 81.1% specific. Fibromyalgia appears to have a multifactorial pathophysiology, which includes a strong familial predisposition, central pain amplification, psychiatric comorbid conditions, and other factors, such as immune dysregulation and the role of neurohormones such as dopamine, and growth hormone. Magnetic resonance imaging studies have provided objective evidence to show that patients with fibromyalgia have a lower threshold for pain sensitivity.
Multiple comorbid symptoms and syndromes may accompany fibromyalgia, including tension/migraine headache, affective disorders, temporomandibular joint disorder, idiopathic low back pain, irritable bowel syndrome, nondermatomal paresthesias, fatigue, memory and cognitive difficulties, and others. Tension headache is one of the most common comorbidities, occurring in over 70% of women and 50% of men with fibromyalgia.
After confirming a diagnosis, Dr. Mease recommended the identification of important symptom domains, their severity, and level of patient function. The only diagnostic instrument that has been validated for measure of function and quality of life in fibromyalgia is the Fibromyalgia Impact Questionnaire (FIQ). Patients should be evaluated for comorbid medical and psychiatric disorders, psychosocial stressors, level of fitness, and barriers to treatment. Education should be provided about fibromyalgia and treatment options should be reviewed.
Despite different modes of action, a variety of neuromodulatory agents may improve the symptoms of fibromyalgia patients. These include antidepressants, analgesics, anticonvulsants, muscle relaxants, and sedative hypnotic drugs. Only 2 drugs are FDA-approved for the specific treatment of fibromyalgia: pregabalin (Lyrica®) and duloxetine hydrochloride (Cymbalta®). However, many other medications are used off-label for the treatment of fibromyalgia.
Two pivotal phase 3 trials of the investigational drug milnacipran have been completed recently and showed favorable results for the treatment of fibromyalgia. Statistically significant durable pain relief as well as multidimensional symptom improvement lasted at least 1 year. The main adverse event was nausea (36.7%), with other adverse effects similar to those associated with duloxetine. Milnacipran has been approved in Europe and Asia for the treatment of depression.
Nonpharmacologic therapy for fibromyalgia includes aerobic exercise, cognitive-behavioral therapy, patient education, strength training, acupuncture, biofeedback, balneotherapy, and hypnotherapy. Both the patient's pain and comorbid conditions should be treated. Referral to a specialist may be necessary for complex cases.
Conclusions
The treatment of chronic pelvic pain, migraine, and fibromyalgia requires a directed history, physical examination, and laboratory evaluations to rule out other diagnoses and appreciation of multiple comorbidities that may influence the expression of symptoms and guide treatment choice. Multiple treatment modalities are available, which must be individualized for each patient.
This activity is supported by an educational grant from PriCara, Division of Ortho-McNeil-Janssen Pharmaceuticals Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.
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