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Combination drug reduces agitation

Many patients with Alzheimer disease don't respond adequately to nonpharmacologic treatment, and therapy with psychotropic drugs may be unsafe or ineffective for older adults. In a 10-week randomized trial of patients with probable Alzheimer disease, a combination of dextromethorphan hydrobromide and quinidine sulfate showed promise as a safe and effective treatment for agitation, restlessness, and periods of aggressive behavior. The combination of quinidine, an antiarrhythmic drug, with a cough suppressant is currently approved to treat pseudobulbar affect in patients with neurologic disease who experience involuntary outbursts of emotion.


In stage 1 of the trial, patients were randomly assigned to the drug group or the placebo group. In stage 2, those in the drug group continued drug therapy while those in the placebo group were stratified by response and reassigned to receive either the drug or placebo. Patients taking stable doses of antidepressants, antipsychotics, hypnotics, and antidementia drugs were included in the study, which was completed by 194 patients.


Comparing the responses of patients who received the combination drug with those receiving the placebo, researchers found significant reductions in both occurrence and severity of agitation based on Neuropsychiatric Inventory Agitation/Aggression scale scores. For example, in stage 2, scores were reduced from 5.8 to 3.8 in the treatment group compared with a reduction from 6.7 to 5.8 in the placebo group.


Adverse events included falls, diarrhea, and urinary tract infection, but researchers said the drug therapy was generally well tolerated and "not associated with cognitive impairment, sedation, or clinically significant QTc prolongation."


Sources: Cummings JL, Lyketsos CG, Peskind ER, et al. Effect of dextromethorphan-quinidine on agitation in patients with Alzheimer disease dementia: a randomized clinical trial. JAMA. 2015;314(12):1242-1254. Combination drug treatment reduces agitation for patients with probable Alzheimer's disease. The JAMA Network Journals. News release. September 22, 2015.



E-pillboxes improve adherence to therapy

A new study published in PLOS Medicine found the use of electronic medication monitor boxes (e-pillboxes) improved treatment adherence in patients with tuberculosis (TB). The devices cue the patient when it's time to take medication, reducing the need for directly observed therapy (DOT).


The study followed more than 4,000 patients newly diagnosed with TB across 36 Chinese districts. Patients were randomized into four groups. Those in the three test groups received medication reminders via text, e-pillbox, or both text and e-pillbox. Those in the control group received standard care with no electronic reminders. All patients took their medications from an e-pillbox, which recorded when the box was opened. The primary outcome was "the proportion of patient-months in which >=20% of doses were missed ('nonadherent months'), measured by either monthly pill counts or electronic pillbox openings."


The percentage of nonadherent months was about 14% for patients who received both text and e-pillbox reminders, compared with 17% for those who received e-pillbox reminders alone. In comparison, the percentage of nonadherent months for patients in the control group was 30%. But text reminders alone didn't encourage medication adherence, with patients in the text-only group taking their medication no more reliably than those in the control group.


The study demonstrates how technology can help reduce the need for DOT, an intensive intervention that isn't always feasible and that can also present individual and health policy concerns.


Sources: Liu X, Lewis JJ, Zhang H, et al. Effectiveness of electronic reminders to improve medication adherence in tuberculosis patients: a cluster-randomised trial. PLoS Med. 2015;12(9):e1001876. Metcalfe JZ, O'Donnell MR, Bangsberg DR. Moving beyond directly observed therapy for tuberculosis. PLoS Med. 2015;12(9):e1001877.



Child ED visits in decline

Hospitals are seeing fewer accidental poisonings in children, reports the CDC. Between 2004 and 2013, EDs handled approximately 640,000 cases of drug ingestion in patients age 5 and younger. Of those, nearly one in five children was hospitalized. However, these cases peaked at 76,000 in 2010; in 2013, 59,000 young children required medical attention for accidental medication ingestion.


Most visits (91%) involved ingestion of just one medication-most commonly prescription pills, tablets, or capsules. While more than 260 different prescription drugs have been implicated in pediatric overdoses, just four drugs account for the vast majority of over-the-counter liquid medication exposures: acetaminophen, ibuprofen, diphenhydramine, and cough and cold medications.


The decline in ED visits is attributed in part to pediatricians working closely with parents to keep medications away from their children, as well as the increase in tamper-proof packaging. However, lead researcher Maribeth Lovegrove points out that nearly 60,000 kids is still too many. "Innovative approaches, such as improved safety packaging and targeted educational messages, may be needed to continue or even accelerate this decline," she commented.


Nurses should advise parents and other caregivers to:


* keep medications in a safe location out of sight and out of reach.


* never tell children medication is candy.


* keep medications in child-resistant packaging whenever possible.


* remind babysitters and other visitors to keep bags and coats containing medication away from children.


* add the Poison Help number (1-800-222-1222) to phone contacts for easy access in case of emergency.



Source: Lovegrove MC, Weidle NJ, Budnitz DS. Trends in emergency department visits for unsupervised pediatric medication exposures, 2004-2013. Pediatrics. 2015;136(4):e821-e829.



Therapy for bipolar disorder, schizophrenia

The FDA has approved cariprazine (Vraylar), a new atypical antipsychotic drug, for treatment of severe mental illnesses in adults, including schizophrenia and manic or mixed episodes associated with bipolar I disorder. The drug was tested in three 6-week clinical trials involving patients with schizophrenia, and three 3-week trials involving patients with bipolar disorder. Each trial demonstrated a reduction in symptoms for participants taking the drug over a placebo.


Cariprazine is a capsule taken orally once a day, similar to other atypical antipsychotics such as aripiprazole and risperidone. The most commonly reported adverse reactions from the trials included tremor, slurred speech, restlessness, dyspepsia, and vomiting. The drug has a boxed warning, included on all FDA-approved drugs for schizophrenia and bipolar disorder, which indicates an increased risk of death in older adults who take the medication for dementia-related psychosis.


Sources: Food and Drug Administration. FDA approves new drug to treat schizophrenia and bipolar disorder. News release. September 17, 2015. Prescribing information. Vraylar (cariprazine) capsules, for oral use.