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Topical treatment rubs out osteoarthritis pain

Recently approved by the FDA, Voltaren Gel is the first prescription topical treatment that can be applied directly to the site of osteoarthritis pain. Providing 1% diclofenac sodium in a topical gel, this nonsteroidal anti-inflammatory drug (NSAID) is specifically indicated to treat painful joints in the knees and hands. In one clinical study, Voltaren reduced osteoarthritic pain levels in the hand by 46%; in another, it reduced knee pain by 51%. Compared with oral diclofenac treatment, Voltaren was associated with 94% less systemic absorption of diclofenac, minimizing the risk of adverse reactions.


In clinical trials, the most common adverse reactions to Voltaren Gel were application site reactions (7% of patients). Like other NSAIDs, Voltaren Gel may increase the risk of cardiovascular thrombotic events and gastrointestinal bleeding. It's contraindicated in patients who are hypersensitive to diclofenac.


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Antihypertensive drugs

Which is better?


It's a draw

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), two drug classes commonly used to treat hypertension, are equally effective, according to a review of 61 studies by the Agency for Healthcare Research and Quality (AHRQ). Researchers also found that ACE inhibitors are somewhat more likely than ARBs to cause a persistent dry cough-1.7% of those taking ACE inhibitors developed a dry cough compared with 0.6% taking ARBs. The studies included more than 16,000 patients who were followed from 12 weeks to 5 years.


The findings didn't show any consistent differences between the two drug classes in effect on lipid levels, diabetes management, renal disease control, or heart function. Researchers say the long-term benefits and risks related to these classes of drugs are unknown and call for more research into how they affect rates of heart disease, stroke, and death.


The AHRQ is part of the U.S. Department of Health and Human Services. The full report is available at


Asthma and COPD

Too many patients use inhalers incorrectly

One-third of people with asthma or chronic obstructive pulmonary disease (COPD) incorrectly use their dry-powder inhalers, researchers reported this past fall at CHEST 2007, the annual meeting of the American College of Chest Physicians. Those who are older adults or who have severe airflow limitations are most likely to use them incorrectly.


The study involved 224 patients with asthma or COPD, average age of 55 years, who'd recently started inhalation therapy for their condition. The misuse rate was 20% for those younger than age 60 and about 42% for those older than age 60. People older than 80 had a misuse rate above 80%.


The misuse rate also varied by severity of condition. Patients with normal lung function had a misuse rate of 25%, compared with a misuse rate of almost 64% among those with severe airway obstruction.


Nearly one-third of patients didn't receive any instruction in using their inhaler and were simply referred to the drug package insert. People who'd received instruction from a health care provider had a misuse rate of 23%, compared with a misuse rate of 53% among those who hadn't received instructions.


Researchers say the message is clear: Professional caregivers must educate patients using proven teaching techniques and follow-up assessment and training. Certain assistive devices can help too. By using a metered dose inhaler with a large-volume spacer, for example, an older adult can inhale the aerosol slowly without having to coordinate his actions.


Medication safety

"Smart" dispenser organizes drugs

A computerized box that stores and dispenses prescription drugs has been approved by the FDA. The Electronic Medication Management Assistant (EMMA) is intended for use in patients' homes with the supervision of a licensed health care provider.


The patient-operated drug delivery unit is about the size of a bread box and plugs into an electric outlet. Loaded with medications packaged in blister cards, it sounds an alarm when a medication is due and releases it into a delivery tray when the patient activates the unit at the right time. A large, color touch screen is easy to use and "senior friendly," according to the manufacturer, INRange Systems. The device's Web-based two-way communication software lets a provider remotely manage prescriptions stored in the box.


According to the FDA, EMMA can reduce drug identification and dosing errors and allows providers to monitor the patient's adherence to her drug regimen. It's especially useful for older adults and anyone with a complex drug regimen who needs help keeping track of medications at home.


Postop pain control

Nerve blockade works well for kids

After orthopedic surgery, children receiving continuous peripheral nerve blockade (CPNB) for pain control can go home sooner with the catheter system in place. Delivering local anesthetic around the nerves, CPNB offers continuous pain relief for up to 100 hours.


Researchers at The Children's Hospital of Philadelphia (CHOP) evaluated outcomes in 217 children ages 4 to 18 years who'd received CPNB for analgesia after orthopedic surgery. Some patients left the hospital with a small anesthesia pouch attached to a belt worn over the shoulder or around the waist. Those who went home with CPNB received daily visits from a home nurse while CPNB was in use. When it was no longer needed, parents could remove the catheter themselves, sparing them another visit to their practitioner. Afterward, physicians or nurse practitioners called patient families once or twice a day until any adverse reactions to discontinuing CPNB, such as numbness, resolved.


Children who receive CPNB benefit from better analgesia and early hospital discharge, according to Arjunan Ganesh, MD, a pediatric anesthesiologist at CHOP and lead study author. The system also decreases the use of opioids and their adverse effects, such as nausea and itching. The percentage of children who didn't need opioids in the first 8, 24, and 48 hours after surgery was 56%, 26%, and 21% respectively. The incidence of nausea and vomiting was only 14%. (Other studies indicate that over 60% of patients taking opioids experience nausea and vomiting, usually during the initial period of therapy.)


Complications from CPNB, which occurred in 2.8% of children, included prolonged numbness that resolved on its own, superficial cellulitis that resolved with antibiotics, and tinnitus that resolved after the catheter was clamped and removed.


Researchers say that using CPNB in children is feasible only when appropriate expertise is available. Patient and family education plus frequent follow-up care are crucial to prevent and correct complications, which may include infection, trouble removing the catheter, inadequate analgesia, leakage at the catheter insertion site, and injury from a fall or trauma involving the insertion site.


Source: Ganesh A, et al., Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children, Anesthesia & Analgesia, November 2007.