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Following the application of oral hormonal contraceptives situations may occur which need fast clarification. In this report we discuss the practical aspects of forgetting to take hormonal contraceptives, the risk for birth defects, the time when to restart taking oral contraceptives after delivery and abortion, the indications for stopping the application, the taking of oral contraceptives under anticoagulant therapy, the behaviour during migraine, the raising need of ethinylestradiol in the case of epilepsy, the procedure in case of oligophrenia, the prevention of the rheumatoid arthritis as well as special questions in cases of diabetes mellitus and gestational diabetes.
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PMID:[Status of problems with administration of hormonal contraceptives]. 1009 7

Selection of beta-adrenergic blockers for formulary addition can be a difficult task, especially with the increasing availability of new beta-blockers, as well as the numerous differences in pharmacodynamic and pharmacokinetic properties of currently available agents. Nevertheless, appropriate evaluation of the important characteristics of beta-blockers should allow selection of the most cost-effective agents for formulary addition. Most importantly, differences in efficacy, product formulation and cost should be carefully considered when making formulary decisions. Notably, evidence from clinical trials indicates differences in efficacy among beta-blockers for post-myocardial infarction prophylaxis, situational anxiety, essential tremor, thyrotoxicosis, migraine prophylaxis and prevention of bleeding associated with oesophageal varices. For many clinical situations, it is also important to select an effective agent that is available in both an oral and intravenous formulation, especially for cardioprotection after acute myocardial infarction and for use in supraventricular arrhythmias. In addition, availability of sustained release products and generic formulations should be considered for their potential to increase compliance and decrease cost, respectively. Comparative drug costs, as well as costs associated with decreased compliance, should also be carefully evaluated. Differences in beta-receptor selectivity, duration of action and presence of intrinsic sympathomimetic activity (ISA) are also important considerations in the selection of beta-blockers for formulary consideration. Although degree of selectivity is relative, beta 1-selective agents may be less likely to induce bronchospasm in patients with chronic obstructive pulmonary disease (COPD) and may be less likely to affect glucose homeostasis in patients with diabetes mellitus. Duration of action of a beta-blocker is an important consideration for evaluation of efficacy throughout the recommended dosage interval. In addition, beta-blockers with a long duration of action can often be administered once or twice daily, potentially leading to increased compliance and thereby improved effectiveness and economic efficiency. The presence of ISA is an important consideration because certain beta-blockers with ISA may be less effective than those without ISA for certain indications. Factors considered to be less important when making formulary decisions of choice of beta-blockers include the route of elimination, lipophilicity and presence of membrane stabilising activity.
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PMID:Formulary considerations in selection of beta-blockers. 1015 Jan 54

This review of the literature reveals that migraine is a common, chronic condition featuring episodic attacks which vary in severity and symptomatology. Throbbing, unilateral headache, which is aggravated by activity, is the most prominent feature, although a high proportion of sufferers also experience phonophobia, photophobia and nausea, which may lead to vomiting. Preceding aura is a less common feature of the attack. The frequency and duration of migraine attacks varies widely between individuals, though the median frequency is around 1 attack per month and median duration is roughly 24 h. Migraine attacks can have a profound effect on the day-to-day lives and well-being of the sufferer. In the long term, migraine may cause profound emotional changes and result in coping strategies that interfere with working, social and family life and many normal daily activities. These effects are apparent in quality of life studies on migraine patients. Thus, the impact of migraine on many quality of life parameters is similar to that of other chronic conditions such as osteoarthritis, diabetes and depression. Reduction in the personal burden of migraine can be facilitated by encouraging migraine sufferers to consult their doctor, through accurate diagnosis of migraine headaches and assessment of the disability suffered by the migraineurs, and through improved and well-executed treatment strategies. Copyright 1998 Lippincott Williams & Wilkins
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PMID:The burden of migraine to the individual sufferer: a review. 1021 Aug 87

Coexisting diseases may have unforeseen yet clinically significant effects on patients' well-being. Both generic and disease-specific measures are frequently used to assess health-related quality of life (QOL). The present study assessed the effects of comorbidity on the results of QOL measures through an analysis of longitudinal data from 3 double-masked, randomized, placebo-controlled clinical trials dealing with heartburn, asthma, and ulcer. Patients were assigned to subgroups by comorbidity status: those with no comorbid diseases and those whose principal disease was heartburn, asthma, or ulcer and whose comorbid condition was chronic obstructive pulmonary disease, asthma, or chronic bronchitis; hypertension; migraine, coronary artery disease, or varicose veins; chronic gastrointestinal conditions; arthritis or back pain; diabetes; or depression. Multivariate analysis of covariance was used to test the study hypotheses. The study results suggest that comorbid conditions significantly and extensively affect patients' scores on generic QOL measures and estimation of treatment effect, whereas their influence on disease-specific QOL scores and estimation of treatment effect is considerably smaller. Further, the most important comorbidities in the 3 trial populations were arthritis or back pain and depression, which respectively accounted for 17% and 5% of the patient population. These findings have significant practical implications for the estimation of true treatment effects, control of comorbidity effects, and design of QOL trials.
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PMID:Effects of comorbidity on health-related quality-of-life scores: an analysis of clinical trial data. 1021 40

(1) The precise cardiovascular risk of oral contraceptives is poorly known because of a lack of reliable clinical studies and the numerous potential biases in epidemiological studies. (2) The absolute risk of coronary events is very low in women under 35 who are non smokers, have no history of coronary heart disease and have normal blood pressure. In women over 35, smoking over 10 cigarettes a day and arterial hypertension substantially increase the risk of coronary heart disease. (3) The absolute risk of stroke is low in young women who are not hypertensive and do not smoke. It is higher in the case of arterial hypertension. (4) The absolute risk of deep vein thrombosis is increased but remains moderate. Obesity, a family history of deep vein thrombosis, and hereditary clotting disorders are risk factors. (5) The cardiovascular risks linked to oral contraception seem to disappear after cessation. (6) The use of oral contraceptives with very low doses of oestrogen (less than 50 mug ethinylestradiol) reduces the associated risk of stroke. The risk of deep vein thrombosis is probably higher with combined contraceptives containing a third-generation progestagen (desogestrel or gestoden). (7) The coronary and cerebrovascular risks of progestagen-only contraceptives are poorly documented. Low-dose progestagen-only oral contraceptives have little effect on clotting factors or on carbohydrate and lipid metabolism. There may be a risk of deep vein thrombosis, however, with this type of contraceptive. (8) History, physical examination and simple laboratory tests before prescribing or renewing oral contraceptives are sufficient to detect the main contraindications, i.e. arterial hypertension, a history of coronary or cerebrovascular conditions, deep vein thrombosis, hypercholesterolaemia exceeding 3 g/l, hypertriglyceridaemia exceeding 3 g/l, unusually severe headache on a combined oral contraceptive and prolonged immobilisation. However, a combined oral contraceptive can be considered for some women with cardiovascular risk factors such as moderate hypercholesterolaemia or hypertriglyceridaemia, well-controlled insulin-dependent diabetes, uncomplicated cardiac valve disease, migraine not worsened by a combined oral contraceptive, varicose veins or a family history of deep vein thrombosis. (9) Pharmacists should be aware of these risk factors so that they can advise patients to see a doctor if new health problems arise between visits.
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PMID:Cardiovascular risk of oral contraceptives. Low, and mainly in women at risk. 1034 51

Migraine, like many other common and costly chronic diseases, may be amenable to the disease management model of healthcare delivery. The disease management approach has improved clinical and economic outcomes in conditions such as asthma, diabetes, congestive heart failure, and arthritis. The critical elements needed for a successful migraine disease management program are: 1) identification of highest-acuity patients, 2) extensive patient education, and 3) implementation of clear evidence-based guidelines for the diagnosis and management of patients. Transition from the current emergency-driven system of severe migraine treatment will require additional training and incentives for primary providers, specialists, and nurses. Both pharmacologic and nonpharmacologic treatments may play a role in attaining the best outcomes in carefully selected patients.
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PMID:Taking a disease management approach to migraine. Based on a presentation by William Parham III, MD. 1034 18

The prevention and treatment of hypertension remain as major challenges for clinicians all over the world. The recently published Sixth Report of the Joint National Committee for the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-VI) uses evidence-based medicine in providing guidelines to aid clinicians in the prevention, detection and treatment of high blood pressure, including pharmacological approaches. Calcium antagonists are used widely for the treatment of hypertension, and JNC-VI focuses on specific situations where calcium antagonists could be considered as preferred treatments. There are a large number of calcium antagonists available, with a variety of pharmacodynamic and pharmacokinetic actions. Several sustained-release formulations of these drugs are also available. In terms of blood pressure control, calcium antagonists are more effective as antihypertensive treatments than beta-blockers, ACE inhibitors and angiotensin II receptor blockers in Black patients. The dihydropyridine calcium antagonists have been shown to reduce morbidity and mortality in elderly patients with isolated systolic hypertension. The rate-lowering calcium antagonists can be used as alternatives to beta-blockers in patients with coronary artery disease and hypertension. Calcium antagonists can be used as alternatives to ACE inhibitors in patients with hypertension and concomitant diabetes mellitus and/or renal disease. Some dihydropyridine calcium antagonists may be useful as alternatives to ACE inhibitors in patients with hypertension and systolic heart failure. Calcium antagonists appear to be extremely useful in patients with cyclosporin-induced hypertension, and in patients with hypertension and concomitant Raynaud's phenomenon and/or migraine. The rate-lowering agents can be used in patients with atrial tachyarrhythmias and hypertension. Clinicians should be aware of drug-drug interactions involving calcium antagonists, especially after the recent problems with mibefradil. Although retrospective studies have caused controversy regarding the safety of calcium antagonists in patients with hypertension, recent prospective studies have revealed no major safety concerns with these drugs.
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PMID:How to use calcium antagonists in hypertension: putting the JNC-VI guidelines into practice. Joint National Committee for the Prevention, Detection, Evaluation and Treatment of High Blood Pressure. 1055 31

Corticosteroids (glucocorticoids), used frequently as potent anti-inflammatory agents, increase the risk of glaucoma by raising the intraocular pressure (IOP) when administered exogenously (topically, periocularly or systemically) and in certain conditions of increased endogenous production (e.g. Cushing's syndrome). Approximately 18 to 36% of the general population are corticosteroid responders. This response is increased to 46 to 92% in patients with primary open-angle glaucoma (POAG). Patients over 40 years of age and with certain systemic diseases (e.g. diabetes mellitus, high myopia) as well as relatives of patients with POAG are more vulnerable to corticosteroid-induced glaucoma. The association of corticosteroid-induced ocular hypertension in other conditions which are considered as risk factors for glaucoma (racial origins, hypertension, migraine, vasospasm) is likely but not fully established. The proposed mechanism of corticosteroid-induced glaucoma includes morphological and functional changes in the trabecular meshwork system and is similar to the pathogenesis of POAG. Trabecular cells exposed to corticosteroids in vitro show endoreplication of nuclei, an increase in cell size and excessive production of an approximately 56kD glycoprotein, identified as myocilin and transcribed by the GLC1A gene. Induction of ocular hypertension after corticosteroid administration depends on the specific drug, the dose, the frequency of administration and the corticosteroid responsiveness of the patient. The risk of corticosteroid-induced glaucoma can be minimised with judicious use of corticosteroids, as well as education of patients and medical practitioners. New treatment modalities include modified steroids and nonsteroidal anti-inflammatory agents that will have less effect on the elevation of IOP.
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PMID:Corticosteroids and glaucoma risk. 1064 55

Pharmacists should be aware of gender-based differences and menstrual cycle-related changes in six diseases: asthma, arthritis, migraine, diabetes, depression, and epilepsy. In general, women report symptoms of physical illness at higher rates, visit physicians more frequently, and make greater use of other health care services than men. Whereas reasons for these gender differences are not fully clear, a combination of biologic, physiologic, social, behavioral, psychologic, and cultural factors most likely contributes. A significant percentage of women with asthma, arthritis, migraine, diabetes, depression, or epilepsy experience worsening of their disease premenstrually. The mechanism is unknown, but is speculated to be multifactorial because of many endogenous and exogenous modulators and mediators of each disease. As part of general therapy for cycle-related exacerbations of any one of these disorders, patients should be encouraged to use a menstrual calendar to track signs and symptoms for two to three cycles; if cyclic trends are identified, the women should anticipate exacerbations and avoid triggering factors. Cyclic modulation with pharmacotherapy may be attempted. If unsuccessful, a trial of medical ovulation suppression with a gonadotropin-releasing hormone (GnRH) analog may be warranted. If that is successful, continuous therapy with a GnRH analog and steroid add-back therapy or less expensive alternatives may be effective. If pharmacotherapy is impractical, hysterectomy and bilateral oophorectomy with estrogen replacement therapy is a last resort. Gender differences and menstrual cycle-related changes are important areas for clinical and mechanistic research.
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PMID:Gender-based differences and menstrual cycle-related changes in specific diseases: implications for pharmacotherapy. 1080 39

Red wine has been a subject of much interest of professionals representing different fields of medicine. However, most of scientific studies have been searching for the reason of so called French paradox, which means that in France and other mediterranean countries the morbidity and mortality due to ischaemic heart disease is significantly lower than in other developed countries, in spite of relatively high consumption of fat and saturated fatty acids. The cardio-protective mechanism of red wine, although incompletely understood, is connected on one hand with the presence of ethanol which increases high-density lipoprotein cholesterol (HDL) and inhibits platelet aggregation, and on the other hand with the presence of polyphenols that have desirable biological properties. These include flavonoids, phenolic acids and stilbenes which are reputed to have antioxidant, vasorelaxing and antiplatelet properties. There is a considerable body of evidence indicating that regular consumption of red wine at moderate doses (200-400 ml a day) exerts a protective effect against ischaemic heart disease, other cardiovascular diseases, and perhaps diabetes, osteoporosis or some cancers. But, since alcohol intake involves a potential danger (risk of dependence, alcoholism, many organic diseases, migraine, allergies) medical recommendations of red wine consumption should be formulated very carefully.
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PMID:[Red wine in medicine: panacea, fashion or ... risk factor?]. 1105 22


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