RESUMO
Purpose: We designed this trial to compare the recovery time of remimazolam and propofol in elderly patients undergoing painless gastrointestinal endoscopy. Patients and Methods: In this randomized, non-Inferiority trial, 360 patients aged 65 years or older, scheduled for elective outpatient gastrointestinal endoscopy, were randomly assigned to the remimazolam combined with fentanyl (RF) group or the propofol combined with fentanyl (PF) group. The primary outcome was the post-anesthesia care unit (PACU) stay time, defined as the time from the end of the examination to scoring 9 points using the Modified Post-Anesthetic Discharge Scoring System (MPADSS) criteria. Secondary outcomes included sedation-related adverse events, recall, injection pain, as well as postoperative Quality of Recovery-15 (QoR-15) scores and Pittsburgh Sleep Quality Index (PSQI) scores at 1 day, 1 week, and 1 month postoperatively. Results: A total of 351 patients completed the study, with 174 receiving remimazolam and 177 receiving propofol. The PACU stay time in RF group was non-inferior to that in PF group [14 (11, 18) vs 13 (10, 17), mean difference 1 (95% confidence interval 0, 2), P=0.084 for noninferiority]. However, remimazolam was associated with lower rate of hypoxemia [4.7% (8/180) vs 12.4% (22/180), P=0.011], reduced use of vasoactive drugs [1 (0, 1) vs 1 (1, 2), P<0.001], less injection pain [2 (1.2%) vs 35 (21.3%), P<0.001], and lower recall [20 (11.8%) vs 36 (20.3%), P=0.034]. There were no differences in the QoR-15 scores and PSQI scores at postoperative 1 day, 1 week, and 1 month between groups. Conclusion: This non-inferiority study revealed that in elderly outpatients undergoing gastrointestinal endoscopy, remimazolam achieved recovery times comparable to propofol, with fewer associated complications.
Assuntos
Benzodiazepinas , Endoscopia Gastrointestinal , Pacientes Ambulatoriais , Propofol , Humanos , Propofol/administração & dosagem , Idoso , Feminino , Masculino , Benzodiazepinas/administração & dosagem , Benzodiazepinas/efeitos adversos , Período de Recuperação da Anestesia , Hipnóticos e Sedativos/administração & dosagem , Idoso de 80 Anos ou maisRESUMO
This commentary on a case describes how social determinants of health also contribute to insomnia and then suggests how to balance risks and benefits of different strategies for managing chronic insomnia. Behaviorally induced insufficient sleep syndrome can exacerbate morning side effects of prescription sleep aids, and there are potentially serious long-term risks (eg, dementia, falls, death) associated with chronic benzodiazepine use. Before trying sleeping pills, chronic insomnia should be treated with cognitive behavioral therapy.
Assuntos
Terapia Cognitivo-Comportamental , Hipnóticos e Sedativos , Distúrbios do Início e da Manutenção do Sono , Humanos , Distúrbios do Início e da Manutenção do Sono/tratamento farmacológico , Hipnóticos e Sedativos/uso terapêutico , Hipnóticos e Sedativos/efeitos adversos , Benzodiazepinas/uso terapêutico , Benzodiazepinas/efeitos adversos , Determinantes Sociais da Saúde , Medicamentos Indutores do Sono/uso terapêutico , Medicamentos Indutores do Sono/efeitos adversos , Feminino , MasculinoRESUMO
Although comprehensive epidemiological data related to long term use and abuse of benzodiazepine (BZD) in our country is scarce, undocumented clinical observation suggests that the prevalence is quite high and constitutes a significant public health problem. This cross-sectional study was carried out in the Department of Medicine, Shaheed Ziaur Rahman Medical College hospital, Bogra, from 1st October 2015 to 31st March 2016. The objectives of the study were to evaluate the indication, dosage, duration and untoward effects of use of benzodiazepine for one month or longer among the patients attending the inpatient and outpatient departments of medicine. A total of 100 cases of long term benzodiazepine users aged between 18 to 72 years with mean age of 44.0±15.02 years were taken for the study. Male to female ratio of the cases was 1.08:1.00, 97.0% were Muslims, 96.0% were married; 77.0% were rural dwellers. Fifty four (54.0%) cases were from middle class society and 39.0% were housewives by occupation. The benzodiazepine dosage ranged from <5mg to 10mg equivalent to diazepam, with mean dose of 7.5±1.71 and the duration ranged from 1-60 months. Benzodiazepine tolerance was found in 21.0% and dependence in 18.0%. The common reason for taking was benzodiazepine for long duration was the different anxiety disorders in 63.0% followed sleep disturbance in 33.0%. Common cause of long term continuation reported by the respondents was rapid relief of symptoms (51.0%) and lack of awareness (21.0%). In 56.0% cases, the drugs were prescribed by providers other than registered physicians. Only 23.0% of patients were counseled beforehand regarding the probable hazards of long term use of the drugs and the counseling were provided only by registered physicians. In conclusion, it can be said that, large scale epidemiologic studies are warranted to evaluate the weight of burden of benzodiazepines abuse in our community and the needs for changes in clinical approach.
Assuntos
Benzodiazepinas , Transtornos Relacionados ao Uso de Substâncias , Centros de Atenção Terciária , Humanos , Masculino , Benzodiazepinas/efeitos adversos , Feminino , Adulto , Pessoa de Meia-Idade , Estudos Transversais , Idoso , Adolescente , Centros de Atenção Terciária/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto JovemRESUMO
INTRODUCTION: Remimazolam is an ultra-short-acting benzodiazepine with a predictable and quick recovery that was FDA approved in 2020. As a relatively new medication, it is not as mainstream as other sedatives such as propofol or midazolam. This research aims to highlight the differences, benefits, and drawbacks of remimazolam in comparison to other short-term sedatives in order to bring greater awareness, and to consolidate the current knowledge of the effects of remimazolam. METHODS: The PubMed database was used to search for current relevant research to review. The search terms used were: "remimazolam", "midazolam", "propofol", and procedural sedation. The search also used qualifiers using only publications in English and published within the last five years. This query yielded 26 articles which were reviewed for content and relevance. RESULTS: Sixteen of the reviewed studies resulted in common themes suggesting remimazolam to be an effective alternative for procedural sedation with fewer adverse effects. Primarily, remimazolam is observed to have decreased procedural hypotension, bradycardia, and injection site pain. With no studies demonstrating an increased frequency of bradycardia, remimazolam is theorized to be superior to propofol in respect to sedation-associated bradycardia. One specific study notes a 14% decrease in frequency of bradycardia compared to propofol. Further benefits of remimazolam over propofol include the availability of an effective and reliable antidote, flumazenil. CONCLUSION: In being that remimazolam has primarily been used and studied in short-term sedation, we can only confidently conclude remimazolam's safety in these settings. There is little research being done in the way of ICU sedation or general anesthesia, but with the relatively similar, or decreased rates of adverse events with remimazolam, we suspect an increase in clinical research of remimazolam in these settings. With continued robust research, remimazolam could become more widely accepted as a safe alternative to current sedatives.
Assuntos
Benzodiazepinas , Hipnóticos e Sedativos , Midazolam , Propofol , Humanos , Benzodiazepinas/efeitos adversos , Midazolam/administração & dosagem , Propofol/efeitos adversos , Propofol/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/administração & dosagemAssuntos
Sistemas de Notificação de Reações Adversas a Medicamentos , Benzodiazepinas , Blefarospasmo , Hipnóticos e Sedativos , United States Food and Drug Administration , Humanos , Benzodiazepinas/efeitos adversos , Sistemas de Notificação de Reações Adversas a Medicamentos/estatística & dados numéricos , Estados Unidos/epidemiologia , Blefarospasmo/tratamento farmacológico , Blefarospasmo/induzido quimicamente , Hipnóticos e Sedativos/efeitos adversos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Fatores de TempoRESUMO
BACKGROUND: Benzodiazepines reduce postoperative nausea and vomiting (PONV); however, conflicting results have been reported regarding the use of remimazolam, a novel benzodiazepine. OBJECTIVE: This meta-analysis examines whether remimazolam reduces PONV incidence compared with propofol or volatile agents used in general anesthesia. MATERIAL AND METHODS: Electronic databases, including PubMed, EMBASE, CENTRAL, and Web of Science, were searched on 31 July 2023. The primary outcome was the incidence of PONV. Secondary outcomes included PONV severity, rescue antiemetic use, amounts of remifentanil used, and participant satisfaction scores. Odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using a random-effects model. The risk of bias (RoB) was assessed using the Cochrane RoB2 tool. RESULTS: A total of 1514 adult patients from 11 randomized controlled trials were included. The incidences of PONV in the remimazolam and control groups were 16.1% and 16.5%, respectively. Remimazolam did not increase the incidence of PONV (OR 0.62; 95% CI, 0.37-1.04; pâ¯= 0.0676; I2â¯= 48%). Subgroup analysis showed a significant reduction in PONV with remimazolam vs. volatile agents (OR 0.25; 95% CI, 0.13-0.47; Pâ¯= 0.0000; I2â¯= 0%) but not vs. propofol (OR 1.04; 95% CI, 0.70-1.56; pâ¯= 0.8332; I2â¯= 0%). More remifentanil was used in the remimazolam group vs. the volatile group, with no significant difference between remimazolam and propofol groups. Participant satisfaction scores were higher with remimazolam. CONCLUSION: Remimazolam did not increase PONV risk compared to propofol and reduced PONV incidence compared to volatile agents, with higher participant satisfaction. To validate the present findings, further well-planned large clinical trials are required.
Assuntos
Anestesia Geral , Benzodiazepinas , Náusea e Vômito Pós-Operatórios , Propofol , Náusea e Vômito Pós-Operatórios/prevenção & controle , Náusea e Vômito Pós-Operatórios/epidemiologia , Humanos , Anestesia Geral/efeitos adversos , Benzodiazepinas/efeitos adversos , Benzodiazepinas/uso terapêutico , Benzodiazepinas/administração & dosagem , Propofol/efeitos adversos , Propofol/uso terapêutico , Propofol/administração & dosagem , Antieméticos/uso terapêutico , Antieméticos/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Incidência , Remifentanil/uso terapêutico , Remifentanil/administração & dosagem , Remifentanil/efeitos adversosRESUMO
BACKGROUND: Benzodiazepines are frequently prescribed to treat anxiety and insomnia, but long-term use has been associated with the development of dependence, tolerance, and cognitive decline, especially among older adults. This study aimed to investigate the pattern of consumption and factors associated with inappropriate prescribing of benzodiazepines in primary health care. METHODS: This is a cross-sectional analytical study, using dispensing records of diazepam, clonazepam, and nitrazepam from public pharmacies in a Brazilian municipality between 2018 and 2022. Metrics for benzodiazepine consumption were DDD (Defined Daily Dose) and DDD/1000PD (per 1000 population per day). Long-term/prolonged benzodiazepine use was defined as consuming at least 90 DDD and at least 2 dispensations per year. To ascertain associations between long-term use and predictor variables, a multivariate logistic regression model was utilized. FINDINGS: A total of 40402 participants were included, with an average age of 55 years (SD = 0.30), 38.5% were older aged. Diazepam and nitrazepam exceeded the daily dose recommended. There was a reduction in diazepam consumption during the study period, as calculated by DDD/1.000PD, while the consumption of other benzodiazepines remained stable. However, a significant increase in diazepam consumption is noted when considering the last decade. Prolonged use was observed in 29.1% of participants, with a significant prevalence among the older people (34.8% of them were long-term users) and advancing age was identified as a risk factor for long-term use. Higher PDDs were also associated with long-term use and aging. Participants who used different benzodiazepines during the period had a higher risk of prolonged use. CONCLUSIONS: These results provide insights into the prevalence of problematic utilization of benzodiazepines in primary health care. Authorities and health care providers must take steps to encourage gradual cessation of prolonged benzodiazepine prescriptions and the embrace of suitable strategies for addressing anxiety and insomnia within primary health care settings.
Assuntos
Benzodiazepinas , Prescrição Inadequada , Atenção Primária à Saúde , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Atenção Primária à Saúde/estatística & dados numéricos , Benzodiazepinas/uso terapêutico , Benzodiazepinas/efeitos adversos , Benzodiazepinas/administração & dosagem , Prescrição Inadequada/estatística & dados numéricos , Estudos Transversais , Idoso , Brasil , Adulto , Diazepam/uso terapêutico , Diazepam/efeitos adversos , Diazepam/administração & dosagem , Nitrazepam/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Clonazepam/uso terapêutico , Clonazepam/efeitos adversos , Distúrbios do Início e da Manutenção do Sono/tratamento farmacológico , Distúrbios do Início e da Manutenção do Sono/epidemiologiaRESUMO
STUDY OBJECTIVE: There is scarce evidence on the hemodynamic stability of remimazolam during anesthetic induction in patients with significant coronary artery disease. This study aims to compare the effects of remimazolam and propofol on post-induction hypotension in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Randomized controlled trial. SETTING: Tertiary teaching hospital. PATIENTS: Adult patients undergoing isolated CABG. INTERVENTIONS: Patients were randomly allocated to received either remimazolam (n = 50) or propofol (n = 50) for anesthetic induction. The remimazolam group received an initial infusion at 6 mg/kg/h, which was later adjusted to 1-2 mg/kg/h to maintain a bispectral index of 40-60 after loss of consciousness. In the propofol group, a 1.5 mg/kg bolus of propofol was administered, followed by 1-1.5% sevoflurane inhalation as needed to achieve the target bispectral index. MEASUREMENTS: The primary outcome was the area under the curve (AUC) below the baseline mean arterial pressure (MAP) during the first 10 min after anesthetic induction. Secondary outcomes included the AUC for MAP <65 mmHg and the requirement for vasopressors. MAIN RESULTS: The remimazolam group demonstrated a significantly lower AUC under the baseline MAP compared to the propofol group (mean [SD], 169.8 [101.0] mmHg·min vs. 220.6 [102.4] mmHg·min; mean difference [95% confidence interval], 50.8 [10.4-91.2] mmHg·min; P = 0.014). Additionally, the remimazolam group had a reduced AUC for MAP <65 mmHg (7.3 [10.3] mmHg·min vs. 13.9 [14.9] mmHg·min; P = 0.007) and a lower frequency of vasopressor use compared to the propofol group (60% vs. 88%, P = 0.001). CONCLUSIONS: Remimazolam may offer improved hemodynamic stability during anesthetic induction in patients undergoing CABG, suggesting its potential advantage over propofol for patients with significant coronary artery disease in terms of hemodynamic stability.
Assuntos
Anestésicos Intravenosos , Ponte de Artéria Coronária , Hipotensão , Propofol , Humanos , Propofol/administração & dosagem , Propofol/efeitos adversos , Masculino , Feminino , Ponte de Artéria Coronária/efeitos adversos , Hipotensão/prevenção & controle , Pessoa de Meia-Idade , Idoso , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Benzodiazepinas/administração & dosagem , Benzodiazepinas/efeitos adversos , Sevoflurano/administração & dosagem , Sevoflurano/efeitos adversos , Pressão Arterial/efeitos dos fármacos , Monitores de Consciência , Doença da Artéria Coronariana/cirurgiaRESUMO
BACKGROUND: Treatment with different antipsychotics can lead to various metabolic side effects in patients with psychosis, impacting long-term prognosis. This study aimed to compare the changes and clinical efficacy of insulin resistance in patients treated with olanzapine and ziprasidone. METHOD: A retrospective analysis was conducted on the clinical data of 80 patients with schizophrenia. The patients were divided into olanzapine treatment group and ziprasidone treatment group. Parameters including body weight, body mass index (BMI), fasting plasma glucose (FPG), fasting plasma insulin (FPI), cholesterol (CHO), triglyceride (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), insulin resistance index, and Positive and Negative Syndrome Scale (PANSS) scores were recorded and compared before and after treatment. RESULTS: BMI, FPG, FPI, homeostatic model assessment of insulin resistance (HOMA-IR), CHO, TG and LDL in both groups were significantly higher than before treatment (p < 0.05). These parameters were significantly higher in the olanzapine group than in the ziprasidone group (p < 0.05). The level of HDL in both groups was significantly decreased after treatment, and the level of HDL in the olanzapine group was significantly lower than that in the ziprasidone group after treatment (p < 0.05). After treatment, the total score and score of PANSS in both groups were significantly lower than before treatment (p < 0.05). After treatment, there was no significant difference in total score and PANSS score between both groups (p > 0.05). The incidence of insulin resistance (IR) was significantly higher in the olanzapine group compared to the ziprasidone group (χ2 = 4.021, p < 0.05). In the IR group, BMI, FPG, FPI, TG, and LDL levels were higher than in the non-IR group (p < 0.05). Multivariate analysis indicated that BMI, FPG, FPI, TG, and LDL were independent risk factors for IR (odd ratio (OR) >1, p < 0.05). CONCLUSIONS: Treatment with olanzapine and ziprasidone improves clinical symptoms in patients with schizophrenia, but increases the risk of insulin resistance. The metabolic side effects of olanzapine are more pronounced.
Assuntos
Antipsicóticos , Resistência à Insulina , Olanzapina , Esquizofrenia , Humanos , Antipsicóticos/uso terapêutico , Antipsicóticos/efeitos adversos , Antipsicóticos/administração & dosagem , Esquizofrenia/tratamento farmacológico , Esquizofrenia/sangue , Masculino , Feminino , Olanzapina/uso terapêutico , Olanzapina/efeitos adversos , Estudos Retrospectivos , Adulto , Pessoa de Meia-Idade , Tiazóis/uso terapêutico , Tiazóis/efeitos adversos , Tiazóis/administração & dosagem , Piperazinas/uso terapêutico , Piperazinas/efeitos adversos , Piperazinas/administração & dosagem , Benzodiazepinas/uso terapêutico , Benzodiazepinas/efeitos adversosRESUMO
Introduction: To evaluate the recovery quality between remimazolam and propofol after general anesthesia surgery. Methods: We included eligible randomized controlled trials (RCTs) in EMBASE, PubMed, Cochrane Central, Scopus, and Web of Science up to June 26, 2024 for comparison the recovery quality of remimazolam and propofol after general anaesthesia. The primary outcomes were the total Quality of Recovery-15 (QoR-15) and five dimensions of QoR-15 on postoperative day 1 (POD1). Secondary outcomes were adverse events, the Quality of Recovery-40 (QoR-40) on POD1, and the intraoperative and postoperative time characteristics. Results: Thirteen RCTs with a total of 1,305 patients were included in this meta-analysis. Our statistical analysis showed that remimazolam group had higher QoR-15 score on POD1, with no significant difference (Mean Difference (MD) = 1.24; 95% confidence interval (CI), [-1.67-4.15]; I2 = 75%; P = 0.41). In the five dimensions of QoR-15, remimazolam group was superior to propofol group in terms of physical independence (MD = 0.79; 95% CI [0.31-1.27]; I2 = 0%; P = 0.001). Remimazolam group was lower than propofol group in incidence of hypotension (Risk Ratio (RR) = 0.48; 95% CI [0.40-0.59]; I2 = 14%; P < 0.00001), bradycardia (RR = 0.18; 95% CI [0.08-0.38]; I2 = 0%; P < 0.0001) and injection pain (RR = 0.03; 95% CI [0.01-0.12]; I2 = 48%; P < 0.00001), respectively. The intraoperative and postoperative time characteristics and the QoR-40 were similar in the two groups. Conclusions: Our analysis showed that the recovery quality of the remimazolam group after general anaesthesia was similar to propofol group, while the incidence of adverse events was low in remimazolam group. As a potential anesthetic, remimazolam can be used in place of propofol for surgical general anesthesia.
Assuntos
Período de Recuperação da Anestesia , Anestesia Geral , Benzodiazepinas , Propofol , Humanos , Anestesia Geral/efeitos adversos , Anestésicos Intravenosos/efeitos adversos , Anestésicos Intravenosos/administração & dosagem , Benzodiazepinas/efeitos adversos , Benzodiazepinas/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/uso terapêutico , Propofol/efeitos adversos , Propofol/administração & dosagem , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Inhaled corticosteroids (ICS) are effective in managing asthma and chronic obstructive pulmonary disease (COPD) but increase the risk of pneumonia. Benzodiazepines (BZD), commonly prescribed for comorbid psychiatric disorders in asthma or COPD patients, are also associated with pneumonia. This study investigates the risk of pneumonia associated with the concomitant use of ICS and BZD. METHODS: Data from the FDA Adverse Event Reporting System from Q4 2013 to Q3 2023 were extracted. Reports involving asthma or COPD patients were included. Disproportionality analysis and logistic regression analysis were performed to assess the risk of pneumonia associated with the combined use of ICS and BZD. Additive and multiplicative models were used to further confirm the results. Additionally, subgroup analyses were conducted based on gender, age, and disease type. RESULTS: A total of 238,411 reports were included. The combined use of ICS and BZD was associated with a higher reporting of pneumonia (ROR: 2.41, 95% CI 2.25-2.58). Using additive and multiplicative methods, the results remained significant. The strongest risk signals were observed in specific drug combinations, such as mometasone with clonazepam, budesonide with temazepam, and mometasone with zopiclone. Subgroup analyses showed higher pneumonia risks in females, patients over 60 years old, and those with asthma. CONCLUSION: Our findings identified a significantly elevated pneumonia risk with the combined use of ICS and BZD. These results highlighted the necessity for cautious co-prescription of ICS and BZD and suggested the need for more comprehensive clinical studies to assess this interaction.
Assuntos
Corticosteroides , Sistemas de Notificação de Reações Adversas a Medicamentos , Asma , Benzodiazepinas , Farmacovigilância , Pneumonia , Doença Pulmonar Obstrutiva Crônica , Humanos , Masculino , Feminino , Administração por Inalação , Benzodiazepinas/efeitos adversos , Benzodiazepinas/administração & dosagem , Pessoa de Meia-Idade , Pneumonia/epidemiologia , Pneumonia/induzido quimicamente , Asma/tratamento farmacológico , Asma/epidemiologia , Idoso , Adulto , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Sistemas de Notificação de Reações Adversas a Medicamentos/estatística & dados numéricos , Corticosteroides/administração & dosagem , Corticosteroides/efeitos adversos , Estados Unidos/epidemiologia , Adulto Jovem , Adolescente , Fatores de Risco , Medição de Risco , Criança , Quimioterapia Combinada , Idoso de 80 Anos ou mais , Clonazepam/efeitos adversos , Clonazepam/administração & dosagemAssuntos
Benzodiazepinas , Delírio , Hipnóticos e Sedativos , Humanos , Delírio/induzido quimicamente , Benzodiazepinas/efeitos adversos , Benzodiazepinas/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Hipnóticos e Sedativos/administração & dosagem , Relação Dose-Resposta a DrogaAssuntos
Benzodiazepinas , Delírio , Hipnóticos e Sedativos , Humanos , Benzodiazepinas/administração & dosagem , Benzodiazepinas/efeitos adversos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Delírio/induzido quimicamente , Relação Dose-Resposta a DrogaRESUMO
BACKGROUND AND OBJECTIVES: Animal studies have suggested a link between benzodiazepine and related Z-drug (BZDR) use and immune dysfunction. Corresponding evidence in humans is limited and focuses mainly on pneumonia. This study aimed to assess the association of incident BZDR use with subsequent development of serious infections. METHODS: This Swedish register-based study included a population-based demographically matched cohort, a co-twin control cohort, and an active comparator cohort. Out of 7,362,979 individuals aged below 65 years who were BZDR naïve by 2007, 713,896 BZDR recipients with incident dispensation of any BZDRs between 2007 and 2019 were 1:1 matched to 713,896 nonrecipients from the general population; 9197 BZDR recipients were compared with their 9298 unexposed co-twins/co-multiples; and 434,900 BZDR recipients were compared with 428,074 incident selective serotonin reuptake inhibitor (SSRI) recipients. The outcomes were identified by the first inpatient or specialist outpatient diagnosis of serious infections in the National Patient Register, or death from any infections recorded as the underlying cause in the Cause of Death Register. Cox proportional hazards regression models were fitted and controlled for multiple confounders, including familial confounding and confounding by indication. To study a possible dose-response association, the cumulative dosage of BZDRs dispensed during the follow-up was estimated for each BZDR recipient and modeled as a time-varying exposure with dose categories in tertiles [≤ 20 defined daily doses (DDDs), > 20 DDDs ≤ 65, and > 65 DDDs). The risk of infections was assessed in BZDR recipients within each category of the cumulative BZDR dosage compared to their demographically matched nonrecipients. RESULTS: In the demographically matched cohort (average age at incident BZDR use 42.8 years, 56.9% female), the crude incidence rate of any serious infections in BZDR recipients and matched nonrecipients during 1-year follow-up was 4.18 [95% confidence intervals (CI) 4.13-4.23] and 1.86 (95% CI 1.83-1.89) per 100 person-years, respectively. After controlling for demographic, socioeconomic, clinical, and pharmacological confounders, BZDR use was associated with 83% relative increase in risk of any infections [hazard ratio (HR) 1.83, 95% CI 1.79-1.89]. The risk remained increased, although attenuated, in the co-twin cohort (HR 1.55, 95% CI 1.23-1.97) and active comparator cohort (HR 1.33, 95% CI 1.30-1.35). The observed risks were similar across different types of initial BZDRs and across individual BZDRs, and the risks increased with age at BZDR initiation. We also observed a dose-response association between cumulative BZDR dosage and risk of serious infections. CONCLUSIONS: BZDR initiation was associated with increased risks of serious infections, even when considering unmeasured familial confounding and confounding by indication. The exact pathways through which BZDRs may affect immune function, however, remain unclear. Further studies are needed to explore the neurobiological mechanisms underlying the association between BZDR use and serious infections, as it can lead to safer therapeutic strategies for patients requiring BZDR.
Assuntos
Benzodiazepinas , Infecções , Sistema de Registros , Humanos , Benzodiazepinas/efeitos adversos , Feminino , Masculino , Pessoa de Meia-Idade , Adulto , Suécia/epidemiologia , Infecções/epidemiologia , Estudos de Coortes , Incidência , Adulto Jovem , Adolescente , Inibidores Seletivos de Recaptação de Serotonina/efeitos adversos , Inibidores Seletivos de Recaptação de Serotonina/administração & dosagem , Relação Dose-Resposta a Droga , Modelos de Riscos ProporcionaisRESUMO
Introduction: Medications are a fundamental part of the treatment of multiple pathologies. However, despite their benefits, some are considered potentially inappropriate medications for older people given their safety profile. Epidemiological data differences related to potentially inappropriate medications make it difficult to determine their effects on elderly people. Objective: To estimate the prevalence and types of potentially inappropriate medications using the 2019 Beers Criteria® in a cohort of adults older than 65 years. Materials and methods: We performed an observational, multicenter, retrospective, longitudinal study of a four-year follow-up of potentially inappropriate medications in community-dwelling older adults. Results: We followed 820 participants from five cities for four years (2012-2016) and evaluated them in three different moments (m1 = 2012, m2 = 2014, and m3 = 2016). The average age was 69.07 years, and 50.9% were women. The potentially inappropriate medication prevalence in the participants was 40.24%. The potentially inappropriate medications' mean among the studied subjects in the first moment was 1.65 (SD = 0.963), in the second was 1.73 (SD = 1.032), and in the third was 1.62 (SD = 0.915). There were no statistical differences between measurements (Friedman test, value = 0.204). The most frequent potentially inappropriate medications categories were gastrointestinal (39.4%), analgesics (18.8%), delirium-related drugs (15.4%), benzodiazepines (15.2%), and cardiovascular (14.2%). Conclusions: About half of the population of the community-dwelling older adults had prescriptions of potentially inappropriate medications in a sustained manner and without significant variability over time. Mainly potentially inappropriate medications were gastrointestinal and cardiovascular drugs, analgesics, delirium-related drugs, and benzodiazepines.
Introducción. Los fármacos son parte fundamental del tratamiento de múltiples enfermedades. Sin embargo, a pesar de sus beneficios, algunos se consideran medicamentos potencialmente inapropiados en adultos mayores, dado su perfil de seguridad. Las diferencias en los datos epidemiológicos relacionados con los medicamentos potencialmente inapropiados dificultan el establecimiento de sus efectos en adultos mayores. Objetivo. Estimar la prevalencia longitudinal y los tipos de medicamentos potencialmente inapropiados, utilizando los criterios Beers® del 2019 en una cohorte de adultos mayores de 65 años. Materiales y métodos. Se realizó un estudio observacional, multicéntrico, retrospectivo y longitudinal, de cuatro años de seguimiento de los medicamentos potencialmente inapropiados en adultos mayores de la comunidad. Resultados. Se evaluaron 820 participantes de cinco ciudades durante cuatro años (2012 a 2016) en tres momentos (m1: 2012, m2: 2014 y m3; 2016). La edad promedio fue de 69,07 años y el 50,9 % eran mujeres. La prevalencia de medicamentos potencialmente inapropiados en los participantes fue del 40,24 %. El promedio de estos medicamentos entre los sujetos estudiados en el primer momento fue de 1,65 (DE = 0,963), en el segundo fue de 1,73 (DE = 1,032) y en el tercero fue de 1,62 (DE = 0,915). No hubo diferencias estadísticas entre las mediciones (prueba de Friedman, p = 0,204). Las categorías de los medicamentos potencialmente inapropiados más frecuentes fueron: gastrointestinales (39,4 %), analgésicos (18,8 %), relacionados con delirium (15,4 %), benzodiacepinas (15,2 %) y cardiovasculares (14,2 %). Conclusiones. En cerca de la mitad de la población de adultos mayores de la comunidad, se prescribieron medicamentos potencialmente inapropiados de manera sostenida y sin variabilidad importante en el tiempo. Los más recetados fueron aquellos para tratar malestares gastrointestinales y cardiovasculares, analgésicos, para el delirium y benzodiacepinas.
Assuntos
Vida Independente , Lista de Medicamentos Potencialmente Inapropriados , Humanos , Idoso , Feminino , Masculino , Estudos Longitudinais , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Prescrição Inadequada/estatística & dados numéricos , Prevalência , Benzodiazepinas/uso terapêutico , Benzodiazepinas/efeitos adversosRESUMO
Remimazolam is a novel ultra-short-acting benzodiazepine with a unique pharmacokinetic profile that makes it an attractive option for use in general anesthesia. This review paper provides an in-depth analysis of remimazolam's applications in the field of general anesthesia, focusing on its pharmacological properties, clinical efficacy, safety profile, and potential advantages compared to other anesthetic agents. Remimazolam acts on GABAa receptors, offering rapid onset and recovery times due to its unique metabolic pathway involving tissue esterases. Clinical trials have demonstrated its efficacy in procedural sedation and general anesthesia, showing a favorable safety profile with minimal cardiovascular and respiratory depression. Compared to traditional anesthetics such as propofol, remimazolam presents distinct advantages, including predictable pharmacokinetics, reduced risk of prolonged sedation, and a reliable safety margin. These attributes position remimazolam as a promising agent in various clinical settings. The purpose of this review is to synthesize current evidence on remimazolam and discuss its potential to improve clinical outcomes in anesthesia practice.
Assuntos
Anestesia Geral , Benzodiazepinas , Humanos , Benzodiazepinas/farmacocinética , Benzodiazepinas/efeitos adversos , Benzodiazepinas/farmacologia , Benzodiazepinas/uso terapêutico , Anestesia Geral/efeitos adversos , Hipnóticos e Sedativos/uso terapêutico , Hipnóticos e Sedativos/farmacocinética , Hipnóticos e Sedativos/farmacologia , AnimaisRESUMO
Drugs have actions that may be classified as therapeutic effects and side effects; side effects are actions that do not contribute to therapeutic benefit. Some side effects are neutral; others, experienced as undesirable or unpleasant, are recorded as adverse effects. Some drug actions are therapeutic for some disorders and adverse for others; or therapeutic during acute illness and adverse during maintenance treatment. As an example, anticholinergic action may be adverse when a tricyclic antidepressant is used to treat depression but therapeutic when the drug is used to treat irritable bowel syndrome with diarrhea. In clinical practice, side or adverse effects of a drug may be leveraged to manage troublesome symptoms. As an example, the sedative effect of a low dose of trazodone may be useful for some patients with insomnia. With this background, studies have examined whether the increase in appetite and weight associated with olanzapine and mirtazapine may be effective against anorexia and cachexia associated with cancer and cancer chemotherapy. The subject is important because cachexia may be present in 30%-50% of patients with cancer (with higher prevalence in patients with more advanced cancer) and because the presence of cachexia is associated with a higher risk of disease progression and mortality. Many randomized controlled trials (RCTs) have examined pharmacologic interventions such as progestins, corticosteroids, anamorelin, and medical cannabis for cancer related cachexia; most results have been disappointing. A recent RCT found that olanzapine (2.5 mg/d for 12 weeks) improved appetite, weight, other nutritional parameters, and quality of life in patients with locally advanced or metastatic cancer treated with chemotherapy. Another RCT, however, found that mirtazapine (30 mg/d for 8 weeks) brought no nutritional or anthropometric gain in patients with cancer and anorexia. It is concluded that olanzapine but not mirtazapine merits further investigation in patients with cancer who have anorexia and cachexia.
Assuntos
Anorexia , Benzodiazepinas , Caquexia , Mianserina , Mirtazapina , Neoplasias , Olanzapina , Humanos , Mirtazapina/uso terapêutico , Mirtazapina/efeitos adversos , Olanzapina/uso terapêutico , Olanzapina/efeitos adversos , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Anorexia/induzido quimicamente , Anorexia/tratamento farmacológico , Mianserina/análogos & derivados , Mianserina/efeitos adversos , Mianserina/uso terapêutico , Benzodiazepinas/efeitos adversos , Benzodiazepinas/uso terapêutico , Benzodiazepinas/farmacologia , Caquexia/tratamento farmacológico , Caquexia/etiologia , Caquexia/induzido quimicamente , Antipsicóticos/efeitos adversos , Antipsicóticos/uso terapêutico , Antidepressivos Tricíclicos/efeitos adversos , Antidepressivos Tricíclicos/uso terapêuticoRESUMO
BACKGROUND: Elderly patients comprise an increasing proportion of patients undergoing surgery, and they require special attention due to age-related physiological changes. Propofol is the traditional agent for anaesthesia, and recently, remimazolam, a novel ultra-short-acting benzodiazepine, has emerged as an alternative to propofol in general anaesthesia. OBJECTIVES: We aim to compare remimazolam vs . propofol for general anaesthesia in elderly patients regarding hypotension, induction characteristics, haemodynamics and recovery outcomes. DESIGN: Meta-analysis with sensitivity and trial sequential analyses (TSA) to assess inconsistencies. Risk ratios and mean differences with 95% confidence intervals (95% CIs) were computed using a random effects model. Subgroups and meta-regression according to anaesthesia methods were also performed. DATA SOURCES: We systematically searched MEDLINE, Embase and Cochrane for randomised controlled trials (RCTs) up to January 1, 2024. ELIGIBILITY CRITERIA: Patients at least 60âyears old, comparing remimazolam vs . propofol for general anaesthesia. RESULTS: Eleven RCTs (947 patients) were included. Compared with propofol, remimazolam was associated with lower postinduction and intra-operative hypotension (RR 0.41, 95% CI 0.27 to 0.62, P â<â0.001) and incidence of bradycardia (risk ratio 0.58, 95% CI 0.34 to 0.98, P â=â0.04), with a higher heart rate ( P â=â0.01). The incidence of injection pain was lower ( P â<â0.001), but remimazolam was associated with a longer time to loss of consciousness ( P â<â0.001) and a higher bispectral index at loss of consciousness ( P â=â0.04). No differences were found for mean arterial pressure, emergence time, extubation time and incidence of emergence agitation. The TSA was consistent and achieved the required information size for hypotension. CONCLUSIONS: Remimazolam significantly reduced the risk of hypotension, bradycardia and injection pain, despite an increase in the time to loss of consciousness. Remimazolam appears to be an effective and well tolerated alternative to propofol in elderly patients undergoing general anaesthesia.
Assuntos
Anestesia Geral , Anestésicos Intravenosos , Benzodiazepinas , Propofol , Idoso , Humanos , Período de Recuperação da Anestesia , Anestesia Geral/efeitos adversos , Anestesia Geral/métodos , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Benzodiazepinas/efeitos adversos , Benzodiazepinas/administração & dosagem , Hipotensão/induzido quimicamente , Propofol/administração & dosagem , Propofol/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodosRESUMO
This study examines trends in medical use, nonmedical use, diversion sources, and perceived procurement difficulty of prescription medications for nonmedical use among US adolescents.