Kerri Wachter

Updated secondary prevention guidelines pull together the latest data from clinical trials to advocate more aggressive management of patients with coronary heart disease.

The American Heart Association/American College of Cardiology Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update assembles evolving evidence from a number of trials involving the management of key risk factors.

“Physicians may have followed the low-density lipid story but they may not be aware of the recommendations for waist circumference or have a good idea about what to do about ACE inhibitors. This puts it all together, hopefully in a useable manner,” said Dr. Sidney C. Smith Jr., chairman of the ACC/AHA writing group.

Here's a look at the new guidelines, which advise the following changes to pharmacologic management:

▸ Lipid management. The goal of less than 100 mg/dL for LDL cholesterol is unchanged, but the guideline adds that further reduction to levels less than 70 mg/dL is reasonable. If triglyceride levels are 200–499 mg/dL, non-HDL cholesterol should be less than 130 mg/dL; further reduction below 100 mg/dL is reasonable.

The lipid management guidelines reflect recommendations made in 2004 by the National Cholesterol Education Program (NCEP) Adult Treatment Panel, which advised a target LDL level of less than 100 mg/dL and offered an optional target of 70 mg/dL in patients at very high risk. More recent study results, such as those from the Treating to New Targets (TNT) and the Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) studies, show that aggressive lipid-lowering therapy provides significant clinical benefit in patients who have stable coronary heart disease.

“These guidelines reinforce the fact that all patients [with coronary heart disease] should have LDL of less than 100 mg/dL and provide a reasonable target of 70 mg/dL,” said Dr. Smith, a professor of medicine and director of the center for cardiovascular science and medicine at the University of North Carolina at Chapel Hill.

▸ Antiplatelet and anticoagulant therapy. Aspirin therapy has been reduced to 75–162 mg/day, down from 75–325 mg/day in all patients, unless contraindicated. The lowering of the aspirin dose for chronic therapy was based largely on antiplatelet trials, which showed that the benefits of aspirin therapy are the same for lower dose regimens (75–80 mg) as for the adult dose (325 mg) but that the risk of bleeding was considerably less for the lower dose, said Dr. Smith.

Following acute coronary syndrome or percutaneous coronary intervention with stent placement, start and continue 75 mg/day of clopidogrel in combination with aspirin for up to 12 months. Therapy for stent recipients, for which the aspirin dosage is 325 mg/day, should last at least 1 month in patients who have received bare-metal stents, at least 3 months in those who have received sirolimus-eluting stents, and at least 6 months in those who have received paclitaxel-eluting stents.

▸ Renin-angiotensin-aldosterone system blockers. The guidance for these agents has expanded considerably. ACE inhibitors are recommended for indefinite use in all patients with a left ventricular ejection fraction (LVEF) of 40% or less and in those with hypertension, diabetes, or chronic kidney disease unless contraindicated. The use of ACE inhibitors should be considered in all patients.

Angiotensin receptor blockers (ARBs) should be used in patients who are intolerant of ACE inhibitors and have heart failure or have had an MI with a LVEF of 40% or less. The use of ARBs should be considered in other patients who are intolerant of ACE inhibitors. In patients with systolic heart failure, ARB use in combination with ACE inhibitors should be considered.

Aldosterone blockade should be used for post-MI patients—without significant renal dysfunction or hyperkalemia—who are already receiving therapeutic doses of an ACE inhibitor and β-blocker and who have a left ventricular ejection fractions of 40% or less, and have either diabetes or heart failure.

▸ β-Blockers. β-Blockers should be started and indefinitely continued in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms unless contraindicated.

Other updated recommendations include the more stringent management of the following risk factors:

▸ Blood pressure control. The aim is to keep patients' blood pressure under 140/90 mm Hg or less than 130/80 mm Hg in patients with diabetes or chronic kidney disease through lifestyle modification. In patients who do not meet this goal, blood pressure medication should be added as tolerated. Initially treatment should be with β-blockers and/or ACE inhibitors, adding other drugs such as thiazides as needed to achieve target blood pressure.

▸ Physical activity. The goal is 30–60 minutes of moderate-intensity aerobic activity 5–7 days per week, up from 3–4 days per week, supplemented by an increase in daily lifestyle activities, such as housework and gardening, and resistance training 2 days per week.

▸ Smoking. Not only should patients completely stop smoking but they also should not be exposed to any environmental tobacco smoke.

▸ Weight management. Not only should patients aim for a BMI between 18.5 and 24.9, but also a waist circumference of less than 40 inches for men and less than 35 inches for women. If waist circumference exceeds these values, patients should initiate lifestyle changes and physicians should consider treatment strategies for metabolic syndrome. The initial goal of weight loss should be to reduce body weight by roughly 10% from baseline. Once this goal has been met, further weight loss can be attempted if indicated.

▸ Flu vaccine. All patients with cardiovascular disease should receive inactivated influenza vaccinations because these individuals are at increased risk for complications from influenza.

The guidelines make a point of noting that ethnic minorities, women, and the elderly are underrepresented in many trials and urge greater participation by these populations in clinical trials to provide additional evidence about the best therapeutic strategies for these groups.

“Having worked in this area for 15 years … I think that it is very important that trials include older patients, that the trials include a high percentage of women … and that they recruit ethnic minorities, because I think that even though it seems logical to assume that the therapies may work, we need the evidence to really strengthen the basis for these recommendations,” said Dr. Smith.

Updated secondary prevention guidelines pull together the latest data from clinical trials to advocate more aggressive management of patients with coronary heart disease.

The American Heart Association/American College of Cardiology Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update assembles evolving evidence from a number of trials involving the management of key risk factors.

“Physicians may have followed the low-density lipid story but they may not be aware of the recommendations for waist circumference or have a good idea about what to do about ACE inhibitors. This puts it all together, hopefully in a useable manner,” said Dr. Sidney C. Smith Jr., chairman of the ACC/AHA writing group.

Here's a look at the new guidelines, which advise the following changes to pharmacologic management:

▸ Lipid management. The goal of less than 100 mg/dL for LDL cholesterol is unchanged, but the guideline adds that further reduction to levels less than 70 mg/dL is reasonable. If triglyceride levels are 200–499 mg/dL, non-HDL cholesterol should be less than 130 mg/dL; further reduction below 100 mg/dL is reasonable.

The lipid management guidelines reflect recommendations made in 2004 by the National Cholesterol Education Program (NCEP) Adult Treatment Panel, which advised a target LDL level of less than 100 mg/dL and offered an optional target of 70 mg/dL in patients at very high risk. More recent study results, such as those from the Treating to New Targets (TNT) and the Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) studies, show that aggressive lipid-lowering therapy provides significant clinical benefit in patients who have stable coronary heart disease.

“These guidelines reinforce the fact that all patients [with coronary heart disease] should have LDL of less than 100 mg/dL and provide a reasonable target of 70 mg/dL,” said Dr. Smith, a professor of medicine and director of the center for cardiovascular science and medicine at the University of North Carolina at Chapel Hill.

▸ Antiplatelet and anticoagulant therapy. Aspirin therapy has been reduced to 75–162 mg/day, down from 75–325 mg/day in all patients, unless contraindicated. The lowering of the aspirin dose for chronic therapy was based largely on antiplatelet trials, which showed that the benefits of aspirin therapy are the same for lower dose regimens (75–80 mg) as for the adult dose (325 mg) but that the risk of bleeding was considerably less for the lower dose, said Dr. Smith.

Following acute coronary syndrome or percutaneous coronary intervention with stent placement, start and continue 75 mg/day of clopidogrel in combination with aspirin for up to 12 months. Therapy for stent recipients, for which the aspirin dosage is 325 mg/day, should last at least 1 month in patients who have received bare-metal stents, at least 3 months in those who have received sirolimus-eluting stents, and at least 6 months in those who have received paclitaxel-eluting stents.

▸ Renin-angiotensin-aldosterone system blockers. The guidance for these agents has expanded considerably. ACE inhibitors are recommended for indefinite use in all patients with a left ventricular ejection fraction (LVEF) of 40% or less and in those with hypertension, diabetes, or chronic kidney disease unless contraindicated. The use of ACE inhibitors should be considered in all patients.

Angiotensin receptor blockers (ARBs) should be used in patients who are intolerant of ACE inhibitors and have heart failure or have had an MI with a LVEF of 40% or less. The use of ARBs should be considered in other patients who are intolerant of ACE inhibitors. In patients with systolic heart failure, ARB use in combination with ACE inhibitors should be considered.

Aldosterone blockade should be used for post-MI patients—without significant renal dysfunction or hyperkalemia—who are already receiving therapeutic doses of an ACE inhibitor and β-blocker and who have a left ventricular ejection fractions of 40% or less, and have either diabetes or heart failure.

▸ β-Blockers. β-Blockers should be started and indefinitely continued in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms unless contraindicated.

Other updated recommendations include the more stringent management of the following risk factors:

▸ Blood pressure control. The aim is to keep patients' blood pressure under 140/90 mm Hg or less than 130/80 mm Hg in patients with diabetes or chronic kidney disease through lifestyle modification. In patients who do not meet this goal, blood pressure medication should be added as tolerated. Initially treatment should be with β-blockers and/or ACE inhibitors, adding other drugs such as thiazides as needed to achieve target blood pressure.

▸ Physical activity. The goal is 30–60 minutes of moderate-intensity aerobic activity 5–7 days per week, up from 3–4 days per week, supplemented by an increase in daily lifestyle activities, such as housework and gardening, and resistance training 2 days per week.

▸ Smoking. Not only should patients completely stop smoking but they also should not be exposed to any environmental tobacco smoke.

▸ Weight management. Not only should patients aim for a BMI between 18.5 and 24.9, but also a waist circumference of less than 40 inches for men and less than 35 inches for women. If waist circumference exceeds these values, patients should initiate lifestyle changes and physicians should consider treatment strategies for metabolic syndrome. The initial goal of weight loss should be to reduce body weight by roughly 10% from baseline. Once this goal has been met, further weight loss can be attempted if indicated.

▸ Flu vaccine. All patients with cardiovascular disease should receive inactivated influenza vaccinations because these individuals are at increased risk for complications from influenza.

The guidelines make a point of noting that ethnic minorities, women, and the elderly are underrepresented in many trials and urge greater participation by these populations in clinical trials to provide additional evidence about the best therapeutic strategies for these groups.

“Having worked in this area for 15 years … I think that it is very important that trials include older patients, that the trials include a high percentage of women … and that they recruit ethnic minorities, because I think that even though it seems logical to assume that the therapies may work, we need the evidence to really strengthen the basis for these recommendations,” said Dr. Smith.

Updated secondary prevention guidelines pull together the latest data from clinical trials to advocate more aggressive management of patients with coronary heart disease.

The American Heart Association/American College of Cardiology Guidelines for Secondary Prevention for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2006 Update assembles evolving evidence from a number of trials involving the management of key risk factors.

“Physicians may have followed the low-density lipid story but they may not be aware of the recommendations for waist circumference or have a good idea about what to do about ACE inhibitors. This puts it all together, hopefully in a useable manner,” said Dr. Sidney C. Smith Jr., chairman of the ACC/AHA writing group.

Here's a look at the new guidelines, which advise the following changes to pharmacologic management:

▸ Lipid management. The goal of less than 100 mg/dL for LDL cholesterol is unchanged, but the guideline adds that further reduction to levels less than 70 mg/dL is reasonable. If triglyceride levels are 200–499 mg/dL, non-HDL cholesterol should be less than 130 mg/dL; further reduction below 100 mg/dL is reasonable.

The lipid management guidelines reflect recommendations made in 2004 by the National Cholesterol Education Program (NCEP) Adult Treatment Panel, which advised a target LDL level of less than 100 mg/dL and offered an optional target of 70 mg/dL in patients at very high risk. More recent study results, such as those from the Treating to New Targets (TNT) and the Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) studies, show that aggressive lipid-lowering therapy provides significant clinical benefit in patients who have stable coronary heart disease.

“These guidelines reinforce the fact that all patients [with coronary heart disease] should have LDL of less than 100 mg/dL and provide a reasonable target of 70 mg/dL,” said Dr. Smith, a professor of medicine and director of the center for cardiovascular science and medicine at the University of North Carolina at Chapel Hill.

▸ Antiplatelet and anticoagulant therapy. Aspirin therapy has been reduced to 75–162 mg/day, down from 75–325 mg/day in all patients, unless contraindicated. The lowering of the aspirin dose for chronic therapy was based largely on antiplatelet trials, which showed that the benefits of aspirin therapy are the same for lower dose regimens (75–80 mg) as for the adult dose (325 mg) but that the risk of bleeding was considerably less for the lower dose, said Dr. Smith.

Following acute coronary syndrome or percutaneous coronary intervention with stent placement, start and continue 75 mg/day of clopidogrel in combination with aspirin for up to 12 months. Therapy for stent recipients, for which the aspirin dosage is 325 mg/day, should last at least 1 month in patients who have received bare-metal stents, at least 3 months in those who have received sirolimus-eluting stents, and at least 6 months in those who have received paclitaxel-eluting stents.

▸ Renin-angiotensin-aldosterone system blockers. The guidance for these agents has expanded considerably. ACE inhibitors are recommended for indefinite use in all patients with a left ventricular ejection fraction (LVEF) of 40% or less and in those with hypertension, diabetes, or chronic kidney disease unless contraindicated. The use of ACE inhibitors should be considered in all patients.

Angiotensin receptor blockers (ARBs) should be used in patients who are intolerant of ACE inhibitors and have heart failure or have had an MI with a LVEF of 40% or less. The use of ARBs should be considered in other patients who are intolerant of ACE inhibitors. In patients with systolic heart failure, ARB use in combination with ACE inhibitors should be considered.

Aldosterone blockade should be used for post-MI patients—without significant renal dysfunction or hyperkalemia—who are already receiving therapeutic doses of an ACE inhibitor and β-blocker and who have a left ventricular ejection fractions of 40% or less, and have either diabetes or heart failure.

▸ β-Blockers. β-Blockers should be started and indefinitely continued in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms unless contraindicated.

Other updated recommendations include the more stringent management of the following risk factors:

▸ Blood pressure control. The aim is to keep patients' blood pressure under 140/90 mm Hg or less than 130/80 mm Hg in patients with diabetes or chronic kidney disease through lifestyle modification. In patients who do not meet this goal, blood pressure medication should be added as tolerated. Initially treatment should be with β-blockers and/or ACE inhibitors, adding other drugs such as thiazides as needed to achieve target blood pressure.

▸ Physical activity. The goal is 30–60 minutes of moderate-intensity aerobic activity 5–7 days per week, up from 3–4 days per week, supplemented by an increase in daily lifestyle activities, such as housework and gardening, and resistance training 2 days per week.

▸ Smoking. Not only should patients completely stop smoking but they also should not be exposed to any environmental tobacco smoke.

▸ Weight management. Not only should patients aim for a BMI between 18.5 and 24.9, but also a waist circumference of less than 40 inches for men and less than 35 inches for women. If waist circumference exceeds these values, patients should initiate lifestyle changes and physicians should consider treatment strategies for metabolic syndrome. The initial goal of weight loss should be to reduce body weight by roughly 10% from baseline. Once this goal has been met, further weight loss can be attempted if indicated.

▸ Flu vaccine. All patients with cardiovascular disease should receive inactivated influenza vaccinations because these individuals are at increased risk for complications from influenza.

The guidelines make a point of noting that ethnic minorities, women, and the elderly are underrepresented in many trials and urge greater participation by these populations in clinical trials to provide additional evidence about the best therapeutic strategies for these groups.

“Having worked in this area for 15 years … I think that it is very important that trials include older patients, that the trials include a high percentage of women … and that they recruit ethnic minorities, because I think that even though it seems logical to assume that the therapies may work, we need the evidence to really strengthen the basis for these recommendations,” said Dr. Smith.

For more information on the WHO Registry Platform, visit www.who.int/ictrp/en

The World Health Organization has launched a major initiative to standardize the way information on clinical trials is made available to the public.

In an attempt to address growing public concerns about the transparency of medical research involving human participants, the World Health Organization is recommending 20 key details that all clinical trial registries should include.

“Registration of all clinical trials and full disclosure of key information at the time of registration are fundamental to ensuring transparency in medical research and fulfilling ethical responsibilities to patients and study participants,” Dr. Timothy Evans, assistant director-general of the World Health Organization, said in a statement.

WHO's International Clinical Trials Registry Platform is not itself a registry, but instead provides standards for all clinical trial registries. These standards require inclusion of information about the following: sources of monetary or material support, primary and secondary sponsors, contacts for public and scientific queries, countries of recruitment, health conditions or problems studied, interventions, key inclusion and exclusion criteria, study design, date of first enrollment, target sample size, recruitment status, and primary and secondary outcomes.

The voluntary initiative is part of a growing movement toward greater accessibility to clinical trial information, prompted in part by high-profile cases involving the suppression of data by pharmaceutical companies.

In the European Union, all clinical trials conducted in member states are required to be registered in the EudraCT database, supervised by the European Medicines Agency. In the United States, www.ClinicalTrials.gov

However, there are several hundred other national and private clinical trial registries located around the world. The Registry Platform seeks to bring participating registries together in a global network to provide a single point of access to the information stored in them, according to a World Health Organization statement.

The World Health Organization has acknowledged the need to balance increased transparency with the protection of competitive advantage, and it appears that this issue may come down to a question of the timing of disclosure.

In comments submitted to a World Health Organization formal consultation on disclosure timing policy in April, the Pharmaceutical Research and Manufacturers of America noted “there may be infrequent instances where companies may regard certain data elements as sensitive for competitive reasons and wish to delay public disclosure.”

In particular, the organization said that companies may wish to delay the disclosure of the official scientific title of the study, specific mechanism or molecular identifiers of the intervention, target sample size, primary outcome, and key secondary outcomes.

The WHO Registry Platform is expected to launch a Web-based search portal later this year. This search portal would allow interested individuals to search among participating registries for clinical trials taking place or completed throughout the world.

For more information on the WHO Registry Platform, visit www.who.int/ictrp/en

The World Health Organization has launched a major initiative to standardize the way information on clinical trials is made available to the public.

In an attempt to address growing public concerns about the transparency of medical research involving human participants, the World Health Organization is recommending 20 key details that all clinical trial registries should include.

“Registration of all clinical trials and full disclosure of key information at the time of registration are fundamental to ensuring transparency in medical research and fulfilling ethical responsibilities to patients and study participants,” Dr. Timothy Evans, assistant director-general of the World Health Organization, said in a statement.

WHO's International Clinical Trials Registry Platform is not itself a registry, but instead provides standards for all clinical trial registries. These standards require inclusion of information about the following: sources of monetary or material support, primary and secondary sponsors, contacts for public and scientific queries, countries of recruitment, health conditions or problems studied, interventions, key inclusion and exclusion criteria, study design, date of first enrollment, target sample size, recruitment status, and primary and secondary outcomes.

The voluntary initiative is part of a growing movement toward greater accessibility to clinical trial information, prompted in part by high-profile cases involving the suppression of data by pharmaceutical companies.

In the European Union, all clinical trials conducted in member states are required to be registered in the EudraCT database, supervised by the European Medicines Agency. In the United States, www.ClinicalTrials.gov

However, there are several hundred other national and private clinical trial registries located around the world. The Registry Platform seeks to bring participating registries together in a global network to provide a single point of access to the information stored in them, according to a World Health Organization statement.

The World Health Organization has acknowledged the need to balance increased transparency with the protection of competitive advantage, and it appears that this issue may come down to a question of the timing of disclosure.

In comments submitted to a World Health Organization formal consultation on disclosure timing policy in April, the Pharmaceutical Research and Manufacturers of America noted “there may be infrequent instances where companies may regard certain data elements as sensitive for competitive reasons and wish to delay public disclosure.”

In particular, the organization said that companies may wish to delay the disclosure of the official scientific title of the study, specific mechanism or molecular identifiers of the intervention, target sample size, primary outcome, and key secondary outcomes.

The WHO Registry Platform is expected to launch a Web-based search portal later this year. This search portal would allow interested individuals to search among participating registries for clinical trials taking place or completed throughout the world.

For more information on the WHO Registry Platform, visit www.who.int/ictrp/en

The World Health Organization has launched a major initiative to standardize the way information on clinical trials is made available to the public.

In an attempt to address growing public concerns about the transparency of medical research involving human participants, the World Health Organization is recommending 20 key details that all clinical trial registries should include.

“Registration of all clinical trials and full disclosure of key information at the time of registration are fundamental to ensuring transparency in medical research and fulfilling ethical responsibilities to patients and study participants,” Dr. Timothy Evans, assistant director-general of the World Health Organization, said in a statement.

WHO's International Clinical Trials Registry Platform is not itself a registry, but instead provides standards for all clinical trial registries. These standards require inclusion of information about the following: sources of monetary or material support, primary and secondary sponsors, contacts for public and scientific queries, countries of recruitment, health conditions or problems studied, interventions, key inclusion and exclusion criteria, study design, date of first enrollment, target sample size, recruitment status, and primary and secondary outcomes.

The voluntary initiative is part of a growing movement toward greater accessibility to clinical trial information, prompted in part by high-profile cases involving the suppression of data by pharmaceutical companies.

In the European Union, all clinical trials conducted in member states are required to be registered in the EudraCT database, supervised by the European Medicines Agency. In the United States, www.ClinicalTrials.gov

However, there are several hundred other national and private clinical trial registries located around the world. The Registry Platform seeks to bring participating registries together in a global network to provide a single point of access to the information stored in them, according to a World Health Organization statement.

The World Health Organization has acknowledged the need to balance increased transparency with the protection of competitive advantage, and it appears that this issue may come down to a question of the timing of disclosure.

In comments submitted to a World Health Organization formal consultation on disclosure timing policy in April, the Pharmaceutical Research and Manufacturers of America noted “there may be infrequent instances where companies may regard certain data elements as sensitive for competitive reasons and wish to delay public disclosure.”

In particular, the organization said that companies may wish to delay the disclosure of the official scientific title of the study, specific mechanism or molecular identifiers of the intervention, target sample size, primary outcome, and key secondary outcomes.

The WHO Registry Platform is expected to launch a Web-based search portal later this year. This search portal would allow interested individuals to search among participating registries for clinical trials taking place or completed throughout the world.

College freshman living in dorms and adolescents entering high school are moving to the head of the line to receive Menactra, following the manufacturer's announcement that it won't be able to meet demand for the meningococcal vaccine at least through this summer.

The Centers for Disease Control and Prevention announced in May that Sanofi Pasteur Inc., maker of the tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4), expects demand for the vaccine to exceed supply (MMWR May 19, 2006/55[Dispatch];1).

The CDC recommends continuing to vaccinate adolescents entering high school and college freshman living in dorms. The company anticipates that enough MCV4 will be available for these two groups. Vaccination of children aged 11–12 years should be deferred until further notice.

Other high-risk groups that should be vaccinated include military recruits, travelers to areas where meningococcal disease is hyperendemic or epidemic, microbiologists who are routinely exposed to isolates of Neisseria meningitidis, and people with anatomic or functional asplenia or terminal complement deficiency.

For vaccine supply updates, visit www.cdc.gov/nip/news/shortages/default.htmwww.vaccineshoppe.com

College freshman living in dorms and adolescents entering high school are moving to the head of the line to receive Menactra, following the manufacturer's announcement that it won't be able to meet demand for the meningococcal vaccine at least through this summer.

The Centers for Disease Control and Prevention announced in May that Sanofi Pasteur Inc., maker of the tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4), expects demand for the vaccine to exceed supply (MMWR May 19, 2006/55[Dispatch];1).

The CDC recommends continuing to vaccinate adolescents entering high school and college freshman living in dorms. The company anticipates that enough MCV4 will be available for these two groups. Vaccination of children aged 11–12 years should be deferred until further notice.

Other high-risk groups that should be vaccinated include military recruits, travelers to areas where meningococcal disease is hyperendemic or epidemic, microbiologists who are routinely exposed to isolates of Neisseria meningitidis, and people with anatomic or functional asplenia or terminal complement deficiency.

For vaccine supply updates, visit www.cdc.gov/nip/news/shortages/default.htmwww.vaccineshoppe.com

College freshman living in dorms and adolescents entering high school are moving to the head of the line to receive Menactra, following the manufacturer's announcement that it won't be able to meet demand for the meningococcal vaccine at least through this summer.

The Centers for Disease Control and Prevention announced in May that Sanofi Pasteur Inc., maker of the tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4), expects demand for the vaccine to exceed supply (MMWR May 19, 2006/55[Dispatch];1).

The CDC recommends continuing to vaccinate adolescents entering high school and college freshman living in dorms. The company anticipates that enough MCV4 will be available for these two groups. Vaccination of children aged 11–12 years should be deferred until further notice.

Other high-risk groups that should be vaccinated include military recruits, travelers to areas where meningococcal disease is hyperendemic or epidemic, microbiologists who are routinely exposed to isolates of Neisseria meningitidis, and people with anatomic or functional asplenia or terminal complement deficiency.

For vaccine supply updates, visit www.cdc.gov/nip/news/shortages/default.htmwww.vaccineshoppe.com

Reported cases of hepatotoxicity associated with bosentan therapy have prompted changes to the pulmonary arterial hypertension drug's prescribing information.

Actelion Pharmaceuticals US Inc., which manufactures bosentan (Tracleer), made the changes to highlight the importance of monthly liver function monitoring for the duration of bosentan treatments and the need to adhere to the new dosage adjustment and monitoring guidelines. The new recommendations include:

▸ For alanine aminotransferase/aspartate aminotransferase (ALT/AST) levels greater than three and up to five times the upper limit of normal, confirm by another aminotransferase test. If confirmed, reduce the daily dose or interrupt treatment and monitor aminotransferase levels at least every 2 weeks. If the aminotransferase levels return to pretreatment values, continue or reintroduce the treatment as appropriate.

▸ For ALT/AST levels greater than five and up to eight times the upper limit of normal, confirm by another aminotransferase test. If confirmed, stop treatment and monitor aminotransferase levels at least every 2 weeks. Once the aminotransferase levels return to pretreatment values, consider reintroduction of the treatment.

▸ For ALT/AST levels greater than eight times the upper limit of normal, treatment should be stopped and reintroduction of the drug should not be considered. There is no experience with reintroduction of the drug in these circumstances.

For more information, contact the company by calling 888-835-5445. Report any serious adverse events that occur with the use of bosentan to the Food and Drug Administration's MedWatch Adverse Event Reporting program by calling 800-332-1088 or online at www.fda.gov/medwatch/report.htm

Reported cases of hepatotoxicity associated with bosentan therapy have prompted changes to the pulmonary arterial hypertension drug's prescribing information.

Actelion Pharmaceuticals US Inc., which manufactures bosentan (Tracleer), made the changes to highlight the importance of monthly liver function monitoring for the duration of bosentan treatments and the need to adhere to the new dosage adjustment and monitoring guidelines. The new recommendations include:

▸ For alanine aminotransferase/aspartate aminotransferase (ALT/AST) levels greater than three and up to five times the upper limit of normal, confirm by another aminotransferase test. If confirmed, reduce the daily dose or interrupt treatment and monitor aminotransferase levels at least every 2 weeks. If the aminotransferase levels return to pretreatment values, continue or reintroduce the treatment as appropriate.

▸ For ALT/AST levels greater than five and up to eight times the upper limit of normal, confirm by another aminotransferase test. If confirmed, stop treatment and monitor aminotransferase levels at least every 2 weeks. Once the aminotransferase levels return to pretreatment values, consider reintroduction of the treatment.

▸ For ALT/AST levels greater than eight times the upper limit of normal, treatment should be stopped and reintroduction of the drug should not be considered. There is no experience with reintroduction of the drug in these circumstances.

For more information, contact the company by calling 888-835-5445. Report any serious adverse events that occur with the use of bosentan to the Food and Drug Administration's MedWatch Adverse Event Reporting program by calling 800-332-1088 or online at www.fda.gov/medwatch/report.htm

Reported cases of hepatotoxicity associated with bosentan therapy have prompted changes to the pulmonary arterial hypertension drug's prescribing information.

Actelion Pharmaceuticals US Inc., which manufactures bosentan (Tracleer), made the changes to highlight the importance of monthly liver function monitoring for the duration of bosentan treatments and the need to adhere to the new dosage adjustment and monitoring guidelines. The new recommendations include:

▸ For alanine aminotransferase/aspartate aminotransferase (ALT/AST) levels greater than three and up to five times the upper limit of normal, confirm by another aminotransferase test. If confirmed, reduce the daily dose or interrupt treatment and monitor aminotransferase levels at least every 2 weeks. If the aminotransferase levels return to pretreatment values, continue or reintroduce the treatment as appropriate.

▸ For ALT/AST levels greater than five and up to eight times the upper limit of normal, confirm by another aminotransferase test. If confirmed, stop treatment and monitor aminotransferase levels at least every 2 weeks. Once the aminotransferase levels return to pretreatment values, consider reintroduction of the treatment.

▸ For ALT/AST levels greater than eight times the upper limit of normal, treatment should be stopped and reintroduction of the drug should not be considered. There is no experience with reintroduction of the drug in these circumstances.

For more information, contact the company by calling 888-835-5445. Report any serious adverse events that occur with the use of bosentan to the Food and Drug Administration's MedWatch Adverse Event Reporting program by calling 800-332-1088 or online at www.fda.gov/medwatch/report.htm

Magnetization transfer imaging (MTI) assays macromolecular protons through their intimate connection and interaction with surrounding tissue water.

“Anywhere it's applied, MTI is very sensitive to macromolecular makeup of the tissue,” said Seth Smith, Ph.D., a postdoctoral fellow at the F.M. Kirby Imaging Center at Johns Hopkins University in Baltimore. In the case of patients with multiple sclerosis (MS), this means myelin. “MTI is a much more sensitive myelin marker than any other conventional imaging technique,” he said.

Conventional MRI targets only water, making it hard to assess the macromolecular subunits of CNS tissue, like myelin. With MTI, an initial off-resonance radiofrequency pulse is applied to the spinal column. This pulse selectively saturates the magnetization of protons attached to such macromolecules as myelin. Some of this magnetization is transferred to free protons in tissue, which reduces the intensity of the observed water signal. Since MT's effect depends on the density of macromolecules in the tissue, “it's a backdoor method for getting at the macromolecular structure,” said Dr. Smith.

The researchers then calculate a slightly modified magnetization transfer ratio, based on the difference in the signal intensity with and without an MT prepulse, to quantify differences between patients with MS and healthy controls.

In the past, it was difficult to ascertain whether or not spinal cord lesions were a significant factor in MS. Conventional MR imaging did not reveal the amount of tissue damage that was actually present in the spinal cord, though inflammation can be seen. MTI reveals much more MS pathology. It is now hypothesized that a lot of the clinical deficit in MS arises from spinal cord damage. “When we use MT imaging, what we find is that every cord [from patients with MS] is damaged in some way,” said Dr. Smith.

The presence of MS spinal lesions on MTI correlates better with the patient's symptoms at presentation than does the presence of brain lesions detected by MRI. A patient with MS brain lesions may be walking at presentation. However, “if I look at the spinal cord and see a bunch of lesions, I can guarantee that the patient is not walking well,” said Dr. Smith.

The researchers have imaged patients of varying ages and at a spectrum of stages in MS: relapsing-remitting, secondary progressive, etc. Since it is difficult to get a patient before he or she has had an attack, information from such studies about the early stages of the disease may prove useful, said Dr. Smith. The researchers also are imaging MS patients periodically (3, 6, 12, and 24 months) to see if they can detect changes in the disease over time.

The researchers are seeking links between MS-induced changes on spinal MTI and brain MTI and the neurologic presentation of patients with MS. The correlation between spinal MTI and the neurologic presentation has been striking.

“We and others find in the brain there is little correlation with clinical presentation. However, the second we look at the spine, everything starts to correlate,” said Dr. Smith. The spine is the main pipeline for nerves in the body, so “if you get a small lesion in something the size of a quarter, the effects could be massive.”

MRI is used to confirm the clinical findings in patients suspected of MS. “We're hoping to make MTI more of a diagnostic tool,” Dr. Smith said. A strong enough correlation between MTI spinal imaging findings and the neurologic presentation could lead to the primary use of MRI to diagnose MS and predict outcome.

MTI also has implications for therapy. Right now, patients with MS often are treated with axonal protection agents, but the effects may take a long time to be seen. “What we hope to see is, can we within a shorter amount of time see that there is any sort of change in the tissue due to therapeutic intervention,” said Dr. Smith.

MTI scans can be done with most higher field MRI scanners using a surface/spine coil and each scan takes only 7 minutes using a 3T magnet. This implies that the technique could easily be integrated into an imaging center or hospital radiology department.

Dr. Smith's collaborators include Dr. Peter Calabresi; Peter van Zijl, Ph.D.; Craig Jones, Ph.D.; Eliza Gordon-Lipkin; and Kathleen Zackowski, Ph.D.

Healthy spine by T2 and T1 3T MRI and MTCSF (top): While T2 and T1 MRI show slight cord atrophy in an MS patient, MTCSF shows hyperintensities in the lateral (green arrow) and dorsal (yellow arrow) column (bottom). Images courtesy Dr. Seth Smith

Magnetization transfer imaging (MTI) assays macromolecular protons through their intimate connection and interaction with surrounding tissue water.

“Anywhere it's applied, MTI is very sensitive to macromolecular makeup of the tissue,” said Seth Smith, Ph.D., a postdoctoral fellow at the F.M. Kirby Imaging Center at Johns Hopkins University in Baltimore. In the case of patients with multiple sclerosis (MS), this means myelin. “MTI is a much more sensitive myelin marker than any other conventional imaging technique,” he said.

Conventional MRI targets only water, making it hard to assess the macromolecular subunits of CNS tissue, like myelin. With MTI, an initial off-resonance radiofrequency pulse is applied to the spinal column. This pulse selectively saturates the magnetization of protons attached to such macromolecules as myelin. Some of this magnetization is transferred to free protons in tissue, which reduces the intensity of the observed water signal. Since MT's effect depends on the density of macromolecules in the tissue, “it's a backdoor method for getting at the macromolecular structure,” said Dr. Smith.

The researchers then calculate a slightly modified magnetization transfer ratio, based on the difference in the signal intensity with and without an MT prepulse, to quantify differences between patients with MS and healthy controls.

In the past, it was difficult to ascertain whether or not spinal cord lesions were a significant factor in MS. Conventional MR imaging did not reveal the amount of tissue damage that was actually present in the spinal cord, though inflammation can be seen. MTI reveals much more MS pathology. It is now hypothesized that a lot of the clinical deficit in MS arises from spinal cord damage. “When we use MT imaging, what we find is that every cord [from patients with MS] is damaged in some way,” said Dr. Smith.

The presence of MS spinal lesions on MTI correlates better with the patient's symptoms at presentation than does the presence of brain lesions detected by MRI. A patient with MS brain lesions may be walking at presentation. However, “if I look at the spinal cord and see a bunch of lesions, I can guarantee that the patient is not walking well,” said Dr. Smith.

The researchers have imaged patients of varying ages and at a spectrum of stages in MS: relapsing-remitting, secondary progressive, etc. Since it is difficult to get a patient before he or she has had an attack, information from such studies about the early stages of the disease may prove useful, said Dr. Smith. The researchers also are imaging MS patients periodically (3, 6, 12, and 24 months) to see if they can detect changes in the disease over time.

The researchers are seeking links between MS-induced changes on spinal MTI and brain MTI and the neurologic presentation of patients with MS. The correlation between spinal MTI and the neurologic presentation has been striking.

“We and others find in the brain there is little correlation with clinical presentation. However, the second we look at the spine, everything starts to correlate,” said Dr. Smith. The spine is the main pipeline for nerves in the body, so “if you get a small lesion in something the size of a quarter, the effects could be massive.”

MRI is used to confirm the clinical findings in patients suspected of MS. “We're hoping to make MTI more of a diagnostic tool,” Dr. Smith said. A strong enough correlation between MTI spinal imaging findings and the neurologic presentation could lead to the primary use of MRI to diagnose MS and predict outcome.

MTI also has implications for therapy. Right now, patients with MS often are treated with axonal protection agents, but the effects may take a long time to be seen. “What we hope to see is, can we within a shorter amount of time see that there is any sort of change in the tissue due to therapeutic intervention,” said Dr. Smith.

MTI scans can be done with most higher field MRI scanners using a surface/spine coil and each scan takes only 7 minutes using a 3T magnet. This implies that the technique could easily be integrated into an imaging center or hospital radiology department.

Dr. Smith's collaborators include Dr. Peter Calabresi; Peter van Zijl, Ph.D.; Craig Jones, Ph.D.; Eliza Gordon-Lipkin; and Kathleen Zackowski, Ph.D.

Healthy spine by T2 and T1 3T MRI and MTCSF (top): While T2 and T1 MRI show slight cord atrophy in an MS patient, MTCSF shows hyperintensities in the lateral (green arrow) and dorsal (yellow arrow) column (bottom). Images courtesy Dr. Seth Smith

Magnetization transfer imaging (MTI) assays macromolecular protons through their intimate connection and interaction with surrounding tissue water.

“Anywhere it's applied, MTI is very sensitive to macromolecular makeup of the tissue,” said Seth Smith, Ph.D., a postdoctoral fellow at the F.M. Kirby Imaging Center at Johns Hopkins University in Baltimore. In the case of patients with multiple sclerosis (MS), this means myelin. “MTI is a much more sensitive myelin marker than any other conventional imaging technique,” he said.

Conventional MRI targets only water, making it hard to assess the macromolecular subunits of CNS tissue, like myelin. With MTI, an initial off-resonance radiofrequency pulse is applied to the spinal column. This pulse selectively saturates the magnetization of protons attached to such macromolecules as myelin. Some of this magnetization is transferred to free protons in tissue, which reduces the intensity of the observed water signal. Since MT's effect depends on the density of macromolecules in the tissue, “it's a backdoor method for getting at the macromolecular structure,” said Dr. Smith.

The researchers then calculate a slightly modified magnetization transfer ratio, based on the difference in the signal intensity with and without an MT prepulse, to quantify differences between patients with MS and healthy controls.

In the past, it was difficult to ascertain whether or not spinal cord lesions were a significant factor in MS. Conventional MR imaging did not reveal the amount of tissue damage that was actually present in the spinal cord, though inflammation can be seen. MTI reveals much more MS pathology. It is now hypothesized that a lot of the clinical deficit in MS arises from spinal cord damage. “When we use MT imaging, what we find is that every cord [from patients with MS] is damaged in some way,” said Dr. Smith.

The presence of MS spinal lesions on MTI correlates better with the patient's symptoms at presentation than does the presence of brain lesions detected by MRI. A patient with MS brain lesions may be walking at presentation. However, “if I look at the spinal cord and see a bunch of lesions, I can guarantee that the patient is not walking well,” said Dr. Smith.

The researchers have imaged patients of varying ages and at a spectrum of stages in MS: relapsing-remitting, secondary progressive, etc. Since it is difficult to get a patient before he or she has had an attack, information from such studies about the early stages of the disease may prove useful, said Dr. Smith. The researchers also are imaging MS patients periodically (3, 6, 12, and 24 months) to see if they can detect changes in the disease over time.

The researchers are seeking links between MS-induced changes on spinal MTI and brain MTI and the neurologic presentation of patients with MS. The correlation between spinal MTI and the neurologic presentation has been striking.

“We and others find in the brain there is little correlation with clinical presentation. However, the second we look at the spine, everything starts to correlate,” said Dr. Smith. The spine is the main pipeline for nerves in the body, so “if you get a small lesion in something the size of a quarter, the effects could be massive.”

MRI is used to confirm the clinical findings in patients suspected of MS. “We're hoping to make MTI more of a diagnostic tool,” Dr. Smith said. A strong enough correlation between MTI spinal imaging findings and the neurologic presentation could lead to the primary use of MRI to diagnose MS and predict outcome.

MTI also has implications for therapy. Right now, patients with MS often are treated with axonal protection agents, but the effects may take a long time to be seen. “What we hope to see is, can we within a shorter amount of time see that there is any sort of change in the tissue due to therapeutic intervention,” said Dr. Smith.

MTI scans can be done with most higher field MRI scanners using a surface/spine coil and each scan takes only 7 minutes using a 3T magnet. This implies that the technique could easily be integrated into an imaging center or hospital radiology department.

Dr. Smith's collaborators include Dr. Peter Calabresi; Peter van Zijl, Ph.D.; Craig Jones, Ph.D.; Eliza Gordon-Lipkin; and Kathleen Zackowski, Ph.D.

Healthy spine by T2 and T1 3T MRI and MTCSF (top): While T2 and T1 MRI show slight cord atrophy in an MS patient, MTCSF shows hyperintensities in the lateral (green arrow) and dorsal (yellow arrow) column (bottom). Images courtesy Dr. Seth Smith

WASHINGTON — There are some new billing codes available this year to think about incorporating into your practice, Dr. Joel F. Bradley Jr. said at a meeting sponsored by the American Academy of Pediatrics.

Dr. Bradley of Vanderbilt University in Nashville, Tenn., and a member of the American Medical Association's CPT Editorial Panel, offered a few thoughts on these cutting-edge codes:

▸ Pay-for-performance. Pay-for-performance may be closer than you think. Although it is presently voluntary for physicians participating in Medicare, “most physicians now will be using CPT codes initially to participate in pay-for-performance programs,” said Dr. Bradley.

To this end, CPT has created a category of codes (category II codes) that are a set of supplemental tracking codes, which can be used for performance measurement. “The American Academy of Pediatrics is participating in the process by which these codes come to fruition in CPT,” said Dr. Bradley.

“What's the Medicare plan—which private payers are likely to follow?” he asked. “In 2006, physicians now enroll in a voluntary pay-for-reporting program … in 2007 or 2008, they'll be paid for reporting quality measures, and then beyond 2008, they should be paid for performance.”

▸ Moderate sedation. “Most of you who work in children's hospitals know that physicians there have not been paid often for doing procedural sedation unless you're an anesthesiologist,” said Dr. Bradley. Physicians who are hospitalists or who specialize in emergency or critical care are doing a lot of sedation as part of sedation teams. “To support that service, new codes were created this year for moderate sedation that allow physicians who are either providing sedation for their own procedure or supporting another physician to get paid,” said Dr. Bradley. These codes are 99143–99145 and 99148–99150.

▸ Special services. “These are a little bit different in that they're not Evaluation and Management] codes but codes that are added on with existing E/M codes when you provide those E/M services under special circumstances,” said Dr. Bradley.

The most commonly used of these codes are 99050, 99051, and 99058.

Code 99050 is used for services provided in the office at times other than regularly scheduled office hours.

Code 99051 “allows you to bill separately on top of an E/M code for services provided during regularly scheduled evening, holiday, and weekend office hours,” said Dr. Bradley.

Code 99058 is an add-on charge for services provided on an emergency basis in the office that disrupt other scheduled office services.

▸ Obesity interventions. Also this year, there are new ICD-9 codes for obesity interventions. “These are V codes that are pediatric codes for [body mass index] percentiles by age,” said Dr. Bradley. “So that at least now, you'll be able to stratify a population in your practice by BMI.” These V codes provide a way of tracking patients through a medical record system. If payers begin to cover obesity interventions based on levels of BMI, “you've got a way to prove to your payers the medical necessity of providing an intervention.”

WASHINGTON — There are some new billing codes available this year to think about incorporating into your practice, Dr. Joel F. Bradley Jr. said at a meeting sponsored by the American Academy of Pediatrics.

Dr. Bradley of Vanderbilt University in Nashville, Tenn., and a member of the American Medical Association's CPT Editorial Panel, offered a few thoughts on these cutting-edge codes:

▸ Pay-for-performance. Pay-for-performance may be closer than you think. Although it is presently voluntary for physicians participating in Medicare, “most physicians now will be using CPT codes initially to participate in pay-for-performance programs,” said Dr. Bradley.

To this end, CPT has created a category of codes (category II codes) that are a set of supplemental tracking codes, which can be used for performance measurement. “The American Academy of Pediatrics is participating in the process by which these codes come to fruition in CPT,” said Dr. Bradley.

“What's the Medicare plan—which private payers are likely to follow?” he asked. “In 2006, physicians now enroll in a voluntary pay-for-reporting program … in 2007 or 2008, they'll be paid for reporting quality measures, and then beyond 2008, they should be paid for performance.”

▸ Moderate sedation. “Most of you who work in children's hospitals know that physicians there have not been paid often for doing procedural sedation unless you're an anesthesiologist,” said Dr. Bradley. Physicians who are hospitalists or who specialize in emergency or critical care are doing a lot of sedation as part of sedation teams. “To support that service, new codes were created this year for moderate sedation that allow physicians who are either providing sedation for their own procedure or supporting another physician to get paid,” said Dr. Bradley. These codes are 99143–99145 and 99148–99150.

▸ Special services. “These are a little bit different in that they're not Evaluation and Management] codes but codes that are added on with existing E/M codes when you provide those E/M services under special circumstances,” said Dr. Bradley.

The most commonly used of these codes are 99050, 99051, and 99058.

Code 99050 is used for services provided in the office at times other than regularly scheduled office hours.

Code 99051 “allows you to bill separately on top of an E/M code for services provided during regularly scheduled evening, holiday, and weekend office hours,” said Dr. Bradley.

Code 99058 is an add-on charge for services provided on an emergency basis in the office that disrupt other scheduled office services.

▸ Obesity interventions. Also this year, there are new ICD-9 codes for obesity interventions. “These are V codes that are pediatric codes for [body mass index] percentiles by age,” said Dr. Bradley. “So that at least now, you'll be able to stratify a population in your practice by BMI.” These V codes provide a way of tracking patients through a medical record system. If payers begin to cover obesity interventions based on levels of BMI, “you've got a way to prove to your payers the medical necessity of providing an intervention.”

WASHINGTON — There are some new billing codes available this year to think about incorporating into your practice, Dr. Joel F. Bradley Jr. said at a meeting sponsored by the American Academy of Pediatrics.

Dr. Bradley of Vanderbilt University in Nashville, Tenn., and a member of the American Medical Association's CPT Editorial Panel, offered a few thoughts on these cutting-edge codes:

▸ Pay-for-performance. Pay-for-performance may be closer than you think. Although it is presently voluntary for physicians participating in Medicare, “most physicians now will be using CPT codes initially to participate in pay-for-performance programs,” said Dr. Bradley.

To this end, CPT has created a category of codes (category II codes) that are a set of supplemental tracking codes, which can be used for performance measurement. “The American Academy of Pediatrics is participating in the process by which these codes come to fruition in CPT,” said Dr. Bradley.

“What's the Medicare plan—which private payers are likely to follow?” he asked. “In 2006, physicians now enroll in a voluntary pay-for-reporting program … in 2007 or 2008, they'll be paid for reporting quality measures, and then beyond 2008, they should be paid for performance.”

▸ Moderate sedation. “Most of you who work in children's hospitals know that physicians there have not been paid often for doing procedural sedation unless you're an anesthesiologist,” said Dr. Bradley. Physicians who are hospitalists or who specialize in emergency or critical care are doing a lot of sedation as part of sedation teams. “To support that service, new codes were created this year for moderate sedation that allow physicians who are either providing sedation for their own procedure or supporting another physician to get paid,” said Dr. Bradley. These codes are 99143–99145 and 99148–99150.

▸ Special services. “These are a little bit different in that they're not Evaluation and Management] codes but codes that are added on with existing E/M codes when you provide those E/M services under special circumstances,” said Dr. Bradley.

The most commonly used of these codes are 99050, 99051, and 99058.

Code 99050 is used for services provided in the office at times other than regularly scheduled office hours.

Code 99051 “allows you to bill separately on top of an E/M code for services provided during regularly scheduled evening, holiday, and weekend office hours,” said Dr. Bradley.

Code 99058 is an add-on charge for services provided on an emergency basis in the office that disrupt other scheduled office services.

▸ Obesity interventions. Also this year, there are new ICD-9 codes for obesity interventions. “These are V codes that are pediatric codes for [body mass index] percentiles by age,” said Dr. Bradley. “So that at least now, you'll be able to stratify a population in your practice by BMI.” These V codes provide a way of tracking patients through a medical record system. If payers begin to cover obesity interventions based on levels of BMI, “you've got a way to prove to your payers the medical necessity of providing an intervention.”

SAN JUAN, P.R. — Atypical antipsychotics appear to have a modest effect on behavioral symptoms in elderly patients with dementia, but the effectiveness of nonpharmacologic treatments is less clear, according to a metaanalysis presented at the annual meeting of the American Association for Geriatric Psychiatry.

Dr. Mark B. Snowden of the department of psychiatry and behavioral sciences at the University of Washington in Seattle and his colleagues used metaanalysis techniques to compare the efficacy of nonpharmacologic treatments with that of pharmacologic therapies.

Articles from peer-reviewed, English language publications, including textbooks, from 1970 on were considered for the analysis. Nursing home residents had to make up at least half of the populations being studied. In addition to literature searches in several medical and nursing databases, the researchers submitted articles that they were aware of but that had not previously been identified. Articles were included only if they documented randomized, controlled trials.

The researchers identified five randomized, controlled trials of antipsychotic drugs and three randomized, controlled trials for nonpharmacologic interventions. The drug trials included four atypical drugs and one traditional antipsychotic drug.

The nonpharmacologic trials included 8 hours of nurses' aide training to communicate more effectively with patients with dementia, 8 hours of education/training with weekly follow-ups and hands-on activities of daily living care, 3 hours per day of psychosocial activities, and combined nonpharmacologic approaches.

The calculated effect size for nonpharmacologic interventions was − .088, which was not statistically significant. In comparison, the calculated effect size for pharmacologic interventions was − .23, which “would be considered small to modest at best,” Dr. Snowden said. “In this instance, the finding was consistent enough across studies that it is statistically significant.”

Only the pharmacologic studies provided data on the number of patients whose condition did or did not improve. giving a statistically significant mean odds ratio of 1.87; thus, patients had an 87% chance of improving with drug treatment.

The researchers also calculated the benefit-to-harm ratio for antipsychotic treatment. “For every 14 people who got a drug and improved, you would expect one excess death,” Dr. Snowden said. While Dr. Snowden pointed out that one excess death is not a trivial number, “when presented with this data, I have yet to have a nursing home family say that they don't want an antipsychotic drug given to their relative.”

In 2003, the American Geriatrics Society and the American Association for Geriatric Psychiatry released a consensus statement on the management of behavioral symptoms associated with dementia. In the statement, the two groups recommended the use of nonpharmacologic interventions as the initial treatment, as long as patients did not display psychotic symptoms and there was no immediate danger to the resident or to others. The statement iterated that antipsychotic drugs should only be considered for first-line treatment in cases with severe behavioral symptoms with psychotic features. Since then, the Food and Drug Administration has issued a public health advisory about increased mortality associated with off-label use of atypical antipsychotics in elderly patients.

“Given the modesty of the effect size, I think we probably need to remove the requirement for psychosis or danger. … Danger is a very high standard,” Dr. Snowden said. “If you say you can only use antipsychotics in someone who is dangerous, there are going to be a lot of people who are distressed that you're not going to treat.”

SAN JUAN, P.R. — Atypical antipsychotics appear to have a modest effect on behavioral symptoms in elderly patients with dementia, but the effectiveness of nonpharmacologic treatments is less clear, according to a metaanalysis presented at the annual meeting of the American Association for Geriatric Psychiatry.

Dr. Mark B. Snowden of the department of psychiatry and behavioral sciences at the University of Washington in Seattle and his colleagues used metaanalysis techniques to compare the efficacy of nonpharmacologic treatments with that of pharmacologic therapies.

Articles from peer-reviewed, English language publications, including textbooks, from 1970 on were considered for the analysis. Nursing home residents had to make up at least half of the populations being studied. In addition to literature searches in several medical and nursing databases, the researchers submitted articles that they were aware of but that had not previously been identified. Articles were included only if they documented randomized, controlled trials.

The researchers identified five randomized, controlled trials of antipsychotic drugs and three randomized, controlled trials for nonpharmacologic interventions. The drug trials included four atypical drugs and one traditional antipsychotic drug.

The nonpharmacologic trials included 8 hours of nurses' aide training to communicate more effectively with patients with dementia, 8 hours of education/training with weekly follow-ups and hands-on activities of daily living care, 3 hours per day of psychosocial activities, and combined nonpharmacologic approaches.

The calculated effect size for nonpharmacologic interventions was − .088, which was not statistically significant. In comparison, the calculated effect size for pharmacologic interventions was − .23, which “would be considered small to modest at best,” Dr. Snowden said. “In this instance, the finding was consistent enough across studies that it is statistically significant.”

Only the pharmacologic studies provided data on the number of patients whose condition did or did not improve. giving a statistically significant mean odds ratio of 1.87; thus, patients had an 87% chance of improving with drug treatment.

The researchers also calculated the benefit-to-harm ratio for antipsychotic treatment. “For every 14 people who got a drug and improved, you would expect one excess death,” Dr. Snowden said. While Dr. Snowden pointed out that one excess death is not a trivial number, “when presented with this data, I have yet to have a nursing home family say that they don't want an antipsychotic drug given to their relative.”

In 2003, the American Geriatrics Society and the American Association for Geriatric Psychiatry released a consensus statement on the management of behavioral symptoms associated with dementia. In the statement, the two groups recommended the use of nonpharmacologic interventions as the initial treatment, as long as patients did not display psychotic symptoms and there was no immediate danger to the resident or to others. The statement iterated that antipsychotic drugs should only be considered for first-line treatment in cases with severe behavioral symptoms with psychotic features. Since then, the Food and Drug Administration has issued a public health advisory about increased mortality associated with off-label use of atypical antipsychotics in elderly patients.

“Given the modesty of the effect size, I think we probably need to remove the requirement for psychosis or danger. … Danger is a very high standard,” Dr. Snowden said. “If you say you can only use antipsychotics in someone who is dangerous, there are going to be a lot of people who are distressed that you're not going to treat.”

SAN JUAN, P.R. — Atypical antipsychotics appear to have a modest effect on behavioral symptoms in elderly patients with dementia, but the effectiveness of nonpharmacologic treatments is less clear, according to a metaanalysis presented at the annual meeting of the American Association for Geriatric Psychiatry.

Dr. Mark B. Snowden of the department of psychiatry and behavioral sciences at the University of Washington in Seattle and his colleagues used metaanalysis techniques to compare the efficacy of nonpharmacologic treatments with that of pharmacologic therapies.

Articles from peer-reviewed, English language publications, including textbooks, from 1970 on were considered for the analysis. Nursing home residents had to make up at least half of the populations being studied. In addition to literature searches in several medical and nursing databases, the researchers submitted articles that they were aware of but that had not previously been identified. Articles were included only if they documented randomized, controlled trials.

The researchers identified five randomized, controlled trials of antipsychotic drugs and three randomized, controlled trials for nonpharmacologic interventions. The drug trials included four atypical drugs and one traditional antipsychotic drug.

The nonpharmacologic trials included 8 hours of nurses' aide training to communicate more effectively with patients with dementia, 8 hours of education/training with weekly follow-ups and hands-on activities of daily living care, 3 hours per day of psychosocial activities, and combined nonpharmacologic approaches.

The calculated effect size for nonpharmacologic interventions was − .088, which was not statistically significant. In comparison, the calculated effect size for pharmacologic interventions was − .23, which “would be considered small to modest at best,” Dr. Snowden said. “In this instance, the finding was consistent enough across studies that it is statistically significant.”

Only the pharmacologic studies provided data on the number of patients whose condition did or did not improve. giving a statistically significant mean odds ratio of 1.87; thus, patients had an 87% chance of improving with drug treatment.

The researchers also calculated the benefit-to-harm ratio for antipsychotic treatment. “For every 14 people who got a drug and improved, you would expect one excess death,” Dr. Snowden said. While Dr. Snowden pointed out that one excess death is not a trivial number, “when presented with this data, I have yet to have a nursing home family say that they don't want an antipsychotic drug given to their relative.”

In 2003, the American Geriatrics Society and the American Association for Geriatric Psychiatry released a consensus statement on the management of behavioral symptoms associated with dementia. In the statement, the two groups recommended the use of nonpharmacologic interventions as the initial treatment, as long as patients did not display psychotic symptoms and there was no immediate danger to the resident or to others. The statement iterated that antipsychotic drugs should only be considered for first-line treatment in cases with severe behavioral symptoms with psychotic features. Since then, the Food and Drug Administration has issued a public health advisory about increased mortality associated with off-label use of atypical antipsychotics in elderly patients.

“Given the modesty of the effect size, I think we probably need to remove the requirement for psychosis or danger. … Danger is a very high standard,” Dr. Snowden said. “If you say you can only use antipsychotics in someone who is dangerous, there are going to be a lot of people who are distressed that you're not going to treat.”

TORONTO — A significant portion of primary care patients may have partial posttraumatic stress disorder and appear to have health and physical functioning problems and medical care utilization similar to patients with the full-blown disorder, according to data presented at the annual meeting of the International Society for Traumatic Stress Studies.

A significant portion of trauma victims don't meet DSM-IV diagnostic criteria for PTSD but still experience significantly higher distress than nontraumatized individuals, said Karen Gillock, Ph.D., a professor of psychiatry at Dartmouth College in Lebanon, N.H.

Dr. Gillock and her colleagues surveyed patients between the ages of 18 and 60 years, who presented to one of two primary care clinics associated with a medical center in rural New England, for symptoms of PTSD. A total of 232 patients completed the surveys; the group was 69% female, 95% white, and had a mean age of 42 years. The prevalence of full PTSD in this sample was 9%, a rate similar to those reported in other studies. Strikingly, the prevalence of partial PTSD was 25%, she said at the meeting, cosponsored by Boston University.

Compared with those without PTSD, patients with both full and partial PTSD were more likely to be hospitalized and had more medical visits. Patients in the full PTSD, partial PTSD, and no PTSD groups averaged 3.4, 2.5, and 1.9 medical visits, respectively, in the past 3 months.

The full PTSD group had the highest scores on the Wahler Physical Symptom Inventory, followed by the partial PTSD group, with the no PTSD group having the lowest scores. Those with no PTSD had the highest functioning, followed by those with partial PTSD, and, last, by those with full PTSD.

TORONTO — A significant portion of primary care patients may have partial posttraumatic stress disorder and appear to have health and physical functioning problems and medical care utilization similar to patients with the full-blown disorder, according to data presented at the annual meeting of the International Society for Traumatic Stress Studies.

A significant portion of trauma victims don't meet DSM-IV diagnostic criteria for PTSD but still experience significantly higher distress than nontraumatized individuals, said Karen Gillock, Ph.D., a professor of psychiatry at Dartmouth College in Lebanon, N.H.

Dr. Gillock and her colleagues surveyed patients between the ages of 18 and 60 years, who presented to one of two primary care clinics associated with a medical center in rural New England, for symptoms of PTSD. A total of 232 patients completed the surveys; the group was 69% female, 95% white, and had a mean age of 42 years. The prevalence of full PTSD in this sample was 9%, a rate similar to those reported in other studies. Strikingly, the prevalence of partial PTSD was 25%, she said at the meeting, cosponsored by Boston University.

Compared with those without PTSD, patients with both full and partial PTSD were more likely to be hospitalized and had more medical visits. Patients in the full PTSD, partial PTSD, and no PTSD groups averaged 3.4, 2.5, and 1.9 medical visits, respectively, in the past 3 months.

The full PTSD group had the highest scores on the Wahler Physical Symptom Inventory, followed by the partial PTSD group, with the no PTSD group having the lowest scores. Those with no PTSD had the highest functioning, followed by those with partial PTSD, and, last, by those with full PTSD.

TORONTO — A significant portion of primary care patients may have partial posttraumatic stress disorder and appear to have health and physical functioning problems and medical care utilization similar to patients with the full-blown disorder, according to data presented at the annual meeting of the International Society for Traumatic Stress Studies.

A significant portion of trauma victims don't meet DSM-IV diagnostic criteria for PTSD but still experience significantly higher distress than nontraumatized individuals, said Karen Gillock, Ph.D., a professor of psychiatry at Dartmouth College in Lebanon, N.H.

Dr. Gillock and her colleagues surveyed patients between the ages of 18 and 60 years, who presented to one of two primary care clinics associated with a medical center in rural New England, for symptoms of PTSD. A total of 232 patients completed the surveys; the group was 69% female, 95% white, and had a mean age of 42 years. The prevalence of full PTSD in this sample was 9%, a rate similar to those reported in other studies. Strikingly, the prevalence of partial PTSD was 25%, she said at the meeting, cosponsored by Boston University.

Compared with those without PTSD, patients with both full and partial PTSD were more likely to be hospitalized and had more medical visits. Patients in the full PTSD, partial PTSD, and no PTSD groups averaged 3.4, 2.5, and 1.9 medical visits, respectively, in the past 3 months.

The full PTSD group had the highest scores on the Wahler Physical Symptom Inventory, followed by the partial PTSD group, with the no PTSD group having the lowest scores. Those with no PTSD had the highest functioning, followed by those with partial PTSD, and, last, by those with full PTSD.

PORTO, PORTUGAL – Stroke was associated with a nearly 20-fold increase in risk for vascular dementia in a univariate, retrospective, case-control analysis presented at the Fourth International Congress on Vascular Dementia.

Among 205 people with vascular dementia and their control cases, those with a history of stroke were 19 times more likely to develop vascular dementia in the univariate analysis, said Dr. Casey R. Caldwell, an internal medicine physician at the Mayo Clinic, Rochester, Minn. The association of dementia with stroke was stronger in men, who had an odds ratio of 28, than in women, who had an odds ratio of 16.

For the analysis, all Mayo Clinic health records from residents of Olmsted County, Minnesota, during the period 1994–2002 were screened for any of 40 diagnoses suggestive of dementia. This screening identified 1,736 potential subjects, among whom 205 cases of vascular dementia were identified using criteria from the National Institute of Neurological Disorders and Stroke and from the Association Internationale pour la Recherché et l'Enseignement en Neurosciences (NINDS-AIREN).

The subjects were age- and gender-matched with community controls. Individuals were excluded as possible community control subjects if they had been diagnosed with dementia of any kind. Medical records were retrospectively evaluated for the pair from the date of vascular dementia diagnosis. The researchers assessed participant demographics and each subject's history of smoking, alcohol abuse, obesity, diabetes, stroke or transient ischemic attack, hypertension, coronary artery disease, heart failure, myocardial infarction, peripheral vascular disease, angina, pulmonary embolism/deep vein thrombosis, and other factors.

The researchers used univariate and multivariate conditional logistic regression to estimate the odds ratio for vascular dementia associated with exposure to specific risk factors and to explore interactions among the different risk factors.

In the univariate analysis, stroke, transient ischemic attack, diabetes, peripheral vascular disease, hypertension, and coronary artery disease were associated with an increased risk of vascular dementia.

In the multivariate analysis, stroke history, atrial fibrillation, and diabetes were associated with an increased risk of vascular dementia. Hypertension approached statistical significance in this model.

PORTO, PORTUGAL – Stroke was associated with a nearly 20-fold increase in risk for vascular dementia in a univariate, retrospective, case-control analysis presented at the Fourth International Congress on Vascular Dementia.

Among 205 people with vascular dementia and their control cases, those with a history of stroke were 19 times more likely to develop vascular dementia in the univariate analysis, said Dr. Casey R. Caldwell, an internal medicine physician at the Mayo Clinic, Rochester, Minn. The association of dementia with stroke was stronger in men, who had an odds ratio of 28, than in women, who had an odds ratio of 16.

For the analysis, all Mayo Clinic health records from residents of Olmsted County, Minnesota, during the period 1994–2002 were screened for any of 40 diagnoses suggestive of dementia. This screening identified 1,736 potential subjects, among whom 205 cases of vascular dementia were identified using criteria from the National Institute of Neurological Disorders and Stroke and from the Association Internationale pour la Recherché et l'Enseignement en Neurosciences (NINDS-AIREN).

The subjects were age- and gender-matched with community controls. Individuals were excluded as possible community control subjects if they had been diagnosed with dementia of any kind. Medical records were retrospectively evaluated for the pair from the date of vascular dementia diagnosis. The researchers assessed participant demographics and each subject's history of smoking, alcohol abuse, obesity, diabetes, stroke or transient ischemic attack, hypertension, coronary artery disease, heart failure, myocardial infarction, peripheral vascular disease, angina, pulmonary embolism/deep vein thrombosis, and other factors.

The researchers used univariate and multivariate conditional logistic regression to estimate the odds ratio for vascular dementia associated with exposure to specific risk factors and to explore interactions among the different risk factors.

In the univariate analysis, stroke, transient ischemic attack, diabetes, peripheral vascular disease, hypertension, and coronary artery disease were associated with an increased risk of vascular dementia.

In the multivariate analysis, stroke history, atrial fibrillation, and diabetes were associated with an increased risk of vascular dementia. Hypertension approached statistical significance in this model.

PORTO, PORTUGAL – Stroke was associated with a nearly 20-fold increase in risk for vascular dementia in a univariate, retrospective, case-control analysis presented at the Fourth International Congress on Vascular Dementia.

Among 205 people with vascular dementia and their control cases, those with a history of stroke were 19 times more likely to develop vascular dementia in the univariate analysis, said Dr. Casey R. Caldwell, an internal medicine physician at the Mayo Clinic, Rochester, Minn. The association of dementia with stroke was stronger in men, who had an odds ratio of 28, than in women, who had an odds ratio of 16.

For the analysis, all Mayo Clinic health records from residents of Olmsted County, Minnesota, during the period 1994–2002 were screened for any of 40 diagnoses suggestive of dementia. This screening identified 1,736 potential subjects, among whom 205 cases of vascular dementia were identified using criteria from the National Institute of Neurological Disorders and Stroke and from the Association Internationale pour la Recherché et l'Enseignement en Neurosciences (NINDS-AIREN).

The subjects were age- and gender-matched with community controls. Individuals were excluded as possible community control subjects if they had been diagnosed with dementia of any kind. Medical records were retrospectively evaluated for the pair from the date of vascular dementia diagnosis. The researchers assessed participant demographics and each subject's history of smoking, alcohol abuse, obesity, diabetes, stroke or transient ischemic attack, hypertension, coronary artery disease, heart failure, myocardial infarction, peripheral vascular disease, angina, pulmonary embolism/deep vein thrombosis, and other factors.

The researchers used univariate and multivariate conditional logistic regression to estimate the odds ratio for vascular dementia associated with exposure to specific risk factors and to explore interactions among the different risk factors.

In the univariate analysis, stroke, transient ischemic attack, diabetes, peripheral vascular disease, hypertension, and coronary artery disease were associated with an increased risk of vascular dementia.

In the multivariate analysis, stroke history, atrial fibrillation, and diabetes were associated with an increased risk of vascular dementia. Hypertension approached statistical significance in this model.

SAN JUAN, P.R. – Seizures in older adults have a different presentation than they do in younger patients, with these events resembling many other conditions and making diagnosis difficult, but there are a few keys that can help make the right diagnosis, said one expert speaking at the annual meeting of the American Association for Geriatric Psychiatry.

Seizures in older adults often are a byproduct of stroke and/or hemorrhage, said Dr. Joseph I. Sirven, of the department of neurology at the Mayo Clinic in Phoenix, who spoke from anecdotal experience. In addition, neurodegenerative conditions, such as dementia, also cause problems that lead to seizures.

In general, partial seizures are most commonly seen in older adults because there is a specific area of injury or damage involved, said Dr. Sirven. In older adults, the foci of seizures usually occur in the frontal or parietal lobes.

“We also know that simple partial seizures, in which there is not a loss of consciousness, tend to have more focal and/or sensory symptoms [such as] tremor or a sense of numbness,” said Dr. Sirven. Auras–primarily dizziness–may also be present. Complex partial seizures often present with altered mental activity, staring, blackouts, and confusion.

Diagnosing seizures in older adults is difficult because the presentation can resemble so many other conditions. “The differential mirrors almost everything else,” said Dr. Sirven, including syncope, transient ischemic attack, transient global amnesia, vertigo, and delirium.

The key to seizure recognition is episodic frequency of symptoms that are stereotypic. In particular, episodes may present with loss of consciousness, dizziness, confusion, or language change. “If you see transient episodes of certain behaviors that are stereotypic, the first test really is the EEG,” said Dr. Sirven. Other diagnostic tests to consider include MRI, laboratory tests, cardiovascular testing, ambulatory EKG, and tilt table testing.

Seizure medication should be considered only if the seizures are truly impacting the patient's quality of life. “Why I'm making a big deal about it is that the moment you start someone on seizure medication … you've branded that person and no one down the road is going to stop that medication,” said Dr. Sirven.

Dr. Sirven listed the following three main points to consider when deciding on a seizure medication for an elderly patient:

▸ Efficacy. Try to use monotherapy whenever possible. Choose a medication that is appropriate for the seizure type. If the seizure type is unspecified, choose a broad-spectrum agent.

▸ Safety and tolerability. First minimize drug interactions. In addition, choose a drug with a favorable safety profile that minimizes the inhibition of cognitive function and has a minimal effect on gait, balance, and orthostatic blood pressure.

▸ Simplification. Once-daily dosing helps with patient compliance. Choose a drug with a quick onset of action. Reduce interacting drugs, especially psychoactive ones.

SAN JUAN, P.R. – Seizures in older adults have a different presentation than they do in younger patients, with these events resembling many other conditions and making diagnosis difficult, but there are a few keys that can help make the right diagnosis, said one expert speaking at the annual meeting of the American Association for Geriatric Psychiatry.

Seizures in older adults often are a byproduct of stroke and/or hemorrhage, said Dr. Joseph I. Sirven, of the department of neurology at the Mayo Clinic in Phoenix, who spoke from anecdotal experience. In addition, neurodegenerative conditions, such as dementia, also cause problems that lead to seizures.

In general, partial seizures are most commonly seen in older adults because there is a specific area of injury or damage involved, said Dr. Sirven. In older adults, the foci of seizures usually occur in the frontal or parietal lobes.

“We also know that simple partial seizures, in which there is not a loss of consciousness, tend to have more focal and/or sensory symptoms [such as] tremor or a sense of numbness,” said Dr. Sirven. Auras–primarily dizziness–may also be present. Complex partial seizures often present with altered mental activity, staring, blackouts, and confusion.

Diagnosing seizures in older adults is difficult because the presentation can resemble so many other conditions. “The differential mirrors almost everything else,” said Dr. Sirven, including syncope, transient ischemic attack, transient global amnesia, vertigo, and delirium.

The key to seizure recognition is episodic frequency of symptoms that are stereotypic. In particular, episodes may present with loss of consciousness, dizziness, confusion, or language change. “If you see transient episodes of certain behaviors that are stereotypic, the first test really is the EEG,” said Dr. Sirven. Other diagnostic tests to consider include MRI, laboratory tests, cardiovascular testing, ambulatory EKG, and tilt table testing.

Seizure medication should be considered only if the seizures are truly impacting the patient's quality of life. “Why I'm making a big deal about it is that the moment you start someone on seizure medication … you've branded that person and no one down the road is going to stop that medication,” said Dr. Sirven.

Dr. Sirven listed the following three main points to consider when deciding on a seizure medication for an elderly patient:

▸ Efficacy. Try to use monotherapy whenever possible. Choose a medication that is appropriate for the seizure type. If the seizure type is unspecified, choose a broad-spectrum agent.

▸ Safety and tolerability. First minimize drug interactions. In addition, choose a drug with a favorable safety profile that minimizes the inhibition of cognitive function and has a minimal effect on gait, balance, and orthostatic blood pressure.

▸ Simplification. Once-daily dosing helps with patient compliance. Choose a drug with a quick onset of action. Reduce interacting drugs, especially psychoactive ones.

SAN JUAN, P.R. – Seizures in older adults have a different presentation than they do in younger patients, with these events resembling many other conditions and making diagnosis difficult, but there are a few keys that can help make the right diagnosis, said one expert speaking at the annual meeting of the American Association for Geriatric Psychiatry.

Seizures in older adults often are a byproduct of stroke and/or hemorrhage, said Dr. Joseph I. Sirven, of the department of neurology at the Mayo Clinic in Phoenix, who spoke from anecdotal experience. In addition, neurodegenerative conditions, such as dementia, also cause problems that lead to seizures.

In general, partial seizures are most commonly seen in older adults because there is a specific area of injury or damage involved, said Dr. Sirven. In older adults, the foci of seizures usually occur in the frontal or parietal lobes.

“We also know that simple partial seizures, in which there is not a loss of consciousness, tend to have more focal and/or sensory symptoms [such as] tremor or a sense of numbness,” said Dr. Sirven. Auras–primarily dizziness–may also be present. Complex partial seizures often present with altered mental activity, staring, blackouts, and confusion.

Diagnosing seizures in older adults is difficult because the presentation can resemble so many other conditions. “The differential mirrors almost everything else,” said Dr. Sirven, including syncope, transient ischemic attack, transient global amnesia, vertigo, and delirium.

The key to seizure recognition is episodic frequency of symptoms that are stereotypic. In particular, episodes may present with loss of consciousness, dizziness, confusion, or language change. “If you see transient episodes of certain behaviors that are stereotypic, the first test really is the EEG,” said Dr. Sirven. Other diagnostic tests to consider include MRI, laboratory tests, cardiovascular testing, ambulatory EKG, and tilt table testing.

Seizure medication should be considered only if the seizures are truly impacting the patient's quality of life. “Why I'm making a big deal about it is that the moment you start someone on seizure medication … you've branded that person and no one down the road is going to stop that medication,” said Dr. Sirven.

Dr. Sirven listed the following three main points to consider when deciding on a seizure medication for an elderly patient:

▸ Efficacy. Try to use monotherapy whenever possible. Choose a medication that is appropriate for the seizure type. If the seizure type is unspecified, choose a broad-spectrum agent.

▸ Safety and tolerability. First minimize drug interactions. In addition, choose a drug with a favorable safety profile that minimizes the inhibition of cognitive function and has a minimal effect on gait, balance, and orthostatic blood pressure.

▸ Simplification. Once-daily dosing helps with patient compliance. Choose a drug with a quick onset of action. Reduce interacting drugs, especially psychoactive ones.