[Profile of the antimigraine drug almotriptan]

Triptans are the most relevant advance in the symptomatic treatment of migraine in the last decade. In this paper the basic properties as well as the efficacy and tolerability data of the last launched triptan, almotriptan, are reviewed. Almotriptan exhibits the highest bioavailability among triptans, this absorption being unaffected by sex, the presence of food in the stomach or by a migraine attack. At the recommended dose of 12.5 mg, almotriptan shows a rapid onset of effect, at 30 minutes, with efficacy parameters comparable to those of placebo. The potential advantages of almotriptan seem to be three: recurrence rate in the low range, lack of interactions with other drugs and a placebo-like tolerability profile, with a very low rate of chest symptoms. This balanced profile between efficacy and tolerability makes almotriptan 12.5 mg a good option for the symptomatic treatment of migraine.

Epidemiology of chronic daily headache

Daily or near-daily headache is a widespread problem in clinical practice. The general term of chronic daily headache (CDH) encompasses those primary headaches presenting more than 15 days per month and lasting more than 4 hours per day. CDH includes transformed migraine (TM), chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC). Around 40% of patients attending a specialized headache clinic meet CDH diagnostic criteria, of which 80% are women. In these clinics about 60% of patients suffer from TM, 20% from CTTH, and 20% meet NDPH criteria. Most, some 80%, overuse symptomatic medications. One should be very cautious on extrapolating these numbers to the general population. CDH prevalence in the general population seems to be around 4% to 5% (up to 8% to 9% for women). Regarding the prevalence of CDH subtypes, NDPH is rare (0.1%), whereas the prevalence of TM (1.5% to 2%) and CTTH (2.5% to 3%) is clearly higher. In contrast to data from specialized clinics, only around a quarter of CDH subjects in the general population overuse analgesics; the prevalence of CDH subjects with analgesic overuse being 1.1% to 1.9% of the general population. Most of these patients with analgesic overuse are TM patients.

Dose, efficacy and tolerability of long-term indomethacin treatment of chronic paroxysmal hemicrania and hemicrania continua

Indomethacin has consistently been proven to provide complete and sustained relief of symptoms in hemicrania continua (HC) and chronic paroxysmal hemicrania (CPH), but is not devoid of side-effects. The goal of this retrospective study is to assess the dose and side-effects of prolonged indomethacin treatment of HC and CPH. Twenty-six patients with either HC or CPH were followed during an average of 3.8 years after onset of treatment with indomethacin. Relief of symptoms occurred within 3 days of treatment, with 84 +/- 32 mg/day of indomethacin. With time, 42% of patients experienced a decrease of up to 60% in the dose of indomethacin required to maintain a pain-free state. Six (23%) patients showed adverse events, mostly gastrointestinal and relieved with ranitidine. No major side-effects were observed. These results indicate that prolonged indomethacin treatment of HC or CPH has a good safety and tolerability profile with a reduction of up to 60% in the initial dose.

[Renal expression of intercellular adhesion molecule-1 (ICAM-1) in IgA deposit mesangial nephropathy. A tubulointerstitial lesion marker]

BACKGROUND

The aim of this study was to determine the significance of the renal expression of ICAM-1 in IgA nephropathy (IgAN).

PATIENTS AND METHOD

First, we identified ICAM-1 (CD54) expression in tubular epithelial cells and interstitial leucocytes in renal biopsies from 45 patients with IgAN and 29 patients with non-glomerulonephritis nephropathy (non-GN). We then analysed the relationship between this expression and both histological and clinical data at the time of renal biopsy and after 2.4 (2) (X [SD]) years in IgAN, and 1.8 (1.5) years in non-GN.

RESULTS

In IgAN, tubular ICAM-1 positive staining was seen in 25 (55%) biopsies; it was associated with extracapillary proliferation, glomerulosclerosis involving less than 50% of glomerular area, interstitial cell infiltration and tubular atrophy. ICAM-1 positive interstitial leucocytes were 234 (307)/mm2; this expression correlated with glomerulosclerosis, tubular atrophy, interstitial fibrosis and serum creatinine (Cr) level. In patients with 50% increase in Cr level, ICAM-1 positive interstitial leucocytes were 516 (360)/mm2 as compared with 66 (87.8)/mm2 (U = 16; p < 0.005) in patients with stable Cr. In non-GN, tubular ICAM-1 expression was observed in 7 (24%) biopsies.

CONCLUSIONS

Tubular and Interstitial expression of ICAM-1 can be a marker of tubulointerstitial damage in IgAN. Interstitial ICAM-1, rather than tubular ICAM-1, may predict the progression of this disease.

Effect of rizatriptan and other triptans on the nausea symptom of migraine: a post hoc analysis

OBJECTIVE

To compare the effects of oral rizatriptan, sumatriptan, naratriptan, and zolmitriptan on the relief and emergence of nausea during a migraine attack.

METHODS

Data from five randomized, placebo-controlled, double-blind clinical trials in which oral rizatriptan 10 mg was directly compared with oral sumatriptan 100 mg (N = 772), 50 mg (N = 1168), 25 mg (N = 1180), naratriptan 2.5 mg (N = 406), or zolmitriptan 2.5 mg (N = 571) for the acute treatment of a migraine attack were retrospectively analyzed. Migraine was diagnosed according to International Headache Society criteria. Presence or absence of nausea was recorded at baseline and at 0.5, 1, 1.5, and 2 hours after dosing. The end points analyzed were relief of nausea in those who had it at baseline and emergence of nausea in those who were free of it at baseline. Treatments were compared using odds ratios estimated from logistic regression models at 2 hours, and averaged odds ratios for the first 2 hours posttreatment.

RESULTS

Approximately 60% of patients in each treatment group had nausea at baseline. In those patients with nausea at baseline, significantly more patients treated with rizatriptan 10 mg were free of nausea at 2 hours compared with sumatriptan 100 mg (66% versus 58%, P =.043), sumatriptan 50 mg (68% versus 57%, P =.010), sumatriptan 25 mg (68% versus 59%, P =.017), and naratriptan 2.5 mg (59% versus 45%, P =.014). Averaging over the four posttreatment time points in the first 2 hours, significantly more patients treated with rizatriptan 10 mg were free of nausea compared with sumatriptan 100 mg (P =.004), sumatriptan 50 mg (P =.001), and naratriptan 2.5 mg (P =.015). No significant differences in nausea relief were seen between rizatriptan 10 mg and zolmitriptan 2.5 mg, either at 2 hours (65% versus 61%, P =.210) or over the first 2 hours (P =.781). Rates of treatment-emergent nausea at 2 hours ranged from 11% to 18% with placebo, from 5% to 13% with rizatriptan 10 mg, and from 10% to 20% with other comparator triptans.

CONCLUSIONS

Oral rizatriptan 10 mg was more effective than oral sumatriptan and naratriptan at eliminating nausea within 2 hours in patients who had it at baseline. Rates of emergent nausea in patients who were free of it at baseline were low, and no consistent differences were observed between active treatments.

Tolerability and efficacy of almotriptan in the long-term treatment of migraine

BACKGROUND

Almotriptan is a highly specific 5-HT(1B/1D) receptor agonist, which acts selectively on blood vessels of the brain. Short-term studies have demonstrated that almotriptan provides rapid, effective and reliable relief of migraine attacks, while offering excellent tolerability.

PURPOSE

To assess the long-term tolerability and efficacy of oral almotriptan 12.5 mg administered for every migraine attack over a 1-year period.

METHODS

A total of 762 patients treated 13,751 attacks (1-97 per patient); 61.5% of attacks were treated with one 12.5-mg dose, while for 38.5% of attacks, patients took a second dose within 24 h.

RESULTS

Three hundred and ninety-one patients (51.3%) experienced a total of 1,617 adverse events (AEs). The majority (88.6%) of AEs were of mild-to-moderate intensity, and only 28.8% of AEs were considered to be related to the study drug. Only 2 patients experienced serious AEs possibly related to almotriptan, syncope and chest pain; both recovered without any sequelae. Patients reported at least 1 AE in 11% of attacks treated. The incidence of AEs decreased during the study. Only 6 (0.8%) study withdrawals were due to AEs considered to be related to almotriptan. Tolerability was not compromised in patients taking 2 doses of almotriptan or in those using migraine prophylactics. Patient age or sex did not influence the incidence of AEs. There was no evidence of tachyphylaxis in those patients completing the study. Pain relief at 2 h after the initial dose was achieved in 84.2% of moderate/severe attacks. Patients were pain free at 2 h after dose in 58.2% of all attacks. Older patients (> 40 years) tended to respond better than younger ones (< 40 years). Efficacy was not modified by use of migraine prophylactics or hormonal contraceptives. Efficacy measurements were consistent on treating repeated moderate/severe migraine attacks.

CONCLUSION

This large, open study indicates that the new, specific 5-HT(1B/1D) agonist almotriptan, at a dose of 12.5 mg, is a well tolerated and effective treatment for migraine pain when used over a period of up to 1 year.

Comparison of preference for rizatriptan 10-mg wafer versus sumatriptan 50-mg tablet in migraine

Rizatriptan (MAXALT, a registered trademark of Merck & Co. Inc.) is a selective 5-HT(1B/1D) receptor agonist with rapid oral absorption and early onset of action in the acute treatment of migraine. This randomized, open-label, crossover outpatient study assessed the preference of 481 patients for rizatriptan 10-mg rapidly disintegrating tablets versus sumatriptan (IMIGRAN, a registered trademark of GlaxoWellcome PLC) 50-mg tablets in the treatment of a single migraine attack with each therapy. Almost twice as many patients preferred rizatriptan 10-mg rapidly disintegrating tablet to sumatriptan 50-mg tablet (64.3 vs. 35.7%, p < or = 0.001). Faster relief of headache pain was the most important reason for the preference, cited by 46.9% of patients preferring rizatriptan and 43.4% of patients who preferred sumatriptan. Headache relief at 2 h was 75.9% with rizatriptan and 66.6% with sumatriptan (p < or = 0.001), with rizatriptan being superior to sumatriptan within 30 min of dosing. Fifty-five percent of patients were pain free 2 h after rizatriptan, compared with 42.1% treated with sumatriptan (p < or = 0.001), rizatriptan being superior within 1 h of treatment. Forty-one percent of patients taking rizatriptan were pain free at 2 h and had no recurrence or need for additional medication, compared to 32.3% of patients on sumatriptan. Rizatriptan was also superior to sumatriptan in terms of the proportions of patients with no nausea, phonophobia or photophobia, and patients with normal function 2 h after treatment intake (p < 0.05). More patients were (completely, very or somewhat) satisfied 2 h after treatment with rizatriptan (73.3%) than 2 h after treatment with sumatriptan (59.0%) (p < or = 0.001). Additionally, 2 h after the dose, more patients found rizatriptan to be very convenient, convenient or somewhat convenient (87.2%) than they did sumatriptan (76.3%) (p < or = 0.001). Both active treatments were well tolerated. The most common side effects with rizatriptan and sumatriptan were nausea (6.6 and 6.9% of patients, respectively), dizziness (6.1 and 5.8%) and somnolence (7.4 and 6.7%).

Outcome of cadaveric renal transplant patients treated for 10 years with cyclosporine: is chronic allograft nephropathy the major cause of late graft loss?

BACKGROUND

The introduction of cyclosporine (CsA) has improved the short-term outcome of renal transplantation, but its effect on the long-term survival is not well known.

METHODS

We analyzed 128 cadaveric first renal transplant recipients with CsA and prednisone as basal immunosuppression followed for at least 10 years, and we have compared them with a group of 185 historical patients treated with azathioprine (Aza) and prednisone.

RESULTS

The 1-year graft survival was 83% in the CsA-treated patients and 68% in the Aza-treated patients (P<0.025), and the differences were significant for 3 years. Acute rejection accounted for the 10.9% of losses in CsA-treated patients and for 23.8% of losses in Aza-treated patients (P=0.046). Chronic allograft nephropathy was the cause of graft losses in 40.6% and 16.8% of cases (P=0.008). Patient survival at 5 years was 88% in CsA-treated patients and 79% in the Aza-treated patients (P<0.025). When analyzing the data of the 64 CsA-treated patients and the 84 Aza-treated patients with one functioning graft at 10 years, mean serum creatinine values were significantly higher in the CsA-treated patients at all time points but the increases were not significantly different. At 10 years, mean blood pressure was higher (P=0.002), and hypercholesterolemia (P=0.011) and hyperuricemia (P=0.000) were more prevalent in the CsA-treated patients.

CONCLUSIONS

CsA resulted in a better short-time patient and graft survival that was not maintained in the long-term outcome. Chronic allograft nephropathy was the leading cause of graft loss in CsA-treated patients. Graft function was poorer in the CsA-treated patients, but its decline was similar in the two groups.

An open preference study with sumatriptan 50 mg and zolmitriptan 2.5 mg in 100 migraine patients

Understanding factors influencing patients' preference will improve guidance to make rational choices in expanded symptomatic migraine treatment. The objective of this open-label, cross-over study was to explore patients' preferences for sumatriptan 50 mg vs. zolmitriptan 2.5 mg tablets, focusing on factors influencing this preference. One hundred consecutive migraine patients attending our clinics were asked to treat three attacks with each medication and then fill out a preference questionnaire. Ninety-four migraineurs completed the trial and 42 (44%, 95% CI 34-58%) reported that they preferred zolmitriptan 2.5 mg over sumatriptan 50 mg tablets and 27 (29%, 20-38%) preferred sumatriptan 50 mg. The remaining 25 (27%, 18-36%) did not show any preference. For the initial treatment of the attacks, there were more patients needing just one tablet of zolmitriptan 2.5 mg compared with sumatriptan 50 mg (67 vs. 39%). The reasons for preference among those 69 patients who had shown preference for either of the two triptans were: a faster onset of action (speed of onset) (73%), a longer duration of the effects (39%), fewer adverse events (35%) and lower price (13%). Only one-quarter of the studied migraine population thought that sumatriptan 50 mg and zolmitriptan 2.5 mg were equivalent, which suggests that most migraine patients differentiate between triptans. A faster onset of action (speed of onset) was the most important reason for preference.

Noninvasive assessment of cardiac risk in type I diabetic patients being evaluated for combined pancreas-kidney transplantation using dipyridamole-MIBI perfusion tomographic scintigraphy

This study was performed to determine the value of dipyridamole-99m Tc-methoxy-isobutyl isonitrile perfusion (99mTC-MIBI) tomographic scintigraphy in the assessment of cardiac risk in patients being evaluated prior to combined pancreas-kidney transplantation (PKT). We performed perfusion tomographic scintigraphy using single photon emission computed tomography (SPECT) on 77 patients. The tomographic images did not show clinically relevant findings in 65 patients. In the remaining 12 patients, coronary arteriography was performed: 2 showed normal results, 4 showed no stenosis, and 6 showed significant stenosis ( > or = 70%). Seventy-two patients underwent PKT. During the follow-up (6-48 months), there were seven cardiac events, 4 patients with significant stenosis, and 3 with nonsignificant stenosis upon coronary arteriography, and all had pathological tomographic images. 99mTc-MIBI tomographic scintigraphy may be useful in identifying patients at low risk of incurring cardiac events after PKT and may, in a large group of patients, obviate the need for routine coronary angiography.

[Neurologic complications of herpes zoster. A retrospective study in 100 patients]

INTRODUCTION AND OBJECTIVES

The neurologic complications associated with herpes zoster are infrequent except for postherpetic neuralgia. The aim of this study was to review the clinical profile and the distribution of these complications in a retrospective series of patients.

PATIENTS AND METHOD

A retrospective analysis of the last 100 patients admitted with the diagnosis of herpes zoster with neurologic complications to our center from 1992 to 1999 by the Departments of Internal Medicine and Neurology was performed. The characteristics of the complications other than postherpetic neuralgia are reported.

RESULTS

Aside from the 88 patients with postherpetic neuralgia, the 12 remaining patients presented other complications: seven different peripheral neuropathies, including three with Ramsay-Hunt syndrome, two meningitis, one encephalitis and one myelitis. In addition, one patient had ophthalmic herpes zoster with cerebral vasculopathy as ipsilateral Wallenberg's syndrome. Nine patients (75%) were males, four (25%) were under the age of 20 years and seven older than 60 years and only three were immunodepressed. The CSF was abnormal in six out of the eight patients in whom it was studied with lymphocytic pleocytosis being shown on analysis without qualitative or quantitative alteration in intrathecal synthesis of IgG. In the immunosuppressed patients the serology in the CSF of the varicela zoster virus was negative. All patients demonstrated regressive evolution following treatment with acyclovir.

CONCLUSIONS

Neurologic complications other than postherpetic neuralgia occurred in 12% of the patients of this series, there was male predominance and peripheral neuropathies were the most frequent complications. Serology of the varicela zoster virus in immunosuppressed patients may be negative. In this series the prognosis was mainly satisfactory.

Differences between peptide and nonpeptide B(2) bradykinin receptor antagonists in blocking bronchoconstriction and hypotension induced by bradykinin in anesthetized Guinea pigs

We have compared the in vivo activity of the bradykinin B(2) receptor peptide antagonists MEN 11270 and Icatibant versus the nonpeptide antagonist FR 173657, after intravenous (i.v.) and intratracheal (i.t.) administration, on the bradykinin (BK)-induced bronchoconstriction and hypotension in anesthetized guinea pigs. We have also assessed the affinity of these antagonists for B(2) receptors in guinea pig lung membranes by radioligand binding and the metabolic stability of peptide antagonists in guinea pig plasma and tissue homogenates. The i.v. administration of MEN 11270, Icatibant, or FR 173657 induced a dose-dependent (10-100 nmol/kg) inhibition of both hypotension and bronchoconstriction induced by bradykinin (10 nmol/kg i.v.). The inhibitory effect of MEN 11270 and Icatibant was comparable both in terms of potency and time course, whereas FR 173657 was less potent and shorter acting. After i.t. administration MEN 11270 and Icatibant (10-100 nmol/kg) dose dependently inhibited both bronchoconstriction and hypotension, whereas FR 173657 (10-100 nmol/kg) reduced bronchoconstriction without affecting hypotension. The antibronchoconstrictor effect of MEN 11270 was more prolonged than that of Icatibant and FR 173657, whereas no differences were found between the peptide antagonists in inhibiting hypotension. These findings indicated that, in vivo, the peptide antagonists are more potent and longer lasting than FR 173657 acting on bradykinin B(2) receptors in guinea pig airways and in the vascular system. The greater efficacy of the antagonists in blocking airway compared with vascular B(2) receptors after topical administration suggests that they can block airway B(2) receptors with little systemic effects.