Fever and altered consciousness are not always equal to central nervous system infection: neuroleptic malignant syndrome in a 15-year-old girl

Neuroleptic malignant syndrome, the most serious and potentially fatal side effect of neuroleptics, is characterized by altered consciousness, extrapyramidal symptoms, hyperthermia, elevated plasma creatine phosphoidnase and leukocytosis. In the child and adolescent population, the syndrome may be underrecognized or underreported. We describe a 15-year-old girl who developed neuroleptic malignant syndrome after a single injection of two different neuroleptics. We find the case interesting because the patient's course was unusual, and she was treated successfully with the combination of diazepam and biperiden. Our aim is to discuss several aspects of the syndrome through this case, particularly the problem of recognition.

Glycopyrrolate treatment of chronic drooling

OBJECTIVE

To describe the use of glycopyrrolate in the control of drooling in children and young adults with cerebral palsy and related neurodevelopmental disabilities.

DESIGN

Prospective, open-label study of drug dosage parameters, response to therapy, and side effects. Follow-up ranged from 8 months to 4 years.

SETTING

Outpatient clinic of a rehabilitation hospital that is a regional referral center for children with disabilities.

PATIENTS

Forty children and young adults with motor and/or cognitive disabilities who were experiencing drooling to a severe degree.

INTERVENTION

Treatment with oral glycopyrrolate.

OUTCOME MEASURES

Change in the quantity of drooling and side effects associated with treatment.

RESULTS

Thirty-six patients (90%) had reduced drooling in response to medication; 2 (5%) could not be assessed and 2 (5%) received no benefit. Side effects resulted in discontinuation of treatment in 11 (28%). Overall, 26 (65%) continued to receive drug therapy because of the perceived benefit. The final effective dose ranged widely from 0.01 to 0.82 mg/kg per day.

CONCLUSIONS

Glycopyrrolate therapy safely and effectively decreased but rarely abolished drooling in patients with cerebral palsy and related neurodevelopmental disabilities. The dose range was surprisingly broad. Side effects, although generally minor and predictable, often led to discontinuation of drug therapy.

Syncope: pathophysiology, diagnosis, and pharmacotherapy

OBJECTIVE

To review the pathophysiology, diagnosis, and pharmacotherapy of syncope, with emphasis placed on neurocardiogenic syncope.

DATA SOURCES

A MEDLINE search (1980-1995) using the term syncope and cross-referencing selected articles.

STUDY SELECTION

Articles selected were those considered to assist in providing the reader with a basic introduction the pathophysiology, diagnosis, and pharmacotherapy of syncope, with emphasis placed on neurocardiogenic syncope.

DATA SYNTHESIS

Syncope is a common disorder with many different etiologies. The patient's history and physical examination are extremely important in making the diagnosis. The recent availability of head-upright tilt testing and electrophysiologic studies of the myocardium have helped define the etiology in many patients in whom an etiology would not have been found in the past. When the cause of syncope has been diagnosed, the appropriate therapy to prevent future attacks will be defined in many instances. One form of syncope, known as neurocardiogenic syncope, can be difficult to treat. Recent trials have suggests the use of beta-blockers, fludrocortisone, disopyramide, or selective serotonin reuptake inhibitors may be helpful in some patients.

Neuroleptic malignant syndrome associated with abrupt withdrawal of anticholinergic agents

Neuroleptic malignant syndrome (NMS) is a severe side-effect of neuroleptic treatment. It is usually related to hypodopaminergic activity. A young schizophrenic patient who developed a typical episode of NMS during abrupt withdrawal of long-acting neuroleptic combined with anticholinergic treatment is described. NMS appeared following combined neuroleptic/ anticholinergic withdrawal and responded to procyclidine administration. The appearance of NMS after discontinuation of antidopaminergic treatment seems to be in conflict with the hypodopaminergic theory of this adverse effect. It is suggested that simultaneous withdrawal of both anticholinergic and neuroleptic medications, mainly long-acting neuroleptics, seems to be a risk factor for NMS.

Adenocarcinoma of the gastro-esophageal junction: CT for monitoring during neoadjuvant chemotherapy

OBJECTIVE

A clinical study was performed to assess the diagnostic value of spiral CT for evaluation of response during neoadjuvant chemotherapy (CTx) in patients with adenocarcinoma of the gastro-esophageal-junction (GEJ). Results were compared to those of endoscopy.

METHODS AND MATERIAL

Twenty-five patients with histologically proven adenocarcinoma of the GEJ scheduled to undergo neoadjuvant CTx were studied. Before CT examination, 1200 ml of a vanilla flavoured paraffin emulsion were applied orally to the fasting patients and 40 mg BuscopanR or 2 mg glucagon were injected i.v. for hypotonia. Iodine (100 ml) was injected automatically (3 ml/s) and the CT scan was started 10 s after complete administration of CM. For response evaluation to CTx, four standardized parameters were measured by two experienced, blinded radiologists. The results were categorized according to the WHO classification of 1981 and compared to those of endoscopy.

RESULTS

In 24 of 25 patients endoscopic and computed tomographic response evaluation showed a close correlation (r = 0.96).

CONCLUSION

Spiral CT with negative oral contrast agent is a suitable technique for monitoring of GEJ masses. In combination with standardized metric parameters it offers a quantitative response evaluation in patients with GEJ masses during neoadjuvant CTx.

Effectiveness and safety of intranasal ipratropium bromide in common colds. A randomized, double-blind, placebo-controlled trial

OBJECTIVE

To determine the tolerability and clinical effectiveness of intranasal ipratropium bromide for the treatment of symptoms of common colds.

DESIGN

Multicenter, double-blind, randomized trial.

SETTING

3 university student health services.

PATIENTS

411 previously healthy persons 14 to 56 years of age who had cold symptoms that had lasted for no more than 36 hours, rhinorrhea subjectively judged to be of at least moderate severity, and documented nasal discharge of at least 1.5 g over a 1-hour observation period.

INTERVENTION

Either 1) ipratropium bromide nasal spray 0.06% in buffered salt solution, two 42-micrograms sprays per nostril administered by metered pump spray; 2) control nasal spray, which consisted of buffered salt solution; or 3) no treatment. Treatments were self-administered three or four times daily during waking hours for 4 days. After receiving their morning dose, patients stayed at the study center for 6 hours on study day 1 and 3 hours on study day 2; symptom severity was recorded and nasal mucus discharges were collected and weighed hourly during these periods.

RESULTS

Ipratropium recipients had 26% less nasal discharge than controls (P = 0.0024) and 34% less nasal discharge than untreated patients (P = 0.0001). Severity of rhinorrhea as judged subjectively was reduced in ipratropium recipients by 31% compared with controls and by 78% compared with untreated patients (P = 0.0001 for both comparisons). In addition to being associated with reductions in daily assessments of the severity of rhinorrhea (P < or = 0.003), ipratropium was associated with reduced sneezing on study days 2 (20% difference; P = 0.03) and 4 (30% difference; P = 0.02) but not with reduced nasal congestion compared with the control spray. Ipratropium was generally well tolerated but was associated with higher rates of blood-tinged mucus (16.8% in the ipratropium group compared with 3.6% in the control group; P = 0.01) and nasal dryness (11.7% in the ipratropium group compared with 3.6% in the control group; P = 0.021) than the control spray. Patient assessments of the overall effectiveness of treatment were more favorable for ipratropium than for the control spray (P < or = 0.026) or for no treatment (P < or = 0.002) on each day of inquiry (study days 1, 2, and 5).

CONCLUSIONS

Intranasal ipratropium bromide provides specific relief of rhinorrhea and sneezing associated with common colds.

Pirenzepine versus scopolamine methyl bromide in double-contrast barium enema study of large bowel

To evaluate the usefulness of pirenzepine for diagnostic double-contrast barium enema study of the large bowel, pirenzepine and scopolamine methyl bromide (SMB) were compared in a single, blind, randomized trial. Sixty consecutive patients were enrolled in the study. Quantitative analysis of bowel distention was done by measuring the maximum diameter of the transverse colon before and after drug administration. Four independent observers blindly evaluated distention and mucosal coating of the large bowel and global quality of the images. No differences were found in the diagnostic performance between the two drugs. However, pirenzepine induced a slight but significantly larger distention of the large bowel (68 +/- 12 vs. 65 +/- 8 mm, p = 0.02). Heart rate and rhythm during the study were recorded by ECG. SMB induced tachycardia in all patients (from 72 +/- 15 to 98 +/- 24 beats/min, p < 0.01), whereas pirenzepine did not (from 76 +/- 13 to 78 +/- 20, p = NS). After SMB, one-patient exhibited faintness, and some patients complained of visual accommodation defects, dryness of the mouth, and dizziness. Pirenzepine had a diagnostic performance similar to SMB in avoiding adverse effects elicited by SMB.

[Effects of injection Salviae miltiorrhizae on senile chronic asthmatic bronchitis patients]

The aim of the study is to investigate the effects of Injection Salviae Miltiorrhizae on the senile patients suffering from chronic asthmatic bronchitis. Fifty-three patients were divided randomly into group A(treated group, 33 cases) and group B(control group, 20 cases). The results showed that in group A, the treatment could ameliorate the symptoms, improve the pulmonary function, lower the PaCO2, elevate the PaO2 and enhance the immune function. They were markedly effective in 26 cases, effective in 6 cases and ineffective in 1 case. The cases in control group were 11, 8, 1 and 95% respectively. There was a significant difference between the effectiveness of the two groups.

Reduction of peristaltic artifacts on magnetic resonance imaging of the abdomen: a comparative evaluation of three drugs

BACKGROUND

Peristaltic motion is an omnipresent source of degradation in abdominal magnetic resonance (MR) imaging by blurring images and producing ghost artifacts that can mask or mimic lesions. The objective of this study was to select an effective and easy-to-administer drug to provide consistent reduction of peristaltic motion artifacts on MR images.

METHODS

One hundred forty-eight adult patients with MR examinations of the abdomen were enrolled in a prospective, single-blind comparative study. Four groups were defined: (a) no-drug control group (n = 35), (b) 1 mg of intravenous (IV) glucagon (n = 19), (c) 20 mg of IV butylscopolamine (n = 28), and (d) 20 mg of oral dicyclomine (n = 66). All patients received high-density barium sulphate as a negative oral contrast medium. Quantitative image analysis was performed with operator-defined region-of-interest measurements of signal intensity. Gastrointestinal noise was measured outside the patient at the posterior part of the left hemiabdomen along the phase-encoding direction on a short inversion time inversion recovery (STIR) sequence.

RESULTS

Treatment groups showed reduced gastrointestinal noise (p < 0.01). When compared with the control group, IV butylscopolamine (p < 0.05) and oral dicyclomine (p < 0.05) significantly reduced gastrointestinal noise, whereas glucagon did not.

CONCLUSION

Anticholinergic drugs significantly reduced the intensity of ghost artifacts on MR imaging of the abdomen. Twenty milligrams of oral dicyclomine is an effective and safe alternative to more expensive and parenterally administered drugs such as glucagon and butylscopolamine.

The M1 muscarinic antagonist pirenzepine reduces myopia and eye enlargement in the tree shrew

PURPOSE

To determine the efficacy of the M1-selective muscarinic antagonist, pirenzepine, in preventing experimentally induced myopia in a mammalian model, the tree shrew.

METHODS

Tree shrews were monocularly deprived (MD) using translucent goggles or negative lenses for a period of 12 days. In two of the MD groups, tree shrews received daily subconjunctival administration of either pirenzepine (17.7 mumol; n = 9) or vehicle control (n = 6). Control groups (n = 6) were used to assess the effects of MD, injection regimen, and drug effects.

RESULTS

In sham-injected and saline-injected MD tree shrews, 12 days of MD produced-13.2 D +/- 0.8 D and -14.1 D +/- 0.5 D of axial myopia, respectively. In pirenzepine-injected MD tree shrews, 12 days of MD induced an axial myopia of only -2.1 D +/- 1.4 D. The significant reduction in myopia in pirenzepine-injected MD tree shrews was caused by significantly less vitreous chamber elongation of the deprived eye (0.05 mm +/- 0.04 mm) relative to the contralateral control eye when compared to sham-injected and saline-injected MD tree shrews (0.24 mm +/- 0.02 mm and 0.29 mm +/- 0.01 mm). Mean equatorial enlargement and increased eye weight were prevented in pirenzepine-injected MD tree shrews (P < 0.01). Pirenzepine also was found to reduce myopia and ocular enlargement in lens defocus-induced myopia. Control experiments demonstrated that pirenzepine did not cause a significant reduction in amplitude of carbachol-induced accommodation.

CONCLUSIONS

Findings demonstrate that chronic administration of the M1-selective muscarinic antagonist, pirenzepine, prevents experimentally induced myopia in this mammalian model by a nonaccommodative mechanism.

Pharmacokinetic optimisation in the treatment of Parkinson's disease

The current symptomatic treatment of Parkinson's disease mainly relies on agents which are able to restore dopaminergic transmission in the nigrostriatal pathway, such as the dopamine precursor levodopa or direct agonists of dopamine receptors. Ancillary strategies include the use of anticholinergic and antiglutamatergic agents or inhibitors of cerebral dopamine catabolism, such as monoamine oxidase type B inhibitors. Levodopa is the most widely used and effective drug. Its peculiar pharmacokinetics are characterised by an extensive presystemic metabolism, overcome by the combined use of extracerebral inhibitors of the enzyme aromatic-amino acid decarboxylase and rapid adsorption in the proximal small bowel by a saturable facilitated transport system shared with other large neutral amino acids. Drug transport from plasma to the brain is mediated by the same carriers operating in the intestinal mucosa. The main strategies to assure reproducibility of both drug intestinal absorption and delivery to the brain and clinical effect include standardisation of levodopa administration with respect to meal times and a controlled dietary protein intake. The levodopa plasma half-life is very short, resulting in marked plasma drug concentration fluctuations which are matched, as the disease progresses, with swings in the therapeutic response ('wearing-off' phenomena). 'Wearing-off' phenomena can be also associated, at the more advanced disease stages with a 'negative', both parkinsonism-exacerbating and dyskinetic effect of levodopa at subtherapeutic plasma concentrations. Dyskinesias may be also related to high-levodopa, excessive plasma concentrations. Recognition of the different levodopa toxic response patterns can be difficult on a clinical basis alone, and simultaneous monitoring of levodopa concentration-effect relationships may prove useful to disclose the underlying mechanism and in planning the correct pharmacokinetic management. Controlled-release levodopa formulations have been developed in an attempt to smooth out fluctuations in plasma profiles and matched therapeutic responses. The delayed levodopa absorption and lower plasma concentrations which characterise controlled-release formulations compared with standard forms must be taken into account when prescribing dosage regimens and can be complicating factors in the management of the advanced disease stages. The pharmacokinetic and pharmacodynamic characterisation of the other antiparkinsonian agents is hampered by the lack of sensitive and specific analytical methods to measure their very low plasma drug concentrations and by the difficulty in quantitatively assessing overall moderate drug clinical effects. In clinical practice an optimal dosage schedule is still generally found for each patient on an empirical basis. Future strategies should focus on the search for pharmacological agents with a better kinetic profile, particularly a higher and reproducible bioavailability and a predictable relationship between plasma drug concentration and clinical response. Treatments aimed not only at controlling the symptoms, but also at slowing the neurodegenerative process, are currently under intensive investigation.

Treatment of diabetic gustatory sweating with topical glycopyrrolate cream

A 42-year-old insulin-dependent diabetic man presented with severe bilateral gustatory sweating associated with a deterioration in his glycaemic control. Conventional oral antimuscarinic medication was contraindicated because of his cardiac insufficiency. Topical 0.5% glycopyrrolate cream was tried and applied on alternate days to his face, which resulted in the complete cessation of his gustatory sweating without side-effects. Topical glycopyrrolate cream is an effective treatment of diabetic gustatory sweating without the adverse effects commonly found with oral anti-muscarinic medication.

The influence of pharmacological pretreatment on efficacy of HI-6 oxime in combination with benactyzine in soman poisoning in rats

1. The influence of pharmacological pretreatment (pyridostigmine, benactyzine and trihexyphenidyle), designated PANPAL, on soman-induced cholinergic and stressogenic effects as well as on the efficacy of antidotal treatment (HI-6 plus obidoxime) in rats was studied. 2. PANPAL prophylaxis significantly decreased soman-induced cholinesterase inhibition in blood, brain and diaphragm as well as stressogenic effects of soman (an increase in plasma corticosterone level and liver tyrosine aminotransferase activity). 3. PANPAL pretreatment did not improve the efficacy of HI-6 in combination with benactyzine on soman-induced anticholinesterase and stressogenic effects. 4. These findings confirm that PANPAL prophylaxis can improve prognosis of soman poisoning especially by protection of cholinesterases.

Time course of methacholine induced bronchoconstriction during drugs and spontaneous resolution

We examined the resolution of the bronchial spasm induced by methacholine after administration of a dose sufficient to provoke PD20 to study, in patients with bronchial asthma, how spontaneous resolution (as opposed to bronchodilator-induced resolution) takes place. According to a randomization criterion, the patients were divided into four groups: 1) resolution induced by salbutamol (S), 2) by ipratropium bromide (I), 3) after placebo (P) and 4) spontaneous resolution (R). In brief, we observed that variations in FEV1 after methacholine PD20, reach statistically significant levels after 15 minutes in patients from groups (S) and (I), after 30 minutes in patients from groups (P) and (R) (p < 0.05). Comparing the phenomenon at various intervals in the four experimental situation, we found a pairing trend: groups (S) and (I) on the one hand, and groups (P) and (R) on the other. On the whole, this phenomenon shows that pharmacological treatment accelerates the process of spontaneous resolution of the bronchial spasm induced by methacholine which, in our experience, beings to show after 15 minutes, and that after 60 minutes, there are no statistically significant differences in the four groups. It is our opinion that closer examination of this phenomenon may provide greater knowledge of the mechanisms that come into play during the phase after stimulation of the muscarinic receptors and that reasonably involve the system to eliminate the muscarinic drug.

Pharmacological activity and receptor-binding characteristics of 2 beta-(2'-phenyl-2'-cyclopentyl-2'-hydroxy-ethoxy)tropane and its optical isomers

This study describes the receptor-binding characteristics, antimuscarinic and antinicotinic activities of 2 beta-(2'-phenyl-2'-cyclopentyl-2'-hydroxy-ethoxy)tropane (beta-PCT) and its four optical isomers. Both arecoline-induced tremor and nicotine-induced convulsion in mice were antagonized by beta-PCT and its optical isomers. These compounds were less potent than atropine in their antimuscarinic potencies, but more potent than atropine in their antinicotinic activities. The isomer with the 1S-2 beta-2'R configuration was about one order of magnitude more potent than the isomer with the 1R-2 beta-2'S configuration in their antimuscarinic activity, but the antinicotinic potencies of these compounds did not differ significantly. The order of potencies of beta-PCT and its optical isomers to displace the specific binding of [3H]quinuclidinyl benzilate to muscarinic receptors was similar to that of their antimuscarinic potencies. The binding of [3H]nicotine to central nicotinic receptors was not inhibited by these compounds. The findings indicate that beta-PCT and its optical isomers are useful affinity ligands to examine the biochemical and functional characteristics of brain cholinergic receptors.

Trihexyphenidyl as a possible therapeutic option in clozapine-induced nocturnal enuresis

Enuresis is an adverse event of clozapine treatment. The occurrence of nocturnal functional enuresis in two schizophrenic patients during the initial phase of clozapine therapy is reported. Beneficial effect of trihexyphenidyl administration (5 mg at 21.00 h) on clozapine-induced enuresis is clearly demonstrated in one patient. Trihexyphenidyl discontinuation and subsequent readministration in this patient led to corresponding recurrence and then disappearance of enuresis. Involvement of the cholinergic system has been proposed as one of the possible pathophysiological mechanisms of clozapine-induced enuresis.

Small-bowel obstruction and the effects of lidocaine, atropine and hexamethonium on inflammation and fluid losses

BACKGROUND

The profuse fluid losses and morbidity of patients suffering from obstructive ileus are closely related to inflammatory changes in the obstructed bowel wall. Previous experimental studies have shown that use of steroids and NSAIDs can reduce fluid losses in obstructive ileus. In the present study, we investigated the effects of lidocaine on fluid losses since local anesthetics have been shown to possess wide and potent anti-inflammatory properties. Hexamethonium and atropine were used to study the importance of the autonomic nervous system in bowel obstruction.

METHOD

Experiments were performed in rats in vivo. After 18 h of total obstruction of the jejunum by thread ligation, a segment of the obstructed jejunum was placed in a chamber with intact nervous and vascular supply and net fluid transport was continuously registered by a gravimetric technique. Extravasation of Evans blue albumin as marker of inflammation was quantified by spectrophotometry.

RESULTS

Hexamethonium (10 mg.kg-1 i.v.) significantly inhibited net fluid secretion (P < .05), while atropine (0.25 mg.kg-1 i.v.) had no significant effect. Net fluid secretion was reversed into absorption following an intravenous bolus dose of lidocaine (2 mg.kg-1) (P < 0.01) and topical administration of lidocaine (20 mg) on the serosa of the obstructed gut (P < 0.01). Single topical administration of lidocaine (20 mg) immediately before ligation significantly reduced net fluid secretion (P < 0.05) and inflammation (P < 0.05) in the obstructed bowel 20 h post-ligation compared to obstructed controls.

CONCLUSION

Lidocaine significantly inhibited or prevented fluid losses when administered intravenously or topically to the obstructed gut. Mechanisms of action could be inhibition of nerve reflexes involved in fluid secretion and by inhibition of inflammation in the bowel wall. The inhibition of fluid losses by hexamethonium further supports the importance of the autonomic nervous system in the pathophysiology of bowel obstruction.

Synthesis and muscarinic activities of 3-(pyrazolyl)-1,2,5,6-tetrahydropyridine derivatives

A series of 3-(pyrazolyl)-1,2,5,6-tetrahydropyridine derivatives (B) was synthesized and tested for muscarinic activity in receptor binding assays using [3H]-oxotremorine-M (3H-OXO-M) and [3H]-pirenzepine (3H-PZ) as ligands. Potential muscarinic agonistic or antagonistic properties of the compounds were determined using binding studies measuring their potencies to inhibit the binding of 3H-OXO-M and 3H-PZ. Preferential inhibition of 3H-OXO-M binding was used as an indicator for potential muscarinic agonistic properties; this potential was confirmed in functional studies on isolated organs. All compounds with agonistic properties showed 3H-PZ/3H-OXO-M potency ratios in excess of 20. In contrast, for antagonists this ratio was found to be close to unity. Mono-halogenation resulted in compounds (4b and 4d) with M3 agonistic properties as shown by their atropine sensitive stimulant properties in the guinea pig ileum, but with very little or no M1 activity. Some minor in vivo effects were observed for both these compounds, with the iodinated compound 4d inducing salivation. Compound 4d also showed some positive mnemonic properties in rats where spatial short-term memory had been compromised by temporary cholinergic depletion. These data indicate that some M3 agonism may be desired in therapeutic agents aimed at the treatment of the cognitive deficits of Alzheimer's disease patients.

A multicenter study of nebulized bronchodilator solutions in chronic obstructive pulmonary disease

A multicenter, 85-day, double-blind, randomized study was conducted to compare the effects of a single-dose and chronic inhalation of ipratropium bromide solution (500 micrograms) to the beta-adrenergic agonist metaproterenol (5% solution, 15 mg) in patients with chronic obstructive pulmonary disease (COPD). Patients were required to have a relatively stable, moderately severe COPD, forced expiratory volume in 1 second (FEV1) < 65% of predicted normal, FEV1 <70% of forced vital capacity (FVC), and a smoking history of > 10 pack-years. Following a 2-week baseline period, patients were randomized into either the ipratropium bromide (106 patients) or metaproterenol (107 patients) study groups. Pulmonary function testing was performed on days 1, 43, and 85. Secondary efficacy variables examined included peak expiratory flow rates, physician's global evaluation, quality of life, COPD symptom score, and use of concomitant medications. FEV1 was comparable between the two groups on day 1 (1.00 and 1.02 liters, ipratropium bromide vs metaproterenol, respectively; p = nonsignificant). The baseline FEV1 increased significantly in the ipratropium bromide group between day 1 and 43 by 10% (from 1.00 to 1.10 liters, p < 0.002) and remained 7% elevated on day 85 (1.07 liters) compared to day 1 (p < 0.02); it did not change in the metaproterenol group across all three test days. A clinically significant (> 15%) mean FEV1 response was observed on each of the 3 test days following drug inhalation in both treatment groups. The median duration of action was similar between groups (5 hours) on test day 1, but on day 85 the median duration for ipratropium bromide was r.5 hours compared to 3.0 hours for metaproterenol (p < 0.04). The secondary efficacy variables were uniformly better in the ipratropium bromide than the metaproterenol group. Side effects were infrequent and generally mild in both groups. These data suggest that the availability of a high-dose ipratropium bromide solution offers a safe and effective means of producing prolonged bronchodilation in patients with COPD.

Therapeutic approaches to chronic obstructive pulmonary disease: an emerging consensus

In response to reports of rising asthma morbidity and mortality, several consensus statements have been drafted to guide the treatment of asthma. More recently, attempts have been made to develop similar guidelines for the management of chronic obstructive pulmonary disease (COPD). Just as the two diseases differ in their pathophysiology, their treatment algorithms have differed. For both disease groups, avoidance of further airway injury is the initial step in treatment. For asthmatics, this is often allergen avoidance, but for patients with COPD the usual inciting factor is cigarette smoking, thereby making smoking cessation the necessary first step. Whereas beta 2-agonist bronchodilators are used as needed in asthma management, regular bronchodilator therapy with anticholinergic drugs is the first-line approach in COPD. The role of anti-inflammatory drugs differs markedly between the two disease groups. Asthmatic patients benefit dramatically from inhaled anti-inflammatory drugs; little or no benefit can be demonstrated for the majority of patients with COPD. In COPD, the role of exercise rehabilitation programs can improve exercise tolerance. For selected patients with COPD with persistent hypoxemia, the use of supplemental oxygen can reduce mortality. For both patient groups, educational interventions can play a valuable role in making patients patients effective partners in their own care.

Nebulized bronchodilators for outpatient management of stable chronic obstructive pulmonary disease

The bronchodilator efficacy, safety, and persistence of effect of the anticholinergic agent ipratropium bromide and the beta-adrenergic agonist albuterol, both given by nebulization, were compared in 223 patients with stable, severe chronic obstructive pulmonary disease (COPD). The study was a randomized, double-blind, parallel group trial conducted over 85 days. Patients took the study drugs (either 500 micrograms of ipratropium bromide or 2.5 mg of albuterol) three times daily on an outpatient basis throughout the study. The acute bronchodilator responses to nebulized ipratropium bromide and albuterol were studied on days 1, 43, and 85. The forced expiratory volume in 1 second (FEV1) response was similar for both drugs on day 1 (33% peak increase after ipratropium bromide and 36% peak increase after albuterol). However, albuterol's effect on FEV1 decreased over time. Clinical improvement was noted in both study groups, but the ipratropium bromide group had a greater symptomatic benefit. Patients receiving ipratropium bromide scored higher on a quality-of-life questionnaire evaluating dyspnea, fatigue, emotional function, and mastery. Side effects were relatively infrequent and generally mild for both study drugs. These results show that ipratropium bromide, given by nebulization, is safe and effective in the outpatient treatment of COPD.

Addition of anticholinergic solution prolongs bronchodilator effect of beta 2 agonists in patients with chronic obstructive pulmonary disease

A randomized, double-blind placebo-controlled clinical trial was designed to assess the safety, efficacy, and duration of the bronchodilation resulting from the addition of 500 micrograms of ipratropium bromide (Atrovent; Boehringer Ingelheim, CT) inhalation solution to standard small volume nebulizer treatments with 2.5 mg albuterol inhalation solution. A total of 195 patients (63% men, average age 64 years) with > 10 pack-year smoking histories and stable, moderate-to- severe chronic obstructive pulmonary disease (COPD; forced expiratory volume in 1 second [FEV1] 1.02 liter, 38.8% predicted) from eight university-affiliated chest clinics in seven U.S. cities were enrolled into the study. Asthma, rhinitis, and eosinophilia were exclusions, as was daily use of > 10 mg of prednisone (or 20 mg on alternate days). There was a 2-week stabilization period during which the patients were instructed in the use of the small volume nebulizers, which they used three times daily with albuterol alone. They were asked to keep daily logs of peak flow rates, pulmonary symptoms, and additional medication usage. On their test day 1 the subjects came to the pulmonary function laboratory having been off theophylline for 24 hours and beta 2-agonists for 12 hours and performed a baseline spirometry. They then received their morning small volume nebulizer treatment of albuterol to which was added either 500 micrograms if ipratropium bromide or a saline placebo. Spirometry was repeated at 15, 30, and 60 minutes, and then hourly for 8 hours. Subjects then took home a 2-week supply of albuterol and test drug for thrice daily use in their small volume nebulizer. They were evaluated for pulmonary symptoms and adverse effects every 14 days. The 8-hour spirometry was repeated on test day 43 and finally on test day 85. Primary data evaluated were the peak increase in FEV1 and the area between the FEV1 baseline value and the 8-hour FEV1 curve. Similar calculations were made for forced vital capacity (FVC) and 25-75% forced expiratory flow (FEF25-75%). On test day 1 the peak increase in FEV1 for the ipratropium bromide + albuterol subjects was 26% greater than those on placebo + albuterol (p < 0.003). The area under the 8-hour FEV1 curve was 64% greater in those given ipratropium bromide on test day 1 (p < 0.0002). Similar increases were seen in FVC and FEF25-75%. The peak improvements in FEV1 and FVC with the addition of ipratropium bromide to albuterol were maintained on test days 43 and 85. Considering the safety and efficacy profiles of this combination, the data would suggest that ipratropium bromide inhalation solution should be considered first-line therapy for those patients with COPD requiring small volume nebulizer treatments.