Premedication with oral alprazolam and melatonin combination: a comparison with either alone--a randomized controlled factorial trial

Role of oral melatonin in prevention of postoperative delirium in patients undergoing elective surgery under general anesthesia: A Randomized controlled trial

Background

Postoperative delirium is a common complication in patients undergoing elective surgery under general anesthesia. We aimed to minimize the incidence with an oral dose of 3 mg of melatonin administered the night before surgery.

Methods

Hundred and sixty-two patients aged 40-80 years posted for various urological and gastrointestinal surgeries under general anesthesia with no preoperative cognitive deficits were randomly distributed equally to melatonin or control groups. In the control group, routine premedication was done with tablet alprazolam (0.25 mg) and ranitidine (150 mg), but in the melatonin group, the patients were given 3 mg melatonin orally the night before surgery along with routine premedication. The CAM scale was used for diagnosis of postoperative delirium.

Results

Incidence of delirium was significantly lower in the melatonin group, 23.5%, 8.6%, and 2.5% at 6, 24, and 48 hours, respectively, and the corresponding mean (SD) values of CAM scores were 1.37 (1.30), 1.07 (1.03), and 0.69 (0.80). In contrast, the incidence of delirium was 46.9%, 30.9%, and 16% at 6, 24, and 48 hours, respectively, in the control group. There was a significant reduction in anxiety, a lower incidence of cognitive dysfunction (i.e., MoCA score <26), and improvement in sleep quality in the melatonin group at 6, 24, 48, and 72 hours after the surgical intervention. The generalized estimating equations model (GEE) model was used to study change in MoCA and CAM scores over time between the two groups, and it showed a significant interaction between time and treatment groups (P < 0.001).

Conclusions

Melatonin premedication reduced incidence of postoperative delirium and cognitive dysfunction and was associated with better sleep quality and anxiolysis.

Bibliometric analysis of pediatric dental sedation research from 1993 to 2022

Statement of problem

Bibliometric analysis methods were used to evaluate pediatric dental sedation research and to identify topical hotspots using quantitative and qualitative methodologies.

Purpose

To conduct bibliometric analysis on the retrieved data and to foresee the development of trends and hotspots in this research area.

Material and methods

We retrieved appropriate research articles from the Web of Science Core Collection on January 1, 2023. VOSviewer, Citespace and the Bibliometrics website were used to conduct bibliometric analysis on the retrieved data. GraphPad Prism 10.0 (GraphPad, San Diego, CA, USA) was used to conduct the statistical analysis.

Results

A total of 396 publications on pediatric sedation in dentistry, published between 1993 and 2022, were retrieved from online databases. The USA published most papers. Furthermore, the most frequent countries who cooperated were the USA and Canada. Six of the top ten publishing establishments were USA based. Papers on the research have appeared primarily in the journals of Dentistry and Anesthesiology. Keyword co-occurrence and co-citation cluster analysis revealed that the most common topics mainly were: dental anxiety; conscious sedation; dental caries; midazolam; propofol; hypoxemia.

Conclusions

During the three decades, the focus of pediatric sedation research has been on drugs, dental anxiety and procedural sedation. Keyword burst detection indicated that procedural sedation; adverse event; respiratory depression is an emerging research hotspot.

Efficacy and Safety of Anxiolytics in Mohs Micrographic Surgery: A Randomized, Double-Blinded, Placebo-Controlled Trial

BACKGROUND

Patient anxiety can complicate surgical outcomes by elevating blood pressure, increasing the need for postoperative pain management, and reducing overall patient satisfaction. Despite the use of anxiolytic medications in outpatient procedures, there is limited comparative evidence on the efficacy and safety of these agents in Mohs micrographic surgery.

OBJECTIVE

To compare the effectiveness and safety of different preprocedural anxiolytic agents in Mohs surgery on perioperative patient anxiety and patient satisfaction.

MATERIALS AND METHODS

A double-blinded, randomized, placebo-controlled trial was conducted of 6 different preprocedural anxiolytic agents (lorazepam, diazepam, alprazolam, gabapentin, pregabalin, and melatonin) in 350 patients undergoing Mohs surgery. Anxiety and vital signs were recorded.

RESULTS

Diazepam demonstrated a statistically significant, sustained reduction in anxiety levels compared with placebo ( p = .03). Gabapentin significantly reduced early anxiety ( p = .02). Alprazolam showed a trend to early anxiety reduction ( p = .08). Lorazepam ( p = .73), pregabalin ( p = .53), and melatonin ( p = .24) failed to reduce patient anxiety compared with placebo at any time point. No anxiolytic significantly impacted any patient vital sign or cognition.

CONCLUSION

Although short-acting benzodiazepines and gamma-aminobutyric acid medications may have transient anxiolytic effects, a single oral dose of 5 mg of diazepam can provide a sustained anxiolytic effect in Mohs surgery, with excellent patient safety.

Effects of tranquilization therapy in elderly patients suffering from chronic non-communicable diseases: A meta-analysis

The current meta-analysis searched the literature connected to different tranquilizers used to treat elderly people and assessed it in terms of dose, types of outcomes and adverse effects, to determine a safe and acceptable tranquilizer and its optimal dose. A systematic literature review was undertaken for randomized controlled trials, case-control, retrospective and prospective studies on the use of tranquilizers in elderly patients, using PubMed, Ebsco, SCOPUS and Web of Science. PICOS criteria were used to select studies, and pertinent event data was collected. This meta-analysis includes 16 randomized control trials spanning the years 2000 to 2022, using the data from 2224 patients. The trials that were included used various tranquilizers such as diazepam, alprazolam, temazepam and lorazepam, and indicated high treatment efficacy and low adverse effects. With a p-value of 0.853 for Egger's test and 0.13 for Begg's test, the current meta-analysis shows a minimal probability of publication bias. A recent meta-analysis supports the use of tranquilizers in older people to treat sleeplessness, epilepsy or anxiety, but only at modest doses, because large doses are harmful and produce numerous withdrawal symptoms.

The Effect of Pre-emptive Oral Melatonin versus Placebo on Post-operative Analgesia in Infants after Thoracotomy for Closed Cardiac Surgeries: A Randomized Controlled Study

BACKGROUND: Thoracotomy pain is one of the severest types of pain that should be managed properly, especially in children. Opioids are the most widely prescribed analgesics for post-operative pain, but they can have a number of undesirable side effects. Melatonin could be employed as an adjuvant analgesic therapy during procedural discomfort as it had no known major side effects. STUDY DESIGN: This was a double-blinded, controlled randomized study. METHODS: Fifty patients divided randomly into two equal groups. One hour before surgery, children in M group (n = 25) were given 0.5 mg/kg orally of melatonin 3 mg tablets) and patients in Group P (n = 25) received a placebo (5 ml of water by syringe 5 ml) orally. Post-operative pethidine consumption over the 1st 24 h (mg) was recorded, the intraoperative fentanyl consumption (HR and ABP) at baseline, 1 min after induction, at skin incision, and every 30 min till the end of the surgery were recorded. Neonatal Infant Pain Score (NIPS) at 4 h, 6 h, 8 h, 12 h, 18 h, and 24 h postoperatively was recorded. Other reported data include demographic data, extubation time, days of ICU stay, and complications. RESULTS: Total post-operative pethidine consumption (mg) over 24 h was significantly lower in M group than P group (3.48 ± 2.23 vs. 7.68 ± 4.52 p = 0.01). Intraoperative fentanyl consumption (ug) was significantly lower in M group than P group (10.28 ± 4.98 vs. 17.08 ± 7.39 p < 0.001). As regards NIPS, it was statistically lower in M group than P group in all times except at 8 h and 24 h with significant difference. CONCLUSION: Oral melatonin is an effective and safe pre-emptive drug as it reduces the total post-operative pethidine consumption over the first 24 h and decreased post-operative pain scores without any unpleasant effects in pediatrics undergoing closed heart surgery.

Melatonin: A novel candidate for the treatment of osteoarthritis

Osteoarthritis (OA), characterized by cartilage erosion, synovium inflammation, and subchondral bone remodeling, is a common joint degenerative disease worldwide. OA pathogenesis is regulated by multiple predisposing factors, including imbalanced matrix metabolism, aberrant inflammatory response, and excessive oxidative stress. Moreover, melatonin has been implicated in development of several degenerative disorders owing to its potent biological functions. With regards to OA, melatonin reportedly promotes synthesis of cartilage matrix, inhibition of chondrocyte apoptosis, attenuation of inflammatory response, and suppression of matrix degradation by regulating the TGF-β, MAPK, or NF-κB signaling pathways. Notably, melatonin has been associated with amelioration of oxidative damage by restoring the OA-impaired intracellular antioxidant defense system in articular cartilage. Findings from preliminary application of melatonin or melatonin-loaded biomaterials in animal models have affirmed its potential anti-arthritic effects. Herein, we summarize the anti-arthritic effects of melatonin on OA cartilage and demonstrate that melatonin has potential therapeutic efficacy in treating OA.

Melatonin for pre-medication in children: a systematic review

Background

Melatonin’s effectiveness as an anxiolytic medication has been confirmed in adults; however, its efficacy in a paediatric population is unclear. A number of small studies have assessed its use in children as a pre-operative anxiolytic, with conflicting results.

Methods

We undertook a systematic review of pre-operative melatonin use in children. Four databases (MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and Web of Science), and ‘ClinicalTrials.gov’ were searched for ongoing and completed clinical trials of relevance. Citation tracking reference lists and relevant articles were also accessed. The review was unrestricted by comparator or outcomes. Eleven studies were judged eligible for inclusion. There were high levels of heterogeneity in melatonin administration (in terms of dose and timing). Variable outcomes were reported and included: anxiety; anaesthetic success; analgesia; sedation; post-operative recovery; and safety. Outcomes were not always assessed with the same measures.

Results

Evidence to support melatonin’s anxiolytic properties in this setting is conflicting. Melatonin was associated with reduced sedative effects, post-operative excitement and improved emergence behaviour, compared to comparator drugs. One study reported the benefit of melatonin use on sleep disturbance at two weeks post-surgery. No adverse safety events were identified to be significantly associated with melatonin, affirming its excellent safety profile.

Conclusion

Despite potential advantages, including improved emergence behaviour, based on current evidence we cannot confirm whether melatonin is non-inferior to current “usual care” pre-medications. Further consideration of melatonin as an anxiolytic pre-medication in paediatric surgery is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03149-w.

Melatonin for preoperative and postoperative anxiety in adults

BACKGROUND

Anxiety in relation to surgery is a well-known problem. Melatonin offers an alternative treatment to benzodiazepines for ameliorating this condition in the preoperative and postoperative periods.

OBJECTIVES

To assess the effects of melatonin on preoperative and postoperative anxiety compared to placebo or benzodiazepines.

SEARCH METHODS

We searched the following databases on 10 July 2020: CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science. For ongoing trials and protocols, we searched clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomized, placebo-controlled or standard treatment-controlled (or both) studies that evaluated the effects of preoperatively administered melatonin on preoperative or postoperative anxiety. We included adult patients of both sexes (15 to 90 years of age) undergoing any kind of surgical procedure for which it was necessary to use general, regional, or topical anaesthesia.

DATA COLLECTION AND ANALYSIS

One review author conducted data extraction in duplicate. Data extracted included information about study design, country of origin, number of participants and demographic details, type of surgery, type of anaesthesia, intervention and dosing regimens, preoperative anxiety outcome measures, and postoperative anxiety outcome measures.

MAIN RESULTS

We included 27 randomized controlled trials (RCTs), involving 2319 participants, that assessed melatonin for treating preoperative anxiety, postoperative anxiety, or both. Twenty-four studies compared melatonin with placebo. Eleven studies compared melatonin to a benzodiazepine (seven studies with midazolam, three studies with alprazolam, and one study with oxazepam). Other comparators in a small number of studies were gabapentin, clonidine, and pregabalin. No studies were judged to be at low risk of bias for all domains. Most studies were judged to be at unclear risk of bias overall. Eight studies were judged to be at high risk of bias in one or more domain, and thus, to be at high risk of bias overall. Melatonin versus placebo Melatonin probably results in a reduction in preoperative anxiety measured by a visual analogue scale (VAS, 0 to 100 mm) compared to placebo (mean difference (MD) -11.69, 95% confidence interval (CI) -13.80 to -9.59; 18 studies, 1264 participants; moderate-certainty evidence), based on a meta-analysis of 18 studies. Melatonin may reduce immediate postoperative anxiety measured on a 0 to 100 mm VAS compared to placebo (MD -5.04, 95% CI -9.52 to -0.55; 7 studies, 524 participants; low-certainty evidence), and may reduce delayed postoperative anxiety measured six hours after surgery using the State-Trait Anxiety Inventory (STAI) (MD -5.31, 95% CI -8.78 to -1.84; 2 studies; 73 participants; low-certainty evidence). Melatonin versus benzodiazepines (midazolam and alprazolam) Melatonin probably results in little or no difference in preoperative anxiety measured on a 0 to 100 mm VAS (MD 0.78, 95% CI -2.02 to 3.58; 7 studies, 409 participants; moderate-certainty evidence) and there may be little or no difference in immediate postoperative anxiety (MD -2.12, 95% CI -4.61 to 0.36; 3 studies, 176 participants; low-certainty evidence). Adverse events Fourteen studies did not report on adverse events. Six studies specifically reported that no side effects were observed, and the remaining seven studies reported cases of nausea, sleepiness, dizziness, and headache; however, no serious adverse events were reported. Eleven studies measured psychomotor and cognitive function, or both, and in general, these studies found that benzodiazepines impaired psychomotor and cognitive function more than placebo and melatonin. Fourteen studies evaluated sedation and generally found that benzodiazepine caused the highest degree of sedation, but melatonin also showed sedative properties compared to placebo. Several studies did not report on adverse events; therefore, it is not possible to conclude with certainty, from the data on adverse effects collected in this review, that melatonin is better tolerated than benzodiazepines.

AUTHORS' CONCLUSIONS

When compared with placebo, melatonin given as premedication (as tablets or sublingually) probably reduces preoperative anxiety in adults (measured 50 to 120 minutes after administration), which is potentially clinically relevant. The effect of melatonin on postoperative anxiety compared to placebo (measured in the recovery room and six hours after surgery) was also evident but was much smaller, and the clinical relevance of this finding is uncertain. There was little or no difference in anxiety when melatonin was compared with benzodiazepines. Thus, melatonin may have a similar effect to benzodiazepines in reducing preoperative and postoperative anxiety in adults.

Adverse events associated with oral administration of melatonin: A critical systematic review of clinical evidence

While melatonin was once thought of simply as a sleep-inducing hormone, recent research has resulted in development of a deeper understanding of the complex physiological activity of melatonin in the human body. Along with this understanding has come widespread, increasing use of melatonin supplementation, extending beyond its traditional use as a sleep aid into novel fields of application. This increased use often involves off-label and self-prescription, escalating the importance of safety data. In order to examine the current knowledge relating to safety of the exogenous neurohormone, we conducted a comprehensive, critical systematic review of clinical evidence. We examined controlled studies of oral melatonin supplementation in humans when they presented any statistical analysis of adverse events. Of the fifty articles identified, twenty-six found no statistically significant adverse events, while twenty-four articles reported on at least one statistically significant adverse event. Adverse events were generally minor, short-lived and easily managed, with the most commonly reported adverse events relating to fatigue, mood, or psychomotor and neurocognitive performance. A few studies noted adverse events relating to endocrine (e.g. reproductive parameters, glucose metabolism) and cardiovascular (e.g. blood pressure, heart rate) function, which appear to be influenced by dosage, dose timing and potential interactions with antihypertensive drugs. Oral melatonin supplementation in humans has a generally favourable safety profile with some exceptions. Most adverse effects can likely be easily avoided or managed by dosing in accordance with natural circadian rhythms. Further research is required to explore the potential for melatonin to interact with endogenous hormones and pharmaceuticals.

Comparison of Effects of Oral Melatonin with Oral Alprazolam used as a Premedicant in Adult Patients Undergoing Various Surgical Procedures under General Anesthesia: A Prospective Randomized Placebo-Controlled Study

BACKGROUND AND AIMS

Preoperative anxiety is a major concern in patients undergoing any surgical procedure. Various drugs have been used to alleviate it. This study aims to compare the effects of oral melatonin versus oral alprazolam on preoperative anxiety, sedation, orientation, and cognitive function.

MATERIALS AND METHODS

A total of 90 adult patients were randomly allocated into three groups. Group M (n = 30) received oral melatonin 3 mg (2 tablets); Group A (n = 30) received oral alprazolam 0.25 mg (2 tablets), and Group P (n = 30) received placebo, multivitamin tablet (2 tablets) as premedication. The objectives of our study were to compare anxiety, sedation, orientation, and cognitive function using visual analog scale (VAS) anxiety score, Ramsay Sedation Score (RSS), orientation score, and Digit symbol substitution test (DSST) score before and after 120 min of giving premedication. For statistical analysis, paired t-test, Chi-square test, analysis of variance, and post hoc bonferroni test were used.

RESULTS

Mean VAS scores for anxiety (after 120 min) were significantly reduced in Group M (3.9 ± 1.53) and Group A (4.43 ± 1.67) when compared to Group P (4.73 ± 0.82) (P < 0.05). RSS was higher in Group A as compared to Group M and Group P (P < 0.05). No significant difference in orientation score was observed in all the three groups before and after premedication (P > 0.05). DSST score (cognitive function) was better in Group M when compared to both Group A and Group P (P < 0.05).

CONCLUSION

Oral melatonin (6 mg) when used as a premedicant is an effective alternative to alprazolam regarding providing better anxiolysis, lesser sedation along with maintenance of cognitive, and psychomotor function.

Critical Analysis of Cardiovascular and Central Nervous System Fixed Dose Combinations Available in Indian Market

INTRODUCTION

Fixed Dose Combinations (FDCs) are being increasingly used to improve compliance and achieve greater benefits of the two or more active ingredients given together than the corresponding individual drug components given separately.

AIM

To analyse the rationality of Cardiovascular (CV) and Central Nervous System (CNS) FDCs available in Indian market.

MATERIALS AND METHODS

CVS and CNS FDCs, enlisted in Indian Drug Review, 2014, were analysed by a pretested validated eight point criteria tool. Each FDC was assessed for number of active pharmacological ingredients, approval by regulatory authority, listing in WHO Essential Medicine List. While efficacy, safety, pharmacokinetic, pharmacodynamic interactions and advantages of each FDC were analysed by literature search. The total score of the tool was 12 and score ≥7 was considered rational. FDCs were divided in four groups as per rationality and DCGI approval. ANOVA was used for statistical analysis and p<0.05 was considering statistically significant.

RESULTS

Out of 152 FDCs, 107 were CV and 45 belonged to CNS group and 40 had documented evidence of efficacy and safety. Majority of FDCs showed advantage of being convenient by reducing pill count and only 32 showed reducing adverse drug reactions. Out of 107 CV FDCs, 46 were rational and 61 were irrational with a mean rationality score of 6.72±2.82 (CI- 95 %, 3.90 - 9.54). While out of 45 CNS FDCs, 8 were rational and 37 were irrational with a mean rationality score of 6.22±2.08 (CI - 95 %, 4.14 - 8.30). A significant difference in mean rationality score of group A (DCGI approved + rational) was observed as compared to group B (DCGI approved + irrational) and group C (DCGI unapproved + rational) as compared to group D (DCGI unapproved + irrational) (p<0.05).

CONCLUSION

The absence of watertight pre-requisite, critical analysis of the scientific validity of the formulations and 'convenience' category has resulted into proliferation of irrational FDCs. This calls for strict regulatory approval process to avoid miserable FDC scenario in the country.

Current methods of sedation in dental patients - a systematic review of the literature

Objetive

The main objective of this systematic literature review is to identify the safest and most effective sedative drugs so as to ensure successful sedation with as few complications as possible.

Study Design

A systematic literature review of the PubMed MEDLINE database was carried out using the key words “conscious sedation,” “drugs,” and “dentistry.” A total of 1,827 scientific articles were found, and these were narrowed down to 473 articles after applying inclusion and exclusion criteria. These 473 studies were then individually assessed for their suitability for inclusion in this literature review.

Results

A total of 21 studies were selected due to their rigorous study design and conduciveness to further, more exhaustive analysis. The selected studies included a total of 1,0003 patients classified as ASA I or II. Midazolam was the drug most frequently used for successful sedation in dental surgical procedures. Ketamine also proved very useful when administered intranasally, although some side effects were observed when delivered via other routes of administration. Both propofol and nitrous oxide (N2O) are also effective sedative drugs.

Conclusions

Midazolam is the drug most commonly used to induce moderate sedation in dental surgical procedures, and it is also very safe. Other sedative drugs like ketamine, dexmedetomidine and propofol have also been proven safe and effective; however, further comparative clinical studies are needed to better demonstrate which of these are the safest and most effective.

Key words:Conscious sedation, drugs, dentistry.

The Effect of Chronic Alprazolam Intake on Memory, Attention, and Psychomotor Performance in Healthy Human Male Volunteers

Alprazolam is used as an anxiolytic drug for generalized anxiety disorder and it has been reported to produce sedation and anterograde amnesia. In the current study, we randomly divided 26 healthy male volunteers into two groups: one group taking alprazolam 0.5 mg and the other taking placebo daily for two weeks. We utilized the Cambridge Neuropsychological Test Automated Battery (CANTAB) software to assess the chronic effect of alprazolam. We selected Paired Associates Learning (PAL) and Delayed Matching to Sample (DMS) tests for memory, Rapid Visual Information Processing (RVP) for attention, and Choice Reaction Time (CRT) for psychomotor performance twice: before starting the treatment and after the completion of the treatment. We found statistically significant impairment of visual memory in one parameter of PAL and three parameters of DMS in alprazolam group. The PAL mean trial to success and total correct matching in 0-second delay, 4-second delay, and all delay situation of DMS were impaired in alprazolam group. RVP total hits after two weeks of alprazolam treatment were improved in alprazolam group. But such differences were not observed in placebo group. In our study, we found that chronic administration of alprazolam affects memory but attentive and psychomotor performance remained unaffected.

Use of melatonin in oral health and as dental premedication

Anxiety is a common problem in dentistry which could affect the correct treatment and involve failure. Oral premedication is needed to treat several anxious patients. Many people are so highly anxious that oral sedation is not effective and need to be under deep sedation or even general anaesthesia in order to receive dental care. In these patients, due to a high level of anxiety, even the insertion of an intravenous catheter can be difficult. Benzodiazepines have been the most commonly used anxiolytic in these cases, but many may be associated with paradoxical reactions. Melatonin has a good potential to be used in this field as alternative to benzodiazepines because it may induce a natural sleepiness and improve sedation. The purpose of this paper was to summarize what is known about the use of melatonin in oral health and as dental premedication in anxious dental patients. Databases were searched for the relevant published literature to 30 April 2015. The following search items were used in various combinations: melatonin, premedication, anxiety, dental, sedation and anaesthesia. Few articles were found about this aspect, and the use of melatonin is still a controversial aspect in dental field. More detailed/specific studies are necessary to extend the therapeutic possibilities of melatonin as premedication in dentistry.