Joshua Caballero

Effects of Quetiapine on Sleep in Nonpsychiatric and Psychiatric Conditions

Objective: To evaluate the use of immediate-release quetiapine for the treatment of insomnia. Data Sources: Pre-MEDLINE and MEDLINE were searched (1966 to October 2008) using the terms quetiapine, sleep, insomnia, and antipsychotics. Study Selection and Data Extraction: All studies and case reports evaluating insomnia as a primary endpoint were reviewed. Data Synthesis: The role of quetiapine for improving sleep in various patient populations is uncertain. Quetiapine has moderately sedative properties, and closes used in treatment of insomnia have ranged from 12.5 to 800 mg. Results of clinical trials and observations in case studies have revealed possible beneficial effects of quetiapine on several subjective and objective sleep parameters. In most studies, significant improvements in sleep were found in areas of total sleep time, sleep efficiency, and subjective sleep scores. However, some of these results may not be clinically significant. Also, quetiapine has been found to have adverse effects such as periodic leg movements, akathisia, and metabolic complications. Additionally, changes in rapid eye movement (REM) and percentage of REM sleep have been noted in different populations and need further study. Despite quetiapines sedative properties, current data do not appear to support its use as first-line treatment for sleep complications. However, it may be useful for treatment of insomnia in patients with psychiatric disorders (eg, bipolar, schizophrenia) who do not respond to primary or secondary treatments. Conclusions: Further studies are needed to define the placement, dose, and adverse effects of quetiapine for the treatment of sleep problems.

A systematic review of eHealth interventions to improve health literacy

Implementation of eHealth is now considered an effective way to address concerns about the health status of health care consumers. The purpose of this study was to review empirically based eHealth intervention strategies designed to improve health literacy among consumers in a variety of settings. A computerized search of 16 databases of abstracts (e.g. Biomedical Reference Collection, Cochrane Central Register of Controlled Trials, Computers & Applied Sciences Complete, Health Technology Assessments, MEDLINE) were explored in a systematic fashion to assess the presence of eHealth applications targeting health literacy. Compared to control interventions, the interventions using technology reported significant outcomes or showed promise for future positive outcomes regarding health literacy in a variety of settings, for different diseases, and with diverse samples. This review has indicated that it is feasible to deliver eHealth interventions specifically designed to improve health literacy skills for people with different health conditions, risk factors, and socioeconomic backgrounds.

Paliperidone Extended-Release for the Treatment of Schizophrenia

Paliperidone, the major active metabolite of risperidone (9‐hydroxy‐risperidone), is a second‐generation antipsychotic that was recently approved by the United States Food and Drug Administration for treatment of acute schizophrenia and for maintenance treatment of schizophrenia. We performed a literature search of PreMEDLINE, MEDLINE, and International Pharmaceutical Abstracts from 1966‐October 2007 to review the available data on the pharmacology, pharmacokinetics, clinical evidence, and safety and tolerability profile of paliperidone extended‐release (ER). Articles from randomized controlled trials, abstracts, and posters presented at national scientific meetings were included in this review. Paliperidone ER has been shown to be significantly more effective in improving schizophrenic symptoms according to the Positive and Negative Symptom Scale (PANSS), Clinical Global Impressions‐Severity Scale, and Personal and Social Performance Scale compared with placebo (p<0.05). In addition, limited evidence suggests similar efficacy between paliperidone ER 6–12 mg/day and risperidone 4–6 mg/day. A 2‐week, double‐blind comparison with quetiapine demonstrated that paliperidone ER was significantly better than quetiapine in improving PANSS scores (p<0.001). Paliperidone ER appears to be well tolerated at the recommended starting dosage of 6 mg/day. The most commonly reported adverse effect was dose‐related extrapyramidal symptoms. Weight gain and metabolic disturbances were minimal. The cost of paliperidone ER appears to be slightly higher than that of other second‐generation antipsychotics. Paliperidone ER tablets may be a safe and effective treatment option for acute schizophrenia and maintenance treatment of schizophrenia compared with placebo. Because well‐designed comparative data are lacking, an additional benefit over other antipsychotics is yet to be determined.

Iloperidone for the Treatment of Schizophrenia

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, and safety data of iloperidone for the treatment of schizophrenia. DATA SOURCES: Data were selected by searching Pre-MEDLINE, MEDLINE, and International Pharmaceutical Abstracts (1966-January 2010). Abstracts, scientific posters, and unpublished data provided by the manufacturer in the English language were also assessed. STUDY SELECTION AND DATA EXTRACTION: All published data including pharmacologic, pharmacokinetic, pharmacodynamic, and clinical studies related to iloperidone were considered for inclusion. Selected studies included randomized controlled trials, abstracts, and posters presented at national scientific meetings providing pertinent data. data synthesis: Iloperidone is a benzisoxazole phenylethanone with a higher affinity for serotonin-2a than dopamine-2 receptors. The recommended therapeutic total daily dose is 12-24 mg divided in 2 doses titrated over 1 week to avoid orthostasis. Acute, 6-week, randomized, placebo-controlled, and active-controlled studies demonstrated iloperidones efficacy in reducing psychotic symptoms according to changes in the total positive and negative symptom scale (PANSS-T) score from baseline. A long-term maintenance trial demonstrated similar efficacy with haloperidol in preventing time to relapse. Pharmacogenomic studies reported possible single nucleotide polymorphisms related to QT interval prolongation and efficacy with iloperidone. Common adverse effects included dizziness, dry mouth, and sustained orthostasis occurring more frequently with higher doses. Weight gain is possible at any dose. Additionally, studies showed that QTc interval prolongation may be dose related. The incidence of extrapyramidal symptoms appears to be low across all dosage ranges; however, akathisia may be more frequent with higher doses. CONCLUSIONS: Iloperidone demonstrated efficacy in acute exacerbations and long-term maintenance in adults with schizophrenia. Caution may be warranted in elderly patients and patients with cardiac disease, due to orthostasis. Further studies regarding pharmacogenomic testing related to the drugs efficacy and tolerability are needed to justify its routine use in practice.

Development and Validation of a Brief Computer-Administered HIV-Related Health Literacy Scale (HIV-HL)

Health literacy is related to a number of health status variables and has been associated with medication adherence in persons treated for HIV infection. Currently-available measures of health literacy require lengthy administration or have content or format limitations. In this paper we report the preliminary development and validation of a brief computer-administered health literacy test that includes content focused on medication adherence as well as questions based on a video simulation of an HIV-related clinical encounter. The measure shows significant relations with other measures of health literacy, HIV-related knowledge, and electronically-measured medication adherence. We also present receiver operating characteristic analyses that provide estimates of various scores’ sensitivities and specificities so that the HIV-Related Health Literacy Scale can be used as a screening measure.ResumenEl alfabetismo en salud está relacionado con un sinnúmero de variables y ha sido asociado con la adherencia a los medicamentos en personas que reciben tratamiento para la infección por el VIH. Las medidas de alfabetismo en salud que están actualmente disponibles toman mucho tiempo en administrarse y evidencian limitaciones de contenido o formato. En este artículo, reportamos el desarrollo preliminar y la validación de una prueba computarizada breve de alfabetismo en salud cuyo contenido se centra en la adherencia a los medicamentos, así como en preguntas basadas en un video que presenta una simulación de una visita médica relacionada con el VIH. Esta medida demuestra relaciones significativas con otras medidas de alfabetismo en salud, el conocimiento relacionado al VIH y la adherencia a los medicamentos medida electrónicamente. También presentamos análisis de la curva ROC que proveen estimados de la sensibilidad y especificidad de varias puntuaciones, de modo que la medida VIH-AS pueda ser utilizada como un cribado.

Cost effectiveness of a computer-delivered intervention to improve HIV medication adherence

BackgroundHigh levels of adherence to medications for HIV infection are essential for optimal clinical outcomes and to reduce viral transmission, but many patients do not achieve required levels. Clinician-delivered interventions can improve patients’ adherence, but usually require substantial effort by trained individuals and may not be widely available. Computer-delivered interventions can address this problem by reducing required staff time for delivery and by making the interventions widely available via the Internet. We previously developed a computer-delivered intervention designed to improve patients’ level of health literacy as a strategy to improve their HIV medication adherence. The intervention was shown to increase patients’ adherence, but it was not clear that the benefits resulting from the increase in adherence could justify the costs of developing and deploying the intervention. The purpose of this study was to evaluate the relation of development and deployment costs to the effectiveness of the intervention.MethodsCosts of intervention development were drawn from accounting reports for the grant under which its development was supported, adjusted for costs primarily resulting from the project’s research purpose. Effectiveness of the intervention was drawn from results of the parent study. The relation of the intervention’s effects to changes in health status, expressed as utilities, was also evaluated in order to assess the net cost of the intervention in terms of quality adjusted life years (QALYs). Sensitivity analyses evaluated ranges of possible intervention effectiveness and durations of its effects, and costs were evaluated over several deployment scenarios.ResultsThe intervention’s cost effectiveness depends largely on the number of persons using it and the duration of its effectiveness. Even with modest effects for a small number of patients the intervention was associated with net cost savings in some scenarios and for durations greater than three months and longer it was usually associated with a favorable cost per QALY. For intermediate and larger assumed effects and longer durations of intervention effectiveness, the intervention was associated with net cost savings.ConclusionsComputer-delivered adherence interventions may be a cost-effective strategy to improve adherence in persons treated for HIV.Trial registrationClinicaltrials.gov identifier NCT01304186.

Development and initial validation of a computer-administered health literacy assessment in Spanish and English: FLIGHT/VIDAS

Current measures of health literacy have been criticized on a number of grounds, including use of a limited range of content, development on small and atypical patient groups, and poor psychometric characteristics. In this paper, we report the development and preliminary validation of a new computer-administered and -scored health literacy measure addressing these limitations. Items in the measure reflect a wide range of content related to health promotion and maintenance as well as care for diseases. The development process has focused on creating a measure that will be useful in both Spanish and English, while not requiring substantial time for clinician training and individual administration and scoring. The items incorporate several formats, including questions based on brief videos, which allow for the assessment of listening comprehension and the skills related to obtaining information on the Internet. In this paper, we report the interim analyses detailing the initial development and pilot testing of the items (phase 1 of the project) in groups of Spanish and English speakers. We then describe phase 2, which included a second round of testing of the items, in new groups of Spanish and English speakers, and evaluation of the new measure’s reliability and validity in relation to other measures. Data are presented that show that four scales (general health literacy, numeracy, conceptual knowledge, and listening comprehension), developed through a process of item and factor analyses, have significant relations to existing measures of health literacy.

The Incidence of Akathisia in the Treatment of Schizophrenia with Aripiprazole, Asenapine and Lurasidone: A Meta-Analysis.

Akathisia is a troubling side effect that leads to non-adherence with antipsychotic regimens. Second generation antipsychotics (SGAs) tend to cause less akathisia than older agents but the risk still exists and rates vary between agents. Little is known about the incidence of akathisia among the newer SGAs. The purpose of this study was to conduct a meta-analysis of akathisia incidence rates for three of the newer SGAs: aripiprazole, asenapine, and lurasidone. Data were drawn from published and unpublished clinical trials comparing the drug of interest to either placebo or another SGA in adults with schizophrenia. Twenty-four studies (11 aripiprazole, 5 asenapine, and 8 lurasidone) provided incidence rates for akathisia and related nervous system events. Data showed that the relative risk (RR) of akathisia was double that of controls, with lurasidone having the highest individual RR at 2.7 [CI: 2-3.6]. Sensitivity analysis changed the RR of akathisia to less than 10%. The RR of akathisia was still elevated (1.75 [1.4-2.1]) when these drugs were compared only to actives (older SGAs). Agitation and anxiety RRs were also higher with the newer SGAs as compared to the older SGAs. Previous theory suggests antagonism of serotonin (5-HT)2A receptors may decrease akathisia risk. Expectations were that aripiprazole, asenapine and lurasidone would have a low incidence of akathisia, as all display strong antagonism at 5-HT2A. However, in this study all three had a significantly higher risk of akathisia compared to placebo or other SGAs. This suggests the pathophysiology of akathisia involves other receptors and is multifactorial.

Use of Serotonin Norepinephrine Reuptake Inhibitors in the Treatment of Attention-Deficit Hyperactivity Disorder in Pediatrics

Objective: To review the current literature on the efficacy and safety of serotonin norepinephrine reuptake inhibitors in the treatment of attention-deficit hyperactivity disorder (ADHD) in the pediatric population. Data Sources: A literature search from 1996 to August 2013 was conducted using MEDLINE, CINAHL, and EMBASE databases. Search terms included attention-deficit hyperactivity disorder, serotonin norepinephrine reuptake inhibitor, pediatric attention-deficit hyperactivity disorder, venlafaxine, duloxetine, desvenlafaxine, milnacipran, and nefazodone. Study Selection and Data Extraction: Relevant articles on duloxetine and venlafaxine for the treatment of pediatric ADHD were reviewed; 5 studies on venlafaxine and 1 study on duloxetine were evaluated. Studies included open-label and randomized, double-blind trials. Case studies in pediatric populations and all studies in adult populations were excluded. Data Synthesis: Patients 6 to 17 years old were evaluated in the venlafaxine and duloxetine studies. Trials on venlafaxine, ranging from 2 to 6 weeks, showed patient improvement as measured by the Conners Rating Scale and ADHD Rating Scale. Venlafaxine was initiated at 12.5 to 25 mg/d and titrated up to 1.4 to 3.8 mg/kg/d to a maximum of 150 mg/d. Duloxetine showed minimal efficacy in treating ADHD symptoms at doses of 60 mg/d at 6 weeks. The most common side effects for venlafaxine and duloxetine included drowsiness and decreased appetite, respectively. Conclusions: Data for venlafaxine and duloxetine are limited. However, venlafaxine may be considered as an alternative agent when patients cannot tolerate or fail stimulants, tricyclic antidepressants, or bupropion. Duloxetine has been studied in children; however, with only 1 study available, it is difficult to recommend.

The Impact of Student-Faculty Ratio on Pharmacy Faculty Scholarship

Objective. To determine the relationship and impact of student-faculty ratio on scholarship of pharmacy faculty members. Methods. The number and rank of faculty members, pharmacy program characteristics, and faculty productivity data were collected to determine the impact of student-faculty ratio on faculty scholarship. Results. Faculty scholarship was not predicted by student-faculty ratio. Factors impacting positively on faculty productivity included National Institutes of Health funding; presence of clinical associate professors, instructors, and lecturers; and programs located in public universities. Conclusions. Faculty productivity is not related to the student-faculty ratio, wherein more faculty members and fewer students equates to increased scholarship. However, public universities may have different infrastructures which are associated with greater academic productivity compared to private institutions. Additionally, utilizing instructors and clinical or nontenure-track faculty members can significantly increase scholarship among faculty members.