Agonistas de receptores adrenérgicos α-2, Ácido Valproico y Carbamazepina como tratamiento adyuvante en la abstinencia alcohólica moderada-grave: Revisión Sistemática / α-2 adrenergic recipients, Valproic and Carbamazepine Acids as a adjuvant treatment in moderate-grave alcoholic abstinence: Systematic Review

La dependencia del alcohol se encuentra entre los principales factores de riesgo para la salud en la mayoría de los países desarrollados y en desarrollo.El éxito terapéutico en la abstinencia modera-grave podría incrementarse con tratamiento adyuvante a las benzodiacepinas. En nuestro medio los agonistas alfa2 (clonidina y dexmedetomidina), ácido valproico y carbamazepina son los de mayor uso. El objetivo de este trabajo fue realizar la búsqueda exhaustiva, análisis crítico y resumen de la evidencia para proporcionar una visión general de la efectividad de estos fármacos cuando son utilizado sin tiempo determinado de tratamiento comparados entre sí, contra ninguna intervención, placebo u otras intervenciones. Se realizó una búsqueda bibliográfica en bases de datos (Pubmed/MEDLINE, LILACs, EMBASE). Dos revisores seleccionaron, extrajeron los datos y evaluaron el riesgo de sesgo de los estudios incluidos de forma independiente mediante el software Covidence. Los desacuerdos fueron resueltos por consenso. Realizamos metanálisis utilizando RevMan 5. 3 y análisis de subgrupos por diseño de estudio. Se incluyeron 22 estudios donde ninguno de ellos presentó bajo riesgo de sesgo en todos los dominios, y la mayoría de los estudios presentaron al menos un dominio con alto riesgo de sesgo. Estudios con resultados estadísticamente bajos mostraron que la dexmedetomidina y el ácido valproico disminuyen los requerimientos de benzodiacepinas en pacientes que recibían placebo. Además, cuando se combinan ácido valproico con benzodiacepinas logran una disminución estable y continua de la abstinencia medido en escala CIWA-Ar. La clonidina fue la única descripta que presentaba disminución en la frecuencia cardiaca frente a placebo con alta significancia, situación clínica a tener presente frente al síndrome simpaticomimético que caracteriza al síndrome de abstinencia por alcohol.

Alcohol dependence is among the main risk factors for health in most developed and developing countries. Therapeutic success in moderate-Grave abstinence could be increased with adjuvant treatment to benzodiazepines. In our environment, agonists Alfa 2 (clonidine and dexmedetomidine), valproic acid and carbamazepine are the most used. The objective of this work was to carry out the thorough search, critical analysis and summary of the evidence to provide an overview of the effectiveness of these drugs when used without a certain time of treatment compared to each other, against any intervention, placebo or other interventions. A bibliographic search was carried out in databases (Pubmed/ Medline, Lilacs, Embase). Two reviewers selected, extracted the data and evaluated the bias risk of independently included studies using the COVIDENCE software. The disagreements were resolved by consensus. We perform meta-analysis using Revman 5. 3 and subgroup analysis by study design. 22 studies were included where none of them presented under a risk of bias in all domains, and most studies presented at least one domain with high bias risk. Studies with statistically low results showed that dexmedetomidine and valproic acid decrease the requirements of benzodiazepines in patients receiving placebo. In addition, when valproic acid is combined with benzodiazepines achieve a stable and continuous decrease in abstinence measured in CIWA-AR scale. Clonidine was the only one described that presented a decrease in heart rate against placebo with high significance, clinical situation to be in mind in front of the sympathomimetic syndrome that characterizes alcohol withdrawal syndrome

Impacto de la implementación de un protocolo de sedoanalgesia en una unidad de cuidados intensivos pediátricos / Impact of the implementation of a sedation and analgesia protocol in a pediatric intensive care unit

Introducción. La adecuada sedación y analgesia es fundamental en el tratamiento de pacientes que requieren asistencia ventilatoria mecánica (AVM). Se recomienda la utilización de protocolos y su monitoreo; son dispares los resultados reportados sobre adhesión e impacto. Objetivos. Evaluar el impacto de la implementación de un protocolo de sedoanalgesia sobre el uso de benzodiacepinas, opioides y evolución en la unidad de cuidados intensivos pediátricos (UCIP), en pacientes que requieren AVM mayor a 72 horas. Métodos. Estudio tipo antes-después, no controlado, en la UCIP de un hospital pediátrico. Se desarrolló en 3 etapas: preintervención de diagnóstico situacional (de abril a septiembre de 2019), intervención y posintervención de implementación del protocolo de sedoanalgesia, educación sobre uso y monitorización de adherencia y su impacto (de octubre de 2019 a octubre de 2021). Resultados. Ingresaron al estudio 99 y 92 pacientes en las etapas pre- y posintervención, respectivamente. Presentaron mayor gravedad, menor edad y peso en el período preintervención. En la comparación de grupos, luego de ajustar por gravedad y edad, en la etapa posintervención se reportó una reducción en los días de uso de opioides en infusión continua (6 ± 5,2 vs. 7,6 ± 5,8; p = 0,018) y los días de uso de benzodiacepinas en infusión continua (3,3 ± 3,5 vs. 7,6 ± 6,8; p = 0,001). No se observaron diferencias significativas en los días de AVM y en los días totales de uso de benzodiacepinas. Conclusión. La implementación de un protocolo de sedoanalgesia permitió reducir el uso de fármacos en infusión continua.

Introduction. Adequate sedation and analgesia is essential in the management of patients requiring mechanical ventilation (MV). The implementation of protocols and their monitoring is recommended; mixed results on adherence and impact have been reported. Objectives. To assess the impact of the implementation of a sedation and analgesia protocol on the use of benzodiazepines, opioids, and evolution in the pediatric intensive care unit (PICU) in patients requiring MV for more than 72 hours. Methods. Before-and-after, uncontrolled study in the PICU of a children's hospital. The study was developed in 3 stages: pre-intervention for situational diagnosis (from April to September 2019), intervention, and post-intervention for implementation of a sedation and analgesia protocol, education on use, and monitoring of adherence and impact (from October 2019 to October 2021). Results. A total of 99 and 92 patients were included in the study in the pre- and post-intervention stages, respectively. Patients had a more severe condition, were younger, and had a lower weight in the preintervention period. After adjusting for severity and age, the group comparison in the post-intervention stage showed a reduction in days of continuous infusion of opioids (6 ± 5.2 versus 7.6­5.8, p = 0.018) and days of continuous infusion of benzodiazepines (3.3 ± 3.5 versus 7.6 ± 6.8, p = 0.001). No significant  differences were observed in days of MV and total days of benzodiazepine use. Conclusion. The implementation of a sedation and analgesia protocol resulted in a reduction in the use of continuous infusion of drugs.

Descripción de la disponibilidad y normas para el uso de las benzodiacepinas en algunos países de América Latina, 2022 / Description of benzodiazepines availability and regulation in several countries of Latin America, 2022 / Descrição da disponibilidade e regulamentação para o uso de benzodiazepínicos em alguns países da América Latina, 2022

Resumen: Introducción: las benzodiacepinas constituyen un grupo farmacológico de amplia prescripción a nivel mundial desde su aparición en la década de 1960. El objetivo del presente estudio fue identificar la disponibilidad, las modalidades de prescripción y dispensación de benzodiacepinas en diferentes países de América Latina, según reglamentación vigente en cada país participante del estudio. Materiales y métodos: estudio observacional, descriptivo y transversal, realizado con los datos disponibles al año 2022 de todos los países miembros de la Red de Centros de Información de Medicamentos de LatinoAmérica y el Caribe (Red CIMLAC) que fueron parte del estudio. Se utilizaron las bases de datos de las agencias regulatorias, la reglamentación vigente y otros documentos necesarios para obtener la información sobre la dispensación y prescripción en cada país. Resultados: doce de los 20 países de la Red CIMLAC completaron el estudio. El total de benzodiacepinas disponible en cada país varió entre 6 y 12 (media: 9). De ellas, en promedio 5 estaban incluidas en listados de medicamentos esenciales nacionales. La mayoría de los países cuentan con combinaciones a dosis fijas con benzodiacepinas. En todos los países se realiza la prescripción por receta especial. Más de la mitad de los países cuentan con recomendaciones nacionales. Conclusiones: la amplia disponibilidad de benzodiacepinas comercializadas, la existencia de combinaciones a dosis fijas y la falta de recomendaciones nacionales pueden ser factores que contribuyan al uso irracional de este grupo terapéutico.

Summary: Introduction: benzodiazepines constitute a widely prescribed group of drugs around the world, since they appeared in the sixties. This study aims to identify the availability, prescription modalities and dispensing of benzodiazepines in different countries around Latin America, as per the legal provisions in force in each of the countries participating in the study. Method: observational, descriptive, transversal study based on the information available in 2022 about all the member countries of the Network Medicines Information Centers of Latin America and the Caribbean (CIMLAC Network) that were part of the study. The databases of regulatory authorities were used and the legal provisions in force and relevant documents were consulted in order to obtain information on benzodiazepines dispensing and prescription in each country. Results: twelve out of the 20 CIMLAC Network member countries completed the study. The total number of benzodiazepines available in the study ranged from 6 to 12 (mean was 9), and 5 of them on average were included in the national essential medications lists. Most countries have benzodiazepines fixed dose combinations and in all countries a special medical prescription is needed. More than half of the countries have national recommendations. Conclusions: the wide availability of benzodiazepines in the market, the existence of fixed-dose combinations and the lack of national recommendations may constitute factors that contribute to the irrational use of this group of drugs.

Resumo: Introdução: os benzodiazepínicos constituem um grupo farmacológico amplamente prescrito em todo o mundo desde seu surgimento na década de 1960. O objetivo deste estudo foi identificar a disponibilidade, prescrição e modalidades de dispensação de benzodiazepínicos em diferentes países da América Latina, de acordo com as regulamentações vigentes em cada país participante do estudo. Materiais e métodos: estudo observacional, descritivo e transversal, realizado com os dados disponíveis até o ano de 2022 dos países membros da Rede de Centros de Informação sobre Medicamentos da América Latina e do Caribe (Red CIMLAC) que faziam parte do estudo. As bases de dados das agências reguladoras, normas vigentes e outros documentos necessários foram utilizados para obter informações sobre dispensação e prescrição em cada país. Resultados: doze dos 20 países da Rede CIMLAC completaram o estudo. O número total de benzodiazepínicos disponíveis em cada país variou entre 6 e 12 (média: 9). Destes, uma média de 5 foram incluídos nas listas nacionais de medicamentos essenciais. A maioria dos países tem combinações de dose fixa com benzodiazepínicos. Em todos os países é necessário prescrição especial. Mais da metade dos países têm recomendações nacionais. Conclusões: a ampla disponibilidade de benzodiazepínicos comercializados, a existência de combinações em doses fixas e a falta de recomendações nacionais podem ser fatores que contribuem para o uso irracional desse grupo terapêutico.

Segundo estudio de consumo de benzodiazepinas en una población uruguaya (2014-2018): el problema avanza / Second study on the use of benzodiazepines in a Uruguayan population (2014-2018): the problem advances / Segundo estudo de consumo de benzodiazepínicos em uma população uruguaia (2014-2018): o problema avança

Resumen: Introducción: las benzodiazepinas (BZD) constituyen uno de los grupos farmacológicos más prescritos. La forma de uso y el riesgo de aumento de efectos adversos evitables a partir del amplio uso, pueden representar en sí mismos problemas de salud pública. Objetivos: conocer el consumo de BZD en una población uruguaya en el período 2014-2018. Métodos: se realizó un estudio de utilización de medicamentos para evaluar el consumo de BZD por vía oral, a través del dato de dispensación de farmacias de instituciones de salud, mediante la variable DHD (dosis diaria definida/1.000 habitantes/día). Resultados: participaron siete instituciones, representando el 65% de la población uruguaya. Las DHD globales fueron 116,05, 114,36, 117,32, 131,17 y 124,4 DHD para los años 2014, 2015, 2016, 2017 y 2018 respectivamente, con un aumento de 7% en el período. Conclusiones: el consumo de BZD a nivel nacional entre 2014 y 2018 persiste elevado y superior al estudio previo realizado entre 2010 y 2012. Comparado con otros países, los valores para Uruguay se encuentran entre los más altos. Es necesario que todos los actores relevantes de la cadena del medicamento desarrollen estrategias para controlar la situación.

Summary: Introduction: benzodiazepines (BZD) constitute one of the most widely prescribed pharmacological groups. The use modality and the risk of increase of avoidable adverse effects resulting from wide consumption may represent a public health problem in itself. Objectives: to learn about the use of benzodiazepine in a Uruguayan population between 2014 and 2018. Method: a study was conducted on the use of medications to evaluate BZD consumption administered orally, by consulting dispensing of pharmacies in the health institutions, through the DHD variable (daily human doses/1.000 inhabitants/day). Results: 7 institutions participated in the study, representing 65% of the Uruguayan population. Global DHD were 116.05, 114.36, 117.32, 131.17 and 124.4 for 2014, 2015, 2016, 2017 and 2018 respectively, with a 7% increase in the period of study. Conclusions: the use of benzodiazepines was still high at the national level between 2014 and 2018 and greater than the figure found in the previous study, conducted between 2010 and 2012. Compared to other countries, Uruguayan figures are among the highest. All relevant actors in the drug chain need to develop strategies to control the situation.

Resumo: Introdução: os benzodiazepínicos (BZD) constituem um dos grupos farmacológicos mais prescritos. A forma de uso e o risco de aumento dos efeitos adversos evitáveis pelo uso extensivo podem representar, por si só, problemas de saúde pública. Objetivos: conhecer o consumo de BZD em uma população uruguaia no período 2014-2018. Métodos: foi realizado um estudo de uso de medicamentos para avaliar o consumo de BZD por via oral, utilizando dados da dispensação em farmácias de instituições de saúde, utilizando a variável DHD (dose diária definida/1000 habitantes/dia). Resultados: dados de sete instituições foram estudados, representando 65% da população uruguaia. Os DHDs globais foram 116,05, 114,36, 117,32, 131,17 e 124,4 DHDs para os anos de 2014, 2015, 2016, 2017 e 2018 respectivamente, com aumento de 7% no período. Conclusões: o consumo de BZD em nível nacional entre 2014 e 2018 continua alto e é superior aos resultados de um estudo anterior realizado entre 2010 e 2012. Quando comparados com outros países, os valores para o Uruguai estão entre os mais altos. É necessário que todos os atores relevantes da cadeia de medicamentos desenvolvam estratégias para controlar a situação.

Insomnio en tiempos de pandemia / Insomnia in pandemic times

El sueño es una función biológica de importancia para los seres vivos y su alteración más frecuente es el insomnio. Se define como la dificultad para conciliar o mantener el sueño, acompañada de una sensación de descanso no reparadora, a pesar de que las condiciones ambientales para ello son adecuadas, y que suele asociarse a fatiga y somnolencia durante el día. En los tiempos prepandemia ya se sabía que existía una alta prevalencia, pero durante la pandemia las cifras han aumentado y probablemente seguirán aumentando postpandemia, lo que conlleva a un incremento de las consultas en la atención primaria. Las medidas no farmacológicas son esenciales para incrementar la eficacia de las medidas terapéuticas. Las benzodiacepinas y los compuestos Z tienen bastantes efectos adversos y no son la primera opción, especialmente en los adultos mayores. La melatonina es mejor tolerada pero su eficacia no está comprobada.

Sleep is an important biological function for living beings and its most frequent alteration is insomnia. It is defined as difficulty in falling or staying asleep, accompanied by a feeling of non-restorative rest, despite adequate environmental conditions, and is usually associated with fatigue and sleepiness during the day. In pre-pandemic times, it was already known that there was a high prevalence, but during the pandemic, the figures have increased and will probably continue to increase post-pandemic, leading to an increase in consultations in primary care. Non-pharmacological measures are essential to increase the efficacy of therapeutic measures. Benzodiazepines and Z-compounds have quite a few adverse effects and are not the first choice, especially in older adults. Melatonin is better tolerated but its efficacy is not verified.

Benzodiazepines utilization in Brazilian older adults: a population-based study / Utilização de benzodiazepínicos em idosos brasileiros: um estudo de base populacional

ABSTRACT OBJECTIVE To evaluate the utilization of benzodiazepines (BZD) in Brazilian older adults, based on the Pesquisa Nacional de Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM - National Survey of Access, Use and Promotion of Rational Use of Medicines). METHODS The PNAUM is a cross-sectional study conducted between 2013 and 2014, representing the Brazilian urban population. In the present study, we included 60 years or older (n = 9,019) individuals. We calculated the prevalence of BZD utilization in the 15 days prior to survey data collection according to independent variables, using a hierarchical Poisson regression model. A semistructured interview performed empirical data collection (household interview). RESULTS The prevalence of BZD utilization in the older adults was 9.3% (95%CI: 8.3-10.4). After adjustments, BZD utilization was associated with female sex (PR = 1.88; 95%CI: 1.52-2.32), depression (PR = 5.31; 95%CI: 4.41-6, 38), multimorbidity (PR = 1.44; 95%CI: 1.20-1.73), emergency room visit or hospitalization in the last 12 months (PR = 1.42; 95%CI: 1.18-1.70 ), polypharmacy (PR = 1.26; 95%CI: 1.01-1.57) and poor or very poor self-rated health (PR = 4.16; 95%CI: 2.10-8.22). Utilization was lower in the North region (PR = 0.18; 95%CI: 0.13-0.27) and in individuals who reported abusive alcohol consumption in the last month (PR = 0.42; 95%CI: 0.19-0.94). CONCLUSION Despite contraindications, results showed a high prevalence of BZD utilization in older adults, particularly in those with depression, and wide regional and sex differences.

RESUMO OBJETIVO Avaliar a utilização de benzodiazepínicos (BZD) em idosos brasileiros,a partir de dados da Pesquisa Nacional de Acesso, Utilização e Promoção do Uso Racional de Medicamentos (PNAUM). MÉTODOS A PNAUM é um estudo transversal, conduzido entre 2013 e 2014, com representatividade da população urbana brasileira. No presente estudo, foram incluídos indivíduos com 60 anos ou mais (n = 9.019). Foi calculada a prevalência de utilização de BZD nos 15 dias anteriores à coleta dos dados da pesquisa, geral e segundo as variáveis independentes, por meio de análise bruta e ajustada, utilizando modelo hierárquico de regressão de Poisson. A coleta de dados foi realizada por meio de entrevista domiciliar. RESULTADOS A prevalência de utilização de BZD em idosos foi de 9,3% (IC95%: 8,3-10,4). Após análise ajustada, foram associados à maior utilização de BZD: sexo feminino (RP = 1,88; IC95%: 1,52-2,32), depressão (RP = 5,31; IC95%: 4,41-6,38), multimorbidade (RP = 1,44; IC95%: 1,20-1,73), visita à emergência ou internação hospitalar nos últimos 12 meses (RP = 1,42; IC95%: 1,18-1,70), polifarmácia (RP = 1,26; IC95%: 1,01-1,57) e autopercepção de saúde ruim ou muito ruim (RP = 4,16; IC95%: 2,10-8,22). A utilização foi menor na região Norte (RP = 0,18; IC95%: 0,13-0,27) e em indivíduos que relataram consumo abusivo de álcool no último mês (RP = 0,42; IC95%: 0,19-0,94). CONCLUSÃO Apesar das recomendações contrárias ao uso, os resultados demonstraram elevada prevalência de utilização de BZD em idosos, particularmente naqueles que apresentam depressão, além de amplas diferenças em relação às regiões do país e ao sexo do indivíduo.

Health-related quality of life in patients treated with atypical antipsychotics

Objective: To assess health-related quality of life and associated factors in patients treated with atypical antipsychotics, as well as to determine utility values using the EuroQol-5D-3L instrument. Methods: A cross-sectional study was conducted at a state-run pharmacy in the Brazilian National Health System. Individuals were included if they were using a single atypical antipsychotic and completed the EuroQol-5D-3L. Sociodemographic, behavioral, and clinical data were collected. The dependent variable was the EuroQol-5D-3L utility score. Associations between the independent variables and the dependent variable were analyzed in a multiple linear regression model. Results: A total of 394 patients were included, and their mean utility score was 0.664±0.232. Patients treated with clozapine had the highest mean score (0.762 [0.202]), followed by olanzapine (0.687 [0.230]), risperidone (0.630 [0.252]), ziprasidone (0.622 [0.234]), and quetiapine (0.620 [0.243]). The following variables were related to higher utility scores: income, employment, clozapine use, no illicit psychoactive substance use, no suicide attempts, and no comorbidities. Conclusion: Evaluating health-related quality of life differences in the available atypical antipsychotics can facilitate the choice of treatment, improve health outcomes, and ensure rational prescriptions.

Lista de medicamentos esenciales para el manejo de pacientes que ingresan a unidades de cuidados intensivos con sospecha o diagnóstico confirmado de COVID-19 / List of essential drugs for the management of patients admitted to intensive care units with suspected or confirmed diagnosis of COVID-19

En el transcurso de la pandemia de COVID-19, numerosos países, de ingresos bajos, medianos y alto, han visto agotadas sus reservas de medicamentos esenciales necesarios para el manejo de los pacientes con COVID-19 en las unidades de cuidados intensivos (UCI). El plan de preparación para emergencias sanitarias de los países requiere incluir una lista de medicamentos esenciales y otros dispositivos médicos necesarios en las UCI para afrontar emergencias sanitarias. La lista de medicamentos esenciales para el manejo de pacientes que ingresan a unidades de cuidados intensivos con sospecha o diagnóstico confirmado de COVID-19 es un documento de orientación fundamental que ayuda a los sistemas de salud de los países a priorizar los medicamentos esenciales que deben estar ampliamente disponibles y ser asequibles para manejar los pacientes en las UCI durante las situaciones de emergencia sanitaria, en este caso con sospecha o diagnóstico confirmado de COVID-19. Está dirigida a las autoridades sanitaras y a los encargados del manejo del sistema de salud de los países. Esta lista incluye fundamentalmente los medicamentos considerados esenciales para el manejo de los cuadros clínicos que con se observan con mayor frecuencia en pacientes hospitalizados en UCI a causa de una infección por SARS-CoV-2. No se incluyen la mayoría de los medicamentos que comúnmente se encuentran en las UCI para el manejo de otras patologías, comorbilidades o la estabilización del paciente (p. ej., insulina o antihipertensivos), salvo aquellos que pueden requerirse para el tratamiento o apoyo (p. ej., bloqueantes neuromusculares o anestésicos) de las dolencias generadas por la infección. Tampoco se incluyen medicamentos específicos para el tratamiento de la infección por SARS-CoV-2, puesto que no existe, por el momento, evidencia científica de alta calidad que avale su uso, salvo en el contexto de ensayos clínicos controlados. Un equipo de expertos en el tema realizó una búsqueda de información sobre la atención de pacientes en UCI durante la pandemia de COVID-19, en Medline (a través de PubMed), Cochrane, Tripdatabase, Epistemonikos y en buscadores generales de internet (Google). Se identificaron también revisiones o guías generadas por ministerios de Salud de varios países de la Región de las Américas, la Organización Mundial de la Salud (OMS), la Organización Panamericana de la Salud (OPS), el Instituto Nacional de Salud y Excelencia Clínica (NICE) de Reino Unido, los Centros para el Control y la Prevención de Enfermedades (CDC) de Estados Unidos y los Institutos Nacionales de Salud (NIH) de Estados Unidos.

Analysis of psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in Medicare Part D in the United States

Abstract Introduction The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths. Objective To describe psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in the United States. Methods We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists' prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis. Results In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States. Conclusions The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription.

Benzodiazepinics and the treatment of delirium: a literature review

SUMMARY OBJECTIVE To discuss the role of the benzodiazepine class in delirium patient management. METHODS Using the PubMed database, articles were reviewed after the year 2000 containing in their title the words 'delirium' and 'benzodiazepines'. DISCUSSION Delirium is an acute confusional state that leads to altered attention, awareness, and cognition. It presents with some well-established risk factors, especially older individuals with cognitive decline. There is currently no definite consensus regarding its pathophysiology, nor regarding pharmacological measures, especially concerning the benzodiazepine class. CONCLUSION Evidence suggests that there may be a role for the use of pharmacological class in the treatment of this condition, indicating a change in the previously paradigmatic pattern of treatment.

RESUMO OBJETIVO Discutir o papel da classe de benzodiazepínicos no manejo do paciente em delirium. MÉTODOS Utilizando base de dados PubMed, foram revisados artigos posteriores ao ano 2000 contendo em seu título as palavras ''delirium'' e ''benzodiazepines''. DISCUSSÃO O delirium é um estado confusional agudo, que cursa com alteração da atenção, consciência e cognição. Apresenta-se com alguns fatores de risco bem estabelecidos, sobretudo em indivíduos de maior idade e com declínio cognitivo. Não há, atualmente, um consenso definido quanto a sua fisiopatologia, tampouco referente às medidas farmacológicas, principalmente acerca da classe dos benzodiazepínicos. CONCLUSÃO Evidências sugerem que pode haver um papel do uso da classe farmacológica no tratamento do quadro em questão, indicando uma mudança no padrão anteriormente paradigmático do tratamento.

Benzodiazepine use in Sao Paulo, Brazil

OBJECTIVES: To report the prevalence and factors associated with the use of benzodiazepines in the general population and those with a mental health condition in the metropolitan area of São Paulo, Brazil. METHODS: 5,037 individuals from the Sao Paulo Megacity Mental Health Survey data were interviewed using the Composite International Diagnostic Interview, designed to generate DSM-IV diagnoses. Additionally, participants were asked if they had taken any medication in the previous 12 months for the treatment of any mental health condition. RESULTS: The prevalence of benzodiazepine use ranged from 3.6% in the general population to 7.8% among subjects with a mental health condition. Benzodiazepine use was more prevalent in subjects that had been diagnosed with a mood disorder as opposed to an anxiety disorder (14.7% vs. 8.1%, respectively). Subjects that had been diagnosed with a panic disorder (33.7%) or bipolar I/II (23.3%) reported the highest use. Individuals aged ≥50 years (11.1%), those with two or more disorders (11.2%), those with moderate or severe disorders (10%), and those that used psychiatric services (29.8%) also reported higher use. CONCLUSION: These findings give an overview of the use of benzodiazepines in the general population, which will be useful in the public health domain. Benzodiazepine use was higher in those with a mental health condition, with people that had a mood disorder being the most vulnerable. Furthermore, females and the elderly had high benzodiazepine use, so careful management in these groups is required.

Aumento da utilização de benzodiazepínicos entre idosos mais velhos: Projeto Bambuí / Increased use of benzodiazepines among older adults: Bambuí Project

RESUMO: Introdução: Os benzodiazepínicos são os psicofármacos mais utilizados globalmente, apesar dos riscos associados ao seu uso prolongado, especialmente entre os idosos. Objetivo: O estudo teve como objetivo investigar a tendência do uso de benzodiazepínicos entre idosos mais velhos (75 anos ou mais) residentes em comunidade. Métodos: Trata-se de um estudo realizado com idosos com idades entre 75 e 89 anos, integrantes da linha base (em 1997) e sobreviventes (em 2012) da coorte idosa do Projeto Bambuí. A prevalência do uso de benzodiazepínicos foi estimada separadamente para cada ano, e a comparação entre elas foi realizada por meio de regressão de Poisson com variância robusta. Resultados: A prevalência do uso de benzodiazepínicos foi maior em 2012 (33,9%) em comparação a 1997 (24,9%). Após o ajuste múltiplo, a diferença de prevalências não permaneceu significativa na população total de estudo (razão de prevalência (RP) = 1,25; intervalo de confiança de 95% (IC95%) 0,99 - 1,60), diferentemente do observado no estrato feminino (RP = 1,38; IC95% 1,04 - 1,84). O clonazepam foi o medicamento que apresentou o mais forte crescimento (RP = 4,94; IC95% 2,54 - 9,62) entre os dois anos. Conclusão: O presente estudo evidenciou um importante aumento no uso de benzodiazepínicos em uma população idosa mais velha. Esses resultados preocupam, pois são medicamentos contraindicados para idosos, especialmente se utilizados cronicamente, e estão disponíveis na relação nacional de medicamentos essenciais. Os profissionais de saúde devem estar atentos para os riscos envolvidos no seu uso por essa população.

ABSTRACT: Background: Benzodiazepines are the most widely used psychoactive drugs, despite the risks associated with their prolonged use, especially among older adults. Objective: To investigate the use of benzodiazepines among community-dwelling people aged ≥ 75 years. Methods: The study was conducted among members of the baseline (in 1997) and survivors (in 2012) of the Bambuí Project cohort. The prevalence of benzodiazepine use was estimated separately for each year, and the comparison between them was performed using the Poisson regression model with robust variance. Results: The prevalence of benzodiazepine use was higher in 2012 (33.9%) compared to 1997 (24.9%). After multiple adjustments, the difference in prevalence did not remain significant in study population (PR = 1.25; 95%CI 0.99 - 1.60), unlike that observed in the female stratum (PR = 1.38; 95%CI 1.04 - 1.84). Clonazepam was the strongest-growing drug between the two years (PR = 4.94; 95%CI 2.54 - 9.62). Conclusion: This study showed an important increase in benzodiazepine use in an older adult population. These results are concerning as these drugs are contraindicated for use in older adults, mainly if used chronically, and are available in the national list of essential medicines. Health professionals should be aware of the risks involved in its use regarding this population.

Viraje de fase maníaca a catatonía por noxa somática aguda / Manic phase shift to catatonia by acute somatic noxa

El síndrome catatónico como entidad neuropsiquiátrica ha sufrido cambios conceptuales a través de la historia, incluyendo tanto la clínica de su presentación como sus posibles causas. Éste último elemento cobra especial importancia, dado que la catatonía puede presentarse tanto por diversos cuadros médicos así como por patología psiquiátrica primaria. Se presenta el caso clínico de una paciente con antecedente de trastorno afectivo bipolar ingresada por un episodio maníaco con síntomas psicóticos asociados a un evento vital estresante. La paciente, durante una infección respiratoria baja, cambia su presentación clínica, objetivándose elementos propios de un estupor depresivo y síndrome catatónico. Una vez tratado el cuadro infeccioso y descartadas las causas neurológicas de la catatonía, se realizó tratamiento con benzodiacepinas, iniciándose luego fármacos para depresión bipolar, obteniéndose excelente respuesta clínica. Se pretende en este reporte dar a conocer la importancia de detectar elementos catatoniformes en pacientes psiquiátricos ingresados en unidades de corta estadía, así como buscar siempre posibles causas médicas relacionadas.

The catatonic syndrome as a neuropsychiatric entity has undergone conceptual changes throughout history, including both the clinical presentation and its possible causes. This last element is particularly important, given that catatonia can occur both in different medical situations as well as in primary psychiatric pathology. We present the clinical case of a patient with a history of bipolar affective disorder, hospitalized because of a manic episode with psychotic symptoms associated with a stressful life event. The patient, during a low respiratory infection, changes its clinical presentation, with elements of a depressive stupor and catatonic syndrome. Once the infectious symptoms were treated and the neurological causes of catatonia were ruled out, treatment with benzodiazepines was carried out, and then drugs for bipolar depression were started, obtaining an excellent clinical response. The aim of this report is to make known the importance of detecting catatoniform elements in psychiatric patients admitted to short-stay units, as well as to look for possible related medical causes.

Pacientes con crisis convulsivas en una unidad de cuidados intensivos pediátrico en un hospital de referencia de la ciudad de Cartagena, Colombia / Patients with seizures in a pediatric intensive care unit in a referral hospital in the city of Cartagena, Colombia

Introducción. Las crisis convulsivas son la urgencia neurológica más frecuente en pediatría, llegando a ser una urgencia vital, sobre todo cuando se presentan status convulsivos que ameritan vigilancia en unidad de cuidados intensivos pediátricos (UCIP). Materiales y métodos. La población de estudio fue un total de 60 pacientes menores de 18 años hospitalizados en UCIP en un hospital ubicado en Cartagena-Colombia. La data resultante se le calculó estadísticos univariados de tendencia central y proporciones, como tablas de frecuencia univariada y bivariadas. Resultados. Se obtuvo una población de 60 pacientes en edad pediátrica, con edad promedio de 3.85 años, teniendo antecedente de epilepsia el 64.81% y el 23,33% parálisis cerebral, la comorbilidad con mayor frecuencia fue la infección meníngea con un 25.71%. Los pacientes con antecedentes de epilepsia el medicamento más utilizado ambulatoriamente fue el ácido valproico con 48.33%, seguidamente de levetiracetam 26.67% y carbamazepina 13.33%. Dentro de la población estudiada el 83.33% presento status convulsivos, siendo la crisis tónico clónica generalizada el tipo de crisis más frecuentemente descrita con un porcentaje del 88%, los medicamentos anticonvulsivantes más utilizados para yugular crisis, se encontró el midazolam con un 98.33%. El 95% salió vivo de la institución y un 5% falleció. Conclusiones. Las principales causas de status epiléptico se encuentran la lesión cerebral aguda, convulsiones febriles atípicas, epilepsia y enfermedades degenerativas, lo que concuerda con lo descrito en la literatura, los medicamentos anticonvulsivantes más utilizados en UCIP son el midazolam en primera estancia y el ácido valproico en segunda estancia.

Introduction. Seizures are the most frequent neurological urgency in pediatrics, becoming a vital urgency, especially when there are convulsive states that merit surveillance in a pediatric intensive care unit (PICU). Materials and methods. The study population was a total of 60 patients under the age of 18 hospitalized in PICU in a hospital located in Cartagena-Colombia. The resulting data were calculated univariate statistics of central tendency and proportions, such as univariate and bivariate frequency tables. Results. A population of 60 pediatric patients with a mean age of 3.85 years was obtained, having a history of epilepsy in 64.81% and 23.33% in cerebral palsy. The most common comorbidity was meningeal infection with 25.71%. Patients with a history of epilepsy, the most widely used outpatient medication was valproic acid with 48.33%, followed by levetiracetam 26.67% and carbamazepine 13.33%. Within the study population, 83.33% presented convulsive status, with the generalized clonic tonic crisis being the most frequently described type of crisis with a percentage of 88%, the most used anticonvulsant drugs for jugular crisis, midazolam was found with 98.33%. 95% left the institution alive and 5% died. Conclusions. The main causes of epileptic status are acute brain injury, atypical febrile seizures, epilepsy and degenerative diseases, which is consistent with what has been described in the literature, the most used anticonvulsant medications in PICU are midazolam in the first stay and valproic acid In second stay.