Efficacy and safety of tolperisone versus baclofen among Chinese patients with spasticity associated with spinal cord injury: a non-randomized retrospective study

There are many medications available to treat spasticity, but the tolerability of medications is the main issue for choosing the best treatment. The objectives of this study were to compare the efficacy and adverse effects of tolperisone compared to baclofen among patients with spasticity associated with spinal cord injury. Patients received baclofen plus physical therapy (BAF+PT, n=135) or tolperisone plus physical therapy (TOL+PT, n=116), or physical therapy alone (PT, n=180). The modified Ashworth scale score, the modified Medical Research Council score, the Barthel Index score, and the Disability Assessment scale score were improved (P<0.05 for all) in all the patients at the end of 6 weeks compared to before interventions. After 6 weeks, the overall coefficient of efficacy of the intervention(s) in the BAF+PT, TOL+PT, and PT groups were 1.15, 0.45, and 0.05, respectively. The patients of the BAF+PT group reported asthenia, drowsiness, and sleepiness and those of the TOL+PT group reported dyspepsia and epigastric pain as adverse effects. When comparing drug interventions to physical therapy alone, both baclofen plus physical therapy and tolperisone plus physical therapy played a significant role in the improvement of daily activities of patients. Nonetheless, baclofen plus physical therapy was tentatively effective. Tolperisone plus physical therapy was slightly effective. In addition, baclofen caused adverse effects related to the sedative manifestation (Level of Evidence: III; Technical Efficacy Stage: 4).

Caso clínico: Diagnóstico de alergia a relajantes musculares y opiáceos / Case report: Diagnosis of allergy to muscle relaxants and opiates

The anesthesiologist is the specialist who most often faces allergic reactions due to the number of drugs and substances that are exposed to the patient during the course of an intervention. Although they are rare, they have a mortality rate between 3% and 10%. We present a clinical case of a 42-year-old woman with a history of anaphylactic reaction grade 2 that is coordinated for a Werthein-Meigs surgery, for which it is decided to test her with skin tests. The results were positive for morphine, fentanil, remifentanil and atracurium, which directly affected the perioperative management.

El anestesiólogo es el especialista que con mayor frecuencia se enfrenta a reacciones alérgicas por el número de fármacos y sustancias a las que se expone al paciente en el transcurso de una intervención. Si bien son poco frecuentes presentan una mortalidad entre 3 a 10%. Presentamos un caso clínico de una mujer de 42 años con un antecedente de reaccion anafiláctica grado 2 que se coordina para una cirugía de Werthein- Meigs, por lo cual se decide testearla con pruebas cutáneas. Los rsultados fueron positivos para morfina, fentani, remifentanil y atracurio, lo cual incidió directamente en el manejo perioperatorio.

Oral Muscle Relaxant May Induce Immediate Allergic Reactions

Eperisone and afloqualone act by relaxing both skeletal and vascular smooth muscles to improve circulation and suppress pain reflex. These drugs are typically prescribed with non-steroidal anti-inflammatory drugs (NSAIDs) as painkillers. However, there have been no reports on serious adverse reactions to oral muscle relaxants; and this is the first report to describe three allergic reactions caused by eperisone and afloqualone. All three patients had histories of allergic reactions after oral intake of multiple painkillers, including oral muscle relaxants and NSAIDs, for chronic muscle pain. An open-label oral challenge test was performed with each drug to confirm which drugs caused the systemic reactions. All patients experienced the same reactions within one hour after oral intake of eperisone or afloqualone. The severity of these reactions ranged from laryngeal edema to hypotension. To confirm that the systemic reaction was caused by eperisone or afloqualone, skin prick testing and intradermal skin tests were performed with eperisone or afloqualone extract in vivo, and basophil activity tests were performed after stimulation with these drugs in vitro. In one patient with laryngeal edema, the intradermal test with afloqualone extract had a positive result, and CD63 expression levels on basophils increased in a dose-dependent manner by stimulation with afloqualone. We report three allergic reactions caused by oral muscle relaxants that might be mediated by non-immunoglobulin E-mediated responses. Since oral muscle relaxants such as eperisone and afloqualone are commonly prescribed for chronic muscle pain and can induce severe allergic reactions, we should prescribe them carefully.

Efficacy and safety of combined piroxicam, dexamethasone, orphenadrine, and cyanocobalamin treatment in mandibular molar surgery

Third molar extraction is a common procedure frequently accompanied by moderate or severe pain, and involves sufficient numbers of patients to make studies relatively easy to perform. The aim of the present study was to determine the efficacy and safety of the therapeutic combination of 10 mg piroxicam, 1 mg dexamethasone, 35 mg orphenadrine citrate, and 2.5 mg cyanocobalamin (Rheumazin®) when compared with 20 mg piroxicam alone (Feldene®) in mandibular third molar surgery. Eighty patients scheduled for removal of the third molar were included in this randomized and double-blind study. They received (vo) Rheumazin or Feldene 30 min after tooth extraction and once daily for 4 consecutive days. Pain was determined by a visual analogue scale and by the need for escape analgesia (paracetamol). Facial swelling was evaluated with a measuring tape and adverse effects and patient satisfaction were recorded. There was no statistically significant difference in facial swelling between Rheumazin and Feldene (control group). Both drugs were equally effective in the control of pain, with Rheumazin displaying less adverse effects than Feldene. Therefore, Rheumazin appears to provide a better risk/benefit ratio in the mandibular molar surgery. Since the side effects resulting from nonsteroidal anti-inflammatory drug administration are a severe limitation to the routine use of these drugs in clinical practice, our results suggest that Rheumazin can be a good choice for third molar removal treatment.

Reversión de la relajación neuromuscular y medios de monitoreo / Reversal of neuromuscular blockade and monitoring

La comprensión de la farmacocinética y la farmacodinamia de los relajantes musculares y el empleo del monitoreo de la transmisión neuromuscular, son elementos esenciales en la reversión del bloqueo neuromuscular. Esa reversión es adecuada cuando el registro de las respuestas musculares al Tren de Cuatro es superior al 70-80 por ciento, mientras que los demás métodos tienen menor especificidad. Entre los medios con registro disponible (fuerza, electromiograma, aceleración), el más práctico para el monitoreo es la acelerometría isotónica. Frente a la ausencia de métodos de registro, se impone la Estimulación de Doble Ráfaga, aunque su especificidad es del 96 por ciento. Antes de intentar la reversión farmacológica, el raciocinio clínico pronóstico de la función neuromuscular debe incluir los siguientes items: profundidad previa del bloqueo, posibilidad de interacciones farmacológicas, duración de la administración del relajante, mecanismo de finalización del efecto relajante según sea el agente usado, método empleado en el mantenimiento de la relajación, balance térmico y ácido-base del paciente, y su condición física. Si el nivel plasmático del relajante es alto, se puede obtener una reversión transitoria inyectando neostigmina, pero deben tomarse los cuidados necesarios en la sala de recuperación para reconocer y tratar adecuadamente una recurrencia del bloqueo neuromuscular.

Monitoría de la relajación muscular

En el presente artículo se hace una revisión de la técnica de dosificación de los relajantes musculares por medio de los estimuladores de nervios periféricos; de las características de la estimulación; de la manera como se efectúa la reversión del bloqueo neuromuscular y algunas indicaciones importantes de la técnica. También se describe la utilización de la contracción única (Single twitch) ó "SI"; de la serie de cuatro (Train of four) ó "S4"; de la serie de dos (Double burst) ó "S2" del estímulo tetánico; y de algunas pautas para aprovechar al máximo esta ayuda diagnóstica