Rufinamide for pediatric patients with Lennox-Gastaut syndrome: a comprehensive overview.

Rufinamide is a triazole derivative with broad-spectrum antiepileptic effects that is unrelated to any antiepileptic drug currently on the market. The European Commission and the US FDA approved rufinamide in 2007 and 2008, respectively, for adjunctive treatment of seizures associated with Lennox-Gastaut syndrome in children 4 years of age or older and adults. The mechanism of action of rufinamide is not completely understood but it is believed to prolong the inactive state of sodium channels, therefore limiting excessive firing of sodium-dependent action potentials. Rufinamide is well absorbed when taken with food, with an absolute bioavailability between 70% and 85%. The elimination half-life of the drug is around 6-10 hours, with a time to maximum plasma concentration (C(max)) of approximately 4-6 hours. The C(max) at a dosage of 10 mg/kg/day and 30 mg/kg/day is 4.01 µg/mL and 8.68 µg/mL, respectively, and the area under the plasma concentration-time curve from time 0 to 12 hours was 37.8 ± 47 µg · h/mL and 89.3 ± 58 µg · h/mL, respectively. Rufinamide exerts non-linear pharmacokinetics with increasing doses. The volume of distribution in children is similar to that in adults (0.8-1.2 L/kg) and the drug binds rather poorly to plasma protein (26.2-34.8%). Rufinamide is mainly metabolized by carboxylesterases to an inactive metabolite (CGP 47292), and the majority of the metabolites are excreted in the urine (91%). No dosage adjustment is required in patients with renal dysfunction. Rufinamide does not affect the plasma concentration of other antiepileptics, but phenytoin, phenobarbital, valproate, and primidone affect the clearance of rufinamide. In a clinical study of 138 patients averaging 12 years of age, rufinamide used as an adjunctive therapy (with an initial dosage of 10 mg/kg/day up to a target dosage of 45 mg/kg/day) in patients with Lennox-Gastaut syndrome reduced the median total seizure frequency by 32.7% versus 11.7% in the placebo group (p = 0.0015). Similar reduction in total seizure frequency was maintained in the extension phase of this study. In other studies, rufinamide also seemed to provide improvement in both partial seizures and refractory epilepsy, but further studies need to validate this observation and to identify its clinical significance. Rufinamide is usually started orally at 10 mg/kg/day, titrating up by 10 mg/kg/day every 2 days to a target dosage of 45 mg/kg/day divided twice daily (maximum dosage of 3200 mg/day). Dosing of rufinamide has not been established in patients <4 years of age. Rufinamide is available as 100, 200, and 400 mg tablets in Europe, and 200 and 400 mg tablets in the US; a suspension of 40 mg/mL can be prepared extemporaneously. Rufinamide is well tolerated, with the most common adverse effects being dizziness, fatigue, nausea, vomiting, diplopia, and somnolence. From the current data, rufinamide serves as an adjunctive therapy in the management of Lennox-Gastaut syndrome. Further studies need to evaluate its efficacy as a first-line agent in the management of this neurologic disorder.

Do clinicians tell patients they have prehypertension?

BACKGROUND: the clinical utility of the prehypertension label is questionable. We sought to estimate how often patients with prehypertension are being told about it by their primary care clinicians. METHODS: we conducted a cross-sectional study of adult patients visiting practices within the North Carolina Family Medicine Research Network in summer 2008. Non-hypertensive patients were asked whether a doctor or other health care provider had ever told them they had "prehypertension"; a subsample of patients with measured blood pressure (BP) in the prehypertension range was asked the same question. RESULTS: of 1008 non-hypertensive patients, 1.9% indicated being told they had prehypertension. Among a subsample of 102 patients with measured BP in the prehypertension range, 2.0% indicated being told they had prehypertension. CONCLUSION: few patients who probably have prehypertension are being told about it by clinicians.

Latino patients' preferences for medication information and pharmacy services.

OBJECTIVES: To examine (1) Latino patients' language preferences for receiving verbal and written medication information in community pharmacies, (2) the types of problems and concerns Latino patients report about using their medications, and (3) the factors that Latino patients believe are important when choosing a community pharmacy. METHODS: Individuals were eligible to participate if they were 18 years of age or older, if they self-identified as being Latino, and if they or their children were currently taking prescription medications. All 93 participating individuals were interviewed in Spanish. RESULTS: The majority of patients did not always receive their prescription labels or written medication information in Spanish. Approximately 52% of the respondents preferred to receive verbal information in Spanish without an interpreter, and 21.5% preferred to receive it in Spanish with an interpreter. Most respondents (70%) preferred written information in Spanish, and 21.5% preferred written information in both Spanish and English. The most commonly reported problems were difficulty paying for medications, difficulty reading the English on the prescription labels, and adverse effects. Participants valued pharmacies with friendly and respectful employees. CONCLUSION: Study participants reported many problems or concerns in using their medications, and the majority preferred receiving written and verbal information about their medication in Spanish. Pharmacies need to find better ways of providing services to the rapidly growing Latino population.

Latinos' sources of medication and medication information in the United States and their home countries.

OBJECTIVE: The objectives of this study were: (1) to investigate what predisposing, enabling, and need factors are related to the purchase of medicines from "tiendas" and other countries and (2) to describe who Latinos typically receive medication information from in the United States and their home countries. In the United States, Latino grocery stores are referred to as "tiendas". METHODS: Individuals were eligible to participate if they: were age 18 and over, self-identified as being Latino, and they or their children were currently taking prescription medications. Ninety-three individuals were interviewed in Spanish. RESULTS: Forty-two percent of participants reported purchasing medicine in "tiendas" but only 5.4% reported that "tiendas" were their usual source of medicine. Ninety-one percent of individuals used U.S. pharmacies as their usual source of medicines. Individuals with health insurance were significantly less likely to have purchased medicine at a "tienda" (odds ratio=0.16, 95% confidence interval=0.03, 0.86). Thirty percent of individuals reported buying medicines in another country to bring back to the U.S. for their use. The most commonly purchased medicines included: antibiotics, vitamins, pain medicine, and herbal medicine. The Latinos in this sample preferred to receive verbal information about medications from their physicians (75.3%) followed by pharmacists (16.1%). CONCLUSION: Despite the fact that the overwhelming majority of Latino patients reported using pharmacies as their usual source of medication, many participants reported having purchased medications from "tiendas" and other countries. PRACTICE IMPLICATIONS: Providers need to make sure to ask patients from all ethnic backgrounds about all medicines they are taking, especially those purchased in "tiendas" or other countries.

Nutritional issues in long-term care.

Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to specialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident's nutritional management.