Mirtazapine: A One-Stop Strategy for Treatment of Opioid Withdrawal Symptoms.

Public health efforts to reduce the opioid overdose epidemic and treat opioid use disorder (OUD) have met with challenges associated with current non-standardized approaches to managing opioid withdrawal symptoms, such as itching, jitteriness, anxiety, depression, craving, vomiting, diarrhea, insomnia, and anorexia. These symptoms pose substantial obstacles to the safe initiation of medications for OUD, maintenance of long-term sobriety, and prevention of relapse. In clinical practice, multiple medications (polypharmacy) are prescribed to manage these withdrawal symptoms, including ondansetron and promethazine for vomiting and nausea, loperamide and Lomotil for diarrhea, hydroxyzine and doxepin for pruritus, benzodiazepines, the Z-drugs, and melatonin for insomnia, and benzos, tricyclic antidepressants (TCAs), and various serotonergic agents for anxiety. This polypharmacy is associated with an increased risk of adverse drug-drug interactions and adverse drug events, increased medical costs, and increased odds of medication non-adherence and relapse. We propose an alternative single medication, mirtazapine, a noradrenergic and specific serotonergic receptor antagonist, that can be used for myriad symptoms of opioid withdrawal. Case series, clinical studies, and clinical trials have shown mirtazapine to be effective for treating nausea and vomiting resulting from multiple etiologies, including hyperemesis gravidarum and chemotherapy-induced emesis. Other evidence supports the salutary effects of mirtazapine on itching and craving. Research findings support mirtazapine's beneficial effects on diarrhea and anxiety, a consequence of its modulating effects on serotonergic receptors mediating mood and gastrointestinal symptoms. There is also evidence supporting its efficacy as a potent and non-addictive sleep aid, which presents itself as a solution for insomnia associated with opioid withdrawal. The current review presents evidence from extant literature supporting mirtazapine as a one-drug strategy to treat the variety of symptoms of opioid withdrawal. This one-drug strategy has much potential to decrease polypharmacy, adverse drug events, relapse, and healthcare cost and increase the likelihood of prolonged sobriety and better quality of life for people living with OUD.

Beneficial Effects of Glucagon-Like Peptide-1 Receptor Agonists in Patients With Asthma: A Literature Review.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are approved to treat type 2 diabetes mellitus. The anti-inflammatory and anti-obesity properties of GLP-1 RAs as well as their moderating effects on multiple pathobiological pathways in asthma pathogenesis may decrease asthma exacerbations, improve quality of life, and decrease premature death among patients with asthma and co-morbid diabetes or obesity. The aim of this literature review is to discuss evidence from basic science, human studies, and clinical trials to support the preferential use of GLP-1 RAs in asthma patients with co-occurring diabetes and obesity. The preliminary data on the effect of GLP-1 RAs on asthma in patients with diabetes are promising and merit further trials and research studies.

Perioperative Multidisciplinary Delirium Prevention: A Longitudinal Case Report.

Postoperative delirium is associated with accelerated cognitive decline, mortality, and high health care costs. The importance of perioperative risk identification is increasingly recognized but optimal prevention strategies are still evolving. We review the case of an at-risk 79-year-old who had 3 lumbar spine surgeries within a year, 2 of which were complicated by postoperative delirium and one which was not. We discuss how a comprehensive preoperative cognitive assessment successfully informed perioperative decision making, including anesthetic management and postoperative multimodal delirium prevention strategies by geriatric medicine. The case exemplifies how coordinated interdisciplinary team management may reduce postoperative delirium in high-risk individuals.

Implementing Delirium Prevention in the Era of COVID-19.

Patients admitted with COVID-19 can develop delirium due to predisposing factors, isolation, and the illness itself. Standard delirium prevention methods focus on interaction and stimulation. It can be challenging to deliver these methods of care in COVID settings where it is necessary to increase patient isolation. This paper presents a typical clinical vignette of representative patients in a tertiary care hospital and how a medical team modified an evidence-based delirium prevention model to deliver high-quality care to COVID-19 patients. The implemented model focuses on four areas of delirium-prevention: Mobility, Sleep, Cognitive Stimulation, and Nutrition. Future studies will be needed to track quantitative outcome measures.