Lege Artis Medicinae

[Agent Orange]

dr. KERESZTES Miklós

MAY 26, 2008

Lege Artis Medicinae - 2008;18(05)

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[The antinociceptive effect of kynurenic acid]

KÉKESI Gabriella, HORVÁTH Gyöngyi

[It is well known that glutamate receptors have significant role in the pain transmission. The activation of N-methyl-Daspartate receptors causes persistent pain, therefore the antagonists acting on these receptors cause antinociception in chronic pain states. As the synthetic N-methyl-D-aspartate receptor antagonists have several side effects, they are not used generally in the clinical therapy. The tryptophan metabolite kynurenic acid is an endogenous antagonist of N-methyl-D-aspartate receptors. Although some data proved its neuroprotective effect, only a few studies suggest the antinociceptive potential of kynurenic acid. The goal of this review to summarise the possible role of kynurenic acid in the pain therapy based on the results of animal studies. Data available concerning this subject demonstrated that kynurenic acid is not an appropriate agent for antinociception neither in single nor in continuous administration because of its side-effect resulting in motor deficiency. On the other hand the combination of low doses of kynurenic acid and endomorphin-1 provides effective antinociception without side-effects on inflammatory pain test, thus may offer a new treatment modality in human pain therapy.]

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[Immunomodulatory treatment in multiple sclerosis ]

CSÉPÁNY Tünde, BERECZKI Dániel

[During the past decade, several disease-modifying agents have been established and have become available for the treatment of multiple sclerosis. The disease-modifying agents could be grouped into immunomodulatory and immunosuppressive therapies altering the long-term course of multiple sclerosis. Therapy is now available for relapsing-remitting, secondary progressive and progressive-relapsing multiple sclerosis. Different disease-modifying agents became also available for the treatment of relapsing-remitting multiple sclerosis in Hungary which makes the therapeutic decision difficult. This overview might help to give an answer for different questions in the management of multiple sclerosis: Which agent to choose? When to initiate the therapy? Which dose to apply? Are the drugs safe? How long to treat the patients with immunomodulatory drugs? We give a review from the literature to assess the efficacy of disease-modifying therapies and to compare the data from phase three trials of interferon β1b, two preparations of interferon β1a or glatiramer acetate for the treatment of multiple sclerosis. We analyzed the efficacy and safety of these agents on physical, inflammatory and cognitive measures of disease activity. Comparison of study results indicated similar effects of immunomodulatory agents on relapse-related and inflammatory measures in relapsing multiple sclerosis. Interferon β1a slowed the progression of disability in relapsing multiple sclerosis. One interferon β1a preparation (intramuscularly injected) demonstrated efficacy in slowing progression of cognitive dysfunction. The interferons reduced relapses at early phase of secondary progressive multiple sclerosis, but their efficacy have not yet been proven in the later phase of secondary progressive multiple sclerosis without relapses. Mitoxantrone demonstrated efficacy in slowing the progression of disability in secondary progressive multiple sclerosis. All of the disease modifying agents are safe and tolerable, if the indication is correct and the patients are strictly controlled.]

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[SOME FORMS OF SECONDARY OSTEOPOROSIS: DIAGNOSIS AND TREATMENT]

GENTI György, PÉNTEK Márta, LICKER-FÓRIS Edit

[Secondary causes of bone loss are not often considered in patients, who are diagnosed as having osteoporosis. There are many causes of secondary osteoporosis, including endocrine diseases, renal disorders, transplantation, glucocorticoid therapy, inflammatory rheumatic diseases etc. This article gives an overview on the most frequent and in the everyday practice important forms of secondary osteoporosis. The first principle is the correct diagnosis and the adequate treatment of the underlying disease. In the prevention and treatment of secondary bone loss similar principles are followed as in the primary forms. Calcium, Vitamin D, personalized, well-aimed physical therapy and continuous physical activity are the basic treatment of secondary osteoporosis. Active form of Vitamin D, which does not require calcium combination, has to be applied in advanced age, in impaired renal function, and in case of ineffective therapy with cholecalciferol. Evidence based data suggest that bisphosphonates (alendronate and risedronate) are the most effective antiresorptive agents in the prevention and treatment of glucocorticoid- induced osteoporosis and in osteoporosis associated with rheumatoid arthritis. To prevent secondary hyperthyreoidism during bisphosphonate treatment, a calcium intake of 1000 1500 mg/d and an 800 IU/d of cholecalciferol are recommended. Ibandronate (150 mg once a month), a new bisphosphonate will be available soon. Parathyroid hormone (teriparatide) is an anabolic agent, that enhances bone formation. Its recent introduction offers new options in the treatment of patients with established osteoporosis.]

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[IVABRADINE - FROM IF INHIBITION TO THE TREATMENT OF PATIENTS WITH STABLE ANGINA]

KOLOZSVÁRI Rudolf, ÉDES István

[Ivabradine is a new agent that selectively inhibits the If channels of the sinus node. Electrophysiological studies have shown a significant heart rate lowering effect of ivabradine compared to placebo, while no significant changes have been observed in the frequency-corrected QT interval (QTc) or in the conductivity or refractoriness of the atrial muscle, AV node, His- Purkinje system or ventricular muscle. In a noninferiority study that compared ivabradine to atenolol, the same efficacy was shown in terms of increasing effort tolerance and reducing anginal events, with less reduction in heart rate. The same results were obtained with the comparison to amlodipine - the two drugs were equally efficient. The longest trial investigated the efficacy and safety of ivabradine for 12 month; both heart rate and the number of anginal episodes significantly decreased during the entire study period. The ongoing BEAUTIFUL trial tests ivabradine in patients with heart failure. The only important side effect of ivabradine is phosphenes, but this rarely requires the treatment to be discontinued. No other side effects such as symptomatic bradycardia or conduction abnormalities have been observed. Ivabradine is currently indicated as an alternative treatment of stable angina pectoris.]

Clinical Neuroscience

[Current practice of antithrombotic treatment in ischemic stroke: a survey among Hungarian neurologists (in English language)]

SZTRIHA K. László, VÉCSEI László

[Background and purpose - Large multicenter trials have already evaluated the relative benefit of various types of antithrombotic medication in ischemic stroke. However, the application of the trial results still remains uncertain in some clinical situations. We set out to evaluate the various aspects of antithrombotic treatment use among clinical practitioners. Methods - A virtually nationwide survey was performed among Hungarian neurologists involved in stroke care, who responded to a questionnaire concerning the use of antiplatelet agents and anticoagulation in acute ischemic stroke and for secondary prevention. Results - The response rate was 65%. Most (69%) practitioners always wait for brain imaging before initiating antithrombotic treatment in acute stroke. Aspirin (100 mg/ day) is the most frequently prescribed antiplatelet agent after a first ischemic episode. Common reasons for the prescription of alternative agents instead of aspirin after a first attack include high-risk cases and intolerance or allergy to aspirin. The results of in vitro platelet aggregation studies frequently influence drug selection. If an event recurs during a given antiplatelet treatment, most neurologists change the medication. Some participants reported the administration of anticoagulation, or of the combination of aspirin plus clopidogrel in certain situations that are not cardiological indications. Conclusions - This study provides information on the use of antithrombotic treatment in general neurological practice, including everyday clinical situations where no help is available from guidelines.]