Pharmacotherapy Treatment

Devise a pharmacotherapy treatment plan for a patient undergoing primary percutaneous coronary intervention in ST-segment elevation myocardial infarction given patient-specific data. 

Devise a pharmacotherapy treatment and monitoring plan for a patient with non-ST-segment elevation acute coronary syndrome given patient-specific data. 

FIGURE 59-1. Pharmacotherapy treatment algorithm. A select population of individuals, based on body mass index (BMI) and waist circumference (WC) together with concurrent risk factors, may benefit from medication therapy as an adjunct to a program of weight loss that includes diet, exercise, and behavioral modification. (CHD, coronary heart disease DM, diabetes mellitus, HTN, hypertension INC WC, >40 inches for males and >35 inches for females LCD, low-calorie diet.)... 

First-line pharmacotherapy treatments include methylphenidate, dextroamphetamine, the mixed amphetamine salts (Adderall), and atomoxetine (see Table 8.3). When an early evening dose is indicated (e.g., completion of homework) it is typically at 25-50% of the doses prescribed earlier in the day. 

Each of the collagen-vascular diseases has its own recommended form of therapy. For most of these diseases, there are few well-controlled clinical trials evaluating pharmacotherapy. Treatment of most of these diseases requires anti-inflammatory or immunosuppressive drugs. Monitoring therapeutic outcomes is essential because drugs and drug doses may need to be modified frequently. 

Trigclic Antidepressants. Imipramine (38) was introduced in the late 1950s as one of the first pharmacotherapies for depression. At that time, chlorproma2ine [50-53-3] was the first effective antipsychotic treatment to be discovered. Researchers looked for similar chemical stmctures and imipramine was found to be effective in the symptomatic treatment of depression. Over the years, other congeners, such as desipramine (39), amitriptyline (40), and dothiepin (41), were synthesized and shown to be clinically efficacious antidepressant dmgs (121). These substances, known under the general mbric of tricycHc antidepressants, share a basic chemical stmcture comprising... 

As evidence accumulates showing that a number of medications are efficacious for the treatment of co-occurring psychopathology and/or the prevention of relapse in alcoholic patients, the therapeutic options available to physicians in treating these patients will increase. As these developments unfold, it is crucial that efforts be directed to enhancing the acceptability of pharmacotherapy to the alcoholism treatment community as a standard ingredient in alcoholism rehabilitation. 

Ciraulo DA, Jaffe JH Tricyclic antidepressants in the treatment of depression associated with alcoholism. Clin Psychopharmacol 1 146—150, 1981 Ciraulo DA, Nace E Benzodiazepine treatment of anxiety or insomnia in substance abuse patients. Am J Addict 9 276—284, 2000 Ciraulo DA, Barnhill JG, Jaffe JH, et al Intravenous pharmacokinetics of 2-hydroxy-imipramine in alcoholics and normal controls. J StudAlcohol 51 366-372, 1990 Ciraulo DA, Knapp CM, LoCastro J, et al A benzodiazepine mood effect scale reliability and validity determined for alcohol-dependent subjects and adults with a parental history of alcoholism. Am J Drug Alcohol Abuse 27 339—347, 2001 Collins MA Tetrahydropapaveroline in Parkinson s disease and alcoholism a look back in honor of Merton Sandler. Neurotoxicology 25 117-120, 2004 COMBINE Study Research Group Testing combined pharmacotherapies and behavioral interventions in alcohol dependence rationale and methods. Alcohol Clin Exp Res 27 1107-1122, 2003a... 

Dundon W, Lynch KG, Pettinati HM, et al Treatment outcomes in type A and B alcohol dependence 6 months after serotonergic pharmacotherapy. Alcohol Clin Exp Res 28 1065-1073, 2004... 

The development of effective pharmacotherapy has lagged behind progress in understanding the reward mechanisms and chronic impairments underlying stimulant abuse. Pharmacological and behavioral treatment approaches that have been used for cocaine abuse have not been as widely tested for the treatment of amphetamine abuse, limiting what can be offered for treatment of this disorder. No treatment agents are approved by the FDA for treatment of cocaine or amphetamine dependence. 

More than 40 medications have been investigated but none have shown consistent efficacy for primary cocaine or amphetamine dependence. These medications include dopaminergic agonists, antidepressants, and more recently disulfiram, selegiline, and a cocaine vaccine (see Table 5—2 for summary). Studies have been relatively brief and have focused on abstinence initiation rather than on relapse prevention, but even these modest treatment goals have not been attained. The focus in the discussion that follows is on pharmacotherapies for cocaine dependence, because very few clinical trials have been completed with amphetamine-dependent patients. Furthermore, none of the studies of amphetamine dependence have shown results different from those described for cocaine dependence (Rawson et al. 2002b Srisurapanont et al. 2001). 

With all of these pharmacotherapies, concurrent behavioral treatment is critical to retain the patient in treatment and maintain adherence to medication treatment. Contingency management programs in which patients receive vouchers that can be used to purchase pro-social goods and services are the most common reinforcer approaches used to initiate and maintain stimulant-free urine test results (Anker and Crowley 1982 Boudin 1972 Higgins et al. 1991, 1993, 1994). The major problem with these approaches has been maintaining abstinence after the reinforcers are withdrawn completely and devel-... 

In research and clinical treatment of substance use disorders, pharmacotherapy and psychotherapy are frequently combined. Medication is often used as a maintenance drug, to reduce cravings or intoxication, or to produce aversion to a substance, while the focus of psychotherapy may be to encourage abstinence, teach the patient new coping skills, or improve motivation to address drug or alcohol problems. 

Studies have shown that CM can be used to directly reinforce adherence to medication treatments as well (Petty 2000). Liebson et al (1978) found that methadone-maintained alcohol-dependent patients reduced alcohol use when methadone treatment was contingent on disulfiram consumption. To date, one of the most common applications of CM techniques to pharmacotherapy has been the provision of vouchers or cash contingent upon naltrexone consumption in recently detoxified opioid-dependent patients (Carroll et al. 2001, 2002 Preston et al. 1999). These studies have generally reported significant increases in retention and reductions in opioid use among patients receiving the CM treatment, relative to other therapies. 

These studies suggest that behavioral treatment strategies, such as CRA and CM, can be effective alone and as adjuncts to pharmacotherapy. Whether the emphasis is on abstinence, treatment retention, or medication compliance, the results of studies on behavioral approaches are promising. 

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