Rescue medication

There is now good evidence that the clinical manifestations of asthma symptoms - impairment of lung function, sleep disturbances, limitations of daily activity, and the use of rescue medications - can be controlled with appropriate treatment. When asthma is controlled, there should be no more than occasional recurrence of symptoms and severe exacerbations should be rare. 

Norton L. Dunn Galvin A. Hourihane JO B Allergy rescue medication in schools modeling a new approach. J Allergy Clin Immunol 2008 122 209-210. 

Evaluate therapy on a regular basis. Assess the patient s control of asthma by evaluating symptoms, PEF diary entries, and rescue medication use. Step long-term control therapy up or down based on these parameters. Before stepping up therapy, reassess the patient s inhaler technique to assure appropriate drug delivery. 

Opioids and derivatives (e.g., meperidine, butorphanol, oxycodone, hydromorphone) provide effective relief of intractable migraine but should be reserved for patients with moderate to severe infrequent headaches in whom conventional therapies are contraindicated or as rescue medication after failure to respond to conventional therapies. Opioid therapy should be closely supervised. 

Acute asthma attacks Montelukast is not indicated for use in acute asthma attacks, including status asthmaticus. Advise patients to have appropriate rescue medication available. Montelukast therapy can be continued during acute exacerbations of asthma. 

Dosage individualization Once therapy is initiated, pain relief and other opioid effects should be frequently assessed. Titrate patients to adequate effect (generally mild or no pain with the regular use of no more than 2 doses of supplemental analgesia per 24 hours). Patients who experience breakthrough pain may require dosage adjustment or rescue medication. Because steady-state plasma concentrations are approximated within 24 to 36 hours, dosage... 

Should not be used for immediafe relief of breafhing problems, i.e., as a rescue medication... 

The subjectively perceived severity of withdrawal symptoms and the readiness to withstand them without recourse to rescue medication vary greatly from one person to another. 

The discontinuation of benzodiazepines with a short half-life is particularly difficult and there is a great tendency to use rescue medication after both abrupt and gradual withdrawal. 

Concomitant medication should not be confused with rescue medications. The latter are nonspecific agents (or potentially effective drugs used in subtherapeutic doses) used so that patients can remain in the study for an adequate time, allowing for a valid comparison between the experimental agent and placebo (or standard drug). Often, rescue medications are used in the early phases and are decreased or eliminated before the critical evaluation at the end of the study. This enables more patients to complete the study (fewer dropouts), with the early impact of the rescue medication having at best only minimal effects on the final evaluations. 

From the perspective of clinical trial methodology, concurrent medications can create a dilemma for the investigator by complicating the interpretation of results. Intermediate rescue medications are often required, however, because mood stabilizers are relatively slow in their onset of action. Further, if rescue medications are avoided, this usually introduces the confound of dropouts before the experimental drug can be fully effective. When feasible, a reasonable compromise is the use of modest amounts of a benzodiazepine (BZD), such as lorazepam, only when necessary for a limited time (e.g., 7 to 10 days) into the active phase of treatment. This can reduce the number of nonresponding, highly agitated patients who may otherwise drop out of treatment and in a trial of several weeks, the initial lorazepam effect should have dissipated by the final assessments. 

Valproate Versus Lithium. The previously discussed Bowden et al. (135) study found the DVPX formulation to be comparable with lithium, which was used as a positive comparator in this placebo-controlled study. Freeman et al. (99) conducted a 3-week, double-blind, parallel-group comparison of VPA and lithium for acute mania. Both drugs demonstrated clinically significant efficacy (i.e., 9 of 14 responded to DVPX and 12 of 13 to lithium), and there was no difference in the need for rescue medications (i.e., lorazepam or chloral hydrate) between the two treatment groups. Response to VPA was associated with high pretreatment depression scores. 

Verapamil Versus Other Psychotropics. Garza-Trevino et al. (258) conducted a 4-week, randomized, double-blind study comparing verapamil with lithium for acute mania and found no clinical or statistically significant differences between the two treatments. These results are difficult to interpret, however, because data about the amount and timing of rescue medication (i.e., haloperidol, lorazepam) were not presented. Further, more patients on verapamil required these agents. 

In a randomized, single-blind trial of 40 patients receiving lithium or verapamil, Walton et al. ( 263) found lithium to be superior to verapamil on all measures. Potential confounding factors included the use of lorazepam throughout the study as a rescue medication given both intravenously and orally, a 1-day washout period, and the use of antipsychotic medications on the last day of the study. 

The efficacy of subcutaneous SIT has been clearly shown in a metaanalysis of 43 double-blind placebo-controlled trials in allergic rhinitis as well as another meta-analysis of 16 double-blind placebo-controlled studies in asthma patients [13]. The mean clinical improvement was 45% reduction in symptoms and medication compared with placebo in rhinitis and 40% in asthma patients, which exceeds the effects of drug therapy. A recent meta-analysis also confirmed that asthma responds favorably to SIT [14], However, recently it could also be demonstrated that SIT is effective in patients with house dust mite allergy, allergic rhinitis and asthma [15]. Immunotherapy in these patients not only reduced rhinitis and asthma symptoms as well as rescue medication, but also had an impact on bronchial hyperreactivity over the 3-year follow-up period. 

Fig. 17.8 Schematic representation of the PK/PD model. C = model predicted drug concentrations in plasma R = the free form of the calcitonine gene-related peptide (CGRP) receptor R = the blocked form of the CGRP receptor, which has been related to the severity of headache and time to rescue medication using logistic regression and time-to-event analysis.

Conclusion A population PK/PD modeling for BIBN4096 was successfully developed describing the plasma concentration-time profiles of BIBN4096 and its influence on the severity of the headache and the time to rescue medication. 

In a double-blind study, 144 agitated patients who required emergency sedation were randomized to ziprasidone 20 mg (n = 46), droperidol 5 mg (n = 50), or midazolam 5 mg (n = 48) (13). Those who were sedated with droperidol or ziprasidone required rescue medications to achieve adequate sedation less often than those who were sedated with midazolam more remained agitated at 15 minutes after ziprasidone. There was akathisia in one patient who received droperidol, one who received midazolam (and subsequently droperidol rescue sedation), and four who received ziprasidone. There were no other adverse events. 

Is there a team of mental health workers specifically trained in critical incident stress management available to debrief rescuers and hospital personnel If not, who will be available to provide stress management for rescue/medical personnel ... 

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