Step Therapies

There is still debate whether oral antihistamines control ocular allergy as well as topical antihistamines. Topical antihistamines are recommended before oral agent in step therapy because of the increased risk of systemic side effects with oral drugs. Additionally, topical antihistamines provide faster relief of ocular symptoms. Consider oral antihistamines... 

Yet another related approach to pharmacotherapy management is step protocols or step therapy. Step protocols limit access to certain drugs until less costly alternative drugs have been tried first. For example, a step protocol might require a patient to have tried a relatively low-cost antihistamine, such as chlorpheniramine, before being prescribed a more expensive nonsedating antihistamine. Step therapy procedures were in place at 68.5% of HMOs in 1998 [1]. 

Tositumomab is another anti-CD20 monoclonal antibody and is complexed with iodine 131 (131I). Tositumomab is used in two-step therapy in patients with CD20-positive, follicular non-Hodgkin s lymphoma whose disease is refractory to rituximab and standard chemotherapy. Toxicities are similar to those for ibritumomab and include severe cytopenias such as thrombocytopenia and neutropenia. Tositumomab should not be administered to patients with greater than 25% bone marrow involvement. 

Tablets, 1 mg, may be crushed before swallowing with water. Initially 1-2 tablets should be taken and thereafter, not more than 4 tablets should be taken in 24 h, the sequence should not be repeated for 4 days, and not more than 8 tablets should be taken in a week. Suppositories, 2 mg, are now preferred as part of stepped therapy (above) they are subject to the same maximum dose restrictions. Caffeine enhances both the speed of absorption and peak concentration of ergotamine and is often combined with it (though it may prevent sleep).

This resume of the possibilities open for the treatment of hepatogenic ascites presents a successful step-by-step therapy programme, (s. fig. 16.16)... 

Step therapy for the drug treatment of patients creates a road map to be used with various medications in order to control the disease or medical condition. The initial step is usually the most common one used in this situation. More complex steps are not attempted to correct the patient s situation until the earlier steps have failed. 

Paganelli G, Grana C, Chinol M, Cremonesi M, De Cicco C, De Brand F, et al. Antibody-guided three-step therapy for high-grade glioma with yttrium-90 biotin. Eur J Nucl Med 1999 26 348-357. 

Over the past 5 years, many HMOs have installed requirements for generic substitution, have allowed therapeutic interchange between two drugs of the same class and have increased the use of step-therapy, a form of precertification. (Step-therapy dmgs are not covered until one or more alternative drugs appropriate to the patients condition have been tried first.)... 

Hypokalemia. Hypokalemia associated with thia2ide diuretic therapy has been knpHcated in the increased incidence of cardiac arrhythmias and sudden death (82). Several large clinical trials have been conducted in which the effects of antihypertensive dmg therapy on the incidence of cardiovascular complications were studied. The antihypertensive regimen included diuretic therapy as the first dmg in a stepped care (SC) approach to lowering the blood pressure of hypertensive patients. 

A third study (85) enrolled 7825 hypertensive patients (55% males and 45% females) having diastoHc blood pressures (DBP) of 99—104 mm Hg (13—14 Pa) there were no placebo controls. Forty-six percent of the patients were assigned to SC antihypertensive dmg therapy, ie, step 1, chlorthaUdone step 2, reserpine [50-55-5] or methyldopa [555-30-6], and step 3, hydralazine [86-54-4]. Fifty-four percent of the patients were assigned to the usual care (UC) sources in the community. Significant reductions in DBP and in cardiovascular and noncardiovascular deaths were noted in both groups. In the SC group, deaths from ischemic heart disease increased 9%, and deaths from coronary heart disease (CHD) and acute myocardial infarctions were reduced 20 and 46%, respectively. 

A number of psychosocial treatments for alcohol and other substance use disorders exist and are widely used. In this chapter, we discuss six of these psychotherapies as they are applied to alcohol, cocaine, and opioid dependence brief interventions, motivational enhancement therapy, cognitive-behavioral therapy, behavioral treatments (including contingency management and community reinforcement approaches), behavioral marital therapy, and 12-step facilitation. We also describe studies that examined the efficacy of a medication in combination with one or more of the six psychotherapies. In the second section of the chapter, we highlight research that directly studied the interaction between psychosocial and pharmacological treatments. 

A number of randomized chnical trials have demonstrated the efficacy of CBT for treating substance use disorders, compared with no-treatment control conditions (see Carroll 1996 for review). However, the superiority of CBT over other psychosocial treatments is not as clear. Although some studies have found CBT to be more effective than other treatments, others have found this method to be comparable to other treatment approaches (Carroll 1996). In Project MATCH, for instance, CBT, MET, and 12-step facihtation produced similar outcomes, with each therapy leading to substantial improvement in alcohol-related symptoms during the 12-week treatment period (Project MATCH Research Group 1997). 

Alcoholics Anonymous (AA) is a self-help organization for people whose common goal is recovery from alcoholism, and it is the most widely accessed resource for individuals with alcohol problems (McCrady and Miller 1993). The philosophy is based on the concept of alcoholism as a chronic disease that cannot be cured, but one that can be halted by means of complete abstinence. AA has described 12 principles or steps to guide those in recovery. Twelve-step facilitation, a manual-based psychotherapy to promote AA participation (Nowinski et al. 1992), was equally efficacious, compared with cognitive-behavioral and motivational enhancement therapies, in a large study of treatments for alcohol dependence (Project Match Research Group, 1997). 

In other substance use disorders, the use of 12-step interventions is also popular, and participation in 12-step groups is correlated with better outcomes in cocaine abusers (e.g., McKay et al. 1994). However, a smdy of 128 cocaine abusers found that cognitive-behavioral therapy was more efficacious than 12-step facilitation in engendering cocaine abstinence (Maude-Griffm et al. 1998). Thus, the relative efficacy of 12-step approaches for drug use disorders requires further investigation. No known studies have systematically evaluated the efficacy of 12-step treatments in opioid-dependent patients, either alone or in conjunction with pharmacotherapies. 

Nowinski J, Baker S, Carroll K Twelve-Step Facilitation Therapy Manual A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence. Project MATCH Monograph Series, Vol 1 (DHHS Publ No ADM-92-1893). Rockville, MD, National Instimte on Alcohol Abuse and Alcoholism, 1992... 

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