Stepped care approach

Use a step-care approach for treatment of allergic conjunctivitis. 

Monitor patients for relief of symptoms. Ensure an adequate trial of the agent. If no improvement is seen, follow a stepped-care approach to treatment. Refer severe cases that do not respond to an ophthalmologist for short-term topical corticosteroids. 

Drugs that inhibit the presynaptic synthesis and storage of norepinephrine are discussed in Chapter 20. The drugs in this category used to treat hypertension are listed in Table 21-4. These drugs are often used in conjunction with other agents in the stepped-care approach to hypertension (see Stepped-Care Approach to Hypertension ). 

In general, treatment of ocular allergic disease is based on symptoms, severity, and characteristics of the allergic reaction. A stepped-care approach to therapy has been advocated, whereby treatment aggressiveness is tailored to the level of disease. When possible, avoidance of environmental allergens such as pollen, dust, and grasses is a key fector in management. 

C. A pathophysiological interpretation of unresponsiveness to spironolactone in a stepped-care approach to the diuretic treatment of ascites in nonazotemic cirrhotic patients. Hepatology 1991 14 231-236... 

According to Sobell and Sobell (2000, pp. 573-574), in the stepped care approach the selection of any treatment is guided by three principles (1) Treatment should be individualized with regard to the client s needs and problems, (2) tltc treatment selected should be consistent with tlie current knowledge about effectiveness, and (3) the treatment that is chosen should be the least restrictive (considering the physical effects of treatment on the client and the client s lifestyle and resources). A consequence of the third principle is that more-intensive treatments are reserved for more severe problems. 

The stepped care approach seems simple in principle but may be complex in application. To use this approach in real clinical settings, several questions have to be considered. Are any scientifically supported treatments available for an individual s needs at a given time Will an individual accept the treatment indicated by the stepped care approach Will he or she be able to afford it What is improvement When is behavior stable ... 

Despite these and other difficult questions, the stepped care approach fits well with our current knowledge about change in patterns of alcohol and drug use and about the economics of treatment delivery. Stepped care fits what we know because it fosters a scientifically based, individualized delivery of effective treatment in the most efficient, least restrictive, and least expensive way. Indeed, major forces in addiction treatment, represented by the model of addiction treatment matching of the American Society of Addiction Medicine (Gastfriend, 2003), and the substance-abuse treatment guidelines of the U.S. Department of Veterans Affairs Healthcare System, take a stepped care approach. 

Schmidt, U., P. J. Cooper, H. Essers, C. P. Freeman, R. L. Holland, R. L. Palmer, et al. (2004). Fluvoxamine and graded psychotherapy in the treatment of bulimia nervosa a randomized, double-blind, placebo-controlled, multicenter study of short-term and long-term pharmacotherapy combined with a stepped care approach to psychotherapy. J Clin Psychopharmacol 24(5) 549-52. 

The availability of many over-the-counter drugs that were formerly prescription medications enables some migraine patients to self-medicate and delay entry into appropriate medical management. Some clinicians feel that over-the-counter products invite patients to take a less effective step-care approach rather than being treated according to evidence-based guidelines. 

Monotherapy with these mixed-acting antihypertensive drugs reduces blood pressure as effectively as other major antihypertensives and their combinations (15,16,17). In the stepped-care approach to antihypertensive drug therapy, mixed a/p-blockers are recommended for initial management of mild to moderate hypertension (step 1). Both drugs effectively lower blood pressure in essential and renal hypertension. Carvediioi also is effective in ischemic heart disease. 

The selection of these drugs for monotherapy or in the stepped-care approach is based on several factors, including their similar mechanism of action, preexisting conditions, pharmacokinetics, distribution, and metabolism. The Q2-adrenergic antagonists show a similarity in adverse effects. 

Hydralazine is used in the management of moderate to severe hypertension. In the stepped-care approach to antihypertensive drug therapy, hydralazine has been suggested as a step 2 or step 3 drug ... 

Hypertension is treated using a stepped-care approach. Each step uses a different group of antihypertensive dmgs to control hypertension. There are four steps. 

Antihypertensive dmgs are used to treat hypertension by using a stepped-care approach where groups of antihypertensive dmgs are used in succession if blood pressure isn t at first decreased. Angiotensin antagonists are used primarily to treat hypertension and some are also effective in treating heart failure. 

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