scholarly journals LO18: The effectiveness of parenteral agents to reduce relapse in patients with acute migraine in emergency settings: a systematic review

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S13
Author(s):  
J. Meyer ◽  
L. Visser ◽  
S. Kirkland ◽  
C. Villa-Roel ◽  
D. Junqueira ◽  
...  
Keyword(s):  
Systematic Review ◽  
Adverse Events ◽  
Acute Care ◽  
Care Setting ◽  
Grey Literature ◽  
Third Party ◽  
Acute Care Setting ◽  
Acute Migraine ◽  
Common Occurrence ◽  
Headache Recurrence

Introduction: Although a variety of parenteral agents exist for the treatment of acute migraine, relapse after an emergency department (ED) visit is still a common occurrence. The objective of this systematic review was to update a previous review examining the effectiveness of parenteral agents for the treatment of acute migraine in the ED or equivalent acute care setting; our review focused on those studies aiming a reduction in relapse after an ED visit. Methods: A comprehensive search of 10 electronic databases and grey literature was conducted to identify comparative studies to supplement the previous systematic review. Two independent reviewers completed study selection, quality assessment, and data extraction. Any discrepancies were resolved by third party adjudication. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity (I2) was reported. Results: Titles and abstracts of 5039 unique studies were reviewed, of which, 51 studies were included. Sixty-four studies from the original review were included, resulting in a total of 115 included studies. Relapse was reported in 44 (38%) included studies and occurred commonly in patients receiving placebo or no interventions (median = 39%; IQR: 14%, 47%). Overall, no differences in headache relapse were found between patients receiving sumatriptan or placebo (RR = 1.09; 95% CI: 0.55, 2.17; I2 = 93%; n = 8). Conversely, patients receiving neuroleptic agents experienced fewer relapses compared to placebo (RR = 0.27; 95% CI: 0.12, 0.58; I2 = 0%; n = 3); however, patients receiving neuroleptics reported an increase in adverse events (RR = 1.87; 95% CI: 1.17, 3.00; I2 = 0%; n = 3). Compared to placebo, patients receiving dexamethasone were less likely to experience a headache recurrence (RR = 0.71; 95% CI: 0.53, 0.95; I2 = 60%, n = 9); however, no differences were found in reported adverse events (RR = 1.09; 95% CI: 0.81, 1.47; I2 = 0%; n = 3). Conclusion: Relapse is a common occurrence for patients with migraine headaches. This review found patients receiving neuroleptics or dexamethasone experienced fewer headache recurrences. Conversely, triptan agents appear to have minimal effect on reducing the risk for headache recurrence following discharge from an acute care setting. Limited available data on adverse events is an important limitation to inform decision-making. Guidelines should be revised to reflect these results.

scholarly journals LO19: Should emergency physicians bother offering triptans to patients with acute migraine? A systematic review of parenteral agents

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S13-S14
Author(s):  
L. Visser ◽  
J. Meyer ◽  
S. Kirkland ◽  
C. Villa-Roel ◽  
D. Junqueira ◽  
...  
Keyword(s):  
Systematic Review ◽  
Acute Care ◽  
Care Setting ◽  
Grey Literature ◽  
Pain Scale ◽  
Third Party ◽  
Acute Care Setting ◽  
Acute Migraine ◽  
Scale Scores ◽  
Anti Inflammatory

Introduction: Acute migraine headaches are common causes of presentation to the emergency department (ED). There is great variability in the efficacy of the available parenteral agents to manage pain, though triptans are among the recommended treatments. The objective of this systematic review was to update a previous review examining the effectiveness of parenteral agents for the treatment of acute migraine in the ED or equivalent acute care setting; our review examined pain management in emergency settings and assessed the effectiveness of triptan agents. Methods: A comprehensive search of 10 electronic databases and grey literature was conducted to supplement the previous systematic review. Two independent reviewers completed study selection, quality assessment, and data extraction. Any discrepancies were resolved by third party adjudication. Pain scale scores were analyzed using standardized mean difference (SMD) with 95% confidence intervals (CIs) calculated using a random effects model; heterogeneity (I2) was reported. Results: Titles and abstracts of 5039 unique studies were reviewed, of which, 51 studies were included. Sixty-four studies from the original review were included, resulting in a total of 115 included studies. Pain was measured within the ED or equivalent acute care setting using a variety of pain scales, most commonly the 0-10 cm or 100 mm visual analog scale. Four studies compared pain scores between patients receiving sumatriptan vs. other agents, of which, patients receiving sumatriptan reported higher pain scale scores (SMD = 0.53; 95% CI: 0.04, 1.02; I2 = 80%). In particular, patients receiving sumatriptan reported higher pain scale scores than patients receiving metoclopramide (SMD = 0.68; 95% CI: 0.31, 1.04; n = 1) or ketorolac (SMD = 1.39; 95% CI: 0.56, 2.21; n = 1). Overall, studies comparing anti-inflammatory agents (i.e., ketorolac or dexketoprofen) to other agents reported improved pain scale scores among patients receiving anti-inflammatory agents (SMD = -0.38; 95% CI: -0.73, -0.03; I2 = 66%; n = 5). Conclusion: Limited evidence suggests that patients treated with metoclopramide or anti-inflammatory agents experience greater pain reduction compared to patients treated with sumatriptan. This review will conduct a network analysis of parenteral agents to examine the comparative effectiveness of parenteral agents to manage pain among patients with acute migraine. Further analysis will also consider the balance between efficacy and adverse events.

A Systematic Review of ICU and Non-ICU Clinical Pharmacy Services Using Telepharmacy

2018 ◽  
Vol 52 (12) ◽  
pp. 1250-1258 ◽  
Author(s):  
Kyle Strnad ◽  
Bethany R. Shoulders ◽  
Pamela L. Smithburger ◽  
Sandra L. Kane-Gill
Keyword(s):  
Systematic Review ◽  
Patient Care ◽  
Acute Care ◽  
Patient Outcomes ◽  
Clinical Pharmacy ◽  
Care Setting ◽  
Pharmacy Services ◽  
Acute Care Setting ◽  
Nursing Satisfaction ◽  
Clinical Pharmacy Services

Objective: To assess the impact of telepharmacy services in the acute care setting. Data Sources: EMBase, MEDLINE, and SCOPUS database searches were performed through April 2018. Study Selection and Data Extraction: PRISMA guidelines were applied for this systematic review. All English-language studies meeting the criteria of the following population, intervention, comparison, and outcome question were included: What impact does the provision of inpatient clinical pharmacy services delivered via telemedicine have on patient outcomes compared with standard of care? Data Synthesis: A total of 11 studies were identified for the acute care setting, including 3 for critically ill patients. All studies demonstrated a positive impact on patient outcomes, nursing satisfaction, and disease management. Varying modes of telepharmacy technology were used, such as remote access to electronic medical records, faxing or scanning documents, pictures or webcams. For communication purposes, telepharmacists used email or electronic communication, facsimile, video review, or telephone to speak directly with hospital personnel and patients. Relevance to Patient Care and Clinical Practice: Inpatient telepharmacy is feasible and should be leveraged to further enhance patient care by complementing existing service models. Conclusions: Telepharmacy services enhanced patient outcomes, improved nursing satisfaction, and expanded services within inpatient settings. Similar technologies were leveraged in non–intensive care units (ICUs) and ICUs, but the goals of telepharmacy appeared to differ. ICUs focused on an expansion of services in the ICU and non-ICUs addressed improved patient outreach in rural areas.

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