Considerations on the use of oxymorphone in geriatric patients
ABSTRACT Pain among the elderly is pervasive, under-treated and can be properly managed by judiciously using analgesics in the armamentarium. For severe pain, opioids generally provide the most effective pain relief, but concerns about safety and tolerability have limited, often unnecessarily, their utilization in the geriatric population.
It is common for geriatric patients to be taking more than one medicine. Oxymorphone might be particularly well suited for use in geriatric patients, in that its metabolism is mainly through non-CYPP450 pathways, thereby posing less risk of interaction with the many drugs that are metabolized by the CYPP450 system. However, oxymorphone is not as familiar to clinicians as morphine or some other opioids. We review here the clinical studies on oxymorphone to outline the key considerations for use of oxymorphone in the geriatric population.
Nine available clinical trials of oxymorphone alone or comparing oxymorphone with placebo or other active agents were analyzed with respect to the safety and tolerability findings. These studies included geriatric patients but were not designed to evaluate oxymorphone exclusively in this population.
Based on the results from nine published clinical studies, oxymorphone is an effective opioid analgesic with a safety profile at least comparable to other opioid drugs. At low starting doses and individual titration, oxymorphone should be considered for appropriate geriatric patients, particularly in whom there is concern about interaction with drugs that are metabolized by CYPP450 enzymes.
Conference Paper: Robust channel estimation in wireless LANs for mobile environments[Show abstract] [Hide abstract]
ABSTRACT: The recently developed wireless LAN systems, HIPERLAN/2 and IEEE 802.11a, operate in the 5 GHz frequency range and were originally designed for stationary terminals in slowly time-varying environments. Hence, pilot symbols for channel estimation are only provided at the beginning of a burst (in the preamble), since the channel behaviour is assumed not to change significantly over the burst duration. In order to support new scenarios with higher terminal mobility, it is essential to track the changes of the channel transfer function over time. We focus on techniques for a robust channel estimation, mainly based on enhanced pilots (EP). Three different channel tracking schemes are developed and applied to the wireless LAN systems: (1) use of scattered pilots; (2) use of midambles; (3) an additional decision-directed technique, combined with the midamble concept. The performance of the different methods is studied and compared quantitatively. As a result, suitable channel tracking techniques for different terminal speeds and data rates are proposed.Vehicular Technology Conference, 2002. Proceedings. VTC 2002-Fall. 2002 IEEE 56th; 02/2002
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ABSTRACT: Musculoskeletal pain in the elderly is common and disabling. As the conditions causing rheumatic pain, including osteoarthritis, inflammatory arthritis and soft-tissue conditions such as tendonitis and bursitis, are, for the most part, not curable, pain control is paramount in order to maintain quality of life. Pain management should be multimodal and tailored to the individual patient, and will likely include a combination of both nonpharmacological and pharmacological interventions. Nonpharmacological treatments begin with education of the patient, encouragement to practise self-management strategies and attention to healthy life habits such as weight control and regular physical activity and exercise. Advice in this regard may be effectively given by healthcare professionals other than physicians. Although herbal products and nutritional supplements are commonly used by patients, studies of their efficacy and safety, especially in the elderly, are limited. In contrast, topical applications, and in particular those containing NSAIDs, are being used more frequently, are associated with fewer adverse effects than oral preparations and offer a new and safer treatment alternative. Similarly, intra-articular and soft-tissue injections of corticosteroids provide an easy and cost-effective option for symptom relief with minimal risk. The use of any pharmacological agent in the elderly should be tempered with caution regarding increased sensitivity to medications, drug-drug interactions and associated co-morbidities. Therefore, the elderly will often require down-adjustment of dosage and careful attention to the risk/benefit ratio of the treatment. There is, however, no single ideal pain medication for management of rheumatic pain. The four broad categories of treatments, namely simple analgesics (i.e. paracetamol [acetaminophen]), NSAIDs, stronger analgesics (i.e. opioids) and adjuvant drugs, each have unique and particular concerns regarding their adverse effect profiles. The continued use of any medication should also be repeatedly assessed to ensure that efficacy is maintained. Throughout the treatment period, physicians must remain vigilant for emergent adverse effects. Patients and physicians should have realistic outcome goals for effective rheumatic pain management. Although complete pain relief is seldom achieved, modulation of pain and the associated components of sleep disturbance, fatigue and mood disorder will improve overall quality of life in the elderly. However, barriers to effective pain management from both the patient and the healthcare professional perspectives still exist, and will be overcome only by educational efforts. Successful rheumatic pain management in the elderly should begin with an accurate diagnosis by the physician, and patients must be realistic in their expectations. Treatments should be multimodal, with attention given to the co-morbidities of pain as well as the global health status of the patient. Whether or not an outcome is favourable should be determined not only by the treatment's impact on pain but also by its capacity to improve function and enhance quality of life. The wider range of treatment options now available is both useful and encouraging for the physician managing musculoskeletal aches and pain in the elderly.Drugs & Aging 06/2010; 27(6):471-90. DOI:10.2165/11536530-000000000-00000 · 2.84 Impact Factor
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ABSTRACT: Drugs without a strong evidence base and outside of recommendations are too often prescribed for older adults. Established guidelines such as Beers criteria have identified both specific medications and certain drug classes as inappropriate for older adults, primarily due to adverse effects. Age-related physiological changes in distribution, metabolism, and elimination often alter the effects of pharmacotherapies in older adults. When designing a therapeutic program, all elements contributing to the pathophysiology of painful conditions should be considered, as well as the mechanisms of action of analgesic drug classes. Both appropriate and inappropriate medications for older adults are detailed herein, as well as their contraindications and potential drug-drug or drug-disease interactions. The number needed to treat (NNT) can be useful in considering efficacy, while the safety of a pharmacotherapy is indicated by the calculated number needed to harm (NNH). The NNT is a measure describing the number of patients who require treatment for every 1 who reaches the therapeutic goal, and the NNH describes the number of participants who manifest side effects; these can further be segregated into numbers who withdraw from studies due to intolerable side effects. These parameters, along with a patient's comorbidities and concomitant medications, should be considered when selecting an analgesic and dose regimen. In addition, practitioners should avoid prescribing multiple-drug therapies that have overlapping pharmacodynamics or that may have an adverse pharmacokinetic interaction.The journal of pain: official journal of the American Pain Society 03/2011; 12(3 Suppl 1):S21-9. DOI:10.1016/j.jpain.2011.01.001 · 4.01 Impact Factor