Adis Medical Writers’s research while affiliated with Springer Nature and other places

Obesity in children, often accompanied by comorbidities, is increasingly common. For many frequently used paediatric drugs, information on dosage adjustment in obese children is lacking or absent. Scalars, such as total body weight, are not always helpful as obese children may weigh more than adults, but differ with regard to aspects of their anatomy and physiology, especially hepatic function. Further pharmacokinetic studies in obese children are urgently needed and, in the interim, close monitoring for therapeutic effect and toxicity is recommended.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in patients with type 2 diabetes (T2D). Not only is T2D a risk factor for ASCVD, common comorbid conditions, such as dyslipidaemia and hypertension, are also risk factors for ASCVD. Controlling these risk factors with agents with proven cardiovascular benefits (e.g. metformin, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 receptor inhibitors, statins, ACE inhibitors and angiotensin receptor blockers) provides considerable clinical benefits.

Patients with moderate-to-severe atopic dermatitis may have partial or non-durable responses to subcutaneous dupilumab, the first targeted systemic agent approved for this indication. Subsequent management approaches in such patients include optimising topical therapy, considering alternative diagnoses, adjusting the dosage of dupilumab dosage and/or using dupilumab in combination with traditional systemic immunosuppressive agents.

Morbidly obese individuals often require surgery, including bariatric (weight management) surgery. Acute pain management in the morbidly obese must consider the risk of chronic post-surgical pain, opioid dependence, and comorbidities (e.g. sleep-disordered breathing). A stepped, multimodal, opioid-sparing approach titrated to the type and severity of pain type should be taken, with co-administration of systemic and local anaesthetic agents when appropriate.

Glaucoma is a leading cause of bilateral blindness. Phosphodiesterase type 5 inhibitors (PDE5Is; e.g. avanafil, sildenafil, tadalafil and vardenafil) may increase blood flow to the ciliary body, thereby elevating intraocular pressure and increasing the risk of glaucoma. PDE5Is are commonly used to treat erectile dysfunction, as well as benign prostatic hyperplasia (tadalafil) and pulmonary hypertension (sildenafil). Patients receiving PDE5Is require glaucoma education and ongoing screening, especially if they are taking a high dosage of a daily PDE5I or have risk factors for glaucoma (e.g. increased age, African-American or Hispanic race, hypertension, intraocular pressure > 21 mm Hg, diabetes, suspicious eye changes or a family history of glaucoma).

Congenital hyperinsulinism (CHI) is rare and causes a particularly damaging form of hypoglycaemia that deprives the brain of all critical fuels (i.e. glucose, ketones and lactate). Prompt recognition and treatment are required to avoid brain damage, with some patients needing pancreatectomy. Treatment of acute hypoglycaemia usually involves dextrose or glucagon, and chronic treatment usually involves nutritional therapy (food and supplemental enteral glucose), alongside a stepwise and combination approach with various pharmacological agents (diazoxide, somatostatin analogues and glucagon, rarely nifedipine and, as a last resort, sirolimus).

Long-term use of systemic azole antifungals (i.e. fluconazole, isavuconazole, itraconazole, ketoconazole, posaconazole and voriconazole) can result in serious adverse drug effects (ADEs), such as hepatotoxicity and cardiac effects. Cytochrome P450 inhibition by azoles contributes to many ADEs, such as adrenal insufficiency due to hormone disruption, while pharmacokinetic interactions can lead to myositis or peripheral neuropathy. Other notable ADEs include pancreatitis, bone pain, renal failure, skin cancer and Stevens-Johnsons syndrome. ADEs may be managed with monitoring, adjusting dosages and switching azoles.

Current hypertension treatment guidelines differ somewhat with regard to their recommendations for treating older patients. Based on the characteristics of the individual, antihypertensive treatment can be optimized by using a decision framework that sets therapeutic goals, estimates absolute cardiovascular (CV) risk, accurately measures blood pressure (BP), determines threshold and target BP levels most likely to confer benefit, and considers situations that warrant deprescribing. In general, hypertension should be treated to a target systolic BP (SBP) of no lower than 130 mmHg in older patients who are fit and have high baseline SBP (≥ 160 mmHg), high baseline CV risk or established CV disease, and to a target SBP of 140–160 mmHg in patients who are frail, aged > 80 years without CV disease, or with certain co-morbid conditions.

Biological immunotherapies for multiple sclerosis (MS) include recombinant proteins (preparations of interferon-β) and monoclonal antibodies (e.g. natalizumab, alemtuzumab, ocrelizumab and off-label rituximab). They have shown unprecedented efficacy in the treatment of MS; however, they are all immunogenic and have been associated with immunological complications, such as neutralizing immunogenicity, secondary immunodeficiency and secondary autoimmunity.

Atopic keratoconjunctivitis (AKC) is the most severe form of allergic conjunctivitis and, if inadequately treated, can cause vision loss. Treatment aims to minimize symptoms, recurrence and consequent eye rubbing, which cause long-term eye damage. First-line treatment generally involves the use of topical ophthalmic formulations of mast-cell stabilizers and/or antihistamines, corticosteroids, calcineurin inhibitors and immunomodulators (used in that order). Systemic formulations of these drugs can be used to treat refractory cases of AKC or when deemed appropriate for the individual.