Damage to the uterus, the fallopian tubes and the ovaries
David J Cahill in Practical Patient Management in Reproductive Medicine, 2019
Medical options include the use of gonadotrophin-releasing hormone agonist drugs (GnRHa drugs), or ulipristal, a selective progesterone receptor modulator (SPRM). These not only have a place in the medical management of fibroids, but they are also frequently used prior to myomectomy or hysterectomy to shrink fibroids, making the surgical procedure safer and easier. The GnRHa family (e.g. triptorelin, goserelin, leuprolide acetate) all shrink fibroids effectively (16). The maximum effect of fibroid shrinkage is likely to be achieved within 3–4 months. Treatment can continue beyond that to maintain the smaller size if the woman needs to lose weight or improve respiratory function or haemoglobin before surgery. The negative effect of long-term GnRHas on bone density means that treatment should not go beyond 6 months in the absence of ‘add-back’ therapy. Add-back therapy is a medication (generally some form of hormone replacement therapy [HRT]), to offset and minimise the menopausal side effects that women experience on GnRHa treatment, particularly bone loss. Tibolone is converted into three major metabolites, two of which have oestrogenic effects, and one which has progestogenic and androgenic effects (17). It is the most effective drug for managing bone loss and vasomotor symptoms associated with GnRNa use (18).
Uterine fibroids
David M. Luesley, Mark D. Kilby in Obstetrics & Gynaecology, 2016
In women who have contraindications to surgery or decline surgery and in whom other medical measures have failed, long-term relief of HMB may be achieved with GnRH agonists in combination with low-dose hormone replacement therapy (HRT).6,10 It has been suggested that the GnRH agonist should be administered alone for 3 months to obtain fibroid shrinkage6 before addition of the HRT [E]. Add-back therapy with tibolone maintains fibroid shrinkage and symptom relief while reducing vasomotor symptoms and preventing bone loss [B].24 Low-dose oral oestrogen–progestogen combinations also relieve hypo-oestrogenic side effects and protect bone6,10 and are less costly than tibolone. Currently there is a lack of evidence relating to the optimum choice of add-back therapy.
Novel treatment modalities
Seema Chopra in Endometriosis, 2020
GnRH agonists are available in both nasal and injectable forms and offer high rates of pain relief and a longer symptom-free period for up to 12 months. Leuprolide acetate 3.75 mg monthly injection or 11.25 mg used every 3 months; goserelin and nafarelin are the most commonly used preparations. Studies have shown that GnRH agonists cause significant reduction in pelvic pain in women with endometriosis; however, they are approved for continuous use for only up to 6 months due to concerns of side effects secondary to hypoestrogenism, such as bone loss, vaginal atrophy and dryness, hot flashes, and abnormalities in lipid profiles [26]. The addition of add-back therapy provides symptomatic relief and decreases the rate of bone loss. Norethindrone acetate, a progestin, is the only FDA-approved add-back therapy, but low-dose estrogen and a combination of estrogen and progesterone have also been used [27]. The combination of GnRH agonists and norethindrone acetate are only approved for use for a duration of 12 months, as the data beyond that duration are not available. Another limitation of the use of GnRH agonists is that they suppress ovulation and cannot be used in women desiring fertility.
Treatment patterns among patients with psoriasis using a large national payer database in the United States: a retrospective study
Published in Journal of Medical Economics, 2019
Mwangi J. Murage, David M. Kern, Lawrence Chang, Kalyani Sonawane, William N. Malatestinic, Ralph A. Quimbo, Steven R. Feldman, Talia M. Muram, Andre B. Araujo
The treatment classes of interest in this study were topicals, phototherapy, non-biologic systemic treatments, and biologics. Up to four lines of treatment were identified for each individual. Treatment characteristics were captured from initiation of each treatment line through discontinuation of the current treatment regimen, switching treatment, or adding a new therapy. Discontinuing therapy was defined as having no claim of the current treatment for 90 days after the date the previous therapy claim supplied would have been completed. Among patients who discontinued treatments, the discontinuation date was defined as the last medication claim date plus the days supplied for that claim. A treatment switch was defined as a patient filling a treatment class that was different from any treatment class in their current or most recent regimen without continuing on the original therapy; discontinuing a medication and then restarting the same treatment was not classified as a switch. Add-on therapy was defined as filling an additional medication class while continuing therapy of another medication class. Up to three treatment changes (adding or switching) were captured, resulting in up to the first four lines of therapy being captured.
Usage of long-acting muscarinic antagonists and biologics as add-on therapy for patients in the United States with moderate-to-severe asthma
Published in Journal of Asthma, 2022
C. Victor Spain, Parul Dayal, Yingjie Ding, Carlos Iribarren, Theodore A. Omachi, Hubert Chen
Despite the common use of inhaled corticosteroids (ICSs) combined with long-acting beta-agonists (LABAs), the standard-of-care asthma treatments, many patients experience uncontrolled symptoms. Historically, treatment options for patients who remain uncontrolled on ICS/LABA were limited mainly to leukotriene modifiers and methylxanthines (e.g. theophylline), of which neither proved greatly effective (1–5). Over the past decade, global asthma treatment guidelines have evolved, and now include additional options for add-on therapy, specifically LAMAs (long-acting muscarinic antagonists) and several biologics (6). Clinical guidance for selecting the appropriate add-on therapy remains limited, however, and to date, our understanding of patient and provider characteristics associated with add-on therapy usage in general US clinical practice is incomplete.
Incremental net monetary benefit of biologic therapies in moderate to severe asthma: a systematic review and meta-analysis of economic evaluation studies
Published in Journal of Asthma, 2023
Sajesh K. Veettil, Vanessa Vincent, Taylor Shufelt, Emma Behan, M. Sakil Syeed, Ammarin Thakkinstian, David C. Young, Nathorn Chaiyakunapruk
According to the European Respiratory Society/American Thoracic Society guidelines (50), patients with uncontrolled severe asthma are those who need to use systemic steroids for symptom control, despite the application of high-intensity treatments corresponding to the stages 4–5 of the GINA guideline (4), excluding all other diagnostic possibilities, comorbidities, worsening factors, compliance, and so on that correspond to severe asthma. Despite being less prevalent, moderate to severe asthma patients use more than 50% of the treatment cost for asthma due to increased use of medications, and frequent outpatient and emergency room visits and hospitalizations (51). Additionally, uncontrolled asthma symptoms can result in significant social economic consequences, including decreased quality of life for patients and their families and negative impact on their academic and professional performance, which lowers productivity (51). Add-on therapy with biologic drugs is effective in reducing exacerbations and hospitalizations, and it may reduce the overall burden of the disease condition. However, it is still questionable whether using these drugs would provide good economic value considering the relatively high costs of these agents for many countries. So far, six biologics (omalizumab, mepolizumab, reslizumab, benralizumab, Tezepelumab and dupilumab) have been approved for severe asthma endotypes, defined as allergic, eosinophilic or type 2 depending on which product is being marketed (52) and several more are in the process of development.
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