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Current recommendations for treating elevated blood pressure (BP) in the acute stroke are based largely on expert opinion and vary with regard to treatment thresholds and choice of antihypertensive agents. In this study we investigate the influence of these recommendations by comparing the management of hypertension in acute stroke at a tertiary care hospital with current guidelines.
Retrospective chart review of patients admitted with acute stroke at The Ottawa Hospital-General Campus over six consecutive months. The use of antihypertensive medications (type, dose, routes of administration, BP recordings) in the first seven days after admission was noted.
Transdermal nitroglycerin paste was the most commonly used antihypertensive agent. In contrast to the 15% reduction in BP over 24 hours recommended for lowering BP in hypertensive patients with ischemic stroke, nitroglycerin caused a >15% reduction of BPover the first 24 hours on 60% of the occasions used. Furthermore, despite concerns about sublingual nifedipine, this was the second most commonly prescribed agent. Surprisingly, the mean time to first BP measurement following initiation of antihypertensive therapy was 117 ± 43 minutes in ischemic stroke and 88 ± 89 minutes in hemorrhagic strokes.
The current guidelines for management of acute poststroke hypertension appear to have little influence on prescribing patterns, leading to considerable variations in practice. Such variations, likely due to uncertainty caused by lack of evidence from randomised controlled trials, are intolerable as patients maybe submitted to nonstandardised, potentially harmful care such as inappropriate choice of antihypertensives and inadequate BP monitoring as observed in this study.
There are presently 26 different generic preparations for five brand name antiepileptic drugs (AEDs) on the Canadian market with others likely to be released in the near future. The purpose of this review is to examine the basis for the controversy surrounding generic substitution for brand name antiepileptic drugs, to present the results of a survey of neurologists' and patients' attitudes toward generic substitution and to increase neurologists'awareness of the issues.
The current federal and provincial regulations pertaining to generic drug approval and substitution are reviewed. Published anecdotal and survey reports of the effectiveness and tolerability of generic substitution for AEDs are reviewed. A pilot questionnaire survey of 83 patients from four adult epilepsy clinics and 46 neurologists from across Canada was undertaken to determine attitudes toward generic substitution.
Results and Conclusions:
Several authors have suggested that some AEDs, particularly those with a narrow therapeutic index, may pose problems with generic substitution. Although generic AEDs are lower in price, possible increased side effects and morbidity and the need for closer monitoring could partially offset the cost savings. The results of our survey highlight significant unawareness of the process of generic substitution among both patients and neurologists and reveal a general level of discomfort among neurologists to prescribe generic AEDs. Further data should be obtained about the potential consequences of generic substitution in epilepsy patients.
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