Drug and Therapeutics Bulletin 

About: Drug and Therapeutics Bulletin is an academic journal published by BMJ. The journal publishes majorly in the area(s): Medicine & Pregnancy. It has an ISSN identifier of 0012-6543. Over the lifetime, 277 publications have been published receiving 391 citations. The journal is also known as: DTB.

How to communicate evidence to patients.

Abstract: All medical treatments have potential harms as well as benefits, and it is vital that everyone has a good understanding of what these might be, how dramatic they might be and how likely. In fact, in the UK, the Montgomery judgement in the supreme court in 2015 (see Box 1) has made it a legal necessity for patients to be given comprehensible, personally relevant information about all reasonable treatment options, including none.1 So, how should we ensure good, clear communication of relevant evidence? Box 1. ### The Montgomery judgement In 1999, Nadine Montgomery was preparing for the birth of her son Sam. She was of small stature, with diabetes, and was concerned about being able to give birth naturally. Unfortunately, difficulties did arise during birth, and Sam suffered brain damage as a result. Her obstetrician had not discussed the risk of this particular complication occurring, deeming it best Nadine attempted a vaginal birth. On appeal at the supreme court, Nadine Montgomery won her case. This laid down a new legal basis for informed consent, in line with the General Medical Council guidelines;1 > “The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.” > > “The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient's position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it. ” > > “The assessment of whether a risk is material cannot be reduced to percentages. The significance of a given risk is likely to reflect a variety of factors besides its magnitude” > > “The doctor’s advisory role involves dialogue, …

Central sensitisation: another label or useful diagnosis?

Abstract: ### Key learning points Chronic pain affects up to 30% of the Western population with a prevalence higher than any other chronic disease.1 Chronic pain is often of a non-specific nature, implying that there is no tissue damage, or that tissue damage is not severe enough to explain the pain experience and/or related symptoms. This non-specific nature accounts for non-cancer pain as well as post-cancer pain (ie, pain in cancer survivors). Chronic pain has a significant personal and socioeconomic impact: among long-term conditions, it is responsible for the highest number of years lived with disability and is the most expensive cause of work-related disability.2–4 Chronic pain also decreases life expectancy, in part due to excess deaths from cancer and cardiovascular disease.5–7 Over the past decades, neuroscience has advanced our understanding about pain, including the role of CNS sensitisation—more briefly termed central sensitisation (CS). The original definition for CS—‘an amplification of neural signaling within the CNS that elicits pain hypersensitivity’—originated from laboratory research, but nowadays the chronic pain management field has more or less …

Overview of Gilbert's syndrome.

Abstract: ### Key learning points Gilbert’s syndrome (GS) is a benign hereditary disorder of bilirubin conjugation resulting in an isolated, elevated blood level of unconjugated bilirubin.1 GS affects 2%–10% of the Caucasian population in the Western world.2,3 The inheritance pattern for GS is commonly autosomal recessive, but can be dominant as well; however, genetic counselling is not necessary as there is no impact on life expectancy. For the patient, however, the condition may be an initial cause for concern as they commonly present with painless, non-pruritic jaundice or an incidental finding of hyperbilirubinaemia on routine blood testing. Episodes of jaundice may be exacerbated by heavy physical exertion, fasting, sleep deprivation, alcohol, dehydration, surgery and concurrent illness. Patients will have normal liver enzymes, normal liver synthetic function (clotting, albumin) and a negative haemolysis screen. GS is a diagnosis of exclusion. The primary care practitioners’ main aim is to confirm the diagnosis, reassure the patient and clarify any concerns related to the condition. GS does not require secondary care referral and is largely asymptomatic. Observational studies highlight that the antioxidant effect of unconjugated bilirubin may confer a survival benefit to patients,4,5 and indeed, the greatest risk to those with the condition is in pursuit of an alternative diagnosis. Patients should …

Stopping, rationalising or optimising antipsychotic drug treatment in people with intellectual disability and/or autism.

Abstract: ### Key learning points Intellectual disability (ID; also known as learning disability) is characterised by significant impairment of both cognitive functioning and adaptive behaviours, and an onset in early childhood. People with ID experience a different pattern of morbidity to the general population and die considerably younger than their counterparts without ID.1 Autism is a neurodevelopmental disorder characterised by troubles with social interaction and communication, and by restricted and repetitive behaviour. In both conditions, complex mental and physical health problems, as well as social issues, are common and are associated with communication difficulties that can result in maladaptive behavioural patterns (often referred to as ‘behaviour that challenges’). Ideally, all people presenting with behaviour that challenges should be assessed by a specialist multidisciplinary team (comprising psychiatrists, psychologists, speech and language therapists, occupational therapists) to develop an understanding of the behaviour and an appropriate support plan with tailored treatment strategies and specialist follow-up.2 Non-pharmacological interventions for challenging behaviour, such as positive behavioural support or cognitive–behavioural therapy and manipulation of environmental triggers, are preferred to psychotropic medication. However, antipsychotic medication is often prescribed to adults with ID and/or autism to manage behaviour that challenges in the absence of severe mental illness, despite there being little research evidence that antipsychotics are effective in this context.3 There …

Where now for opioids in chronic pain

Abstract: Video 1 ### Key learning points Chronic pain has always been and will remain difficult to manage. There have been important developments in our understanding of the neurobiology of pain, but perhaps the greatest advance is our ability to analyse trial data more critically and to realise that we may have been wrongly optimistic about the use of some therapies. Although the publication of high-quality literature reviews may have reduced our therapeutic options, it also provides an opportunity to improve patient care by ensuring that we are not exposing patients with pain, whose lives are difficult enough as it is, to the harms of medicines that do not help them. In particular, there is a need to reconsider the place of opioids in the management of chronic pain. This includes the so-called weak opioids (eg, codeine and dihydrocodeine), and strong opioids (eg, morphine, oxycodone, fentanyl and buprenorphine), as well as tramadol (a non-selective agonist at mu, delta and kappa opioid receptors with monoaminergic properties), which should be considered alongside the strong opioids. Opioids emerged into the chronic pain management scene in the 1990s. The recognition of their potent role in the management of acute and end-of-life pain, the inappropriate adoption of WHO analgesic ladder designed for …