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Mula M.,University Hospital Maggiore Della Carita
Panminerva Medica

The management of patients with epilepsy, especially those with drug refractory syndromes, may be complicated by psychiatric comorbidities that significantly affect prognosis, morbidity and mortality. In general terms, a careful distinction between true psychiatric manifestations and seizure-based phenomena (i.e. peri-ictal psychiatric symptoms) is crucial, having implications in terms of prognosis and treatment. Guidelines of treatment for psychiatric disorders in epilepsy are still lacking. In general terms, internationally adopted guidelines of treatment outside epilepsy may be considered taking into account a number of special issues related to the underlying brain disorder. New compounds are generally well tolerated and reasonably safe in patients with epilepsy. SSRIs, especially citalopram, are considered first line agents in mood and anxiety disorders and new antipsychotics, especially olanzapine, quetiapine and risperidone, in interictal psychoses. The potential for drug interactions is generally minimized although drug dosages need to be adjusted according to clinical response in patients taking inducers (e.g. carbamazepine, barbiturates or phenytoin). Long term tolerability need to be balanced with long term side effects such as weight gain and sedation. Comprehensive treatment of people with epilepsy requires that psychiatric comorbidities are recognized and taken into account in the overall management. Continued clinical research is needed to obtain further knowledge about the optimal use of the expanding antiepileptic armamentarium and on how to tailor treatment to each individual patient according to clinical circumstances. Source

Epis O.M.,Rheumatology Unit | Deidda S.,University Hospital Maggiore Della Carita | Bruschi E.,Rheumatology Unit
Autoimmunity Reviews

In the last decade, treatment strategies for rheumatoid arthritis (RA) have included the early use of disease-modifying anti-rheumatic drugs, since prompt suppression of disease activity is associated with a reduction in radiological damage. This strategy has now been incorporated into the broader concept of "tight control", defined as a treatment strategy tailored to each patient with RA, which aims to achieve a predefined level of low disease activity or remission within a certain period of time. To pursue this goal, tight control should include careful and continuous monitoring of disease activity, and early therapeutic adjustments or switches should be considered as necessary. It is noteworthy that the key role of tight control of RA has been stressed by the recent EULAR Guidelines.This review discusses the most recent evidence concerning the role of a tight control strategy in the treatment of RA, and on how this strategy should be pursued. © 2012 Elsevier B.V. Source

Krengli M.,University of Piemonte Orientale | Terrone C.,University of Piemonte Orientale | Jereczek-Fossa B.A.,University of Milan | Beldi D.,University Hospital Maggiore Della Carita | Orecchia R.,University of Milan
Critical Reviews in Oncology/Hematology

Treatment of locally advanced prostate cancer is still a challenge. Combined treatments including hormone therapy, radiotherapy, and/or surgery can achieve less than 50% of disease free survival at 10 years. Almost 50% of patients with locally advanced disease after radical prostatectomy experience local relapse and biochemical failure occurs up to 70% of cases after radiotherapy and hormone therapy. Postoperative radiotherapy has recently demonstrated to improve biochemical and clinical outcome in pT3 and/or positive margin tumors in 3 large randomized trials. Therefore, combining surgery and intra-operative radiotherapy (IORT) might be of value in this patient population. Recently, a number of studies have shown the feasibility of IORT, delivered with dedicated linear accelerators, combined or not with external beam radiotherapy with the aim of improving clinical outcome and possibly shortening overall treatment time. Preliminary clinical results look encouraging and could be the premise for future controlled prospective phase III trials. © 2011 Elsevier Ireland Ltd. Source

Antiepileptic drugs (AEDs) continue to be the basis of epilepsy treatment but benefits of seizure control need to be balanced with their psychotropic potential. In fact, some AEDs are widely used in psychiatric practice in the management of mood and anxiety disorders. However, treatment-emergent psychiatric adverse events of AEDs are more frequently reported in patients with epilepsy than in subjects with psychiatric disorders. Therefore, it can be argued that several factors need to be considered apart from the mechanism of action of the drug. This article discusses available literature regarding clinical and neurobiological variables implicated in the occurrence of psychiatric adverse events during treatment with AEDs in order to operate tailored treatment strategies in patients with epilepsy. © 2011 Future Medicine Ltd. Source

Mula M.,University Hospital Maggiore Della Carita
Therapeutic Advances in Drug Safety

Topiramate is an antiepileptic drug (AED) with multiple mechanisms of action that has been shown to be effective in a number of neuropsychiatric disorders. However, cognitive dysfunction is frequently observed in such patients, often representing a relevant challenge in their management. Moreover, there is a long-held recognition that AEDs may profoundly affect cognitive functions. This paper reviews available data on cognitive adverse events in patients with neurological disorders treated with topiramate, discussing the role of different contributing factors such as the pharmacological properties of the drug, the specific features of the brain disorder, and other variables pertinent to the discussion. All studies agree that up to 10% of patients may complain of treatment-emergent adverse events on cognition. Such problems occur early during treatment (i.e. within 6 weeks) and emerge in a dose-dependent fashion, suggesting that such prevalence may be significantly reduced using the drug in monotherapy and adopting individualized doses and titration schedules. The magnitude of the problem is generally mild to moderate and the subjective perception of the patient needs to be taken into account. In fact, apart from language problems, data are not conclusive. Comparisons with new AEDs are limited to levetiracetam and lamotrigine, in both cases generally disfavoring topiramate, while data regarding first-generation AEDs show clear differences only for verbal fluency. © The Author(s), 2012. Source

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