Quirke order 2mg estradiol with amex, ‘War and change in the pharmaceutical industry: a comparative study of Britain and France in the twentieth century’ purchase estradiol 2mg with visa, Entreprises et Histoire safe estradiol 2 mg, 36 (2004), 64-83. Imitating the Americans to compete on the British market War had also strengthened the faith in the power of science and modern medicine to improve health and treat diseases. Combined with the National Health Service created after the war, it stimulated companies into investing in research. It was headed by Alfred Spinks, who in 1950-2 had been sent to Oxford to gain a degree in physiology. It drew its inspiration from American laboratories – both public and private – adopting a speculative approach (based on scientifc hypotheses, in contrast with routine chemical investigations) to the development of drug treatments for chronic diseases, such as hypertension, which represented a vast market for medicines. Loughlin (eds), Producing Health: medicine, the market and the mass media in the C20th, London: Routledge, 2005, pp. Walpole (eds), A Symposium on the Evaluation of Drug Toxicity, London: Churchill, 1958. His contribution was later acknowledged by making him head of his own unit, the Biological Electronic Unit of the Biology/Biochemistry Department. In one of his reports, he wrote: ‘It has not been shown that 38,174 is a candidate for clinical trial and much work on toxicity, and particularly on pharmacological side-effects, including hypotensive action, will be necessary before its suitability for trial can be assessed’. By then, small-scale trials had also begun, and an additional set of tests could now be carried out. These were described under the title ‘biochemistry’ (in addition to the already existing pharmacology and chemistry sections of the reports), and probably coincided with the creation of a new Biochemistry Section. Duncan, who devised a spectrofuorometric method for estimating the presence of 8,174 in blood and tissues, in order to obtain basic information about the behaviour of the drug not only in animals, but also in man. This allowed him to measure the concentration of 38,174, and study its degradation products in vivo. The basic principle in novel drug discovery is to demonstrate specifcity of action, i. At the pre-clinical stage of the drug discovery process, the ‘safety’ of 38,174 corresponded to the results of the pharmacological experiments and toxicity tests, and therefore was as yet indistinguishable from laboratory phenomena. As part of the biological and chemical work involved in the development of Pronethalol, which in preparation for market launch was named Alderlin (a near-anagram of Alderley Park), compound 45,5 0 was identifed, which had 10 to 0 times greater activity than Alderlin. The tests included in vitro and in vivo blockade, effect on resting heart rates, and half-life (used as an indication of the drug’s persistence in the body). Toxicity tests included both acute and chronic tests, the latter showing that, whereas with 38,174, thymic tumours appeared within 120 days, ‘the test with 45,520 had been running since 18. Meanwhile, the tests on Propranolol were gaining in complexity, which now included additional studies into its metabolism and mechanism of action (almost certainly in reaction to the Kefauver amendments that had followed Thalidomide). It was suspected that the lower toxicity of Sotalol was due to its lower fat solubility. Woodbridge, ‘Social aspects of pharmaceutical innovation: heart disease’, PhD thesis, Birmingham: University of Aston, 1981, pp. Moreover, Inderal caused bronchoconstriction, hence it was contraindicated in patients with asthma. Therefore the search continued for a compound superior to Inderal, despite the evidence that patients with angina were improved, that incidence of side effects was small, and that mortality was not increased. Not only was it cardio-selective, but had no depressant activity on the heart (which it was thought might be associated with cardiac failure). Moreover, although less potent than Inderal, it had a much greater duration of action. Nevertheless, in the midst of debates among clinicians as to the optimal combination of properties for a beta-blocker, pressure mounted to take Practolol through to clinical study. The need for speed in the face of such competition was stressed in a report, dated 20 June 1968, in which a new screening programme for beta-blockers ‘now included a bronchospasm test and an additional check on selectivity’ in order to save time ‘on following false leads’. The divergences between the pharmacological and chemical agendas, and between the scientifc and commercial agendas, created tensions within the company. Again, the direction of the beta-blocker project was determined by the head of the biological team, still dominated by pharmacologists: ‘Analysis of the mechanism of action of Inderal and 50,172 is complicated by their possession of different properties. The choice of the eventual successor to Inderal depends in part on a better understanding of the relevant contribution of these different properties. The principal objective of the screening programme has been to fnd compounds which would help to defne the properties of the “ideal” beta-blocker more clearly. On the other hand, of 66,082 it was said that ‘This compound may be very important since it is uniquely selective and non- stimulant. In the light of the most recent clinical results, the positions of Inderal and Eraldin were reviewed at a meeting of the cardiovascular team on 5 November 1969. Eraldin was not proving to be superior or even equal to Inderal in angina, although there appeared to be fewer side-effects with Eraldin than with Inderal. It was concluded that the position of Inderal in clinical practice was now reasonably secure. There followed a detailed analysis of the relative advantages of Inderal and Eraldin, which was complicated by the lack of information concerning the true signifcance of certain properties (such as membrane- stabilizing activity, cardio-specifcity, lipid solubility). It was against this background of scientifc and clinical uncertainty and competitive pressure that Eraldin was launched onto the market, in 1970. Meanwhile, work continued on possible successors to Inderal, around which a controversy had arisen concerning the likely cause of its ability to depress the heart rate. In an attempt to clarify this, the biological team modifed the screening procedure for new beta-blocking compounds to separate their properties into various classes: a) sympathomimetic selective beta-blockers; b) membrane-stabilising selective beta-blockers; c) selective beta-blockers without additional properties; d) non-selective beta-blockers without additional properties. His observations had been made in vitro, and he thought that these may not be relevant to the action of Propranolol in man. However, matters were complicated further by a recent publication by Gibson and Coltart, which suggested that both membrane-stabilising and intrinsic properties were irrelevant in achieving improved safety, and that cardio-selectivity really was the most important factor. At the same time, fears were being expressed about the potential carcinogenicity of the newly synthesized hydrazine beta-blockers. Time constraints were also becoming apparent in connection with possible replacements for Inderal and Eraldin. The cardio- vascular team therefore returned to two compounds in earlier series, 66,082 and 66,081. If 66,081 ultimately failed on further toxicity tests, then the team would search for a non-teratogenic member of the series (an evidence that teratogenic tests had become routine part of the battery of tests performed by the team). However, there was still uncertainty about which had the most desirable properties, both from a scientifc and from a commercial point of view (see Figure 5). By 197 , however, evidence of the serious side-effects associated with Eraldin precipitated a decision, and the advice of the Dr K. Green (since 1965 – according to the organograms - Manager of Medical Department)53 was sought. However, he favoured an altogether different compound, 72,222: We have been concerned, for the past years, with the discovery of beta-blocking drugs possessing various combinations of additional pharmacological properties. It seems that we should have been seeking a safe effective hypotensive beta-blocking drug… It is clear that there is now considerable urgency to bring 72,222 to clinical trial… strengthened by the possibility that Eraldin administration is associated with a drug-induced immune complex syndrome in certain rare cases.
Concomitant administration of drugs known to inhibit the activity of cytochrome P450 isozymes may increase the plasma levels of clozapine buy estradiol 1mg line. Cimetidine cheap estradiol 1mg on-line, caffeine purchase 2 mg estradiol with visa, and erythromycin may increase plasma levels of clozapine, potentially resulting in adverse effects. Skin Rash Haematological System Leukopaenia, neutropaenia, agranulocytosis, eosinophilia Clozapine! Gastrointestinal System: Nausea, vomiting, abdominal pain or diarrhoea may be particularly troublesome in the presence of peptic ulcer or spastic colon. Infuse over 60 to 90 minutes Fluid restriction or high dose infusion: 1 vial (5ml) diluted with 75ml of 5% glucose 6 vials (30ml) diluted with 500ml of 5% glucose More than 6 vials diluted with 1000ml of 5% glucose Inspect for signs of turbidity or precipitation – if present, discard. Infuse over a period not exceeding 60 minutes and flush line thoroughly after drug administration. When diluted in Hartmann’s, the prepared solution is stable for 8 hours at a 1 in 25 dilution and for 24 hours at a 1 in 35 dilution. Trimethoprim blocks the production of tetrahydrofolic acid from dihydrofolic acid by binding to and reversibly inhibiting the required enzyme, dihydrofolate reductase. Thus, sulfamethoxazole; trimethoprim blocks two consecutive steps in the biosynthesis of nucleic acids and proteins essential to many bacteria. The following organisms are usually susceptible: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, indole-positive Proteus species including Proteus vulgaris, Haemophilus influenzae (including ampicillin- resistant strains), Streptococcus pneumoniae, Shigella flexneri and Shigella sonnei. The overall prevalence of sulfite sensitivity in the general population is unknown and probably low. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people. It has been reported that sulfamethoxazole; trimethoprim may prolong the prothrombin time in patients who are receiving the anticoagulant warfarin. This interaction should be kept in mind when sulfamethoxazole; trimethoprim is given to patients already on anticoagulant therapy, and the coagulation time should be reassessed. Allergic Reactions: Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis, allergic myocarditis, erythema multiforme, exfoliative dermatitis, angioedema, drug fever, chills. Henoch-Schoenlein purpura, serum sickness-like syndrome, generalized allergic reactions, generalized skin eruptions, conjunctival and scleral injection, photosensitivity, pruritus, urticaria and rash. In addition, periarteritis nodosa and systemic lupus erythematosus have been reported. Gastrointestinal: Hepatitis (including cholestatic jaundice and hepatic necrosis), elevation of serum transaminase and bilirubin, pseudomembranous enterocolitis, pancreatitis, stomatitis, glossitis, nausea, emesis, abdominal pain, diarrhoea, anorexia. Neurologic: Aseptic meningitis, convulsions, peripheral neuritis, ataxia, vertigo, tinnitus, headache. Diuresis and hypoglycaemia have occurred rarely in patients receiving sulfonamides. Cyclizine may be mixed with morphine in a syringe immediately before use If cyclizine must be diluted in a syringe, either water for injection or 5% dextrose is recommended as the diluent rather than normal saline. In such patients, cyclizine may cause a fall in cardiac output associated with increases in heart rate, mean arterial pressure and pulmonary wedge pressure. Because of its anticholinergic activity cyclizine may enhance the side-effects of other anticholinergic drugs. Respiratory System: dryness of the mouth, nose and throat Cardiovascular System: tachycardia Gastrointestinal System: Cholestatic jaundice, constipation, hypersensitivity hepatitis Haematological System: agranulocytosis Urogenital System: Urinary retention, Skin: Urticaria, drug rash Cyclizine! Patients admitted to the intensive care unit may be on cyclosporin at the time of admission for the following indications: 1. Ensure concentrate is well mixed in diluent fluid to reduce risk of an initial bolus of heavier non-solubilised polyoxyethylated castor oil, which carries an increased risk of anaphylactoid reactions. Visually inspect infusion concentrated and infusion solution for particulate matter and / or discolouration. Laboratory Tests: Cyclosporin has a narrow therapeutic index and variable pharmacokinetics and so monitoring of therapy is mandatory in the critically ill. C0 sampling has been widely used although it appears that C0 is only a weak indicator of absorption of drug. Moreover, the results are assay-dependent as samples of this type contain a large proportion of metabolite that may interfere. Moreover, most of the measured drug found at this time is parent drug, making the measurement relatively free of interference from metabolites. A disadvantage of C2 is the need for samples to be taken close to the 2-hour time-point (+ or -15 minutes). Factors affecting the target ranges for treatment include time of sampling (C0 or C2), organ transplanted, time since transplantation, and other medications. More specific recommended target concentrations for transplant patients are as follows. They may vary in individual cases on the basis of age, gender, renal function, number of episodes of rejection, and concomitant immunosuppressive medication. Target trough (C0) ranges are as follows: Liver: Induction 225-300 ng/mL Maintenance 100-150 ng/mL Heart: Induction 250-325 ng/mL Maintenance 125-175 ng/mL Kidney: Induction 150-225 ng/mL Maintenance 100-180 ng/mL Bone Marrow: Induction 95-205 ng/mL Maintenance 95-205 ng/mL Autoimmune indications: Induction 150-200 ng/mL Maintenance 100-150 ng/mL Target C2 ranges are as follows: Liver: 0-3 months post transplant 800-1200 ng/mL 3-6 months post transplant 640-960 ng/mL >6 months post transplant 480-720 ng/mL Renal: 1 months post transplant 1360-2040 ng/mL 2 months post transplant 1200-1800 ng/mL 3 months post transplant 1040-1560 ng/mL 4-6 months post transplant 880-1320 ng/mL 7-12 months post transplant 720-1080 ng/mL >12 months post transplant 640-960 ng/mL Lung: 0-2 days post transplant >800 1-7 days post transplant 1200 1-4 weeks post transplant 1200-1700 2 months post transplant 1000-1500 3 months post transplant 800-1200 4-6 months post transplant 700-1000 7-12 months post transplant 600-900 >12 months post transplant 600-800 Cyclosporin! Drugs That Alter Cyclosporin Concentrations Cyclosporin is extensively metabolized cytochrome P-450 3A. Substances that inhibit this enzyme could decrease metabolism and increase cyclosporin concentrations. Substances that are inducers of cytochrome P-450 activity could increase metabolism and decrease cyclosporin concentrations. Monitoring of circulating cyclosporin concentrations and appropriate dosage adjustment are essential when these drugs are used concomitantly. Drugs That Increase Cyclosporin Concentrations Calcium Channel Blockers: Diltiazem, nicardipine, verapamil. Other Drugs: Allopurinol, bromocriptine, danazol, metoclopramide, colchicine, amiodarone. Severe digitalis toxicity has been seen within days of starting cyclosporin in several patients taking digoxin. There are also reports on the potential of cyclosporin to enhance the toxic effects of colchicine such as myopathy and neuropathy, especially in patients with renal dysfunction. Cyclosporin should not be used with potassium-sparing diuretics because hyperkalaemia can occur. A large bore, vented needle (as found in the malignant hyperthermia box in theatre) will hasten the transfer of diluent and reconstituted solution. Reconstituted solution should be stored at room temperature and must be protected from direct light. The usual dose for chronic spasticity is between 25mg daily and 50mg four times a day.
The elucidation of the molecular events which tightly regulate the processes by which these compounds induce Leishmania’s growth arrest and death might allow the definition of a more comprehensive view of the operating cell’s death machinery quality estradiol 2 mg. It was initially assumed that apoptosis arose with multicellularity buy cheap estradiol 1 mg online, being crucial for embryogenesis quality estradiol 1 mg, tissue homeostasis and disease control (Vaux and Strasser, 1996). However, several findings have indicated the occurrence of a similar process in single celled eukaryotes, including kinetoplastid protozoan parasites (Ameisen et al. Nevertheless, genome database comparisons revealed that the majority of proteins involved in mammalian apoptosis (especially from the Bcl-2/Bax pathway) are apparently not encoded in the genome of Leishmania or related protozoa (Ivens et al. Significantly, no caspase encoding gene can be found in the two completed Leishmania genomes described so far. These enzymes, containing a C-terminal proline rich domain, were unable to cleave caspase-specific substrates but efficiently cleave trypsin substrates (Lee et al. Unlike what was expected, metacaspases do not seem to be responsible for the caspase-like activity already reported in Leishmania, even though they might have a role in Leishmania apoptosis, as suggested by their increased activity upon cell treatment with H2O2 and increased susceptibility to H2O2 in the cells overexpressing metacaspases (Sen et al. With the exception of southern Europe, the access to ready diagnosis, affordable treatment and effective disease control is limited due to economic reasons. The necessity of improving the drug repertoire to treat leishmaniasis is commonly agreed. Therefore, we consider that overcoming this situation is extremely urgent, in order to guarantee the availability of an effective therapy in endemic areas. Greater attention should be paid to this situation, since it might contribute to the selection of resistant parasites. Furthermore, it is questionable whether what we call effective drugs promote an overall clearance of the parasites in infected patients. Indeed, it is possible that a few number of Leishmania parasites could persist in cured individuals and their progress controlled by an effective immune system. In the case of immune-compromised individuals, however, the parasites progression may occur, leading to disease. Therefore, an exploitation of potential parasite persistence sites upon an effective drug treatment might disclose unravelled locations where drugs probably do not but should have access. A trypanothione cascade seems to be involved in the Farmacia´ and Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, detoxiﬁcation process. Activated 3 B-cells underwent further proliferation, as indicated by increased [ H]thy- midine incorporation. Cordeiro-da-Silva, (IgM), IgG1 and IgG3 isotypes, with a minimum reactivity against other Faculdade de Farmacia´ and Instituto de heterologous antigens. Leishmaniasis, a disease caused by protozoan parasites of Interestingly, these cells participate in the ﬁrst line of the genus Leishmania, remains a serious public health defence against pathogens through their antimicrobial 3 problem in areas of the tropics, the subtropics and south- and/or antigen-presenting functions. In murine models of ern Europe, with approximately 12 million people being experimental leishmaniasis, the development of potent 1 + affected in these regions. For instance, of oxidoreductases found in trypanosomatids and that is Leishmania parasites are capable of modelling the T-cell related to the ubiquitous thioredoxins. However, it tive T helper type 2 (Th2) response, characterized by the was observed to be up-regulated and excreted/secreted 19 secretion of anti-inﬂammatory cytokines such as interleu- only in the infective stages. In addition to the suppression of parasite spe- of this secreted protein on the immune system, focusing ciﬁc Th1 cell-mediated responses during active disease, a on T- and B-cell functions. The activated B cells under- parasite non-speciﬁc antibodies with self autoreactivity, went both proliferation and differentiation, as shown by particularly of the immunoglobulin M (IgM) and IgG iso- the production of speciﬁc antibodies. The recombinant protein content was deter- 11 20 action of these ‘immunopathological’ antigens. As the major Leishmania species complexes diverged 12 some 40–80 million years ago, it is not surprising that Injection of mice different correlatives of protection are found for each pathology. Never- Two weeks after the ﬁnal injection, spleens and sera were theless, there is considerable evidence supporting a central collected. This Th1 suppressive cytokine is also responsible for com- After cervical dislocation, spleens were removed and promising antigen speciﬁc T-cell stimulation and for homogenized to obtain a single cell suspension. Reactions were stopped by the addition of 10% an automated multiple sample harvester and dried. Unlabelled Cytokine production was determined by two site sand- puriﬁed isotypes were used in serial dilutions as standards. The results represent the means and standard deviations of three experiments carried out independently. B-cell proliferation can occur in a T-cell depen- cultured in vitro in the presence or absence of ConA, as dent or independent manner. Statisti- cally signiﬁcant differences between non-stimulated and stimulated cells are indicated: **P<0Á01. The data represent the means and standard deviations for three animals analysed individually and are representative of three independent experiments. Mice sera were diluted analysed individually and are representative of three independent 1/900 and optical density was recorded at 492 nm. Moreover, analysis of IgG antibodies showed Discussion that only IgG1 (1Á9 fold, P<0Á01) and IgG3 (2Á2 fold, P<0Á01) serum levels were signiﬁcantly increased in Leishmania is a typical intracellular pathogen. For tested isotypes were increased in previously immunized successful establishment of the infection, Leishmania must mice. However, this increase was higher for IgG1 and be capable of surviving the acidic and protease rich envi- IgG3 than for the other isotypes studied (data not ronment inside the phagolysosome but also deal with shown). We have recently identiﬁed and cloned a tein, namely Leishmania infantum cytosolic tryparedoxin novel L. The observed effect occurred All these data prompted us to study the cytokine proﬁle even in the absence of accessory cells. No signiﬁcant of host defence mechanisms against the pathogenic inva- 37,38 alteration of the responses of spleen or isolated B cells to sion. This suggestion is supported circulating antibodies infected with different Leishmania by observations that T-cell independent antigens are poor 41 species showed enhanced resistance compared with inducers of immunological memory. Moreover, susceptibility to leish- suggests the existence of B regulatory cells (Breg). Their maniasis is recovered when the B-cell population is regulatory functions are mediated by the production of 25,26 reconstituted. However, in the case of visceral tions of B cells, termed B-1 and B-2, which differ with leishmaniasis, a counterproductive Th2 response is not respect to lineage origins, phenotype and anatomical ori- 45 apparent in mice, although it has been described in gins. However, no signiﬁcant difference in the parasite 48 dent immune responses generally involve these cells. Nevertheless, in It has been reported that Leishmania possesses a large a recent study a tryparedoxin peroxidase, which is present number of molecules characterized by their immunosup- in the same hydroperoxide cascade as tryparedoxin, was 49,50 pressive and mitogenic like activities. Indeed, As an obligate intracellular parasite, Leishmania has soluble parasite derived antigens from L. These antibodies Acknowledgements were able to promote complement mediated killing of promastigotes and amastigotes and to inhibit their This work was supported by Fundac¸ao˜ para a Cienciaˆ e multiplication inside macrophages. Costimulation and the regulation of antimicrobial lines of evidence have suggested that excreted/secreted immunity. Production of These proteins have been selected by evolution to be interferon gamma, interleukin 2, interleukin 4, and interleukin immunologically ‘silent’, allowing them to perform func- Ó 2007 Blackwell Publishing Ltd, Immunology, 123, 555–565 563 S. Polyclonal B cell activation, circulat- mediated peroxide metabolism in Crithidia fasciculata.
Erkinjuntii et al buy estradiol 2mg on-line, Vascular dementia: diagnostic criteria for research studies purchase estradiol 2 mg on-line, Neurology 1 mg estradiol otc, 43 (1993): 250-260; O. The State of California vascular dementia criteria queried the “imperfect biological validity” for the theoretical concepts of areas of cognition for brain function, and therefore does not state type or number of defcits other than “deterioration from a known or estimated prior level of intellectual function” (Chui et al. Gustafson, et al Frontotemproal lobar degeneration: a consensus on clinical diagnostic criteria. Alzheimer’s disease, arguably dementia’s most prevalent subtype despite the encroachment of these newly emerging diagnoses, remains a tangible fear of those who at 65 years of age have a fve to eight percent probability of being diagnosed with dementia, and an incidence doubling every fve years after. Techniques to establish regulatory effcacy fall short of effectiveness In 198 , the importance of the cholinergic defcit in Alzheimer’s disease was frst described in Science. Burville, A Critique of Current Criteria for Early Dementia in Epidemiological Studies. Frey, Clinically diagnosed Alzheimer disease: neuropathologic fndings in 650 cases. Kling, Oral tetrahydroaminoacridine in long-term treatment of senile dementia, Alzheimer type. Indeed, it took more than a decade before the acetylcholinesterase inhibitors frst became available for the symptomatic treatment of mild to moderate Alzheimer’s disease. With the wider approval of a second generation safer alternative, tacrine is no longer recommended in the United States. Feldman suggests that cognition or behaviour domains could be substituted for the Global Impressions of Change, thereby compressing the amount of criteria necessary for ascertaining improvement even further. Alzheimer Dis 231 Janice Graham clinical judgement, that is, some observable improvement in the functional performance and global impression of change in the individual. With a desperate elderly population awaiting some action, “the trials were never intended to be ‘ecologically valid’ experiments in which ordinary, representative patients were treated and assessed; rather they were intended to get the drugs approved for marketing”. As it turns, 90% of people being treated for mild or moderate Alzheimer’s disease in California, for instance, would have been excluded from the industry-run clinical trials (Schneider 2004). The non-representative nature of these data did not deter the use of the research results to make decisions on effectiveness, costs and clinical meaning. McDowell, Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Science and therapeutic reform in the United States, 232 Facilitating Regulation: Technologies of Effcacy and Effectiveness for Dementia Drugs trend towards evidence from large scale epidemiological population studies and sophisticated statistical analyses neglected “biologic logic” and “clinical judgment”. By the late 1990s, researchers began developing tools that were sensitive to clinically meaningful outcomes. Most importantly, because their recommendations serve as guidance to health care practices which are funded by the National Health Service, their decisions take into account issues of cost and harm-beneft. Barrett, Meaning and misunderstanding in occupational forms: a study of therapeutic goal setting. Rockwood, A qualitative analysis of the Clinician Interview-Based Impression of Change (Plus): Methodological Issues and Implications for Clinical research. Clinical effectiveness was based on the evidence from fve Pharma-sponsored randomized controlled trials for donepezil, fve for rivastigmine and three for galantamine, three systematic reviews for the former two and one for galantamine. They recommended that future research include better methodologically aligned comparative studies with both drug and non-drug interventions, that attention be given to response during the course of treatment and to identifying characteristics of those who respond to the drugs, and that protocols needed to be developed to withdraw those not benefting from the treatment. They made clear that the drug companies would need to be able to make a more convincing case for the clinical signifcance57 of their products, that they had to provide ongoing and stronger evidence for their drug’s clinical effectiveness if they wished to continue the privilege of having their drugs purchased free-of-charge and made nationally available for some 400,000 individuals with Alzheimer’s disease indicated for treatment. Consultations were also undertaken on extra manufacturer analyses based upon individual patients outcome data, issued in November 2005, and on the Second Appraisal document issued in January 2006. Donepezil, galantamine, rivastigmine (review) and memantine for the treatment of Alzheimer’s disease, Technology Appraisal Guidance No 111. Donepezil, galantamine, 234 Facilitating Regulation: Technologies of Effcacy and Effectiveness for Dementia Drugs private interest in these treatments was evident in the eighteen profession/specialist and patient/ carer groups who made submissions. Industry and its clinical- researchers had been served notice that new data should provide for the methodological and substantive analytical limitations of previous studies and most especially address quality of life measures of outcomes and sub-group analyses of response to treatment. Donepezil, galantamine, rivastigmine (review) and memantine for the treatment of Alzheimer’s disease, Technology Appraisal Guidance No 111. Despite only “modest” beneft and estill with higher rates of adverse events and discontinuation of treatment compared to placebo,66 the evidence of statistical signifcance has been suffcient to advocate for an end to placebo control trials for many clinical-researchers. Gauthier, Cholinesterase Inhibitors for Alzheimer’s Disease: a systemic review of randomized controlled trials [Technology report no 58]. Ottawa: Canadian Coordinating Offce for Health Technology Assessment/ Canadian Agency for Drugs and Technologies in Health (2005). MacKnight, Assessing the clinical importance of statistically signifcant improvement in anti-dementia drug trials. Tying memory loss, social and behavioural decline into events that were viewed with importance and as meaningful by the patients and their carers themselves meant an entirely different set of actors beyond clinicians had to be consulted. Clinician’s needed a whole new set of instruments to ascertain these patient-centred and recognized target symptoms. In light of the many distressing symptoms beyond a decline in memory, Winblad and colleagues decided that “Alzheimer’s disease is more than just memory loss”74 and “that benefts in areas such as behaviour or functional activities alone are legitimate therapeutic goals”. They recommended revising the defnition of treatment response so that long-term (1 year) stabilization, maintenance, or preservation of cognition, function or behaviour, be considered “improvement”. Fujimura, Crafting Science: a sociohistory of the quest for the genetics of cancer. Rockwood and Janice Graham, Protocol for Defning the expectations and effects of treatment with an anti-dementia medication (donepezil) in patients with Alzheimer’s disease. The Atlantic Canadia Alzheimer’s Disease Investigations of Expectations, 1997; Janice Graham, Harbinger of Hope or Commodity Fetishism: Re-cognizing Dementia in an Age of Therapeutic Agents. Fay, Goal setting and attainment in patients with Alzheimer’s disease treated with donepezil. Aisen, Anti-infammatory therapy for Alzheimer‘s disease: implications of the prednisone trial. Relative stabilization … is an important outcome… We propose redefning “responders” to Alzheimer’s disease treatment as those patients who maintain baseline scores (improvement over baseline ≥ 0 points) for 1 year on appropriate scales, assessing cognition and/or functional abilities, and/or behaviour” (Winblad 001: 66 ). The virtues of the powerful are turned upon those with less power when there are profts to be made. With the revised defnition of Responder, maintenance in any one of the three domains (cognition, function or behaviour) was all that was needed to “be considered improvement. Applying the authoritative capital of consensus recommendations, Winblad and colleagues could overshoot those research activities that were directed at developing new tools by simply weakening the criteria that already existed to ascertain response (and, in fact, cases). The contingent and political nature of epidemiological facts demands that we recognize and not ignore the partial nature of the aggregated assemblage. Some truths are better than others, but always, their selection requires careful auditing. Attaining consistency in statistical signifcance across the various tools used to measure the domains (cognition, function, activities of daily living) involved in this multidimensional, heterogeneous socio-neurodegenerative process challenges methods and theories. Progressive decline is not apparent in all domains at the same time at a constant rate.
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