Manage postpartum depression with psychosocial strategies, psychotherapy and/or pharmacotherapy based on its severity Abstract Postpartum depression (PPD) is more intense than the ‘baby blues’, and may last for months to years without treatment. PPD may have significant, as well as devastating, consequences, but is often under-detected and under-treated. Screening questions and questionnaires can be used to identify patients with PPD, and psychosocial strategies (e.g. peer support, professional counselling), psychotherapy (e.g. cognitive behavioural therapy, interpersonal therapy) and pharmacotherapy (e.g. brexanolone, sertraline) can be used to treat the disorder. Severe and refractory cases may benefit from electroconvulsive therapy or hospitalization.

Intranasal esketamine in treatment-resistant depression: a profile of its use Abstract Intranasal esketamine (Spravato™), the S-enantiomer of ketamine, targets the glutamatergic system via non-competitive antagonism of the N-methyl-D-aspartate receptor, thereby providing a novel approach to traditional antidepressants that target modulation of the monoaminergic system. In conjunction with an oral antidepressant (OAD), intranasal esketamine is approved in the USA for use in adult patients with treatment-resistant depression (TRD). Given its novel mechanism and rapid onset of action, convenient weekly or once every 2 weeks maintenance regimen, and the current paucity of approved pharmacotherapy options for TRD, esketamine nasal spray in conjunction with an OAD provides an important treatment option for this difficult-to-treat high-risk patient population. In pivotal clinical trials in adult patients with TRD, flexible-dose intranasal esketamine in conjunction with a newly initiated OAD provided rapid and sustained improvements in depression symptoms, and had a manageable tolerability and safety profile. Further long-term clinical experience is required to fully define the potential benefits and risks of esketamine therapy in combination with an OAD in TRD.

Manage cutaneous adverse effects induced by diabetes medications or devices by removing the offending agent and choosing appropriate treatment Abstract Numerous cutaneous adverse effects (CAEs) have been reported with glucose-lowering medications (e.g. insulin, dipeptidyl peptidase 4 inhibitors and sulfonylureas) and medical devices (e.g. continuous subcutaneous insulin infusion and continuous glucose monitoring) used in the management of diabetes. Notable CAEs include angioedema, autoimmune blistering diseases, contact dermatitis, Stevens-Johnson syndrome and worsening blood glucose control. While some of CAEs are common and others rare, it is important for healthcare providers to be aware of the potential culprits and their associated CAEs, as well as effective methods to prevent and/or treat such effects.

Managing nocardiosis: a review and case series of its treatment with trimethoprim–sulfamethoxazole Abstract Nocardiosis is clinically challenging because of its variable clinicopathologic features, the inherent difficulties in cultivating the pathogen, the lack of exact treatment regimen, and its high propensity to recur. We report a case series of nocardiosis with diverse clinical presentations (primary pulmonary, primary cutaneous, and disseminated) and successful treatment with trimethoprim–sulfamethoxazole (TMP–SMX). We briefly review the cases to assess the efficacy of treatment with TMP–SMX. The optimal therapy for nocardiosis has yet to be established. Our clinical experience, together with the clinical evidence in the literature, suggests that TMP–SMX should be considered as the therapeutic drug of choice for treating nocardiosis.

Recent and updated pharmacotherapy of migraine Abstract Migraine is a complex and still debatable neurovascular disorder that is on the rise globally, affecting patients of all ages. Various drugs are available for acute and chronic management, but migraine appears to be a chronic and progressive condition, with 5.1% of patients ultimately becoming refractory to drugs. For the acute and preventative management of migraine, newer molecules targeting calcitonin gene-related peptide (CGRP) have been approved and others are in various phases of development. This narrative review aims to give an overview of migraine therapy with special emphasis on CGRP and the molecules targeting this that are either approved or have completed phase III trials.

Properly prescribed, proton pump inhibitors are largely safe, but precautions are needed to prevent potential problems, overuse and misuse Abstract Adverse events have been widely reported in users of popular proton pump inhibitors (PPIs). Most data come from observational studies, with clear causation rarely demonstrated. Evidence linking PPIs to gastrointestinal infections is stronger and some drug interactions are important. The use of PPI is often prolonged, without a clear reason for continued therapy. PPIs should be prescribed after a careful assessment of risks and benefits and their use reviewed regularly.

Fexinidazole in human African trypanosomiasis: a profile of its use Abstract Fexinidazole winthrop (hereafter fexinidazole) is the first all-oral therapy available for the treatment of human African trypanosomiasis (HAT; commonly known as ‘sleeping sickness’). Fexinidazole is a 5-nitroimidazole derivative developed by the Drugs for Neglected Diseases initiative in collaboration with Sanofi. It has received a positive opinion from the European Medicines Agency (under Article 58) for the treatment of both stage 1 and 2 HAT due to Trypanosoma brucei gambiense (g-HAT) in patients aged ≥ 6 years and weighing ≥ 20 kg, supporting its registration in endemic countries. In clinical trials, fexinidazole was associated with high rates of treatment success in both stage 1 and 2 g-HAT, with its efficacy in late stage 2 g-HAT being noninferior to that of the standard of oral nifurtimox + intravenous eflornithine combination therapy (NECT). Fexinidazole has an acceptable tolerability profile, with an overall incidence of adverse events generally similar to NECT. However, unlike NECT, fexinidazole has a simple 10-day tablet-based regimen, requires no definitive staging diagnosis before use, and may be administered to selected patients in an outpatient setting. WHO g-HAT treatment guidelines have been updated to provide interim recommendations on the use of fexinidazole.

Adverse events and monitoring requirements associated with monoclonal antibody therapy in patients with multiple sclerosis Abstract Multiple sclerosis (MS) is treated with a variety of immunomodulatory and immunosuppressive drugs. Among the most potent therapeutic options are monoclonal antibodies (MAbs). So far, the MAbs natalizumab, alemtuzumab, and ocrelizumab have been approved for MS treatment. While their efficacy is indisputable, these drugs have safety issues not seen with previous MS drugs. MAbs are the ideal class of treatment for many patients with MS, but neurologists prescribing these MAbs need to be aware of their potential risks and monitor patients closely. Although rare, adverse events associated with MAbs may be fatal; opportunistic infections, tumors, and infusion-related events require planning and monitoring of patients before, during, and after MAb therapy. This review summarizes the type and management of adverse events associated with MAb treatment in patients with MS, and emphasizes the importance of evidence-based knowledge for all neurologists involved in MS therapy.

Association between variants of COQ2 and TNF-α genes and statin-induced toxicities in Bangladeshi hyperlipidemic patients Abstract Statin-induced toxicities are widely prevalent in Bangladesh, and most commonly include skeletal muscle disorders, which range from mild myalgia and myositis to rhabdomyolysis and myoglobinuria, and decreased libido. However, the genetic basis of statin-related toxicities is largely unknown in Bangladesh. As mutations in the coenzyme Q2 (COQ2) gene are associated with a severe type of myopathy and variations in the tumor necrosis factor (TNF)-α gene are related to serious inflammatory pain, in this study, we hypothesized that polymorphisms in COQ2 (rs4693075) and TNF-α (rs1799724) genes would be related to individual variation in statin intolerance. The most widespread cases of statin intolerance in Bangladesh (i.e., myopathy, myalgia, and decreased libido) were the chosen toxicities for this study. We studied 57 patients who developed different types of toxicities upon statin monotherapy and 94 matched controls who tolerated statins without any incident or complaint. In comparison with TNF-α polymorphisms, COQ2 genotypes showed significant associations with statin intolerance in patients with myopathy and decreased libido. For the mutant homozygous CC genotype, the odds ratio (OR) for myopathy was 10.10 (95% CI 2.60–39.23; p = 0.001), whereas for decreased libido, the OR was 0.18 (95% CI 0.03–0.97; p = 0.046). In conclusion, this preliminary pharmacogenetic study identifies that COQ2 gene polymorphism (rs4693075, G > C), not TNF-α gene polymorphism (rs1799724, C > T), is involved in causing statin-induced myopathy in Bangladeshi hyperlipidemic patients.

Manage vulvodynia using a multimodal and individualized approach Abstract Vulvodynia (i.e. vulvar pain lasting ≥ 3 months) is common, but is often not correctly diagnosed. Causative factors and pain profiles are varied and a multimodal approach to management, starting with non-pharmacological interventions, is recommended. Cognitive behaviour therapy and pelvic floor physical therapy are first-line treatments for most cases. Pharmacological options, including anti-nociceptive, anti-inflammatory and neuromodulating agents, warrant further investigation. Surgical vestibulectomy is an effective option in women with localized provoked vulvodynia.