Expert Opinion on Pharmacotherapy最新文献

Introduction: Acetaminophen (paracetamol, APAP) overdose remains a leading cause of drug-induced acute liver failure, yet N-acetylcysteine (NAC) prevents hepatic injury.

Areas covered: We conducted a narrative search of PubMed/MEDLINE, Embase, and Google Scholar (January 2000-August 2025) and reviewed NAC regimens, including the 3-bag protocol (21 h), the U.S. FDA-labeled 2-bag regimen (20 h), and the 12-h Scottish and Newcastle Acetylcysteine Protocol (SNAP), as well as early-stop pathways. Across regimens, efficacy is broadly similar, but simplified protocols reduce non non-immunoglobulin E reactions and dosing errors. SNAP delivers 300 mg/kg over 12 h and is extended only when stopping criteria are not met, whereas early-stop pathways (NACSTOP/SARPO) are restricted to selected low-risk patients. In most acute overdoses, NAC can be stopped when APAP is < 10 mg/L, ALT/AST are stable or falling, and INR is acceptable.

Expert opinion: A protocolized NAC pathway with clear stop/extend rules is the most impactful way to improve care. Escalation (higher or prolonged dosing, early hepatology/transplant referral, and consideration of ECTR) should be reserved for high-risk cases. In low- and middle-income countries (LMICs), dose and timing history can guide empiric NAC when levels are delayed. Biomarkers and artificial intelligence remain useful adjuncts, not substitutes, for laboratory-based decisions.

Background: Obesity is a chronic disease with significant global health repercussions. GLP-1 receptor agonists (GLP-1RAs) and dual GIP/GLP-1 receptor agonists (GIP/GLP-1RAs) are now established as evidence-based options for long-term obesity management. This review compares semaglutide and tirzepatide aims to support precise, equitable, and durable care for people with the disease of obesity.

Areas covered: This review provides clinicians with a comparative analysis of semaglutide (Ozempic) and tirzepatide (Mounjaro) in obesity management. We synthesize data from pivotal clinical trials (STEP, SELECT, SURMOUNT, SUMMIT) to guide evaluation of weight loss, metabolic, and cardiovascular benefits. Mechanistic differences, tolerability, and real-world implementation, including patient access and sustainability. The literature search was conducted using PubMed and Google Scholar and through a review of major international cardiology and endocrinology publications from 2020 to 2025.

Expert opinion: Semaglutide and tirzepatide represent foundational options in contemporary obesity pharmacotherapy. Semaglutide offers robust cardiovascular protection; tirzepatide yields greater weight loss and broad metabolic benefits. Both agents require clinicians to reconceptualize obesity as a chronic disease needing ongoing pharmacological management.

Introduction: The therapeutic landscape of multiple myeloma (MM) is rapidly evolving through advances in immune-based strategies. Bispecific antibodies (BsAbs), chimeric antigen receptor T-cell (CAR-T) therapies, and emerging trispecific antibodies (TsAbs) are reshaping expectations by delivering deep and durable responses even in heavily pretreated disease.

Areas covered: Off-the-shelf BsAbs such as teclistamab, elranatamab, and talquetamab show robust activity in triple-class - exposed patients, with earlier use and combination regimens further enhancing response depth. However, challenges remain, including T-cell exhaustion, infection risk, hypogammaglobulinemia, and logistical issues related to step-up dosing and cytokine release syndrome. CAR-T therapies, particularly idecabtagene vicleucel and ciltacabtagene autoleucel, achieve high response rates and rapid MRD negativity, but wider use is limited by manufacturing time, toxicity management, and relapse mechanisms such as antigen loss. Innovations including dual-target CAR-T, armored constructs, and allogeneic platforms aim to improve durability and expand access. MRD assessment has become a biomarker guiding treatment intensity, and duration. In parallel, refined risk stratification -especially for high-risk cytogenetic, functional, and extramedullary disease- helps identify patients who may benefit from early integration of immunotherapies.

Expert opinion: Overall, these advances support a shift toward personalized strategy designed to achieve deep remission, reduce toxicity, and approach functional cure in selected patients.

Introduction: Fibromyalgia (FMS), or Fibro-Myalgia Syndrome, is a complex disorder characterized by pain, fatigue and impaired quality of life. FMS will affect a patient's functionality and often lead to significant disability. FMS remains underdiagnosed and undertreated and is an important comorbidity in patients with musculoskeletal disease. The optimal management of FMS is hindered due to the limited evidence base for treatments. The chronic nature of FMS means increased healthcare costs and an economic burden.

Areas covered: We searched articles from Cochrane reviews and PubMed with a focus on treatments in FMS. Research continues to focus on central sensitization, peripheral sensitization, and inflammatory dysfunction. Objective diagnosis remains difficult due to lack of biomarkers. Current pharmacological options include drugs like Pregabalin, Duloxetine, and Milnacipran, alongside off-label therapies and emerging treatments such as antivirals and cannabinoids.

Expert opinion: FMS is not a diagnosis of exclusion and diagnosis of FMS can allow a patient's distress to be explained and understood. Though no cure exists for FMS management strategies have been shown to improve patients' symptoms and quality of life.

Introduction: Vapes are the most used tobacco product by school children in the U.S.A. Vaping commonly leads to combustible cigarette smoking, marijuana use, and initiation of other drugs of abuse. Consequently, ways to help youths stop vaping are required.

Area covered: The varenicline for nicotine vaping cessation in adolescents (ViVA) clinical trial was of varenicline in youths using vapes but not smoking cigarettes. Adding varenicline to behavioral counseling significantly increased the abstinence rate from 14% to 51% at 12 weeks. The efficacy of varenicline reduced through weeks 9-24 to 28%.

Expert opinion: More youths in the varenicline group than placebo group adhered to their medication and undertook counseling, and this may have biased the data toward higher abstinence in the varenicline group. The results of ViVA do not apply to adults, and those youths who are not actively seeking to stop vaping, and youths who smoke and are, probably, addicted to smoking/nicotine. Longer-term clinical trials in both youths and adults will be necessary to determine whether varenicline causes meaningful abstinence and is safe in long-term vaping.

Introduction: Pharmacologic treatment to reduce the risk of fractures focusses on the bone component of fracture risk. We present a narrative review for clinicians to optimize drug treatments in six frequently occurring clinical situations with a high/very high fracture risk.

Areas covered: We reviewed drug treatment in postmenopausal women according to their fracture risk before a clinical fracture, after a recent clinical non-hip and after a hip fracture, and in GC users and the treatment targets to optimize the choice and sequence of drugs and to develop lifelong follow-up and treatment strategies. New data are available to guide the choice of start and sequence of anti-resorptives and osteo-anabolics according to the level of fracture risk in postmenopausal women, in patients treated with glucocorticoids, after a hip fracture and in patients treated with a treat to target strategy.

Expert opinion: Integrating FRAX, the level of aBMD, a detailed fracture history including imaging of the spine, and additional risk factors contributes to decide on treatment with antiresorptive-treatment (in high-risk subjects) and osteoanabolic-treatment (in very high-risk subjects) and their sequence to achieve a target with a low fracture risk which needs lifelong follow up for further diagnostic and treatment decisions.

Introduction: This review evaluates recent therapeutic advances in colorectal cancer (CRC), with a focus on late-phase clinical trials published between January 2024 and March 2025. The objective was to synthesize emerging data on chemotherapy, immunotherapy, targeted therapy, in metastatic colorectal cancer (mCRC) and locally advanced rectal cancer (LARC).

Areas covered: Notable findings include durable survival with pembrolizumab and nivolumab + ipilimumab in MSI-H/dMMR mCRC, efficacy of fruquintinib in refractory disease, and promising early outcomes with SCRT-based immunochemotherapy in LARC.

Expert opinion: Recent trials support precision oncology in CRC, highlighting durable benefits of targeted and immune therapies. However, heterogeneity in trial designs and underrepresentation of real-world populations limit generalizability.

Introduction: Dermatophytosis is the most common fungal infection encountered by primary care providers and outpatient physicians. In recent years, new patient populations with chronic infections - accompanied by a history of recurrences and relapses - presenting with unusual or severe manifestations have been reported worldwide. This is broadly referred to as recalcitrant dermatophytosis.

Areas covered: Through an electronic literature search spanning the last 25 years, we discuss systemic treatment options for recalcitrant dermatophytosis, including conventional terbinafine and itraconazole treatments, either alone or in combination with topicals. Dosing strategies and treatment durations are summarized along with potential reasons for treatment failure. There is mounting evidence suggesting that dermatophyte resistance is a significant cause of terbinafine nonresponse, making itraconazole the preferred first-line treatment. However, pharmacokinetic variability may cause sub-therapeutic exposure and induce resistance to itraconazole. In some instances, super-bioavailable itraconazole may be a consideration. Corticosteroids should be strictly avoided.

Expert opinion: The current literature is limited by case reports and small case series. Newer triazoles and ketoconazole have been reported as drugs of last resort. Increased advocacy and collaboration are needed to standardize the management of recalcitrant dermatophytosis including antifungal susceptibility testing, especially concerning special populations such as pregnant individuals and children.