I am pleased to see the Journal publish an article concerning the use of medications following traumatic brain injury ["Pharmacological interventions for traumatic brain injury," BCMJ 2011;53:26-31], as it is my experience that individuals with brain injury are at many times not appropriately treated with medications in British Columbia—medications that can make a very significant improvement in their psychiatric, cognitive, and behavioral status.
I find the table on page 27 to be particularly useful.
This is a review article and all review articles depend to a great extent on whether all relevant materials from the scientific literature have been appropriately surveyed. Unfortunately the authors have missed reviewing what I consider to be the single most authoritative paper on this subject, “Guidelines for the pharmacological treatment of neurobehavioral sequelae of traumatic brain injury,” published in the Journal of Neurotrauma 2006;23:1468-1501. This is a paper from the Neurobehavioral Guidelines Working Group.
There are some significant differences between the conclusions from this paper and those reached by the authors of the current paper. For example, for managing depression, tricyclic antidepressants are one of the options referenced in the guidelines.
In regards to neurocognitive sequelae, the guidelines also recommend the use of dextroamphetamine as well as methylphenidate for some cognitive problems.
There is significant difference in regards to the neurobehavioral sequelae, particularly in regard to agitation, in which the guidelines clearly recommend the beta blockers propranolol and pendolol over all other medications.
Finally, there is one other paper that has been missed in the review of the literature, “Impact of early pharmacological treatment on cognitive and behavioral outcome after traumatic brain injury in adults: A meta-analysis,” published in the Journal of Clinical Psychopharmacology 2009;29:468-477.
These authors looked at early pharmacological intervention and found that amantadine and bradykinin antagonist (CP-0127 [Bradycor]) produced marked treatment benefits using the Glasgow Coma Score as a measurement.
I would recommend that your readers review these two additional meta-analyses in reaching conclusions in treating patients with brain injury.
—Derryck H. Smith, MD
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