Annals of Pharmacotherapy

Of all the infectious complications which plague the immunosuppressed patient, viral infections are the least amenable to drug therapy. Disseminated herpes zoster infections are relatively uncommon in immunosuppressed patients, but affect as many as 25 percent of patients with Hodgkin's disease. Herpes zoster infections are caused by the varicella-zoster virus (VZV), a DNA containing virus which is the etiological agent of both chickenpox and shingles. Vidarabine (ara-A) is a synthetic nucleoside which inhibits viral induced DNA-dependent DNA polymerase, and therefore viral replication. While vidarabine is remarkably nontoxic at a daily dose of 10 mg/kg, there is at present little evidence that early therapy of disseminated herpes zoster prevents visceral disease, further dissemination, or affects the incidence of postherpetic neuralgia. Initial studies employing human leukocyte interferon show promise, but large scale trials have been hampered by limited supplies of interferon.

This article summarizes the results of a study designed to evaluate clinical pharmacy services as a means of reducing drug usage in a 170-bed community hospital. A total of 591 medication orders for 93 hospitalized patients were evaluated. A pharmacy resident made recommendations regarding the appropriateness of the medication order to the attending physicians. A team of reviewing physicians later evaluated these recommendations. The resident's suggestions were also monitored by a university-affiliated and experienced clinical pharmacist. The number of medications ordered which the pharmacy resident would have prescribed during consultation with physicians was 312 (53 percent), while the overseeing clinical pharmacist would have prescribed 352 (60 percent). Two hundred and fifteen therapeutic recommendations were provided by the pharmacy resident, of which 38 (17.6 percent) were carried out by the attending physician. The reviewing physicians did not agree with 37 of these recommendations. Twenty-two drug interactions were detected, of which eleven were thought to be of definite clinical significance by the pharmacy resident. The study demonstrated that a 40 percent reduction in medication utilization could result in a community hospital, while the same level of therapeutic effectiveness was maintained, by using the services of a properly trained clinical pharmacist. The patient care appraisal committee which was appointed to evaluate the study reviewed the results and agreed that, based on the cost factor and improvement of patient care, clinical pharmacy services would be beneficial.

Staffing a majority of hospitals with full-time clinical pharmacists is an aim that will not be attainable for many years. In an effort to demonstrate an interim approach to clinical practice that could be applied to a large percentage of hospitals, a part-time clinical pharmacist's services were documented.

Serving a teaching hospital with an average census of 97 patients, the pharmacist, with a 50 percent time allotment for clinical services, monitored 229 total admissions during an eleven week period. The majority of patients were on either a pulmonary medicine or urology service.

The total number of actions taken as a result of pharmacy consultations was 106, with 70 percent of these being related to dosing problems.

It was concluded that a pharmacist providing clinical services to a large patient population on a less than full-time basis can have a positive impact on drug therapy.

A case study of an interaction between digoxin and quinidine is presented and its clinical significance is discussed. The serum digoxin concentration increased during quinidine therapy and the patient showed signs of digitalis toxicity. The proposed mechanism, incidence and manifestations of this rise in digoxin serum level are presented. A method of monitoring for this interaction, and its implications for clinical pharmacists, are also given.