Annals of Pharmacotherapy

The most frequently employed measure in attempts to alleviate symptoms and improve the quality of life of patients with chronic obstructive airways disease (COAD) is to prescribe medications. However, COAD is largely an irreversible condition and no therapeutic intervention has been shown to be universally useful. Theophylline or corticosteroid are occasionally helpful but most patients will not benefit. Of the remaining options, only oxygen has been shown to be effective in selected patients and should be administered on a continuous basis. It is becoming increasingly evident that clinicians should be more discriminating when making therapeutic decisions for persons with COAD. Maintenance therapy with pharmacological agents should be entertained only after individually conducted therapeutic trials. Moreover, enormous costs can result from treating even a small fraction of the population estimated to have COAD.

The nutrient-drug interaction between folate and phenytoin is a two-way interaction. Folate deficiency resulting from long-term phenytoin therapy is a common occurrence, but progression of the deficiency to a megaloblastic anemia is rare. However, there are data to suggest nonanemic folate deficiency may be detrimental to the patient. Several mechanisms have been proposed to explain the ability of phenytoin to deplete body folate. The supplementation of folic acid to folate-deficient patients taking phenytoin has been shown to result in lowered serum concentrations of phenytoin, and possibly loss of control of the seizure disorder. Folate appears to be associated with the hepatic metabolism of phenytoin, although the effect of folic acid supplementation on phenytoin elimination kinetics is suggested to be individualized.

Tobacco smoking may interact with the metabolism of a number of drugs. This has been demonstrated clearly in pharmacokinetic studies in animals and man. However, tobacco smoking as a variant has been studied with relatively few clinically essential drugs and these studies do not always demonstrate a consistent effect of smoking.

This review therefore not only records what data have emerged from pharmacokinetic or other studies, but it also attempts to determine whether such interactions have clinical significance.

The main finding of this review is that, in the majority of examples, there is little evidence that there is a recognizable hazard from the interaction per se. The exceptions to this general conclusion are limited to four drugs: insulin, propoxyphene, propranolol, and theophylline preparations. With these drugs, there is some evidence of clinical importance of an interaction with tobacco smoking.

Isotretinoin is remarkably effective in the treatment of severe cystic acne, however, many complications have been observed during treatment and new toxic effects have been reported. Hypertriglyceridemia associated with decreases in high density lipoprotein (HDL) cholesterol has occurred in 25 percent of patients and requires monitoring during treatment. Painful erosions with granulation tissue recently have been reported in patients with severe acne. Other complications have included corneal opacities, pseudotumor cerebri, hypercalcemia, photosensitivity reactions, abnormal liver function tests, and skeletal hyperostosis. Isotretinoin is teratogenic and should be avoided during pregnancy. With the increasing acceptance and use of isotretinoin for cystic acne, as well as related disorders (inflammatory papulopustular acne with scarring, gram-negative folliculitis, and acne rosacea), a reevaluation of isotretinoin aimed at reducing complications is in order. Patient selection criteria and guidelines directed at reducing these complications are presented.

Sulfonylureas hypoglycemic action may be potentiated by sulfonamides. This case report describes a 69-year-old female with a hypoglycemic episode suggestive of an interaction between chlorpropamide and sulfamethoxazole (co-trimoxazole). The patient had no renal or liver dysfunction. This interaction is rare but one should be aware of it, especially with combination products.

Two patients are described who developed neuroleptic drug-induced tardive dyskinesia (TD) secondary to the treatment of schizophrenia. In both patients, neuroleptic drug discontinuation brought about a decrease in the severity of the TD and an increase in schizophrenic symptomatology. Reserpine was added for both antipsychotic coverage and reported beneficial effects in the treatment of TD. The patients' schizophrenia was controlled using reserpine 1 mg/d; the TD dissipated in one patient and decreased in the other. After about seven weeks of reserpine therapy, both patients developed depressive symptoms that required the addition of alprazolam. Within a month of the initiation of alprazolam, the depressions had cleared. Alprazolam may block reserpine-induced increases in β-adrenergic receptors in the brain and may account for the antidepressive effects in these two patients.

A case of skin necrosis caused by subcutaneously administered heparin is reported. A 76-year-old woman received subcutaneous injections of porcine sodium heparin twice a day to prevent deep vein thrombosis. Nineteen days after heparin therapy began, black necrotic areas were noted on her abdomen, and heparin injections were discontinued. The patient received small amounts of heparin intravenously for three additional days without apparent complications.

Proposed mechanisms for heparin-induced skin necrosis include allergic vasculitis and localized platelet aggregation with intravascular thrombosis. Heparin therapy should be stopped if necrosis develops. Intravenous administration of heparin to sensitive patients may be followed by life-threatening reactions. Necrotic areas may heal spontaneously, but often require debridement and skin grafting. Various agents, including steroids, may be useful in preventing the development of necrotic lesions. Drug Intell Clin Pharm 1984;18:313–4.

A patient with acute renal failure and gram-negative septicemia developed hypoprothrombinemia during treatment with cefoperazone. The coagulation defect was corrected by vitamin K administration. A multifactorial pathogenetic mechanism of vitamin K deficiency that developed during treatment with parenteral antibiotics is presented.

All physician orders for metoclopramide tablets at a 500-bed hospital were monitored for a one-year period to determine whether the drug was being used exclusively for the one indication approved by the Food and Drug Administration, diabetic gastroparesis. Eighteen patients received a total of 20 courses of therapy with dosage schedules ranging from 5 mg tid to 10 mg qid. The drug was prescribed for a wide variety of indications, but no patient received it for the symptomatic treatment of diabetic gastroparesis. Extensive literature documentation was lacking for some of the uses, and the doses employed may have been insufficient in some cases. Use of metoclopramide for both approved and nonapproved indications may increase as clinical studies further define its potential uses and physicians become more familiar with the drug.

Relationships between use of pharmacy computers and performance of selected professional activities were investigated, via a survey of southern Michigan pharmacists. Respondents included users of two major computer systems as well as pharmacists who do not use computers. A net response rate of 65.7 percent (213 usable questionnaires) was achieved. In general, computer users reported encountering more drug-related problems than did nonusers and more frequent contacts with prescribers for drug-therapy problems. Little difference was found between the two groups in regard to patient counseling activities, except that computer users were more likely to use auxiliary labels. When responses from users of the two computer systems were examined separately, results suggested that one of the systems contributed positively to certain aspects of pharmacists' professional activities while the other system had little influence. These results indicate that it may not be possible to state general conclusions about the effect of computers on the professional practice of pharmacy.

Post-doctoral training is becoming increasingly important as a means of preparing for faculty positions in the clinical or pharmacy practice departments of colleges of pharmacy. This article suggests that such training is the most appropriate means of providing the research skills necessary for growth in the academic environment and discusses the impact of post-doctoral programs on the individuals taking them, on the colleges of pharmacy, and on the profession as a whole. For the profession, there is seen a very positive gain as a result of high-caliber clinical research in our colleges and, hence, post-doctoral training is essential to produce the manpower needed. Some suggestions are offered for enhancing the current level of training.

The objectives of this study were to identify benefits and costs that a family practice clinic could expect to incur by including a clinical pharmacist in that clinic, to derive equations to estimate the magnitude of each benefit and cost, to discuss the rationale for each equation, and to demonstrate the application of these equations through the use of sample calculations.

The benefits, freed physician time and improved quality of care, are discussed. The physician's time is freed since the clinical pharmacist can provide many services that were provided previously by a physician. Quantification is based on a determination of the amount of time spent by physicians in providing specific services and the proportion of those services that could be assumed by a clinical pharmacist.

Literature sources document an improvement in quality of care due to clinical pharmacy services. The principle used to quantify this improvement in the quality of care involves determining a monetary value for this care before the addition of a clinical pharmacist. This baseline quality of care value is then multiplied by the projected fractional increase in the overall quality of care that would result from the inclusion of a clinical pharmacist.