Changes in Use of Hepatitis C Direct-Acting Antivirals After Access Restrictions Were Eased by State Medicaid Programs

Importance

Direct-acting antivirals (DAAs) are safe and highly effective for curing hepatitis C virus (HCV) infection, but their high cost led certain state Medicaid programs to impose coverage restrictions. Since 2015, many of these restrictions have been lifted voluntarily in response to advocacy or because of litigation.

Objective

To estimate how the prescribing of DAAs to Medicaid patients changed after states eased access restrictions.

Design, Setting, and Participants

This modified difference-in-differences analysis of 39 state Medicaid programs included Medicaid beneficiaries who were prescribed a DAA from January 1, 2015, to December 31, 2019. DAA coverage restrictions were measured based on a series of cross-sectional assessments performed from 2014 through 2022 by the US National Viral Hepatitis Roundtable and the Center for Health Law and Policy Innovation.

Exposure

Calendar quarter when states eased or eliminated 3 types of DAA coverage restrictions: limiting treatment to patients with severe liver disease, restricting use among patients with active substance use, and requiring prescriptions to be written by or in consultation with specialists. States with none of these restrictions at baseline were excluded.

Main Outcomes and Measures

Quarterly number of HCV DAA treatment courses per 100 000 Medicaid beneficiaries.

Results

Of 39 states, 7 (18%) eliminated coverage restrictions, 25 (64%) eased restrictions, and 7 (18%) maintained the same restrictions from 2015 to 2019. During this period, the average quarterly use of DAAs increased from 669 to 3601 treatment courses per 100 000 Medicaid beneficiaries. After states eased or eliminated restrictions, the use of DAAs increased by 966 (95% CI, 409-1523) treatment courses per 100 000 Medicaid beneficiaries each quarter compared with states that did not ease or eliminate restrictions.

Conclusions and Relevance

The results of this study suggest that there was greater use of DAAs after states relaxed coverage restrictions related to liver disease severity, sobriety, or prescriber specialty. Further reductions or elimination of these rules may improve access to a highly effective public health intervention for patients with HCV.

Incorporating the benefits of vegetative filter strips into risk assessment and risk management of pesticides

The pesticide registration process in North America, including the USA and Canada, involves conducting a risk assessment based on relatively conservative modeling to predict pesticide concentrations in receiving waterbodies. The modeling framework does not consider some commonly adopted best management practices that can reduce the amount of pesticide that may reach a waterbody, such as vegetative filter strips (VFS). Currently, VFS are being used by growers as an effective way to reduce off-site movement of pesticides, and they are being required or recommended on pesticide labels as a mitigation measure. Given the regulatory need, a pair of multistakeholder workshops were held in Raleigh, North Carolina, to discuss how to incorporate VFS into pesticide risk assessment and risk management procedures within the North American regulatory framework. Because the risk assessment process depends heavily on modeling, one key question was how to quantitatively incorporate VFS into the existing modeling approach. Key outcomes from the workshops include the following: VFS have proven effective in reducing pesticide runoff to surface waterbodies when properly located, designed, implemented, and maintained; Vegetative Filter Strip Modeling System (VFSMOD), a science-based and widely validated mechanistic model, is suitable for further vetting as a quantitative simulation approach to pesticide mitigation with VFS in current regulatory settings; and VFSMOD parametrization rules need to be developed for the North American aquatic exposure assessment. Integr Environ Assess Manag 2024;20:454-464. © 2023 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Top-Down Holography in an Asymptotically Flat Spacetime

We propose a holographic duality for a four dimensional Wess-Zumino-Witten model with target manifold SO(8), coupled to scalar-flat Kähler gravity on an asymptotically flat, four dimensional background known as the Burns metric. The holographic dual is a two dimensional chiral algebra built out of gauged β-γ systems with SO(8) flavor. We test the duality by matching two-point correlators of soft gluon currents with two-point gluon amplitudes, and their leading operator product expansion coefficients with collinear limits of three-point gluon amplitudes.

Associativity of One-Loop Corrections to the Celestial Operator Product Expansion

There has been recent interest in the question of whether QCD collinear singularities can be viewed as the operator product expansion of a two-dimensional conformal field theory. We analyze a version of this question for the self-dual limit of pure gauge theory (incorporating states of both helicities). We show that the known one-loop collinear singularities do not form an associative chiral algebra. The failure of associativity can be traced to a novel gauge anomaly on twistor space. We find that associativity can be restored for certain gauge groups if we introduce an unusual axion, which cancels the twistor space anomaly by a Green-Schwarz mechanism. Alternatively, associativity can be restored for some gauge groups with carefully chosen matter.

Chern-Simons Origin of Superstring Integrability

We derive the AdS_{5}×S^{5} Green-Schwarz superstring from four-dimensional Beltrami-Chern-Simons theory reduced on a manifold with singular boundary conditions. In this construction, the Lax connection and spectral parameter of the integrable superstring have a simple geometric origin in four dimensions as gauge connection and reduction coordinate. κ symmetry arises as a certain class of singular gauge transformations, while the world-sheet metric comes from complex-structure-changing Beltrami differentials. Our approach offers the possibility of investigating integrable holography using traditional field theory methods.

Empowering Patients with Alzheimer's Disease To Avoid Unwanted Medical Care: A Look At The Dementia Care Triad

Patients with Alzheimer's disease and other types of dementia with acute medical problems, who have lost capacity and are without advance directives, are at risk of being over treated inhospitals. To deal with this growing demographic and ethical crisis, patients with dementia need to plan for their future medical care while they have capacity to do so. This article will examine the role of each member of the dementia care triad and how to empower the patient to participate in planning future medical care. A case will be made that physicians have the same professional disclosure obligations to dementia patients as they do to all other capable patients with terminal illnesses. Because there is little consensus about what facts should be included in a diagnostic disclosure, this article will offer a proposal to empower newly diagnosed patients with dementia with capacity to plan for their future medical care.

Effects of the ResQPOD on Kinetics, Hemodynamics of Vasopressin, and Survivability in a Porcine Cardiac Arrest Model

BACKGROUND

Ventilation through an impedance threshold device (ITD) purportedly improves hemodynamics and survivability and is given a Class IIb recommendation by the American Heart Association/American College of Cardiology for adult cardiac arrest. No studies have investigated the effects of an ITD with vasopressin.

METHODS AND RESULTS

This study compared return of spontaneous circulation (ROSC), time to ROSC, hemodynamics, and pharmacokinetics with and without the use of a ResQPOD ITD. Swine were randomized to three groups: cardiopulmonary resuscitation and defibrillation alone, vasopressin with ResQPOD, and vasopressin without ResQPOD. Survival differences between the cardiopulmonary resuscitation and defibrillation group versus with and without ResQPOD groups were found (p = 0.001, FET; p = 0.021, FET, respectively) but no differences between with and without ResQPOD groups (p = 0.462). A test of Cmax between the IV and IV/ResQPOD group provided limited evidence that the IV/ResQPOD group attained higher Cmax than then IV only group (U = 11.00, p = 0.097). Median Tmax and ROSC were not statistically different between the groups (U = 11.00, p = 0.314).

CONCLUSIONS

Our data suggest that there is no difference in drug kinetics or clinical outcomes in terms of survivability with or without the ResQPOD.

Fractured OG tip: a case report

This case report describes a complication from use of an orogastric tube not previously described in the literature. An OG tube was placed and removed non-traumatically for the anesthetic management for an anterior-posterior cervical spinal fusion. Despite smooth placement and removal, the patient coughed up the tip of the OG tube while in the post anesthesia care unit. Orogastric (OG) and nasogastric (NG) tubes are routinely used in anesthesia as well as many other fields of medicine. OG and NG tubes leading to morbidity are rare; however, this report describes a new potential adverse event that clinicians should be aware of.

Prevalence of and risk factors for HIV-associated neuropathy in Melbourne, Australia 1993-2006

OBJECTIVES

The aim of the study was to describe the prevalence of and risk factors for HIV-associated sensory neuropathy (HIV-SN) in 2006 [the era of stavudine, didanosine and zalcitabine (dNRTI)-sparing highly active antiretroviral therapy (HAART)] and to compare our findings with data obtained in the same clinic in 1993 (pre-HAART) and 2001 (frequent use of dNRTI-containing HAART).

METHODS

This was a cross-sectional comparative study using convenience sampling. HIV-positive adults attending a tertiary referral clinic over a 2-week period were screened for HIV-SN using the AIDS Clinical Trials Group screening tool. HIV-SN was defined as present if the patient had both neuropathic symptoms and abnormal signs. Demographic, clinical, laboratory and treatment data were considered as possible risk factors for HIV-SN, and results were compared with data obtained in the same clinic in 1993 and 2001.

RESULTS

One hundred patients were screened. The prevalence of HIV-SN was 42%, which was unchanged since 2001 (44%) despite a significant reduction in the use of dNRTIs. HIV-SN remained much more common than in 1993 (42% vs 13%; P<0.0001). The only independent associations with HIV-SN in 2006 were increasing patient age and a history of exposure to either stavudine or indinavir. This compares with 1993 when neuropathy was increased in those with Mycobacterium avium complex infection, and 2001 when patient age and use of stavudine and didanosine were the independent associations with HIV-SN in this clinic.

CONCLUSIONS

HIV-SN remained common among ambulatory patients in 2006 (42% prevalence) despite a significant reduction in the use of dNRTIs. In addition to patient age and stavudine exposure, indinavir use may be a risk factor for HIV-SN.

Clinical response to glatiramer acetate correlates with modulation of IFN-γ and IL-4 expression in multiple sclerosis

Objective To determine whether glatiramer acetate (GA)-induced lymphoproliferation and IFN-γ and IL-4 modulation correlate with the clinical response in multiple sclerosis (MS).

Background GA therapy involves the induction of anti-inflammatory cytokine shifts. However, it is not known whether this response correlates with the clinical outcome.

Methods Thirty-six relapsing-remitting (RR) MS patients were treated with GA for at least two years, and classified clinically as GA-responders (GA-R=22) or hypo/non-responders (GA-HR/NR = 14). Proliferation of peripheral blood mononuclear cells (PBMC) to GA and Tetanus toxoid (TT), as well as IL-4 and IFN-γ ELISPOT, were performed.

Findings There was no difference in PBMC proliferation to GA or TT between GA-R and GA-HR/NR before and during treatment (P>0.05). The mean number of IFN-γ ELISPOTS in unstimulated, TT and anti-CD3/CD28-stimulated PBMC was lower among GA-R (unstimulated: GA-R =10.1±6.21 (n=22) versus GA-HR/NR=17.8±12.7 (n=14), P=0.04; TT-GA-R =12.2±4.06 (n=12) versus GA-HR/NR=26.8±21.0 (n=8), P=0.028; anti-CD-3/CD28 GA-R=217.3±140.4 (n=22) versus GA-HR/NR=368.5±170.1 (n=14), P=0.006). In contrast, the number of IL-4 ELISPOTS remained unchanged in the GA-R group, but was progressively reduced in the GA-HR/NR group during GA therapy (GA-HR/NR IL-4: pre-Rx: 59±34 versus 22±11 at 12 months (n =6), P=0.0429). The IL-4/ IFN-γ ratio in anti-CD3/CD28-stimulated PBMC was significantly higher among GA-R compared to GA-HR/NR (P=0.0474).

Interpretation Lymphoproliferation to GA did not differentiate GA-R from GA-HR/NR. However, reduced IFN-γ expression and stable IL-4 expression in anti-CD3/CD28-stimulated PBMC, and an increased IL-4/IFN-γ ratio was associated with favorable clinical response. More data are needed to validate the prospective use of IL-4/IFN-γ expression in PBMC as a biomarker of clinical response to GA for individual patients. Multiple Sclerosis 2007; 13: 754-762. http://msj.sagepub.com

Optimization of the safety and efficacy of interferon beta 1b and azathioprine combination therapy in multiple sclerosis

We conducted an open-label pilot clinical trial to evaluate the safety and efficacy of adding oral azathioprine to the treatment regimen of 15 multiple sclerosis patients breaking through monotherapy with interferon beta-1b. There were no serious adverse events. Gastrointestinal side effects and leukopenia were the most common adverse events and limited dose escalation. There was a 65% reduction in the number of gadolinium-enhanced magnetic resonance imaging (MRI) lesions on combination therapy compared to the baseline values (P =0.003). A total WBC count less than 4800/mm3 was the best predictor of MRI response.

[D.L.vo n. 626/94 - Musculoskeletal diseases caused by use of micropipette in laboratory]

The use of manual pipettes has been associated with a high prevalence of upper extremity and neck cumulative trauma disorders (CTD's) and work-related musculoskeletal disorders (WMSD's) among laboratory workers. The primary risk factor for these disorders are poor ergonomics in three specific areas: posture, repetition and force. Federal agencies have issued guidelines for pipetting practices to reduce the risk of injury and WMSD's. Pipette manufacturing have responded to the problem by improving the ergonomics and buttons and plungers that require less forces during operations. Another problem was still open with the traditional axial-design pipette: deviation of body or extremity from an ergonomically favourable neutral position. The new generation of micropipettes solves this problem.

Multidisciplinary HIV adherence intervention: a randomized study

Maintaining greater than 95% adherence to antiretroviral medication is necessary in order to have the greatest therapeutic impact on HIV infection. Furthermore, evidence suggests that adherence rates of between 70% and 89% are significantly associated with viral rebound and the development of drug resistance. Adherence rates at and above the 95% level are difficult for patients to achieve and maintain. Our aim was to determine if an adherence intervention could improve adherence among patients attending an ambulatory care clinic at a large public hospital. The intervention was delivered by a multidisciplinary team of health care professionals and consisted of education coupled with the provision of devices designed to assist patient memory and adherence. A crucial component of the intervention consisted of the identification of patient specific barriers to adherence and the development of strategies to circumvent these problems. Adherence was assessed using patient self-report over the past 4, 7, and 28 days and by calculation of the Morisky score. The study was conducted as a randomised controlled trial using the stepped wedge design with a total of 68 subjects randomised to receive the intervention over a 20-week period. Adherence before and after the intervention formed the analysis. There was a significant decrease in the number of missed doses over the past 4 (1.9 to 1.0, p < 0.001), 7 (3.0 to 1.8, p < 0.001) and 28 (7.4 to 4.2, p < 0.001) days and a decrease in the Morisky score, indicating an improvement in medication taking behaviour (1.3 to 0.5 p < 0.001).

Randomized trial of an adherence programme for clients with HIV

Our aim was to determine if a comprehensive adherence package improved self reported adherence to antiretroviral therapy. The adherence package included an education programme, individualized planning of regimens, and the opportunity for a patient to choose from a number of adherence aids and reminder devices. A randomized step wedge design was used. Forty-three individuals were randomized to begin the intervention over a five-month period. There was a substantial fall in the number of missed doses reported for the last four days (0.76 to 0.38, P =0.03) and last seven days (1.5 to 0.74, P =0.005) but not for the last 28 days (2.5 to 2.5, P =0.63). There was no statistical difference in the viral load or CD4 lymphocyte count in the period before or after the intervention. The Morisky score during the pre and post intervention periods was significantly different (P =0.006), 2.9 (SD 0.9) and 3.3 (SD 0.8) respectively. This adherence package improved self reported adherence during the last four and seven days.

Effect of combined IFNbeta-1a and glatiramer acetate therapy on GA-specific T-cell responses in multiple sclerosis

The combined treatment with interferon beta (IFNbeta) and glatiramer acetate (GA) is of current interest in multiple sclerosis (MS). The therapeutic effect of GA in MS is believed to be mediated by GA-specific Th2 cells. IFNbeta has a significant anti-proliferative effect on GA-induced lymphoproliferation in vitro. Therefore, we examined the possibility that IFNbeta may interfere with the generation and phenotype of GA T-cell responses in MS patients receiving combined therapy. Sixty-six GA-specific T-cell lines (TCL) were generated ex vivo from five MS patients enrolled in an open-label dinical trial of combined IFNbeta/GA treatment. Controls included 83 pretreatment and 131 on-treatment GA-TCL from 11 MS patients treated with GA only, and five GA-TCL generated from four patients receiving IFNbeta-1a monotherapy. IFNgamma and IL-5 (markers of Th1 and Th2 responses, respectively) were assayed by ELISA in GA-TCL supematants. Th1/Th2 bias was defined by the IFNgamma/IL-5 level ratio ( >2 = Th1 bias, <0.5 = Th2 bias, and 0.5-2 = Th0 bias). The frequency with which GA-reactive TCL were generated was 37.0% for the patients in the combination trial compared to 33.3% in the patients receiving GA alone. The mean stimulation index of the GA-TCL was 8.41 (range 2-42) for the combination compared to a mean of 6.29 (range 2-37) for the GA-treated group--a nonsignificant difference. Mean GA-TCL IFNgamma production was significantly lower in all treatment groups compared to pretreatment IL-5 levels were enhanced in all treatment groups compared to pretreatment levels, but the change was not statistically significant. The Th1/Th0/Th2 distribution of GA-TCL was 7%/30%/63% for the GA+IFNbeta group, 8%/9%/83% for the GA group, compared to 48%/21%/31% pre-GA treatment. All five GA-TCL from the IFNbeta-1a monotherapy patients were Th2-biased. We conclude that IFNbeta-1a does not affect the generation of GA-reactive T cells in vivo. Although more Th0 G4-TCL occurred with combination therapy than with G4 treatment alone, both groups shared an overall Th2 bias. Therefore, we speculate that combined therapy is unlikely to reduce the efficacy of GA treatment in MS.

Glatiramer acetate induces a Th2-biased response and crossreactivity with myelin basic protein in patients with MS

Glatiromer acetate (GA) is an approved treatment for multiple sclerosis (MS). The proposed mechanism of action is the induction of GA-specific T cells characterized by protective anti-inflammatory Th2 response. We tested this hypothesis in 11 MS patients treated with GA from 1-19 months. Interferon-gamma and IL-5 (markers of Th1 and Th2 responses respectively) were assayed by ELISA in GA-specific T-cell lines (TCL) supernatants. Th1/Th2 bias was defined based on the ratio of IFN-gamma/IL-5 secretion. Fifty-eight pre-treatment and 75 on-treatment GA-specific TCL were generated. On-treatment mean IL-5 levels in GA-TCL increased significantly, whereas those for IFN-gamma were markedly reduced. Consequently, the ratio of IFN-gamma IL-5 also shifted in favor of a Th2 response. The percentage of GA-TCL classified as Th1 was decreased, whereas those classified as Th2 increased on-treatment as compared to pre-treatment. Some GA-specific TCL, (approximately 25%) generated during treatment secreted predominantly IL-5 in response to MBP and the immunodominant MBP peptide 83-99, indicating that these crossreactive antigens can act as partial agonists for GA-reactive TCL. These results strongly suggest that the mechanism of action of GA in MS involves the induction of crossreactive GA-specific T cells with a predominant Th2 cytokine profile.

Nursing management of MS patients receiving interferon beta-1b therapy

In 1993, recombinant interferon beta-1b (Betaseron, Berlex Laboratories) was approved by the Food and Drug Administration as a treatment for relapsing-remitting multiple sclerosis (MS). Betaseron is the first therapeutic agent licensed for use with therapeutic patients with MS in more than 20 years. Many patients and their families have expressed great interest in obtaining information about this agent. In response, MS centers throughout the United States have developed Betaseron training programs. This article describes how rehabilitation nurses can educate patients and families about Betaseron.

The Myers-Briggs type indicator--a management tool

The Myers-Briggs Type Indicator can be an enlightening experience for managers as it uncovers blind spots as well as provides insight into managerial styles. This tool offers a way to build communication patterns that meet nurse managers' needs and the needs of the people they supervise.

Stimulation of human polymorphonuclear leukocyte phosphatidylinositol-4-phosphate kinase by concanavalin A and formyl-methionyl-leucyl-phenylalanine is calcium-independent. Correlation with maintenance of actin assembly

Chemoattractants directly stimulate the enzyme activity that synthesizes phosphatidylinositol-4,5-bisphosphate (PIP2), phosphoinositol-4-monophosphate (PIP) kinase. The present study determined whether stimulation of this enzyme correlates with actin assembly by assessing the calcium dependence of this reaction. Incubation of neutrophils with 5 to 100 micrograms/ml Con A caused a concentration-dependent increase in PIP kinase activity ranging from 1.38- to 3.4-fold. The effective concentration which stimulated PIP kinase by 50% (17 micrograms/ml, EC50) corresponded with the EC50 for Con A-induced superoxide production (32 micrograms/ml). Like chemoattractants, the increase in PIP kinase by Con A was characterized by a 2.6-fold increase in the maximum velocity (Vmax) of the enzyme, and no change in the Km for ATP. The kinetics of FMLP- and Con A-induced filamentous actin formation preceded stimulation of PIP kinase and was sustained over the same time period that this increased enzyme activity was noted. Although transmembrane signaling by FMLP and Con A requires an increase in intracellular calcium for some polymorphonuclear leukocyte (PMN) functional responses, calcium depletion of PMN by incubation with 100 microM Quin 2 A/M and 5 mM EGTA did not prevent the stimulation of PIP kinase by FMLP or Con A. In addition, calcium depletion did not prevent the increase in filamentous actin formation by FMLP and Con A in PMN. These findings demonstrate that Con A increases PIP kinase activity in human PMN and that PIP kinase stimulation and maintenance of actin assembly are independent of calcium fluxes in these cells. Because PIP2 controls the function of the actin-regulatory proteins, profilin and gelsolin, changes in the synthetic rate of PIP2 through regulation of PIP kinase may provide a molecular basis for the prolonged stimulation of actin assembly in human PMN by agonists such as Con A and FMLP.

Stimulation of human polymorphonuclear leukocyte phosphatidylinositol-4-phosphate kinase by concanavalin A and formyl-methionyl-leucyl-phenylalanine is calcium-independent. Correlation with maintenance of actin assembly

Chemoattractants directly stimulate the enzyme activity that synthesizes phosphatidylinositol-4,5-bisphosphate (PIP2), phosphoinositol-4-monophosphate (PIP) kinase. The present study determined whether stimulation of this enzyme correlates with actin assembly by assessing the calcium dependence of this reaction. Incubation of neutrophils with 5 to 100 micrograms/ml Con A caused a concentration-dependent increase in PIP kinase activity ranging from 1.38- to 3.4-fold. The effective concentration which stimulated PIP kinase by 50% (17 micrograms/ml, EC50) corresponded with the EC50 for Con A-induced superoxide production (32 micrograms/ml). Like chemoattractants, the increase in PIP kinase by Con A was characterized by a 2.6-fold increase in the maximum velocity (Vmax) of the enzyme, and no change in the Km for ATP. The kinetics of FMLP- and Con A-induced filamentous actin formation preceded stimulation of PIP kinase and was sustained over the same time period that this increased enzyme activity was noted. Although transmembrane signaling by FMLP and Con A requires an increase in intracellular calcium for some polymorphonuclear leukocyte (PMN) functional responses, calcium depletion of PMN by incubation with 100 microM Quin 2 A/M and 5 mM EGTA did not prevent the stimulation of PIP kinase by FMLP or Con A. In addition, calcium depletion did not prevent the increase in filamentous actin formation by FMLP and Con A in PMN. These findings demonstrate that Con A increases PIP kinase activity in human PMN and that PIP kinase stimulation and maintenance of actin assembly are independent of calcium fluxes in these cells. Because PIP2 controls the function of the actin-regulatory proteins, profilin and gelsolin, changes in the synthetic rate of PIP2 through regulation of PIP kinase may provide a molecular basis for the prolonged stimulation of actin assembly in human PMN by agonists such as Con A and FMLP.

Comparative efficacy and bioequivalence of a brand-name and a generic triamterene-hydrochlorothiazide combination product

The clinical efficacy, safety, and bioavailability of a generic triamterene-hydrochlorothiazide product were compared with those of Dyazide. Thirty patients who had a diagnosis of nonlabile essential hypertension and who were receiving Dyazide (triamterene 50 mg and hydrochlorothiazide 25 mg) were continued on Dyazide maintenance for 16 days to determine the stability of blood pressure control and serum chemistry values. After this baseline period, the subjects were randomized to receive either Dyazide or a generic version for 21 days. They were then crossed over to receive the opposite product for another 21 days. Blood pressures were monitored throughout the study period, and blood samples were taken for measurement of serum electrolytes and of serum triamterene and its major metabolite, hydroxytriamterene sulfate. Hydrochlorothiazide was assayed in 24-hour urine samples. There were no statistically significant differences between regimens in recumbent and standing mean diastolic blood pressures or in mean concentrations of serum potassium, chloride, glucose, creatinine, and uric acid. Area under the concentration-time curve from 0 to 24 hours after drug administration, maximum concentration in serum, and time to achieve maximum concentration in serum did not differ significantly between regimens for triamterene and hydroxytriamterene sulfate. Similarly, there were no significant differences in excretion, maximum rate of excretion, and time to achieve maximum rate of excretion for urinary hydrochlorothiazide. Patients treated with a brand-name fixed-combination product containing triamterene 50 mg and hydrochlorothiazide 25 mg were given a generic formulation without loss of therapeutic efficacy or development of toxicity.