Use of intravenous inotropic therapy in the home

The role of home i.v. inotropic therapy in managing patients with refractory congestive heart failure (CHF) is reviewed. CHF is a fairly common health care problem in the United States and is associated with significant morbidity and mortality. Although several oral medications are used to treat CHF, individuals with New York Heart Association class III or IV disease may require i.v. inotropic therapy. Typically, these patients are managed in the hospital. However, some patients dependent on i.v. therapy may be safely treated at home. While the functional status and quality of life of these individuals may be improved, there is no evidence that home i.v. inotropic therapy increases their overall survival. Dobutamine is currently the preferred i.v. inotropic agent, but amrinone and milrinone are suitable alternatives. Although tolerance to dobutamine may develop with continuous drug administration, intermittent therapy has been associated with an increased risk of sudden death. The optimal infusion schedules for amrinone and milrinone have not been clearly established. Home i.v. inotropic therapy may improve the quality of life in carefully selected patients with refractory CHF.

Alternatives to estrogen for the treatment of hot flashes

Postmenopausal women experiencing hot flashes in whom estrogen replacement is contraindicated have alternatives available to them; however, there is no clearly defined treatment modality. The literature addressing many of these alternatives has serious limitations, which include the small number of women enrolled and lack of comparative studies between agents. Each patient needs to be assessed in terms of her current medical status, concomitant medications, and the degree to which vasomotor instability interferes with everyday activities. The literature suggests that megestrol acetate 20 mg bid may provide significant relief. Women who opt to use megestrol acetate must be told in advance that the effects will not be felt immediately particularly if tamoxifen is used concomitantly. Clonidine and medroxyprogesterone may constitute potential alternatives, but patients may not be able to tolerate the adverse effects. Because of the lack of literature supporting their clinical use, options such as vitamin E and ginseng need to be approached cautiously. Exercise has a role in alleviating some of the complications associated with menopause, such as heart disease and osteoporosis, but its effect on neurotransmitters and hormone concentrations, and how this relates to the treatment of hot flashes have not been characterized. Patients should be told that regular physical activity, a balanced diet, avoidance of alcohol and caffeine, and stress reduction may be of additional help in decreasing vasomotor flushing.

Potentiation of nephrotoxicity by H2-antagonists in patients receiving cyclosporine

The literature does not support a pharmacodynamic interaction between H2-antagonists and cyclosporine that would result in potentiation of cyclosporine's nephrotoxicity. The increase in serum creatinine associated with cimetidine, in the majority of cases, is due to competition with creatinine for tubular secretion. Ranitidine is unlikely to produce a change in serum creatinine. Additionally, there is no support for a pharmacokinetic interaction. However, cimetidine may influence peak concentrations of cyclosporine. Besides the clinical data reviewed here, two abstracts concur with these findings. Information was unavailable regarding interactions between cyclosporine and either famotidine or nizatidine that potentiate nephrotoxicity in transplant patients. Furthermore, the drug manufacturers state that no evidence is available to support any interaction of their products with cyclosporine. Thus, interpretation of renal function may be confusing with concomitant administration of cimetidine and cyclosporine unless GFR is accurately monitored. On the basis of the information available at this time, ranitidine may be considered the H2-antagonist of choice in a patient treated with cyclosporine.

Barriers to compliance with OBRA'90 regulations in community pharmacies

OBJECTIVE

To identify which barriers have been most significant to community pharmacists in their ability to comply with the Omnibus Budget Reconciliation Act of 1990 (OBRA'90) regulations during its first year of implementation.

METHODS

Mailing of a two-page survey in April 1994.

SETTING

Four hundred randomly selected community pharmacies in the Commonwealth of Massachusetts.

PARTICIPANTS

Of 400 pharmacies surveyed, 156 surveys were completed and returned for analysis.

RESULTS

Barriers that were considered most significant to pharmacies surveyed in their ability to implement OBRA'90 regulations were excessive workload, lack of financial compensation, and patients' attitudes. Of least significance were inadequate knowledge about drugs, inadequate references, and store layout. Almost half the responding pharmacists indicated that OBRA'90 regulations had not affected or changed their practice, one-quarter of the pharmacists believed their practice was less rewarding after OBRA'90, and about one-fifth believed it was more rewarding.

CONCLUSIONS

Community pharmacists in Massachusetts are making an attempt to comply with OBRA'90, but there are specific barriers that are affecting their ability to do so. The OBRA'90 regulations appear to have had little impact on the practice of most community pharmacies. Community pharmacy management needs to examine (1) expanded roles of supportive personnel to give pharmacists more time to spend counseling patients, (2) reimbursement mechanisms for cognitive service, and (3) approaches to educating patients about these changes in the pharmacy profession.

Health effects of salicylates in foods and drugs

There is much (renewed) interest about the effects of salicylates on food intolerance, attention-deficit disorders, and cardiovascular disease. Current evidence for the efficacy of salicylate-elimination diets in the treatment of attention-deficit disorders and hyperactivity is weak, and further investigation is required on the relationship between salicylates and cardiovascular disease.

Drug stop: newer beta-lactam antimicrobials

The newer beta-lactam antimicrobials offer an expanded spectrum of activity and a similar safety profile compared to their older counterparts. The penicillins appear to be useful in the combination treatment of systemic Pseudomonal infections, and cefuroxime and the third generation cephalosporins may be valuable in the management of meningitis caused by susceptible organisms. However, to avoid the emergence of resistance and to help contain the cost of antimicrobial therapy, these newer agents should be reserved for those clinical situations where older beta-lactams would not be indicated.

Cephalosporin-use restrictions in teaching hospitals

A survey of pharmacy directors in teaching hospitals was conducted in March 1983 to ascertain policies for management of cephalosporin use. Surveys were sent to 298 institutions in each of the United States except Alaska. Respondents were asked various questions regarding hospital policies on cephalosporin use. Responses were received from 179 hospitals that had formularies; 99 of these had formal restriction policies, more frequently for second- and third-generation agents than for first-generation agents, and 13 planned to institute restriction policies. In 68% of hospitals with restriction policies, restricted drugs were released only after consultation with the infectious disease service. Chart review was the most frequently reported method of monitoring use of restricted cephalosporins. Approximately 40% of respondents had therapeutic equivalence policies, and more than 40% had recently deleted one or more cephalosporins from the formulary. The percentage of hospitals with formal restriction policies (55%) was greater than in a 1979 survey (32%). Many teaching hospitals have initiated policies to curb rising drug costs associated with the use of cephalosporin antibiotics.