Effects of widely used drugs on micronutrients: A story rarely told

Vitamins and trace elements are essential to the body, however, deficiencies are frequently observed in the general population. Diet is mostly responsible for these deficiencies but drugs also may play a significant role by influencing their metabolism. These effects are rarely assessed in clinical practice, in part because of limited data available in the literature. Drug-induced micronutrient depletions, however, may be the origin of otherwise unexplained symptoms that might sometimes influence medication compliance.We present various examples of widely prescribed drugs that can precipitate micronutrient deficiencies. This review aims at sensitizing physicians on drug–micronutrient interactions. High-risk population groups also are presented and supplementation protocols are suggested.     

Cisapride treatment for children with gastro-esophageal reflux

The prokinetic drug cisapride is widely used for treating gastro-oesophageal reflux in infants and children. As in the Netherlands it is not officially registered for use in these age groups, prescribing doctors have problems obtaining adequate information on proper use and side effects. In the treatment of pediatric gastro-oesophageal reflux with cisapride the major recommendations include not to exceed the maximum dose of 0.2 mg/kg four times daily, to avoid comedication with imidazoles and macrolides and to check the QTc interval in patients with known risk factors for QTc prolongation.     

Disaster after the plaster. Fentanyl withdrawal symptoms in a curable hospice patient

Opioids have been used for thousands of years for pain relief. Transdermal fentanyl (TDF) is a synthetic opioid that is prescribed for the treatment of chronic pain. This clinical lesson demonstrates that TDF may be easy to start but sometimes difficult to stop. Like any other opioid there is a substantial risk of physical dependence and subsequent withdrawal symptoms after discontinuation of the drug. Here, we present a case of a hospice patient who developed withdrawal symptoms after a first TDF tapering attempt according to the manufacturer's instructions. A second, more gradual tapering regimen did not result in withdrawal symptoms. The mechanisms and treatment modalities for physical dependence along with a tailor-made tapering strategy that is suitable for general practice are presented in this clinical lesson.     

Diagnosis and treatment of gastroesophageal reflux disease in the mentally retarded: guidelines of a multidisciplinary consensus work group. Dutch Association of Physicians in Care of Mentally Handicapped

Gastroesophageal reflux disease (GORD) is more frequent among people with intellectual disability than among the intellectually normal population. Also GORD is more serious in this population. The diagnosis is often missed, because most intellectually disabled cannot express their complaints of GORD. For that reason a multidisciplinary working group of the Dutch Association of physicians active in the care of persons with a mental handicap has developed guidelines. The working group recommends endoscopy in case of a (alarm) symptoms: haematemesis, prolonged vomiting, irondeficiency anaemia e.c.i., and a 24 hour oesophageal pH test in case of b (aspecific) symptoms: recurrent pneumonia, refusal of food, regurgitation, rumination, dental erosions. In general most patients are cured with drug treatment (omeprazol or another proton pump inhibitor). If symptoms are not improved after 6 months of optimal treatment, surgical treatment may be considered.     

Summarisation of the NHG practice guideline 'Anxiety'

- Anxiety and anxiety disorders are addressed in the practice guideline of the Dutch College of General Practitioners (NHG).- It is important to distinguish anxiety and anxiety disorders because of differences in prognosis and treatment.- Several visits may be needed before the diagnosis is established.- Treatment is based on a stepped-care model. For anxiety, psychoeducation and follow-up visits are often sufficient. For anxiety disorders with relatively low levels of distress or social dysfunctioning, self-help with supervision in addition to psychoeducation is helpful. If this is not effective or if there is severe distress or social dysfunctioning, cognitive behavioural therapy is the first choice treatment. An antidepressant could be started after or in addition to cognitive behavioural therapy.- If an antidepressant is prescribed, SSRIs are preferred above tricyclic antidepressants because of the lesser risk of severe adverse effects.     

Listen carefully: The risk of error in spoken medication orders

Clinicians and patients often confuse drug names that sound alike. We conducted auditory perception experiments in the United States to assess the impact of similarity, familiarity, background noise and other factors on clinicians' (physicians, family pharmacists, nurses) and laypersons' ability to identify spoken drug names. We found that accuracy increased significantly as the signal-to-noise (S/N) ratio increased, as subjective familiarity with the name increased and as the national prescribing frequency of the name increased. For clinicians only, similarity to other drug names reduced identification accuracy, especially when the neighboring names were frequently prescribed. When one name was substituted for another, the substituted name was almost always a more frequently prescribed drug. Objectively measurable properties of drug names can be used to predict confusability. The magnitude of the noise and familiarity effects suggests that they may be important targets for intervention. We conclude that the ability of clinicians and lay people to identify spoken drug names is influenced by signal-to-noise ratio, subjective familiarity, prescribing frequency, and the similarity neighborhoods of drug names.     

不同状态绝经后妇女激素替代疗法的个性化选择策略

激素替代疗法（HRT）是目前缓解绝经相关症状和预防绝经后骨质疏松等疾病最有效的方案。HRT治疗中要求遵循个性化原则,根据患者的不同症状、年龄和不同的基础疾病状况,有无HRT适应证和禁忌证,掌握慎用情况及不同药物的特点,选择最佳治疗窗,使用最低剂量从而达到最佳治疗效果。     

Isoniazid plus thioacetazone compared with two regimens of isoniazid plus PAS in the domiciliary treatment of pulmonary tuberculosis in South Indian patients

Previous reports from the Tuberculosis Chemotherapy Centre, Madras, have established that ambulatory treatment of pulmonary tuberculosis with a standard daily regimen of isoniazid plus PAS for one year yields satisfactory results. However, this regimen may be unsuitable for large-scale use in many developing countries, because PAS is expensive, bulky and unpleasant to take, and has poor keeping qualities, especially in tropical countries. It might be possible to overcome these disadvantages, by substituting for the PAS a drug which is equally effective but less expensive and more acceptable, or by reducing the daily dosage of PAS and the period for which it is prescribed.     

Experience of healthcare workers taking postexposure prophylaxis after occupational HIV exposures: findings of the HIV Postexposure Prophylaxis Registry.

OBJECTIVE: To collect information about the safety of taking antiretroviral drugs for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP). DESIGN: A voluntary, confidential registry. SETTING: Hospital occupational health clinics, emergency departments, private physician offices, and health departments in the United States. RESULTS: 492 healthcare workers (HCWs) who had occupational exposures to HIV, were prescribed HIV PEP, and agreed to be enrolled in the registry by their healthcare providers were prospectively enrolled in the registry. Three hundred eight (63%) of 492 of the PEP regimens prescribed for these HCWs consisted of at least three antiretroviral agents. Of the 449 HCWs for whom 6-week follow-up was available, 195 (43%) completed the PEP regimen as initially prescribed. Forty-four percent (n=197) of HCWs discontinued all PEP drugs and did not complete a PEP regimen. Thirteen percent (n=57) discontinued > or =1 drug or modified drug dosage or added a drug but did complete a course of PEP Among the 254 HCWs who modified or discontinued the PEP regimen, the two most common reasons for doing so were because of adverse effects attributed to PEP (54%) and because the source-patient turned out to be HIV-negative (38%). Overall, 340 (76%) HCWs with 6-week follow-up reported some symptoms while on PEP: nausea (57%), fatigue or malaise (38%), headache (18%), vomiting (16%), diarrhea (14%), and myalgias or arthralgias (6%). The median time from start of PEP to onset of each of the five most frequently reported symptoms was 3 to 4 days. Only 37 (8%) HCWs with 6-week follow-up were reported to have laboratory abnormalities; review of the reported abnormalities revealed that most were unremarkable. Serious adverse events were reported to the registry for 6 HCWs; all but one event resolved by the 6-month follow-up visit. Fewer side effects were reported by HCWs taking two-drug PEP regimens than by HCWs taking three-drug PEP regimens. CONCLUSIONS: Side effects from HIV PEP were very common but were rarely severe or serious. The nature and frequency of HIV PEP toxicity were consistent with information already available on the use of these antiretroviral agents. Clinicians prescribing HIV PEP need to counsel HCWs about PEP side effects and should know how to manage PEP toxicity when it arises.     

Lengthening of the QT-interval in a newborn treated with cisapride

In a 7-week-old female infant a prolonged QTc interval, up to 485 ms, was measured and attributed to the use of the prokinetic agent cisapride. The girl was born at 32 1/7 weeks of gestational age, started to use cisapride (0.8 mg/kg/day) at the age of 7 weeks because of gastro-oesophageal reflux. After cessation of cisapride therapy, the QTc interval returned to normal. A normal QTc interval had also been observed before the use of cisapride. Because of the risk of QTc prolongation and possibly cardiac arrhythmias during the use of cisapride by newborn infants, electrocardiography should be performed before and during cisapride therapy; they should also be checked for possible risk factors like electrolyte disturbances and congenital QTc prolongation. Prudence is called for in case of patients with pre-existing disorders which could result in QT prolongation like electrolyte disturbances, congenital QT prolongation, and the concomitant use of medication associated with QT prolongation.     

Predictors of the initiation of psychotherapeutic medicine use.

This study examined the hypothesized predictive association between illicit drug use and the onset of prescribed psychotherapeutic medicine use. The effect of psychiatric symptoms on this relationship was also explored. Data were gathered retrospectively, through standardized household interviews conducted in 1981 for the Baltimore site of the National Institute of Mental Health Epidemiologic Catchment Area Program. For this analysis, the sample was restricted to 1,716 respondents ages 18-44 at the time of interview, drawn by probability sampling area household residents of all adult ages. Using Cox proportional hazards models, the onset of psychotherapeutic medicine use was modeled as a function of illicit drug use and psychiatric symptoms, both defined as time-dependent covariates. Newly observed in this analysis was an independent association of illicit drug use with psychotherapeutic medicine use, which was unexplained by psychiatric symptoms (relative hazard = 2.61, 95% confidence interval (CI) = 2.15, 3.18). Adjustment for age of onset of alcohol intoxication did not alter the impression that illicit drug users were more likely to initiate use of prescribed psychotherapeutic medicines (relative hazard = 2.52, 95% CI = 2.02, 3.11).     

The role of pharmacotherapy in anorexia nervosa and bulimia

The purpose of this article is to review the basic pharmacology and the role of drugs that are used to treat anorexia nervosa and bulimia. The pharmacological treatment of eating disorders is based upon theoretical principles. The theoretical models include: (a) an illness secondary to other psychiatric disorders, (b) a disorder in the hypothalamic control of food intake, (c) a disorder of hypothalamic endocrine regulation, (d) a syndrome secondary to depressive illness, and (e) a disorder in the hypothalamic regulation of food intake. Theoretical models a, b, and c govern the choice of drug therapy for anorexia nervosa, and models d and e govern the choice of drug therapy for bulimia. Drugs used to treat anorexia nervosa and bulimia include tricyclic antidepressants and lithium carbonate. Chlorpromazine, metoclopramide, cyproheptadine, and clomiphene citrate have also been prescribed for the treatment of anorexia nervosa. Monoamine oxidase inhibitors are commonly prescribed to treat bulimia. Fenfluramine has the potential to be of therapeutic value in patients with bulimia. Although drug therapy plays a limited role in the treatment of eating disorders, drugs are commonly prescribed. Therefore, the nutritionist should be familiar with the basic pharmacology and the side effects related to drug therapy.     

Implications of directly observed therapy in tuberculosis control measures among IDUs.

Tuberculosis (TB) is a rapidly growing problem among injecting drug users (IDU), especially those infected with human immunodeficiency virus. The authors review IDUs'' responses to current TB control strategies and discuss the implications of their findings for the proposed implementation of directly observed therapy (DOT), a method for ensuring that patients take prescribed medication. Field workers carried out 210 ethnographic interviews with 68 IDUs in a Brooklyn, NY, community during 1990-93. Case studies suggested that many IDUs are uninformed about TB and often misinformed about their personal TB status. Ethnographic interviews and observations indicated that the threat of TB-related involuntary detainment may lead IDUs to avoid TB diagnostic procedures, treatment for TB, or drug abuse treatment, and to avoid AIDS outreach workers and other health-related services. IDUs who tested positive for the purified protein derivative (PPD) of TB sometimes have left hospitals before definitive diagnoses were made, because of a perceived lack of respectful treatment, fear of detention, or lack of adequate methadone therapy to relieve the symptoms of withdrawal from drugs. Current TB diagnosis and treatment systems are, at best, inadequate. The threat of TB-related detention discourages some IDUs from seeking any type of health care. There is an urgent need to educate IDUs about TB and to educate and sensitize health care providers about the lifestyles of IDUs. DOT may help in servicing this difficult-to-serve population, particularly if techniques are incorporated that have been developed for other successful public health interventions for IDUs.     

严重女性尿道综合征的药物综合治疗研究

目的探讨以托特罗定为基础,药物综合治疗严重女性尿道综合征的疗效。方法采用前瞻性研究观察严重的尿道综合征女性患者23例。以托特罗定为基础用药,根据患者实际情况及症状联合应用a-受体阻断剂、雌激素、低成瘾性止痛剂、抗组胺药物、抗精神抑郁药物及镇静药物治疗。服药1周后复诊,如症状改善明显则继续服用;如用药有效但改善不明显,则再据病情加用更多的联合用药。对于症状尤其严重者或多方治疗无效及已实施过初始治疗效果不明显者,则开始时即加以多种药物联合应用。总疗程2个月,观察用药前及用药2个月后患者临床症状（每日排尿次数、尿痛程度评分及盆腔痛发作次数）,并记录不良反应发生情况。结果（1）用药2个月后每日排尿次数明显减少,治疗前后分别为（3l_5±4．4）和（16．6±3．2）次,盆腔痛发作次数明显减少,治疗前后分别为（15．6±2．7）次／周及（2．4±1．6）次／周。上述指标用药前后相比均有统计学意义（P〈0．01）。（2）尿痛程度评分明显下降,治疗前后分别为（6．8±1．1）和（3．7-I-1．5）分,盆腔痛程度有明显缓解。生活质量评分明显降低,治疗前后分别为（5．8±0．6）和（2．2±0．8）分,用药前后比较,差异有统计学意义（P〈0．01）。（3）精神症状明显改善,自杀倾向消除。（4）23例患者均无明显的服药后不适,考虑可能是明显缓解症状后精神状态的改善掩盖了患者对副作用的感受,其副作用有待于进一步的扩大病例及临床观察研究。结论以托特罗定为基础用药,并根据患者实际病情联合应用其他对症药物综合治疗,能有效而迅速缓解严重女性下尿路综合征的临床症状,明显改善其生活质量及精神状态,且耐受性及安全性较好。     

Prophylactic treatment after myocardial infarction in primary care: how far can we go?

BACKGROUND: Despite best practice, it may not be achievable in some patients to reach the optimal goals of secondary prevention recommendations for various reasons, such as co-morbidity, contraindications for some drugs or side effects. OBJECTIVE: Our aim was to estimate the achievable standards for audit purposes in primary care for prophylactic treatment of secondary prevention of myocardial infarction. METHODS: We conducted a survey of consecutive patients with a hospital diagnosis of first acute myocardial infarction during 1997 who were identified from discharge books from four hospitals and interviewed at their primary health centre 2 years after admission. The achievable standard for a prophylactic drug was then defined as the proportion of patients that could benefit from the treatment excluding those that for one justified reason or another were off medication. RESULTS: Three hundred and sixty-nine patients were interviewed in the follow-up. Aspirin or another antiplatelet regimen was prescribed in 86.9 patients, beta-blockers in 50.2%, angiotensin-converting enzyme (ACE) inhibitors in 32.5% and lipid-lowering drugs in 52%. The estimated achievable standards for those prescribed drugs were 94.5, 71,8, 50.5 and 69.8%, respectively. CONCLUSIONS: There is an underuse of prophylactic drug therapies after myocardial infarction. The standards established in this study for secondary preventive drug treatment might be achieved through a reasonable effort by GPs working in primary care committed to improving the quality of care.