bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of a Limited Fluoroquinolone Reimbursement Policy on Antimicrobial Prescription Claims
Authors: MacCara Mary E , Sketris Ingrid S , Comeau Donna G , Weerasinghe Swarna DS
Published: June 2003

OBJECTIVE:

To examine the influence on administrative pharmacy claims of a policy that limited the reimbursement of the fluoroquinolones and other antimicrobials in the senior population within Nova Scotia, Canada.

METHODS:

The administrative claims database of the Nova Scotia Seniors' Pharmacare Program was used to identify all prescription claims for orally administered antibiotics and urinary antiinfectives. The number of beneficiaries receiving antimicrobials and the number, duration, and cost of prescriptions for antimicrobials were measured monthly. Descriptive time-series plots were used to compare antimicrobial use for two 12-month periods before the institution of the policy (December 1, 1994–November 30, 1995, and December 1, 1995–November 30, 1996) and the 12 months after the policy took effect (January 1, 1997–December 31, 1997).

RESULTS:

Following the implementation of the fluoroquinolone reimbursement policy, the number of patients using antimicrobials decreased by 2.2% and the number of prescriptions for antimicrobials decreased by 3.4%. Fluoroquinolone prescriptions decreased by 80.2%; prescriptions for sulfonamides and trimethoprim increased by 34.9%, cephalosporins by 17.0%, and macrolides and lincosamides by 16.5%. The only prescription duration to change was the fluoroquinolones, which increased by 25%. The average cost per antimicrobial user/year decreased from $35.24 during prepolicy period 2 to $27.51 during the postpolicy period.

CONCLUSIONS:

Prescription claims for fluoroquinolones in seniors decreased following the introduction of the policy. Total antimicrobial use also decreased, although this may be related to other factors. The effect of this policy change on patient outcomes requires further study.
Gynecomastia Associated with Highly Active Antiretroviral Therapy
Authors: Manfredi Roberto , Calza Leonardo , Chiodo Francesco
Published: June 2003

OBJECTIVE:

To report four cases of HIV-associated gynecomastia diagnosed during treatment with nucleoside analogs with or without protease inhibitors.

CASE SUMMARY:

Four HIV-infected patients developed gynecomastia while taking two nucleoside analogs (stavudine combined with lamivudine in 3 patients, stavudine with didanosine in 1 patient) and protease inhibitors (indinavir, nelfinavir, ritonavir—saquinavir in 3 patients) all patients had received prior treatment with single or associated nucleoside analogs for ≥21 months. Gynecomastia occurred three to seven months after the start of a triple regimen in the first three patients, and 17 months after initiating the last dual nucleoside analog therapy in the remaining patient. Liver, kidney, and thyroid function were normal; a routine endocrinologic workup showed slight follicle-stimulating hormone and luteinizing hormone abnormalities in one patient only. Other possible causes of drug-or disease-induced gynecomastia were excluded. A concurrent fat redistribution syndrome was present in three patients (including the patient who received nucleoside analogs only), while serum lipid and/or glucose concentration abnormalities were present in all patients. Gynecomastia remained unchanged during the subsequent seven- to 16-month follow-up, even after modification of antiretroviral therapy.

DISCUSSION:

Gynecomastia has been recently associated with antiretroviral therapy, and all reported cases but one occurred two to 17 months after the start of a protease inhibitor—based regimen. Our experience underlines the possible occurrence of gynecomastia in the absence of protease inhibitor administration, its persistence despite changes of antiretroviral regimen (thus resembling some signs related to lipodystrophy syndrome), and the apparently constant association with prolonged nucleoside analog administration (especially stavudine).

CONCLUSIONS:

Gynecomastia should be included among emerging adverse effects of antiretroviral therapy, although its etiopathogenesis deserves further investigation.
Linezolid for the Treatment of Resistant Gram-Positive Cocci
Authors: Bain Kevin T , Wittbrodt Eric T
Published: June 2003

OBJECTIVE:

To provide a comprehensive review of linezolid, the first of a new class of antibiotics, the oxazolidinones. Therapeutic issues regarding the emergence of multidrug-resistant bacteria and a brief history of the oxazolidinones are also discussed.

DATA SOURCES:

A MEDLINE search (1966–March 2001) was conducted to identify pertinent literature, including preclinical trials, clinical trials, and reviews. Unpublished clinical data, adverse effects, and dosing information were abstracted from product labeling.

STUDY SELECTION:

Clinical efficacy data were extracted from clinical trials, case reports, and abstracts that mentioned linezolid. Additional information concerning antibiotic resistance, the oxazolidinones, in vitro susceptibility, and the pharmacokinetic profile of linezolid also was reviewed.

DATA SYNTHESIS:

Linezolid exhibits activity against many gram-positive organisms, including vancomycin-resistant Enterococcus faecium, methicillin-resistant Staphylococcus aureus, and penicillin-resistant Streptococcus pneumoniae. Linezolid inhibits bacterial protein synthesis at an early step in translation and is rapidly and completely absorbed from the gastrointestinal tract following oral administration. Efficacy has been demonstrated in a number of unpublished clinical trials in adults with pneumonia, skin and skin structure infections, and vancomycin-resistant E. faeciuminfections. The adverse effect profile is similar to that of comparator agents (β-lactams, clarithromycin, vancomycin).

CONCLUSIONS:

Linezolid is the first oral antimicrobial agent approved for the treatment of vancomycin-resistant enterococci. Since the oxazolidinones have a unique mechanism of action and expanded spectrum of activity against virulent and highly resistant gram-positive pathogens, linezolid is a valuable alternative to currently available treatment options. Clinical trials evaluating linezolid and other oxazolidinones for antibiotic-resistant gram-positive infections, as well as comparator studies comparing linezolid with other candidate drugs, such as quinupristin/dalfopristin and chloramphenicol, will further define the role of linezolid.
Olanzapine-Induced Diabetes Mellitus
Authors: Bonanno Danielle Graci , Davydov Liya , Botts Sheila R
Published: June 2003

OBJECTIVE:

To report two cases of new-onset diabetes mellitus resulting after the initiation of olanzapine treatment.

CASE SUMMARY:

A 31-year-old African American man and a 44-year-old white man, both with schizoaffective disorder, developed diabetes mellitus within weeks or months of olanzapine initiation.

DISCUSSION:

Our reports of new-onset diabetes due to olanzapine are consistent with those in the literature. Although the mechanism is not yet known, it has been hypothesized that perhaps damage to the pancreatic islet cells, weight gain, dysregulation of the sympathetic system, and insulin resistance are contributing factors.

CONCLUSIONS:

Diabetes mellitus secondary to olanzapine use seems to be a rare occurrence. However, certain risk factors such as obesity, family history, and concomitant medications may predispose an individual to development of diabetes mellitus while taking olanzapine. An increased awareness of this reaction is essential in the treatment of patients at risk. Periodic serum glucose monitoring in these individuals may be warranted.
Use of Lepirudin in Patients with Heparin-Induced Thrombocytopenia and Renal Failure Requiring Hemodialysis
Authors: Dager William E , White Richard H
Published: June 2003

OBJECTIVE:

To report two cases of successful lepirudin use in two patients with heparin-induced thrombocytopenia (HIT) and renal failure.

CASE SUMMARY:

Two patients with renal failure requiring hemodialysis developed HIT syndrome during intravenous heparin therapy. Anticoagulation was necessary to prevent recurrent, acute venous thrombosis in one patient and to prevent arterial thrombosis associated with the use of an intraaortic balloon pump in the second. Intravenous lepirudin was initiated at doses of 0.01 mg/kg/h and 0.005 mg/kg/h, respectively, and titrated based on the activated partial thromboplastin time (aPTT). Steady-state doses were 0.015 mg/kg/h to maintain aPTT values of approximately 60 seconds in one patient, and 0.005–0.008 mg/kg/h to achieve an aPTT of approximately 45 seconds in the other patient.

DISCUSSION:

Lepirudin is one of few anticoagulants that can be safely used in patients with HIT. Because it is eliminated through the kidneys, great care must be taken when administering lepirudin to patients with renal failure; in fact, its use is currently not recommended in patients requiring hemodialysis. Lepirudin effectively prevented acute thrombosis in both of our patients with documented HIT, with no bleeding complications. We describe how we selected the initial doses and report results of aPTT monitoring.

CONCLUSIONS:

In patients with renal failure who develop HIT, lepirudin is one available alternative to heparin despite its poor renal elimination pattern and subsequently prolonged half-life.
Effect of Levothyroxine Administration Time on Serum TSH in Elderly Patients
Authors: Elliott David P
Published: June 2003

BACKGROUND:

Standard drug information resources recommend that levothyroxine be taken on an empty stomach due to the potential for interaction with food or medications. Due to concern about unpredictable response to levothyroxine in patients receiving morning doses in a skilled nursing facility, the standard administration time for the drug was changed from 0900 to midnight.

OBJECTIVE:

To determine if a change in response to levothyroxine as determined by the serum ultrasensitive thyroid-stimulating hormone (TSH) concentration occurred when the time of administration was changed from early morning to midnight.

DESIGN:

Retrospective chart review.

SETTING:

A 187-bed skilled nursing facility.

PARTICIPANTS:

Fifteen nursing home residents receiving levothyroxine during the change of administration time with a mean age of 84 years met inclusion criteria, with at least one TSH concentration reported prior to and at least one serum TSH concentration reported after the change in administration time to midnight.

MEASUREMENTS:

Serum TSH concentrations.

RESULTS:

There was a decrease in serum TSH of 0.286 ± 1.722 mU/mL (mean ± SD) after changing the administration time to midnight that was not statistically significant (t = 0.643; p = 0.532).

CONCLUSIONS:

Based on the results of the study, we conclude that levothyroxine could be routinely administered after breakfast.
Medication Adherence in Elderly Patients Receiving Home Health Services following Hospital Discharge
Authors: Gray Shelly L , Mahoney Jane E , Blough Dave K
Published: June 2003

OBJECTIVE:

To assess prevalence and risk factors for medication under- and overadherence in a two-week period following hospital discharge in adults ⩾ 65 years.

DESIGN:

Prospective, cohort study.

SETTING:

Three home healthcare agencies in Madison, Wisconsin, and surrounding vicinity.

PARTICIPANTS:

One hundred forty-seven older participants taking three or more medications who were hospitalized for medical illness, received home nursing after discharge, and completed the two-week interview.

MEASUREMENTS:

The main outcome measures were having at least one medication with less than 70% adherence (underadherence) and having at least one medication with more than 120% adherence (overadherence) based on pill counts.

RESULTS:

Forty-five (30.6%) participants were underadherent and 27 (18.4%) participants were overadherent with at least one medication. In a multivariate model, underadherence was predicted by poor cognition (OR 2.5; 95% CI 1.02 to 6.10) and higher medication use (OR 1.16; 95% CI 1.03 to 1.31, for each 1-unit increase in number of medications). Both poor cognition and low education were significantly associated with overadherence in univariate analysis; however, neither variable was significant once included in the multivariate model.

CONCLUSIONS:

Under- and overadherence to medications is common after hospital discharge. Poor cognition and a greater number of medications were associated with underadherence. Poor cognition and lower education were markers for overadherence; however, further study is needed to determine whether these are independent predictors. Patients who have impaired cognition or are taking a greater number of medications after hospitalization may benefit from targeted interventions to monitor and improve medication compliance.
Eradication of Severe Neonatal Systemic Candidiasis with Amphotericin B Lipid Complex
Authors: Knoppert David C , Salama Husam EM , Lee David SC
Published: June 2003

OBJECTIVE:

To report the successful use of amphotericin B lipid complex in treating severe systemic candidiasis in a very-low-birth-weight infant.

CASE SUMMARY:

A preterm female infant, born at 25 weeks' gestational age with a birth weight of 870 g, had received full supportive care in the neonatal intensive care unit (NICU), including mechanical ventilation, total parenteral nutrition, and placement of central venous catheters. At seven weeks of age, she developed severe disseminated candidiasis, which failed to respond to conventional amphotericin B and fluconazole therapy. Her progressive deterioration was reversed only after amphotericin B lipid complex (A-complex) was substituted for conventional amphotericin B. The improvement in her condition was impressive, and she made a full recovery without any adverse effect.

DISCUSSION:

With increased reliance on invasive technologies for life support, systemic candida infections have become increasingly common among premature infants in the NICU. Such infections are potentially fatal for the high-risk neonate. A literature review shows limited documentation of the use of lipid-based formulations of amphotericin B, especially A-complex, in preterm infants. However, the collective experience with these products appears to show that they are effective and cause fewer adverse effects than conventional amphotericin B. The infant reported here had shown progressive deterioration from disseminated candidiasis until conventional amphotericin B therapy was replaced with A-complex. Her recovery corresponded to the clearance of the candidemia.

CONCLUSIONS:

With favorable results and increasing experience with lipid-based formulations of amphotericin B, it is reasonable to consider these new formulations as therapy for candidemia in preterm infants who are at a high risk of nephrotoxicity or who have failed conventional therapy.
Argatroban for Prevention and Treatment of Thromboembolism in Heparin-Induced Thrombocytopenia
Authors: Kondo L Midori , Wittkowsky Ann K , Wiggins Barbara S
Published: June 2003

OBJECTIVE:

To review the pharmacology, pharmacokinetics, efficacy, adverse events, and cost of argatroban in the prevention and treatment of thromboembolism in patients with heparin-induced thrombocytopenia (HIT).

DATA SOURCES:

A MEDLINE search (1980 to August 2000) of English-language literature was conducted using the search term argatroban to identify pertinent case reports, clinical trials, abstracts, and review articles. Additional reports were identified from the reference lists compiled in the literature reviewed, as well as from the manufacturer.

DATA SYNTHESIS:

Argatroban is a synthetic direct thrombin inhibitor indicated for parenteral use in the prevention and treatment of thromboembolism in patients with HIT. Its elimination half-life is approximately 40–50 minutes, and it is primarily eliminated by hepatic metabolism and biliary secretion. Compared with historical controls, argatroban-treated patients with HIT or HIT with thrombosis (HITTS) experienced lower rates of the composite end point of death, amputation, and new thrombosis. Dosing is initiated at 2 μg/kg/min and adjusted to maintain the activated partial thromboplastin time at 1.5–3 × the patient's baseline. In Japan, argatroban is approved for use in acute ischemic stroke and chronic peripheral occlusive disease. It has also been used as an alternative to unfractionated heparin (UFH) in patients with a history of HIT or HITTS undergoing percutaneous coronary intervention and other procedures. Additionally, argatroban has been compared with UFH in patients with acute myocardial infarction who were receiving thrombolytic therapy. Hemorrhage is the primary adverse event associated with argatroban. Argatroban increases the prothrombin time, making assessment of the intensity of warfarin therapy during concurrent administration more complex.

CONCLUSIONS:

The use of argatroban in patients with HIT and HITTS is associated with improvement in clinical outcomes compared with historical controls. Argatroban offers several practical advantages over other available agents with respect to dosing, monitoring, reversibility of effect with discontinuation of the drug, and cost.
Effect of Common Over-the-Counter Medications on Blood Alcohol Levels
Authors: Monroe Michelle L , Doering Paul L
Published: June 2003

OBJECTIVE:

T o assess the clinical and legal significance of the potential pharmacokinetic interaction between common over-the-counter (OTC) medications and alcohol that may result in increased blood alcohol levels (BALs).

DATA SOURCES:

A MEDLINE search (1966–February 2000) of English-language articles was performed using the terms aspirin, acetaminophen, histamine (H2)-receptor antagonist, ethanol, and blood alcohol level and then supplemented by a bibliographic review of relevant articles.

STUDY SELECTION AND DATA EXTRACTION:

Two H2-receptor antagonist studies using methodologies representative of other published trials and a meta-analysis of 24 H2-receptor antagonist trials were chosen for detailed review. All identified studies examining aspirin and acetaminophen were addressed.

DATA SYNTHESIS:

More than 30 studies have examined the potential interaction between OTC drugs and blood alcohol. Because this issue has important medical and legal implications for patients, prescribing physicians, and pharmaceutical manufacturers, a critical analysis of the literature addressing this potential interaction is presented.

CONCLUSIONS:

Numerous factors arguing against a clinically significant interaction were identified. First, data from the relevant studies cannot be extrapolated to the general population because of the multitude of variables that determine an individual's BAL. Also, a publication bias for small studies (=10 subjects) finding a statistically significant increase in peak BAL was observed. In addition, study results supporting an increase in BAL were often irreproducible when these trials were repeated under similar conditions. Finally, although some studies detected statistically significant increases in peak BAL, these changes were often clinically irrelevant.
Dalteparin as Periprocedure Anticoagulation for Patients on Warfarin and at High Risk of Thrombosis
Authors: Tinmouth Alan H , Morrow Beverley H , Cruickshank Moira K , Moore P Mary , Kovacs Michael J
Published: June 2003

BACKGROUND:

Patients taking warfarin and at high risk for thromboembolic complications have traditionally been hospitalized for two to three days to receive standard treatment with intravenous heparin both prior to and following procedures while their international normalized ratio (INR) is subtherapeutic.

OBJECTIVE:

To assess the feasibility of protocol implementation for outpatient anticoagulation with low-molecular-weight heparin to eliminate or reduce the length of hospital admission needed solely for anticoagulation.

METHODS:

Patients included were receiving warfarin for a prosthetic heart valve, mitral valve disease with atrial fibrillation, or recent episode of venous thromboembolism. Warfarin was discontinued four days prior to the procedure. Subcutaneous dalteparin 200 units/kg was given on the two mornings prior to the procedure and restarted 12–24 hours after the procedure until the INR was in the therapeutic range. Warfarin was reinitiated on the evening of surgery.

RESULTS:

Twenty-four patients underwent 26 procedures. There were two minor bleeding complications, and one patient experienced a transient ischemic attack. Patients received a median of five days of dalteparin. The INR returned to the therapeutic range on the median postoperative day 4. All patients avoided two days of hospitalization prior to the procedure (i.e., no patients needed to be admitted preoperatively for anticoagulation). A median of four days would have been required for the sole purpose of postoperative anticoagulation.

CONCLUSIONS:

Outpatient perioperative anticoagulation with dalteparin for high-risk patients requiring long-term oral anticoagulation appears feasible and warrants further study.
Proton-Pump Inhibitors for Acute Peptic Ulcer Bleeding
Authors: Erstad Brian L
Published: June 2003

OBJECTIVE:

To review the use of proton-pump inhibitors for acute peptic ulcer bleeding.

DATA SOURCES:

Articles were obtained through computerized searches of MEDLINE (1966–September 2000). Additionally, several textbooks containing information on the diagnosis and management of acute peptic ulcer bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references.

STUDY SELECTION:

All randomized studies and pharmacoeconomic evaluations that used proton-pump inhibitor therapy for acute peptic ulcer bleeding were included. Randomized controlled trials and meta-analyses involving other therapies for treating peptic ulcer bleeding were also reviewed for possible inclusion.

DATA EXTRACTION:

The primary outcomes extracted from the literature were persistent or recurrent bleeding, transfusion requirements, need for endoscopic intervention or surgery, length of stay, and mortality.

DATA SYNTHESIS:

Data from double-blind, placebo-controlled trials involving more than 1000 patients demonstrate that short-term, high-dose omeprazole therapy is effective for reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding. The patients most likely to benefit from this therapy are hospitalized patients at high risk for rebleeding and patients in whom endoscopic evaluation must be delayed or is unavailable.

CONCLUSIONS:

Omeprazole (and likely other proton-pump inhibitors) is useful in reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding, although better delineation of appropriate candidates is needed.
Effect of Levofloxacin on Theophylline Clearance during Theophylline and Clarithromycin Combination Therapy
Authors: Nakamura Hiroyoshi , Ohtsuka Tomoko , Enomoto Hiromi , Hasegawa Atsushi , Kawana Hidetada , Kuriyama Takayuki , Ohmori Shigeru , Kitada Mitsukazu
Published: June 2003

OBJECTIVE:

To report a case of decreased theophylline clearance by the addition of levofloxacin in a patient receiving theophylline and clarithromycin.

CASE SUMMARY:

A 59-year-old Japanese man who was receiving theophylline for emphysema experienced stimulation, insomnia, and tachycardia due to theophylline toxicity after clarithromycin and levofloxacin were added to the regimen. The combination of these agents resulted in a decrease in theophylline clearance to approximately 60% of the initial value obtained while the patient was receiving theophylline alone. The adverse effects disappeared after the dosage was reduced and the theophylline serum concentration decreased; however, there was no change in theophylline clearance. After discontinuation of levofloxacin, the theophylline serum concentration decreased, and theophylline clearance returned to the initial level even though clarithromycin was continued.

DISCUSSION:

Levofloxacin is believed not to influence the clearance of theophylline, although some new fluoroquinolones have been reported to do so. This case indicates that levofloxacin and clarithromycin inhibited theophylline metabolic pathways catalyzed by both CYP1A2 and CYP3A4 and resulted in the decrease in theophylline clearance. The clearance of theophylline, therefore, is not influenced by clarithromycin alone.

CONCLUSIONS:

Careful monitoring is required when levofloxacin is prescribed for patients who are taking clarithromycin with theophylline.
Octreotide for Acute Variceal Bleeding
Authors: Erstad Brian L
Published: June 2003

OBJECTIVE:

To review the use of octreotide for acute variceal bleeding.

DATA SOURCES:

Articles were obtained through computerized searches involving MEDLINE (from 1997 to October 2000). Additionally, several textbooks containing information on the diagnosis and management of acute variceal bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references.

STUDY SELECTION:

All randomized studies and pharmacoeconomic evaluations that used octreotide therapy for acute variceal bleeding were considered. Randomized controlled trials and meta-analyses involving other therapies for treating variceal bleeding were also reviewed for possible inclusion.

DATA EXTRACTION:

The primary outcomes extracted from the literature were persistent or recurrent bleeding, need for endoscopic intervention or balloon tamponade, and mortality.

DATA SYNTHESIS:

Although both endoscopic therapies and medications are used to control bleeding and rebleeding episodes, the endoscopic approach has the additional goal of obliterating the varix. Since rebleeding episodes are common as long as the varix is present, endoscopic and medication therapies cannot be considered interchangeable based on bleeding control alone. However, octreotide by continuous intravenous infusion has demonstrated effectiveness in reducing blood loss and transfusion requirements as both an initial intervention (until definitive sclerotherapy can be performed) or as adjunctive therapy to endoscopic measures. Octreotide can be started quickly, has a relatively rapid onset of action, and does not require someone with endoscopy training to initiate. Additionally, octreotide is relatively free of significant adverse effects.

CONCLUSIONS:

While additional investigations are needed, particularly in the area of pharmacoeconomics, there is substantial evidence that octreotide is an efficacious therapy with relatively few adverse effects when used in the management of acute variceal bleeding.
Medicaid's β2-Agonist Recipients and Their Treatment by National Standards
Authors: Reddy Prabashni , Kelly Edward T , Kophazi Martha E , Geary Elizabeth A , Markelon Jennifer D , Welter Karissa J
Published: June 2003

OBJECTIVE:

To determine whether Connecticut's Medicaid high-dose β2-agonists (HDB) users (>1 canister/mo) are receiving medications according to National Institutes of Health (NIH) asthma guidelines, and to compare healthcare utilization between HDB users and patients receiving no more than one canister of a short-acting β2-agonist per month.

METHODS:

All Connecticut Medicaid pharmacy claims from April to December 1998 were examined. Subjects were included if they had an asthma diagnosis and were excluded if they had chronic obstructive pulmonary disease. The percentage of HDB users not receiving long-term-control medication; receiving low doses of a long-term-control medication; and receiving oral, nebulized, or long-acting β2-agonists was determined. Healthcare utilization between HDB users and patients receiving no more than one canister of a short-acting β2-agonist per month was also compared.

RESULTS:

Of 1599 profiles included, 14% (n = 223) were HDB users. Twenty-five percent of these patients did not receive a long-term-control medication, and 35% received low doses of a long-term-control medication. Claims for oral, nebulized, and long-acting β2-agonists were submitted for 4%, 29%, and 22% of HDB users, respectively. More claims for short courses of oral corticosteroids were submitted for HDB users than for patients receiving no more than one canister of a short-acting β2-agonist per month (n = 1376) (1.99 ± 3.60 vs. 0.39 ± 1.07 mean ± SD; p < 0.001). HDB users visited their physicians' offices an average of 4.72 ± 24.08 × per month compared with an average of 2.40 ± 14.4 office visits per month for patients receiving no more than one canister of a short-acting β2-agonist (p = 0.04).

CONCLUSIONS:

A high proportion of Connecticut's Medicaid HDB users are not receiving medications according to NIH guidelines. HDB users were significantly more likely to receive short courses of oral corticosteroids and required significantly more office visits than patients receiving no more than one canister of a short-acting β2-agonist per month. Intervention programs designed to improve adherence to the guidelines will be developed.
Effect of Acetaminophen on Atherosclerosis
Authors: Chong Pang H , Kezele Bob , Pontikes Pamala J
Published: June 2003

OBJECTIVE:

To evaluate the antioxidant effects of acetaminophen in atherosclerosis.

DATA SOURCES:

Experimental literature and abstracts accessed through MEDLINE (1966–February 2001).

DATA SYNTHESIS:

Atherosclerosis is an inflammatory disorder associated with coronary events. The oxidative stress burden resulting from excess pro-oxidant free radical formation contributes to oxidative modification of low-density lipoprotein (lipid peroxidation) and is associated with atherosclerosis. Acetaminophen (phenol-like compound) may limit these key processes that are involved. The findings of earlier experimental laboratory tests and abstracts are evaluated.

CONCLUSIONS:

In vitro data suggest that acetaminophen may reduce lipid peroxidation, whereas animal data showed decreased progression of atherosclerosis. Further animal model and human studies are required to confirm these earlier findings.
Seizures with Intravenous Codeine Phosphate
Authors: Zolezzi Monica , Al Mohaimeed Sulaiman A
Published: June 2003

OBJECTIVE:

To describe an adverse effect with intravenous codeine in a child diagnosed with sickle cell anemia.

CASE SUMMARY:

A seven-year-old boy with sickle cell anemia was admitted to the emergency department with severe pain unresponsive to high doses of oral acetaminophen; subsequently, intravenous codeine phosphate was administered. The patient immediately developed a tonic—clonic seizure, which was treated with intravenous diazepam and naloxone.

DISCUSSION:

Seizures associated with the intravenous administration of codeine phosphate have not been extensively reported in the literature, and special precautions for using the parenteral route for this drug have been vague and limited. Because of the frequent need for acute pain control in children with sickle cell crisis, they may be exposed to this type of reaction when intravenous narcotics are administered. The need for clear guidelines regarding the drug's appropriate parenteral dosing and administration is essential.

CONCLUSIONS:

Codeine phosphate—induced seizures are not common. The need for special instructions for its intravenous administration may prevent this type of reaction, especially in patients in need of acute pain control requiring intravenous narcotics.
Use of Cidofovir in Progressive Multifocal Leukoencephalopathy
Authors: Segarra-Newnham Marisel , Vodolo Kristen M
Published: June 2003

BACKGROUND:

Progressive multifocal leukoencephalopathy (PML) is a subacute demyelinating illness caused by the JC virus, a polyomavirus that occurs in 4–5% of HIV-positive patients. Mortality is high, and no useful therapy has been identified. Highly active antiretroviral therapy (HAART) has been reported to be effective in halting progression of the disease in some, but not all, patients. Cidofovir has been shown to be active against polyomaviruses.

OBJECTIVE:

To review data on the use of cidofovir to treat PML.

DATA SOURCES:

English-language case reports and clinical studies were located through a literature search (MEDLINE and AIDSLINE, 1995–July 2000).

STUDY SELECTION AND DATA EXTRACTION:

Relevant case reports and studies describing the use of cidofovir for PML were reviewed.

DATA SYNTHESIS:

Most case reports describing the use of cidofovir have shown that the drug is effective in the treatment of PML. Some patients were also receiving HAART concurrently; therefore, it is not clear which treatment modality had a greater impact on PML. However, cidofovir may be effective in patients whose disease has progressed despite HAART or who are unable to tolerate these regimens. A pilot study of cidofovir for treating PML has completed enrollment, but preliminary results showed no benefit.

CONCLUSIONS:

Cidofovir may be the most reasonable treatment option for PML in HIV-infected individuals who fail to improve with HAART or who are unable to tolerate these regimens. Patients who receive cidofovir should be monitored for renal and ocular toxicity.
Opioid Analgesics versus Ketorolac in Spine and Joint Procedures: Impact on Healthcare Resources
Authors: Gora-Harper Mary Lea , Record Kenneth E , Darkow Theodore , Tibbs Phillip A
Published: June 2003

BACKGROUND:

Ketorolac's efficacy as a postoperative analgesic has been shown to be comparable to that of narcotic analgesics, but with significantly fewer narcotic-related adverse events.

OBJECTIVE:

To assess whether the choice of postoperative analgesic, narcotic or ketorolac, has an impact on healthcare resource utilization and cost during inpatients' recovery period.

DESIGN:

Retrospective, multicenter, controlled, parallel, cost-minimization analysis.

SETTING:

Six US teaching hospitals.

PATIENTS:

This study included 559 patients that underwent either a spine or joint procedure and received adequate doses of narcotic (n = 284 of either morphine or meperidine) or ketorolac (n = 275).

MEASUREMENTS:

Time to reach recovery milestones, average utilization of healthcare resources, and average per-case postoperative treatment cost.

RESULTS:

Several recovery milestones, including time to first bowel movement, first oral intake, and first unassisted ambulation, were reached sooner in the ketorolac group, with a resultant shorter mean length of postoperative stay (narcotic 3.78 d, ketorolac 2.80 d; p = 0.01). Total per-patient cost of treatment was 32% greater in the narcotic group, resulting primarily from higher costs associated with hospitalization.

CONCLUSIONS:

Despite the higher acquisition cost of medication, healthcare resource utilization and total per-patient cost of treatment were lower for patients in the ketorolac group compared with patients in the narcotic analgesic study group. The majority of patients in the ketorolac group were also given concurrent narcotic analgesics; therefore, the beneficial effects observed may be secondary to the combination of ketorolac and narcotic analgesics.

TRASFONDO:

La eficacia de ketorolac como agente analgésico postoperatorio se ha demostrado que es comparable a la de los analgésicos narcóticos pero con significativamente menos eventos adversos relacionados con el efecto narcótico.
Use of Antihypertensive and Antithrombotic Medications after Stroke in Community-Based Care
Authors: Rigler Sally K , Webb Melissa J , Patel Atul T , Lai Sue Min , Duncan Pamela W
Published: June 2003

BACKGROUND:

Secondary stroke prevention strategies include pharmacologic approaches to control hypertension and reduce thromboembolic risk.

OBJECTIVE:

To describe antithrombotic and antihypertensive medication use, and rates of blood pressure control in the Kansas City Stroke Study, a prospective stroke cohort receiving community-based care after primarily mild and moderate stroke.

METHODS:

Participants from 12 area hospitals provided information about medication use prior to stroke. Study personnel measured blood pressures at enrollment and at one, three, and six months, and collected medication data at six months during in-home assessment.

RESULTS:

Complete data at six months were available for 355 subjects with ischemic stroke, among whom 13% had atrial fibrillation and 67% had prior hypertension. Prior to stroke, only 45% of the patients were receiving any antithrombotic (anticoagulant and/or antiplatelet) therapy; this figure rose to 77% at six months. Antithrombotic treatment rates among those with atrial fibrillation were 59% before stroke and 83% at six months, including warfarin in 64%. Approximately 70% of subjects had controlled blood pressures one, three, and six months after stroke, defined as systolic blood pressure ≤140 mm Hg and diastolic blood pressure ≤90 mm Hg. Use of multiple antihypertensive agents was common; calcium-channel blockers and angiotensin-converting enzyme inhibitors were used most frequently. However, 19% of subjects with uncontrolled blood pressure were untreated at six months.

CONCLUSIONS:

Although room for improvement remains, these data suggest improved rates of antithrombotic and antihypertensive medication use after stroke in community-based care in a midwestern metropolitan community, compared with previous reports.
Topical Tacrolimus in the Treatment of Atopic Dermatitis
Authors: Gianni Laura M , Sulli Maria Marzella
Published: June 2003

OBJECTIVE:

To review the efficacy of topical tacrolimus in the treatment of atopic dermatitis (AD).

DATA SOURCES:

Searches of MEDLINE (1966–October 2000), International Pharmaceutical Abstracts (1970–October 2000), and ScienceDirect (1994–October 2000) were performed using the key search terms tacrolimus, FK506, and atopic dermatitis.

DATA SYNTHESIS:

Since patients with AD have defects in cell-mediated immunity, the immunosuppressant properties of the macrolides (cyclosporine and tacrolimus) may prove to be beneficial in the treatment of AD. Topical tacrolimus has been frequently studied in the treatment of AD because it was found to have better skin penetration and higher potentency than topically applied cyclosporine. Studies evaluating the use of topical tacrolimus are presented and provide evidence that topical tacrolimus is effective in the treatment of AD with no evidence thus far of systemic adverse effects.

CONCLUSIONS:

There is a fair amount of documentation of the efficacy and safety of topical tacrolimus. Further trials are needed to determine the optimal duration of therapy and its efficacy and safety in children less than seven years of age.
Barriers to Use of Electronic Adherence Monitoring in an HIV Clinic
Authors: Wendel Christopher S , Mohler M Jane , Kroesen Kendall , Ampel Neil M , Gifford Allen L , Coons Stephen Joel
Published: June 2003

OBJECTIVE:

To evaluate barriers to Medication Event Monitoring System (MEMS) measurement of adherence to combination antiretroviral therapy in an HIV clinic.

DESIGN:

Descriptive, cross-sectional study measured MEMS adherence to one antiretroviral for one month.

SETTING:

HIV clinic in a Veterans Affairs Medical Center.

PARTICIPANTS:

Sixty-four men on a stable antiretroviral treatment regimen.

MAIN OUTCOME MEASURES:

Decanting (removing >1 dose at a time) before and during monitoring over a 30-day observation period was used to determine the qualitative impact of MEMS on adherence. The adherence index was the proportion of prescribed doses not missed.

RESULTS:

Subjects were primarily white (73%) with mean CD4+ count 408 cells/mm3, log viral load 1.81 copies/mL, and duration of antiretroviral therapy 5.5 years. Twenty-seven (42%) had some decanting routine established prior to monitoring; 12 (44%) of these patients used daily decanters and 15 (56%) used weekly pillboxes. Of those who decanted prior to the study, 10 (37%) did not stop decanting during monitoring, 14 (52%) stopped decanting only the capped medication, and three (11%) stopped decanting all antiretrovirals. Other adherence strategies did not accommodate MEMS. Eight (13%) subjects said MEMS made adherence more difficult, six (9%) said MEMS was a reminder to adhere, and two (3%) mentioned both. Two subjects attributed skipped doses or time changes to the MEMS cap. The majority who refused to participate used pillboxes.

CONCLUSIONS:

Personal adherence strategies incompatible with MEMS are common in persons on complex treatment regimens. Although MEMS data on decanters underestimate adherence, excluding decanters erodes applicability of descriptive measures. MEMS use may have affected adherence behavior. Measures in conjunction with MEMS should include self-reported adherence and decanting assessment.
Prescription Drug Use, Diagnoses, and Healthcare Utilization among the Elderly
Authors: Jörgensen Tove , Johansson Saga , Kennerfalk Anita , Wallander Mari-Ann , Svärdsudd Kurt
Published: June 2003

BACKGROUND:

More elderly patients affected by severe and chronic diseases are treated in primary care. Reports on the use of prescription drugs by the general elderly population are scarce, and more investigations are needed to optimize pharmaceutical care for these patients.

OBJECTIVE:

To analyze prescription drug use, diagnoses, and healthcare utilization among noninstitutionalized elderly patients.

DESIGN:

Retrospective cohort study.

SETTING AND PATIENTS:

All people ±65 years old (n = 4642) living in the community of Tierp, Sweden, in 1994 were included. Prescription drug use and healthcare utilization have been registered for all inhabitants of the community since 1972. Information about filled prescriptions and diagnoses were obtained from a computerized research register.

RESULTS:

Prescription drug use was high among the elderly (78%); the most used pharmacologic groups were cardiovascular, nervous system, and gastrointestinal medications. Women used more prescription drugs than men (average 4.8 vs. 3.8) and had more nonfatal diagnoses. Use of five or more different prescription drugs during 1994 was common (39.0%), and multivariate analysis showed that the greatest number of primary care visits occurred with multiple drug use (±5 drugs over 1 y).

CONCLUSIONS:

This study shows an extensive multiple drug use among elderly people living at home. Whether this multiple drug use per se is harmful to the patients or not could not be evaluated in this study. Further focused investigations are needed to assess the effect of multiple drug use in an elderly population.
Safety of Intravenous Bolus Administration of Gentamicin in Pediatric Patients
Authors: Robinson Renee F , Nahata Milap C
Published: June 2003

OBJECTIVE:

To determine the safety of gentamicin administered intravenously as a bolus.

METHODS:

All patients (n = 123, ages: up to 18y, 121; 21y, 1; 31y, 1) who received gentamicin intravenously as a bolus over a four-month period were studied retrospectively. Patient demographics, type of infection, dosing regimen, length of therapy, peak and trough serum concentrations, blood urea nitrogen, serum creatinine, and urine output were reviewed. Patients were stratified into four groups and data analyzed statistically.

RESULTS:

Mean initial dose (5.32 ± 2.38 mg/kg/d) was consistent with established guidelines for age and kidney development, with subsequent adjustments based on serum concentrations. Susceptible organisms were eradicated with a mean length of therapy of 6.9 ± 6.9 days (range 1–35). Patients received a median of nine doses: 42% received doses every eight hours and 33% received doses every 24 hours. No relationship between dosing and abnormal serum creatinine were found (p = 0.69). The estimated cost savings mainly from less nursing time and lower equipment and supply use were $50/patient with bolus administration of gentamicin.

CONCLUSIONS:

Intravenous bolus administration was safe in pediatric patients and was associated with lower costs.
Ischemic Heart Disease Associated with Vincristine and Doxorubicin Chemotherapy
Authors: Calvo-Romero José M , Fernández-Soria-Pantoja Rafael , Arrebola-García Juan D , Gil-Cubero Mercedes
Published: June 2003

OBJECTIVE:

To report the ocurrence of ischemic heart disease (IHD) in a patient with multiple myeloma treated with vincristine and doxorubicin.

CASE SUMMARY:

A 46-year-old man developed a Q-wave inferior and right-ventricle myocardial infarction with postinfarction angina after receiving his third cycle of vincristine and doxorubicin for immunoglobulin A multiple myeloma. Angiography showed two small filling defects consistent with thrombi in the distal right coronary artery.

DISCUSSION:

IHD may be a serious but uncommon complication of treatment with several chemotherapeutic agents. It is likely that chemotherapy played a role in the development of IHD in our patient. Several putative mechanisms for vascular toxicity have been associated with chemotherapy.

CONCLUSIONS:

Chemotherapy with vincristine and doxorubicin may play a role in the ocurrence of IHD. Physicians should possess an awareness of this potentially serious complication of chemotherapy.
Seizures Associated with Fluoroquinolones
Authors: Kushner Janine M , Peckman Howard J , Snyder Clyde R
Published: June 2003

OBJECTIVE:

To report two cases of seizures following administration of levofloxacin and ciprofloxacin.

CASE SUMMARY:

A 75-year-old white woman admitted to the hospital was prescribed levofloxacin for ischemic toes. After receiving three doses of oral levofloxacin, the patient experienced a seizure. One month later, the patient was rechallenged with ciprofloxacin and again experienced a seizure. The patient was hypomagnesemic and had elevated serum creatinine at the time of both seizures, and was hyponatremic during the second seizure. A 74-year-old white woman admitted to the hospital was prescribed levofloxacin for bacterial pneumonia. After five doses, the patient experienced a seizure. The woman had no electrolyte imbalances at the time of the seizure and no history of a seizure disorder.

DISCUSSION:

Quinolone antibiotics vary in their ability to induce seizures, with trovafloxacin having the greatest potential and levofloxacin possibly having the least potential. Neither patient had a history of a previous seizure disorder. Electrolyte imbalances are common with previous reports of fluoroquinolone-induced seizures.

CONCLUSIONS:

Although levofloxacin monotherapy has not been implicated in inducing seizures, it appears to be the causative agent in the second case. In the first case, the quinolones may have been a necessary, but not sufficient, cause in a patient with electrolyte abnormalities. Risk factors for fluoroquinolone-induced seizures may include seizure history, electrolyte imbalances, dose unadjusted for renal insufficiency, and concomitant treatment with agents that lower the seizure threshold.
Warfarin and Ropinirole Interaction
Authors: Bair Jennifer D , Oppelt Thomas F
Published: June 2003

OBJECTIVE:

To report a case of increased international normalized ratio (INR) in a geriatric patient receiving warfarin and ropinirole.

CASE SUMMARY:

A 63-year-old African-American man with a history of Parkinson disease, Alzheimer disease, and status postcardio-vascular accident was evaluated for symptoms of progressing stiffness and rigidity. Ropinirole was added to his current therapy for Parkinson disease, with a corresponding decrease in the dose of levodopa/carbidopa to allow levodopa sparing. On laboratory evaluation, he was noted to have an increased INR nine days after these adjustments; the INR had previously been stable. No other significant medication, social, or diet changes were noted. Warfarin was withheld for four days and restarted at approximately 75% of the previous weekly dose. The patient had no obvious signs of bleeding. Furthermore, the warfarin dose was again increased after discontinuation of ropinirole due to common gastrointestinal adverse effects.

DISCUSSION:

Warfarin is an oral anticoagulant whose narrow therapeutic index and potential for drug interaction is well documented. It is always possible that a change in blood coagulability can occur without an obvious contributable cause; however, an acute change in a previously stable INR with the addition of other medications always raises questions as to the possible mechanism of adverse reaction. No previously documented interaction of this precise nature has been identified.

CONCLUSIONS:

Ropinirole may elevate the anticoagulant effects of warfarin. Patients receiving warfarin should be considered for more frequent INR monitoring when ropinirole is added, adjusted, or discontinued from their medical regimen.