bluuebunny/crossref_metadata_2025 huggingface dataset:
1993 Bibliography: A 32-Year Literature Review on the Value and Acceptance of Ambulatory Care Provided by Pharmacists
Authors: Hatoum Hind T. , Akhras Kasem
Published: January 2017

OBJECTIVE:

To review the published literature on the value and acceptance of pharmaceutical services provided by pharmacists in ambulatory care settings.

DATA SOURCES AND METHODS:

Articles published between 1960 and 1992. A MEDLINE search of the English-language literature was conducted using the terms pharmacists, services, and ambulatory settings. Studies were selected for inclusion if they addressed services provided by pharmacists in ambulatory settings and dealt with the cost of patient care, quality of care, or attitudinal surveys. Original research reports were summarized according to objectives, sample size, duration of study, methods, and findings. Summaries were categorized according to reported positive impact, negative impact, or investigational reports with no outcome.

RESULTS:

One hundred seventy articles were identified; 104 of them reported research data and were summarized. The 1970s was the most prolific decade for publication of articles reporting positive, negative, or no impact, which numbered 47, 20, and 37, respectively. Positive correlation was found among studies conducted according to predetermined protocol and reporting positive impact. Moreover, academic interest in pharmacy varied for the different decades.

CONCLUSIONS:

Collectively, this article provides references of the published reports on pharmacy professional services in ambulatory care settings, and a summary of the articles reporting research data. Additional and more focused research on pharmaceutical services in the community is needed. Emphasis is required on practicing pharmacists' attitudes toward nondispensing, patient-oriented pharmaceutical services; the impact of educational changes on the practice of pharmacy and consumers' attitudes and willingness to pay for services; and the link between patient outcome and pharmaceutical services.
Prescription Drug Use among Ambulatory Elderly in a Swedish Municipality
Authors: Jörgensen Tove M. , Isacson Dag G.L. , Thorslund Mats
Published: January 2017

OBJECTIVE:

To analyze prescription drug use among the elderly in a Swedish municipality.

METHODS:

The municipality of Tierp, located in mideastern Sweden, is a well-defined geographic area that includes both rural areas and a few small, industrial towns. All people aged 65 years and older (n=4769) as of 1986 in a total population of 21000 inhabitants were included in the study. Their drug use was studied by registering all prescriptions filled by the pharmacies in the area.

RESULTS:

Most of the elderly (>70 percent) obtained at least one prescription during the year studied. Drug use was more common among women than men. However, the difference between men and women was much smaller among those aged 85 years or more. The drugs most commonly prescribed were cardiovascular, psychotropic, and analgesic agents. Furthermore, the study showed that simultaneous use of several drugs was quite common. One-fourth of all people aged 65 years and older used drugs from at least four different pharmacologic groups.

CONCLUSIONS:

Our results revealed widespread use of prescription drugs among the elderly. An important finding was extensive drug use among men aged 85 years or more. This age group is increasing and there is need for further studies of its medication use.
Penetration of Intravenous and Oral Ciprofloxacin into Sterile and Empyemic Human Pleural Fluid
Authors: Joseph Joe , Vaughan Leigh M. , Basran Gurnam S.
Published: January 2017

OBJECIVE:

To compare the penetration of oral and intravenously administered ciprofloxacin into infected (empyemic) and noninfected(sterile) human pleural fluid.

DESIGN:

Eleven men and 5 women (aged 29–76) were consecutivelyselected from adult patients referred to the respiratory unit forpleural effusion. In this open-label, prospective trial, 13 patients withsterile pleural effusions were nonrandomly assigned to receive eitherciprofloxacin 200 mg (single intravenous dose), 750 mg (single oraldose), or 750 mg (two oral doses per day for 3 days); 3 patients withinfected pleural effusions received 750 mg oral doses for 10 days. Simultaneous pleural fluid and venous blood specimens were drawnover 5 hours after single dose or when steady-state was attained, andciprofloxacin concentrations were measured by HPLC.

RESULTS:

Pleural fluid concentrations of ciprofloxacin equaledplasma concentrations 1.5 hours after 200 mg was givenintravenously and the pleural/plasma ratio remained ∼ 0.9 for 4hours. After a single 750-mg oral dose, pleural ciprofloxacinconcentrations rose from 0 to 1.4 ug/ml, over 5 hours with thehighest pleural fluid/plasma ratio (0.7) at 5 hours. Average steadystateciprofloxacin concentrations in sterile pleural fluid after 750mg administered twice daily for 3 days, ranged between 1.1 and 1.8ug/rnl, with ratios between 0.3 and 0.9 over 4 hours. In empyemicpleural fluid at the same dosage, average steady-state ciprofloxacinconcentrations ranged between 1.9 and 3.4 ug/ml, with ratiosbetween 1.0 and 2.0 over 5 hours.

CONCLUSIONS:

Oral ciprofloxacin penetrates into sterile andempyemic pleural fluid with concentrations 30–90 percent and100–200 percent of plasma concentrations, respectively.
Otic Administration of Amphotericin B 0.25% in Sterile Water
Authors: Kintzel Polly E. , Trausch Diane E. , Copfer Amy L.
Published: January 2017

OBJECTIVE:

To report otic administration of parenteral amphotericin B 0.25% in sterile water.

CASE SUMMARY:

A 44-year-old HIV+ man was diagnosed with otitis extema. The patient's past medical history was remarkable for positive Coccidioides immitis serology for more than five months, essential hypertension, and Barrett's esophagitis. Culture results from an ear swab revealed 4+ Aspergillus fumigatus and 3+ Staphylococcus, coagulase negative. Antiinfective therapy for the otitisextema included oral and topical antibacterial and antifungal medications. AmphotericinB 0.25% in sterile water was prepared by the pharmacy for topical otic administration. The otic amphotericin B was dispensed with instructions to refrigerate and assigned a one-week expiration date. The prescription called for instillation of 1–2 drops in each ear three times a day. The patient's signs and symptoms of otitis extema resolved during several weeks of antiinfective therapy. Topical administration of amphotericin B 0.25% in sterile water was not associated with any local adverse effects in this patient.

DISCUSSION:

The rationale for use of the parenteral amphotericin B formulation to prepare an otic dosage form, and the rationale for the specific concentration and expiration date chosen are discussed.

CONCLUSIONS:

This patient tolerated topical otic administration of amphotericinB 0.25% in sterile water when administered three times daily.
Cyclosporine Monitoring Improves Graft-Versus-Host Disease Prophylaxis after Bone Marrow Transplantation
Authors: Ghalie Richard , Fitzsimmons William E. , Weinstein Alan , Manson Sharon , Kaizer Herbert
Published: January 2017

OBJECTIVE:

The principal objective of this study was to determine whether a relationship exists between trough cyclosporine concentrations measured by HPLC and the development of acute graft-versus-host disease (GVHD) after allogeneic bone marrow transplantation.

DESIGN:

A retrospective analysis of 59 consecutive human leukocyte antigen-matched bone marrow transplants. Patients received uniform GVHD prophylaxis with cyclosporine and methotrexate. Whole blood trough cyclosporine concentrations were measured at least twice weekly during hospitalization and weekly after discharge.

SETTING:

A dedicated bone marrow transplant unit in an academic center.

MAIN OUTCOME MEASURES:

The means of cyclosporine concentrations were assessed for each patient on a weekly basis during the first 50 days after transplant. These means were compared between patients developing grade 2–4 acute GVHD and patients without significant GVHD.

RESULTS:

Eighteen patients developed acute GVHD at a median of 25 days after bone marrow transplant (range 10–50). There was no correlation between the development of GVHD and patient age, diagnosis, donor age, donor gender, donor-recipient gender mismatch, and time to neutrophil engraftment (> 1000 × 106cells/L). Although mean weekly cyclosporine concentrations were consistently lower in patients developing acute GVHD, the difference in values compared with those of patients with GVHD was not statistically significant. Mean weekly cyclosporine concentrations at the time of neutrophil engrafiment were statistically associated with the development of GVHD. Patients with GVHD had mean ? SD concentrations of 174 ± 69 ng/mL, significantly lower than 254 ± 114 ng/mL in patients without GVHD. Furthermore, the rate of GVHD was 82 percent in patients with mean concentrations <200 ng/mL at the time of neutrophil engrafiment as compared with a rate of 34 percent in patients with concentrations ≥200 ng/mL (relative risk = 2.4). Also, mean cyclosporine concentrations measured during the week of onset of GVHD were significantly lower compared with mean cyclosporine concentrations of all other patients at risk of GVHD during that week.

CONCLUSIONS:

Cyclosporine concentrations are associated with the development of acute GVHD. Patients with HPLC whole blood concentrations <200 ngl/mL are at significantly higher risk of developing GVHD, particularly if these concentrations are observed during the week of neutrophil engrafirnent. More effective GVHD prophylaxis could be achieved by careful monitoring of cyclosporine concentrations after transplant.
Theophylline Disposition in Korean Patients with Congestive Heart Failure
Authors: Jeong Chan Su , Hwang Soon Chul , Jones Daniel W. , Ryu Hwan Sun , Sohn Kieho , Sands Charles D.
Published: January 2017

OBJECTIVE:

This study proposed to determine the systemic disposition on of theophyllinein Korean adult patients during decompensated congestive heart failure compared with disposition after recovery.

DESIGN:

An experimental, prospective, self-controlled, non randomized design was used.

SETTING:

The study was performed in a general communityhospital located in Pusan, Korea.

PATIENTS:

Eight nonsmoking elderly Korean patients with decompensated congestive heart failure presenting to the emergency department were included in the study. Consecutive patients who met entrance criteria were selected. All patients completed the study.

INTERVENTIONS:

A single dose of aminophylline 6 mg/kg was administered by intravenous infusion over 30 minutes. Standard methods of congestive heart failure therapy were used in each patient, including bed rest, restriction of sodium, and drug therapy including digoxin. After compensation of congestive heart failure was achieved the theophylline infusion was repeated.

OUTCOME MEASURES:

Serum theophylline concentrations were measured at 2, 6, 12, and 18 hours after completion of the dose at base line and following treatment.

RESULTS:

A clinically and statistically significant improvement in mean theophylline total body clearance was demonstrated following treatment (from 21.7 ± 2.8 to 43.4 ± 4.7 mL/kg/h [mean ± SEM]; p<0.01). Comparison of these results with a computer model based on literature averages of peoples of all nationalities showed significant underprediction of theophylline clearance both before (p<0.05)and after (p<0.01) treatment. The theophylline elimination half-life prior to treatment was 18.2 ± 2.2 hours and decreased to 9.1 ± 0.8 hours following treatment(p<0.O1). There was no statistical difference between the computer-model predicted initial theophylline half-life and the measured value, but the model significantly underpredicted the improvement following treatment.

CONCLUSIONS:

The improvement in theophylline clearance demonstrated in this study appears to be greater than that reported for Western patients. This has practical application to the calculation of appropriate theophylline maintenance dosage regimens in Korean patients with cardiac failure. These data support the need for consideration of racial differences in individualizing dosage regimens. We suggest that all kinetic models, whether software supported or not, should consider incorporating ethnic origin as a demographic factor that helps select the proper model for individual patients.
Stability and Activity of Intravenous Immunoglobulin with Neonatal Dextrose and Total Parenteral Nutrient Solutions
Authors: Lindsay Christine A. , Dang Ken , Adams James M. , Ou Ching Nan , Baker Carol J.
Published: January 2017

OBJECTIVE:

To determine in vitro the compatibility of reconstituted intravenous immunoglobulin (IVIG) (Gammagard, Baxter-Hyland) with five different neonatal and pediatric intravenous solutions in Viaflex polyvinyl chloride bags.

DESIGN:

In vitro compatibility study.

INTERVENTIONS:

Samples were taken at time=0, 10, 30, 60, 90, and 120 minutes and at 4, 8, 12, and 24 hours and assayed for total immunoglobulin G content and antibodies to hepatitis B surface antigen. Type III group B Streptococcus (GBS) and opsonic activity for type III GBS were analyzed at time=0, 60, and 120 minutes and 12 and 24 hours. All results were compared with those from pure IVIG.

RESULTS:

Our results demonstrate that mixing IVIG with intravenous solutions commonly used in the care of premature infants (dextrose 5% in water [D5W], D15W, D5W/NaCl 0.225%, and total parenteral nutrition [TPN]) does not significantly alter total immunoglobulin G concentrations or concentration of antibodies to hepatitis B surface antigen or type III GBS. As well, the in vitro functional activity for type III GBS of the IVIG, when mixed with these solutions for up to 24 hours, remained intact. An apparent decrease in bactericidal killing was seen with the IVIG/central TPN mixture. This apparent decrease was found to be an artifact of the high concentration of glucose (20 percent) in the solution.

CONCLUSIONS:

We propose that Gammagard may be mixed with these solutions through Y-site connections without loss of antibody content or functional activity of the IVIG.
Stability of Diluted Dexamethasone Sodium Phosphate Injection at Two Temperatures
Authors: Lugo Ralph A. , Nahata Milap C.
Published: January 2017

OBJECTIVE:

Premature neonates with bronchopulmonary dysplasia frequently are treated with intravenous dexamethasone for their chronic lung disease. The injection volumes of the commercially available products often are too small to measure accurately. The objective of this study was to evaluate the stability over 28 days of dexamethasone sodium phosphate injection 4 mg/mL diluted with bacteriostatic NaCl 0.9% to 1 mg/mL.

DESIGN:

Ten vials of dexamethasone 1 mg/mL were prepared from dexamethasone sodium phosphate injection, USP 4 mg/mL and bacteriostatic NaCl 0.9% injection. Five vials were stored at 4 °C and five at 22 °C. Dexamethasone was measured on days 0, 1, 3, 7, 14, 21, and 28 by an accurate, reproducible, and stability-indicating HPLC method. Samples were also inspected visually for precipitation or discoloration on each study day.

RESULTS:

The samples retained at least 97.7 percent of the original concentration of dexamethasone sodium phosphate when stored at either 4 or 22 °C for 28 days. No discoloration or precipitation was observed.

CONCLUSIONS:

Dexamethasone sodium phosphate injection 1 mg/mL in bacteriostatic NaCl 0.9% was stable for 28 days at 4 and 22 °C.
Busulfan
Authors: Buggia Isabella , Locatelli Franco , Regazzi Mario B. , Zecca Marco
Published: January 2017

OBJECTIVE:

To review the current published studies evaluating the pharmacokinetics, clinical efficacy, safety, and toxicity of busulfan in pediatric and adult patients.

DATA SOURCES:

English-language literature published between 1953 and 1993 was analyzed; pertinent literature was reviewed.

STUDY SELECTION:

Emphasis was placed on pharmacologic studies and clinical trials involving busulfan therapy both in myeloproliferative disorders and in conditioning regimens for autologous or allogeneic bone marrow transplantation.

DATA EXTRACTION:

Data from both pediatric and adult studies were evaluated; emphasis was placed on the relationship between plasma concentrations of busulfan and its efficacy and toxicity.

DATA SYNTHESIS:

Busulfan has been used widely at conventional dosages (1–12 mg/d) for the treatment of patients with chronic myelogenous leukemia (CML). Busulfan at high doses (usually 16 mg/kg) given with other cytotoxic drugs (especially cyclophosphamide) is a common preparative regimen in patients undergoing allogeneic or autologous bone marrow transplantation (BMT) for acute or chronic leukemia and other nonmalignant disorders (e.g., hemoglobinopathies, inborn error of immune system, congenital metabolic disorders). Pharmacokinetics of high-dose busulfan are age-dependent. Busulfan systemic exposure and, thus, tissue and tumor exposure are lower in children than with adults. Relationships between toxicity (principally neutropenia, hepatic veno-occlusive disease, incidence of seizures) and drug exposure were found for busulfan.

CONCLUSIONS:

Busulfan is a useful, sufficiently safe drug in the treatment of patients with CML. At higher dosages, busulfan is a fundamental part of myeloablative therapies for patients undergoing BMT. As the pharmacokinetics and metabolism of busulfan is further understood, there is great potential for improving treatment outcome. An assessment of maximal tolerated exposure determined by therapeutic drug monitoring may decrease the incidence and lethality of regimen-related toxicities.
Salmeterol: Its Place in Asthma Management
Authors: Milavetz Gary , Kelly H. William , Kamada Alan K. , Spahn Joseph D. , Blake Kathryn V.
Published: January 2017

SALMETEROLXINAFOATE (Serevent, Allen and Hanburys) is an inhaled beta-adrenergic agonist approved for mainte-nance asthma therapy in adults and children older than 12 years of age. The recommended dose is two inhalations (42 μg) twice daily. Its adverse effect profile is similar to that of albuterol; however, salmeterol has a prolonged, 12-hour duration of action. It may also have activity as an antiinflammatory agent, which may be beneficial in the treatment of asthma; however, the clinical relevance of these potential effects remains to be elucidated. As a new therapeutic agent for the treatment of asthma, its place in the hierarchy of asthma therapies is currently undefined and a number ofquestions may arise regarding its use.
Ifosfamide Extravasation
Authors: Mateu Javier , Alzamora Mónica , Franco Mercedes , Buisán María-José
Published: January 2017

OBJECTIVE:

To report a case in which a local reaction is attributed to an ifosfamide extravasation. Previously, extravasated ifosfamide has been considered a nonirritant.

CASE SUMMARY:

A 54-year-old woman with a non-Hodgkin's lymphoma in stage IV B developed a local reaction in her right arm after an ifosfamide extravasation. No pressure was prescribed, no bandaging was applied on the affected area, and the limb was elevated to the heart level. In addition, chondroitinsulfatase 150 turbidity-reducing units was administered subcutaneously around the area. This procedure was repeated 12 hours later, resulting in a satisfactory decrease in the inflammatory signs and pain.

DISCUSSION:

The local reaction in the patient's arm cannot be attributed to the hypertonicity of the infusing solution or to the vehicle of the infusate. The antidote used was chondroitinsulfatase, an enzyme similar to hyaluronidase. It enhances the systemic uptake of the drug from the tissue.

CONCLUSIONS:

Extravasated ifosfamide is a potential irritant. General measures applied after its extravasation can be potentiated strongly by local subcutaneous administration of chondroitinsulfatase or hyaluronidase, repeated if necessary.
Salivary Concentrations of Ketoconazole and Fluconazole: Implications for Drug Efficacy in Oropharyngeal and Esophageal Candidiasis
Authors: Force Rex W. , Nahata Milap C.
Published: January 2017

Objective:

To determine whether salivary concentrations of ketoconazole and fluconazole may explain the apparent disparity between in vitro activity and clinical efficacy observed with these drugs.

Design:

Healthy subjects received a single oral dose of ketoconazole 400 mg or fluconazole 100 mg in a randomized, crossover fashion. Saliva was collected at 0, 1, 2, 3, 6, 12, and 24 hours. Blood samples were obtained at 2 and 24 hours. Salivary concentrations and plasma concentrations for each drug were determined by HPLC. Minimum inhibitory concentration (MIC) testing was determined in triplicate on 6 clinical isolates of Candida albicans, and times over the median MIC values were calculated.

Participants:

Eight subjects completed the study.

Results:

The mean (± SD) peak salivary concentration for ketoconazole was 0.119 ± 0.050 pg/mL at 3 hours; no subject had a detectable ketoconazole salivary concentration at 24 hours. At 2 and 24 hours, mean ketoconazole plasma concentrations were 7.64 ± 3.87 and 0.11 ± 0.05 μg/mL, respectively. The saliva to plasma concentration ratio at 2 hours was 0.01. The mean peak salivary concentration of fluconazole was 2.56 ± 0.34 pg/mL at 3 hours. At 24 hours, the mean salivary concentration was 1.44 ± 0.33 μg/mL. At 2 and 24 hours, mean fluconazole plasma concentrations were 4.39 ± 3.33 and 3.72 ± 2.83 pg/mL, respectively. The saliva to plasma concentration ratio at 2 hours was 0.55. Median MIC values were 0.0625 μg/mL (range 0.0313-0.125) for ketoconazole and 0.25 μg/mL (range 0.125-0.5) for fluconazole. Calculated times over which ketoconazole and fluconazole exceeded the median MICs in saliva were approximately 13 and greater than 24 hours, respectively.

Conclusions:

After a single oral dose, fluconazole achieved higher salivary concentrations than did ketoconazole. This may explain the increased clinical efficacy of fluconazole in the treatment of oropharyngeal-esophageal candidiasis when compared with ketoconazole.
Monitoring of Intravenous Quinidine Infusion in the Treatment of Plasmodium Falciparum Malaria
Authors: Bhavnani Sujata M. , Preston Sandra L.
Published: January 2017

Objective:

To report a case of Plasmodium falciparum malaria in which intravenous quinidine was used, resulting in a prolonged QT interval.

Case summary:

P. falciparum malaria was diagnosed in a woman visiting from Nigeria. Treatment was instituted with intravenous quinidine given the high level of parasitemia. During the quinidine infusion, the patient experienced a prolonged QT interval and an episode of supraventricular tachycardia. The infusion rate was decreased and the QT duration returned to normal; there was no further episode of arrhythmia. Subsequently the patient was given oral quinine. Her condition improved and she was discharged on day 4 of therapy.

Discussion:

P. falciparum malaria, not commonly seen in the US, is associated with severe morbidity and mortality. This condition necessitates prompt treatment with intravenous quinidine, which can be associated with toxicity. The use of this agent to treat malaria is reviewed herein.

Conclusions:

In patients with P. falciparum malaria, a high-level parasitemia may require treatment with a potentially toxic agent, intravenous quinidine. Cardiac monitoring of these patients is essential during such therapy.
Efficacy and Pharmacokinetics of Simvastatin in Heart Transplant Recipients
Authors: Campana Carlo , Iacona Isabella , Regazzi Mario B. , Gavazzi Antonello , Perani Guido , Raddato Vincenzo , Montemartini Carlo , Viganò Mario
Published: January 2017

Objective:

To evaluate the efficacy and safety of simvastatin administered to a group of heart transplant patients receiving triple-drug immunosuppressive therapy. We also assessed the potential pharmacokinetic interaction between simvastatin and cyclosporine by comparing mean plasma concentrations of simvastatin beta-hydroxy acid, the major metabolite of the drug, in a group of heart transplant patients treated with cyclosporine and in a control group of patients who had not received heart transplants. Both groups received long-term (>6 wk) simvastatin therapy.

Design:

We monitored hyperlipidemia in 20 hypercholesterolemic heart transplant patients receiving simvastatin 10 mg/d and triple-drug immunosuppressive therapy. Changes in laboratory results before and after 4 months of simvastatin therapy were considered. The same laboratory data were monitored in a control group of 20 nonhypercholesterolemic heart transplant patients who were not treated with simvastatin but were receiving triple-drug immunosuppressive therapy. Plasma concentrations of simvastatin beta-hydroxy acid were measured in 14 hypercholesterolemic patients, 7 of whom had received heart transplants and 7 who had not.

Setting:

The Division of Cardiology and the First Medical Clinic for the clinical study, as well as the Department of Pharmacology for the pharmacokinetic analysis.

Participants:

Forty heart transplant patients and 7 hypercholesterolemic nontransplant patients.

Main Outcome Measures:

Effectiveness of simvastatin was determined by comparing cholesterol and lipoprotein plasma concentrations in 20 patients who underwent heart transplant and were treated with simvastatin for 4 months. The safety of the drug was determined by analyzing changes in laboratory results in the treated group and in the control group, both those who had received heart transplants and those who had received immunosuppressive therapy.

Results:

After 4 months of simvastatin therapy, total cholesterol decreased by 12.5% and low-density lipoprotein cholesterol decreased by 21.3%. The only statistically significant laboratory change was an increase of 28.7% in the alanine aminotransferase concentrations. Plasma concentrations of simvastatin beta-hydroxy acid were higher in heart transplant patients than in those who had not received heart transplants, the control group.

Conclusions:

Low-dosage simvastatin treatment seems to be safe and sufficiently effective to decrease cholesterol concentrations. Concomitant treatment with immunosuppressive therapy (primarily cyclosporine) in heart transplant patients appeared to cause a reduced metabolic clearance of simvastatin from the plasma. More extensive studies on the interaction between simvastatin and cyclosporine are needed to understand the marked variability found in the response to simvastatin.
Pruritus Associated with Intravenous Rifampin
Authors: Walker-Renard Pamela
Published: January 2017

Objective:

To report a probable case of moderate pruritus associated with intravenous rifampin.

Case Summary:

A 57-year-old woman was started on vancomycin 1 g iv q72h following a positive blood culture for methicillin-resistant Staphylococcus epidermidis. The patient's past medical history was significant for uterine carcinoma, radiation-induced enteritis, congestive heart failure, and renal insufficiency. Other therapy consisted of total parenteral nutrition, digoxin 0.125 mg/d iv, and furosemide 60 mg iv prn for edema. Seven days later, the patient's white blood cell count increased and rifampin 600 mg/d iv was added to the drug regimen for potential synergy. On day 3 of rifampin therapy, the patient experienced pruritus beginning 30 minutes after the rifampin infusion ended and lasting for 6–8 hours. After 7 days of rifampin therapy, the medication was discontinued and the pruritus resolved.

Conclusions:

This case evaluation demonstrated probable pruritus induced by intravenous rifampin. Clinicians should be alerted that intravenous rifampin, as well as orally administered rifampin, has the potential to cause moderate pruritus.
Surveillance of Colony-Stimulating Factor use in us Academic Health Centers
Authors: Yim Josephine M , Matuszewski Karl A , Vermeulen Lee C , Ratko Thomas A , Burnett David A , Vlasses Peter H
Published: January 2017

Objective:

To characterize and evaluate hematopoietic colony-stimulating factor (CSF) use, including cost implications, in US academic health centers.

Design:

An observational study of patients who received granulocyte colony-stimulating factor (G-CSF) or granulocytemacrophage colony-stimulating factor (GM-CSF) from September 1 to October 15, 1993.

Setting:

Thirty academic health centers in the US.

Participants:

Five hundred sixty-five patients were evaluated.

Main Outcome Measures:

The appropriateness of CSF use was assessed, based on consensus-derived indication guidelines and the Food and Drug Administration-approved product labeling. Indication, type of CSF, and dosage were considered in determining the appropriateness of CSF therapy.

Results:

Based on indication evaluation criteria, 71% of CSF use was appropriate, 7% was inappropriate, and 22% was unproven, although the majority of unproven use was deemed promising by the expert panel. Based on dosage evaluation criteria, 51% of CSF use was appropriate, 27% was inappropriate, and 22% was for promising and other unproven indications. More than 90% of the patients studied received G-CSF. Approximately 3.4% of patients who received G-CSF had an adverse event, compared with 22% of those who received GM-CSF. Approximately $791 000 was spent on CSF therapy in the 565 patients: $401 000 (51%) on appropriate indications and doses, $160 000 (20%) on inappropriate doses for appropriate indications, $124 000 (16%) on promising indications, and $106 000 (13%) on unproven or inappropriate indications.

Conclusions:

Substantial costs are incurred currently for CSF therapy without adequate literature support. Further studies are warranted to justify promising but unproven uses of CSFs, as well as to clarify proper dosing, monitoring, and relative safety of CSFs.
Two Cases of Therapeutic Failure Associated with Levothyroxine Brand Interchange
Authors: Copeland Paul M
Published: January 2017

Objective:

To report the loss of therapeutic control in 2 hypothyroid patients and remind clinical pharmacists and other healthcare professionals to remain cognizant of possible product quality differences within or bioequivalency differences between levothyroxine products.

Case Summaries:

Two patients with stable hypothyroidism experienced symptoms of hypothyroidism with increased serum thyroid-stimulating hormone (TSH) concentrations after switching from 1 levothyroxine product to another. One tablet from 1 of the patient's levothyroxine prescriptions was assayed, and its levothyroxine content was 74.5% of the label claim, a value outside of the United States Pharmacopeia requirements of 90–110%.

Discussion:

Two patients with hypothyroidism had remained euthyroid and stable while receiving 1 levothyroxine product, but became symptomatic with dramatically increased serum TSH concentrations while receiving what were thought to be comparable dosages of another levothyroxine product. Therapeutic control was reestablished in both patients after therapy with the original levothyroxine product was reinstated.

Conclusions:

Clinical pharmacists and other healthcare professionals should remain cognizant of possible product quality differences within or bioequivalency differences between levothyroxine products. These differences necessitate close monitoring of hypothyroid patients, counseling these patients about the clinical signs of sub- and supratherapeutic levothyroxine dosages, and prudence when switching patients with stable hypothyroidism to alternative levothyroxine products. If there are inconsistencies between levothyroxine products, resultant deleterious effects on the therapeutic stability of patients with hypothyroidism may undermine cost savings that might be incurred by such a change. If these patients are switched to alternative levothyroxine products, it is recommended that thyroid function tests be repeated after equilibration to the new product.
Low-Dose Dopamine in Severe Right Heart Failure and Chronic Obstructive Pulmonary Disease
Authors: Chan Thomas YK
Published: January 2017

Objective:

To describe the beneficial effects of low-dose dopamine infusion (2-5 μg/kg/min) in a patient with severe cor pulmonale complicating chronic obstructive pulmonary disease (COPD).

Case Summary:

A 53-year-old woman with severe cor pulmonale and generalized edema complicating COPD received low-dose dopamine to stabilize blood pressure and, perhaps, improve cardiac output. Low-dose dopamine also improved her renal function and enhanced the diuretic response to furosemide therapy.

Discussion:

Previous studies of dopamine in such patients were reviewed. Both dopamine infusion (4 μg/kg/min) and oral administration of its precursor, l-dopa, can increase the cardiac output, decrease pulmonary vascular resistance, and enhance oxygen delivery in patients who are stable with cor pulmonale secondary to COPD. In patients with COPD during acute respiratory failure, high-dose dopamine (10 μg/kg/min) has been shown to increase the diaphragmatic blood flow and contraction. Low-dose dopamine also has been reported to be useful in patients with congestive heart failure or cirrhosis of the liver.

Conclusions:

Low-dose dopamine is useful in the acute management of patients with severe cor pulmonale complicating COPD because of the drug's beneficial effects on blood pressure, cardiac output, renal perfusion, natriuresis, and diuresis. Low-dose dopamine also may enhance the natriuretic and diuretic response to loop diuretics, decrease pulmonary vascular resistance, and enhance oxygen delivery.
Estimating Phenytoin Concentrations by the Sheiner-Tozer Method in Adults with Pronounced Hypoalbuminemia
Authors: Dager William E , Inciardi John F , Howe Ted L
Published: January 2017

Objective:

To assess the performance of the Sheiner-Tozer equation when used to evaluate total phenytoin concentrations in patients with pronounced hypoalbuminemia.

Design:

Patients with phenytoin concentrations drawn at least 5 days after initiation of therapy and with serum albumin concentrations of less than 25 g/L were identified during routine daily monitoring. Phenytoin samples were frozen at −30 °C, batched, and later thawed for total and free phenytoin assay. Separation of free phenytoin concentration was performed at 37 °C using a Centrifree micropartition filter.

Setting:

A 400-bed university teaching hospital.

Patients:

Twenty-nine adults with hypoalbuminemia receiving phenytoin therapy. Patients receiving drugs known to displace phenytoin, or those with renal failure, abnormal liver enzymes, or increased bilirubin concentrations were excluded.

Main Outcome Measure:

Precision and bias of the normalized result using the Sheiner-Tozer equation were assessed with respect to observed phenytoin concentrations.

Results:

The Sheiner-Tozer equation underpredicts the measured free concentration by approximately 12.4%. The equation provides a small but statistically significant bias (−2.7 mg/L) and a root mean squared error significantly different from 0. For most of our patients these departures appear small enough to warrant an initial empiric appraisal of hypoalbuminemia using the Sheiner-Tozer method.

Conclusions:

The Sheiner-Tozer equation can normalize total phenytoin concentrations reliably in patients with low albumin concentrations at our institution.
Disease-Based Assessment of Peripheral Vascular Disease in Nursing Facility Patients
Authors: Gonzalez Edgar R , Liberto Rhonda B , Davidson H Edward , Chamberlain Thomas M , Mendelson Marilyn A
Published: January 2017

Objective:

To determine the frequency of diagnosis of peripheral vascular disease (PVD) and selected related conditions in patients in a nursing facility, to determine the frequency of patients with risk factor(s) for or clinical evidence of PVD but without a diagnosis of PVD or a related condition, and to determine the frequency with which patients with and without a diagnosis of PVD or a related condition were treated with drug and nondrug therapies.

Design:

A multicenter, disease-based, retrospective evaluation.

Settings:

41 nursing facilities in 6 regions of the US.

Patients:

4038 patients in a nursing facility: 827 patients with a PVD or related diagnosis; 2719 patients without a PVD or related diagnosis but with risk factor(s) for or clinical evidence of PVD; and 492 patients without a PVD or related diagnosis, risk factor(s), and clinical evidence.

Main Outcome Measures:

Evidence of disease and drug therapy for PVD.

Results:

PVD was documented in 21% of patients; another 67% had risk factor(s) for or clinical evidence of PVD but no diagnosis of PVD or a related condition. Pentoxifylline was prescribed for 3% of the total sample and 12% of patients with PVD or a related condition.

Conclusions:

PVD appears to be inadequately evaluated in patients in a nursing facility. Disease treatment strategies should be developed and implemented to educate healthcare professionals and the general public about the need to acknowledge, assess, and treat PVD and related conditions.
Hydrochlorothiazide-Induced Acute Pulmonary Edema
Authors: Fine Stanley R , Lodha Ajay , Zoneraich Samuel , Mollura Joseph L
Published: January 2017

Objective:

To describe a patient with noncardiogenic acute pulmonary edema induced by hydrochlorothiazide.

Case Summary:

A 70-year-old woman in generally good health, except for mild pedal edema, developed acute pulmonary edema after ingesting hydrochlorothiazide 12.5 mg for the first time.

Discussion:

This is the fifteenth reported case of noncardiogenic pulmonary edema induced by hydrochlorothiazide. The investigations by previous authors seemed to rule out an immunologic mechanism; thus, the pathogenesis of the reaction is unknown. Most of the reactions have occurred in women.

Conclusions:

Noncardiogenic pulmonary edema appears to be an idiosyncratic reaction that occurs with some specificity with the thiazide diuretics. Clinicians should be aware of this potential, serious adverse reaction that occurs without warning.
Continuous Subcutaneous Heparin Infusion for Treatment of Trousseau's Syndrome
Authors: Alderman Christopher P , McClure Anna F , Jersmann Hubertus PA , Scott Shane D
Published: January 2017

Objective:

To describe the use of continuous subcutaneous heparin infusion in the treatment of 2 cases of Trousseau's syndrome.

Case Summaries:

Two patients with metastatic carcinoma presented to the hospital with acute coagulopathies consistent with a diagnosis of Trousseau's syndrome. In both cases conventional anticoagulant therapies proved to be impractical and ineffective.

Discussion:

Considerable literature suggests that oral anticoagulants such as warfarin are ineffective in the treatment of Trousseau's syndrome. Heparin is more effective for this purpose, although continuous intravenous infusion may prove difficult in the ambulatory setting. Intermittent subcutaneous injections of heparin or low-molecular-weight heparin may not provide reliable anticoagulation for the entire dosage interval. Although the use of continuous subcutaneous infusion of heparin has been used for anticoagulation during pregnancy, this is the first report of the use of sodium heparin administered by continuous subcutaneous infusion in the treatment of Trousseau's syndrome.

Conclusions:

Continuous subcutaneous heparin infusion may be an effective option for the treatment of Trousseau's syndrome in the ambulatory setting.
Diclofenac-Associated Thrombocytopenia and Neutropenia
Authors: Kim Harold L , Kovacs Michael J
Published: January 2017

Objective:

To report a case of thrombocytopenia and a case of neutropenia, both associated with the use of diclofenac.

Case Summaries:

A 63-year-old woman was receiving diclofenac for osteoarthritis. During a hospital admission for pneumonia, she was found to have severe thrombocytopenia. Diclofenac therapy was stopped and the thrombocytopenia resolved. Several months later she was inadvertently treated with diclofenac by another physician and again experienced thrombocytopenia, which again resolved on discontinuation of the drug and has not recurred since. A 72-year-old man was receiving diclofenac for 9 months for osteoarthritis. He was then found to have asymptomatic neutropenia. Diclofenac therapy was stopped and the neutropenia resolved with no other intervention. He was not rechallenged.

Discussion:

Severe thrombocytopenia and neutropenia are extremely rare adverse reactions to diclofenac. To date, there is only 1 case of each that is well documented and supported in the literature.

Conclusions:

Severe thrombocytopenia and neutropenia are potential serious adverse effects of the use of diclofenac. Patients who are receiving diclofenac and develop symptoms of either thrombocytopenia or neutropenia should have a complete blood count, and if this diagnosis is confirmed, the drug therapy should be stopped.
Comparative Evaluation of the Safety and Efficacy of HMG-CoA Reductase Inhibitor Monotherapy in the Treatment of Primary Hypercholesterolemia
Authors: Hsu Irene , Spinier Sarah A , Johnson Nelda E
Published: January 2017

Objective:

To evaluate the comparative efficacy and safety of the 4 currently available hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, fluvastatin, lovastatin, pravastatin, and simvastatin, in the treatment of primary hypercholesterolemia.

Data Sources:

English-language clinical studies, abstracts, and review articles identified from MEDLINE searches and bibliographies of identified articles. Unpublished data were obtained from the Food and Drug Administration in accordance with the Freedom of Information Act.

Study Selection:

Placebo-controlled and comparative studies of HMG-CoA reductase inhibitor monotherapy in the treatment of primary hypercholesterolemia.

Data Extraction:

Pertinent studies were selected and the data were synthesized into a review format.

Data Synthesis:

The chemistry, pharmacology, and pharmacokinetics of the 4 HMG-CoA reductase inhibitors are reviewed. Clinical trials evaluating the hypocholesterolemic efficacy of the HMG-CoA reductase inhibitors are examined, and results on the comparative efficacy and safety of these agents are summarized. On a milligram-per-milligram basis, simvastatin is twice as potent as lovastatin and pravastatin. The hypocholesterolemic effects of fluvastatin appear to be approximately 30% less than that of lovastatin. In posttransplant patients receiving cyclosporine, safety has been documented for low doses of lovastatin and simvastatin, but when a higher dosage of an HMG-CoA reductase inhibitor is warranted, pravastatin should be considered the drug of choice because of a lower incidence of myopathy. Relevant data on the incidence of adverse effects are presented. Pertinent outcomes data from clinical trials evaluating the effect of HMG-CoA reductase inhibitors on atherosclerosis regression and coronary mortality, as well as published economic analyses of cholesterol-lowering agents, are summarized. Recommendations on the selection of an HMG-CoA reductase inhibitor in various clinical situations are provided.

Conclusions:

The literature supports the comparable safety and tolerability of all 4 currently available HMG-CoA reductase inhibitors. Therefore, the choice of an HMG-CoA reductase inhibitor should depend on the extent of cholesterol lowering needed to meet the recommended treatment goal established by the National Cholesterol Education Program. Direct comparative studies are needed to confirm the relative, long-term cost-effectiveness of the various HMG-CoA reductase inhibitors in the treatment of primary hypercholesterolemia.
Therapeutic Approaches for Aids-Related Toxoplasmosis
Authors: Behbahani Roya , Moshfeghi Mersedeh , Baxter John D
Published: January 2017

Objective:

To summarize current knowledge of prophylaxis and treatment of AIDS-related toxoplasmosis.

Data Sources:

A MEDLINE search (1985-1994) was used to identify pertinent literature, including reviews.

Study Selection and Data Extraction:

All articles were considered for possible inclusion in the review. Pertinent information, as judged by the authors, was selected for discussion.

Data Synthesis:

Trimethoprim/sulfamethoxazole (TMP/SMX) appears to be useful for prophylaxis against toxoplasmosis in patients with AIDS. The most effective TMP/SMX dose for prevention of toxoplasmosis needs to be determined. Dapsone in combination with pyrimethamine therapy may be an effective alternative for toxoplasmosis prophylaxis. The most effective regimen for the treatment of AIDS-related toxoplasmosis is the combination therapy of pyrimethamine/sulfadiazine. In patients who cannot tolerate sulfadiazine therapy because of adverse effects or allergy, pyrimethamine with clindamycin therapy may be considered as a second-line alternative. Lifelong suppressive therapy is required after either treatment regimen to prevent relapse. Other newer agents such as azithromycin, clarithromycin, atovaquone, or trimetrexate-leucovorin need further studies to confirm their true effectiveness in the treatment of toxoplasmosis.

Conclusions:

TMP/SMX remains a useful agent in prophylaxis against toxoplasmosis. Pyrimethamine/sulfadiazine is the most effective combination in the treatment of acute toxoplasmosis.
Effect of Standard-Dose Trimethoprim/Sulfamethoxazole on the Serum Potassium Concentration in Elderly Men
Authors: Witt James M , Koo Ji M , Danielson Byron D
Published: January 2017

OBJECTIVE:

To determine the effect of standard-dose trimethoprim/sulfamethoxazole (TMP/SMX) (TMP 160 mg and SMX 800 mg q12h) on the serum potassium concentration.

DESIGN:

Retrospective and concurrent study.

SETTING:

A Veterans Affairs Medical Center.

PATIENTS:

Fifty-three men hospitalized at the Fargo Veterans Affairs Medical Center. Thirty-three patients who received standard-dose TMP/SMX for 3 or more days comprised the study group. Twenty patients who received oral cephradine or amoxicillin for 3 or more days comprised the control group. Patients who received potassium supplements, potassium-sparing diuretics, angiotensin-converting enzyme inhibitors, nonsteroidal antiinflammatory drugs, beta-blockers, heparin, known nephrotoxic agents, patients with a serum creatinine concentration of more than 177 μmol/L, and patients with baseline hyperkalemia (serum potassium concentration>5.1 mmol/L) were excluded.

RESULTS:

The serum potassium concentration in the study group was 4.22 ± 0.40 mmol/L and increased by 0.31 ± 0.38 mmol/L at the end of therapy (p < 0.001). Twenty-six patients in the study group (78.8%) had an increase in the serum potassium concentration during TMP/SMX therapy. Fourteen of these patients had follow-up serum potassium concentrations obtained after completion of therapy. The serum potassium concentration returned to baseline in 10 of these patients. The serum creatinine concentration also increased during therapy. However, the correlation between the increase in the serum potassium concentration and the increase in the serum creatinine concentration was weak (Pearson r = 0.29). The serum potassium in the control group was 4.34 mmol/L and remained essentially unchanged during therapy.

CONCLUSIONS:

Therapy with standard-dose TMP/SMX is associated with a slight increase in the serum potassium concentration. Routine monitoring of the serum potassium concentration in patients who are treated with standard-dose TMP/SMX therapy is unnecessary. However, TMP/SMX should be considered as a possible cause of unexplained hyperkalemia in elderly patients receiving TMP/SMX therapy.