Second-generation antihistamines: a comparative review.

Second-generation histamine H1 receptor antagonists (antihistamines) have been developed to reduce or eliminate the sedation and anticholinergic adverse effects that occur with older H1 receptor antagonists. This article evaluates second-generation antihistamines, including acrivastine, astemizole, azelastine, cetirizine, ebastine, fexofenadine, ketotifen, loratadine, mizolastine and terfenadine, for significant features that affect choice. In addition to their primary mechanism of antagonising histamine at the H1 receptor, these agents may act on other mediators of the allergic reaction. However, the clinical significance of activity beyond that mediated by histamine H1 receptor antagonism has yet to be demonstrated. Most of the agents reviewed are metabolised by the liver to active metabolites that play a significant role in their effect. Conditions that result in accumulation of astemizole, ebastine and terfenadine may prolong the QT interval and result in torsade de pointes. The remaining agents reviewed do not appear to have this risk. For allergic rhinitis, all agents are effective and the choice should be based on other factors. For urticaria, cetirizine and mizolastine demonstrate superior suppression of wheal and flare at the dosages recommended by the manufacturer. For atopic dermatitis, as adjunctive therapy to reduce pruritus, cetirizine, ketotifen and loratadine demonstrate efficacy. Although current evidence does not suggest a primary role for these agents in the management of asthma, it does support their use for asthmatic patients when there is coexisting allergic rhinitis, dermatitis or urticaria.

Treatment of nicotine dependence.

Drug and nondrug interventions used in treating nicotine dependence are reviewed. Tobacco use is the leading preventable cause of death in the United States. Risks of smoking-related disease and death decline sharply when smokers quit, but 26% of Americans continue to smoke. Most smokers find it extremely difficult to quit smoking because of their nicotine addiction. Nonpharmacologic interventions used to promote smoking cessation include behavioral therapy, setting a specific date for quitting, receiving advice to quit from a health care professional, follow-up visits to review progress, self-help approaches, group counseling, filtration devices, hypnosis, and acupuncture. The efficacy of these approaches ranges from substantial to almost nil. The only pharmacologic agent with FDA-approved labeling for use in smoking-cessation therapy is nicotine. When used in conjunction with appropriate nonpharmacologic interventions, nicotine-replacement therapy roughly doubles the rate of quitting obtained with placebo. Nicotine-replacement therapies consist of nicotine transdermal (patch) systems and nicotine chewing gum. The nicotine patch is the first-line replacement therapy because it is effective when accompanied by only minimal (as opposed to more intensive) nonpharmacologic interventions and because it is easier to use and comply with than gum. Clonidine, antidepressants, and buspirone require further study to determine what role, if any, they should play in the treatment of nicotine dependence. The stages of smoking cessation are precontemplation, contemplation, action, and maintenance; interventions are selected on the basis of the stage the smoker is in. Nicotine dependence is difficult to treat, but there are aids that boost a smoker's chances of quitting. Nicotine patches and chewing gum offer the most effective pharmacologic options, especially when combined with behavioral interventions and counseling.

Manufacturers' distribution of drug samples to a family medicine clinic.

The distribution of drug product samples by pharmaceutical companies to a family medicine clinic was studied. Data on all deliveries of drug samples to the clinic site of a university-affiliated family medicine residency program from November 1992 through December 1993 were collected. In addition, the 11 faculty family physicians were surveyed about their experiences with the deliveries of samples. Forty-three manufacturers delivered samples of 331 drugs during the 14-month study period. There were 366 visits by the drug company representatives, who made 1117 separate deliveries. The total value of the samples, based on the average whole-sale price, was $240,782. Twenty-nine percent of the drugs were nonformulary, and only 49% were stocked by the pharmacy. The physicians surveyed indicated that they were either usually or always asked to sign for samples they did not in fact request, that they usually did not know what was recorded on the receipts for samples that they signed, and that they seldom verified what was actually delivered. Pharmaceutical manufactures delivered large quantities of drug samples during the study period, and many of the drugs were nonformulary or not stocked by the pharmacy. The physicians indicated that they were not well informed about delivered samples for which they signed receipts.

The treatment of nonstreptococcal pharyngitis with erythromycin: a preliminary study.

This preliminary study evaluated the effectiveness of enteric-coated erythromycin in the treatment of adults with nonstreptococcal pharyngitis. Twenty-six patients, aged 12 or older, with nonstreptococcal pharyngitis were randomly assigned in a double-blind fashion to receive either enteric-coated erythromycin or placebo for 10 days. Each day the patients rated the soreness of their throats and how sick they felt. The use of erythromycin appeared to decrease the median number of days for the feeling of sickness to improve (two days versus four days, P less than .01) as well as to decrease the median number of days for the feeling of sickness to resolve (three-and-a-half days versus five days, P less than .05). This apparent improvement in sickness occurred even though there was no significant decrease in the soreness of the throat in patients treated with erythromycin compared to those patients treated with placebo. Treatment with enteric-coated erythromycin appeared to shorten the time until improvement in this group of adults with nonstreptococcal pharyngitis.

Characteristics and perceptions of nicotine patch users.

BACKGROUND: Although transdermal nicotine patches are frequently prescribed to aid in smoking cessation, little information exists about their use in general medical practice. In clinical studies, nicotine patches have been found to be effective when used in conjunction with nonpharmacologic interventions, such as physician counseling and follow-up visits. This study examines the characteristics and perceptions of patients regarding treatment with nicotine patches. METHODS: Patients filling or refilling prescriptions for a nicotine patch at 17 pharmacies were asked to complete a questionnaire. RESULTS: Seventy-six questionnaires were returned. Thirty-six percent of the respondents first learned about the nicotine patch from the media, 32% from friends, family, or co-workers, and 25% from their physicians. Most respondents (87%) had requested the patch, whereas only 9% had been asked by their prescriber to try the patch. Most of the surveyed smokers were highly motivated to quit, and 86% smoked at least one pack per day. Eighty percent indicated they had received a clear message from their physicians to quit, 56% said their physician had counseled them about relapse, and 55% had follow-up arranged. A quit date had been set by 37%, and only 24% reported the use of self-help materials. Approximately one half of smokers (54%) who had started using the patch indicated that they continued to smoke. CONCLUSIONS: Most respondents were good candidates for the nicotine patch based on how much they smoked and their motivation to quit. Direct-to-consumer advertising may have influenced many smokers to request treatment with the patch. Physicians should recognize that some persons may use the patch as a "quick fix," as very few respondents used the number of nonpharmacologic interventions that have proved useful in nicotine patch clinical trials. Physicians should follow the progress of patch users to ensure that they completely stop smoking during treatment.

Family practice physicians' perceptions of the usefulness of drug therapy recommendations from clinical pharmacists.

Family practice physicians' perceptions of the usefulness and clinical outcome of drug therapy recommendations made by clinical pharmacists in a family medicine clinic were determined. For 15 weeks, pharmacists in the clinic recorded all consultations in which they made recommendations about the drug therapy of specific patients. At the time of each consultation, the pharmacists gave the physician a questionnaire designed to gauge the physician's opinion of the usefulness of the consultation. Physicians who implemented the recommendations were sent a second questionnaire and asked to indicate the extent to which the clinical pharmacist influenced their decision to implement the recommendation, the effect the recommendation had on the patient's clinical status, and the usefulness of the recommendation to the patient in ways unrelated to clinical status (such as greater patient acceptance, safety, or lower cost). Five clinical pharmacists provided 59 consultations to 33 physicians. The physicians rated 51 (88%) of the consultations as very useful, and they implemented 78 (98%) of the 80 recommended actions. Of the 56 physicians who attributed their decision to implement the recommendation to their consultation with the clinical pharmacist, 43 believed that the recommendations had improved the clinical status of the patient, and 38 believed that the recommendations were useful to patients in ways unrelated to clinical status. Physicians in a family medicine residency training program had positive perceptions of the usefulness of drug therapy recommendations made by clinical pharmacists. A majority of the physicians believed that the recommendations had a positive effect on patients' clinical status.

Elimination of over-the-counter medication coverage in the Oregon Medicaid population: the impact on program costs and drug use.

OBJECTIVES: To reduce program costs, the Oregon Medicaid program eliminated reimbursement for over-the-counter (OTC) medications. Considering that physicians might substitute more expensive prescription-only products for eliminated OTC therapy, this investigation evaluates the policy's impact on medication costs. METHODS: This retrospective investigation examines pharmacy claims for adult Medicaid eligible recipients between March 1992 and February 1994 using an interrupted time-series analysis. The policy's impact on program costs and on the number of submitted claims was evaluated separately for prescription-only and total prescribing in nine therapeutic categories. RESULTS: In the preintervention period, OTC products comprised 36% (213,516 of 592,672) of drug claims and 9% ($1.36 million of $14.58 million) of medication costs in the nine therapeutic categories. Decreased program costs were noted in five categories and no significant changes were found in four others; overall, medication costs decreased from $7.86 to $7.39 per eligible recipient per month. A significant increase in prescription-only prescribing was noted in the hematinics category, but the net effect on total costs demonstrated a significant decrease. CONCLUSIONS: The OTC elimination policy was successful in reducing program drug costs with limited evidence for substitution of prescription-only products. Further study is needed to determine the impact on patients who regularly received OTC medications and to evaluate secondary effects on outpatient visits, hospitalization, and clinical outcomes.

Possible interactions with terfenadine or astemizole.

Concurrent use of terfenadine or astemizole with erythromycin or ketoconazole can prolong the QT interval and produce potentially fatal ventricular arrhythmias. We examine the frequency and patterns of concurrent prescribing and suggest methods to reduce the incidence of serious drug interactions. By retrospectively reviewing Oregon Medicaid prescription claims data over 22 months, we determined the frequency of concurrent prescribing of terfenadine or astemizole with macrolide antibiotics or ketoconazole. From 1991 to 1992, terfenadine use increased by 29%, with a seasonal peak in June of each year. Terfenadine was one of the most prescribed medications from March through July 1992. During the 22 months reviewed, there were 122 episodes of concurrent use of terfenadine or astemizole with macrolide antibiotics or ketoconazole. Most of these episodes (94%) involved terfenadine. The frequency of concurrent use increased more than threefold from 1991 to 1992. Although patients received prescriptions from different physicians in 48% of these episodes, they used different pharmacies only 3% of the time. We demonstrate that terfenadine use is extensive and increasing, thus increasing the possibility of serious interactions, and many physicians may remain unaware of this potential. Effective prospective screening by pharmacists could dramatically reduce the incidence of concurrent prescribing. Physicians must be aware of the potential for these drug interactions, avoid prescribing these medications concurrently, and consider these interactions in the evaluation of syncope and cardiac arrhythmias.

Intervention assessment in an Indian health service pharmacy.

OBJECTIVE: To document and evaluate pharmacists' interventions in a setting that has complete and immediate access to patient information. DESIGN: Descriptive report evaluating self-reported interventions made by pharmacists during the conduct of routine dispensing activities. The data collection period was from February 15 to April 1, 1994. SETTING: Ambulatory care facility offering medical and dental care to high school residents, Native Americans, and Alaska Natives in Northwestern Oregon. MAIN OUTCOME MEASURES: Intervention rate per 100 new prescriptions dispensed. Each intervention was evaluated with regard to the information used to initiate it, when during the dispensing process it was initiated, and the intervention type. Outside evaluators determined the clinical significance of the interventions, including potential adverse health consequences, the likelihood of their occurrence, and the level of medical care that would have been required to treat the problem. RESULTS: Of 2,535 orders screened, 104 interventions (4.1%) were collected; 71% of these occurred during chart screening. Pharmacists most often used the medication order itself (60.6%) to detect prescribing problems, followed by other records in the patient's chart (29.8%). Outside evaluators identified 47.1% of the 104 interventions as clinically significant. The most common adverse health consequence prevented was inadequate control of the patient's condition. Outside evaluators also found that the most common level of corrective care that would have been needed if the intervention had not occurred, was a scheduled physician office visit (59.2%). CONCLUSION: This information suggests that pharmacists who have access to patient information may intervene at higher rates and that more of their interventions may be deemed clinically significant. However, larger, double-blinded, case-controlled studies are needed to definitively draw these conclusions.