[Role of community pharmacist in the management of patients in ophthalmology]. / Place du pharmacien de ville dans la prise en charge des patients en ophtalmologie.

OBJECTIVES: To assess the role of community pharmacists in ophthalmology, to evaluate the frequency of giving patients advice, and to report their difficulties in daily practice. MATERIAL AND METHODS: An anonymous questionnaire consisting of 13 questions was sent to 620 community pharmacists of Burgundy (France). Pharmacists were asked about their ophthalmic products, their ophthalmic activity in giving patients advice on ocular symptoms, and patients' expectations. For analysis, community pharmacies were separated into three groups: pharmacies in rural areas (under 2000 inhabitants), pharmacies in an urban zone with fewer than 10,000 inhabitants, and pharmacies in an urban zone with more than 10,000 inhabitants. RESULTS: The response rate was 46.9%. Ophthalmic products were mainly glasses for presbyopia (84.5%), eye care hygiene products (76.0%), and contact lens solutions (55.3%). Ophthalmic vitamin supplements were sold by 36.8% of pharmacists, mainly in urban areas. On average, the pharmacist was consulted for ocular problems seven times a week. Acute benign symptoms were most frequent. Advice on prescriptions came next. Then, information on contact lenses and chronic ocular disease were given (cataract, glaucoma, visual acuity loss, age-related maculopathy). Finally, the pharmacist either sold the patient an ocular treatment or oriented the patient to an ophthalmologist when needed. DISCUSSION: The pharmacist and his staff are active players in providing advice on ocular diseases and taking care of patients. Moreover, pharmacists have to manage ocular therapeutics, urgent symptoms, and chronic diseases. However, in our study, 46.0% of pharmacists felt confident with their knowledge on ophthalmology, 36.4% did not give their opinion, and 7.0% were uncomfortable with some questions. Most community pharmacists mentioned a lack of continuing education from pharmaceutical companies and postgraduate education on ocular diseases and treatment, mainly for age-related maculopathy.

[The prescription in dispensary practice]. / La prescription en pratique officinale.

Although the medical prescription is a well-established process, prescribing in the pharmacy does not follow a well-defined set of rules as, in official terms, there is no such thing as a pharmaceutical prescription. Despite this fact, daily pharmacy practice involves giving professional advice and dispensing drugs not only in fulfillment of a medical practitioner's prescription but also by selling drugs the pharmacist personally advises use of. In this particular case, the pharmacist must assess the patients desire for a specific treatment and determine whether it is well founded. The pharmacist has to decide whether he/she can deal with the presenting symptom or whether the person should be referred to a practising physician. For example, often-recurring mouth disease such as mouth-ulcers and gingivitis can be handled within the pharmacy. The pharmacist may think of implementing a suitable treatment involving dietary and hygienic counselling and dispense carefully selected drugs. The situation is similar in many other clinical conditions. As the pharmacist has had professional training in drugs at the university and teaching hospital, he/she is the expert in drugs and can rightly claim entitled to prescribing drugs within reasonable limits.

Cinchonine per os: efficient circumvention of P-glycoprotein-mediated multidrug resistance.

We have previously suggested that quinine and cinchonine could be good candidates for the clinical circumvention of multidrug resistance (MDR) in haematological malignancies because of their tolerance and their retained efficacy in serum. We have also shown that cinchonine was more efficient than quinine as an anti-MDR agent in vitro, ex vivo and in vivo after parenteral administration. Here, we report that cinchonine administered per os (po) is much more active than quinine po in circumventing MDR in rats bearing resistant colon tumours. The pharmacokinetics of cinchonine and quinine administered po in rat are shown to be very different. Cinchonine demonstrates a greater absolute bioavailability than quinine (44% versus 30%, respectively). Its serum concentration correlates with the anti-MDR activity measured ex vivo and in vivo. Cinchonine administered po does not significantly modify the pharmacokinetics of intravenous doxorubicin (DXR). However, cinchonine induces a significant increase of DXR uptake in organs which express the mdr1 gene (liver, kidney, lung). When associated with VAD (vincristine, adriamycin, dexamethasone) combined therapy in rats, cinchonine does not significantly increase the toxicity of the cytotoxic drugs. Based on these experimental data, a phase I clinical trial is currently in progress to test the tolerance of this potent MDR-reversing agent administered po.

Comparative effects of quinine and cinchonine in reversing multidrug resistance on human leukemic cell line K562/ADM.

We have previously suggested that quinine and cinchonine could be good candidates for clinical circumvention of multidrug resistance (MDR) in hematological malignancies because of their tolerance and their retained efficacy in serum. In the present study, we have used the well-characterized multidrug resistant human leukemic cell line K562/ADM to compare the effect in vitro of quinine and cinchonine on doxorubicin, mitoxantrone, and vincristine uptake and cytotoxicity. In serum-free medium, quinine induced a dose-dependent increase of doxorubicin uptake reaching about 200% at 40 microM, while it had a slight and no effect on mitoxantrone and vincristine uptake respectively. In the same conditions, cinchonine induced a rapid and significant increase in the accumulation of the three drugs, reaching a plateau phase between 5 and 10 microM. Quinine and cinchonine induced both potentiation of doxorubicin, vincristine and mitoxantrone cytotoxicity in K562/ADM cells. However, quinine reached a plateau phase at 10 microM, while cinchonine had a maximal effect at 5 microM and was significantly more potent at low concentrations. When diluted in plasma, cinchonine was less bound to proteins than quinine. The free fraction of alkaloids was 37-55% for cinchonine and 20-30% for quinine. Cinchonine-induced enhancement of vincristine cellular accumulation was little modified by plasma proteins. When incubated in whole blood, the fraction of cinchonine trapped in red blood cells was rapidly and completely exchangeable with plasma. We conclude that cinchonine is a stronger inhibitor of MDR than quinine.