Physician perspective on propoxyphene as a potentially inappropriate medication in Tennessee.

Medicare Part D data from the Quality Improvement Organization's 9th Statement of Work drug safety indicator project under the direction of the Centers for Medicare & Medicaid Services define the potentially inappropriate medications (PIMs) list for Tennessee. These data reveal propoxyphene as the main contributor to the state's PIM rate. In Tennessee, PIM and drug-drug interaction (DDI) rates indicate propoxyphene as the most prescribed medication among elderly patients despite decades of attention for potentially adverse effects. During this project, physicians agreed that PIM rates are too high, but disagreed in approach preference, i.e., administrative limits and bans versus a proactive educational approach. Physicians were interested in participating in quality improvement by using individual pharmacy data to influence prescribing patterns. Exploring alternatives in research and survey, a potential and reachable point of intervention was found, a prescribing paradigm proposed by researchers to improve outcomes by reducing adverse effects in minimizing PIMs and DDIs.

Quality improvement process in the adherence to gastric decontamination guidelines for poison exposures as recommended by a poison control center.

PURPOSE: Adherence to new guidelines for the use of ipecac syrup, gastric lavage, cathartics, and activated charcoal by a poison control center was studied with a quality improvement framework. METHODS: The rates of gastric decontamination were monitored through an electronic case record system. In February 2002, a revised guideline that narrowed the use of gastric decontamination was implemented with a performance improvement process. The rates of recommendation and utilization during 12 months following implementation of the new guidelines were compared with those during 12 previous months. RESULTS: Recommendations for the use of ipecac syrup declined from 1.50% to 0.02% (OR; 95% CI = 0.02; 0.01, 0.03), single-dose-activated charcoal declined from 5.39% to 1.38% (0.25; 0.22, 0.28), gastric lavage declined from 4.19% to 0.22% (0.05; 0.04, 0.06), and a cathartic declined from 1.48% to 0.13% (0.08; 0.06, 0.12). Declines in utilization were also significant (P < .001) for all forms of gastric decontamination. The proportions of patients managed at the scene of the poisoning were unchanged (1.04; 0.99, 1.09) before (67.64%) and after (68.50%) the new guidelines as were those for referral to a health care facility (20.57% and 21.42%, respectively, 1.05; 1.00, 1.11). CONCLUSION: Recommendations on gastric decontamination can be effectively modified with no detriment to patient outcome.

Histamine and antihistamines in anaphylaxis.

Anaphylaxis and anaphylactoid reactions are potentially fatal. These disorders are sometimes iatrogenic, and increase with increased exposure to drugs, synthetic substances, and medical procedures. Non-IgE-mediated anaphylactoid reactions are common in medical settings and are clinically indistinguishable from anaphylaxis. These reactions may be unrecognized if a rigid classic definition of anaphylaxis is used. Histamine is a primary mediator of anaphylaxis and signs and symptoms of anaphylaxis can be reproduced by histamine infusion. Histamine triggers a cascade of inflammatory mediators and modulates its own release. H1-antihistamines are adjunctive treatment therapy for acute anaphylaxis and anaphylactoid reactions, in which many mediators of inflammation are involved. Compared with epinephrine, the first-response medication of choice, antihistamines have a slow onset of action, and they cannot block events that occur subsequent to histamine binding to its receptors. Antihistamines are an important component of regimens for the prevention of anaphylaxis and anaphylactoid reactions in patients at risk, and may eventually have more widespread application in the perioperative setting. In some instances, such as with exercise-induced anaphylaxis and reactions to latex in sensitized individuals, prophylaxis regimens are not always effective. H2-antagonists are not detrimental in the therapy of anaphylaxis and many studies show a favorable outcome when combining H1- and H2-antagonist therapy for prophylaxis. They should be added to therapy at the discretion of the treating physician. Because of decreased antimuscarinic and central nervous system side effects, the newer antihistamines can be given in high doses, allowing more complete blockade of histamine receptors. These agents should lead to a reevaluation of the usefulness of antihistamines in both the treatment of acute anaphylaxis and in prophylactic regimens. The unavailability of parenterally administered second-generation H1-antagonists limits their usefulness in acute anaphylaxis and perioperative prophylaxis.

The Pharmacology of Alcohol Withdrawal Syndrome Treatment Reviewed: Efficacy, Cost, and Safety.

Alcohol continues to be one of the most common drugs of abuse. The morbidity and mortality associated with alcohol withdrawal has decreased significantly with the advent of pharmacologic intervention. However, the best method for the treatment of alcohol withdrawal syndrome remains controversial. With chronic use, alcohol can disturb the function and balance of several neurotransmitter systems such as excitatory amino acids, GABA, serotonin, and acetylcholine. Compensatory mechanisms in these pathways appear to predominate during chronic use but may become pathologic during withdrawal. As the understanding of alcohol-induced cellular changes increases, treatment of chronic abuse and withdrawal can be refined. Several groups of drugs are efficacious as either primary or adjunct agents in the treatment of alcohol withdrawal. This review describes the current theories on the etiology and treatment of alcohol withdrawal syndrome with emphasis on efficacy, cost, pharmacokinetic parameters, and safety considerations. A proposed withdrawal regimen is also described. Benzodiazepines appear to be the safest and most efficacious choice. With a wide variety of pharmacokinetic parameters and low cost of treatment, they remain the drugs of choice for withdrawal. Ethanol, barbiturates, antiseizure medications, and sympatholytic and sympathomimetic drugs are also reviewed. Newer agents that may have a future role in withdrawal are discussed as well.