Chromium: friend or foe?

Chromium is an essential nutrient with many natural sources, but several investigators have presented evidence that healthy persons often have an inadequate intake of this metal. Advocates of its use as a dietary supplement believe that people with diabetes, lipoprotein abnormalities, and increased risk of cardiovascular disease may benefit from such supplementation. Others suggest a therapeutic role for chromium in obese people and in those who seek to improve their body composition for other reasons, but research provides little support for these uses. For the general public, current data do not warrant routine use of chromium supplements, whose risk-benefit function has not yet been adequately characterized.

Alendronate treatment to prevent osteoporotic fractures.

Alendronate sodium, an aminobisphosphonate, has been approved by the Food and Drug Administration for the prevention and treatment of osteoporosis in postmenopausal women, thus providing an effective alternative to estrogen replacement therapy in women who cannot or will not take estrogen. Large, randomized, controlled trials have demonstrated approximately a 50% reduction in vertebral, hip, and wrist fractures. Efficacy and safety beyond 3 years has not been determined. To avoid esophagitis and maximize absorption, alendronate should be taken with 180 to 240 mL of water on arising for the day, allowing at least 30 minutes before the first food, beverage, or oral medication of the day is ingested.

Mifepristone (RU 486): current knowledge and future prospects.

Mifepristone (RU 486) has received recent attention for its effects as an abortifacient. Mifepristone has not yet been approved for use in the United States. The Food and Drug Administration issued an "approvable letter" in September 1996, but mifepristone will not be available in the United States until a new manufacturer is found. Experience with mifepristone is extensive in Europe, and there have been retrospective studies and large, controlled clinical trials of its efficacy. It is most efficacious when administered to women who are less than 8 weeks pregnant, in a single 600-mg oral dose followed 48 hours later by administration of intravaginal misoprostol. This regimen has a success rate of 98%, as do most surgical abortive procedures. The most frequent adverse effect is painful contractions, which occur in up to 93% of women, with oral analgesia required in as many as half the cases. Large-scale surveys of women who elected medical abortion reported high patient satisfaction. Mifepristone is likely to have additional clinical uses. Researchers are exploring mifepristone's potential uses in cervical ripening and labor induction; contraception; delivery after intrauterine demise; treatment of breast cancer, unresectable meningioma, and prostate cancer; amelioration of endometriosis; and management of Cushing syndrome.

Drug interactions: keeping it straight.

Drug interactions are common causes of treatment failure and adverse reactions. Patients who have a number of chronic disorders, patients who take many medications or patients who have impaired renal function are at increased risk for these problems. Special attention must be given to drugs that require blood level monitoring, because these agents have a narrow margin of safety. Drug interactions are especially likely to occur with enzyme inhibitors such as erythromycin, cimetidine, ciprofloxacin and metronidazole. Mechanisms of drug interactions include problems with absorption secondary to binding by antacids or other cations, interference with the distribution of drugs secondary to the displacement of highly protein-bound drugs, differences in metabolism secondary to variability of the cytochrome P450 enzyme system, and interaction-related problems with drug excretion by renal tubules. Antagonistic and synergistic reactions also need to be considered. Finally, the time course in which a given drug interaction is likely to occur must be taken into account when deciding whether the interaction is responsible for an adverse effect or treatment failure.

Salary survey of ambulatory care clinical pharmacists.

To determine salary and selected fringe benefits of members of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy, we developed a self-administered questionnaire that surveyed demographic information, schooling and training, academic appointments, yearly salary (as of February 1, 1995), source of salary, outside income, annual raise, vacation time, financial support for continuing education, and board certification. Ninety-nine surveys were returned (return rate 46%). Respondents were mostly women (58%), their average age was 34 years (range 25-51 yrs), and they had a median of 5 years in the work force. Most respondents (67%) had residency training, whereas only 21% had fellowship experience. Board certification was reported by 46%. The median salary was $53,500 (average $55,861, range $35-90 k), with progression for academic rank. The last salary increase averaged 3.7%. Most (93%) respondents received an average of $1509 for travel. The survey represents a young work force. The salaries vary but show progression for accomplishment.

Pharmaceutical marketing: implications for medical residency training.

An educational intervention was developed to improve family practice residents' ability to obtain useful information from pharmaceutical representatives. The curriculum is based on the traditional one-on-one drug detail. The objectives are to develop residents' skills in controlling the interview, promote skills for critically analyzing drug-promotional material, and discuss ethical issues. The contents include an assessment tool, suggested readings, and interview questions with rationale. After 5 years, residents' confidence in all areas of the curriculum improved significantly.

Ritalin for nicotine withdrawal: Nesbitt's paradox revisited.

This was a unblinded clinical trial of the stimulant methylphenidate (Ritalin) for nicotine withdrawal. Nineteen nicotine-dependent smokers received oral methylphenidate (30 mg target daily dosage) for 5 days following abrupt cessation. Tobacco withdrawal, Spielberger state anxiety, blood pressure, and pulse were measured at baseline, then serially for 7 days. Tobacco withdrawal and state anxiety increased significantly, but 12 (71%) of the 17 smokers who completed the study rated withdrawal relief "very define" and 13 (76%) rated this quit attempt "much easier than other times." Methylphenidate neither increased blood pressure nor blocked cessation-related pulse decrease and appears safe for this indication. Twelve (63%) of the enrolled smokers were confirmed abstinent at day 5. Methylphenidate effect on nicotine withdrawal should be studied in a placebo-controlled clinical trial.

Impact of compliance and side effects on the clinical outcome of patients treated with oral erythromycin.

STUDY OBJECTIVE: To determine the relationship among compliance, side effects, and self-reported outcome for patients in an erythromycin trial. DESIGN: A retrospective analysis of data from a multicenter, prospective, single-blind, randomized trial. SETTING: Five metropolitan ambulatory care offices. PATIENTS: The 252 adults (> 18 yrs) were prescribed oral erythromycin 1.0 g/day (base equivalent) for infectious disorders. INTERVENTION: Subjects received erythromycin for 10 days and reported compliance, drug efficacy, and side effects in a daily diary. Compliance was measured by tablet count. RESULTS: A negative correlation was found between gastrointestinal symptom severity score and percentage of tablets taken (p < 0.001). A significant positive correlation was seen between compliance and outcome (p < 0.001). Subjects who took greater than 80% of the drug achieved the treatment goal more frequently than those taking 80% or less (94% vs 59%, p < 0.001). CONCLUSIONS: Side effects of erythromycin adversely affected compliance. Compliance had a positive effect on self-reported outcome.

A comparison of the gastrointestinal side effects of two forms of erythromycin.

BACKGROUND: The gastrointestinal (GI) side effects of erythromycin frequently limit therapy and compliance. PCE Dispertab, a more expensive brand of erythromycin, has been promoted as a well-tolerated new dosage form; however, no studies compare its GI side effects with those of other forms of erythromycin. We compared erythromycin PCE (particles-in-tablet) with E.E.S. (erythromycin ethylsuccinate) to determine whether there is a difference in the incidence and severity of GI side effects. METHODS: This was a multicenter, prospective, single-blind, randomized trial. Observers, but not participants, were blinded to the brand of erythromycin taken until after data analysis. We enrolled ambulatory patients who were at least 18 years old and weighed at least 90 lb for whom erythromycin had been prescribed at a dosage of 1.0 g/d. Subjects were given either the particles-in-tablet form, 333 mg three times daily, or the ethylsuccinate form, 400 mg four times daily, for 10 days and asked to report efficacy, compliance, and the frequency and severity of four GI symptoms (abdominal pain, nausea, vomiting, and diarrhea) in a daily diary. RESULTS: There were no significant differences between the particles-in-tablet and ethylsuccinate forms in incidence of GI side effects (63% and 61%, respectively), average daily GI symptom severity score (0.62 and 0.68, respectively), and GI-related discontinuations (8.5% and 8.2%, respectively). The incidence of moderate or severe nausea was 5% for the particles-in-tablet form and 25% for the ethylsuccinate form (P < .001). CONCLUSIONS: Although ethylsuccinate caused a higher incidence of moderate to severe nausea, there were no differences in the three main outcome measures: incidence of GI side effects, average daily GI-symptom severity score, and GI-related discontinuations. Therefore, we support prescribing erythromycin ethylsuccinate as a first line of treatment because it costs less.