Managing insulin therapy.

Diabetic patients present a special challenge to your employees: Blood glucose levels require monitoring, medications must be administered appropriately, and all complications demand rapid assessment. The latest developments in insulin therapy will help to better manage this unique inpatient population.

New strategies in the medical management of asthma.

Asthma, a common chronic inflammatory disease of the airways, may be classified as mild intermittent or mild, moderate, or severe persistent. Patients with persistent asthma require medications that provide long-term control of their disease and medications that provide quick relief of symptoms. Medications for long-term control of asthma include inhaled corticosteroids, cromolyn, nedocromil, leukotriene modifiers and long-acting bronchodilators. Inhaled corticosteroids remain the most effective anti-inflammatory medications in the treatment of asthma. Quick-relief medications include short-acting beta2 agonists, anticholinergics and systemic corticosteroids. The frequent use of quick-relief medications indicates poor asthma control and the need for larger doses of medications that provide long-term control of asthma. New guidelines from the National Asthma Education and Prevention Program Expert Panel II recommend an aggressive "step-care" approach. In this approach, therapy is instituted at a step higher than the patient's current level of asthma severity, with a gradual "step down" in therapy once control is achieved.

Acute pulmonary edema associated with ocular metipranolol use.

OBJECTIVE: To report a case of pulmonary edema associated with the use of ocular metipranolol, a nonselective beta-blocker. CASE SUMMARY: A 72-year-old woman with no history of pulmonary or cardiac disease presented to the emergency room with signs and symptoms consistent with cardiogenic pulmonary edema. The patient had used metipranolol eyedrops approximately 1 hour before becoming symptomatic. When rechallenged inadvertently while hospitalized, the patient again became symptomatic. The patient's metipranolol eyedrops then were substituted with betaxolol eyedrops. She continued to be free of symptoms of pulmonary edema at subsequent clinic visits 1, 4, and 6 weeks following discharge. DISCUSSION: This is the first reported case of pulmonary edema associated with metipranolol. There was a reasonable temporal association between use of the eyedrops and the onset of symptoms. Beta-blockers may cause cardiogenic pulmonary edema secondary to their negative inotropic and negative chronotropic effects. The drug's lipid solubility or a deficiency in the enzyme responsible for its metabolism may have allowed the drug to accumulate to a critical concentration over the 6-week period of use. CONCLUSIONS: Ocular beta-blockers must be used with caution in patients with relative contraindications to beta-blockade. This case illustrates that these agents must be used prudently even in patients with no history of symptomatic congestive heart failure.

Suspected trimethoprim/sulfamethoxazole-induced hypoprothrombinemia.

The following report illustrates a case of trimethoprim/sulfamethoxazole-induced hypoprothrombinemia in a patient receiving ongoing warfarin therapy for atrial fibrillation and aortic valve replacement. He was treated with trimethoprim/sulfamethoxazole (TMP/SMX) for sinusitis. During this time, the patient's prothrombin time international normalized ratio (INR) increased 3.5 times higher than the baseline value. The INR values decreased when the antibiotic was discontinued. If a patient is on warfarin and TMP/SMX is added, INR values should be monitored closely.

Use of fluoroquinolones: practical considerations.

The fluoroquinolone class of antibiotics has expanded the therapeutic options available for serious bacterial infections. These antibiotics have activity against a wide variety of gram-negative organisms, including Pseudomonas aeruginosa, and selected gram-positive pathogens. Fluoroquinolones are well absorbed orally and are widely distributed into most tissues and fluids. Therapeutic indications include urinary tract infections, urethral and cervical gonorrhea, traveler's diarrhea, selected gram-negative respiratory and bone infections, and certain mycobacterial infections. Because adequate concentrations of fluoroquinolones are not achieved in cerebrospinal fluid, their use should be avoided in meningitis. Cost, drug interactions, adverse effects and resistance pose problems for the clinician. Fluoroquinolones should be restricted to proven indications when less costly agents are inappropriate.

Septic discitis resulting from Escherichia coli urosepsis.

Septic discitis refers to a primary suppurative process involving the intervertebral disc space and occurs as a result of hematogenous invasion or contamination by pyogenic organisms. A case of septic discitis is described in a 77-year-old woman following an episode of Escherichia coli urosepsis. Despite bed rest, an orthosis, and appropriate antibiotics, the patient ultimately had to undergo surgical disc removal. The diagnosis of septic discitis is often made in the context of other diseases that share common clinical and laboratory findings. Magnetic resonance imaging appears well suited for diagnostic confirmation of septic discitis. Needle biopsy and aspiration results should be used to determine the appropriate choice of antibiotic for this disease process.

Monitoring diabetes mellitus: the pharmacist's role.

The pharmacist is in a unique position to monitor and counsel the patient with diabetes mellitus. Providing these services requires familiarity with both the disease and its contemporary management. Pharmacists can provide the necessary counseling and guidance regarding the myriad products and devices available to the patient and can serve as a resource to the physician and other health care professionals. Pharmacists with a special interest in diabetes are encouraged to develop services that are compatible with their practice resources. This shared-care approach to treatment will help contribute to the goal of a normal lifestyle for the person with diabetes mellitus.