Hypertensive crisis and myocardial infarction following massive clonidine overdose.

OBJECTIVE: To describe a patient who experienced a hypertensive crisis and myocardial infarction following a massive dose of parenteral clonidine. CASE SUMMARY: A 62-year-old white woman with stage 3 breast cancer metastatic to the spine and a history of hypertension received a combined injection of hydromorphone 48.3 mg and clonidine 12.24 mg subcutaneously in an attempt to refill an implanted epidural infusion pump. She promptly developed mental deterioration, blurred vision, worsening respiration, tachycardia, and hypertension. She was immediately treated with naloxone, but subsequently experienced hypertensive urgency, a short-duration tonic-clonic seizure, and an anteroseptal myocardial infarction. Cardiac catheterization showed no arteriolar narrowing or blockage, but an anterior infarct was confirmed. DISCUSSION: Clonidine is a commonly used alpha-adrenergic agonist. At usual oral doses of 0.2-2 mg/d, it acts centrally to produce hypotensive effects; at doses >7 mg/d, it acts peripherally to stimulate alpha1- and alpha2-adrenergic receptors, leading to vasoconstriction and increased blood pressure. These effects are not easy to control by standard medical therapies and can cause significant morbidity. CONCLUSIONS: Clonidine, although a safe medication with usual dosages, must be used with caution when given in injectable form. An overdose of this alpha-adrenoreceptor agonist can produce significant vasospasm and hypertensive emergency. Drugs used to treat overdose, such as naloxone, can potentiate clonidine's adverse effects, leading to further morbidity.

Angioedema and photosensitive rash induced by valsartan.

A 71-year-old woman experienced an acute onset of angioedema and a photosensitive pruritic rash after 3 months of therapy with valsartan, an angiotensin II receptor antagonist. After discontinuing valsartan and treatment with subcutaneous epinephrine, intravenous methylprednisolone, diphenhydramine, and Eucerin cream, her symptoms dissipated and the rash resolved. Rash and angioedema have been reported with angiotensin-converting enzyme inhibitors and, very rarely, with losartan, the other currently marketed angiotensin II receptor antagonist. To our knowledge, this is the first report of such a reaction with valsartan.

Using literature in health care: reflections on "the yellow wallpaper".

OBJECTIVE: To discuss how literature can be used to educate healthcare practitioners and students about the patient's physical and emotional response to treatment. DATA SOURCES: A MEDLINE search (January 1975-November 1997) of English-language literature pertinent to using literature in health care was performed. Additional literature was obtained from a search of the New York University Web site on medicine and humanities, biographies of Charlotte Perkins Gilman, and a search of the MLA and INFOTRAC database. SELECTION AND DATA EXTRACTION: All articles and literature were considered for possible inclusion in this article. Pertinent information, as judged by the author, was selected for discussion. SUMMARY: Literature can pose a wealth of information to the healthcare professional. The short story "The Yellow Wallpaper" is analyzed in this article as one example of how literature portrays the patient's emotional response to disease. This short story describes a 19th-century woman's "descent into madness" and the ineffective treatment attempted by her well-meaning physician husband. The author, Charlotte Perkins Gilman, loosely based the story on her own experience with the respected physician, S Weir Mitchell and his famous rest cure. Some biographical information about Mitchell and Perkins is included, as well as a commentary on the treatment of depression in the 19th century. CONCLUSIONS: Short stories such as "The Yellow Wallpaper," novels, and other short stories can help to remind the healthcare professional of the subjective nature of even our most proven therapies. As we strive to teach and deliver pharmaceutical care, we can use literature to help us understand the emotional impact of our drug therapies.

Drug-induced pancreatitis.

Recent information about drugs implicated in causing pancreatitis is summarized. Although the frequency of drug-induced acute pancreatitis is generally low, the disease is associated with substantial morbidity and mortality, which makes timely identification of the offending agent important. Mechanisms suggested for drug-induced pancreatitis include pancreatic duct constriction; immunosuppression; cytotoxic, osmotic, pressure, or metabolic effects; arteriolar thrombosis; direct cellular toxicity; and hepatic involvement. Agents reported to have a definite association with pancreatitis are asparaginase, azathioprine, didanosine, estrogens, furosemide, mercaptopurine, pentamidine, sulfonamides, sulindac, tetracyclines, thiazides, and valproic acid. Agents reported to have a probable association with pancreatitis include cimetidine, clozapine, corticosteroids, endoscopic retrograde cholangiopancreatography contrast media, methyldopa, metronidazole, salicylates, and zalcitabine. Agents reported to have a questionable association with pancreatitis include acetaminophen, cyclosporine, cytarabine, erythromycin and roxithromycin, ketoprofen, metolazone, and octreotide. When ethanol abuse and biliary disease are ruled out as etiologies for pancreatitis, the possibility of drug-induced disease should be investigated.

Reducing i.v. waste to under 2.25 percent.

Reduction of IV waste is of extreme importance in the maintenance of cost-effective, quality pharmacy services. This report describes the methods undertaken by a large community hospital to decrease IV waste to under 4%. The program uses several techniques including: "status sheets", IV reminder labels, commercial partial fill containers, extensive recycling procedures and close communication between the central IV service, pharmacy satellites and nursing units.