Helicobacter pylori-related disease: guidelines for testing and treatment.

OBJECTIVE: To develop practical guidelines for the treatment of patients with suspected and documented Helicobacter pylori-related gastroduodenal diseases. METHODS: A panel of physicians with expertise in H. pylori reviewed, critically appraised, and synthesized the literature on assigned topics and presented their overviews to the panel. Consensus was obtained in controversial areas through discussion. RESULTS AND CONCLUSIONS: The panel recommended testing for H. pylori in patients with active ulcers, a history of ulcers, or gastric mucosa-associated lymphoid tissue lymphomas. Young, otherwise healthy patients with ulcerlike dyspepsia and those with a family history or fear of gastric cancer may also undergo H pylori testing. Non-endoscopic methods are preferred for H. pylori diagnosis. Dual medication regimens should not be used for therapy; twice-daily triple therapy with a proton pump inhibitor or ranitidine bismuth citrate, clarithromycin, and amoxicillin for 10 to 14 days is an appropriate therapy. Posttreatment assessment of H. pylori status using urea breath testing should be considered in patients with a documented history of ulcer disease or with persistent symptoms.

Identification, diagnosis, and treatment of acid-related diseases in the elderly: implications for long-term care.

Acid-related disorders such as peptic ulcer disease and gastroesophageal reflux disease occur frequently in the elderly and are associated with a high frequency of morbidity and mortality. The proton pump inhibitors lansoprazole and omeprazole produce faster rates of healing and greater symptomatic relief in patients with acid-related disorders than histamine2-receptor antagonists, are well tolerated, and are associated with few adverse events. Compared with omeprazole, which interacts with diazepam, warfarin, and phenytoin, lansoprazole produces only a minor increase in theophylline clearance. Proton pump inhibitors in combination with antibiotic therapy can eradicate Helicobacter pylori, the main risk factor in the recurrence of peptic ulcer disease, obviating the need for maintenance therapy. Long-term acid suppression with proton pump inhibitors may be necessary to prevent the recurrence of gastroesophageal reflux disease. The safety and efficacy profile of these agents makes them ideal for the treatment of acid-related diseases in elderly patients.

Current treatment of gram-positive infections: focus on efficacy, safety, and cost minimalization analysis of teicoplanin.

The current health care environment has had a significant impact on hospital Pharmacy and Therapeutics Committee formulary decisions. In evaluating a new therapy for formulary inclusion, a cost savings along with equivalent or an improvement in patient care and safety is optimal. Teicoplanin is an investigational glycopeptide antimicrobial agent with a spectrum of activity similar to vancomycin. Unlike vancomycin, however, teicoplanin has a long elimination half-life permitting administration once daily, and is well tolerated when given intramuscularly. In addition, teicoplanin is associated with a favorable safety profile. Red man syndrome does not appear to be a significant clinical problem. Results of our cost minimalization analysis using the average acquisition costs of vancomycin revealed that teicoplanin (400 mg), at an average acquisition cost of less than $28.46 when administered intravenously and $30.93 when administered intramuscularly, offers a clinically efficacious, safe, and less expensive alternative to vancomycin therapy.

Pharmacologic management of endometriosis.

The incidence, pathogenesis, staging, and treatment of endometriosis are reviewed, with an emphasis on pharmacologic management of this condition. Endometriosis--the presence of ectopic endometrial tissue--can be found in 15-25% of infertile women and may be found in 1-5% of all women between menarche and menopause. Although the pathogenesis of endometriosis is uncertain, the most tenable etiologic theory is a combination of celomic metaplasia and retrograde menstruation. Staging is based on the American Fertility Society classification scheme, with stage I being the mildest and stage IV the most severe form of the disease. The management of endometriosis depends on the extent of the disease, the severity of the symptoms, the age of the patient, and the patient's desire for future fertility. Treatment modalities include expectant management, surgery, induction of a pseudopregnancy state with hormonal therapy (e.g., oral contraceptives), or induction of a pseudomenopausal state. The induction of a pseudomenopausal state with the use of oral danazol gained widespread favor in the 1970s as the treatment of choice in patients with endometriosis, but therapy is often associated with unpleasant adverse effects. Gonadotropin-releasing hormone (GnRH) agonists may provide a safe and clinically effective alternative to danazol therapy in patients with endometriosis. Results of a multicenter study comparing nafarelin with danazol for treatment of endometriosis indicated no significant differences between treatment groups with respect to improvements in disease state and symptomatology. The most common adverse effect associated with nafarelin therapy is hot flashes. The GnRH agonist nafarelin is as effective as danazol or oral contraceptives for the treatment of endometriosis and causes fewer adverse reactions. GnRH agonists may replace danazol as the treatment of choice in patients with endometriosis.

PIP: The medical management of endometriosis depends on the stage of the disease, the severity of symptoms, the age of the patient, and her future fertility intentions. The most widely utilized treatment modalities are expectant management, surgery, induction of a pseudopregnancy state with hormonal therapy, and induction of a pseudomenopausal state. Over 50% of women with mild endometriosis and 25% of those with moderate disease can conceive without surgical or pharmacologic intervention. Total hysterectomy or bilateral salpingo-oophorectomy represent the only curative form of treatment, but definitive surgery is recommended only in women who do not want to retain their reproductive function or in whom all previous medical and surgical efforts have failed. Pseudopregnancy therapy (administration of low-dose combined oral contraceptives or medroxyprogesterone acetate) eliminates cyclical changes in the endometrium and bleeding, but is associated with the side effects common to these agents and carries a 5-10% annual recurrence rate. During the 1970s, induction of a pseudomenopausal state through administration of oral danazol was the treatment of choice. In dosages of 100-800 mg day, danazol produces symptomatic improvement in 70-95% of patients and disease regression in 8595%; however, recurrence rates as high as 30-40% have been reported, and weight gains of 20-30 pounds are common. Recent studies have shown the gonadotropin releasing hormone agonist nafarelin to be as effective as danazol or combined oral contraceptives for the treatment of endometriosis. Hot flashes are the most common adverse effect, but are tolerated by the majority of patients. Nafarelin has the additional advantage of not requiring intramuscular injection or monthly office visits, but patients must be given detailed instructions about its intranasal administration.

Tetracyclines in urology: current concepts.

Tetracyclines have an unusually broad spectrum of antimicrobial activity. They are generally well tolerated, with relatively few side effects compared with alternative antibiotic choices. Tetracyclines also compare favorably with newer antimicrobials, i.e., oral quinolones, with respect to cost and microbial resistance. Doxycycline's and minocycline's spectrum of antibacterial activity, pharmacokinetic profile, and safety profile make them preferred drugs when tetracyclines are indicated in urologic infections.

Drug-induced jaundice. An uncommon but puzzling reaction.

Drug-induced jaundice is relatively uncommon but can be a diagnostic puzzle. Because so many pharmaceutical classes and individual agents can produce jaundice, a thorough history of medications taken should be obtained from a patient presenting with jaundice. Jaundice usually resolves when the offending agent is discontinued.

Monitoring of drug-drug and drug-food interactions.

A program for detecting and preventing potentially serious drug-drug and drug-food interactions is described. Two clinical pharmacists developed drug interaction alert (DIA) cards for each potential interaction to be monitored. The cards contain information about the proposed mechanism and potential result of the interaction, as well as information about how to monitor or circumvent the interaction. Staff pharmacists check for the occurrence of potential interactions daily as they verify the filling of the patient-medication cassettes; a poster of all the interactions that are included in the program is posted in each satellite pharmacy to serve as a quick reference for the pharmacists. When a pharmacist detects a potential interaction, he or she completes a DIA card and places it in the medication cassette drawer (if the notice is directed to the nurse) or on the front of the patient's chart (if the notice is directed to the physician). The program was introduced to hospital personnel through inservice education programs and departmental newsletters. The results of a quality assurance review indicated that 95 of 279 (34%) cards dispensed to nurses and 40 of 49 (82%) cards dispensed to physicians resulted in some form of action. The program to detect and prevent potentially serious drug-drug and drug-food interactions has been successful.

Drug and nutrient interactions.

The pharmacokinetic and pharmacodynamic parameters of many commonly used drugs can be affected by diet. Conversely, nutritional status can be altered by various medications. These interactions become clinically significant when they alter the intended response to a drug or impair the patient's nutritional status.

Cost-justification of a clinical pharmacist-managed anticoagulation clinic.

A cost-benefit evaluation of a clinical pharmacist-managed anticoagulation clinic (AC) was performed. Outpatient and hospital records were examined for 26 patients in the treatment group with an AC clinic and 26 patients in the control group. Therapeutic prothrombin times were maintained within the treatment group to a significantly greater extent than within the control group (p less than 0.001). The AC was successful in preventing hospitalizations resulting from hemorrhage or thromboembolism (p less than 0.01). The abnormal prothrombin times on admission in the control group correlated with hemorrhagic and thromboembolic admissions (p less than 0.05, p less than 0.005, respectively). Patients were hospitalized 3.22 days and .048 days per patient-treatment-year in the control and treatment groups, respectively. The net savings in reduced hospitalization costs per year in the treatment group was $211776. The benefit:cost ratio (B:C) was 6.55, suggesting the program is socially valuable. This clinical pharmacist-managed AC was effective in maintaining therapeutic prothrombin times, and reducing the incidence of hospitalization resulting from anticoagulation complications, and can be cost-justified based on a cost-benefit analysis.

Patient compliance.

Compliance is a highly individual phenomenon, and the decision to comply is a dynamic process. The physician who wishes to respond to compliance problems must offer behavioral strategies that are tailored to the individual patient and are continuously applied. Compliance behavior is complex and multifactorial. No single compliance-improving strategy is as effective as multiple approaches within the context of a good physician-patient relationship.

Adverse effects secondary to baclofen withdrawal.

Drug therapy is now the preferred method of treatment for spasticity, and several effective agents have been developed. The safety and efficacy of these drugs has been established in short-term studies. Overall, due to its low incidence of sedation and serious side effects, baclofen appears to be the drug of choice in the treatment of spinal cord-related spasticity. It is, however, not without its side effects due to both its administration and abrupt withdrawal. This case illustrates some significant problems associated with the abrupt withdrawal of long-term baclofen therapy in a patient with multiple sclerosis.

Retrospective evaluation of a pharmacist-managed warfarin anticoagulation clinic.

The effectiveness of a pharmacist-managed warfarin anticoagulation clinic in maintaining therapeutic prothrombin times and preventing hospitalizations secondary to inadequate control of anticoagulation was evaluated. Patients who had received warfarin sodium for at least one year before being referred to the anticoagulation clinic were studied using retrospective chart reviews. Clinical pharmacists provided patient education, monitored patients for hemorrhagic and thromboembolic complications, and adjusted warfarin sodium dosage to maintain therapeutic prothrombin times. The patients' primary physicians retained responsibility for overall care and were consulted by pharmacists regarding complications of anticoagulation and patient unreliability. The percentage of patients requiring hospitalization (39% versus 4%) and the percentage of prothrombin times outside the therapeutic range (35.8% versus 14.4%) were significantly higher during the preclinic phase (before referral to the clinic) than during the clinic phase. Eight patients were hospitalized for hemorrhagic complications and four for thromboembolism during the preclinic phase; only one hospitalization for hemorrhage occurred during the clinic phase. The warfarin anticoagulation clinic staffed by specially trained pharmacists provided improved therapy compared with treatment received by patients before their referral to the clinic.