Subcutaneous enoxaparin for outpatient anticoagulation therapy in a patient with an aortic valve replacement.

Low-molecular-weight heparins have been administered for a variety of clinical conditions. A patient with a mechanical aortic valve replacement patient underwent elective transurethral prostatectomy. Anticoagulation was managed with unfractionated heparin immediately preoperatively and postoperatively. Warfarin was begun on postoperative day 1. The patient had a prolonged hospitalization due to subtherapeutic international normalized ratios (INR) despite warfarin administration. Because he intended to leave the hospital against medical advice before therapeutic INR was achieved, enoxaparin 1 mg/kg subcutaneously every 12 hours was prescribed to provide anticoagulation, facilitating discharge and improving the patient's quality of life. Enoxaparin was associated with an approximate saving of $4500 over warfarin. The only adverse event reported was bruising at the injection site.

Drug-use review program for concurrent histamine H2-receptor antagonist-sucralfate therapy.

The effect of drug-use review on concomitant histamine H2-receptor antagonist-sucralfate therapy at a 600-bed, university-affiliated Veterans Affairs medical center was studied. In an effort to curtail the concomitant use of H2-antagonist plus sucralfate therapy, the department of pharmacy, in conjunction with the gastroenterology service, developed and introduced criteria for the appropriate use of combination therapy. The extent of prescribing of concomitant histamine H2-receptor antagonist-sucralfate therapy before and after implementation of criteria-based guidelines and the appropriateness of current H2-receptor antagonist-sucralfate combination therapy, based on the guidelines, were assessed. The effectiveness of the intervention process was evaluated, and cost savings associated with intervention were calculated. After intervention, the number of treatment courses of histamine H2-receptor antagonist-sucralfate combination therapy decreased by 30%. However, of the 109 evaluable postintervention combination treatment courses, only one complied with both the indication and the duration of treatment criteria. This review of prescribing patterns and the implementation of criteria-based guidelines proved an effective means of reducing inappropriate combination therapy and resulted in annual cost savings of $25,000.

Misoprostol: a prostaglandin E1 analogue.

The pharmacology, pharmacokinetics, clinical efficacy, contraindications and precautions, adverse effects, dosage, and cost of misoprostol are reviewed. Misoprostol is a synthetic analogue of natural prostaglandin E1. It produces a dose-related inhibition of gastric acid and pepsin secretion and enhances mucosal resistance to injury. Misoprostol is extensively absorbed from the stomach and undergoes rapid de-esterification to its biologically active metabolite, misoprostol acid. The average absorption after an oral dose is 88%; peak plasma concentrations of misoprostol acid are achieved in less than 30 minutes. Clinical trials have demonstrated ulcer healing rates of approximately 60-80% in patients with duodenal ulcers who received misoprostol 800 micrograms daily for four weeks. Misoprostol was generally no more efficacious than conventional therapy with the H2-receptor antagonists cimetidine and ranitidine. The healing rate observed for gastric ulcers was less than that observed for duodenal ulcers. In trials involving healthy volunteers and patients with arthritis receiving aspirin, naproxen, tolmetin, ibuprofen, or piroxicam, misoprostol was consistently superior to placebo, cimetidine, and sucralfate in the prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced gastropathy. The majority of these studies have been of short duration; however, long-term studies (up to three months) have corroborated superiority over placebo. Misoprostol is an abortifacient and is contraindicated in pregnant women and women of childbearing potential not using effective contraception. The most common adverse effect of misoprostol therapy is diarrhea, which is often mild and self-limiting and can be minimized by administration of misoprostol after meals and at bedtime. The cost (based on retail price) of four weeks of therapy with misoprostol is comparable to that of other antiulcer agents. Misoprostol has been shown to be an effective agent for the prevention of NSAID-induced gastric ulcers. However, there is no evidence that it offers any clinical advantage over H2-receptor antagonists for the treatment of gastric or duodenal ulcer disease.