Considerations in pharmaceutical conversion: focus on antihistamines.

The practice of pharmaceutical conversion, which encompasses three types of drug interchange (generic, brand, and therapeutic substitution), is increasing in managed care settings. Pharmaceutical conversion has numerous implications for managed care organizations, their healthcare providers, and their customers. Although drug cost may be a driving consideration in pharmaceutical conversion, a number of other considerations are of equal or greater importance in the decision-making process may affect the overall cost of patient care. Among these considerations are clinical, psychosocial, and safety issues; patient adherence; patient satisfaction; and legal implications of pharmaceutical conversion. Patient-centered care must always remain central to decisions about pharmaceutical conversion. This article discusses the issues related to, and implications of, pharmaceutical conversion utilizing the antihistamines class of drugs as the case situation.

Screening for hypertension in adolescents: the search for normal values.

Appropriate control of adult hypertension is currently challenging our health care system. Evaluation of juvenile hypertension may assist in alleviating this massive medical problem by helping to identify potentially remediable risk factors. Assessment of "normal" blood pressure values for children and adolescents must first be accomplished before attempting modification of "abnormals." A hypertension detection and referral surveyed the blood pressures of 7,498 New Orleans high school students aged 14 to 18, to identify youngsters with high blood pressure and to refer them for further evaluation; to demonstrate the range of adolescent blood pressures in this population; to stimulate cooperative blood pressure screening efforts; and to increase the awareness of hypertension and cardiovascular risk factors. Peer group analysis for age, sex, and race showed some variation and divergence to the "tracking" effect. Black boys, for example, showed a sharp increase in diastolic blood pressures at age 16. Blood pressures greater than the 90th percentile are recommended as criteria for referral for further medical evaluation, and were found in this study to be 140-150/84-90 mm Hg for boys and 130-140/84-90 mm Hg for girls.

The abrupt discontinuation of antihypertensive treatment.

Although deleterious events following abrupt withdrawal of antihypertensive treatment are relatively uncommon, considerable attention has recently been focused on this problem. A withdrawal syndrome may occur after termination of almost all types of antihypertensive drugs, but most experience has been with the centrally acting agents and with beta-adrenoreceptor blockers. Abrupt discontinuation of high doses of centrally acting drugs such as alpha-methyldopa, clonidine, and guanabenz can produce a syndrome of sympathetic overactivity that includes agitation, headache, sweating, and nausea and less commonly can provoke rapid upswings in blood pressure. If beta blockers are suddenly stopped, a similar pattern can occur that may be related to excessive activity of thyroid hormones as well as sympathetic factors. Additionally, patients with ischemic heart disease may be susceptible to an acute exacerbation of their cardiac disease when beta-blocker treatment is stopped. It seems likely that discontinuation events can be particularly severe when combinations of different types of antihypertensive medications are sud-disease when betablocker treatment is denly stopped. This problem can be dealt with by educating patients to avoid sudden drug cessation and when elective discontinuation is planned, by gradual dose reduction.

Hypertension due to renal artery stenosis in transplanted kidneys.

Hypertension appeared to be related to stenosis of the hypogastricrenal artery system in 5 patients among 153 recipients of renal allografts. Renin assay and arteriography were crucial in the comprehensive evaluation of patients whose hypertension was not clearly related to rejection or excessive sodium intake. Hypereninemia was persistent in 4 of the 5 patients. Stenoses of the transplant renal arteries in three patients were caused by extensive intimal plaque formation. In one patient, periarterial fibrosis caused reduction of flow; 180 degrees torsion of the anastomosis resulted in stenosis in the fifth patient. Surgical correction is difficult and may be facilitated by a transabdominal approach. Vein bypass is probably preferable to patch angioplasty for intimal lesions. Following operation, hypertension was ameliorated and function improved in all patients. Rejection, which has been suggested as one of the causes of intimal plaque formation, ultimately led to the loss of the transplant in one patient. Function is normal in two patients; two patients have evidence of chronic rejection. No effort should be spared to evaluate this special group of patients whose transplant function can predictably be prolonged by decisive surgical management.

Guidelines for blood pressure mass screening projects.

Community-wide blood pressure screening is one of many methods of detecting unknown or inadequately treated hypertension. The first mass blood pressure screeing in a major metropolitan area was conducted in New Orleans on Aril 28 and 29, 1973. The 43 public and parochial schools were used as screening sites. Medical volunteers screened 30,329 individuals, 8,953 of whom were referred to their physician for treatment of high blood pressure. This project has shown that with adequate volunteers and publicity, mass screening is feasible and may be the only realistic method of reaching the numerous undetected hypertensives. An added bonus has been the spin-off in public awareness of the problem and its sequelae. A follow-up program for those individuals referred for further evaluation is strongly recommended. Guidelines and suggestions for mass screeings are described for use by medical groups or agencies. The blood pressure data are studied in relation to demographic data to facilitate comprehension of the problem on a larger scale.