- Email: [email protected]
COST-BENEFIT OF SELF PRESCRIBING
281 PATIENTS AND DOSE SCHEDULES
of British doctors. Some might even consider extending their stay and offering more practical help. An Australian surgeon who did just that, and thereby released a hard-pressed medical superintendent for two weeks holiday became known as the Angel of Mercy. Are there no such angels in the UK? 12 Turner Close, London NW11 6TU
ANNE SAVAGE
COST-BENEFIT OF SELF PRESCRIBING
SIR,-Dr Cutting (May 13, p 1080) discusses the risks of selling antidiarrhoeal remedies over-the-counter while Dr Blenkinsopp (June 17, p 1393) recommends that "pharmacists are ideally placed to offer the type of health education advice which is needed". We agree, but wish to add a note of caution. Twenty pharmacists in Newcastle were interviewed about their advice on diarrhoea in childhood. 70% said they would ask about the duration, 45% about stool character, and only 30% would request the age of the child. None would ask about signs of dehydration. Half the pharmacists advised oral rehydration solution (ORS) alone in treatment, and 40% recommended ORS plus kaolin, 50% recommended starvation (which we believe is incorrect according to worldwide experience, even though it is common practice in the UK), and 65% would ask mothers to stop
breastfeeding.
However, pharmacists recognised their own shortcomings, and 90% thought they should have more clinical training in common aihnents. National and local training of this kind should be initiated before reliance is placed on pharmacists to give health advice. Tropical Child Health Unit, Institute of Child Health, London
ELIZABETH GOODBURN SUELY MATTOSINHO PYANDE MONGE
Department of Community Health, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
TONY WATERSTON
ASK YOUR PHARMACIST
SiR,—Your complaint (In England Now, June 3, p 1256), although valid, was published in the wrong journal; the Pharmaceutical _7ournal would have been more fitting. I have heard of a general practitioner who told his manicdepressive patient to stop taking lithium because it interacts with atenolol, which the patient was taking for hypertension. In fact, such an interaction has not been reported to my knowledge. In view of the disastrous consequences of sudden withdrawal of lithium,l one might ask, was the patient given good advice? A few months ago a patient brought in a vial of insulin which had been supplied by a dispensing doctor twelve months after its expiry date. I have learned that a widely used antidepressant is available to dispensing doctors at a handsome discount-thinly veiled bribery to prescribe accordingly. Inter-professional sniping is discreditable. The medical profession would do well to remember the old proverb about glass houses. Pharmacy Department, St Matthew’s Hospital, Walsall, West Midlands WS7 9ES
D. W. BUDDEN
1 Mander AJ, Loudon JB. Rapid recurrence of mania following abrupt discontinuation of lithium. Lancet 1988; ii 15-17
I
of recombinant interleukin-2 (rIL-2) have limited benefit in chronic hepatitis.l-4 High doses may increase production of immunoglobulins from lymphocytes in conjunction with CD4-positive cells. Thus levels of antibody to hepatitis B antigens may be raised. 3,4 We have tried an intermediate-dose rIL-2 over a 12-week period in patients with chronic viral hepatitis. Despite plans to recruit ten patients with chronic hepatitis B and ten with chronic non-A, non-B infection, only two patients in each group were entered. Severe side-effects, including high fever, chills, courses
I
I cases
3 and 4 had
hepatitis
fatiguability, and disabling muscle pain, prompted abandonment of our trial. At first all patients received 100 000 units/kg rIL-2 (kindly supplied by Cetus Corporation) via intravenous bolus three times a week. Adverse effects, however, necessitated modification of dosing schedules in all four patients (table). Complete blood counts, routine liver tests, and prothrombin time were measured every 2 weeks during treatment and every 3 months thereafter. HBeAg, anti-HBe, and anti-HD were measured in patients who were positive for HBsAg. Pre-treatment liver biopsies confirmed the diagnosis of chronic viral hepatitis in all patients. Only two patients completed the 12-week course. By the end of the trial one patient with hepatitis B showed a decrease in ALT (case 2) while the other had a decrease followed by a rise at the end of therapy (case 1). This patient converted to anti-HBe within a year of the completion of therapy with rIL-2. The rise of ALT at the completion of rIL-2 therapy may have heralded HBeAg seroconversion. In one patient with NANB hepatitis ALT activity returned to normal during therapy; however, one year later his ALT activity had risen to pretreatment levels. We conclude that the severity of side-effects makes the use of rIL-2 in its present formulation and in doses we used impractical for outpatient therapy of chronic viral hepatitis. nausea,
Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine of the City University of New York, New York, 10029, USA
NANCY BACH FENTON SCHAFFNER
Division of Gastroenterolgy and Liver Diseases, Department of Medicine, Mackay Memorial Hospital, Taipei, Taiwan
SHEE-CHAN LIN
M, Kagawa H, Shirai M, et al. Effects of human recombinant interleukin-2 in patients with chronic hepatitis B: a preliminary report. Am J Gastroenterol 1987; 82: 438-42. 2. Kakumu S, Fuji A, Yoshika K, et al. Pilot study of recombinant human interleukin-2 for chronic type B hepatitis. Hepatology 1988; 8: 487-92. 3. Onji M, Kondoh H, Horiike N, et al. Effects of recombinant interleukin-2 on hepatitis Be antigen positive chronic hepatitis. Gut 1987; 28: 1648-52. 4. Ralph P, Jeong G, Welte K, et al. Stimulation of immunoglobulin secretion in human B lymphocytes as a direct effect of high concentrations of IL-2. J Immunol 1984; 133: 2442-45. 1. Nishioka
DIGOXIN IN HEART FAILURE
HIGH-DOSE RECOMBINANT INTERLEUKIN-2 FOR CHRONIC VIRAL HEPATITIS
SIR,-Short
I
*Cases 1 and 2 had hepatitis B (HBaAg and HBeAg positive); NANB tAs U/kg 3, 2, or 1 times a week, for 1-9 weeks.
SiR,—Your editorial on digoxin (July 8, p 79) does not comment the limitations of recent trials with digoxin for the treatment of heart failure or on controversy concerning an increased mortality after myocardial infarction. The charge against digoxin is not that it has no benefit in selected groups of patients-for example, those with some degree of fluid overload and suboptimum treatment with diuretics-but that the drug is less effective and safe than alternative treatments such as the appropriate use of diuretics and angiotensin converting enzyme (ACE) inhibitors, and may be largely redundant.1,2 on
of British doctors. Some might even consider extending their stay and offering more practical help. An Australian surgeon who did just that, and thereby released a hard-pressed medical superintendent for two weeks holiday became known as the Angel of Mercy. Are there no such angels in the UK? 12 Turner Close, London NW11 6TU
ANNE SAVAGE
COST-BENEFIT OF SELF PRESCRIBING
SIR,-Dr Cutting (May 13, p 1080) discusses the risks of selling antidiarrhoeal remedies over-the-counter while Dr Blenkinsopp (June 17, p 1393) recommends that "pharmacists are ideally placed to offer the type of health education advice which is needed". We agree, but wish to add a note of caution. Twenty pharmacists in Newcastle were interviewed about their advice on diarrhoea in childhood. 70% said they would ask about the duration, 45% about stool character, and only 30% would request the age of the child. None would ask about signs of dehydration. Half the pharmacists advised oral rehydration solution (ORS) alone in treatment, and 40% recommended ORS plus kaolin, 50% recommended starvation (which we believe is incorrect according to worldwide experience, even though it is common practice in the UK), and 65% would ask mothers to stop
breastfeeding.
However, pharmacists recognised their own shortcomings, and 90% thought they should have more clinical training in common aihnents. National and local training of this kind should be initiated before reliance is placed on pharmacists to give health advice. Tropical Child Health Unit, Institute of Child Health, London
ELIZABETH GOODBURN SUELY MATTOSINHO PYANDE MONGE
Department of Community Health, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
TONY WATERSTON
ASK YOUR PHARMACIST
SiR,—Your complaint (In England Now, June 3, p 1256), although valid, was published in the wrong journal; the Pharmaceutical _7ournal would have been more fitting. I have heard of a general practitioner who told his manicdepressive patient to stop taking lithium because it interacts with atenolol, which the patient was taking for hypertension. In fact, such an interaction has not been reported to my knowledge. In view of the disastrous consequences of sudden withdrawal of lithium,l one might ask, was the patient given good advice? A few months ago a patient brought in a vial of insulin which had been supplied by a dispensing doctor twelve months after its expiry date. I have learned that a widely used antidepressant is available to dispensing doctors at a handsome discount-thinly veiled bribery to prescribe accordingly. Inter-professional sniping is discreditable. The medical profession would do well to remember the old proverb about glass houses. Pharmacy Department, St Matthew’s Hospital, Walsall, West Midlands WS7 9ES
D. W. BUDDEN
1 Mander AJ, Loudon JB. Rapid recurrence of mania following abrupt discontinuation of lithium. Lancet 1988; ii 15-17
I
of recombinant interleukin-2 (rIL-2) have limited benefit in chronic hepatitis.l-4 High doses may increase production of immunoglobulins from lymphocytes in conjunction with CD4-positive cells. Thus levels of antibody to hepatitis B antigens may be raised. 3,4 We have tried an intermediate-dose rIL-2 over a 12-week period in patients with chronic viral hepatitis. Despite plans to recruit ten patients with chronic hepatitis B and ten with chronic non-A, non-B infection, only two patients in each group were entered. Severe side-effects, including high fever, chills, courses
I
I cases
3 and 4 had
hepatitis
fatiguability, and disabling muscle pain, prompted abandonment of our trial. At first all patients received 100 000 units/kg rIL-2 (kindly supplied by Cetus Corporation) via intravenous bolus three times a week. Adverse effects, however, necessitated modification of dosing schedules in all four patients (table). Complete blood counts, routine liver tests, and prothrombin time were measured every 2 weeks during treatment and every 3 months thereafter. HBeAg, anti-HBe, and anti-HD were measured in patients who were positive for HBsAg. Pre-treatment liver biopsies confirmed the diagnosis of chronic viral hepatitis in all patients. Only two patients completed the 12-week course. By the end of the trial one patient with hepatitis B showed a decrease in ALT (case 2) while the other had a decrease followed by a rise at the end of therapy (case 1). This patient converted to anti-HBe within a year of the completion of therapy with rIL-2. The rise of ALT at the completion of rIL-2 therapy may have heralded HBeAg seroconversion. In one patient with NANB hepatitis ALT activity returned to normal during therapy; however, one year later his ALT activity had risen to pretreatment levels. We conclude that the severity of side-effects makes the use of rIL-2 in its present formulation and in doses we used impractical for outpatient therapy of chronic viral hepatitis. nausea,
Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine of the City University of New York, New York, 10029, USA
NANCY BACH FENTON SCHAFFNER
Division of Gastroenterolgy and Liver Diseases, Department of Medicine, Mackay Memorial Hospital, Taipei, Taiwan
SHEE-CHAN LIN
M, Kagawa H, Shirai M, et al. Effects of human recombinant interleukin-2 in patients with chronic hepatitis B: a preliminary report. Am J Gastroenterol 1987; 82: 438-42. 2. Kakumu S, Fuji A, Yoshika K, et al. Pilot study of recombinant human interleukin-2 for chronic type B hepatitis. Hepatology 1988; 8: 487-92. 3. Onji M, Kondoh H, Horiike N, et al. Effects of recombinant interleukin-2 on hepatitis Be antigen positive chronic hepatitis. Gut 1987; 28: 1648-52. 4. Ralph P, Jeong G, Welte K, et al. Stimulation of immunoglobulin secretion in human B lymphocytes as a direct effect of high concentrations of IL-2. J Immunol 1984; 133: 2442-45. 1. Nishioka
DIGOXIN IN HEART FAILURE
HIGH-DOSE RECOMBINANT INTERLEUKIN-2 FOR CHRONIC VIRAL HEPATITIS
SIR,-Short
I
*Cases 1 and 2 had hepatitis B (HBaAg and HBeAg positive); NANB tAs U/kg 3, 2, or 1 times a week, for 1-9 weeks.
SiR,—Your editorial on digoxin (July 8, p 79) does not comment the limitations of recent trials with digoxin for the treatment of heart failure or on controversy concerning an increased mortality after myocardial infarction. The charge against digoxin is not that it has no benefit in selected groups of patients-for example, those with some degree of fluid overload and suboptimum treatment with diuretics-but that the drug is less effective and safe than alternative treatments such as the appropriate use of diuretics and angiotensin converting enzyme (ACE) inhibitors, and may be largely redundant.1,2 on