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Overprescribing of benzodiazepine hypnotic drugs in the elderly
CORRESPONDENCE
tween patient age and the number of doses of benzodiazepine hypnotic drugs prescribed at a single physician visit. The hospital in which this study was performed, however, had no such limitations on minimum quantities prescribed. ANDREW LLOYD, M.B., B.S. We did not intend our findings IAN HICKIE, M.D. to implicate community physiDENIS WAKEFIELD,M.D. cians, but our results suggest that JOHN D WYER,M.B., B.S.,ph.0 Sydney, Australia the prescribing of sedative-hypnotic drugs should be studied in 1. Oxtoby A, Jones A, Robinson M. Is your ‘doubleblind’ design truly double-blind? Br J Psychiatry other outpatient settings.
I was particularly disturbed by the addendum to the article in which the authors indicate that they have discontinued the evaluation of pulse cyclophosphamide therapy in WG. What the Hoffman study illustrates is that patients with relapsing disease may respond poorly to pulse cyclophosphamide. There is inadequate information to extend this conclusion to patients who present with new-onset disease. Because long-term, oral cyclophos1989; 155: 700-l. RONALD I. SHORR,M.D.,MS. phamide may be quite toxic, I am Nashville, Tennessee disappointed that Dr. Hoffman C.SETHLANDEFELD,M.D. Cleveland, Ohio has elected to discontinue evaluOVERPRESCRIBINGOF STEVENF. BAUWENS,P~~~~.D. ating pulse cyclophosphamide. In South Bend, Indiana an earlier report by Fauci et al BENZODIAZEPINEHYPNOTIC [2], 34% of recipients of oral cyDRUGSIN THE ELDERLY To The Editor: clophosphamide were noted to PULSECYCLOPHOSPHAMIDE develop cystitis. In a more recent In the December 1990 issue, THERAPYFORWEGENER’S Shorr et al [l] went to great study, 47% of patients with WG who received long-term cyclolengths to demonstrate that ben- GRANULOMATOSIS phosphamide developed microzodiazepine hypnotic drugs are To The Editor: being overprescribed in the elderHoffman and associates [l] re- scopic hematuria [3]. In addition port that intermittent high-dose to hemorrhagic cystitis, longly. Their data suggest the elderly (pulse) cyclophosphamide does term cyclophosphamide adminisreceive quantitatively larger prescriptions for these drugs. not induce lasting remissions in tration is clearly associated with I suggest they have overlooked Wegener’s granulomatosis (WG). urothelial neoplasms [4]. This prospective, noncontrolled The present study by Hoffman an important factor. Prescripquestions retions plans that mandate that 3 trial evaluated 14 patients, 12 of raises important months’ supply of medicine be whom were being retreated in a garding management of relapsing prescribed are much more ramsalvage protocol. In fact, eight of WG. To suggest that pulse cyclopant amongst the elderly. It is an 14 (57%) of the patients were said phosphamide should not be evalunfortunate fact that prescripto have relapsing WG. Their uated for efficacy as an initial study indicated that when this treatment of patients with WG is tion design is often dictated by these prescription plans. Their group of patients was treated inappropriate based on the preindictment of the physician com- with pulse cyclophosphamide, an sented data. This study raises immunity is probably incorrect. initial response was frequently portant questions regarding the NICHOLASJ.BELITSOS,M.D., followed by a relapse of WG. use of intravenous versus oral cyF.A.C.G. They concluded that “daily lowclophosphamide, but the findings Baltimore, Maryland dose cyclophosphamide and glu- do not warrant suspending the 1. Shorr RI. Bauwens SF, Landefeld CS. Failure to cocorticoids remain the treatevaluation of pulse cyclophoslimit quantities of benzodiazepine hypnotic drugs for ment of choice for this disease.” phamide for initial management outpatients: placing the elderly at risk. Am J Med 1990; 89: 725-32. What this study does indicate is of WG. that patient8 with relapsing WG JOHNS. COWDERY,M.D. Submitted January 4. 1991, and accepted March University of Iowa College of 13. 1991 may be unresponsive to pulse cyMedicine clophosphamide administration. Iowa City, Iowa The Reply: Treatment was categorized as 1. Hoffman GS, Leavitt RY. Fleisher TA, Manor JR, We appreciate Dr. Belitsos’ com- having failed in the two patients Fauci AS. Treatment of Wegener’s granulomatosis ments. We agree that if our study with new-onset WG. The authors with intermittent high-dose intravenous cyclophoshad been performed in a commuindicate that treatment was con- phamide. Am J Med 1990; 89: 403-10. nity setting, membership in cer- sidered to have failed after 3 2. Fauci AS, Hayes BF, Katz P, Wolff SM. Wegener’s granulomatosis: prospective and therapeutic expetain prescription plans would be weeks in these two patients. This rience with 85 patients for 21 years. Ann Intern Med an important potential conmay be too early to make a final 1983; 98: 76-85. founder in the relationship be- assessment. 3. Stillwell TJ. Benson RC Jr, DeRemee RA. McDoncompletion of treatment, a time point specifically chosen to allow resolution of the transient adverse effects, to minimize placebo response, and to provide a conservative estimate of the beneficial effect of immunoglobulin therapy.
September 1991 The American Journal of Medicine
Volume 91
321
tween patient age and the number of doses of benzodiazepine hypnotic drugs prescribed at a single physician visit. The hospital in which this study was performed, however, had no such limitations on minimum quantities prescribed. ANDREW LLOYD, M.B., B.S. We did not intend our findings IAN HICKIE, M.D. to implicate community physiDENIS WAKEFIELD,M.D. cians, but our results suggest that JOHN D WYER,M.B., B.S.,ph.0 Sydney, Australia the prescribing of sedative-hypnotic drugs should be studied in 1. Oxtoby A, Jones A, Robinson M. Is your ‘doubleblind’ design truly double-blind? Br J Psychiatry other outpatient settings.
I was particularly disturbed by the addendum to the article in which the authors indicate that they have discontinued the evaluation of pulse cyclophosphamide therapy in WG. What the Hoffman study illustrates is that patients with relapsing disease may respond poorly to pulse cyclophosphamide. There is inadequate information to extend this conclusion to patients who present with new-onset disease. Because long-term, oral cyclophos1989; 155: 700-l. RONALD I. SHORR,M.D.,MS. phamide may be quite toxic, I am Nashville, Tennessee disappointed that Dr. Hoffman C.SETHLANDEFELD,M.D. Cleveland, Ohio has elected to discontinue evaluOVERPRESCRIBINGOF STEVENF. BAUWENS,P~~~~.D. ating pulse cyclophosphamide. In South Bend, Indiana an earlier report by Fauci et al BENZODIAZEPINEHYPNOTIC [2], 34% of recipients of oral cyDRUGSIN THE ELDERLY To The Editor: clophosphamide were noted to PULSECYCLOPHOSPHAMIDE develop cystitis. In a more recent In the December 1990 issue, THERAPYFORWEGENER’S Shorr et al [l] went to great study, 47% of patients with WG who received long-term cyclolengths to demonstrate that ben- GRANULOMATOSIS phosphamide developed microzodiazepine hypnotic drugs are To The Editor: being overprescribed in the elderHoffman and associates [l] re- scopic hematuria [3]. In addition port that intermittent high-dose to hemorrhagic cystitis, longly. Their data suggest the elderly (pulse) cyclophosphamide does term cyclophosphamide adminisreceive quantitatively larger prescriptions for these drugs. not induce lasting remissions in tration is clearly associated with I suggest they have overlooked Wegener’s granulomatosis (WG). urothelial neoplasms [4]. This prospective, noncontrolled The present study by Hoffman an important factor. Prescripquestions retions plans that mandate that 3 trial evaluated 14 patients, 12 of raises important months’ supply of medicine be whom were being retreated in a garding management of relapsing prescribed are much more ramsalvage protocol. In fact, eight of WG. To suggest that pulse cyclopant amongst the elderly. It is an 14 (57%) of the patients were said phosphamide should not be evalunfortunate fact that prescripto have relapsing WG. Their uated for efficacy as an initial study indicated that when this treatment of patients with WG is tion design is often dictated by these prescription plans. Their group of patients was treated inappropriate based on the preindictment of the physician com- with pulse cyclophosphamide, an sented data. This study raises immunity is probably incorrect. initial response was frequently portant questions regarding the NICHOLASJ.BELITSOS,M.D., followed by a relapse of WG. use of intravenous versus oral cyF.A.C.G. They concluded that “daily lowclophosphamide, but the findings Baltimore, Maryland dose cyclophosphamide and glu- do not warrant suspending the 1. Shorr RI. Bauwens SF, Landefeld CS. Failure to cocorticoids remain the treatevaluation of pulse cyclophoslimit quantities of benzodiazepine hypnotic drugs for ment of choice for this disease.” phamide for initial management outpatients: placing the elderly at risk. Am J Med 1990; 89: 725-32. What this study does indicate is of WG. that patient8 with relapsing WG JOHNS. COWDERY,M.D. Submitted January 4. 1991, and accepted March University of Iowa College of 13. 1991 may be unresponsive to pulse cyMedicine clophosphamide administration. Iowa City, Iowa The Reply: Treatment was categorized as 1. Hoffman GS, Leavitt RY. Fleisher TA, Manor JR, We appreciate Dr. Belitsos’ com- having failed in the two patients Fauci AS. Treatment of Wegener’s granulomatosis ments. We agree that if our study with new-onset WG. The authors with intermittent high-dose intravenous cyclophoshad been performed in a commuindicate that treatment was con- phamide. Am J Med 1990; 89: 403-10. nity setting, membership in cer- sidered to have failed after 3 2. Fauci AS, Hayes BF, Katz P, Wolff SM. Wegener’s granulomatosis: prospective and therapeutic expetain prescription plans would be weeks in these two patients. This rience with 85 patients for 21 years. Ann Intern Med an important potential conmay be too early to make a final 1983; 98: 76-85. founder in the relationship be- assessment. 3. Stillwell TJ. Benson RC Jr, DeRemee RA. McDoncompletion of treatment, a time point specifically chosen to allow resolution of the transient adverse effects, to minimize placebo response, and to provide a conservative estimate of the beneficial effect of immunoglobulin therapy.
September 1991 The American Journal of Medicine
Volume 91
321