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Pharmacy and Podiatry—Interprofessional Relations
Pharmacy and PodiatryInterprofessional Relations By Ara H. Der Marderosian
Ara H. Der Marderosian is an associate professor of pharmacognosy at Philadelphia College of Pharmacy and Science, lecturer in pharmacology at Pennsylvania College of Podiatry and adjunct associate professor of pharmacology at the University of Pennsylvania College of Veterinary Medicine. Having earned his PhD in pharmaceutical sciences at the University of Rhode Island, Der Marderosian has given numerous lectures and written many articles for professional publications. He is a member of Massachusetts and Rhode Island pharmaceutical associations and the Philadelphia APhA Chapter. His research interests are in the areas of hallucinogenic botanicals, medicinal and poisonous plants; marine pharmaceuticals and their phytochemistry and pharmacology.
n this era of continued interprofessional interdependence there arises a need for greater communication between allied members of the health team. Such is the status between podiatry and pharmacy today. These professions have long espoused the same high ethical and philosophical goals with the ultimate aim of greater service to the public. For many years now the profession of podiatry has sought to elevate its status and promote a good working relationship with pharmacy. The concept of preventative medicine, the population explosion and the rise in geriatric treatment have fostered a greater importance and dependence on this specialty as well as others. This in turn has created a greater need for closer collaboration and interprofessional liaison between podiatry and pharmacy which is one of the reasons for the preparation of this article. Many of the ideas presented here grew from a joint effort of the American Pharmaceutical Association and the American Podiatry Association liaison committee which has met several times at the national offices of both organizations in Washington, D.C. To better understand the current status of podiatry, it will be instructive to review a few facts about the profession. Podiatry (chiropody is a synonymous but older term) is the health service concerned with the care of the human foot in health and disease. By virtue of his training the doctor of podiatric medicine is able to diagnose and treat diseases of the foot
I
by medical, surgical and other appropriate methods. While history records the early neglect of foot disorders and their treatment, a few individuals on an itinerant basis provided some foot care service. This was a transplanting from abroad of a serviCe provided there to the upper classes, having emerged as a "specialty" from the guild of barbersurgeons. In 1846 Nehemiah Kenison opened an office in.Boston. However, two other chiropodists had opened offices earlier~Julius Davidson in Philadelphia in 1841 and John Littlefield in New York in 1843. Kenison is recognized as the outstanding pioneer because he trained others who established "Kenison offices" in 10 cities in the United States. Later, in 1862, Abraham Lincoln's personal foot doctor (and confidant) , Isachar Zacharie, wrote a treatise on "Surgical and Practical Observations on Diseases of the Foot." However, it was not until 1895 that the first laws regulating the practice of the profession of podiatry were enacted in New York State. By 1912, the national association, now known as the American Podiatry Association, and two colleges began to broaden the profession's educational program and scope of activities. These efforts led to the establishment of practice acts in many states and allowed the contributions of podiatry to become more significant. In 1939, the Judicial Council of the American Medical Association stated
that podiatry was a practice related to medicine much like dentistry, pharmacy and nursing were. Further, the council stated, "General opinion seems to be that chiropody fairly well satisfies a gap in medical care that the (medical) profession has failed to fill." Today, more than 8,500 podiatrists in the United States serve in private practice, the Armed Forces, government installations, hospitals, nursing homes and many other institutions. Almost all of these podiatrists have graduated from any one of five colleges of podiatry in existence today and all are accredited by the Council on Education of the American Podiatry Association. They include the California College of Podiatric Medicine, the Illinois College of Podiatric Medicine, the M.J. Lewi College of Podiatry (New York), the Ohio College of Podiatric Medicine and the Pennsylvania College of Podiatric Medicine. All of the colleges are independent, incorporated, nonprofit institutions and are governed by charters, supervised by boards of trustees and regulated by the respective state departments of education. All are listed in the Directory of Institutions of Higher Education of the U.S. Department of Health, Education and Welfare. 1 The association's Council on Education is a national accrediting agency recognized by the U.S. Department of Health, Education, and Welfare, Office of Education, and the National Commission on Accrediting. These institutions offer a four-year professional course of didactic, laboratory and clinical instruction. A minimum of two years of undergraduate instruction of prescribed courses in an approved college of liberal arts and sciences is required prior to admission to a college of podiatry. In recent years the majority of students possess a baccalaureate degree. The full program of instruction is four years and includes over 4,200 clock hours of course work. The first two years are devoted mainly to the basic biological Vol. NSll, No. 4, April 1971
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sciences such as anatomy, histology, embryology, physiology, biochemistry, microbiology, pharmacology, neurology and pathology (with some premedical podiatry orientation courses, radiology and public health included). The last two years include the clinical subjects such as orthopedics, internal medicine, dermatology, roentgenology, peripheral vascular diseases and surgery, among others, which concentrate on relating these subjects to actual practice of the profession. 1- 4 A number of internships and residences are available for podiatrists throughout the country also. In fact, internships are required for licensure in New Jersey, Rhode Island and Michigan. Postgraduate training programs are offered by all the podiatry colleges. The geographic distribution of podiatrists is not uniform throughout the United States. There are eight states which include 72 percent of all U.S. podiatrists within their borders. These are California, Connecticut, Illinois, Massachusetts, New Jersey, New York, Ohio and Pennsylvania. It has been estimated that all podiatrists in private practice receive an estimated 28.2 million patient visits per year, or some. 3,730 visits per year per individual practitioner. This is slightly more than one-third the patients normally seen by the physician in general practice and is slightly more than all the visits per year per practitioner when compared to dentists in general practice. With respect to patterns of patient age, about three percent of the patients seen are under 10 years old, while most (51 percent) are 20-59 years old. Slightly over two-thirds of the podiatrist's patients are women. These figures also indicate that most conditions tre ated are chronic in nature. It is also interesting to note that of patients making their first visit to podiatrists for foot problems, some 20 percent are found to have been referred by a physician.8 Some other interesting facts which show the great need and potential of podiatry include the followingl1. Almost 70 percent of the population have or will suffer from some foot ailment with about half of these requiring professional care. 2. Four out of five geriatric patients endure one form of foot disorder or another. 3. About 60 percent of school children show foot problems with 10-15 percent of these requiring professional care. 4. Of the first two million men drafted during World War II, over 25,000 were rejected during preliminary examinations because of various foot conditions. Of those who were accepted another 20,000 were eliminated at basic training for similar problems. Of 172
the five million rejected, twice as many were rejected for foot problems ( 1.4 percent) as for dental defects (0.7 percent). 5. As many as one out of nine disabling work injuries involve the foot. In one state alone some 15. million dollars had been paid from 1957 to i962 in workmen's compensation for foot disorders alone! 6. The human foot can be a "remarkable mirror" for constitutional disease, in fact, it has been compared to the eye in its early diagnostic importance. Some of the initial signs of diabetes, anemia, peripheral vascular and other systemic diseases often show up in the foot; arthritic conditions often appear in the foot joints too. Another area of interest to pharmacists is the extent and scope of the podiatric profession. Most of the practice acts of the various states define the purview of podiatry as the diagnosis, medical, physical or surgical treatment of the ailments of the human foot, with the exception of administration of general anesthetics, or amputation of the foot. On a practical level the most common treatments involve removal of benign skin growths of the feet, excision of corns and calluses, removal of ingrown toenails, bunion removal, correction of hammer toes and care of fractures of the bones of the feet. In addition, corrective surgery of the feet may be performed in podiatric hospitals or in hospitals where podiatrists serve on the staff. 4 .11 One aspect of great import to pharmacists concerning the scope of podiatric medicine is its prescribing potential. Podiatrists have the legal right in most states to prescribe any medication justifiable for the treatment of lower extremity disorders. The vast majority of podiatrists are unrestricted in their use of chemotherapy. Only 14 states place any limitation on their drug use and only eleven states prohibit the use of narcotics. Even less, only eight states (with only six percent of the total podiatrist population), actually limit drug use to external medications and local injections.8 There are several changes in restrictive laws currently in progress in some of the states. It is a matter of record that next to the physician, the podiatrist perhaps prescribes more medication than any other member of the allied medical professions. Recent surveys have indicated that podiatrists write over four million prescriptions each year. A typical p0diatrist may write some 600 prescriptions annually. Another survey indicates that the nation's podiatrists are currently responsible for some 18.6 million drug appearances (including non -prescription items) per year. If more recent statistics are available, these figures would probably be much
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
higher. The U.S. Public Health Service recently sponsored a national survey of podiatrists which yielded much information regarding number, age, location, etc., of podiatrists currently in practice. The national survey of podiatry manpower began in October 1969, with the mailing of a questionnaire to every podiatrist in the United States. Specifically, the study ran from January through March 1970 and was conducted by the National Center for Health Statistics (NCHS) with the cooperation of the American Podiatry Association. Essentially the study showed that the average age of podiatrists was 51; that 94 percent were male and six percent female; that 95 percent were native born citizens with five percent naturalized ; that 74 percent were graduates of the five colleges of podiatry now in operation; that one percent had a PhD, two percent a masters degree and 20 percent a bachelors degree in addition to their podiatry degrees; that 75 percent were licensed in only one state, 23 percent in two states and seven percent in three or more states; and that they averaged 21 years of active podiatric practice. In the United States the number of full-time and part-time podiatrists who are active in practice is 88 percent. The complete details of the preliminary results of this manpower survey can be found in the March 1971 Journal of the American Podiatry Association in an article by J. Gleason. With respect to projected manpower requirements in podiatry, the American Podiatry Association estimates a potential for utilization of one podiatrist for every 10,000 persons. At this ratio, a requirement of 24,000 active podiatrists is estimated to be needed by 1980, with an anticipated supply of only 9,900. These figures leave little doubt for the need for increased numbers of podiatrists for direct services, education and research.5 In a survey conducted by the Texas Pharmaceutical Association some years ago, a total of 330 pharmacists kept records for six months of prescriptions written by podiatrists antl ·dr.ntists. In this period of time, the dentists had written over $18,000 worth of prescriptions while the podiatrists wrote over $15,000 worth, and there were only 200 podiatrists to some 3,000 dentists.G,7 The size of the podiatrists' market was also estimated a few years back based on a survey of the National Prescription Audit. The findings of this study projected to an annual basis showed a rise in number of new prescription orders dispensed from 294,000 in 1962 to 348,000 in 1964. These figures in equivalent manufacturers' dollars represent a corresponding rise from $326,000 in 1962 to
$400,000 in 1964. It suffices to say that many prescriptions are written by podiatrists nationally which many pharmacists are not generally aware of.B In a recent article on podiatric practice in the United States which reviewed the year 1969, it was shown ·that the podiatrists performed 83 different services. 9 In addition, they used 634 different drug products of which 500 were prescription items.
As would be expected, the antiseptic and anti-infective class led with 21.1 percent of all drug uses. Several other therapeutic classes (e.g., escharotics/ vesicants, topical antifungals, topical antibiotics/ sulfas and emollients) each had over two million podiatry-engendered uses during this 1969 survey. Further, the topical enzyme product class registered nearly one million podiatry uses of all types in this year. To obtain some idea of the typical
products written for by the podiatrist see Table I (see below). One can readily see by reference to this that a relatively wide spectrum of products is prescribed and used. Many topicals are represented, particularly ointments and topical liquids. lnjectables also are common. About one in five drugs are oral agents. Almost half of the products are prescribed, dispensed for home use or recommended to the patient.
TABLE I
Examples of Phannaceuticals Used in Podiatry Classified by Therapeutic Categories Topical Antifungals Onychophytex Tinactin Desenex Sana Balm Gentian Violet Quinsana Potassium Permanganate Desenex Aerosol Advicin Onychomycetin Carfusin Castellanis Paint Mycostatin Vioform Whitfield's Ointment Fungoid Sopronol Sporostacin Asterol Bismuth Violet Nail Solution Clin Rx Clinical Rx UO Verdefam Undecylenic Acid Anafung HH Phytex NP-27 Benzo Salicylic Compound Timofax Castilannis Solution Rx G4 Solution Keralac Nail Fungicide Unspecified
Betadine Hydrogen Peroxide Iodine Iodoform Iodide TBC Polysept Septisol Sodium Hypochlorite Dilute Neopan ST 37 Mercresin Triburon Lysol Chlorazine Clinical Rx WD Hexaresorcinal
Escharotics and Vesicants Salicylic Acid Salisicom Ointment Silver Nitrate Monochloroacetic Acid Pyrogallic Acid Phenol Bichloracetic Acid Xine Trichloracetic Acid Cantharone Nitric Acid Fibrasol
Emollients Polysorb Hydrate Vitamin A Ointment Nivea Aquasol A Creme Lanolin Panthoderm Dermassage Oil a tum Alpha Keri Sardo Bath Oil Husk Ointment Foot Cream Unspecified Lubriderm Vitamin A & D Ointment Nutraderm Zinc Oxide Mennen's Baby Magic Saratoga Ointment Desitin Keri Lotion Vaseline Do mol Cyscal Pedisine Acid Mantle Borofax Tashan Cream Vi Dom A Creme Mello bath J & J Baby Lotion Universal Ointment
Antiseptics, Other Anti-Infectives Merthiolate Furacin Icthammol Ichthyol Alcohol Bactine Metaphen Zephiran Iodex BFI Powder
Anesthetics Xylocaine Xylocaine with Epinephrine Carbocaine Americaine Procaine Ethyl Chloride Nesacaine Cetacaine Nupercainal Novocain Ravocaine with Procaine
Benzocaine Parathesin Cyclaine Aero Freeze Butesin Picrate Nupercaine Novothesia
Astringents and Antiperspirants Domeboro Formalin Burows Solution Dalidome "D''
Efosorb "K"
Topicai Antibiotics and Sulfas Neosporin Bacitracin NeoPan Aureomycin Ointment Neomycin Terramycin Ilotycin Mycitracin Sulfathiazole Bacimycin Spectrocin Polymixin Neomycin Bacitracin Achromycin Polysporin Penicillin G NeoPolycin Sulfadiazine D eclomycin Tryotrace
Topical Enzymes Chymar Ointment Biozyme Blase Parenzyme Macrozyme
Non-Narcotic Analgesics Darvon Compound 65 Aspirin Darvon Compound D arvon Phenaphen Ascriptin APC Tylenol Zactirin Butfcrin Salicylate ASA Norgesic Pedisal Empirin Compound Equagesic Zactirin Compound 100 Prolaire Synalogos Anacin SaiEze An alexin
Chamo Packet Alum
Vitamins and Minerals Aquasol A Vitamin A Vitamin B12 (gen) ViDomA Vitamin B12 Fosfree Vitamin C Hydroxocobalamin Century Vitamins Vitamin B Complex with B12 ViDom AC Wheat Germ Surbex T Thiamine Hydrochloride Ascorbic Acid Ferrous Sulfate Car Vit Tabolin A
Injectable Corticoids Depo Medrol Celestone Decadron Celestone Soluspan Hydeltra TBA Decadron with Xylocaine Kenalog Hydrocortone Hydeltrasol Hydrocortisone Prednisolone ACTH Cortisone
Bland Lotions and Powders Curaped Zeasorb Epiderm Foot Balm Larson's Balm Pedirut Peditrin Maseda Foot Powder Talc Mexsana (continued on next page)
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TABLE I
(continued)
Examples of Pharmaceuticals Used in Podiatry Classified by Therapeutic Categories Oral Antibiotics and Sulfas
Wet Soaks
Penicillin Panalba Lincocin Tetracycline Pentids Ilosone Terramycin Erythrocin Achromycin Declomycin Mysteclin F Tetracycline Madribon Erythromycin Tetrex Polycillin
Magnesium Sulfate Boric Acid Sodium Chloride
Topical Plain Corticoids Synalar Cort Dome Celestone Medrol Kenalog Metiderm Decadron
Neo Cort Dome Neo Lida Mantle HC Neo Cortef Neo Medrol Neodecadron Neo Synalar Caldecort Mycolog Ictho-Cort Cortisporin Hydrocerm Neomycin HC Neo Aristocort Celestone with Neomycin Terra Cortril N eo Domeform HC Poliacort CorTarQuin
Liniment-Type Products Methaquen Banalg Myoflex Imadyl Unguent Iodex with Methyl Salicylate
Oral and Injectable Enzymes Chymoral Tablets Ananase Tablets Papase Tablets Orenzyme Tablets Avazyme Tablets
Vergo Keramin Aquasol A Injection Vitamin A Injection
Demerol Empirin Compound with Codeine Perocodan Mepergan Fortis Phenaphen with Codeine Codeine Mepergan Meperidine ASA & Codeine Compound
Oral Antifungals Fulvicin U/F Fulvicin Griseofulvin Grisactin Grifulvin V Grifulvin
Sedatives and Hypnotics Seconal Nembutal Phenobarbital (gen) Butisol Amy tal
Cleansing Agents and Detergents PhisoHex Tergitol with Fuchsin 3 Wea Solution Green Soap Tincture Basis Soap
At this point, it will be useful to consider some of the leading categories of drugs used and which items within these categories are popularly used by the podiatrist. In the analgesic category, which represents about five percent of all products used by the podiatrist, by far the most popular drug is dextro-propoxaphine (Darvon Compound 65-Lilly). No figures are available for narcotic analgesics since their use in various states is restricted. Of the antibiotics and sulfas about one in ten products fit in this group. Most are topicals, followed by oral products and injectable forms . The leading topical agent is neosporin, while the leading oral products were 174
Indocin Butazolidin Colchicine Butazolidin Alka Benemid Colbenemid
Other Corticoid Products Pantho F Pantho Foam
Tranquilizers Compazine Vistaril Largon
Other Wart Products
Narcotic Analgesics Corticoids With Anti-Infectives
Antiarthriti·cs and Antigout Agents
Peripheral Vasodilators Arlidin Vasodilan Cyclospasmol
Oral Corticoids Celestone Prednisolone Prednisone Hexadrol Decadron Dexameth Medrol Prednis
Diuril Naqua Anhydron Pavabid Adrenalin
Antihistamines Phenergan Chlor Trimeton Benadryl Teldrin
Coal Tar Sulfur Products Vlemnicks Solution Salicylic Acid with Sulfur
Injectable Antibiotics
Miscellaneous Dermatologicals
Penicillin G Terramycin Lincocin
Medaprin Sigmagen Delenar Decagesic Cord ex
Benzoin Benzoin Compound Ouiod Ointment Chloresium Copper Sulfate Icthyol Collodian Unnas Paste DMSO Riasol Collodion Obtundia Cream Nolytic
Antipruritics
Miscellaneous Products
Ennex Ennexeez Derma Medicone
Quinine Gelfoam Nitrogen (liquid) Adenosine Carbon Dioxide (solid) Prantal Tetanus Toxoid My B Den Adrenalin Forte
Corticoid Analgesic Combinations
Oral Muscle Relaxants Rei a Robaxin Robaxisal
various brands of penicillin G. The antifungal class of products is widely used in podiatry with topical forms predominating. Some examples of typical products in this category include Unimed's Onycho-Phytex, Tinactin and Desenex and others shown in Table I. The corticoid compounds are another class of drugs which enjoy wide use and include numerous topical and injectable forms. Popular examples here include Depo Medral (Upjohn), Synalar and Neo-Cort-Dome. Within the group of agents widely used on a prophylactic basis, one finds numerous examples of various emollients, bland lotions and powders. Almost two million product appearances
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
Other Cardiovascular Drugs
each year may be shown in this broad group of agents. Some widely used examples here are Desenex, Nivea Creme, Polysorb Hydrate, lanolin, Dcrmassage, Oilatum and others shown in the table. In the enzyme products, figures seem to indicate that podiatrists use more. of these than physicians do in general. Again topical forms are the most widely used. The products Chymar, Chymoral, Ananase, Biozyme and Papase are some of the more commonly prescribed items of the group. The escharotics and vesicants; which are mainly used for the destruction or removal of tissue, are widely used by podiatrists particularly in ·the treatment of warts. Many products !Ire
used here, examples being Salisicom ( 60 percent salicylic acid), silver nitrate, monochloracetic acid and others. Certain vitamins are prescribed by podiatrists for lower extremity dermatological conditions and these mainly include such agents as vitamin A (Aquasol A) and vitamin B12 .IO It may interest pharmacists to learn of the various publications which are used widdy in podiatry. The American Podiatry Association publishes an annual desk reference which gives the current board of trustees, the various councils and committees, the component state societies and affiliated and related organizations (each with current officers given), a description of various awards and citations, Standard Podiatric Nomenclature of Diseases and Operations coded for both the International Classifications of Disease (ICDA) and the AMA Standard Nomenclature of Diseases and Operations (SNDO), an advertisers and exhibitors index, abbreviations, weights and measures, code of ethics, a computerized geographical and alphabetical directory of members, and, finally, an audio-visual aid informational and educational materials catalog.12 The official professional journal of podiatry is the Journal of the American Podiatry Association which is published monthly. It contains clinically and research-oriented articles on current treatments in podiatry in addition to various reviews, book reviews, practice management articles, digests from the literature, letters to the editor, meetings and other similar material pertinent to the normal function of the organization. The colleges of podiatry also publish newsworthy articles of local interest in the various states. Schering Corporation also publishes "Podiatry News" on a quarterly basis as a service to the profession. In addition, W.T.S. Pharmacraft, Division of Wallace & Tiernan, Inc., publishes and distributes "Podiatry Management Letter" as a service to the podiatry profession. Several formularies designed for specific podiatric preparations are available. One of the first of these was originated by Dr. Ralph Owens, graduate pharmacist and podiatric surgeon of Oklahoma and the staff of the Oklahoma State Pharmaceutical Association. Many of these formularies are older and may be generally available only within certain states. Some of these include the New Jersey Chiropodists Formulary (Second Edition, 1958) prepared through the joint committees on professional relations of the New Jersey Podiatry Society and the New Jersey Pharmaceutical Association, a chiropodical formulary published by the Oklahoma State Pharmaceutical Association, the Texas Chiro-
podical Formulary published and distributed by the Texas Pharmaceutical Association (Austin, Texas), 13 and the Hospital Drug Formulary (1968) of the California Podiatry Hospital (San Francisco), prepared by the pharmacy and therapeutic committee of this institution. Apparently several of the formularies are reprints of ones from other states. Briefly, most of these contain sections on prescription writing, abbreviations, common weights and measures, local state prescription and narcotic laws and many typical formulations (with directions for preparation and use) of drugs useful in the management of podiatric disorders. Some of the formularies are general in nature while others list commercial products. A recent podiatric formulary and manual has been published by the Pennsylvania College of Podiatric Medicine. It is perhaps one of the most comprehensive and up-to-date publications of this kind currently available. A short section on podiatric pharmacy, including typical prescriptions, may be found in Husa's Pharmaceutical Dispensing.l2 The National Formulary (Twelfth Edition) carried a small section on podiatry drugs and preparations. Most of these were formulas for various liniments, tinctures, powders and ointments. However, they were dropped from the current thirteenth edition of the National Formulary in line with the new therapeutic value criterion adopted for the entire compendium. The current board has concluded that the interests of podiatry, like general medicine, medical specialties and dentistry are best served by ensuring that drugs of importance in the practice of podiatry are included in the regular monographs section. In this way, the customary requisites of safety and demonstrated effectiveness can be required and insured. With this overview in mind one can see the many areas for interprofessional liaison. As with general medicine, podiatry relies heavily on the knowledge, counsel and expertise offered by pharmacy in its attempt to keep abreast of the enormous increase in drug products manufactured each It would certainly behoove year. those pharmacists who have many podiatrists within their immediate area to detail them occasionally and make them aware of new items of potential value to their profession. In addition, it may be advantageous for the pharmacist to prepare bulk quantities of certain ointments, lotions and solutions for office use by the podiatrist. Many podiatrists must rely on mail order for these items through small specialty houses. One has only to attend the annual meetings of the Ameri-
can Podiatry Association to see the numerous displays of products made available and promoted for the podiatry profession by various pharmaceutical concerns. Liaison, on a continuing basis, should be established between the various state podiatry and pharmacy organizations to fos~er mutually beneficial legislation regarding narcotic laws, social security amendments (e.g., Medicare), development of formularies and other similar matters. Already, the Pharmacy-Podiatry Liaison Committee has caused both organizations to jointly express concern for better consumer protection through recognition of the misuse and "over-treatment" involved with over-the-counter products containing salicylic acid. The American Podiatry Association, through a resolution adapted by its 1969 house of delegates, will assist the American Pharmaceutical Association in its efforts to change the federal law to provide that non-prescription medication be divided into two classes-those which must be· dispensed personally by a pharmacist and those which can be made available by any individual or outlet,15 As with most political problems, strength lies in numbers and those organizations which present a positive united front usually are better served, and in the case of pharmacy and podiatry this would ultimately allow for better and more complete service to the patient. The pharmacist also has the moral obligation to help "educate" both the public and other members of the health profession about the capabilities and skills of the podiatrist. Just as the pharmacist serves as a local reference guide to health facilities, and dentists and physicians, in a given community for his clientele, so must he guide those who have lower extremity disorders to the podiatrist. The podiatrist in the health team has the special ski11s, training and experience to cope with the complex problems of maintaining efficient foot function in acute and chronic conditions. • Acknowledgments The author wishes to acknowledge the valuable assistance lent by the several members of the Pharmacy-Podiatry Liaison Committee (Dr. Richard Penna, secretary, Academy of General Practice of Pharmacy; William Taggart, pharmacy representative; Dr. Ralph Owens, American Podiatry Association board of trustees; Dr. John Graham American Podiatry Association board of trustees; Dr. Seward Nyman, American Podiatry Association executive director; Dr. Sam~el Moskow, Council on Podiatric Therapeuttcs; John Neumann, APhA board of trustees, and Dr. Harry Hoffman, Council on Podiatric Therapeutics) whose talen_ts and expe;t_ise help~d make this article posstble. In addttton, speetal thanks are due to R. Gosselin & Co. and Lea Associates whose statistical surveys contributed heavily to this article. More detailed and specific information may be obtained by contacting these concerns.
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Pharmacy and Podiatry (continued from page 175) A final note of thanks is due to D ean Charles Gibley, Dr. Arthur Helfand and Dr.. T~d Eng~! of th e Pennsylvania College of Podwtnc Medtcine who helped review this article.
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3. Brachman, Philip, "The Profeosional · Education of a Podiatrist," Ill. Pharmacist, 345 (June 1964) 4. Guenzler, George, "The Scope of Podiatric Practice," Ill. Pharmacist, 347 (June 1964) 5. Pennell, M.Y., "Podiatric Education and Manpower,"], of Pod. Ed., 1, 1 (1970) 6. DiGilio,. Frank, "Prescriptions in Podiatry Practice," Ill. Pharmacist, 349 (June 1964) 7. Gilbert, Arthur, " Report of the 1964 Survey of the Podiatry Professkln," ]. Am. Podiatry Assn., 54, 626 ( 1964) 8. Gosselin, Ray, A Special Report on the Podiatrists' Prescription Market, R.A. Gosselin & Co., Inc., Dedham, Mass. (May 1964) 9 . Wepprecht, K., and Baima, J,, " P odiatric Practice in the United States-1969;'' ] . of the Am. Pod. Assn., 61, 37 ( 1971)
Educ., 21, 338 ( 1957) 22. Bellafiore, I.J., "Therapeutic Consultant," ]APhA, Pract. Pharm. Ed., 19, 90 (1958 ) 23. Gelperin, A., "Physician-Pharmacist Team Plays Key Roles in Drug Evaluation," Am. ]. Hosp . Pharm., 16,217 (1959) 24. Greth, P .A., " The Pharmacist as a Therapeutic Consultant," S. Dakota ]. Med. Pharm ., 18, No. 2, 48 ( 1965) 25. Francke, D .E. , "The Role of the Pharmacist as a Drug Information Specialist," ( editorial), Am. ]. Hasp. Pharm., 23, 49 (1966) 26. Autian, J., and Berman, A ., " Role of the Pharmacist in Drug Evalua tion," Am. ]. Pharm., 134, 195 (1962) 27. Brodie, D.C ., a nd Meyers, F.H., " Role of the Pharmacist .as a Drug Consultant in the Hospital," Am. ]. Hosp. Pharm., 18, 11 (1961) 28. Masur, ]., "Whither Pharmacy Services," Am. J, Hasp. Pharm., 20, 450 ( 1963) 29. Pellegrino, E .D., "Drug Information Services and the Clinicia n," Am. J, Hasp. Pharm., 22, 38 ( 1965) 30. Keefer, C.S., "A Physician L ooks at Drug Information," Am. ]. Hosp. Pharm., 23, 55 (1966) 31. Letourneau, C.U., "Future of the Hospital Pharmacist," Hosp. Formulary Management, 1, No. 7, 23 ( 1966) 32. Francke, D.E.; Latiolais, C .J.; Francke, G.N., and Ho, N.F.H., "Mirror to Hospital Pharmacy," ASHP, Washington, D.C., 131 (1964) 33. Teplitsky, B., "Nine Out of Ten MD's Ask Re tailers for Data About 'Rx Prices," Am. Druggist, 141, No. 12, 52 ( 1960) 34. Mille r, M.L., "Source of Information to the Physician," ]APhA, NS1, 151 ( 1961) 35. Menzel, H ., and Katz, E ., "Social Relations a nd Innovation in the Medical Profession : The Epidemiology of a New Drug," Fublic Opinion Quart., 19, 337 (1955) 36. Coleman, J.; Menzel, H. , a nd Katz, E., "Social Processes in Physicians' Adoption of a New Drug," ]. Chronic Diseases, 9, 1 (1959) 37. Menzel, H. ; Coleman, J., and Katz, E. , "Dimensions of Being ' Modem' in Medical Practice," ] . Chronic Diseases, 9, 20 ( 1959) 38. Ferber, R., and Wales, H.G., " The Effectiveness of Pharmaceutical Promotion," University of Illinois, Urbana, 21 ( 1958) 39. Caplow, T., " Market Attitudes: A Research Report From the Medical Field," Harvard Bus. Rev., 30, No. 6, 105 ( 1952) 40. Caplow, T., and Raymond, J,J., " Factors Influencin g the Selection of Pharmaceutical Produots," ]. Marketing, 19, No. 1, 18 (1954) 41. Winick, C., uThe Diffusion of an Innovation Among Physicians in a L arge City," Sociometry, 24, 384 ( 1961) 42. Wilson, C .W .M.; Banks, J.A.; Mapes ,
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10. Anonymous, "A Study of U.S. Practice of Podiatry," The Special Studies Group, Lea Associates, Inc., Ambler, Pa. ( 1966) 11. Anonymous, "Podiatry Association President Calls for Closer Relationship With Pharmacy," Am. Druggist (Nov. 18, 1968) 12. Rubin , Abe, Editor, Desk Reference of. the American Podiatry Association, Amencan Podiatry Association, Washington, D.C. (1970) 13. Anonymous, " Chiropody Formulary Compilation," Several articles in Tex. Pharmacy · ] , (Jan., M arch, April, June 1959) 14. Martin, E.W., Husa's Pharmaceutical Dispensing, 6th ed., Mack Publishing Co., .Easton, Pa., 827 ( 1966) 15. Rubin, Abe, " APA and APhA Recognize Need for Better Consumer Protection," /. Am. Pod. Assn., 59, 403 (1969)
R.E .A., and Korte, S.M.T ., " Influence of Different Sources of Therapeutic Information' on Prescribing by General Practitioners," Brit. Med. ]., 2, 599 ( 1963) 43 . Wilson, C .W .M.; Banks, J.A .; M apes, R.E.A., and Korte, S.M.T., "Pattern of Prescribing in General Practice," Brit. Med. ]., 2, 604 (1963) 44. "Survey of Physicians' Opinion on Means of Obtaining Comprehensive Drug Information," PMA, Washington, D .C. , 1 ( 1960) 45. Fein, R., " The Doctor Shortage: An Econ omic Diagn osis," Brookings Institution, Washington, D.C . ( 1967) 46. Zugich, J ,J ,, " Physician's Rounds and Pharmacy Training," Am. Prof. Pharm., 23, 882 (1957) 47. Parker, P .F. , " Hospital Pharmacists Provide Consultant Services," ]APhA, Pract. Pharm. Ed., 18, 678 (1957) 48. Susina, S.V.; Adams, W .H. ; Shirkey, H.C., and Byrum, W .R., "The Hospital-A Pharmacology L aboratory for Pha rmacy Stud ents," Am. ], Pharm . Educ., 28, 216 ( 1964) 49. Blake, D .A., " The Role of Pharm acology in the Clinically Oriented Curriculum," Hosp. Pharm., 4, 24 ( 1969) 50. Piccoli, L.R., and Piccoli, L ,J,, "A Preliminary Study, Hospitalwide Externship Program for Pharmacy," Am. Prof. Pharmacist, 34, No. 1, 64 ( 1967) 51. Hayes, T.I., Jr., "As a Pharmacy Intern, I Make Rounds With Hospital MD's," Am. Prof. Pharmacist, 32, No. 3 , 66 ( 1966) 52. Greth, P.A.; T ester, W.W., and Black, H.J., "Decentralized Pharmacy Operations Utilizing the Unit Dose Concept II : Drug Information Services and Utilization in a Decentralized Pharmacy Substation,'' Am. ]. Hasp. Pharm., 22, 558 ( 1965) 53. Piecoro, J .J ,, Jr., "An Evaluation of the Pharmacist Serving as a Source of Drug Information to the Physician," Mastel'S Thesis, Ohio State University, Columbus, Ohio, 20 (1966) 54. Smith, W .E ., " The Future Role of the Hospital Pharmacist in the Patient Care Area," Am. J. Hasp. ·Pharm., 24, 228 ( 1967) 55. Rosenberg, A., "How to Improve the Image of Hospital Pharmacy's New L ook," Am. Prof. Pharmacist, 30, No. 8, 62 ( 1964) 56. D'Ambola, J.V. , "Hospital Rx M en Shoul,d Take the Initiative to Enhance Phannacy s Image with MD's," Am. Prof. Pharmacist, 30, No . 11, 64 ( 1964) 57. O'Brien, W.P. , "Your Professional Image," ]APhA, NS6, 426 ( 1966) 58. Blasingame, F .J.L., "Cut Your Medical Costs!," This Week, United Newspaper Magazine Corp., N.Y., 10 (May 21 , 1967) 59. "Physician-Pharmacist Code of Understanding," APhA Newsletter, 2, No. 13, 3 ( 1963)
Ara H. Der Marderosian is an associate professor of pharmacognosy at Philadelphia College of Pharmacy and Science, lecturer in pharmacology at Pennsylvania College of Podiatry and adjunct associate professor of pharmacology at the University of Pennsylvania College of Veterinary Medicine. Having earned his PhD in pharmaceutical sciences at the University of Rhode Island, Der Marderosian has given numerous lectures and written many articles for professional publications. He is a member of Massachusetts and Rhode Island pharmaceutical associations and the Philadelphia APhA Chapter. His research interests are in the areas of hallucinogenic botanicals, medicinal and poisonous plants; marine pharmaceuticals and their phytochemistry and pharmacology.
n this era of continued interprofessional interdependence there arises a need for greater communication between allied members of the health team. Such is the status between podiatry and pharmacy today. These professions have long espoused the same high ethical and philosophical goals with the ultimate aim of greater service to the public. For many years now the profession of podiatry has sought to elevate its status and promote a good working relationship with pharmacy. The concept of preventative medicine, the population explosion and the rise in geriatric treatment have fostered a greater importance and dependence on this specialty as well as others. This in turn has created a greater need for closer collaboration and interprofessional liaison between podiatry and pharmacy which is one of the reasons for the preparation of this article. Many of the ideas presented here grew from a joint effort of the American Pharmaceutical Association and the American Podiatry Association liaison committee which has met several times at the national offices of both organizations in Washington, D.C. To better understand the current status of podiatry, it will be instructive to review a few facts about the profession. Podiatry (chiropody is a synonymous but older term) is the health service concerned with the care of the human foot in health and disease. By virtue of his training the doctor of podiatric medicine is able to diagnose and treat diseases of the foot
I
by medical, surgical and other appropriate methods. While history records the early neglect of foot disorders and their treatment, a few individuals on an itinerant basis provided some foot care service. This was a transplanting from abroad of a serviCe provided there to the upper classes, having emerged as a "specialty" from the guild of barbersurgeons. In 1846 Nehemiah Kenison opened an office in.Boston. However, two other chiropodists had opened offices earlier~Julius Davidson in Philadelphia in 1841 and John Littlefield in New York in 1843. Kenison is recognized as the outstanding pioneer because he trained others who established "Kenison offices" in 10 cities in the United States. Later, in 1862, Abraham Lincoln's personal foot doctor (and confidant) , Isachar Zacharie, wrote a treatise on "Surgical and Practical Observations on Diseases of the Foot." However, it was not until 1895 that the first laws regulating the practice of the profession of podiatry were enacted in New York State. By 1912, the national association, now known as the American Podiatry Association, and two colleges began to broaden the profession's educational program and scope of activities. These efforts led to the establishment of practice acts in many states and allowed the contributions of podiatry to become more significant. In 1939, the Judicial Council of the American Medical Association stated
that podiatry was a practice related to medicine much like dentistry, pharmacy and nursing were. Further, the council stated, "General opinion seems to be that chiropody fairly well satisfies a gap in medical care that the (medical) profession has failed to fill." Today, more than 8,500 podiatrists in the United States serve in private practice, the Armed Forces, government installations, hospitals, nursing homes and many other institutions. Almost all of these podiatrists have graduated from any one of five colleges of podiatry in existence today and all are accredited by the Council on Education of the American Podiatry Association. They include the California College of Podiatric Medicine, the Illinois College of Podiatric Medicine, the M.J. Lewi College of Podiatry (New York), the Ohio College of Podiatric Medicine and the Pennsylvania College of Podiatric Medicine. All of the colleges are independent, incorporated, nonprofit institutions and are governed by charters, supervised by boards of trustees and regulated by the respective state departments of education. All are listed in the Directory of Institutions of Higher Education of the U.S. Department of Health, Education and Welfare. 1 The association's Council on Education is a national accrediting agency recognized by the U.S. Department of Health, Education, and Welfare, Office of Education, and the National Commission on Accrediting. These institutions offer a four-year professional course of didactic, laboratory and clinical instruction. A minimum of two years of undergraduate instruction of prescribed courses in an approved college of liberal arts and sciences is required prior to admission to a college of podiatry. In recent years the majority of students possess a baccalaureate degree. The full program of instruction is four years and includes over 4,200 clock hours of course work. The first two years are devoted mainly to the basic biological Vol. NSll, No. 4, April 1971
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sciences such as anatomy, histology, embryology, physiology, biochemistry, microbiology, pharmacology, neurology and pathology (with some premedical podiatry orientation courses, radiology and public health included). The last two years include the clinical subjects such as orthopedics, internal medicine, dermatology, roentgenology, peripheral vascular diseases and surgery, among others, which concentrate on relating these subjects to actual practice of the profession. 1- 4 A number of internships and residences are available for podiatrists throughout the country also. In fact, internships are required for licensure in New Jersey, Rhode Island and Michigan. Postgraduate training programs are offered by all the podiatry colleges. The geographic distribution of podiatrists is not uniform throughout the United States. There are eight states which include 72 percent of all U.S. podiatrists within their borders. These are California, Connecticut, Illinois, Massachusetts, New Jersey, New York, Ohio and Pennsylvania. It has been estimated that all podiatrists in private practice receive an estimated 28.2 million patient visits per year, or some. 3,730 visits per year per individual practitioner. This is slightly more than one-third the patients normally seen by the physician in general practice and is slightly more than all the visits per year per practitioner when compared to dentists in general practice. With respect to patterns of patient age, about three percent of the patients seen are under 10 years old, while most (51 percent) are 20-59 years old. Slightly over two-thirds of the podiatrist's patients are women. These figures also indicate that most conditions tre ated are chronic in nature. It is also interesting to note that of patients making their first visit to podiatrists for foot problems, some 20 percent are found to have been referred by a physician.8 Some other interesting facts which show the great need and potential of podiatry include the followingl1. Almost 70 percent of the population have or will suffer from some foot ailment with about half of these requiring professional care. 2. Four out of five geriatric patients endure one form of foot disorder or another. 3. About 60 percent of school children show foot problems with 10-15 percent of these requiring professional care. 4. Of the first two million men drafted during World War II, over 25,000 were rejected during preliminary examinations because of various foot conditions. Of those who were accepted another 20,000 were eliminated at basic training for similar problems. Of 172
the five million rejected, twice as many were rejected for foot problems ( 1.4 percent) as for dental defects (0.7 percent). 5. As many as one out of nine disabling work injuries involve the foot. In one state alone some 15. million dollars had been paid from 1957 to i962 in workmen's compensation for foot disorders alone! 6. The human foot can be a "remarkable mirror" for constitutional disease, in fact, it has been compared to the eye in its early diagnostic importance. Some of the initial signs of diabetes, anemia, peripheral vascular and other systemic diseases often show up in the foot; arthritic conditions often appear in the foot joints too. Another area of interest to pharmacists is the extent and scope of the podiatric profession. Most of the practice acts of the various states define the purview of podiatry as the diagnosis, medical, physical or surgical treatment of the ailments of the human foot, with the exception of administration of general anesthetics, or amputation of the foot. On a practical level the most common treatments involve removal of benign skin growths of the feet, excision of corns and calluses, removal of ingrown toenails, bunion removal, correction of hammer toes and care of fractures of the bones of the feet. In addition, corrective surgery of the feet may be performed in podiatric hospitals or in hospitals where podiatrists serve on the staff. 4 .11 One aspect of great import to pharmacists concerning the scope of podiatric medicine is its prescribing potential. Podiatrists have the legal right in most states to prescribe any medication justifiable for the treatment of lower extremity disorders. The vast majority of podiatrists are unrestricted in their use of chemotherapy. Only 14 states place any limitation on their drug use and only eleven states prohibit the use of narcotics. Even less, only eight states (with only six percent of the total podiatrist population), actually limit drug use to external medications and local injections.8 There are several changes in restrictive laws currently in progress in some of the states. It is a matter of record that next to the physician, the podiatrist perhaps prescribes more medication than any other member of the allied medical professions. Recent surveys have indicated that podiatrists write over four million prescriptions each year. A typical p0diatrist may write some 600 prescriptions annually. Another survey indicates that the nation's podiatrists are currently responsible for some 18.6 million drug appearances (including non -prescription items) per year. If more recent statistics are available, these figures would probably be much
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
higher. The U.S. Public Health Service recently sponsored a national survey of podiatrists which yielded much information regarding number, age, location, etc., of podiatrists currently in practice. The national survey of podiatry manpower began in October 1969, with the mailing of a questionnaire to every podiatrist in the United States. Specifically, the study ran from January through March 1970 and was conducted by the National Center for Health Statistics (NCHS) with the cooperation of the American Podiatry Association. Essentially the study showed that the average age of podiatrists was 51; that 94 percent were male and six percent female; that 95 percent were native born citizens with five percent naturalized ; that 74 percent were graduates of the five colleges of podiatry now in operation; that one percent had a PhD, two percent a masters degree and 20 percent a bachelors degree in addition to their podiatry degrees; that 75 percent were licensed in only one state, 23 percent in two states and seven percent in three or more states; and that they averaged 21 years of active podiatric practice. In the United States the number of full-time and part-time podiatrists who are active in practice is 88 percent. The complete details of the preliminary results of this manpower survey can be found in the March 1971 Journal of the American Podiatry Association in an article by J. Gleason. With respect to projected manpower requirements in podiatry, the American Podiatry Association estimates a potential for utilization of one podiatrist for every 10,000 persons. At this ratio, a requirement of 24,000 active podiatrists is estimated to be needed by 1980, with an anticipated supply of only 9,900. These figures leave little doubt for the need for increased numbers of podiatrists for direct services, education and research.5 In a survey conducted by the Texas Pharmaceutical Association some years ago, a total of 330 pharmacists kept records for six months of prescriptions written by podiatrists antl ·dr.ntists. In this period of time, the dentists had written over $18,000 worth of prescriptions while the podiatrists wrote over $15,000 worth, and there were only 200 podiatrists to some 3,000 dentists.G,7 The size of the podiatrists' market was also estimated a few years back based on a survey of the National Prescription Audit. The findings of this study projected to an annual basis showed a rise in number of new prescription orders dispensed from 294,000 in 1962 to 348,000 in 1964. These figures in equivalent manufacturers' dollars represent a corresponding rise from $326,000 in 1962 to
$400,000 in 1964. It suffices to say that many prescriptions are written by podiatrists nationally which many pharmacists are not generally aware of.B In a recent article on podiatric practice in the United States which reviewed the year 1969, it was shown ·that the podiatrists performed 83 different services. 9 In addition, they used 634 different drug products of which 500 were prescription items.
As would be expected, the antiseptic and anti-infective class led with 21.1 percent of all drug uses. Several other therapeutic classes (e.g., escharotics/ vesicants, topical antifungals, topical antibiotics/ sulfas and emollients) each had over two million podiatry-engendered uses during this 1969 survey. Further, the topical enzyme product class registered nearly one million podiatry uses of all types in this year. To obtain some idea of the typical
products written for by the podiatrist see Table I (see below). One can readily see by reference to this that a relatively wide spectrum of products is prescribed and used. Many topicals are represented, particularly ointments and topical liquids. lnjectables also are common. About one in five drugs are oral agents. Almost half of the products are prescribed, dispensed for home use or recommended to the patient.
TABLE I
Examples of Phannaceuticals Used in Podiatry Classified by Therapeutic Categories Topical Antifungals Onychophytex Tinactin Desenex Sana Balm Gentian Violet Quinsana Potassium Permanganate Desenex Aerosol Advicin Onychomycetin Carfusin Castellanis Paint Mycostatin Vioform Whitfield's Ointment Fungoid Sopronol Sporostacin Asterol Bismuth Violet Nail Solution Clin Rx Clinical Rx UO Verdefam Undecylenic Acid Anafung HH Phytex NP-27 Benzo Salicylic Compound Timofax Castilannis Solution Rx G4 Solution Keralac Nail Fungicide Unspecified
Betadine Hydrogen Peroxide Iodine Iodoform Iodide TBC Polysept Septisol Sodium Hypochlorite Dilute Neopan ST 37 Mercresin Triburon Lysol Chlorazine Clinical Rx WD Hexaresorcinal
Escharotics and Vesicants Salicylic Acid Salisicom Ointment Silver Nitrate Monochloroacetic Acid Pyrogallic Acid Phenol Bichloracetic Acid Xine Trichloracetic Acid Cantharone Nitric Acid Fibrasol
Emollients Polysorb Hydrate Vitamin A Ointment Nivea Aquasol A Creme Lanolin Panthoderm Dermassage Oil a tum Alpha Keri Sardo Bath Oil Husk Ointment Foot Cream Unspecified Lubriderm Vitamin A & D Ointment Nutraderm Zinc Oxide Mennen's Baby Magic Saratoga Ointment Desitin Keri Lotion Vaseline Do mol Cyscal Pedisine Acid Mantle Borofax Tashan Cream Vi Dom A Creme Mello bath J & J Baby Lotion Universal Ointment
Antiseptics, Other Anti-Infectives Merthiolate Furacin Icthammol Ichthyol Alcohol Bactine Metaphen Zephiran Iodex BFI Powder
Anesthetics Xylocaine Xylocaine with Epinephrine Carbocaine Americaine Procaine Ethyl Chloride Nesacaine Cetacaine Nupercainal Novocain Ravocaine with Procaine
Benzocaine Parathesin Cyclaine Aero Freeze Butesin Picrate Nupercaine Novothesia
Astringents and Antiperspirants Domeboro Formalin Burows Solution Dalidome "D''
Efosorb "K"
Topicai Antibiotics and Sulfas Neosporin Bacitracin NeoPan Aureomycin Ointment Neomycin Terramycin Ilotycin Mycitracin Sulfathiazole Bacimycin Spectrocin Polymixin Neomycin Bacitracin Achromycin Polysporin Penicillin G NeoPolycin Sulfadiazine D eclomycin Tryotrace
Topical Enzymes Chymar Ointment Biozyme Blase Parenzyme Macrozyme
Non-Narcotic Analgesics Darvon Compound 65 Aspirin Darvon Compound D arvon Phenaphen Ascriptin APC Tylenol Zactirin Butfcrin Salicylate ASA Norgesic Pedisal Empirin Compound Equagesic Zactirin Compound 100 Prolaire Synalogos Anacin SaiEze An alexin
Chamo Packet Alum
Vitamins and Minerals Aquasol A Vitamin A Vitamin B12 (gen) ViDomA Vitamin B12 Fosfree Vitamin C Hydroxocobalamin Century Vitamins Vitamin B Complex with B12 ViDom AC Wheat Germ Surbex T Thiamine Hydrochloride Ascorbic Acid Ferrous Sulfate Car Vit Tabolin A
Injectable Corticoids Depo Medrol Celestone Decadron Celestone Soluspan Hydeltra TBA Decadron with Xylocaine Kenalog Hydrocortone Hydeltrasol Hydrocortisone Prednisolone ACTH Cortisone
Bland Lotions and Powders Curaped Zeasorb Epiderm Foot Balm Larson's Balm Pedirut Peditrin Maseda Foot Powder Talc Mexsana (continued on next page)
Vol. NSll, No. 4, April 1971
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TABLE I
(continued)
Examples of Pharmaceuticals Used in Podiatry Classified by Therapeutic Categories Oral Antibiotics and Sulfas
Wet Soaks
Penicillin Panalba Lincocin Tetracycline Pentids Ilosone Terramycin Erythrocin Achromycin Declomycin Mysteclin F Tetracycline Madribon Erythromycin Tetrex Polycillin
Magnesium Sulfate Boric Acid Sodium Chloride
Topical Plain Corticoids Synalar Cort Dome Celestone Medrol Kenalog Metiderm Decadron
Neo Cort Dome Neo Lida Mantle HC Neo Cortef Neo Medrol Neodecadron Neo Synalar Caldecort Mycolog Ictho-Cort Cortisporin Hydrocerm Neomycin HC Neo Aristocort Celestone with Neomycin Terra Cortril N eo Domeform HC Poliacort CorTarQuin
Liniment-Type Products Methaquen Banalg Myoflex Imadyl Unguent Iodex with Methyl Salicylate
Oral and Injectable Enzymes Chymoral Tablets Ananase Tablets Papase Tablets Orenzyme Tablets Avazyme Tablets
Vergo Keramin Aquasol A Injection Vitamin A Injection
Demerol Empirin Compound with Codeine Perocodan Mepergan Fortis Phenaphen with Codeine Codeine Mepergan Meperidine ASA & Codeine Compound
Oral Antifungals Fulvicin U/F Fulvicin Griseofulvin Grisactin Grifulvin V Grifulvin
Sedatives and Hypnotics Seconal Nembutal Phenobarbital (gen) Butisol Amy tal
Cleansing Agents and Detergents PhisoHex Tergitol with Fuchsin 3 Wea Solution Green Soap Tincture Basis Soap
At this point, it will be useful to consider some of the leading categories of drugs used and which items within these categories are popularly used by the podiatrist. In the analgesic category, which represents about five percent of all products used by the podiatrist, by far the most popular drug is dextro-propoxaphine (Darvon Compound 65-Lilly). No figures are available for narcotic analgesics since their use in various states is restricted. Of the antibiotics and sulfas about one in ten products fit in this group. Most are topicals, followed by oral products and injectable forms . The leading topical agent is neosporin, while the leading oral products were 174
Indocin Butazolidin Colchicine Butazolidin Alka Benemid Colbenemid
Other Corticoid Products Pantho F Pantho Foam
Tranquilizers Compazine Vistaril Largon
Other Wart Products
Narcotic Analgesics Corticoids With Anti-Infectives
Antiarthriti·cs and Antigout Agents
Peripheral Vasodilators Arlidin Vasodilan Cyclospasmol
Oral Corticoids Celestone Prednisolone Prednisone Hexadrol Decadron Dexameth Medrol Prednis
Diuril Naqua Anhydron Pavabid Adrenalin
Antihistamines Phenergan Chlor Trimeton Benadryl Teldrin
Coal Tar Sulfur Products Vlemnicks Solution Salicylic Acid with Sulfur
Injectable Antibiotics
Miscellaneous Dermatologicals
Penicillin G Terramycin Lincocin
Medaprin Sigmagen Delenar Decagesic Cord ex
Benzoin Benzoin Compound Ouiod Ointment Chloresium Copper Sulfate Icthyol Collodian Unnas Paste DMSO Riasol Collodion Obtundia Cream Nolytic
Antipruritics
Miscellaneous Products
Ennex Ennexeez Derma Medicone
Quinine Gelfoam Nitrogen (liquid) Adenosine Carbon Dioxide (solid) Prantal Tetanus Toxoid My B Den Adrenalin Forte
Corticoid Analgesic Combinations
Oral Muscle Relaxants Rei a Robaxin Robaxisal
various brands of penicillin G. The antifungal class of products is widely used in podiatry with topical forms predominating. Some examples of typical products in this category include Unimed's Onycho-Phytex, Tinactin and Desenex and others shown in Table I. The corticoid compounds are another class of drugs which enjoy wide use and include numerous topical and injectable forms. Popular examples here include Depo Medral (Upjohn), Synalar and Neo-Cort-Dome. Within the group of agents widely used on a prophylactic basis, one finds numerous examples of various emollients, bland lotions and powders. Almost two million product appearances
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
Other Cardiovascular Drugs
each year may be shown in this broad group of agents. Some widely used examples here are Desenex, Nivea Creme, Polysorb Hydrate, lanolin, Dcrmassage, Oilatum and others shown in the table. In the enzyme products, figures seem to indicate that podiatrists use more. of these than physicians do in general. Again topical forms are the most widely used. The products Chymar, Chymoral, Ananase, Biozyme and Papase are some of the more commonly prescribed items of the group. The escharotics and vesicants; which are mainly used for the destruction or removal of tissue, are widely used by podiatrists particularly in ·the treatment of warts. Many products !Ire
used here, examples being Salisicom ( 60 percent salicylic acid), silver nitrate, monochloracetic acid and others. Certain vitamins are prescribed by podiatrists for lower extremity dermatological conditions and these mainly include such agents as vitamin A (Aquasol A) and vitamin B12 .IO It may interest pharmacists to learn of the various publications which are used widdy in podiatry. The American Podiatry Association publishes an annual desk reference which gives the current board of trustees, the various councils and committees, the component state societies and affiliated and related organizations (each with current officers given), a description of various awards and citations, Standard Podiatric Nomenclature of Diseases and Operations coded for both the International Classifications of Disease (ICDA) and the AMA Standard Nomenclature of Diseases and Operations (SNDO), an advertisers and exhibitors index, abbreviations, weights and measures, code of ethics, a computerized geographical and alphabetical directory of members, and, finally, an audio-visual aid informational and educational materials catalog.12 The official professional journal of podiatry is the Journal of the American Podiatry Association which is published monthly. It contains clinically and research-oriented articles on current treatments in podiatry in addition to various reviews, book reviews, practice management articles, digests from the literature, letters to the editor, meetings and other similar material pertinent to the normal function of the organization. The colleges of podiatry also publish newsworthy articles of local interest in the various states. Schering Corporation also publishes "Podiatry News" on a quarterly basis as a service to the profession. In addition, W.T.S. Pharmacraft, Division of Wallace & Tiernan, Inc., publishes and distributes "Podiatry Management Letter" as a service to the podiatry profession. Several formularies designed for specific podiatric preparations are available. One of the first of these was originated by Dr. Ralph Owens, graduate pharmacist and podiatric surgeon of Oklahoma and the staff of the Oklahoma State Pharmaceutical Association. Many of these formularies are older and may be generally available only within certain states. Some of these include the New Jersey Chiropodists Formulary (Second Edition, 1958) prepared through the joint committees on professional relations of the New Jersey Podiatry Society and the New Jersey Pharmaceutical Association, a chiropodical formulary published by the Oklahoma State Pharmaceutical Association, the Texas Chiro-
podical Formulary published and distributed by the Texas Pharmaceutical Association (Austin, Texas), 13 and the Hospital Drug Formulary (1968) of the California Podiatry Hospital (San Francisco), prepared by the pharmacy and therapeutic committee of this institution. Apparently several of the formularies are reprints of ones from other states. Briefly, most of these contain sections on prescription writing, abbreviations, common weights and measures, local state prescription and narcotic laws and many typical formulations (with directions for preparation and use) of drugs useful in the management of podiatric disorders. Some of the formularies are general in nature while others list commercial products. A recent podiatric formulary and manual has been published by the Pennsylvania College of Podiatric Medicine. It is perhaps one of the most comprehensive and up-to-date publications of this kind currently available. A short section on podiatric pharmacy, including typical prescriptions, may be found in Husa's Pharmaceutical Dispensing.l2 The National Formulary (Twelfth Edition) carried a small section on podiatry drugs and preparations. Most of these were formulas for various liniments, tinctures, powders and ointments. However, they were dropped from the current thirteenth edition of the National Formulary in line with the new therapeutic value criterion adopted for the entire compendium. The current board has concluded that the interests of podiatry, like general medicine, medical specialties and dentistry are best served by ensuring that drugs of importance in the practice of podiatry are included in the regular monographs section. In this way, the customary requisites of safety and demonstrated effectiveness can be required and insured. With this overview in mind one can see the many areas for interprofessional liaison. As with general medicine, podiatry relies heavily on the knowledge, counsel and expertise offered by pharmacy in its attempt to keep abreast of the enormous increase in drug products manufactured each It would certainly behoove year. those pharmacists who have many podiatrists within their immediate area to detail them occasionally and make them aware of new items of potential value to their profession. In addition, it may be advantageous for the pharmacist to prepare bulk quantities of certain ointments, lotions and solutions for office use by the podiatrist. Many podiatrists must rely on mail order for these items through small specialty houses. One has only to attend the annual meetings of the Ameri-
can Podiatry Association to see the numerous displays of products made available and promoted for the podiatry profession by various pharmaceutical concerns. Liaison, on a continuing basis, should be established between the various state podiatry and pharmacy organizations to fos~er mutually beneficial legislation regarding narcotic laws, social security amendments (e.g., Medicare), development of formularies and other similar matters. Already, the Pharmacy-Podiatry Liaison Committee has caused both organizations to jointly express concern for better consumer protection through recognition of the misuse and "over-treatment" involved with over-the-counter products containing salicylic acid. The American Podiatry Association, through a resolution adapted by its 1969 house of delegates, will assist the American Pharmaceutical Association in its efforts to change the federal law to provide that non-prescription medication be divided into two classes-those which must be· dispensed personally by a pharmacist and those which can be made available by any individual or outlet,15 As with most political problems, strength lies in numbers and those organizations which present a positive united front usually are better served, and in the case of pharmacy and podiatry this would ultimately allow for better and more complete service to the patient. The pharmacist also has the moral obligation to help "educate" both the public and other members of the health profession about the capabilities and skills of the podiatrist. Just as the pharmacist serves as a local reference guide to health facilities, and dentists and physicians, in a given community for his clientele, so must he guide those who have lower extremity disorders to the podiatrist. The podiatrist in the health team has the special ski11s, training and experience to cope with the complex problems of maintaining efficient foot function in acute and chronic conditions. • Acknowledgments The author wishes to acknowledge the valuable assistance lent by the several members of the Pharmacy-Podiatry Liaison Committee (Dr. Richard Penna, secretary, Academy of General Practice of Pharmacy; William Taggart, pharmacy representative; Dr. Ralph Owens, American Podiatry Association board of trustees; Dr. John Graham American Podiatry Association board of trustees; Dr. Seward Nyman, American Podiatry Association executive director; Dr. Sam~el Moskow, Council on Podiatric Therapeuttcs; John Neumann, APhA board of trustees, and Dr. Harry Hoffman, Council on Podiatric Therapeutics) whose talen_ts and expe;t_ise help~d make this article posstble. In addttton, speetal thanks are due to R. Gosselin & Co. and Lea Associates whose statistical surveys contributed heavily to this article. More detailed and specific information may be obtained by contacting these concerns.
(continued on page 180) Vol. NSll, No. 4, April 1971
175
Pharmacy and Podiatry (continued from page 175) A final note of thanks is due to D ean Charles Gibley, Dr. Arthur Helfand and Dr.. T~d Eng~! of th e Pennsylvania College of Podwtnc Medtcine who helped review this article.
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