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Letters to the Editor
(Aust Prescr 1994;17:79-81)
Letters, which may not necessarily be published in full, should be restricted to not more than 250 words. When relevant, comment on the letter is sought from the author. Due to production schedules, it is normally not possible to publish letters received in response to material appearing in a particular issue earlier than the second or third subsequent issue.
Editor, - Australian Prescriber has published a number of articles about the prescribing of benzodiazepines (Aust Prescr 1993;16:12-4 and 1993;16:75). Current fashion appears to be directed at restricting these drugs to short-term use only. There may be other psychiatrists who would agree that this emphasis is accompanied by a campaign which at times appears to reach the point of hysteria. There is a place for the long-term prescribing of benzodiazepines for some psychiatric patients.
One of the U.K.'s most eminent psychiatrists, in vigorously challenging the fashion, may well have stated what many clinicians believe and indeed practise, but are afraid to say. He has commented that 'There is a belief abroad that benzodiazepines usually lose their therapeutic power during prolonged administration. There is no convincing evidence for this belief. Indeed, the evidence to the contrary is stronger. Whenever rebound phenomena occur, they prove that benzodiazepines had been active in suppressing the clinical expression of a cerebromolecular pathology. Moreover, when patients have been fairly well adjusted on benzodiazepines for a long time but succumb, after a successful withdrawal procedure, almost immediately to a modified recurrence of their anxiety illness, the proof that there had been a continuing therapeutic activity of benzodiazepines could hardly be stronger. Of course, it then also follows that the patients are in need of further medication and perhaps even of further prescriptions for benzodiazepines. This would help the patients, even though it is anathema to a narrow-minded damnation chorus.'1 It might be worthwhile for the government to consider a new category of authority for long-term use of benzodiazepines: 'chronic psychiatric illness where other therapy has failed or is inappropriate'.
A.H.
Dinnen
Consultant
Psychiatrist
Sydney, N.S.W.
R E F E R E N C E
1. Taylor FK. The damnation of benzodiazepines [see comments]. Br J Psychiatry 1989;154:697-704. Comments in: Br J Psychiatry 1989;155:268,421-2,717. Comment in: Br J Psychiatry 1990;156:278-9.
The
Editor comments:
In general, benzodiazepines should be prescribed for short-term treatment
only. There may be a very limited role for the long-term use of benzodiazepines
in some patients who do not respond to cognitive, behavioural or other
psychotherapeutic interventions.
Editor, - Dr Bradley ('Your questions to the PBAC 'Aust Prescr 1993;16:96) observes that it is easy to lose touch with a patient's medications because 'a complete list (is not available) ... all at one time.'
There are several ways in which patients could have such a list, with its obvious advantages. One is by using the 'Medi-List' issued by the Pharmaceutical Society of Australia and illustrated in 'Medication review: what your patients may not tell you' (Aust Prescr 1993;I6:40-2).This card has spaces for information about the individual and the medications, and folds down to a convenient pocket size similar to the pension card. Its main drawbacks are:
The 'Medi-List' has been used at Whyalla Hospital for some months and, after about 80 cards had been issued, an alternative method was investigated. A detailed printout of patients' medications is prepared on computer in a form similar (but not identical) to the 'Medi-List'. It is provided to selected patients on discharge, mainly those on multiple long-term treatments.
The printout is designed to be understood easily by patients and their carers, with extra attention to legibility for those with mild visual impairment. It saves handwriting and is very quick to update if any changes have been made to medication. So far, about 20 patients have been supplied, and the initial response has been favourable.
Such a small scheme may not provide all the answers to Dr Bradley's problems, but, so far, it appears to assist with many of the difficulties which patients have with compliance, and to help others involved in their care. In the next part of this project, it is planned to study in more detail how patients and others use this printout, the costs or savings that result and any consequences that may emerge.
Michael Patkin,
Visiting Surgeon
Hugh
Dearnley, Visiting Medical Officer
Chris Thompson, Pharmacist
Whyalla
Hospital & Health Services, S.A.
Regimens for hormone replacement therapy
ditor, - I refer to Dr D. Palmer's article on this subject (Aust Prescr 1994;17:13-6). It is annoying that oestrogen alone is constantly promoted as hormone-replacement therapy (HRT) for women after hysterectomy. Should not HRT be just that -- therapy to provide a hormone profile similar to the premenopausal level? If progestogens are found to be protective for breast cancer1, how can we as a profession be taken seriously when promoting hormonal therapy with oestrogen only? Once bitten (1960s), twice shy (1990s). First - do no harm.
G. Bates
General
Practitioner
North
Ringwood, Vic.
R E F E R E N C E
1. Gambrell RD Jr. Estrogen replacement therapy and breast cancer risk. A new look at the data. Female patient 1993;18:50,55-60,62.
Dr D.
Palmer, the author of the article, comments:
Oestrogen
is recommended as unopposed therapy for women post-hysterectomy because
it is the specific medication required to relieve symptoms and
to protect against future disease. Progestogens were added to HRT regimens
after being shown to protect against the increased risk of endometrial
carcinoma. While it may be logical to include progestogens in all HRT
regimens to mimic the premenopausal hormone profile, their effect on breast
tissue remains unclear and they have associated problems.
There is debate whether progestogens antagonise the effect of oestrogen on breast tissue in the way that they protect endometrium. It is uncertain whether the increased mitotic activity in breast epithelium in the luteal phase of the cycle is a concern when using exogenous progestogen.1
A recent meta-analysis of 4 studies2 specifically addressed the hypothesis that the addition of progestogen to oestrogen reduces the risk of breast cancer. Contrary to Gambrell's earlier study3 (which did not adjust for age), use of combined HRT did not reduce the overall slight increase in relative risk of breast cancer.
Progestogenic adverse effects, while not life-threatening have been suggested as being one of the most important reasons for women stopping HRT.4 The potential adverse effects of progestogens on lipid profiles and attenuation of the beneficial effect of oestrogen on cardiovascular disease are controversial. These have not been significant in most short-term studies, but long-term results are not available.
Thus, despite limited data suggesting addition of progestogen may protect against breast cancer, most authorities5 would consider the data insufficient to warrant progestogen use in women who have had a hysterectomy; especially in view of the small but real incidence of adverse effects and the theoretical adverse effects on lipid profile.
References
1. Anderson U, Battersby S, King RJ, McPherson K, Going JJ. Oral contraceptive use influences resting breast proliferation. Hum Pathol 1989;20:1139-44.
2. Colditz GA, Egan KM, Stampfer MJ. Hormone replacement therapy and risk of breast cancer: results from epidemiologic studies. Am J Obstet Gynecol 1993;168:1473-80.
3. Gambrell RD Jr, Maier RC, Sanders Bl. Decreased incidence of breast cancer in postmenopausal estrogen-progestogen users. Obstet Gynecol 1983;62:435-43.
4. Smith RN, Holland EF, Studd J W The symptomatology of progestogen intolerance. Maturitas 1994;18:87-91.
5. Khoo SK. Cancer, the menopause and hormone replacement therapy. Aust Prescr 1993;16:66-8.
Editor, - Thank you for your circular letter of 1 February 1994 to readers of Australian Prescriber. I completely agree with your list of selling points for this journal, but I am really irritated that you persist with the myth that Australian Prescriber is independent.
This publication is fully funded by a Federal government department and can therefore never claim to be independent. The true test of independence is to survive in the marketplace and be paid for by your individual subscribers.
I recognise some familiar names among the contributors to Australian Prescriber. Many are academics undertaking research and writing articles for journals supported by pharmaceutical companies. You do your colleagues (and indeed yourself) a disservice when you imply that their opinions expressed in one publication may be tainted while the same opinions in another publication will be certified free of such impurities.
Let us have no more of this holier than thou nonsense. Australian Prescriber is an excellent little journal. It meets its objectives of readability, balance, etc., but no more or less than any of the small pile of journals on drugs and prescribing that we all receive.
Graham Row
Nephrology
Unit
Greenslopes
Repatriation Hospital Greenslopes, Qld
The Editor
comments:
Australian
Prescriber is a member of the International Society of Drug
Bulletins (ISDB). The ISDB is aware of the potential conflict between
medical publications and advertisers and forbids its member journals from
accepting pharmaceutical advertising. Dr Row can rest assured that Australian
Prescriber is free from commercial influence.
I accept that the journal is funded by the Commonwealth. However, the articles are commissioned by an independent Executive Editorial Board of practising clinicians. The Editorial Board can seek advice from the Advisory Editorial Panel (see back cover of journal) which represents many groups of health professionals. Therefore, the content of Australian Prescriber is determined by the professions and not dictated by the government. All articles are extensively reviewed by both the Editorial Board and independent external referees.
Freedom from government and commercial interests results in an impartial and balanced journal. This freedom was recognised in the most recent readership survey, where only 3% of respondents thought that the Editor, Editorial Board or contributors were not independent and unbiased.
Generic prescribing or labelling
Editor, - Case study: An 18-year-old female with a chlamydial pelvic infection was prescribed a prolonged course of doxycycline 100 mg twice daily. The prescription was written as the generic 'doxycycline'.
One week later the patient presented with a scaling rash on the face and dorsa of the hands, presumably the photosensitivity rash described as a possible adverse effect of tetracycline therapy. She produced her tablets: she had both 'Doryx' and Vibramycin' and had been taking two of each per day. Presumably the pharmacist had had insufficient stocks of either brand and so had dispensed some of each. Communication failure, both by me and by the pharmacist, had led to an inadvertent overdose by this patient.
The rash resolved within a week of withdrawal of the doxycycline.
How to prevent this? Either, do not prescribe generically, or force pharmaceutical companies to label their products with the generic names in the same size print as the trade names. The latter seems the preferable solution to me as patients receiving prescriptions from different doctors may still inadvertently make the same mistake as my patient.
Nick
Silberstein
General Practitioner
Mount Barker, W.A.
Zounds! What confuzion reigns!
Editor, - The following drugs have all been (relatively) recently marketed (except Zentel/albendazole, but it is coming soon), have names beginn ing with 'Z' and are of two syllables. Surely, this is sowing the seeds of confuzion, with perhaps dire conzequences?
|
Zadine |
Zantac |
Zentel |
|
Zestril |
Zocor |
Zofran |
|
Zoloft |
Zoton |
Zyrtec |
Cheerz
Dr Alain
Rohan
Zecretary
and
Dr Ian Boyd
Adverse
Drug Reactions Advisory Committee
Editorial note: No commentz.
| Guidelines for the rational use of benzodiazepines |
| The Royal Australian College of General Practitioners has recently reviewed its 'Guidelines for the rational use of benzodiazepines'. These are available from The Royal Australian College of General Practitioners PO Box 906 Rozelle NSW 2039. |
| Australian Statistics on medicines |
| The second edition of Australian Statistics on Medicines, which presents dispensing data on the community (non-hospital) use of most drugs marketed in Australia from 1990 to 1992, is now available from the Australian Government Publishing Service (Freecall 008 020 049) at a cost of $34.95. |
