Medication discrepancies in an outpatient electronic medical record.
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Ambulatory Care↗
Biomedical subjects
M W Kelly
Publications and source records attributed to M W Kelly.
Medication administration practices of school nurses.
This study assessed the medication administration practices of school nurses. From a random sample of 1,000 members of the National Association of School Nurses, 649 (64.9%) completed the survey developed for the study. These school nurses report that during a typical day, 5.6% of children receive medication in school, with 3.3% receiving medications for ADHD. Almost all the school nurses follow written guidelines for administering medication. Potential problems were identified in documenting side effects of medications, storage of medications, student self-administration practices, and appropriate authorization of nonprescription drug use. Most nurses (75.6%) delegate medication administration to unlicensed assistive personnel (UAP), with secretaries (66.2%) the most common UAP. Discomfort with delegation and confusion over state nurse practice laws were noted. Errors in administering medications were reported by 48.5% of the school nurses, with missed dose (79.7%) the most common error. Factors identified as contributing to errors included use of UAP and responsibility for large numbers of students.
Adolescent↗
Metformin hydrochloride: an antihyperglycemic agent.
The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, drug interactions, and dosage and administration of metformin hydrochloride are reviewed. Metformin is an antihyperglycemic agent; it lowers the blood glucose concentration without causing hypoglycemia. Proposed mechanisms of action include decreased intestinal absorption of glucose, increased glucose uptake from the blood into the tissues, decreased glucose production in the liver, and decreased insulin requirements for glucose disposal. Metformin is slowly absorbed from the small intestine and does not undergo hepatic metabolism. The half-life is about five hours. The major route of elimination is renal; the drug is contraindicated in patients with impaired renal function. In double-blind, placebo-controlled trials, metformin has shown efficacy in the treatment of non-insulin-dependent diabetes mellitus (NIDDM). The drug is as effective as sulfonylureas in patients with diabetes who are nonobese or obese and whose diabetes is uncontrolled by diet alone. Metformin may be useful as addon therapy in obese patients with diabetes uncontrolled by sulfonylureas and diet. Lipid profiles may be favorably influenced. The most common adverse effects are gastrointestinal. A rare but potentially fatal adverse effect is lactic acidosis. Metformin has the potential to interact with cationic drugs eliminated by the renal tubular pathway. The usual effective dosage is 1.5-2.5 g/day orally in two or three divided doses. Metformin hydrochloride is an effective alternative to sulfonylureas in obese and non-obese patients with NIDDM in whom diet alone has not achieved glycemic control, and it may be useful as addon therapy in patients whose diabetes has not responded adequately to sulfonylureas plus dietary measures.
Clinical Trials as Topic↗
Movement disorders in patients treated with long-acting injectable antipsychotic drugs.
The frequencies of antipsychotic drug-induced movement disorders documented by physicians and identified by researchers using standardized clinical rating scales were compared, as were the frequencies associated with use of fluphenazine decanoate and haloperidol decanoate. All outpatients at a Veterans Affairs medical center who were being maintained with intramuscular injections of fluphenazine decanoate or haloperidol decanoate and were in otherwise good health were studied. The patients were assessed by a pharmacist using the Abnormal Involuntary Movement Scale to evaluate the presence and severity of tardive dyskinesia (TD) and the Simpson-Angus EPS Rating Scale to evaluate the presence and severity of extrapyramidal symptoms (EPS). The patients' medical records for the previous two years were reviewed to determine whether a movement disorder had been documented, whether the patient's informed consent for antipsychotic drug use had been obtained, and to collect other data about the patient and his or her drug therapy. A total of 50 patients were evaluated. A neurologic examination by a physician had been documented in the chart within six months before clinical testing for 36 patients; abnormal movements had been found in 8 patients. Twenty-one subjects met the study criteria for probable TD or EPS or both. Of these patients, only six had been identified within the previous six months as having a movement disorder. Two patients with medical-record documentation of a movement disorder were not so identified by their test scores. Informed consent had been obtained from only 10 patients. Patients receiving haloperidol decanoate had a higher frequency of EPS but were also receiving higher drug dosages than patients given fluphenazine decanoate.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Multidisciplinary committee on the abuse of prescription medications.
A program for (1) coordinating the care of patients suspected of abusing prescription medications and (2) providing data on the long-term outcomes of these interventions is described. A substance abuse committee composed of physicians, psychologists, pharmacists, and administrators was established to review individual cases of suspected misuse or abuse of medications at a large Department of Veterans Affairs medical center. After reviewing each case, the committee recommended specific actions, such as requesting that the identified medication be restricted from the patient or that the patient receive counseling or treatment for substance abuse. To evaluate the program's effectiveness, the records of the 161 cases referred to the committee between 1981 and 1992 were reviewed. The patient's outcome one year after committee intervention could be determined in 105 cases. Of those, 70 revealed either no evidence of continuing prescription drug abuse or reduced use of the targeted medication in the medical center. Eighteen other patients were no longer receiving care at the institution. A multidisciplinary substance abuse committee helped identify and treat patients suspected of abusing prescription drugs.
Drug Prescriptions↗
Efficacy of fluoxetine in trichotillomania.
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Adolescent↗
Tricyclic antidepressant withdrawal syndrome.
OBJECTIVE: To examine the evidence pointing to a withdrawal syndrome associated with the discontinuation of tricyclic antidepressants (TCAs). DATA SOURCES: MEDLINE searches were conducted. References used in relevant articles were screened for additional published information. STUDY SELECTION: Emphasis was placed on human trials and individual case reports. DATA SYNTHESIS: Symptoms of gastrointestinal and somatic distress, sleep disturbance, and movement disorders and mania have been temporally linked to withdrawal of TCAs. Cholinergic and adrenergic overdrive after TCA discontinuation have been suggested as the proposed mechanism for this syndrome. Reported symptoms may be psychosomatic or related to underlying mental illness. CONCLUSIONS: Clinicians should be aware that discontinuation of TCA therapy may produce a withdrawal syndrome in some patients.
Adolescent↗
The influence of cigarette smoking on haloperidol pharmacokinetics.
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Adult↗
Reduced haloperidol plasma concentration and clinical response in acute exacerbations of schizophrenia.
Twenty-nine hospitalized patients suffering acute exacerbations of schizophrenia were treated for 2 weeks with fixed daily oral doses of haloperidol prospectively calculated to achieve a haloperidol plasma concentration of either 8-18 ng/ml or 25-35 ng/ml. Reduced haloperidol as well as haloperidol concentrations were assayed to determine if the former enhanced the predictability of response. Wee 2 haloperidol plasma concentrations were negatively correlated to clinical response as measured by the percentage change in the BPRS score from baseline (r = -0.43, P less than 0.05). In contrast, week 2 plasma concentrations of reduced haloperidol, total haloperidol (haloperidol + reduced haloperidol), and reduced haloperidol/haloperidol ratio did not correlate with the change in the BPRS score. Chi-square analysis concluded that patients with ratios greater than one were no less likely to be treatment responders (less than 25% improvement in BPRS from baseline and week 2 BPRS less than 55) than those with ratios less than one. Although these data lend additional support to reports of a curvilinear relationship between haloperidol plasma concentration and clinical response, they also suggest that reduced haloperidol plasma concentrations are of no value in predicting treatment response.
Acute Disease↗
A comparison of the effect of fluoxetine and trazodone on the cognitive functioning of depressed outpatients.
Tricyclic antidepressants with clinically significant amounts of anticholinergic activity can adversely affect memory and cognitive functioning. The study evaluated the effect of two non-anticholinergic antidepressants, fluoxetine and trazodone, on immediate and short-term memory in clinically depressed outpatients. The results of this study demonstrated that neither drug affected the depressed patients' cognitive skills as measured by the Guild memory test (digit span and paired associations) during their treatment and recovery. The only factor that was useful in predicting an improvement in cognitive functioning was the change in the measures of depression (Hamilton Rating Scale for Depression and Clinical Global Impression) with time.
Depressive Disorder↗
The effect of gender and subtype on platelet MAO in alcoholism.
Decreased platelet MAO activity has been identified in male alcoholics with suggestions that this is primarily true of Type 2 alcoholics as defined by criteria from the Stockholm Adoption Study. Little information has been available regarding platelet MAO activity in female alcoholics. This study evaluated a group of 71 alcoholics receiving inpatient treatment, including 16 female alcoholics, for platelet MAO activity compared to controls. Female alcoholic's platelet MAO was significantly lower than controls and not different from activity levels in male alcoholics. Among male alcoholics, both Type 1 and Type 2 subgroups were lower than controls and Type 2 levels did not differ from Type 1 levels. Thus, we were unable to replicate a gender and subgroup low platelet MAO specificity among alcoholics, but did find significant differences between alcoholics and controls.
Adult↗
Pharmacokinetic protocol for predicting plasma haloperidol concentrations.
The accurate prediction of steady-state plasma haloperidol concentrations was successfully accomplished by obtaining two blood samples following a 20 mg test dose (kinetic method). Prediction of steady-state concentrations on the basis of a mg/kg/day dosage (dose method), although equally precise, generated significantly less information concerning the variance between observed and predicted haloperidol plasma concentrations. Both predictive methods were less precise when the daily doses exceeded 0.47 mg/kg/day. Fifty percent (6/12 patients) of the haloperidol plasma concentrations were underpredicted if this threshold was exceeded. This finding may suggest the possibility of dose-dependent pharmacokinetics with haloperidol in some patients.
Dose-Response Relationship, Drug↗
HPA axis disturbance in obsessive-compulsive disorder.
Twenty nondepressed outpatients with DSM-III obsessive-compulsive disorder entered a 10-week placebo-controlled study of clomipramine and underwent a 1-mg dexamethasone suppression test (DST) at baseline; 11 had a repeat DST at the end of treatment: Nonsuppression was rare. When compared to 82 previously described outpatients with panic disorder studied in a similar fashion, OCD patients had postdexamethasone cortisol values that were substantially lower and more stable over time. Results within the OCD group closely resembled those from a group of never-ill controls.
Clinical Trials as Topic↗
Serum fluoxetine and norfluoxetine concentrations and antidepressant response.
A high-performance liquid chromatography assay for fluoxetine and its major metabolite, norfluoxetine, was established. Serum concentrations of the two were measured in 13 depressed outpatients following a 6-week trial of the drug. No significant correlations were obvious between clinical improvement as measured by the Hamilton Rating Scale for Depression and the Clinical Global Impression scores and the serum concentrations of fluoxetine and its major metabolite, norfluoxetine, according to these initial pilot data.
Adult↗
A comparative trial of fluoxetine versus trazodone in outpatients with major depression.
The effectiveness of fluoxetine as an antidepressant was contrasted with trazodone in a 6-week double-blind trial in 40 patients. The total score on the Hamilton Rating Scale for Depression and the global improvement score on the Clinical Global Impressions scale favored trazodone at the end of 3 weeks of treatment. However, that difference was no longer apparent during the remainder of the study. The authors hypothesize that fluoxetine 20 mg/day may be an ineffective dosage of the drug or that fluoxetine has a slower onset of antidepressant action than does trazodone.
Adult↗
The relationship of haloperidol concentrations to therapeutic response.
Data from pharmacokinetics studies that examined the relationship of haloperidol serum concentrations and therapeutic response in schizophrenic patients were reexamined utilizing the method of logistic regression analysis. A linear rather than a curvilinear relationship was obvious between serum haloperidol concentration and therapeutic response according to both the regression analysis and inspection of the distribution of the data. It was concluded that a serum haloperidol concentration in the range of 9 to 15 ng/ml was associated with a 30% decrease in the total Brief Psychiatric Rating Scale (BPRS) score. Haloperidol concentrations above these appear unlikely in the majority of patients to produce any additional reduction of symptoms. The BPRS psychosis factor finding suggested an analogous finding for serum haloperidol concentrations between 12 and 17 ng/ml. The analyses suggest that the probability of response to haloperidol seems to reach a point of diminishing return at concentrations of approximately 9 to 17 ng/ml. Serum concentrations above this limit do not appear to either decrease or increase the probability of response.
Adolescent↗
Prescription medication costs: a study of physician familiarity.
BACKGROUND: Studies in the past 25 years have suggested that physicians are not familiar with the costs of common prescription medications. OBJECTIVES: To determine physician familiarity with the cost of common prescription medications and to determine the value physicians place on knowing information regarding the cost of medications. DESIGN: Survey. SETTING: Seven community-based family medicine residency teaching clinics in Iowa. PARTICIPANTS: Two hundred five practicing resident and faculty physicians. INTERVENTIONS: From a series of $10 price intervals (range, $0.01-$80.00), physicians were asked to select the interval containing the cash price of the medication to an uninsured patient for 50 medications commonly prescribed in outpatient family medicine clinics. Physicians were also questioned about the value of medication cost information to their practice. MAIN OUTCOME MEASURES: The percentage of correct responses and the mean pricing scores were calculated for each respondent and for all medications. RESULTS: One hundred seventy-eight physicians responded (86.8%). Only 22.9% of the responses correctly identified the cost of the medication. More than two thirds (68.3%) of the responses underestimated the correct price interval. Branded drugs were underestimated in 89.9% of responses, while generic drugs were overestimated in 90.2% of responses. Overall, 64.4% of physicians believed they did not receive sufficient information in their practices regarding prescription drug costs, and nearly all (93.6%) reported that regular information on prescription medication costs would help them prescribe more cost-effectively. CONCLUSIONS: Physicians are unfamiliar with the costs of medications they commonly prescribe, and they report that regular access to information on prescription medication costs would help them prescribe more cost-effectively. Arch Fam Med. 2000;9:1002-1007
Humans↗
Clomipramine: a tricyclic antidepressant effective in obsessive compulsive disorder.
Clomipramine hydrochloride, a chlorinated analog of imipramine, is a widely used antidepressant recently approved for use in the U.S. for the treatment of obsessive-compulsive disorder (OCD), a potentially incapacitating affliction. Its primary pharmacologic action is blockade of the reuptake of the neurotransmitter serotonin. Its metabolite, desmethylclomipramine, is a potent norepinephrine reuptake inhibitor. Significant first-pass metabolism reduces oral bioavailability to less than 62 percent. The drug is widely distributed throughout the body (volume of distribution 9-25 L/kg) and is 90-98 percent protein-bound. Clomipramine follows first-order elimination pharmacokinetics, with a plasma half-life of 20-24 hours. Recent double-blind controlled clinical trials have demonstrated the drug's effectiveness in the treatment of OCD. Response is most often associated with doses greater than 75 mg/d, with 250 mg the maximum recommended daily dose. Relapse upon withdrawal is frequently reported. The adverse effect profile of clomipramine is similar to other tricyclic antidepressants, with anticholinergic, cardiovascular, sexual, and central nervous system effects the most prominent.
Clomipramine↗