In response to the availability of one nonsedating antihistamine as an over-the-counter drug, state Medicaid and several large health insurers are considering whether to end prescription drug coverage for all nonsedating antihista-mines. These policies, by their design, would diminish access to recognized standards of treatment for millions of patients with allergic diseases. Professional experience suggests that these actions not only would lower the quality of medial care for affected patients but also would have significant health and safety implications for the general public.

Allergic diseases occur in 10% to 25% of the population, and up to 40% of those affected are children.
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To varying degrees, antihistamines have the capacity to compete with hista-mine for type H1 receptors and to reduce receptor-mediated activation, thus blocking histamine’s adverse effects. Although all of the members of this class of medications are referred to as “antihistamines,” they vary in their pharmacology. Therefore, the selection of any one of these agents should be made in consultation with an experienced health care practitioner, especially for the majority of patients with persistent disease.

One of the concerns created by these policies is the danger associated with self-medication.

Policies that limit patients’ access to appropriate medications impede a physician’s ability to prescribe the best treatment regimens and should not be mistakenly viewed as being endorsed by trained health care professionals.

The FDA has notified health care professionals and patients that serious and sometimes fatal breathing problems have occurred in children younger than two years of age who were given the anti-histamine agent promethazine HCl (e.g., Phenergan medication, Wyeth). Parents and care-givers should obtain a doctor’s advice about giving promethazine in any form to children age two and older.

The labeling on all canadian promethazine brand-name and generic products has been changed to reflect these strengthened warnings.

Topical anesthesia can eliminate the need for an anesthetic injection. “Layering,” a technique for administering topical anesthetics, has been studied mainly in children and in small wounds, but a Harvard study suggests that the practice might have a broader application.

Researchers compared a sequential layered application of anesthetic ingredients with 2% lidocaine infiltration in 100 patients with lacerations that needed to be sutured.

Three ingredients are usually used: lidocaine, epinephrine, and tetracaine. The researchers used only topical lidocaine and epinephrine (TLE) to limit toxicity. They soaked a piece of cotton just large enough to cover the laceration, plus 2 mm of surrounding skin, with TLE, placed it on the wound for 10 to 15 minutes, and then removed it. They then placed a second piece of TLE-soaked cotton deeper inside the wound for 10 to 15 minutes and removed it.

For deeper wounds, they packed a third layer farther into the wound. When the wound edges showed a 3-mm-wide or greater area of vasoconstrictive pallor, the wound was considered anesthetized and ready for suturing.

In the controls, the time necessary for adequate anesthesia ranged from 1 to 12 minutes (mean, 5 minutes). The amount of lidocaine needed to achieve adequate anesthesia varied from 10 to 340 mg.

In the layered-anesthesia group, the time needed for anesthesia varied from 20 to 40 minutes, (mean, 29 minutes). One to four layer applications were needed. Half of the patients required three layers. Deeper lacerations were more time-consuming.

Although it took longer for the anesthesia to work, the TLE patients reported less pain and 66% of them reported no pain, compared with 0% of controls. On follow-up, 95% of the TLE patients rated their experience as “excellent,” compared with 5% of the control patients.

Is layering worth the time? The researchers say yes: the technique eliminated painful injections, the risk of needle injury, and distortion of infiltrated wound tissue. They also felt that patient satisfaction justified the extra time. They waited 10 to 15 minutes for anesthesia to take effect for each layer. They also thought that the time could be reduced without compromising the effectiveness of anesthesia.

Source: Am J Emerg Med 2007

The FDA has approved Extavia (interferon beta-1b) to reduce the frequency of exacerbations in patients with relapsing forms of multiple sclerosis (MS). Developed by Novartis, Extavia is also indicated for patients who have experienced a first clinical episode of MS and who have features consistent with the disease, as shown by magnetic resonance imaging (MRI).

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A black-box warning is now required for the injectable form of promethazine drug , a sedative and an antinausea/antiemetic agent. The warning highlights the risk of serious tissue injury when the drug is administered incorrectly.

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