patient, Dr T. Olsen for permission to report his patient and Ms L. Crilly for typing the manuscript. Date of submission: 7 May 1992 A. A. SULLIVAN,
Medical Registrar, S. F. FANNING, Haematology Registrar, A. M. ALLWORTH, Infectious Diseases Physician, Royal Hrisbane Hospital, Qld.
References 1. Josten KM, Tooze JA, Borthwick-ClarkeC, Gordon-Smith EC, Rutherford TR. Acquired aplastic anaemia and paroxysmal nocturnal haemoglobinuria:studies on clonality. Blood 1991; 78: 3 162-7. 2. Rotoli B, Luzzatto L. Paroxysmal nocturnal hemoglobinuria.Sem in Hematol 1989; 26: 201-7. 3. Sugar AM. Agents of mucormycosis and related species. In: Mandell/Douglas/Bennett(Eds). Principles and practices of infectious diseases, 3rd edition. New York: Churchill-Livingstone, 1990; 1962-1972.
Glutethimide withdrawal syndrome supply and demand Glutethimide is an hypnosedative drug with little to recommend its use because ofits addictive potential and the severity of its withdrawal syndrome which can be at least as severe as that found with barbiturates with antimuscarinic effects also predominating. ‘ This letter illustrates the difficulties encountered in the management of glutethimide withdrawal syndrome and briefly addresses the ethics of prescribing and dispensing such a drug when safer hypnosedatives are currently available. A 70-year-old divorcee was urgently admitted to hospital with two generalised seizures followed by agitated confusion. He had a long history o f a severe anxiety state for which he had been taking the now discontinued hypnosedative drug glutethimide (Doriden* Ciba Geigy) in quantities greatly exceeding the generally recommended dose. The patient’s source of glutethimide supply had ceased a few days prior to admission. There were no abnormalities on physical examination, apart from drowsiness and mild pyrexia. Blood alcohol concentration was nil, urine drug screen was also negative and other relevant investigations were normal. A diagnosis of glutethimide withdrawal syndrome was made and oral diazepam 10 mg four hourly commenced. The hospital stay was punctuated by persistent nausea, anxiety, and sleep disturbance. Phenytoin was required for two further brief, generalised seizures complicated by a fractured vertebral body and neck of humerus. A paralytic ileus also occurred on day 5. At the end of the second week, the patient still required diazepam 30 mg daily in addition to regular codeine-containing analgesics for his painhl fractures. Following review by the liaison psychiatrist and drug and alcohol counseller, the patient was discharged three weeks after admission, still requiring phenytoin and moderate doses of diazepam and analgesics. Clinicians should be aware that discontinued drugs like glutethimide are still to be found in the community and alerted to the possibility of glutethimide use, when patients present with symptom complexes consistent with chronic hypnosedative ingestion, overdose or the abstinence syndrome.
708
Aust NZ J Med 1992; 22
- the ethics of
The alarming occurrence of generalised seizures up to four days after admission, despite administration of moderately large doses of diazepam and in the absence of premonitory signs such as tremulousness and muscle twitching, resulted in significant morbidity in this patient. The sole local supplier of glutethimide, Ciba Geigy, ceased world wide supply and distribution of Doriden* tablets in late 1986 in response to the problems associated with the drug’s use and decreased demand. Surprisingly, supplies of glutethimide are still obtainable six years later. Prescribing or supplying discontinued drugs like glutethimide is not illegal but would be considered by most as undesirable. Despite this, it is notable that the patient was able to obtain supplies ofthis drug from several pharmacies with whom he was well acquainted. The unreliability of his sources of supply became obvious on his presentation. An arrangement existed between the patient, the medical practitioner and the pharmacist which resulted in significant morbidity from the glutethimide withdrawal syndrome. This situation could have been prevented by transferring the patient to equipotent doses of a long-acting benzodiazepine with frequent clinical assessment, and aiming for slow detoxification whilst addressing the problems associated with the anxiety state. R. E. LUCAS, Registrar , W. S. MONTGOMERY, Deputy Director of Pharmacy, Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, NSW. Date of submission: 18 May 1992 References 1. Rall TW. Hypnotics and sedatives; Ethanol. In: Goodman Gillman A, Rall TW, Nies AS, Taylor P (eds).The pharmacologicalbasis of therapeutics. New York: Pergamon Press 1990, 365-6. LETTERS AND CASE REPORTS
Medical Registrar, S. F. FANNING, Haematology Registrar, A. M. ALLWORTH, Infectious Diseases Physician, Royal Hrisbane Hospital, Qld.
References 1. Josten KM, Tooze JA, Borthwick-ClarkeC, Gordon-Smith EC, Rutherford TR. Acquired aplastic anaemia and paroxysmal nocturnal haemoglobinuria:studies on clonality. Blood 1991; 78: 3 162-7. 2. Rotoli B, Luzzatto L. Paroxysmal nocturnal hemoglobinuria.Sem in Hematol 1989; 26: 201-7. 3. Sugar AM. Agents of mucormycosis and related species. In: Mandell/Douglas/Bennett(Eds). Principles and practices of infectious diseases, 3rd edition. New York: Churchill-Livingstone, 1990; 1962-1972.
Glutethimide withdrawal syndrome supply and demand Glutethimide is an hypnosedative drug with little to recommend its use because ofits addictive potential and the severity of its withdrawal syndrome which can be at least as severe as that found with barbiturates with antimuscarinic effects also predominating. ‘ This letter illustrates the difficulties encountered in the management of glutethimide withdrawal syndrome and briefly addresses the ethics of prescribing and dispensing such a drug when safer hypnosedatives are currently available. A 70-year-old divorcee was urgently admitted to hospital with two generalised seizures followed by agitated confusion. He had a long history o f a severe anxiety state for which he had been taking the now discontinued hypnosedative drug glutethimide (Doriden* Ciba Geigy) in quantities greatly exceeding the generally recommended dose. The patient’s source of glutethimide supply had ceased a few days prior to admission. There were no abnormalities on physical examination, apart from drowsiness and mild pyrexia. Blood alcohol concentration was nil, urine drug screen was also negative and other relevant investigations were normal. A diagnosis of glutethimide withdrawal syndrome was made and oral diazepam 10 mg four hourly commenced. The hospital stay was punctuated by persistent nausea, anxiety, and sleep disturbance. Phenytoin was required for two further brief, generalised seizures complicated by a fractured vertebral body and neck of humerus. A paralytic ileus also occurred on day 5. At the end of the second week, the patient still required diazepam 30 mg daily in addition to regular codeine-containing analgesics for his painhl fractures. Following review by the liaison psychiatrist and drug and alcohol counseller, the patient was discharged three weeks after admission, still requiring phenytoin and moderate doses of diazepam and analgesics. Clinicians should be aware that discontinued drugs like glutethimide are still to be found in the community and alerted to the possibility of glutethimide use, when patients present with symptom complexes consistent with chronic hypnosedative ingestion, overdose or the abstinence syndrome.
708
Aust NZ J Med 1992; 22
- the ethics of
The alarming occurrence of generalised seizures up to four days after admission, despite administration of moderately large doses of diazepam and in the absence of premonitory signs such as tremulousness and muscle twitching, resulted in significant morbidity in this patient. The sole local supplier of glutethimide, Ciba Geigy, ceased world wide supply and distribution of Doriden* tablets in late 1986 in response to the problems associated with the drug’s use and decreased demand. Surprisingly, supplies of glutethimide are still obtainable six years later. Prescribing or supplying discontinued drugs like glutethimide is not illegal but would be considered by most as undesirable. Despite this, it is notable that the patient was able to obtain supplies ofthis drug from several pharmacies with whom he was well acquainted. The unreliability of his sources of supply became obvious on his presentation. An arrangement existed between the patient, the medical practitioner and the pharmacist which resulted in significant morbidity from the glutethimide withdrawal syndrome. This situation could have been prevented by transferring the patient to equipotent doses of a long-acting benzodiazepine with frequent clinical assessment, and aiming for slow detoxification whilst addressing the problems associated with the anxiety state. R. E. LUCAS, Registrar , W. S. MONTGOMERY, Deputy Director of Pharmacy, Department of Clinical Pharmacology and Toxicology, St Vincent’s Hospital, Sydney, NSW. Date of submission: 18 May 1992 References 1. Rall TW. Hypnotics and sedatives; Ethanol. In: Goodman Gillman A, Rall TW, Nies AS, Taylor P (eds).The pharmacologicalbasis of therapeutics. New York: Pergamon Press 1990, 365-6. LETTERS AND CASE REPORTS
