Code of ethics To the editor: For some years I have struggled with student and house staff assessment forms that asked me to judge an individual's ethics by grading them from "poor" to "excellent" on a 5- or 10-point scale. This will be even more confusing now that various well-meaning groups believe that something as basic as a code of ethics should be subject to the whim of members of a general meeting acting on an amendment from the floor. Persons so intent should pause to reflect on just where this course of action may lead us, regardless of how righteous they believe the cause they are defending. For example, I am sceptical of the value of hypnosis therapy for cigarette smoking and obesity, of transcendental meditation for angina pectoris and of acupuncture for all sorts of disorders. Is this because of my beliefs or because of my scientific training? If the latter, is not dedication to the scientific method a "belief"? Therefore, should we be expected to post signs in our offices declaring all our beliefs or scepticisms, and, if confronted with a patient with any of these problems, suggest consultation with a colleague who is more "liberal"? Surely we will never do better than to depend on the good sense and dedication of our colleagues. The use of a code of ethics as an issue in a current political debate is a dangerous precedent and one that I, for one, would wish abandoned forthwith. HUGH M. Scorr, MD
Centre hospitalier universitaire de Sherbrooke Sherbrooke, PQ
Isoniazid overdose To the editor: Dr. W.M. Cameron's article on isoniazid overdose (Can Med Assoc J 118: 1413, 1978) is alarming. From January 1973 to December 1976, 17 persons from three reserves in the Kenora area were hospitalized with overdoses of isoniazid. The national reference centre for tuberculosis, Laboratory Centre for Disease Control, Ottawa has been dealing with similar problems from a laboratory point of view, and has drawn the attention of the tuberculosis control authorities of Ontario to this fact. In 1970 two Indian girls from the Thunder Bay region took
an overdose of isoniazid and died. Another Indian from that area died of an isoniazid overdose in 1976. It appears, from Dr. Cameron's report as well as from our experience, that isoniazid poisoning is an important problem in some parts of Ontario. Serum samples for isoniazid determination were also submitted to our laboratory from other parts of Canada. Between 1975 and 1978 we received samples from five patients with isoniazid overdose in the Winnipeg region. Most of the patients were treated by dialysis and all five survived. On the other hand, as recommended by Brown,1 it seems essential to administer large doses of pyridoxine to counteract isoniazid poisoning. The serum concentrations in the five patients were occasionally as high as 189 and 193 .tg/mL. Two autopsies revealed that the blood collected had a very high content of acetylisoniazid (80 to 124 .tg/mL). In 1977 in Toronto our assistance was required at a coroner's inquest into an Indian girl's death due to the ingestion of 20 g of isoniazid. We believe that Dr. Cameron's report is very revealing. There must be a way to prevent suicide by isoniazid overdose and the nonmedical use of isoniazid in combination with alcohol as a stimulant. Fully supervised twice-weekly drug therapy for ambulatory native patients with tuberculosis is one solution; it would avoid the gross irregularity of selfadministration of the drug and ensure better therapeutic results. It would also eliminate the distribution of monthly supplies of drugs that are often not taken as prescribed or are misused. The Tuberculosis Chemotherapy Centre in Madras introduced intermittent chemotherapy, but its name and therapeutic approach have undergone several changes; in developed countries it is now known as diphasic intermittent therapy.2 During the first phase, an indispensable part of the entire curative program, isoniazid and rifampin are given daily for 2 to 3 months. The therapy might be supported by either streptomycin or pyrazinamide administration. In the second, intermittent phase isoniazid and streptomycin are usually administered twice weekly. Intermittent administration of rifam-
692 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
Catapres® clonidine hydrochloride
PRESCRIBING INFORMATION COMPOSITION 2-(2,6-dichlorophenylamino)-2-imidazoline hydrochloride. INDICATIONS Catapres has been used successfully to treat hypertension of all grades of severity. CONTRAINDICATIONS There are no known absolute contraindications to the use of Catapres. WARNINGS If Catapres therapy is discontinued for any reason, withdrawal should be done gradually over several days rather than abruptly. There have been rare instances of rebound hypertensive crises following sudden discontinuation of high doses of the drug. This can be effectively controlled by reinstituting Catapres at the previous dosage level; however if more rapid control is necessary, intravenous infusions of alpha adrenergic blocking agents such as intravenous phentolamine (5-10 mg doses at 5 minute intervals up to a total of 30 mg) are effective in reducing the bldod pressure. PRECAUTIONS Patientawith a known history of depression should be carefully supervised while under treatment with Catapres, as there have been occasional reports of further depressive episodes occurring in such patients. As an abrupt withdrawal of Catapres is followed in rare instances by an excess of circulating catecholamines, caution should be exercised in the concomitant use of drugs which affect the metabolism or the tissue uptake of these amines (MAO inhibitors and tricyclic antidepressants respectively). A few instances of a condition resembling Raynaud's phenomenon have been reported. Caution should therefore be observed if patients with Raynaud's disease or thromboanglitis obliterans are to be treated with Catapres. Catapres has a mucous membrane drying effect on the eyes. On rare occasions this has led to corneal ulceration. As with any drug excreted primarily in the urine, smaller doses of Catapres are often effective in treating patients with a degree of renal failure. The use of Catapres during the first trimester of pregnancy is subject to the normal precautions surrounding the use of any drug. Animal tests have shown no evidence of foetal abnormality, though there was some decreased fertility. ADVERSE EFFECTS The most commonly encountered side effects are initial sedation and dry mouth. However these effects are seldom severe and tend to be dose related and transient. There are occasional reports of fluid retention and weight gain during the initial stages of treatment with Catapres. This side effect is usually transient, but the addition of a diuretic will correct any tendency to fluid retention in these cases. Other occasional drug-related side effects which have been noted in literature include dizziness, heedache, dryness, itching orburning of the eyes, rarely corneal ulceration, nocturnal unrest, nausea, euphoria, constipation, impotence (rarely), and agitation on withdrawal of therapy. Facial pallor has occasionally been noted at high dosage levels. No toxic reactions have been observed on investigating blood status, renal function and liver function. Long-term treatment has shown no adverse effect on blood urea nitrogen levels, and in patients with pre-existing renal damage there is no suggestion of further impairment of the renal blood flow despite a fall in arterial blood pressure. SYMPTOMS AND TREATMENT OF OVERDOSAGE Cases of accidental overdosage have shown skin pallor, bradycardia, pronounced hypotension, dryness of the mouth, and deep sedation or coma. Gastric lavage and the administration of an analeptic and a vasopressor have produced complete recovery within 24 hours. DOSAGE Initially 0.05-0.1 mg four times daily. This dosage may be increased every few days until satisfactory control is achieved. When used a/one the final dosage usually ranges between 0.2 and 1.2 mg daily. The last dose of the day should be given immediately before retiring to ensure blood pressure control during sleep. Cafapres used with a diuretic Catapres has been used successfully together with chlorthalidone, furosemide and the thiazide diuretics. Lower doses of Catapres or the diuretic may be used to achieve the same degree of blood pressure control whenever a diuretic is added to the Catapres regimen or vice versa. In these circumstances, most mild-to-moderate hyperfensives can be controlled using only 0.3-0.6 mg of Catapres daily in divided doses. Severe hypertensives have been successfully treated with a diuretic and higher doses of Catapres (frequently up to 1.2 mg daily and occasionally up to 5 mg daily). When extremely high doses of Catapres are necessary dosage adjustments should be made over a period of several months. Catapres used with other antihypertensive agents Catapres has been used together with methyldops, guanethidine, bethanidine and hydralazi ne, and further reductions in blood pressure have been achieved. AVAILABILITY 1. 0.1 mg Tablet: A white, single-scored tablet, impressed with the motif . on one side and the Boehringer Ingelheim symbol on the reverse. Bottles of 100 and 500. 2. 0.2 mg Tablet: An orange, single-scored tablet, impressed with the motif 02C on one side and the Boehringer Ingelheim symbol on the reverse. Bottles of 50 and 500. For further prescribing information, consult the Catapres Product Monograph or your Boehringer Ingelheim representative. I I
-. nillin
Boebrlnger Ingelhelm (Canada) Ltd. I B 3049A, Deacon Road II I Dollard des Ormeaux, P.O. HBB 2M5 PP
B-351 -78
pin could increase the frequency of adverse reactions. Undoubtedly, there are highly effective antituberculous drugs, but the incidence of tuberculosis is still very high among Indians and Inuit. One may agree with Fox3 that the main problem is how to apply the currently available knowledge successfully. Unless the organizational problems are overcome even excellent drug regimens will produce only modest results. At present there is a considerable gap between the results attained and those that could be achieved; this is tragic not only for the patient but also for the entire community.4 The failure of patients to continue treatment is common in both developing and technically advanced countries. It is especially frequent in remote areas and low socioeconomic regions, and among alcoholics and middle-aged vagrant city dwellers. Although diphasic intermittent chemotherapy is recommended by the World Health Organization, the British Medical Research Council and recently the American Thoracic Society5 for patients not complying with the daily regimen in ambulatory treatment, it is only reluctantly accepted in Canada. In the United States this mode of therapy was successfully applied in the treatment of uncooperative outpatients'-' and alcoholics,"10 as well as persons at the Fort Apache reservation in eastcentral Arizona, a rural setting with serious social problems.11 In Manitoba E. Hershfield, medical director of the Canadian Lung Association, uses diphasic intermittent therapy in the treatment of natives with tuberculosis (personal communication, 1978). Certainly this endeavour may also meet from time to time with difficulties. However, the results so far are very promising and the method used seems superior to the present practice of daily ambulatory therapy. LESLIE ElDus, MD Director, bureau of bacteriology MARY M. HODGKIN Chemist National reference centre for tuberculosis Laboratory Centre for Disease Control Health and Welfare Canada Ottawa, Ont.
References 1. BROWN CV: Acute isoniazid poisoning. Am Rev Respir Dis 105: 206, 1972
2. VIvIEN JN, THIBIER R, LEPEUPLE A:
Recent studies on isoniazid. Adv Tuberc Res 18: 148, 205; 1972 3. Fox W: Considerations g6n6rales sur le choix et le maniement des regimes thErapeutiques dans la tuberculose pulmonaire. Bull mt Union Tuberc 47 51, 1972 4. ROUILLON A: Probl.mes poses par l'organisation d'un traitement ambulatoire efficace des malades tuberculeux. Motivation. Ibid, p 72 5. Symposium on controversies in treatment of tuberculosis, 74th annual meeting of the American Lung Association, Boston, May 14-17, 1978. Am Rev Respir Dis 17 (no 4, part 2): 37, 1978 6. HUDSON LD,
SBARBARO
JA:
Twice
weekly tuberculosis chemotherapy. JAMA 223: 139, 1973 7. SBARBARO JA: Intermittent chemotherapy for adult with tuberculosis (C). Am Rev Respir Dis 111: 367, 1975 8. SBARBARO JA, HUDSON LD: High dose ethambutol; an oral alternate for intermittent chemotherapy. Am Rev RespirDis 110: 91, 1974 9. BAILEY WC,
SELLERS
CA,
SUTFoN
FD, et al: Tuberculosis and alcoholism. A partial solution through detection. Chest 73: 183, 1978 10. BAILEY WC, SurroN F, ElDus L: Supervised short-term weekly chemotherapy of pulmonary tuberculosis (abstr). Presented at the XXIVth International Conference of the International Union Against Tuberculosis, Brussels, Sept 5-8, 1978 11. WESTLEY
TA,
BAUGH
DO:
Twice
weekly chemotherapy for tuberculosis (C). JAMA 224: 247, 1973
Normal blood pressure in offspring of persons with essential hypertension To the editor: I read with interest the article by Dr. B.S. Kaplan and colleagues (Can Med Assoc 1 118: 1415, 1978) in which they reported that no hypertension had been found among 94 healthy offspring of persons with essential hypertension. Aside from stressing the point that the prevalence of hypertension in children is probably lower than that suggested by the literature16 (usually written by hypertension specialists rather than by epidemiologists), the paper by Kaplan and colleagues raises another question - should the definition of hypertension in children be based on statistics or on morbidity? If one decides to define as hypertensive the children whose blood pressure falls above the 95th percentile, then 5% of the children sampled will be hypertensive whatever the population studied, as long as the shape of the distribution is
694 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
DERMOVATE
(clobetasol propionate 0.05%) TOPICAL CORTICOSTEROID
Rapid relief can mean an early return to nonnal living. INDICATIONS ¶Jbpical therapy of recalcitrant corticosteroidresponsive dermatoses, including severe cases of psoriasis and eczematous dermatitis. CONTRAINDICATIONS Infected skin lesions if no anti-infective agent is used simultaneously; fungal and viral infections of the skin, including herpes simplez vaccima and varicella; pregnancy and lactation; hypersensitivity to any of the ingredients. 'lbpical corticosteroids are also contraindicated in tuberculous lesions of the skin. WARNINGS Dermovate should not be used in the eye. When used over extensive areas for prolonged periods, it is possible that sufficient absorption may take place to give rise to systemic effects. It is advisable, therefore, to use Dermovate for brief periods only, and to discontinue its use as soon as the lesion has cleared up. Do not use more than fifty grams of Dermovate per week. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. PRECAUTIONS ¶lbpical corticosteroids should be used with caution on lesions close to the eye. Posterior subcapsular cataracts have been reported following systemic use of corticosteroids. Although hypersensitivity reactions are rare with topically applied steroids, the drug should be discontinued and appropriate therapy initiated if there are signs of hypersensitivity. In cases of bacterial infections of the skin, appropriate antibacterial agents should be used as primary therapy. If it is considered necessary, the topical corticosteroid may be used as an adjunct to control inflammation, erythema and itching. Ifs symptomatic response is not noted within a few days to a week, the local application of corticosteroid should be discontinued until the infection is brought under controL Significant systemic absorption may occur when steroids are applied over large areas of the body, especially under occlusive dressings. Because the degree of absorption of clobetasol 17-propionate when applied under occlusive dressing has not been measured, its use in this fashion is not recommended Because the safety and effectiveness of Dermovate has been established in children, its use in children is not recommended. ADVERSE REACTIONS Local burning, irritation, itching, skin atrophy, strise, change in pigmentation, secondary ininfection, hypertrichosis and adrenal suppression have been observed following topical corticosteroid therapy. DOSAGE AND ADMINISTRATION Dermovate Cream and Dermovate Ointment are applied thinly to cover the affected area. and gentiy rubbed into the skin. Frequency of application is two to three times daily; according to the severity of the condition. The total dose of Dermovate applied weekly should not exceed fifty grams. Therapy should be discontinued if no response is noted after a week or as soon as the lesion heals. It is advisable to use Dermovate for brief periods only. Note: If malntenance therapy is required, a lower strength topical steroid, such as Betnovate, is indicated. DOSAGE FORMS Dermovate Cream and Dermovate Ointment are available in 15 and 60 g tubes, and in 100 gjars. Product monograph avallable on request REFERENCE: 1. Floden, C.H. et al., Current Med. Research and Opinion, 3:875-877,1975.
\Et/Glaxo Laboratories
EEJ
Centre hospitalier universitaire de Sherbrooke Sherbrooke, PQ
Isoniazid overdose To the editor: Dr. W.M. Cameron's article on isoniazid overdose (Can Med Assoc J 118: 1413, 1978) is alarming. From January 1973 to December 1976, 17 persons from three reserves in the Kenora area were hospitalized with overdoses of isoniazid. The national reference centre for tuberculosis, Laboratory Centre for Disease Control, Ottawa has been dealing with similar problems from a laboratory point of view, and has drawn the attention of the tuberculosis control authorities of Ontario to this fact. In 1970 two Indian girls from the Thunder Bay region took
an overdose of isoniazid and died. Another Indian from that area died of an isoniazid overdose in 1976. It appears, from Dr. Cameron's report as well as from our experience, that isoniazid poisoning is an important problem in some parts of Ontario. Serum samples for isoniazid determination were also submitted to our laboratory from other parts of Canada. Between 1975 and 1978 we received samples from five patients with isoniazid overdose in the Winnipeg region. Most of the patients were treated by dialysis and all five survived. On the other hand, as recommended by Brown,1 it seems essential to administer large doses of pyridoxine to counteract isoniazid poisoning. The serum concentrations in the five patients were occasionally as high as 189 and 193 .tg/mL. Two autopsies revealed that the blood collected had a very high content of acetylisoniazid (80 to 124 .tg/mL). In 1977 in Toronto our assistance was required at a coroner's inquest into an Indian girl's death due to the ingestion of 20 g of isoniazid. We believe that Dr. Cameron's report is very revealing. There must be a way to prevent suicide by isoniazid overdose and the nonmedical use of isoniazid in combination with alcohol as a stimulant. Fully supervised twice-weekly drug therapy for ambulatory native patients with tuberculosis is one solution; it would avoid the gross irregularity of selfadministration of the drug and ensure better therapeutic results. It would also eliminate the distribution of monthly supplies of drugs that are often not taken as prescribed or are misused. The Tuberculosis Chemotherapy Centre in Madras introduced intermittent chemotherapy, but its name and therapeutic approach have undergone several changes; in developed countries it is now known as diphasic intermittent therapy.2 During the first phase, an indispensable part of the entire curative program, isoniazid and rifampin are given daily for 2 to 3 months. The therapy might be supported by either streptomycin or pyrazinamide administration. In the second, intermittent phase isoniazid and streptomycin are usually administered twice weekly. Intermittent administration of rifam-
692 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
Catapres® clonidine hydrochloride
PRESCRIBING INFORMATION COMPOSITION 2-(2,6-dichlorophenylamino)-2-imidazoline hydrochloride. INDICATIONS Catapres has been used successfully to treat hypertension of all grades of severity. CONTRAINDICATIONS There are no known absolute contraindications to the use of Catapres. WARNINGS If Catapres therapy is discontinued for any reason, withdrawal should be done gradually over several days rather than abruptly. There have been rare instances of rebound hypertensive crises following sudden discontinuation of high doses of the drug. This can be effectively controlled by reinstituting Catapres at the previous dosage level; however if more rapid control is necessary, intravenous infusions of alpha adrenergic blocking agents such as intravenous phentolamine (5-10 mg doses at 5 minute intervals up to a total of 30 mg) are effective in reducing the bldod pressure. PRECAUTIONS Patientawith a known history of depression should be carefully supervised while under treatment with Catapres, as there have been occasional reports of further depressive episodes occurring in such patients. As an abrupt withdrawal of Catapres is followed in rare instances by an excess of circulating catecholamines, caution should be exercised in the concomitant use of drugs which affect the metabolism or the tissue uptake of these amines (MAO inhibitors and tricyclic antidepressants respectively). A few instances of a condition resembling Raynaud's phenomenon have been reported. Caution should therefore be observed if patients with Raynaud's disease or thromboanglitis obliterans are to be treated with Catapres. Catapres has a mucous membrane drying effect on the eyes. On rare occasions this has led to corneal ulceration. As with any drug excreted primarily in the urine, smaller doses of Catapres are often effective in treating patients with a degree of renal failure. The use of Catapres during the first trimester of pregnancy is subject to the normal precautions surrounding the use of any drug. Animal tests have shown no evidence of foetal abnormality, though there was some decreased fertility. ADVERSE EFFECTS The most commonly encountered side effects are initial sedation and dry mouth. However these effects are seldom severe and tend to be dose related and transient. There are occasional reports of fluid retention and weight gain during the initial stages of treatment with Catapres. This side effect is usually transient, but the addition of a diuretic will correct any tendency to fluid retention in these cases. Other occasional drug-related side effects which have been noted in literature include dizziness, heedache, dryness, itching orburning of the eyes, rarely corneal ulceration, nocturnal unrest, nausea, euphoria, constipation, impotence (rarely), and agitation on withdrawal of therapy. Facial pallor has occasionally been noted at high dosage levels. No toxic reactions have been observed on investigating blood status, renal function and liver function. Long-term treatment has shown no adverse effect on blood urea nitrogen levels, and in patients with pre-existing renal damage there is no suggestion of further impairment of the renal blood flow despite a fall in arterial blood pressure. SYMPTOMS AND TREATMENT OF OVERDOSAGE Cases of accidental overdosage have shown skin pallor, bradycardia, pronounced hypotension, dryness of the mouth, and deep sedation or coma. Gastric lavage and the administration of an analeptic and a vasopressor have produced complete recovery within 24 hours. DOSAGE Initially 0.05-0.1 mg four times daily. This dosage may be increased every few days until satisfactory control is achieved. When used a/one the final dosage usually ranges between 0.2 and 1.2 mg daily. The last dose of the day should be given immediately before retiring to ensure blood pressure control during sleep. Cafapres used with a diuretic Catapres has been used successfully together with chlorthalidone, furosemide and the thiazide diuretics. Lower doses of Catapres or the diuretic may be used to achieve the same degree of blood pressure control whenever a diuretic is added to the Catapres regimen or vice versa. In these circumstances, most mild-to-moderate hyperfensives can be controlled using only 0.3-0.6 mg of Catapres daily in divided doses. Severe hypertensives have been successfully treated with a diuretic and higher doses of Catapres (frequently up to 1.2 mg daily and occasionally up to 5 mg daily). When extremely high doses of Catapres are necessary dosage adjustments should be made over a period of several months. Catapres used with other antihypertensive agents Catapres has been used together with methyldops, guanethidine, bethanidine and hydralazi ne, and further reductions in blood pressure have been achieved. AVAILABILITY 1. 0.1 mg Tablet: A white, single-scored tablet, impressed with the motif . on one side and the Boehringer Ingelheim symbol on the reverse. Bottles of 100 and 500. 2. 0.2 mg Tablet: An orange, single-scored tablet, impressed with the motif 02C on one side and the Boehringer Ingelheim symbol on the reverse. Bottles of 50 and 500. For further prescribing information, consult the Catapres Product Monograph or your Boehringer Ingelheim representative. I I
-. nillin
Boebrlnger Ingelhelm (Canada) Ltd. I B 3049A, Deacon Road II I Dollard des Ormeaux, P.O. HBB 2M5 PP
B-351 -78
pin could increase the frequency of adverse reactions. Undoubtedly, there are highly effective antituberculous drugs, but the incidence of tuberculosis is still very high among Indians and Inuit. One may agree with Fox3 that the main problem is how to apply the currently available knowledge successfully. Unless the organizational problems are overcome even excellent drug regimens will produce only modest results. At present there is a considerable gap between the results attained and those that could be achieved; this is tragic not only for the patient but also for the entire community.4 The failure of patients to continue treatment is common in both developing and technically advanced countries. It is especially frequent in remote areas and low socioeconomic regions, and among alcoholics and middle-aged vagrant city dwellers. Although diphasic intermittent chemotherapy is recommended by the World Health Organization, the British Medical Research Council and recently the American Thoracic Society5 for patients not complying with the daily regimen in ambulatory treatment, it is only reluctantly accepted in Canada. In the United States this mode of therapy was successfully applied in the treatment of uncooperative outpatients'-' and alcoholics,"10 as well as persons at the Fort Apache reservation in eastcentral Arizona, a rural setting with serious social problems.11 In Manitoba E. Hershfield, medical director of the Canadian Lung Association, uses diphasic intermittent therapy in the treatment of natives with tuberculosis (personal communication, 1978). Certainly this endeavour may also meet from time to time with difficulties. However, the results so far are very promising and the method used seems superior to the present practice of daily ambulatory therapy. LESLIE ElDus, MD Director, bureau of bacteriology MARY M. HODGKIN Chemist National reference centre for tuberculosis Laboratory Centre for Disease Control Health and Welfare Canada Ottawa, Ont.
References 1. BROWN CV: Acute isoniazid poisoning. Am Rev Respir Dis 105: 206, 1972
2. VIvIEN JN, THIBIER R, LEPEUPLE A:
Recent studies on isoniazid. Adv Tuberc Res 18: 148, 205; 1972 3. Fox W: Considerations g6n6rales sur le choix et le maniement des regimes thErapeutiques dans la tuberculose pulmonaire. Bull mt Union Tuberc 47 51, 1972 4. ROUILLON A: Probl.mes poses par l'organisation d'un traitement ambulatoire efficace des malades tuberculeux. Motivation. Ibid, p 72 5. Symposium on controversies in treatment of tuberculosis, 74th annual meeting of the American Lung Association, Boston, May 14-17, 1978. Am Rev Respir Dis 17 (no 4, part 2): 37, 1978 6. HUDSON LD,
SBARBARO
JA:
Twice
weekly tuberculosis chemotherapy. JAMA 223: 139, 1973 7. SBARBARO JA: Intermittent chemotherapy for adult with tuberculosis (C). Am Rev Respir Dis 111: 367, 1975 8. SBARBARO JA, HUDSON LD: High dose ethambutol; an oral alternate for intermittent chemotherapy. Am Rev RespirDis 110: 91, 1974 9. BAILEY WC,
SELLERS
CA,
SUTFoN
FD, et al: Tuberculosis and alcoholism. A partial solution through detection. Chest 73: 183, 1978 10. BAILEY WC, SurroN F, ElDus L: Supervised short-term weekly chemotherapy of pulmonary tuberculosis (abstr). Presented at the XXIVth International Conference of the International Union Against Tuberculosis, Brussels, Sept 5-8, 1978 11. WESTLEY
TA,
BAUGH
DO:
Twice
weekly chemotherapy for tuberculosis (C). JAMA 224: 247, 1973
Normal blood pressure in offspring of persons with essential hypertension To the editor: I read with interest the article by Dr. B.S. Kaplan and colleagues (Can Med Assoc 1 118: 1415, 1978) in which they reported that no hypertension had been found among 94 healthy offspring of persons with essential hypertension. Aside from stressing the point that the prevalence of hypertension in children is probably lower than that suggested by the literature16 (usually written by hypertension specialists rather than by epidemiologists), the paper by Kaplan and colleagues raises another question - should the definition of hypertension in children be based on statistics or on morbidity? If one decides to define as hypertensive the children whose blood pressure falls above the 95th percentile, then 5% of the children sampled will be hypertensive whatever the population studied, as long as the shape of the distribution is
694 CMA JOURNAL/OCTOBER 7, 1978/VOL. 119
DERMOVATE
(clobetasol propionate 0.05%) TOPICAL CORTICOSTEROID
Rapid relief can mean an early return to nonnal living. INDICATIONS ¶Jbpical therapy of recalcitrant corticosteroidresponsive dermatoses, including severe cases of psoriasis and eczematous dermatitis. CONTRAINDICATIONS Infected skin lesions if no anti-infective agent is used simultaneously; fungal and viral infections of the skin, including herpes simplez vaccima and varicella; pregnancy and lactation; hypersensitivity to any of the ingredients. 'lbpical corticosteroids are also contraindicated in tuberculous lesions of the skin. WARNINGS Dermovate should not be used in the eye. When used over extensive areas for prolonged periods, it is possible that sufficient absorption may take place to give rise to systemic effects. It is advisable, therefore, to use Dermovate for brief periods only, and to discontinue its use as soon as the lesion has cleared up. Do not use more than fifty grams of Dermovate per week. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. PRECAUTIONS ¶lbpical corticosteroids should be used with caution on lesions close to the eye. Posterior subcapsular cataracts have been reported following systemic use of corticosteroids. Although hypersensitivity reactions are rare with topically applied steroids, the drug should be discontinued and appropriate therapy initiated if there are signs of hypersensitivity. In cases of bacterial infections of the skin, appropriate antibacterial agents should be used as primary therapy. If it is considered necessary, the topical corticosteroid may be used as an adjunct to control inflammation, erythema and itching. Ifs symptomatic response is not noted within a few days to a week, the local application of corticosteroid should be discontinued until the infection is brought under controL Significant systemic absorption may occur when steroids are applied over large areas of the body, especially under occlusive dressings. Because the degree of absorption of clobetasol 17-propionate when applied under occlusive dressing has not been measured, its use in this fashion is not recommended Because the safety and effectiveness of Dermovate has been established in children, its use in children is not recommended. ADVERSE REACTIONS Local burning, irritation, itching, skin atrophy, strise, change in pigmentation, secondary ininfection, hypertrichosis and adrenal suppression have been observed following topical corticosteroid therapy. DOSAGE AND ADMINISTRATION Dermovate Cream and Dermovate Ointment are applied thinly to cover the affected area. and gentiy rubbed into the skin. Frequency of application is two to three times daily; according to the severity of the condition. The total dose of Dermovate applied weekly should not exceed fifty grams. Therapy should be discontinued if no response is noted after a week or as soon as the lesion heals. It is advisable to use Dermovate for brief periods only. Note: If malntenance therapy is required, a lower strength topical steroid, such as Betnovate, is indicated. DOSAGE FORMS Dermovate Cream and Dermovate Ointment are available in 15 and 60 g tubes, and in 100 gjars. Product monograph avallable on request REFERENCE: 1. Floden, C.H. et al., Current Med. Research and Opinion, 3:875-877,1975.
\Et/Glaxo Laboratories
EEJ
