90 is that
multidisciplinary approach is often required for satisresolution of problems in drug usage, and we hope that factory this approach will be retained when the regional drug-informa-
DIURETIC-INDUCED ŒDEMA
a
tion units
develop to full maturity.
Department of Clinical Pharmacology, University of Manchester, Manchester M13 9PT.
Regional Drug Information Service, St. Mary’s Hospital, Manchester M13 0JH.
G. E. MAWER
F. N. LEACH
SiR,—This subject has attracted a lot of correspondence, of it supporting the development of centralised drug-information services to provide assistance to local services or practitioners. Professor Rawlins and Dr Davies (Dec. 13, p. 1201) question the value of pharmacists in providing clinically useful drug information, but our experience in western Missouri would indicate that pharmacists can provide this type of most
information. The Drug Information Service of the Western Missouri Area Health Education Center began in September, 1973. Eight strategically located hospital pharmacy departments have been designated as regional drug-information centres in this large geographical area (38 counties). These regional centres are supported by a single, fully equipped centre in Kansas City. During the first six months of 1975, these centres received 1564 inquiries from health professionals, the 1768 physicians of the region being the predominant group of users. 91% of the inquiries were answered by the pharmacists at the regional centres. The remaining 9% were answered by the pharmacists in the Kansas City centre. In the past two years, we believe that the pharmacists of our area have demonstrated that they can provide an economical and reliable source of clinically useful drug information. W.M.A.H.E.C. Drug Information Service, School of Medicine, University of Missouri—Kansas City, 2411 Holmes Street, Kansas City, Missouri 64108, U.S.A.
SIR,-Following the excellent article by MacGregor et al.,’ I was able to diagnose a similar case. Norbiato et al. thought that a clue to the pathogenesis might be that it only occurred in young or middle-aged women. An 86-year-old man with leg oedema for 7 years had been treated with frusemide in a dosage of 80-160 mg daily for 4 years. He had gross oedema extending up to the thighs with a small varicose ulcer at one ankle. There were no other abnormal findings; he had never been breathless and his E.c.G. was normal. Frusemide was discontinued, and six months later he remains very well with no oedema. Ease of administration of diuretics may result in permanent use with all the hazards. The ztiology of the original oedema may not be noted so that medication is continued, lest it was heart-failure. Without the remarkable cooperation of the patient, the diagnosis in this further case would never had been made. 10 Park Avenue, Eastbourne.
ANTHONY CHURCHER
TREATMENT OF UNIPOLAR DEPRESSION
SIR,-Dr Winston (Nov. 1, p.868) suggested that the striking success of L-tryptophan reported by Dr MacSweeney (Sept. 13, p.510) in the treatment of depression may be related to the absence of pyridoxine in the preparation of L-tryptophan that he used. I do not think this is so. In the original investigation of the antidepressant action of D,L-tryptophan together with a monoamine-oxidase inhibitor,’ we gave pyridoxine because it is a coenzyme involved in the decarboxylation of 5-hydroxytryptophan to form 5-hydroxytryptamine. We thought that pyridoxine might have been defi- Tryptophan onty(n-7) Tryptophan with vitamins (n.7)
WILLIAM G. TROUTMAN
-
ALLERGIC REACTIONS TO CIS PLATINUM to draw attention to possible allergic antitumour compound cis-diamminedi-
SIR,-We would like reactions
to
the
new
chloroplatinum (D.D.P., NSC-119875). Over the past year we have had eight cases of anaphylacticlike reactions possibly secondary to cis-platinum reported to the Investigational Drug Branch. 12 The reactions consisted of facial oedema, wheezing, tachycardia, and hypotension within a few minutes of intravenous drug administration. 1 2 All reactions were controlled with intravenous adrenaline, corticosteroids, or antihistamines. All of these patients had received prior cis-platinum and all were receiving cis-platinum with various combinations of other chemotherapeutic agents. Additional details on some of these cases will appear in publications by the responsible investigators. 12 Cis-platinum is proving to be a useful antitumour agent with impressive activity in testicular malignancies.3-’ With the increasing use of this compound we feel investigators administering cis-platinum should be aware of the possible hypersensitivity reactions to that drug, and be prepared for that emergency.
Chemotherapy Evaluation Program and Investigational Drug Branch, Division of Cancer Treatment, National Cancer Institute, Bethesda, Maryland 20014, U.S.A.
Weeks Hamilton rating
1. Khan, A., Hill, J. M., Grater, W., Loeb, E., MacLellan, A., Hill, N. Cancer Res. 1975, 35, 2766. 2. Cvitkovic, E. Personal communication. 3. Lippman, A. J., Helson, C., Helson, L., Krakoff, I. H. Cancer Chemother. Rep. 1973, 57, 191. 4. Higby, D. J., Wallace, H. J., Holland, J. F. ibid. p. 459. 5. Talley, R. W., O’Bryan, R. M., Gutterman, J. U., Brownlee, R. W., McCredie, K. B. ibid. p. 465.
in
patients receiving L-tryptophan with and with-
cient in some depressives who had been anorexic for before starting treatment. We have examined this point
a
time
experi-
mentally. 14 primary depressive patients were treated randomly either with L-tryptophan (3 g thrice daily) or with the same dose of L-tryptophan with added ascorbic acid (20 mg/g L-tryptophan) and pyridoxine hydrochloride (10 mg/g L-tryptophan). The patients were rated on the Hamilton rating scale. before starting medication and twice a week for 4 weeks
DANIEL D. VON HOFF MILAN SLAVIK FRANCO M. MUGGIA
scores
out added vitamins.
on a
double-blind basis.
The results are shown in the figure. No significant difference was found between the two groups, although the patients treated with L,tryptophan and pyridoxine showed a marginally greater improvement. We could not, therefore, substantiate the interesting suggestion of Dr Winston, and for the reasons 1.
MacGregor,
G. A.,
Tasker,
P. R.
W., de Wardener, H. E. Lancet, 1975, i,
489. 2.
Norbiato, G., Sommariva, D., Gandini, R., Fasoli, A. ibid. 1975, ii, 3. Coppen, A., Shaw, D. M., Farrell, J. P. Lancet, 1963, i, 79. 4. Hamilton, M. J. Neurol. Neurosurg. Psychiat. 1960, 23, 56.
1304.
multidisciplinary approach is often required for satisresolution of problems in drug usage, and we hope that factory this approach will be retained when the regional drug-informa-
DIURETIC-INDUCED ŒDEMA
a
tion units
develop to full maturity.
Department of Clinical Pharmacology, University of Manchester, Manchester M13 9PT.
Regional Drug Information Service, St. Mary’s Hospital, Manchester M13 0JH.
G. E. MAWER
F. N. LEACH
SiR,—This subject has attracted a lot of correspondence, of it supporting the development of centralised drug-information services to provide assistance to local services or practitioners. Professor Rawlins and Dr Davies (Dec. 13, p. 1201) question the value of pharmacists in providing clinically useful drug information, but our experience in western Missouri would indicate that pharmacists can provide this type of most
information. The Drug Information Service of the Western Missouri Area Health Education Center began in September, 1973. Eight strategically located hospital pharmacy departments have been designated as regional drug-information centres in this large geographical area (38 counties). These regional centres are supported by a single, fully equipped centre in Kansas City. During the first six months of 1975, these centres received 1564 inquiries from health professionals, the 1768 physicians of the region being the predominant group of users. 91% of the inquiries were answered by the pharmacists at the regional centres. The remaining 9% were answered by the pharmacists in the Kansas City centre. In the past two years, we believe that the pharmacists of our area have demonstrated that they can provide an economical and reliable source of clinically useful drug information. W.M.A.H.E.C. Drug Information Service, School of Medicine, University of Missouri—Kansas City, 2411 Holmes Street, Kansas City, Missouri 64108, U.S.A.
SIR,-Following the excellent article by MacGregor et al.,’ I was able to diagnose a similar case. Norbiato et al. thought that a clue to the pathogenesis might be that it only occurred in young or middle-aged women. An 86-year-old man with leg oedema for 7 years had been treated with frusemide in a dosage of 80-160 mg daily for 4 years. He had gross oedema extending up to the thighs with a small varicose ulcer at one ankle. There were no other abnormal findings; he had never been breathless and his E.c.G. was normal. Frusemide was discontinued, and six months later he remains very well with no oedema. Ease of administration of diuretics may result in permanent use with all the hazards. The ztiology of the original oedema may not be noted so that medication is continued, lest it was heart-failure. Without the remarkable cooperation of the patient, the diagnosis in this further case would never had been made. 10 Park Avenue, Eastbourne.
ANTHONY CHURCHER
TREATMENT OF UNIPOLAR DEPRESSION
SIR,-Dr Winston (Nov. 1, p.868) suggested that the striking success of L-tryptophan reported by Dr MacSweeney (Sept. 13, p.510) in the treatment of depression may be related to the absence of pyridoxine in the preparation of L-tryptophan that he used. I do not think this is so. In the original investigation of the antidepressant action of D,L-tryptophan together with a monoamine-oxidase inhibitor,’ we gave pyridoxine because it is a coenzyme involved in the decarboxylation of 5-hydroxytryptophan to form 5-hydroxytryptamine. We thought that pyridoxine might have been defi- Tryptophan onty(n-7) Tryptophan with vitamins (n.7)
WILLIAM G. TROUTMAN
-
ALLERGIC REACTIONS TO CIS PLATINUM to draw attention to possible allergic antitumour compound cis-diamminedi-
SIR,-We would like reactions
to
the
new
chloroplatinum (D.D.P., NSC-119875). Over the past year we have had eight cases of anaphylacticlike reactions possibly secondary to cis-platinum reported to the Investigational Drug Branch. 12 The reactions consisted of facial oedema, wheezing, tachycardia, and hypotension within a few minutes of intravenous drug administration. 1 2 All reactions were controlled with intravenous adrenaline, corticosteroids, or antihistamines. All of these patients had received prior cis-platinum and all were receiving cis-platinum with various combinations of other chemotherapeutic agents. Additional details on some of these cases will appear in publications by the responsible investigators. 12 Cis-platinum is proving to be a useful antitumour agent with impressive activity in testicular malignancies.3-’ With the increasing use of this compound we feel investigators administering cis-platinum should be aware of the possible hypersensitivity reactions to that drug, and be prepared for that emergency.
Chemotherapy Evaluation Program and Investigational Drug Branch, Division of Cancer Treatment, National Cancer Institute, Bethesda, Maryland 20014, U.S.A.
Weeks Hamilton rating
1. Khan, A., Hill, J. M., Grater, W., Loeb, E., MacLellan, A., Hill, N. Cancer Res. 1975, 35, 2766. 2. Cvitkovic, E. Personal communication. 3. Lippman, A. J., Helson, C., Helson, L., Krakoff, I. H. Cancer Chemother. Rep. 1973, 57, 191. 4. Higby, D. J., Wallace, H. J., Holland, J. F. ibid. p. 459. 5. Talley, R. W., O’Bryan, R. M., Gutterman, J. U., Brownlee, R. W., McCredie, K. B. ibid. p. 465.
in
patients receiving L-tryptophan with and with-
cient in some depressives who had been anorexic for before starting treatment. We have examined this point
a
time
experi-
mentally. 14 primary depressive patients were treated randomly either with L-tryptophan (3 g thrice daily) or with the same dose of L-tryptophan with added ascorbic acid (20 mg/g L-tryptophan) and pyridoxine hydrochloride (10 mg/g L-tryptophan). The patients were rated on the Hamilton rating scale. before starting medication and twice a week for 4 weeks
DANIEL D. VON HOFF MILAN SLAVIK FRANCO M. MUGGIA
scores
out added vitamins.
on a
double-blind basis.
The results are shown in the figure. No significant difference was found between the two groups, although the patients treated with L,tryptophan and pyridoxine showed a marginally greater improvement. We could not, therefore, substantiate the interesting suggestion of Dr Winston, and for the reasons 1.
MacGregor,
G. A.,
Tasker,
P. R.
W., de Wardener, H. E. Lancet, 1975, i,
489. 2.
Norbiato, G., Sommariva, D., Gandini, R., Fasoli, A. ibid. 1975, ii, 3. Coppen, A., Shaw, D. M., Farrell, J. P. Lancet, 1963, i, 79. 4. Hamilton, M. J. Neurol. Neurosurg. Psychiat. 1960, 23, 56.
1304.
