No other antihypertensive available works like
Catapres I.
PRESCRIBING INFORMATION Catapsws cloeldlne hydrochloride Conrpo.lUon
2-2
ch
henylamino)-2-imofazotine hydrochloride.
hsd.a5ona Cataprea has bean used succeastuty to treat hypertension ot att grades ot
severity.
at 6 months with which, combined with flailing arms and legs, he may tip the seat. From kitchen counter height, or even less, serious injuries have occurred. A distraught mother asked me "How was I to know at what age my baby had outgrown the seat?" And besides, she might have added, if the "sturdy non-tip design" applies at floor level, then why not at counter level? Or, if it is considered safe for a 5-month-old, then why not for a 6-month-old? Perhaps age should be translated to pounds, or better still, kilograms. I suggest that the absence of standards relating infant size to design makes this "help to mother" a potentially dangerous and even lethal household item. Interestingly, at least one of these seats is sold in a plastic bag, on which the bag's hazardous properties are clearly printed.
Cotitrmndlcatlons
There are no known absolute contraindications to the use ot Catayres.
AC. SmICKLER, MD
84 Princess Ann Cres. Tslington, ON
Warnings
Catapres therapy ts discontinued for any reason, withdrawal shotild be done gradualyoversevaraldays ratherthan abruptty. Therehavebeen rareinstances of rebound hypertensivecrlaestoloalng . the drug. This can be eaectivelycontroied by reerstituting Catapras attheprevisue dosage tenet; however if more rapid control is necessary, intravenous isfualone of atpha adranergic blocking agents such as intravenous phenfolamine (5-10 mg doses at 5 minute intervals up to a total of 30 mg) are effective in reducing the blood pressure.
Precautions
Patientawith aknown history of dapreasion shouki be carefulysupetvisedahiis undertreatment with Catapres, as them have been occesinnat reports of further dapressiva apisodes occurring it such patients Men altnjptwithdrawisof Cafapres isfosowed in rare histancesbyanescessof ciroufatln9catechotenrines, cautionsinouldbeesercissdinthsconcomitanfuseof drugs ahtch affect the mefabofism or the tissue uptake of these amines (MAO inhibitom and fricyctc antidapressants respectively). A few instances of a condthon resembling Raynau.s phenomenon have bees raported. Castion should therefore be observed if patients mob Raynsods disease or thromboanglifis obiterans are to be treated with Catapres. Catapres has amucous mambranedrying effect on the eyes. On rareoccaisons this has led to comeal ulceration. Aa with any drug escreted primarily in the urine, smalar doses of Catapres are often effective in treating patients with a degree of renal fislure. ThesssofCatapresdunng thstirsttrimsstsrofpregnancyisssbjecttothenormal precautions surrounding the use of any drug. Animal tests have shows no evidence of fostal abnormality, though there was sums decreased fertility. Advrse affects The most commonly encountered rids effects are sirtisl sedahon anddry mouth. However these effects are seldom severs and teed to be doss related and transient. There are occasional reports of fold retenhon and weight gain during the initial .sti of treatmentwith Catapres. This side effect is usualy transisnt, but the stic will correct any tendency to fuld retention in these cases. Other occasional drug-related ode affects which have bean noted in iteratore inclods dizziness, headeche, dryness, itching or homing of the ayes, rarely comeal ulceration, noctumsl unrest, nassea, euphoria, constipation, impotence (rarelyl, and agitation on wrthdrawal of therapy. Penal pallor has occasionally been noted at high dosage levels. No toarc reections have bean observed on inves sting Mood status, renal function and iver function. Lon9-tsrm treatment has shown no adverse effect on bloodursanitrogsnlevsls, and in patientuwlth pre-esisting ranaldamagathere is nosuggestionof turtherimpisrmentofthsranalbloodfowdeaprts sf511 inarterial blood pressure.
.0.titi-ti.1 mg four times disly. This dosage mey be increased every tea days until satisfactory control is achieved. When utied alone the final dosage usualy ranges betwean 0.2 and 1.2mg disly. The lastdons of the day should be given tremediatelybefom reltringloensure bloodpressurscontmlduring sleep. Catapres used with a dioretic Catapres has bean used successluly together with chlorfhaldons, furosemids
endthethiazidediurstics. Lowerdosesof Cataprestirthadiursticmaybeussdto echieveths samedegres of blood pressurecootml whenever adiurebc is added to the Catapres regimen or vice versa. In these circumstances, most mild-tomoderate hypertenaires can be controsed using only 0.30.5 mgof Catapres rally in dialded doses. Severe hypertsnalves have bean successfully treated wtih a diuretic sodhigher doses of Catapres (frequently up to 1.2 mg daily and occasionally up to S mg dallyl. When extremely high doses of Catapres are necessary dosage arlustmenlo should be made ever a period of several months. Catapren used with other antihypertensive agents Catapres has been used tugether with methyldupa, guanethidins, bethaindise and hydralarins, and further reductions in blood pressure havebean achieved. AvaildellIty 1,0.1 mg Tablet: A white, singls-scorsd tablet, impressed with the motif .on one side and the Boehringsr Ingelheim symbol on the 2,0.2 mg Tableto: An orange, single-scored tablet, impressed with the motif .on one side end the Boobringer Ingelbem symbol on the BoCles of 50 and 500 tablets. Forlorthsrprescribrngintormahon, consutiths Cataprss Pmductldonographor your ffoehringsr Ingetheim representative.
OVER75O PUBLISS4EDSTUDIESONCATAPRES NAVEAPPEAREDINThE WORLD-WIDE UTERATURE TO DATE. Retemnoss 1, Rahos, J., Med. J. Aust., April 21, 1873, pp. 785-793.
2. Onesti, G. at at, Supplementlt toCirculahon Research, VoL XXVtII arldXXlX,
May 1971, pp. 53-59. I Onesti. 0. a at An. J. Cardiolosy, 28:74-83, Jab 1971. 4, Muir, A. L et at The Lancet, July 25, 1589, pp. 181-185. 5, Smet, G. at at Am. Heart J., 77:473-478, April 1955. 6, Hoobter, S. W. and Sagastums, E., Am. J. Cardiolugy, 28:57-73, July 1971. 7. Putzays, M. A. and Hoobler, S. W., Am. Heart J.,83:454-455, April 1972. 5, Parsons, ob. B. and Mortadge, J. H., Am. J. Cardiolugy, 25:255-251, Sept. 1870. 9, Medougas, A. I. at al, Br. Medical J., 3:440-442, August 22,1970. 10. Ration, J., Med. J. Australia, Oct. 4, 1959, pp. 584-587. 11. Mroczsk, 50. J.. Leibel, 8. A. and Finnerty, F. A., Am,J. Cardiolegy, 29:712-717, May 1972. 12, Khan, A. at al, Current Therapeutic Research, 12:10-18, Jan. 1970. 12, Sung, P-K, at al, Currant Therapeutic Research, 13:250-285, May 1971.
14, Mroczsk, W. J., Davidov, M. and Finnerty, F. A., Am.J. Cardiolugy. 30:535-541, Oct. 1972.
(.III.,'. B.hringer Ingeiheim (Canada) Ltd. \.e.eleuie] 2121 Trans Canada Highway, Dorval, P.O. HOP 1J3 8-185-75
Antibodies to poliovirns and measles virus To the editor: I commend the authors of the article "Antibody status to poliomyelitis, measles, rubella, diphtheria and tetanus, Ontario, 1969-70: deficiencies discovered and remedies required" (MacLeod and colleagues: Can MedAssocJ 113: 619, 1975). The seroimmunity surveys reported were competently conducted and their findings add much to a relatively meagre body of knowledge about vaccine-induced immunity in populations. However, I take issue with the authors when they consider a serum neutralizing titre to poliomyelitis of 1/10 as being evidence of immunity and the absence of such a titre as evidence of susceptibility. Several years ago the Center for Disease Control, in collaboration with Case Western Reserve University school of medicine at the Cleveland Metropolitan General Hospital and the bureau of biologics, Food and Drug Administration, surveyed the immune status of children 1 to 4 years of age, as determined by history and antibody measurements, in Cleveland, Ohio.1 Of the 160 children studied, over one half had antibody titres of less than 1/10 (the lowest serum dilution tested) to one or more types of poliovirus. The possibility that such low antibody titres simply reflected inadequate immunization was obviated by a review of immunization records. Serum samples from a group of children, all with neutralizing antibody titres of less than 1 / 10 to type 3 poliovirus, were later retested at lower serum dilutions. Among the children who had received three or more doses of oral vaccine, 15 of 17 (88.2%) had antibody titres
412 CMA JOURNAL/MARCH 6, 1976/VOL. 114
between 1 / 2 and 1 / 10. Thus, although antibodies were "absent" when measured at the screening dilution of 1/10, they were detectable at lower dilutions in the majority of children who had an adequate immunization history. These data and the fact that, in many persons with no demonstrable antibodies to measles, subclinical reinfection develops when they are exposed to wild measles virus illustrate clearly that absence of demonstrable antibody is not synonymous with susceptibility. Jossr.i J. Wirra, MD Director, immunization division Bureau of state services Department of Health, Education and Welfare Center for Disease Control Atlanta, GA
Reference 1. GOLD E, FEYRIER A, HATCH MH, et al: Immune status of children one to four years of age as determined by history and antibody measurement. N Engi J Med 289: 231, 1973
Retinoic acid in acne therapy To the editor: In response to Dr. R.D. Wilkinson's letter about retinoic acid (Can Med Assoc J 113: 606, 1975) I wish to clarify the situation in Canada with regard to this drug. About 3 years ago a pharmaceutical manufacturer presented a new drug submission for retinoic acid in the treatment of acne. After evaluating this information, as well as literature reports, the health protection branch was of the opinion that retinoic acid had potential for deleterious effects on the human fetus. The problem was presented to nongovernment consultants in dermatology and medical genetics. This committee, who asked for and were promised anonymity, recommended a contraindication in women of childbearing potential be set forth in product monographs and package inserts and that indications be restricted to two types of acne. This recommendation was accepted by the branch, but to date no pharmaceutical manufacturer has agreed to market retinoic acid under these conditions. AB. MosuusoN, PH D
Assistant deputy minister Food and drugs Health protection branch Health and Welfare Canada Ottawa, ON
To the editor: I question the validity of a recommendation made by a committee who wishes to remain anonymous, particularly when that recommendation runs counter to the findings of similar committees in the other major countries of the Western world. For the reasons set out in my previous letter I think this new, highly effective modality deserves an open hearing. R.D. WILKINsON, MD, CM, FRCP[C] Dermatologist-in-chief Royal Victoria Hospital Montreal, PQ
Catapres I.
PRESCRIBING INFORMATION Catapsws cloeldlne hydrochloride Conrpo.lUon
2-2
ch
henylamino)-2-imofazotine hydrochloride.
hsd.a5ona Cataprea has bean used succeastuty to treat hypertension ot att grades ot
severity.
at 6 months with which, combined with flailing arms and legs, he may tip the seat. From kitchen counter height, or even less, serious injuries have occurred. A distraught mother asked me "How was I to know at what age my baby had outgrown the seat?" And besides, she might have added, if the "sturdy non-tip design" applies at floor level, then why not at counter level? Or, if it is considered safe for a 5-month-old, then why not for a 6-month-old? Perhaps age should be translated to pounds, or better still, kilograms. I suggest that the absence of standards relating infant size to design makes this "help to mother" a potentially dangerous and even lethal household item. Interestingly, at least one of these seats is sold in a plastic bag, on which the bag's hazardous properties are clearly printed.
Cotitrmndlcatlons
There are no known absolute contraindications to the use ot Catayres.
AC. SmICKLER, MD
84 Princess Ann Cres. Tslington, ON
Warnings
Catapres therapy ts discontinued for any reason, withdrawal shotild be done gradualyoversevaraldays ratherthan abruptty. Therehavebeen rareinstances of rebound hypertensivecrlaestoloalng . the drug. This can be eaectivelycontroied by reerstituting Catapras attheprevisue dosage tenet; however if more rapid control is necessary, intravenous isfualone of atpha adranergic blocking agents such as intravenous phenfolamine (5-10 mg doses at 5 minute intervals up to a total of 30 mg) are effective in reducing the blood pressure.
Precautions
Patientawith aknown history of dapreasion shouki be carefulysupetvisedahiis undertreatment with Catapres, as them have been occesinnat reports of further dapressiva apisodes occurring it such patients Men altnjptwithdrawisof Cafapres isfosowed in rare histancesbyanescessof ciroufatln9catechotenrines, cautionsinouldbeesercissdinthsconcomitanfuseof drugs ahtch affect the mefabofism or the tissue uptake of these amines (MAO inhibitom and fricyctc antidapressants respectively). A few instances of a condthon resembling Raynau.s phenomenon have bees raported. Castion should therefore be observed if patients mob Raynsods disease or thromboanglifis obiterans are to be treated with Catapres. Catapres has amucous mambranedrying effect on the eyes. On rareoccaisons this has led to comeal ulceration. Aa with any drug escreted primarily in the urine, smalar doses of Catapres are often effective in treating patients with a degree of renal fislure. ThesssofCatapresdunng thstirsttrimsstsrofpregnancyisssbjecttothenormal precautions surrounding the use of any drug. Animal tests have shows no evidence of fostal abnormality, though there was sums decreased fertility. Advrse affects The most commonly encountered rids effects are sirtisl sedahon anddry mouth. However these effects are seldom severs and teed to be doss related and transient. There are occasional reports of fold retenhon and weight gain during the initial .sti of treatmentwith Catapres. This side effect is usualy transisnt, but the stic will correct any tendency to fuld retention in these cases. Other occasional drug-related ode affects which have bean noted in iteratore inclods dizziness, headeche, dryness, itching or homing of the ayes, rarely comeal ulceration, noctumsl unrest, nassea, euphoria, constipation, impotence (rarelyl, and agitation on wrthdrawal of therapy. Penal pallor has occasionally been noted at high dosage levels. No toarc reections have bean observed on inves sting Mood status, renal function and iver function. Lon9-tsrm treatment has shown no adverse effect on bloodursanitrogsnlevsls, and in patientuwlth pre-esisting ranaldamagathere is nosuggestionof turtherimpisrmentofthsranalbloodfowdeaprts sf511 inarterial blood pressure.
.0.titi-ti.1 mg four times disly. This dosage mey be increased every tea days until satisfactory control is achieved. When utied alone the final dosage usualy ranges betwean 0.2 and 1.2mg disly. The lastdons of the day should be given tremediatelybefom reltringloensure bloodpressurscontmlduring sleep. Catapres used with a dioretic Catapres has bean used successluly together with chlorfhaldons, furosemids
endthethiazidediurstics. Lowerdosesof Cataprestirthadiursticmaybeussdto echieveths samedegres of blood pressurecootml whenever adiurebc is added to the Catapres regimen or vice versa. In these circumstances, most mild-tomoderate hypertenaires can be controsed using only 0.30.5 mgof Catapres rally in dialded doses. Severe hypertsnalves have bean successfully treated wtih a diuretic sodhigher doses of Catapres (frequently up to 1.2 mg daily and occasionally up to S mg dallyl. When extremely high doses of Catapres are necessary dosage arlustmenlo should be made ever a period of several months. Catapren used with other antihypertensive agents Catapres has been used tugether with methyldupa, guanethidins, bethaindise and hydralarins, and further reductions in blood pressure havebean achieved. AvaildellIty 1,0.1 mg Tablet: A white, singls-scorsd tablet, impressed with the motif .on one side and the Boehringsr Ingelheim symbol on the 2,0.2 mg Tableto: An orange, single-scored tablet, impressed with the motif .on one side end the Boobringer Ingelbem symbol on the BoCles of 50 and 500 tablets. Forlorthsrprescribrngintormahon, consutiths Cataprss Pmductldonographor your ffoehringsr Ingetheim representative.
OVER75O PUBLISS4EDSTUDIESONCATAPRES NAVEAPPEAREDINThE WORLD-WIDE UTERATURE TO DATE. Retemnoss 1, Rahos, J., Med. J. Aust., April 21, 1873, pp. 785-793.
2. Onesti, G. at at, Supplementlt toCirculahon Research, VoL XXVtII arldXXlX,
May 1971, pp. 53-59. I Onesti. 0. a at An. J. Cardiolosy, 28:74-83, Jab 1971. 4, Muir, A. L et at The Lancet, July 25, 1589, pp. 181-185. 5, Smet, G. at at Am. Heart J., 77:473-478, April 1955. 6, Hoobter, S. W. and Sagastums, E., Am. J. Cardiolugy, 28:57-73, July 1971. 7. Putzays, M. A. and Hoobler, S. W., Am. Heart J.,83:454-455, April 1972. 5, Parsons, ob. B. and Mortadge, J. H., Am. J. Cardiolugy, 25:255-251, Sept. 1870. 9, Medougas, A. I. at al, Br. Medical J., 3:440-442, August 22,1970. 10. Ration, J., Med. J. Australia, Oct. 4, 1959, pp. 584-587. 11. Mroczsk, 50. J.. Leibel, 8. A. and Finnerty, F. A., Am,J. Cardiolegy, 29:712-717, May 1972. 12, Khan, A. at al, Current Therapeutic Research, 12:10-18, Jan. 1970. 12, Sung, P-K, at al, Currant Therapeutic Research, 13:250-285, May 1971.
14, Mroczsk, W. J., Davidov, M. and Finnerty, F. A., Am.J. Cardiolugy. 30:535-541, Oct. 1972.
(.III.,'. B.hringer Ingeiheim (Canada) Ltd. \.e.eleuie] 2121 Trans Canada Highway, Dorval, P.O. HOP 1J3 8-185-75
Antibodies to poliovirns and measles virus To the editor: I commend the authors of the article "Antibody status to poliomyelitis, measles, rubella, diphtheria and tetanus, Ontario, 1969-70: deficiencies discovered and remedies required" (MacLeod and colleagues: Can MedAssocJ 113: 619, 1975). The seroimmunity surveys reported were competently conducted and their findings add much to a relatively meagre body of knowledge about vaccine-induced immunity in populations. However, I take issue with the authors when they consider a serum neutralizing titre to poliomyelitis of 1/10 as being evidence of immunity and the absence of such a titre as evidence of susceptibility. Several years ago the Center for Disease Control, in collaboration with Case Western Reserve University school of medicine at the Cleveland Metropolitan General Hospital and the bureau of biologics, Food and Drug Administration, surveyed the immune status of children 1 to 4 years of age, as determined by history and antibody measurements, in Cleveland, Ohio.1 Of the 160 children studied, over one half had antibody titres of less than 1/10 (the lowest serum dilution tested) to one or more types of poliovirus. The possibility that such low antibody titres simply reflected inadequate immunization was obviated by a review of immunization records. Serum samples from a group of children, all with neutralizing antibody titres of less than 1 / 10 to type 3 poliovirus, were later retested at lower serum dilutions. Among the children who had received three or more doses of oral vaccine, 15 of 17 (88.2%) had antibody titres
412 CMA JOURNAL/MARCH 6, 1976/VOL. 114
between 1 / 2 and 1 / 10. Thus, although antibodies were "absent" when measured at the screening dilution of 1/10, they were detectable at lower dilutions in the majority of children who had an adequate immunization history. These data and the fact that, in many persons with no demonstrable antibodies to measles, subclinical reinfection develops when they are exposed to wild measles virus illustrate clearly that absence of demonstrable antibody is not synonymous with susceptibility. Jossr.i J. Wirra, MD Director, immunization division Bureau of state services Department of Health, Education and Welfare Center for Disease Control Atlanta, GA
Reference 1. GOLD E, FEYRIER A, HATCH MH, et al: Immune status of children one to four years of age as determined by history and antibody measurement. N Engi J Med 289: 231, 1973
Retinoic acid in acne therapy To the editor: In response to Dr. R.D. Wilkinson's letter about retinoic acid (Can Med Assoc J 113: 606, 1975) I wish to clarify the situation in Canada with regard to this drug. About 3 years ago a pharmaceutical manufacturer presented a new drug submission for retinoic acid in the treatment of acne. After evaluating this information, as well as literature reports, the health protection branch was of the opinion that retinoic acid had potential for deleterious effects on the human fetus. The problem was presented to nongovernment consultants in dermatology and medical genetics. This committee, who asked for and were promised anonymity, recommended a contraindication in women of childbearing potential be set forth in product monographs and package inserts and that indications be restricted to two types of acne. This recommendation was accepted by the branch, but to date no pharmaceutical manufacturer has agreed to market retinoic acid under these conditions. AB. MosuusoN, PH D
Assistant deputy minister Food and drugs Health protection branch Health and Welfare Canada Ottawa, ON
To the editor: I question the validity of a recommendation made by a committee who wishes to remain anonymous, particularly when that recommendation runs counter to the findings of similar committees in the other major countries of the Western world. For the reasons set out in my previous letter I think this new, highly effective modality deserves an open hearing. R.D. WILKINsON, MD, CM, FRCP[C] Dermatologist-in-chief Royal Victoria Hospital Montreal, PQ
