Lasix
for the long term
Composition: Each tablet containa 40 mg or 20 mg furoaemide Each 2 ml ampoule containa 20 mg furoaemide; each 4 ml ampoule containa 40 mg. Indicailons - Oral: Mild to moderate hypertenalon or with other hypotenxivea in aevere caaea. Edema aaaociated with congeative heart failure, cirrhoaia of the liver, renal diaeaae including the nephrotic ayndrome, aa well aa other edematoua atatea. Parenteral: Acute pulmonary, cardiac, hepatic or renal edema. ContraIndications: Complete renal ahutdown. Diacontinue if increasing azotemia and oliguria occur during treatment of progressive renal diaeaae. In hepatic coma and electrolyte depletion, do not inatitute therapy until the baaic condition is improved or corrected. Until further experience has been accumulated, do not adminiater parenterally to children. Warnings: Sulfonamide diuretica have been reported to decrease arterial responalveneaa to prexaor aminea and to enhance the effecta of tubocurarine. Exerciae caution in adminiatering curare or ita derivativea during Laaix therapy. Diacontinue 1 week prior to elective aurgery. Caaea of reveraible deafnesa and tinnitua have been reported when Laaix Parenteral waa given at doaea exceeding aeveral timea the usual therapeutic doae of 20 to 40 mg. Tranaient deafneaa ia more likely to occur in patienta with aevere impairment of renal function and in patienta alao receiving drugs known to be ototoxic. Precautions: Inject Laxix Parenteral slowly [1 to 2 minuteal when i.v. route ia uaed. Sodium intake should not be leax than 3 g/day. Potaaaium aupplementa should be given when high doaea are uaed over prolonged perioda. Caution with potaaaium levels ia desirable when on digitalis glycoaidea, potasaium-depleting ateroida, or in impending hepatic coma. Potaaaium aupplementation, diminution in doae, or discontinuation of Laaix may be required. Aldoaterone antagoniata ahould be added when treating aevere cirrhoaia with aacitea. Reproduction atudiea in animals have produced no evidence of drug-induced fetal abnormalities. Laaix haa had only limited uae in pregnancy and ahould .be uaed only when deemed easential. Check urine and blood glucoae as decreaaed glucose tolerance haa been obaerved. Check aerum calcium levels aa rare caaea of tetany have been reported. Patients receiving high doaea of aalicylatex with Lasix may experience salicylate toxicity at lower dosea. Adverse reactions: Aa with any effective diuretic, electrolyte depletion may occur especially with high doaea and reatricted aalt intake. Electrolyte depletion may manifeet itaelf by weakneaa, dizzinesa, lethargy, leg crampa, anorexia, vomiting and/or mental confuxion. Check aerum alectrolytex, eapecially potaaaium at higher doae levela. In edematoua hypertenaivea reduce the doaage of other antihypertenaivex aince Laaix potentiatea their effect. Aaymptomatic hyperuricemia can occur and gout may rarely be precipitated. Reversible elevations of BUN may be aeen especially in renal inaufficiency. Dermatitis, pruritua, parsetheaia, blurring of viaion, postural hypotenaion, nauaea, vomiting, or diarrhea may occur. Anemia, leukopenia, and thrombocytopenia [with purpural and rare caaea of agranulocytoaia have occurred. Weaknees, fatigue, dizzineaa, muacle crampa, thirst, increaaed perapiration, bladder apaam and aymptoma of urinary frequency may occur. Overdosage: Symptoms: Dehydration and electrolyte depletion. Treatment: Dixcontinue drug and inatitute water and electrolyte replacement. Dosage and admInIstratIon - Oral: Hypertension: Uaual doaage ix 40 to 80 mg daily. Individualize therapy and adjuat doxage of concomitant hypotenaive therapy. Edema: Usual initial dosage ia 40 to 80 mg. Adjuat according to reaponxe. If diurexis haa not occurred after 6 hours, increaae doaage by incrementa of 40 mg aa frequently ax every 6 houra if neceasary. The effective doxe can then be repeated 1 to 3 timex daily. A maximum daily doxe of 200 mg ahould not be exceeded. Maintenance doxage muat be adjuated individually. An intermittent doxage achedule of 2 to 4 conxecutive dayx each week may be utilized. With doxee exceeding 120 mg/day, clinical and laboratory obeervationa are advisable. Parenteral: Uxual doxage ix 20 to 40mg given ax a aingle doxe, injected i.m. or i.v. The i.v. injection ahould be given alowly [1 to 2 minutex]. Ordinarily, a prompt diurexix enxuex. If diurexix ix not axtiefactory, aucceeding doxex may be increased by incrementx of 20 mg 2 houra after the previoux doxe, until the required diurexix ix obtained. The maximum recommended daily doxage ix 100 mg. Acute pulmonary edema: Adminixter 40 mg immediately by slow i.e. injection. May be followed by another 40 mg ito 1/a hourx later. PediatrIc use: Institute Lxxix orally under cloxe obxervation in the hoxpital. Single oral doxe ix 0.5 to 1 mg/kg. The daily oral doxe ahould not exceed 2 mg/kg in divided doxex. In newborns and prematurex, the daily oral dose ahould not exceed 1 mg/kg. Particular caution with potaxalum levels is desirable. Do not administer to jaundiced newbornx or infantx suffering from dixeaxee with the potential of cauxing hyperbilirubinemia and poaxibly kernicterus. SuppI. Yellow, round, scored 40 mg tablets [Code DLI] in bottlex of 50 and 500. White round 20 mg tablets [Code DLF] in bottles of 30. Amber ampoules of 2 ml in boxes of 5 and 50; 4 ml in boxex of 50. Complete information on requset.
HOECHST Hoechst Pharmaceuticals. Division of canadian Hoechst Ltd.. Montreal
1229/7065/E
EReg Hoechst TM
complete recovery of his sensorimotor function. In patients who are likely to be heparinized for hemodialysis before or after a renal transplant operation, one should think of this syndrome if femoral neuropathy develops in the immediate postoperative period. Timely surgical removal of the hematoma may spare the patient dysfunction of his femoral nerve. H. TRIVEDI, MB, FRCP[C] St. Joseph's Hospital Hamilton, Ont.
Marfan's syndrome and Sherlock Holmes To the editor: The letter "Marfan's syndrome and Sherlock Holmes" (Can Med Assoc J 112: 423, 1975) from Dr. Cooperman has been brought to my attention. This is of much interest indeed and reinforces the judgement that Arthur Conan Doyle was an astute diagnostician, admirably trained in Edinburgh under Joseph Bell. Dr. Cooperman wrote that "A Study in Scarlet" was copywritten (sic) "before 1896". In fact, the story was published in late 1887 and had been written not later than 1886. Doyle's description of Marfan's syndrome therefore predates the classic recognition by a decade and was made a very few years after Doyle's graduation. DA. REDMOND Chief librarian Douglas Library Queen's University Kingston, Ont.
Occupational medicine To the editor: I must take exception to the statements made by Dr. J.S. Bennett in his report on occupational medicine to The Canadian Medical Association's Council on Community Health (Can Med Assoc J 112: 886, 1975). I cannot help but conclude that he has no first-hand knowledge of this particular branch of medicine and that he has made the classic error in formal logic of going from the particular to the general in using isolated instances to come to broad conclusions and thus to tar all occupational physicians with the same brush. Dr. Bennett has outlined the aims of the occupational health services quite well but occupational physicians do not "verify the justification of absence on the grounds of sickness". The job of the occupational physician is to determine a worker's fitness for work. As secretary of the Canadian Council on Occupational Medicine (which has just become a CMA affiliate)
I have occasion to be acquainted personally with a great many full-time and part-time occupational physicians. I know of none who are required to act as a policeman for absent workers. Indeed this is contrary to the ethics of occupational medicine, which are outlined in the CMA pamphlet "Guiding Principles for the Provision of Occupational Health Services". With regard to environmental hazards, it is the duty of the occupational physician to provide his employer with his professional opinion about any potential hazard. It then becomes the responsibility of the employer, not the physician, to take appropriate steps to control or eliminate the hazard. I am unable to understand how a company physician can help a corporation make money. An important function of the occupational physician is to save his company money in terms of benefits paid out in sickness and compensation. This he does by cooperating with family physicians in the rehabilitation of the employee, analysing his job and recommending modified work if necessary in order to help the employee return to work sooner than he otherwise might. Before presenting his report Dr. Bennett should have checked his information more thoroughly by conferring with acknowledged experts in the field of occupational medicine. A.W. K.ARR, MD
Chief physician Ford Motor Company Oakviile, Ont.
To the editor: Dr. Karr agrees with the opening paragraph of the report but finds the generalizations in error. The generalizations to which he takes exception arose from the discussion by the Council on Community Health and cannot be attributed to any individual. In compiling the presentation we sought and obtained input from a variety of sources, including physicians engaged in the full-time practice of occupational medicine in Canada. Subsequent to the report in the Journal and subsequent also to a meeting of a number of occupational health physicians, we received a letter from one such physician, which reads in part: "In the discussion several had to agree that some (occupational health physicians) were less than truthful about environmental hazards and that most of them felt that they were hired by corporations to make money for them." J.S. BENNETT, MB, FRCS[C] Director, scientific councils The Canadian Medical Association Ottawa, Ont.
CMA JOURNAL/JULY 12, 1975/VOL. 113
19
for the long term
Composition: Each tablet containa 40 mg or 20 mg furoaemide Each 2 ml ampoule containa 20 mg furoaemide; each 4 ml ampoule containa 40 mg. Indicailons - Oral: Mild to moderate hypertenalon or with other hypotenxivea in aevere caaea. Edema aaaociated with congeative heart failure, cirrhoaia of the liver, renal diaeaae including the nephrotic ayndrome, aa well aa other edematoua atatea. Parenteral: Acute pulmonary, cardiac, hepatic or renal edema. ContraIndications: Complete renal ahutdown. Diacontinue if increasing azotemia and oliguria occur during treatment of progressive renal diaeaae. In hepatic coma and electrolyte depletion, do not inatitute therapy until the baaic condition is improved or corrected. Until further experience has been accumulated, do not adminiater parenterally to children. Warnings: Sulfonamide diuretica have been reported to decrease arterial responalveneaa to prexaor aminea and to enhance the effecta of tubocurarine. Exerciae caution in adminiatering curare or ita derivativea during Laaix therapy. Diacontinue 1 week prior to elective aurgery. Caaea of reveraible deafnesa and tinnitua have been reported when Laaix Parenteral waa given at doaea exceeding aeveral timea the usual therapeutic doae of 20 to 40 mg. Tranaient deafneaa ia more likely to occur in patienta with aevere impairment of renal function and in patienta alao receiving drugs known to be ototoxic. Precautions: Inject Laxix Parenteral slowly [1 to 2 minuteal when i.v. route ia uaed. Sodium intake should not be leax than 3 g/day. Potaaaium aupplementa should be given when high doaea are uaed over prolonged perioda. Caution with potaaaium levels ia desirable when on digitalis glycoaidea, potasaium-depleting ateroida, or in impending hepatic coma. Potaaaium aupplementation, diminution in doae, or discontinuation of Laaix may be required. Aldoaterone antagoniata ahould be added when treating aevere cirrhoaia with aacitea. Reproduction atudiea in animals have produced no evidence of drug-induced fetal abnormalities. Laaix haa had only limited uae in pregnancy and ahould .be uaed only when deemed easential. Check urine and blood glucoae as decreaaed glucose tolerance haa been obaerved. Check aerum calcium levels aa rare caaea of tetany have been reported. Patients receiving high doaea of aalicylatex with Lasix may experience salicylate toxicity at lower dosea. Adverse reactions: Aa with any effective diuretic, electrolyte depletion may occur especially with high doaea and reatricted aalt intake. Electrolyte depletion may manifeet itaelf by weakneaa, dizzinesa, lethargy, leg crampa, anorexia, vomiting and/or mental confuxion. Check aerum alectrolytex, eapecially potaaaium at higher doae levela. In edematoua hypertenaivea reduce the doaage of other antihypertenaivex aince Laaix potentiatea their effect. Aaymptomatic hyperuricemia can occur and gout may rarely be precipitated. Reversible elevations of BUN may be aeen especially in renal inaufficiency. Dermatitis, pruritua, parsetheaia, blurring of viaion, postural hypotenaion, nauaea, vomiting, or diarrhea may occur. Anemia, leukopenia, and thrombocytopenia [with purpural and rare caaea of agranulocytoaia have occurred. Weaknees, fatigue, dizzineaa, muacle crampa, thirst, increaaed perapiration, bladder apaam and aymptoma of urinary frequency may occur. Overdosage: Symptoms: Dehydration and electrolyte depletion. Treatment: Dixcontinue drug and inatitute water and electrolyte replacement. Dosage and admInIstratIon - Oral: Hypertension: Uaual doaage ix 40 to 80 mg daily. Individualize therapy and adjuat doxage of concomitant hypotenaive therapy. Edema: Usual initial dosage ia 40 to 80 mg. Adjuat according to reaponxe. If diurexis haa not occurred after 6 hours, increaae doaage by incrementa of 40 mg aa frequently ax every 6 houra if neceasary. The effective doxe can then be repeated 1 to 3 timex daily. A maximum daily doxe of 200 mg ahould not be exceeded. Maintenance doxage muat be adjuated individually. An intermittent doxage achedule of 2 to 4 conxecutive dayx each week may be utilized. With doxee exceeding 120 mg/day, clinical and laboratory obeervationa are advisable. Parenteral: Uxual doxage ix 20 to 40mg given ax a aingle doxe, injected i.m. or i.v. The i.v. injection ahould be given alowly [1 to 2 minutex]. Ordinarily, a prompt diurexix enxuex. If diurexix ix not axtiefactory, aucceeding doxex may be increased by incrementx of 20 mg 2 houra after the previoux doxe, until the required diurexix ix obtained. The maximum recommended daily doxage ix 100 mg. Acute pulmonary edema: Adminixter 40 mg immediately by slow i.e. injection. May be followed by another 40 mg ito 1/a hourx later. PediatrIc use: Institute Lxxix orally under cloxe obxervation in the hoxpital. Single oral doxe ix 0.5 to 1 mg/kg. The daily oral doxe ahould not exceed 2 mg/kg in divided doxex. In newborns and prematurex, the daily oral dose ahould not exceed 1 mg/kg. Particular caution with potaxalum levels is desirable. Do not administer to jaundiced newbornx or infantx suffering from dixeaxee with the potential of cauxing hyperbilirubinemia and poaxibly kernicterus. SuppI. Yellow, round, scored 40 mg tablets [Code DLI] in bottlex of 50 and 500. White round 20 mg tablets [Code DLF] in bottles of 30. Amber ampoules of 2 ml in boxes of 5 and 50; 4 ml in boxex of 50. Complete information on requset.
HOECHST Hoechst Pharmaceuticals. Division of canadian Hoechst Ltd.. Montreal
1229/7065/E
EReg Hoechst TM
complete recovery of his sensorimotor function. In patients who are likely to be heparinized for hemodialysis before or after a renal transplant operation, one should think of this syndrome if femoral neuropathy develops in the immediate postoperative period. Timely surgical removal of the hematoma may spare the patient dysfunction of his femoral nerve. H. TRIVEDI, MB, FRCP[C] St. Joseph's Hospital Hamilton, Ont.
Marfan's syndrome and Sherlock Holmes To the editor: The letter "Marfan's syndrome and Sherlock Holmes" (Can Med Assoc J 112: 423, 1975) from Dr. Cooperman has been brought to my attention. This is of much interest indeed and reinforces the judgement that Arthur Conan Doyle was an astute diagnostician, admirably trained in Edinburgh under Joseph Bell. Dr. Cooperman wrote that "A Study in Scarlet" was copywritten (sic) "before 1896". In fact, the story was published in late 1887 and had been written not later than 1886. Doyle's description of Marfan's syndrome therefore predates the classic recognition by a decade and was made a very few years after Doyle's graduation. DA. REDMOND Chief librarian Douglas Library Queen's University Kingston, Ont.
Occupational medicine To the editor: I must take exception to the statements made by Dr. J.S. Bennett in his report on occupational medicine to The Canadian Medical Association's Council on Community Health (Can Med Assoc J 112: 886, 1975). I cannot help but conclude that he has no first-hand knowledge of this particular branch of medicine and that he has made the classic error in formal logic of going from the particular to the general in using isolated instances to come to broad conclusions and thus to tar all occupational physicians with the same brush. Dr. Bennett has outlined the aims of the occupational health services quite well but occupational physicians do not "verify the justification of absence on the grounds of sickness". The job of the occupational physician is to determine a worker's fitness for work. As secretary of the Canadian Council on Occupational Medicine (which has just become a CMA affiliate)
I have occasion to be acquainted personally with a great many full-time and part-time occupational physicians. I know of none who are required to act as a policeman for absent workers. Indeed this is contrary to the ethics of occupational medicine, which are outlined in the CMA pamphlet "Guiding Principles for the Provision of Occupational Health Services". With regard to environmental hazards, it is the duty of the occupational physician to provide his employer with his professional opinion about any potential hazard. It then becomes the responsibility of the employer, not the physician, to take appropriate steps to control or eliminate the hazard. I am unable to understand how a company physician can help a corporation make money. An important function of the occupational physician is to save his company money in terms of benefits paid out in sickness and compensation. This he does by cooperating with family physicians in the rehabilitation of the employee, analysing his job and recommending modified work if necessary in order to help the employee return to work sooner than he otherwise might. Before presenting his report Dr. Bennett should have checked his information more thoroughly by conferring with acknowledged experts in the field of occupational medicine. A.W. K.ARR, MD
Chief physician Ford Motor Company Oakviile, Ont.
To the editor: Dr. Karr agrees with the opening paragraph of the report but finds the generalizations in error. The generalizations to which he takes exception arose from the discussion by the Council on Community Health and cannot be attributed to any individual. In compiling the presentation we sought and obtained input from a variety of sources, including physicians engaged in the full-time practice of occupational medicine in Canada. Subsequent to the report in the Journal and subsequent also to a meeting of a number of occupational health physicians, we received a letter from one such physician, which reads in part: "In the discussion several had to agree that some (occupational health physicians) were less than truthful about environmental hazards and that most of them felt that they were hired by corporations to make money for them." J.S. BENNETT, MB, FRCS[C] Director, scientific councils The Canadian Medical Association Ottawa, Ont.
CMA JOURNAL/JULY 12, 1975/VOL. 113
19
