incleral7 (PROPRANOLOL)
A beta-adrenergic receptor blocking agent for the treatment of angina pectorls. INDERAL, given daily, prophylactically, reduces the incidence of anginal pains and the requirements for nitroglycerin tablets. Exercise tolerance and physical activity are increased. In many cases, pulse rate may be reduced. Dosage should be adjusted to patient's requirements for maximal benefit with minimal adverse effects (see PRECAUTIONS). Dosage and administration: First day 20 mg; then increase by 20 mg per day for one week. Then 40 mg four times daily before meals and at bedtime. Occasionally, in resistant cases, doses as high as 320-400 mg per day have been administered safely with beneficial results. If treatment is to be discontinued, reduce dosage .RECAUTIO a period of about two weeks (see NS). Caution: Abrupt Cessation of INDERAL Therapy in Angina Pectoris There have been reports of severe exacerbation of angina and myocardial infarction occurring in patients with angina pectoris following abrupt discontinuation of INDERAL. Therefore, when discontinuation of INDERAL is planned in patients with angina pectoris, the dosage should be gradually reduced over a period of about two weeks and the patient should be carefully observed. The same frequency of administration should be maintained. In situtations of greater urgency, INDERAL therapy should be discontinued stepwise and under close observation. If angina markedly worsens or acute coronary insufficiency develops, it is recommended that treatment with INDERAL be reinstituted promptly, at least temporarily. In addition, patients with angina pectoris should be warned against abrupt discontinuation of INDERAL. Note: The CAUTION concerning the abrupt cessation of INDERAL therapy referred to under ANGINA PECTORIS (see above) need not apply to patients with hypertension provided they have no angina pectoris. Contraindicatlons: Bronchial asthma. Allergic rhinitis during the pollen season. Sinus bradycardia and g reaterthan second degree or total heart block. Cardiogenic shock. Right ventricular failure secondary to pulmonary hypertension. Congestive heart failure unless the failure is secondary to a tachyarrhythmia treatable with INDERAL. In chloroform and in ether anesthesia. Precautions: Occasionally, INDERAL has caused sinus bradycardia due to unopposed vagal activity which has been corrected by atropine. A resting pulse of 55-60 is frequently associated with INDERAL therapy. Patients without a previous history of cardiac failure have occasionally developed failure, or patients in incipient failure have developed overt congestive failure after treatment with INDERAL. In such cases, if the response is unsatisfactory, INDERAL should be stopped immediately. If a good response is obtained, patients should be fully digitalized and observed closely. If failure persists, INDERAL should be withdrawn completely. The number of patients with such difficulties is small compared with the total number treated. The safety of INDERAL in pregnancy has not been established. INDERALahouId be administered cautiously to children, patients subject to hypoglycemia, patients on hypoglycemic agents, patients with impaired renal or hepatic function, uncontrolled diabetes, shock, metabolic acidosis, and to patients undergoing elective surgery. Patients receiving catecholamine-depleting drugs, such as reserpine, should be closely watched when INDERAL is given concomitently. Adverse reactIons: Epigastric distress; dry mouth; mild diarrhea; constipation; lightheadednesa; dizziness. Hypotension, congestive heart failure and marked bradycardia, including sinus arrest, have been reported. Bronchospasm and, rarely, respiratory distress and laryngospasm have occurred, particularly in patients with bronchial asthma. During anesthesia, INDERAL may produce bradycardia due to unopposed vagal activity, reversible with atropine. A few cases of marked bradycardia have resulted while on INDERAL in the presence of hypovolemia and a vasoconstrictor. For other, rarely observed adverse reactIons see Product Monograph. Supplied: Tablets of 10 mg and 40 mg in bottles of 100 and 1000; tablets of 80 mg in bottles of 100. Also INDERAL Starter Pak-incremental dosage forfirst weekof therapy in push-through blister pack.
Ayerst.*
-
AYERST LABORATORIES Division of Ayerst McKenna & Harrison Limited Montreal Canada Made in Canada by arrangement with IMPERIAL CHEMICAL INDU STRI ESL IMITED Product Monograph available on rectuest Reg d
His letter complements our review, which described admissions of WCBO patients with low back pain to a general hospital. ANDREW KERTESZ, MD, FRCP[C] Department of clinical neurological sciences Faculty of medicine University of Western Ontario London, Ont.
Family planning and birth control counselling To the editor: The following item appeared recently in our local newspaper: The Federal Government plans to press the provinces to establish special abortion clinics that would also provide family planning services, Health Minister Marc Lalonde announced. The proposed clinics would combine abortion services with family planning and birth control counselling, cancer screening and other services related to the health of mothers, he said. It seems that the federal government is attempting to cover the bitter pill of a therapeutic abortion clinic with the sugar coating of family planning and contraceptive counselling. Family planning and contraceptive counselling is an important part of the day-to-day work of the great majority of family physicians and gynecologists, and I urge all physicians who are opposed to Mr. Lalonde's proposal to contact their members of Parliament and their representatives in the provincial legislatures. Let us urge the Canadian Medical Association to make it clear that the appropriate setting for contraceptive counselling and related services should be the office of the family physician or gynecologist. The time has come for the association to take a more aggressive approach in the field of family planning and birth control counselling and, at the same time, actively discourage government involvement in this important area of preventive medicine. Further, let us make it clear that the whole question of therapeutic abortions and abortion clinics is to be regarded as distinct from family planning and contraceptive counselling. A.G. DAWRANT, MA, MB, B CH, LMCC 8702 Meadowlark Rd., #270 Edmonton, Alta.
Rational and irrational use of antibiotics To the editor: I object to the article "Rational and irrational use of antibiotics in a Canadian teaching hospital" by Achong, Hauser and Krusky (Can Med Assoc J 116: 256, 1977) on several grounds. The results of this study parrot those
of many previous studies (listed as references in their paper) that have claimed to show overuse of antibiotics. The findings of Achong and colleagues add nothing to this already widely held view. The bias of the authors is obvious from the title of the article, and it is apparent to me that they set out to prove their biased thesis that antibiotics are used in an incorrect manner. The term "irrational use" is used in a derogatory sense, suggesting that physicians who practise are totally ignorant and use antibiotics in a random manner. It is obvious that physicians must rationalize the specific use of antibiotics in each case. This study shows only that the authors' rationalization differs from that of the practising physician. The use of antibiotics, as with other medical tools, has shown extreme cyclic variation in the years since their introduction: in the mid-1950s there was widespread prophylactic use of antibiotics, especially in surgery; in the mid-1960s this use of antibiotics was taboo; and now, in the mid-1970s, there is a resurgence of the prophylactic use of antibiotics. In my opinion, as a small-town physician who graduated from medical school 10 years ago, the cyclic nature of use has depended upon the bias of medical school educators. Educators who advocate the use of any medical tool on the basis of biased studies add nothing to the practice of medicine. It takes approximately 10 years for the practising physician to eradicate some of the biases he learned in medical school and to judge therapy on the basis of clinical experience gained in practice. I take for granted that antibiotic use is likely to differ from the various therapeutic groups suggested by Achong and colleagues. But whether the guidelines for use are rational or irrational will take approximately 10 years to tell. H.R. SPEIRS, MD Penticton Regional Hospital Penticton, BC
To the editor: Dr. Speirs' first comment is that our study adds nothing to other studies describing the inappropriate use of antibiotics. I suggest that our study was different in that we surveyed prescribing patterns of antibiotics in a teaching hospital in Canada; this, to my knowledge, has not been done recently. Furthermore, unlike many of the studies quoted, great care was taken to identify very specifically what problems, if any, there were in the use of antibiotics. Other studies have alluded to the problem of the prophylactic use of antibiotics, but none have documented the duration and timing of prophylaxis as being an important aspect of inappropriate therapy.
CMA JOURNAL/JUNE 18, 1977/VOL. 116 1347
A beta-adrenergic receptor blocking agent for the treatment of angina pectorls. INDERAL, given daily, prophylactically, reduces the incidence of anginal pains and the requirements for nitroglycerin tablets. Exercise tolerance and physical activity are increased. In many cases, pulse rate may be reduced. Dosage should be adjusted to patient's requirements for maximal benefit with minimal adverse effects (see PRECAUTIONS). Dosage and administration: First day 20 mg; then increase by 20 mg per day for one week. Then 40 mg four times daily before meals and at bedtime. Occasionally, in resistant cases, doses as high as 320-400 mg per day have been administered safely with beneficial results. If treatment is to be discontinued, reduce dosage .RECAUTIO a period of about two weeks (see NS). Caution: Abrupt Cessation of INDERAL Therapy in Angina Pectoris There have been reports of severe exacerbation of angina and myocardial infarction occurring in patients with angina pectoris following abrupt discontinuation of INDERAL. Therefore, when discontinuation of INDERAL is planned in patients with angina pectoris, the dosage should be gradually reduced over a period of about two weeks and the patient should be carefully observed. The same frequency of administration should be maintained. In situtations of greater urgency, INDERAL therapy should be discontinued stepwise and under close observation. If angina markedly worsens or acute coronary insufficiency develops, it is recommended that treatment with INDERAL be reinstituted promptly, at least temporarily. In addition, patients with angina pectoris should be warned against abrupt discontinuation of INDERAL. Note: The CAUTION concerning the abrupt cessation of INDERAL therapy referred to under ANGINA PECTORIS (see above) need not apply to patients with hypertension provided they have no angina pectoris. Contraindicatlons: Bronchial asthma. Allergic rhinitis during the pollen season. Sinus bradycardia and g reaterthan second degree or total heart block. Cardiogenic shock. Right ventricular failure secondary to pulmonary hypertension. Congestive heart failure unless the failure is secondary to a tachyarrhythmia treatable with INDERAL. In chloroform and in ether anesthesia. Precautions: Occasionally, INDERAL has caused sinus bradycardia due to unopposed vagal activity which has been corrected by atropine. A resting pulse of 55-60 is frequently associated with INDERAL therapy. Patients without a previous history of cardiac failure have occasionally developed failure, or patients in incipient failure have developed overt congestive failure after treatment with INDERAL. In such cases, if the response is unsatisfactory, INDERAL should be stopped immediately. If a good response is obtained, patients should be fully digitalized and observed closely. If failure persists, INDERAL should be withdrawn completely. The number of patients with such difficulties is small compared with the total number treated. The safety of INDERAL in pregnancy has not been established. INDERALahouId be administered cautiously to children, patients subject to hypoglycemia, patients on hypoglycemic agents, patients with impaired renal or hepatic function, uncontrolled diabetes, shock, metabolic acidosis, and to patients undergoing elective surgery. Patients receiving catecholamine-depleting drugs, such as reserpine, should be closely watched when INDERAL is given concomitently. Adverse reactIons: Epigastric distress; dry mouth; mild diarrhea; constipation; lightheadednesa; dizziness. Hypotension, congestive heart failure and marked bradycardia, including sinus arrest, have been reported. Bronchospasm and, rarely, respiratory distress and laryngospasm have occurred, particularly in patients with bronchial asthma. During anesthesia, INDERAL may produce bradycardia due to unopposed vagal activity, reversible with atropine. A few cases of marked bradycardia have resulted while on INDERAL in the presence of hypovolemia and a vasoconstrictor. For other, rarely observed adverse reactIons see Product Monograph. Supplied: Tablets of 10 mg and 40 mg in bottles of 100 and 1000; tablets of 80 mg in bottles of 100. Also INDERAL Starter Pak-incremental dosage forfirst weekof therapy in push-through blister pack.
Ayerst.*
-
AYERST LABORATORIES Division of Ayerst McKenna & Harrison Limited Montreal Canada Made in Canada by arrangement with IMPERIAL CHEMICAL INDU STRI ESL IMITED Product Monograph available on rectuest Reg d
His letter complements our review, which described admissions of WCBO patients with low back pain to a general hospital. ANDREW KERTESZ, MD, FRCP[C] Department of clinical neurological sciences Faculty of medicine University of Western Ontario London, Ont.
Family planning and birth control counselling To the editor: The following item appeared recently in our local newspaper: The Federal Government plans to press the provinces to establish special abortion clinics that would also provide family planning services, Health Minister Marc Lalonde announced. The proposed clinics would combine abortion services with family planning and birth control counselling, cancer screening and other services related to the health of mothers, he said. It seems that the federal government is attempting to cover the bitter pill of a therapeutic abortion clinic with the sugar coating of family planning and contraceptive counselling. Family planning and contraceptive counselling is an important part of the day-to-day work of the great majority of family physicians and gynecologists, and I urge all physicians who are opposed to Mr. Lalonde's proposal to contact their members of Parliament and their representatives in the provincial legislatures. Let us urge the Canadian Medical Association to make it clear that the appropriate setting for contraceptive counselling and related services should be the office of the family physician or gynecologist. The time has come for the association to take a more aggressive approach in the field of family planning and birth control counselling and, at the same time, actively discourage government involvement in this important area of preventive medicine. Further, let us make it clear that the whole question of therapeutic abortions and abortion clinics is to be regarded as distinct from family planning and contraceptive counselling. A.G. DAWRANT, MA, MB, B CH, LMCC 8702 Meadowlark Rd., #270 Edmonton, Alta.
Rational and irrational use of antibiotics To the editor: I object to the article "Rational and irrational use of antibiotics in a Canadian teaching hospital" by Achong, Hauser and Krusky (Can Med Assoc J 116: 256, 1977) on several grounds. The results of this study parrot those
of many previous studies (listed as references in their paper) that have claimed to show overuse of antibiotics. The findings of Achong and colleagues add nothing to this already widely held view. The bias of the authors is obvious from the title of the article, and it is apparent to me that they set out to prove their biased thesis that antibiotics are used in an incorrect manner. The term "irrational use" is used in a derogatory sense, suggesting that physicians who practise are totally ignorant and use antibiotics in a random manner. It is obvious that physicians must rationalize the specific use of antibiotics in each case. This study shows only that the authors' rationalization differs from that of the practising physician. The use of antibiotics, as with other medical tools, has shown extreme cyclic variation in the years since their introduction: in the mid-1950s there was widespread prophylactic use of antibiotics, especially in surgery; in the mid-1960s this use of antibiotics was taboo; and now, in the mid-1970s, there is a resurgence of the prophylactic use of antibiotics. In my opinion, as a small-town physician who graduated from medical school 10 years ago, the cyclic nature of use has depended upon the bias of medical school educators. Educators who advocate the use of any medical tool on the basis of biased studies add nothing to the practice of medicine. It takes approximately 10 years for the practising physician to eradicate some of the biases he learned in medical school and to judge therapy on the basis of clinical experience gained in practice. I take for granted that antibiotic use is likely to differ from the various therapeutic groups suggested by Achong and colleagues. But whether the guidelines for use are rational or irrational will take approximately 10 years to tell. H.R. SPEIRS, MD Penticton Regional Hospital Penticton, BC
To the editor: Dr. Speirs' first comment is that our study adds nothing to other studies describing the inappropriate use of antibiotics. I suggest that our study was different in that we surveyed prescribing patterns of antibiotics in a teaching hospital in Canada; this, to my knowledge, has not been done recently. Furthermore, unlike many of the studies quoted, great care was taken to identify very specifically what problems, if any, there were in the use of antibiotics. Other studies have alluded to the problem of the prophylactic use of antibiotics, but none have documented the duration and timing of prophylaxis as being an important aspect of inappropriate therapy.
CMA JOURNAL/JUNE 18, 1977/VOL. 116 1347
![[Rational and irrational of azithromycin use].](/assets/img/hold.png)
