Patient Counseling

Patient Counseling

Patient Counseling Take This Candy (and Other Hazardous Pleasures) from a Baby ive-month-old Sharon loves F M&Ms. She thinks her mother does, too, be...

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Patient Counseling

Take This Candy (and Other Hazardous Pleasures) from a Baby ive-month-old Sharon loves F M&Ms. She thinks her mother does, too, because every day Sharon

Weisman notes that even bona fide candies can hurt children: "Some chocolate-covered cherries contain up to 15% or 20% alcohol, and they have up to 15 ml of liquor inside the coating. If a small child were to eat four or five of those, he would get a potentially toxic dose of ethanol."

watches her take the colorful round pieces from a brown bottle and pop them into her mouth. Sharon wonOther hazards: ders if her mother's supply tastes dif• Colorful fniniature characters deferent from hers. signed as collectibles that emit fruitDrugs that look like sweets, like scents and make them smell sweets that are whimsically packgood enough for young children to aged to look like drugs-or like batwant to eat; teries or matches, and products that • Capsules containing bright sponmay smell or look like food but gy material that swell in the bath aren't-such as tiny plastic replicas into figures of "friendly boys and offruits or hamburgers--pose an ingirls;" and sidious poisoning hazard to young • A jump rope whose handles are children who can't tell the difference. painted to look just like Amanita Accidental ingestion of items that look like edibles are probably under- sociate professor of clinical phar- muscaria, one of the prettiest, most reported, says Neal E. Flomenbaum, macy at St. John's University and toxic mushrooms in the Western assistant professor of clinical med- consultant to the New York City hemisphere. Perhaps the largest class of potenicine at New York University School Poison Control Center, suggests that of Medicine and associate director of pharmacists urge parents not to tially hazardous toys are those comemergency services at Bellevue and cajole their children into taking pressed sponge objects that can exUniversity Hospitals in New York: medicine by telling them it tastes pand as easily in warm tummies as "It's the kind of thing you want to like candy. continued on page 12 alert parents to and then let them decide whether they want to , . . - - - - - - L - - - - - - - - - - - - - - - - - - L - - - - - - - - - - - - - - - - il risk confusing their children by making such products available." Adds Richard Weisman, director of the New York City Poison Control Center, he Food and Drug Adfollowed instructions "Parents need to underministration (FDA) is about cleaning their stand what happened and urging pharmacists and lenses, nor about length what can be done to prevent other health care pracof wearing time. it from happening again." titioners to report cases The FDA points out The potential for sending of corneal ulceration in that by being ready to anmixed signals to curious contact lens wearers. swer questions, alert children who love to put This will help the agency pharmacists can help pretty, nice-tasting things survey the conditions' excontact lens wearers rein their mouths has lots of tent and determine the duce their risk of infecby the University of facets. In addition to the posrisk potential of specific tion and ulceration. Re- ' California at San Fransibility that experience lens types. port cases of corneal ulcisco School of Pharmacy with pill-like goodies such Case reports describe a ceration to the FDA by as a self-study course, the as Sharon's M&Ms or Asperpossible association becall ing toll free (800) handbook covers regigum-shaped Chiclets may tween extended wear 638-6725. mens for hard, soft, and entice an unsuspecting contact lenses designed The "Pharmacist's gas-permeable contact child to sample the real for around-the-clock use Handbook of Contact lenses plus product referthing, novelty candies that and bacterial keratitis, Lenses and Contact Lens ence charts by brand are deliberately packaged which can result in Solutions," published by name and function. like pills encourage kids to corneal ulceration. In Barnes-Hind, Inc., can Write Bames-Hind Prothink all "real things" are some of these cases, it help pharmacists underfessional Services Decandy treats. was clear that patients stand more about contact partment, 139 Kifer Ct., Mary Ann Howland, asneither understood nor Sunnyvale, CA 94086. ® lens wearing. Accredited

Pharmacists Urged to Report Corneal Ulceration



American Pharmacy, Vol. NS26, No.9, September 1986/62.3


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Patient Counseling


continued from page 10 in warm baths. And perhaps the most dangerous example, according to the three New York toxicologists, is a "Grobug" that, when wet, slowly enlarges to 200 times its dry size. After seven to ten days in liquid, it attains its "adult" proportionsroughly the size of an adult's fist . Grobugs' leisurely expansion plus their nonbiodegradable status render them a potential cause of bowel obstruction. Childrens' propensity to imitate adult behavior-and not just pilltaking behavior-can encourage them to experiment with, for example, furniture polish, "just like Mommy does." Then, in the time it takes to swallow, the results of the experiment suddenly become of more consequence than a spilled bottle. Parents who put toxic materials in jars or bottles that once held applesauce or soft drinks or infant formula should find other, safe containers, the toxicologists suggest. Recent packaging trends echo this parental indescretion: 12-ounce aluminum cans with pull-up tabs are now being used for motor oil and radiator sealer, not just for beer and soda. Parents must be warned not to store food and cleaning or other household products side by side, say the three toxicologists. Parents also need to be more careful about storing drugs, both prescription and nonprescription. Flomenbaum notes, "The idea that only medications containing controlled substances need to be locked away is not a good one. It plants the false impression that other drugs are not lethal and that's not true." The three toxicologists agree that the lack of uniform, effective federal regulations prohibiting the packaging of nonfood items in food containers or of food in forms associated with nonfood items invites children to disaster. They ask that examples of these practices be reported to the Consumer Product Safety Commission, which is authorized to recall dangerous products. The Commission can be reached toll-free at 1800-638-2772. ®

American Pharmacy, Vol. NS26, No.9, September 1986/625

Patient Counseling

Are Some Cigarettes Safer than Others? There's substantial evidence that I people who smoke filtered cigarettes run smaller risks of developing lung cancer than people who smoke unfiltered brands. But we're left to wonder about the relative risks posed by various brands of the newer low tar and nicotine cigarettes. Should public health policy be to encourage people who can't stop smoking to switch to a brand with lower numbers? To gain some resolution, researchers from the Clinical Pharmacology Unit of the Medical Service, San Francisco General Hospital Medical Center, and the Langley Porter Psychiatric Institute, University of California-San Francisco decided to bypass the epidemiologic study route, which takes a good 20 years, by taking a much more rapid one: making direct measures of human exposure to the toxic chemicals in tobacco smoke. The researchers studied exposure to nicotine, carbon monoxide, and tar in habitual smokers who switched from high- to low-yield or from high- to ultralow-yield cigarettes to see if their toxin levels would be reduced. Exposure to tar was reflected in urine mutagenicity, and nicotine intake by blood levels of cotinine. Both were measured by gas liquid chromatography. The 22 subjects were studied in four experimental blocks. Within each, they were told to smoke as much as they wanted. During the first block of two days, they smoked their own brands. In each of the next two blocks of four days apiece, they smoked a popular, high-yield brand, or a lowor ultralow-yield brand, with 11 ofthesubjectssmoking lows and 11 smoking the ultralows. During the last four-day block, no one smoked so that the mutagenicity of their urine could be measured in this clean condition.

Basically, the study was designed so that exposure to the same highyield test cigarette compared with the usual brand in both groups could be used as a control for subsequent switching to low- or ultralow brands in different groups. Because the low-yield cigarettes were less satisfying compared with the usual brands, smokers were determined to pull the same amounts of nicotine, carbon monoxide and tar from them-and did, the researchers found. Despite determination, however, no such result was possible with the ultralow brands; smokers were unable to compensate, no matter

American Pharmacy, Vol. NS26, No.9, September 19861626

how much or how hard they smokel Exposures to hazardous compound therefore, were substantially less. The researchers conclude that prl dictions about the relative safety ( different cigarette brands, which ru typically based on machine and nc human data, are likely to be invaH They also observe, in line with ea lier studies by others, that carbo monoxide intake is reduced to a Ie ser extent than nicotine intake 1: switching to low-yield cigarette and they extend this observation 1 .ultralow brands. The researchers state: "The publ: should be informed that ultralm yield cigarettes are not virtual] 'tar-free' but that exposure to ta nicotine, and carbon monoxide me be reduced by 30% to 50% by switc: ing to such cigarettes. Whether 50% reduction in exposure 1 nicotine and tar and a 30% reductic in exposure to carbon monoxide ar other gaseous toxins will make meaningful difference in the d velopment of smoking-related dj eases must be determined 1 epidemiologic studies, which wj take many years. In the meantirn it appears reasonable to encoura~ smokers who are unable to quit . switch to ultralow-yield cigarettes.:



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Patient Counseling

Book Cited for Patients' Concerns \Nith Yeast Infections little knowledge, it's been said, can be a dangerous thing. Two physicians reported in a letter to the Journal ofthe A merican MedicalAssociation their suspicion that a book about yeast infection was the culpable agent in the general malaise of four female patients whose readings had persuaded them that they harbored Candida albicans. All four presented with non-specific complaints including chronic fatigue, anxiety, and depression; all had~- normal physicaf examination and laboratory reports that showed no clinical evidence of yeast infec-


tion; yet all were taking ketoconazole or nystatin, prescribed by family physicians. And all had read a book called The Yeast Connection. "We have read this book," say the physician letter-writers, "and find it an amusing collection of anecdotes and speculation. The author's central tenet is that unidentified 'toxins' are elaborated by Candida albicans harbored in the vagina. These toxins then are suggested to be responsible for an astonishing array of physical problems." ~ The physicians remark that no scientific evidence or clinical data are

presented either in the book or in any of the references. They also state that "major problems" stemming from the book include the author's recommendations for dietary changes and for specific antifungal therapies including nystatin and ketoconazole. "We think," say the physicians, "that this book may be responsible for significant iatrogenic illness." They point out that chronic nystatin and/or ketoconazole therapy is both expensive and potentially toxic. And they note that one of their book-believing patients subsequently developed symptomatic hepatitis temporally associated with ketoconazole therapy that resolved when treatment was discontinued. ®

Drug Therapy

Monoclonal Antibody Fights Transplant Rejections The first approved therapeutic I use for a monoclonal antibody within the body-possibly able to reverse acute kidney transplant rejections and reduce the need for subsequent surgery-was approved for marketing this June by the Food and Drug Administration (FDA). Each year, about 7,000 Americans receive new kidneys, and about 60% of these patients' bodies reject the transplant, requiring treatment that involves suppressing their immune systems. In one clinical trial of the monoclonal antibody, kidney rejections were reversed in about 94% of the patients who received it intravenously. In another study, the antibody reversed rejection in the 65% of patients who had not responded to conventional therapy. This monoclonal antibody is the fourth product of biotechnology to be approved as a therapy by the FDA. The others were human insulin in October 1982, genetically en gineered human growth hormone in October 1985, and alpha interferon this June.


These three products are the result of gene splicing, a procedure that duplicates genes by placing them in bacteria where they can multiply. But monoclonal antibodies are produced differently-by fusing and cloning genetic material.

Kidney rejections were reversed in about 94% of the patients.

Hybridoma technology shows promise in producing highly specific antibodies to treat some of the world's most serious illnesses, incl uding some cancers, according to FDA Commissioner Frank E. Young, MD. He said he hopes to see more clinical studies testing monoclonal antibodies for other types of organ rejection. ®

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This particular monoclonal antibody works by acting against the body's T-cells-white blood cells responsible for rejecting transplanted kidneys. While various body cells produce antibodies to a foreign material, uniform or monoclonal antibodies are produced by fusing one antibody-producing cell with another cell that is constantly reproducing. The result is a hybridoma-colonies of hybrid, identical cells producing a specific monoclonal antibody.

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