High Blood Pressure in Elderly, Diabetics
Poison Prevention Week is in March National Poison Prevention Week, March 20-26, provides a special opportunity for pharmacists to educate patients about avoiding accidental poisonings and handling pOisonings if they do occur. For more than 30 years, National Poison Prevention Week has focused consumers' attention on the importance of keeping dnlgs and chemicals out of children's reach. Thanks to increased public awareness, the number of children dying from poisoning decreased from 450 in 1961 to 55 in 1989. Educational materials are available each year from the Poison Prevention Week COlllcil and other sources. Key points they emphasize are: • Use child-resistant packaging. Even people without small children should use this packaging if there is any chance small children will visit. • Call a poison center or physician immediately if someone ingests a poison. Children under age five are especially at risk for accidental poisonings because they explore their environment by putting things in their mouths. And they cannot tell the difference between Vol. NS34, No.2
things that taste good-like candy or soda-and drugs or household cleaners. • Always read the label and follow instructions when taking medicines. Inspect the packaging and the product itself to protect against taking medicines that have been tampered with. • Store pesticides in locked cabinets or sheds. Follow the product's directions precisely. Keep children and their toys away from areas where pesticides are to be applied; keep them away llltil the chemicals are dry, or as recommended on the labels. For information and a list of available materials contact the Poison Prevention Week Council, P.o. Box 1543, Washington, DC 20013.
Children Act Fast. ,,So Do Poisons
Don't Let It Happen To Your Child ~
NATIONAL POISON PREVENTION WEEK
Single copies of this poster are available free from the Poison Prevention Week Council Quantities are for sale at $1 Ofor 25 copies, $18 for 50 copies, and $32 for 100 copies.
Although hypertension in elderly patients is common, it should not be viewed as normal or an inevitable consequence of aging, according to a report fmalized in November by the National High Blood Pressure Education Program. The report on hypertension in the elderly, and a companion report on hypertension in people with diabetes, provide an overview of hypertension's risks in these special populations and recommend treatments. The reports define "hypertension" as systolic blood pressure of 140 mmHg or higher, or diastolic blood pressure of 90 mmHg or higher-the same classification put forth in 1993 by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The report on the elderly notes that variability of blood pressure according to when the measurement is taken is more pronounced in older people, as are the effects on blood pressure of food, position, and other influences. Other important points contained in the report: • Blood pressure should be reduced slowly and cautiously in the elderly. Lifestyle modifications should be tried before drug therapy is initiated. Key lifestyle changes include losing weight; getting aerobic exerAMERICAN PHARMACY
Hypertension Treatment for Diabetic Patients Treatment Goal < 130/85 mmHg
lifestyle Modifications Weight reduction Control of hyperglycemia Moderation of alcohol intake Regular physical activity Reduction of sodium intake Smoking cessation
I Inadequate Response*
t Continue lifestyle Modifications Initial pharmacologic selection (in alphabetical order): ACE inhibitors, alpha-receptor blockers, calcium antagonists, and diuretics in low doses are preferred because of fewer adverse effects on glucose homeostasis, lipid proftles, and renal fimction. (Beta-blockers can have adverse effects on peripheral blood flow, prolongation of hypoglycemia, and masking of hypoglycemic symptoms.)
+ Increase drug dose
Add a second agent from a different class (e.g., a diuretic, if not selected initially)
J Inadequate Response*
+ Add a second or third agent, one of which should be a diuretic, if not already prescribed
*Response means achieved blood pressure goal or considerable progress toward this goal. Source: National High Blood Pressure Education Program Working Group Report on Hypertension in Diabetes.
cise; limiting salt, fat, and alcohol intake; and avoiding smoking. • All classes of antihypertensive drugs are effective in older people. Although adverse drug reactions are two-to-three times more common in the elderly, there is no evidence that they tolerate certain antihypertensive drugs or classes less well than YOlmger patients do. • Health care professionals should reinforce to patients during every visit the importance of controlling hypertension and taking blood pressure medications as prescribed. • To encourage compliance, schedules for taking medications should be as simple as possible. Both verbal and written instructions should be provided. Other aids, such as refillable lmitdose dispensers, may be helpful. • Prescribing medications in small quantities until the drug of choice is established is helpful, especially for patients with limited incomes. The size of the tablet or capsule is an important consideration in this age group because some elderly people have difficulty swallowing. According to the report on hypertension with diabetes, patients with hypertension and diabetes are at higher risk for coronary heart disease, stroke, peripheral vascular disease, diabetic retinopathy, and end-stage renal disease, and are more likely to require amputations February 1994
Vol. NS34, No.2
of lower extremities. Although the general approach to treating hypertension in patients with or without diabetes is the same, special considerations must be taken into account for diabetic patients: • Diabetic patients whose blood pressures have been lowered to 140/90 mmHg remain candidates for further intervention. The recommended goal is 130/85 mmHg. • When making therapeutic decisions, the effects of a specific antihypertensive therapy on renal function and the progression of diabetic nephropathy must be considered. • Some therapies can have adverse effects on glucose and lipid metabolism. • Autonomic dysfunction, which can result in postural hypotension, is common with diabetes and must be taken into account when therapeutic decisions are made. For more infonnation on these reports or other educational materials contact the National High Blood Pressure Education Program, Infonnation Center, P.O. Box 30105, Bethesda, MD 20824-0105.
Public Lacks Knowledge on Genital Warts A recent survey of more than 1,200 Americans found that fewer than half had ever heard of genital warts. More than 90% of those unfamiliar Vol. NS34, No.2
with the condition believe they have no personal risk of contracting genital wartsdespite evidence that there is a 50% risk of transmission from a single sexual encounter with an infected partner. The survey, conducted by the Opinion Research Corporation for the Condyloma Education Council, also found that 49% of respondents do not know how to prevent genital warts. Genital warts, caused by the human papilloma virus (HPV), affects about eight million Americans, making it one of the four most common sexually transmitted diseases. The only foolproof way to avoid transmitting the warts is abstinence, because warts often occur in outlying genital areas on both men and women. According to Marcia Bowling, MD, a professor of
obstetrics and gynecology at the University of Cincinnati and a member of the council, "This is a virus that may exist outside the area protected by a condom -even if the warts are not visible. " After the warts are removed, the virus "remains in or on the skin and may cause the wart to reappear and infect or reinfect a sexual partner," she said. Some strains of HPV are believed to be associated with cervical cancer in women and other genital cancers. The warts, which appear as pink or flesh-colored cauliflower-like lesions, are unsightly and can be uncomfortable when they persist or recur. Symptoms may range from none at all, to itching; burning; tenderness; vaginal discharge; frequent urination or bleeding during urination, for men; or pain during sexual intercourse.
Hypertension May be Linked to Tension in Men Despite a lack of supporting medical evidence, people often think hypertension is linked in some way with nervous tension and anxiety. A recent study suggests that they may be right: in middle-aged men, at least, anxiety and anger may increase the risk for developing hypertension (lAMA. 1993;270:2439-43). Researchers followed 1,123 men and women for 18 to 20 years. All had nonnal blood pressure at the start of the study. Highly anxious middle-aged men were found to have twice the risk of developing hypertension compared with men in the same age group without tension symptoms. Among symptoms the researchers considered indicative of tension were headache; nervousness or shaking; feeling tense, restless, or worried; holding anger in; and taking anger out on others. An association between tension and hypertension was found neither in women, whether they worked in or outside the home, nor in elderlymen.
Although people with multiple sex partners are at greatest risk for contracting genital warts, they can be spread from any skin-to-skin contact, and even by sharing underwear or bath towels. Treatments include topical solutions such as podophyllin and trichloroacetic acid, surgical removal, cryotherapy, electrocautery, laser therapy, or repeated injections of alpha interferon-the only treatment that attacks the underlying HPV infection.
Health Dates FEBRUARY
American Heart Month. American Heart Association, 7320 Greenville Ave., Dallas, TX 75231. (800) AHA-USA1. 14-21, National Condom Week. Men's Support Center, P.O. Box 30564, Oakland, CA 94604. (510) 891-0455. MARCH
National Chronic Fatigue Syndrome Awareness Month. National Chronic Fatigue Syndrome Association, 3521 Broadway, Suite 222, Kansas City, MO 64111. (816) 931-4777. National Eye Donor Month. Eye Bank Association of America, Inc., 1001 Connecticut Ave., NW, Suite 601, Washington, DC 20036. (202) 775-4999. National Kidney Month. National Kidney Foundation, 30 East 33rd St., New York, NY 10016. (800) 622-9010 or (212) 889-2210. AMERICAN PHARMACY
7-13, Save Your Vision Week. American Optometric Association, Communications Center, 243 N. Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100. 21-27, National Poison Prevention Week. Poison Prevention Week Council, 5401 Westbard Ave. , Bethesda, MD 20207. (301) 5040580. 23, American Diabetes Alert. American Diabetes Association, 1660 Duke St. , Alexandria, VA 2231 4. (800) 232-3472 or 003) 549-1500. APRIL
Cancer Control Month. American Cancer Society, National Headquarters, 1599 Clifton Rd. , NE, Atlanta, GA 30329-4251. (800) ACS-2345 or (404) 320-3333. National Alcohol Awareness Month. National Council on Alcoholism and Drug Dependence, Inc. , 12 West 21st St., New York, NY 10010. (212) 206-6770. sm Awareness Month. American Social Health Association, P.O. Box 13827, Research Triangle Park, NC 27709. (919) 361-8400. 7, World Health Day. American Association for World Health, 1129 20th St., N.W. , Suite 400, Washington, DC 20036. (202) 4665883. MAY
Asthma and Allergy Awareness Month. Asthma and Allergy Foundation of America, 1125 15th St., NW, Suite 502, Washington, DC 20005. (800) 7-ASTHMA or (202) 466-7643. AMERICANPHARMACY
Better Sleep Month. Better Sleep Council, 2233 Wisconsin Ave., NW, Suite 500, Washington, DC 20007. (202) 333-0700. Mental Health Month. National Mental Health Association, 1021 Prince St., Alexandria, VA 22314-2971. (703) 684-7722. National Arthritis Month. Arthritis Foundation, 1314 Spring St. , NW, Atlanta, GA 30309. (800) 283-7800 or (404) 872-7100. National Digestive Diseases Awareness Month. Digestive Disease National Coalition, 711 2nd St. , NE, Suite 200, Washington, DC 20002. (202) 544-7499. National High Blood Pressure Month. National High Blood Pressure Education Program Information Center, P.O. Box 30105, Bethesda, MD 20824-0105. (301) 951-3260. National Melanoma/ Skin Cancer Detection and Prevention Month. American Academy of Dermatology, 930 N. Meacham Rd. , P.O. Box 4014, Schaumburg, IL 60173. 008) 3300230. National Sight-Saving Month. National Society to Prevent Blindness, 500 East Remington Rd., Schaumburg, IL 60173. (800) 3312020 or 008) 843-2020. 1-7, National Medic Alert Week. Medic Alert Foundation U.S., P.O. Box 10009, 2323 Colorado Ave., Turlock, CA 95381-1009. (800) 344-3226. 8-14, National Hospital Week. American Hospital Association, 840 N. Lake
Shore Dr., Chicago, IL 60611. (312) 280-6000. 8-14, National Nursing Home Week. American Health Care Association, 1201 L St., NW, Washington, DC 20005. (202) 842-4444.
8--14, National Osteoporosis Prevention Week. National Osteoporosis Foundation, 1150 17th St., NW, Suite 500, Washington, DC 20036. (202) 223-2226.
NEW DRUGS & DEVICES
Livostin Ophthalmic Suspension Levocabastine HCI ophthalmic suspension (Livostin 0.05%-IOLAB), a new, selective HI-receptor antagonist, is a topical medication for the temporary relief of redness and itching associated with seasonal allergic conjunctivitis. The Food and Drug Administration classified the drug 1P, which means it is a new chemical entity receiving a priority review. Adverse Effects: In clinical studies, mild, transient stinging and burning occurred in 15% of patients and 5% experienced headaches. In less than 3% of patients, these side effects were reported: visual disturbances, dry mouth, fatigue, pharyngitis, eye pain and dryness, somnolence, red eyes, cough, nausea, rash, eyelid edema, and dyspnea. Contraindications: The drug should not be used while soft contact lenses are beingwoffi. Dosage: The recommend-
ed dosage is one drop instilled in affected eyes four times a day for up to two weeks. Patients should shake the suspension well before using. Children: Safety and effectiveness have not been established in children under age 12. Pregnancy: Category C. Adequate studies have not been conducted in pregnant women. Nursing Mothers: Based on administration of the drug to one nursing woman, it was calculated that the daily dose of levocabastine to the infant was about 0.5 mcg. How Supplied: In squeeze bottles with polyethylene dropper tips, 2.5-mL, 5-mL, and 10-mL sizes. Storage: Store at room temperature; protect from freezing. Keep tightly closed when not in use. Do not use if the suspension has discolored. For More Information: Cecilia Henderson, (909) 399-1252.
Vol. NS34, No.2