Bruce R. Canaday

Documenting Pharmaceutical Care: Creating a Standard

OBJECTIVE: To examine the need for a standardized, systematized approach to document patient pharmacotherapy, workable in all pharmacy practice settings, and to propose a model to meet the identified needs. DATA SOURCE: A MEDLINE search was conducted, in addition to an assessment of current practices and a review of known sources of pharmacotherapy/pharmaceutical care evaluation and documentation methodology. CONCLUSIONS: Pharmacy lacks a universally accepted, standardized, systematized approach to document the evaluation of a patients pharmacotherapy. An approach is presented that distills the concepts of pharmaceutical care into a manageable documentation format and provides a customization of the medical history and physical examination/subjective-objective-assessment-plan system to meet the unique needs of pharmacy. This approach provides a convenient format for notes for all pharmacists, applicable in any practice setting. It provides a starting point for decisions on what pharmacy wants and accepts as a standard to provide continuity of pharmaceutical care to patients, uniform communication with healthcare colleagues, appropriate instruction to students, data analysis to demonstrate the value of services, and needed guidance to software vendors, medical records departments, and third-party payers.

Propantheline bromide in the management of hyperhidrosis associated with spinal cord injury.

Objective: To report 2 cases in which oral propantheline reduced the discomfort associated with sweating related to spinal cord injury (SCI), and to review the literature on the management of SCI-related sweating. Case Summaries: Case 1: A 27-year-old quadriplegic man with an American Spinal Injury Association (ASIA) Frankel class C injury to C5/C6 experienced profuse sweating and requested propantheline. He stated that he had received the medication previously and reported that propantheline 15 mg tid had controlled his sweating. Propantheline bromide was reinstituted, and within 24 hours, the patients episodes of profuse sweating had decreased markedly in number and frequency. Case 2: A 35-year-old quadriplegic woman had an ASIA class D lesion at C3. Since her injury, she had experienced profuse sweating that worsened when she became cold and at night. She stated that her sweating was under control as long as she took propantheline. Propantheline therapy was continued and no further sweating episodes have occurred. Data Source: A MEDLINE search was used to identify pertinent literature including reviews. Standard texts and texts referenced in the pertinent literature also were examined. Study Selection: All available sources of information were reviewed. Data Synthesis: The earliest case reports of systemic therapy for hyperhidrosis described the use of the anticholinergic methantheline bromide. Methantheline in combination with ergoloid mesylates also was suggested for the treatment of congenital hyperhidrosis. Local topical therapy for hyperhidrosis, such as aluminum chlorohydrate and aluminum chloride, the active ingredients in some antiperspirants, have been tried with some success. Talc, starch, and other powders have been suggested to absorb excessive sweat. Formalin and glutaraldehyde also have been used. Topical propantheline bromide has been used successfully in treating palmar and plantar hidrosis. Clonazepam has been used successfully in a case of unilateral localized hyperhidrosis. Systemic phenoxybenzamine has been used with some success and there have been attempts at other systemic therapy using mecamylamine, atropine, propoxyphenel, and methenamine. Scopolamine patches also have been used successfully in a small number of patients. Other agents that have been used include dibenamine, piperoxan, and phentolamine. Systemic propantheline also has been listed as an agent with potential efficacy in treating the profuse sweating associated with SCI, but was not recommended primarily because of adverse effects and difficulty in titrating to the lowest effective dosage. However, studies or case reports specific to the use of propantheline in patients with SCI appear to be lacking, as are reports of direct comparison between propantheline and other agents. Discussion: Concerning the mechanism of action of propantheline bromide for hyperhidrosis, it seems reasonable to attribute its effects to the drugs well-documented anticholinergic/antimuscarinic actions. At dosages used to effectively treat neurogenic bladder, propantheline bromide also should block the muscarinic receptors responsible for sweat gland stimulation. Central nervous system adverse effects should be minimal at usual clinical dosages, as propantheline does not cross the blood–brain barrier. Conclusions: It would appear that in some patients with SCI who are subject to incidental episodes of profuse sweating, oral propantheline may offer some relief and may, in fact, be well tolerated, as in the cases described. Additionally, propantheline would seem a good therapeutic choice in SCI patients with excessive sweating and neurogenic bladder dysfunction who may derive dual benefit from the agent.

A pocket calculator program for prediction of warfarin maintenance dose

A 398 step program, written for the TI59 programmable calculator, has been presented. The procedure allows the user to estimate a patients maintenance warfarin dose requirements after administration of three 10 mg doses or after any series of doses which produces a PT value greater than or equal to 20. The equation used, although based on published literature data, require further evaluation to adequately assess their clinical accuracy. They may, however, provide a starting point for maintenance dose treatment after initial therapy.