Janice L. Stumpf

Safety of Angiotensin-Converting Enzyme Inhibitors in Patients with Insect Venom Allergies

Objective: To review the literature with respect to the safety of angiotensin-converting enzyme (ACE) inhibitors in patients allergic to insect venom and those undergoing venom immunotherapy (VIT). Data Sources: A MEDLINE search was conducted (1966–March 2006) using the following search terms: bee sting, venom, insect stings, ACE inhibitors, angiotensin II receptor blockers, immunotherapy, and desensitization. The bibliographies of qualifying articles were also searched for relevant references. Data Synthesis: Several case reports have described severe allergic reactions, including anaphylaxis, in patients taking ACE inhibitors subsequent to being stung or receiving VIT. Exacerbation of the allergic response by ACE inhibitors is thought to be related to accumulation of bradykinin and inhibition of the formation of angiotensin II. Similar reactions have not been described with angiotensin-receptor blockers, but are theoretically possible. Conclusions: ACE inhibitors may exacerbate the response to insect venom, resulting in potentially life-threatening allergic reactions to insect stings or VIT. Although this risk is difficult to quantify based only on data from case reports, it seems prudent that patients with documented allergic reactions to insect venom avoid ACE inhibitor therapy, if possible. If, after careful consideration of the risks and benefits, ACE inhibitor therapy is deemed warranted, education regarding measures to minimize exposure to insect stings and training on self-administration of epinephrine should be provided, as with any person with venom allergy. In patients in whom VIT is appropriate, temporary discontinuation of the ACE inhibitor prior to each venom injection may prevent subsequent adverse reactions.

Effect of Glucosamine on Glucose Control

Objective: To review the literature regarding the effect of glucosamine on glucose control. Data Sources: English-language articles on the effects of administration of exogenous glucosamine on glucose control were identified through a search of MEDLINE (1966–March 2006), EMBASE (1988–March 2006), and International Pharmaceutical Abstracts (1970–March 2006) databases using the search terms glucosamine, blood glucose, and diabetes mellitus. Abstracts of articles were then reviewed to determine relevance to the topic. Bibliographies of selected articles were screened for other pertinent references. Data Synthesis: Theoretically, glucosamine may alter glucose metabolism. Insulin resistance has been noted following intravenous administration of glucosamine in animal studies; however, these findings have not been confirmed in humans. Alterations in glucose control have not been documented in long-term efficacy studies using oral glucosamine for osteoarthritis or in trials of short duration conducted in healthy or diabetic subjects. The long-term effects of glucosamine in patients with diabetes have yet to be established in well-controlled trials. Conclusions: Small, short-term studies suggest that glucosamine may be used in selected patients without affecting glucose control; however, data in patients with diabetes mellitus are limited, and close monitoring for potential changes in glucose control is recommended.

Finasteride Treatment of Hair Loss in Women

Objective: To review available evidence on the safety and efficacy of finasteride in the treatment of alopecia in women. Data Sources: A literature search was conducted through PubMed (1948–March 2010) and MEDLINE (1950–March 2010) using the search terms finasteride and alopecia. References cited in relevant publications were reviewed. Study Selection and Data Extraction: All data sources identified were reviewed for inclusion. Reports of finasteride treatment of female alopecia were included in the review. This included prospective and retrospective trials, case series, and case reports. Studies in men were not included. Data Synthesis: Few pharmacologic options exist for women with alopecia who do not achieve satisfactory responses to topical minoxidil solution. Treatment successes with finasteride in women with female pattern hair loss, although an off-label indication, have been primarily described in uncontrolled studies and anecdotal reports. In 2 controlled clinical studies, finasteride showed no benefit over placebo or no treatment in female pattern hair loss. A finasteride regimen of 1 mg orally daily, as indicated in male pattern hair loss, may be recommended for those who fail or cannot tolerate minoxidil therapy. A 12-month trial is needed to assess stabilization of hair toss, and hair regrowth may take 2 years or longer Although data are sparse, menopausal status, circulating androgen concentrations, and concomitant symptoms of hyperandrogenism do not appear to predict response to finasteride. Overall, finasteride is well tolerated; however, women of childbearing potential must adhere to reliable contraception while receiving finasteride, and treatment is contraindicated in pregnancy, due to known teratogenicity. Conclusions: Although objective evidence of efficacy is limited, finasteride may be considered for treatment of female pattern hair loss in patients who fail topical minoxidil treatment.

Albumin utilization in a university hospital

The inappropriate use of high-priced agents such as human serum albumin significantly contributes to the rising cost of medical care. A utilization review was conducted at the University of Michigan Hospital in order to identify the appropriateness of use of this agent. Criteria were developed and prescribing was retrospectively evaluated for 81 patients. Of the 935 units administered to these patients, 692 (74 percent) were judged to be inappropriate. This inappropriate use accounted for a projected annual expenditure of nearly

Treatment of Selective Mutism : Focus on Selective Serotonin Reuptake Inhibitors

281 000. Interventions have previously demonstrated success in improving prescribing.

Use of Albumin in a University Hospital: The Value of Targeted Physician Intervention

Selective mutism is a pediatric psychiatric disorder that occurs when a child consistently fails to speak in specific situations in which speaking is expected, such as at school and social gatherings, but speaks appropriately in other settings. Selective mutism often is diagnosed when a child starts school and does not talk to teachers or peers, but talks to family members at home; the condition is frequently accompanied by anxiety and shyness. Although the underlying etiology of the condition remains unclear, psychotherapy is the preferred initial treatment, with the support of parents and teachers. If the child does not respond to psychotherapy, addition of pharmacologic treatment should be considered, depending on the severity of symptoms and presence of other illnesses. Although data are limited to case reports and trials with small patient populations and short follow‐up periods, some patients with selective mutism respond to therapy with selective serotonin reuptake inhibitors (SSRIs). Fluoxetine is the most studied SSRI as treatment for the condition, although further investigation is required to determine the optimal dosage and duration of therapy.

Fatal Hepatotoxicity Induced by Hydralazine or Labetalol

Results of a preliminary study of albumin use at the University of Michigan Hospital were shared with one surgical service (thoracic surgery) that had a documented high rate of inappropriate use. To determine the effectiveness of this targeted educational intervention in reducing inappropriate use and associated drug costs, albumin prescribing for all adult inpatients at University Hospital over a 30-day period was assessed in a retrospective review. Eighty-six patients used a total of 843 units, a ten percent reduction in total albumin use. Albumin administration to thoracic surgery patients decreased by 38 percent. The 35 percent reduction in inappropriate albumin use by this service (Fishers exact test, p<0.001) was associated with an estimated annual cost savings of

Efficacy of a Creon Delayed-Release Pancreatic Enzyme Protocol for Clearing Occluded Enteral Feeding Tubes

83500. Inappropriate albumin use by other medical services generally increased over previously measured levels. This study demonstrated the effectiveness of targeted educational interventions in reducing inappropriate albumin use and thereby controlling rising healthcare costs.

Venous Thromboembolism Prevention in Acutely Ill Nonsurgical Patients

Antihypertensive agents have been associated with adverse reactions that, if unrecognized by health practitioners, may have devastating consequences. The pattern of hepatotoxicity observed during therapy with the vasodilator hydralazine is highly variable, often making its diagnosis difficult. Serious hepatic injury induced by the α‐ and β‐adrenergic receptor antagonist labetalol has only recently been reported and therefore, many clinicians may be unaware of this adverse effect. Familiarity with the clinical features and course of hydralazine‐ and labetalol‐induced hepatic injury is necessary to ensure prompt recognition and discontinuation of the agent.

Methotrexate for the Management of Crohn’s Disease in Children

Background: Alkalinized Viokase pancreatic enzyme tablets restored patency to 71.9% of occluded Dobhoff tubes in a prospective study. After removal of Viokase tablets from the US market, the hospital protocol for unclogging enteral feeding tubes was adapted to use Creon pancreatic enzyme delayed-release capsules, despite the lack of published data. Objective: To evaluate the effectiveness of a Creon-based protocol to clear occluded enteral feeding tubes. Methods: This retrospective study included all adult and pediatric patients seen in the emergency department or in an inpatient setting who received Creon 12 000 units lipase delayed-release capsule dissolved in a solution of sodium bicarbonate 650 mg and sterile water for clearing occluded enteral feeding tubes between May 1 and November 30, 2010. The Creon protocol was deemed effective if tube clearance was documented in the medical record or if enteral feedings were resumed with no note regarding tube replacement. Results: Alkalinized Creon delayed-release capsules were administered to 83 patients with a total of 118 clogged tubes. Three poorly documented cases and 5 tubes with mechanical clogs were excluded from data analysis. Patency was restored to 53 of 110 (48.2%) occluded tubes. More than 1 treatment course was attempted in 5 cases, with success in 3. Conclusion: An alkalinized Creon pancreatic enzyme protocol was effective in clearing approximately half of the occluded enteral feeding tubes in this retrospective study, an efficacy rate much less than that previously reported in the literature with a Viokase-based protocol.