The extent of medication use and drug information preferences was surveyed randomly from patients at six different pharmacy health care systems. Following verbal consultation, each patient was given one or more modified United States Pharmacopeia drug information leaflets corresponding to the verbal information and a self-addressed, stamped questionnaire to complete. Chi-square analysis was performed on 317 responses with overwhelming acceptance (96 percent) of the medication information provided. Although a majority of respondents (62 percent) preferred a combination of both written and oral information, specific information preferences (oral, written, or both) were significantly related to educational level, pharmacy attended, and prescription status. Nearly 45 percent of the respondents indicated the information was responsible for changing their medication use. Subjects who were elderly, taking cardiovascular medications, or getting refill prescriptions were significantly less likely to change as a result of the information provided. Although 65 percent of the respondents were unwilling to pay an additional fee for the service, females and those who were 45–54 years and over 65 years old were significantly more willing to pay for the information. In addition, the willingness to pay tended to increase as the number of daily medications taken increased. Consideration of socioeconomic and prescription variables may help define subgroups with specific information preferences and counseling activities that may be directly reimbursable.
The impact of home infusion therapies on the pharmaceutical services drug budget of the Colorado Medicaid program was evaluated retrospectively. Pharmacy billing claims and prior authorization forms for home infusion therapies submitted to the Colorado Department of Social Services during a 26-month period were reviewed to determine the costs of the drug or hydration solutions and ancillary products necessary for the preparation and administration of the solutions. A dispensing fee of +3.40 per dose was figured into calculations of total costs of home infusion therapies, and an estimated cost of +100-+150 per day for follow-up care was added. Equivalent costs of hospitalization were calculated using an average per diem charge of +315. A total of 61 patients received 1361 days of home infusion therapy during the study period. The majority of patients received home antimicrobial therapy; 752 days of hospitalization theoretically were avoided because of home administration of antimicrobial agents, which translates into a cost savings of +76,716-+114,316. Patients also received home parenteral nutrition therapy, analgesic therapy, and rehydration therapy that yielded cost savings of +48,374-+78,824 but in some cases resulted in higher costs than hospitalization would have. Home infusion therapies increased pharmaceutical services costs by +99,475, representing an important shift of costs from the hospital services budget to the pharmaceutical services budget. Home infusion therapies generally incur lower costs than would be incurred during an equivalent hospital stay. The Colorado Medicaid budget should be adjusted to compensate for the shift of costs from hospital to pharmaceutical services.
This study was performed in order to correlate changes in blood levels of diazepam and desmethyldiazepam with the symptomatology of withdrawal and to examine their elimination kinetics in abusers. The determined half-life of desmethyldiazepam in five diazepam abusers had a wide range of 46.2 to 94.5 hours. Two episodic very high dose abusers exhibited shorter desmethyldiazepam half-lives than was considered normal, possibly due to auto-induction. The half-life of diazepam in a documented very high dose user exceeded that reported in the literature, probably due to accumulation. Withdrawal symptoms reported by the subjects were moderate and included some mental confusion. The most distressing symptom reported was dramatic mood swings which occurred over a matter of minutes. The disappearance of diazepam from blood appears to be the initial cause of withdrawal. Desmethyldiazepam may moderate the severity of the abstinence syndrome but probably lengthens the withdrawal process.
A piroxicam-warfarin interaction is presented with a discussion of the possible mechanism of action. A 60-year-old white male on warfarin therapy for recurrent pulmonary embolism and deep venous thrombophlebitis showed a decrease in his previously therapeutic and stable prothrombin time when piroxicam was discontinued from his drug regimen. On two rechallenges over a ten-month period, his prothrombin times showed consistent and clinically significant fluctuations as piroxicam was added and deleted from his drug regimen.
OBJECTIVE To report a case of possible interaction of smokeless tobacco with warfarin in a patient treated after several thromboembolic events. CASE SUMMARY A white man with a long history of smokeless tobacco use was unsuccessfully treated with warfarin up to 25–30 mg/day. International normalized ratio (INR) values never stabilized >2.0 over 4.5 years of therapy. This patient had experienced 3 myocardial infarctions (MIs) and 2 ischemic strokes between the ages of 29 and 31 years and experienced another MI at age 33 years. This was followed by several episodes of transient ischemic attacks at age 34 years. During the final year of warfarin treatment, tobacco use was terminated, followed by an increase in INR values from 1.1 to 2.3 within one week. Warfarin therapy was discontinued and smokeless tobacco use was reinstated and tapered slowly to discontinuation. Following warfarin discontinuation, ticlopidine therapy was initiated. Subsequently, this patient was placed on long-term clopidogrel therapy. Mechanisms responsible for this interaction have not been established, but would most likely involve an increased dietary source of vitamin K from tobacco. DISCUSSION Tobacco contains high levels of vitamin K, and its use may have contributed directly to the failure of warfarin therapy to achieve therapeutic INR levels in this patient. An objective causality scale indicates a probable association between this combination and the adverse effects. Smokeless tobacco use should be charted in patients undergoing warfarin therapy, and patients who desire to stop tobacco use should be aided in this process. CONCLUSIONS Possible health effects of smokeless tobacco may include potential drug interactions. These interactions may be based on pharmacodynamic and/or pharmacokinetic parameters involving any of the many pharmacologically active substituents of tobacco. Proposed mechanisms of drug interaction may include increased vitamin K levels in the diet.
