Has clinical pharmacology lost its way?

Pharmacokinetic and pharmacodynamic modelling of metoprolol in rabbits with liver failure

The pharmacokinetic and pharmacodynamic profiles of metoprolol were studied in adult male rabbits given 3.2 mg/kg i.v. before and during liver failure. The partition of metoprolol between blood cells and plasma averaged 1.14 in both conditions. Plasma protein binding, concentration-independent, was 32% and 17% in normal and pathological status, respectively. With normal liver function the terminal elimination half-life for the drug was 0.54-0.96 h, rising to 1.0-2.1 h in liver failure. Differences of the same order were observed for total plasma drug clearance (average 3.7 vs 1.5 1/h/kg), MRT (0.77 vs 1.92 h), AUC (0.9 vs 2.2 mg h/l) and k10 (3.17 vs 1.80 h-1). Liver impairment did not affect the volume of distribution of the central compartment, the steady-state volume of distribution and the other intercompartmental rate constants. Although metoprolol was eliminated in the urine, the amount excreted was low (1.5% of the administered dose) in both conditions. The pharmacokinetic model was extended by an 'effect compartment', which has no influence on the predetermined mass of drug in the body, to analyse the relationship between heart rate fall and changes in metoprolol plasma concentrations. After drug administration, heart rate fell rapidly about 90 beats in both states. The mean unbound plasma concentration producing 50% of this reduction was double during liver failure compared to normal condition (0.03 vs 0.07 mg/l), but the temporal aspects of drug equilibration with site of action were similar.

Information on drug use in pregnancy from the Viewpoint Regional Drug Information Centre

The need for information on drug use during pregnancy was assessed by reviewing the requests for information arriving at a drug information centre in the past nine years. Of all the queries received 24% concerned this aspect, of which the majority were focused on drug use during pregnancy. Mothers received an average of 2.6 prescriptions, most frequently for antiinfectives, psychotropics, hormones and non-narcotic analgesics. Questions were answered personally after a literature search. A profile of questions and a summary of model cases registered in the archives of the centre are reported. The evaluation confirmed the need for and value of a drug information service in relation to pregnancy, so as to avoid alarmist and falsely reassuring attitudes in a field where knowledge is often based on scanty information.

The Clinical Pharmacology Consultation Service: results of a physician survey before and after implementation

A total of 175 physicians were surveyed by questionnaire before a Clinical Pharmacology Consult Service was started. Of those that responded, 72% thought the service would be helpful, although 40% said they would use the service no more than once a month. Most physicians (75%) preferred self-initiated consultations to automatic surveillance. Ninety-two percent believed a physician should be involved in making drug recommendations. A second questionnaire was circulated 30 months later. Actual use of the service closely paralleled the results of the first survey. There was an increased preference for automatic surveillance (5% vs 32%) and many physicians (48%) indicated they felt comfortable accepting drug consultations from a pharmacist or clinical pharmacist. Despite a general attitude of acceptance, the majority of respondents ranked the Clinical Pharmacology Consult Service last as a source of drug information.

Clinical pharmacological and therapeutic considerations in general intensive care. A review

The application of clinical pharmacological concepts and therapeutic standards in intensive care settings presents particularly difficult problems due to the lack of adequately controlled background information and the highly variable and rapidly evolving clinical conditions where drugs must be administered and their impact evaluated. In this review, an attempt has been made to discuss the available knowledge within the framework of a problem-oriented approach, which appears to provide a more clinically useful insight than a drug-centred review. Following a brief discussion of the scanty data and the most interesting models to which reference can be made from a pharmacokinetic point of view (the burn patient being taken as an example), the review concentrates on the main general intervention strategies in intensive care patients. These are based mainly on non-pharmacological measures (correction of fluid and electrolyte balance, total parenteral nutrition, enteral nutrition, oxygenation and ventilatory management) and are discussed with respect to the specific challenge they present in various clinical conditions and organ failure situations. In addition, 4 major selected clinical conditions where general management criteria and careful use of prophylactic and therapeutic drug treatments must interact to cope with the variety of presentations and problems are reviewed. These include: acute cerebral damage; anti-infective prophylaxis and therapy; cardiovascular emergencies; and problems of haemostasis. Each problem is analysed in such a way as to frame the pharmacological intervention in its broader context of the underlying (established or hypothesised) pathophysiology, with special attention being paid to those methodological issues which allow an appreciation of the degree of reliability of the data and the recommendations which appear to be practiced (often haphazardly) in intensive care units. The thorough review of the published literature provided (up to mid-1986) clearly shows that in this field the quality of randomised controlled and epidemiological studies is rather unsatisfactory. It would be highly beneficial to research and to clinical care if larger multicentric protocols and prospective epidemiological comparative investigations could be carried out to investigate more timely and adequately the variables which determine drug action, and the final outcome in the many subgroups of patients which must be considered in a proper stratification of intensive care unit populations.

Feasibility of a large prospective study in general practice: an Italian experience. Gruppo di Studio sulla Pressione Arteriosa nell'Anziano

A study of blood pressure control in elderly outpatients was carried out with the participation of 444 Italian general practitioners. Of 4096 patients aged 65 years or over who were considered for recruitment, 3959 (96.7%) fulfilled all the criteria of admission and were followed up for 12 months. The findings regarding one of the aims of the study--that is, to assess the feasibility of a large scale trial in general practice--are reported. Most (87%) of the doctors completed the study. Their adherence to the protocol was highly satisfactory, leading to an acceptable quality of work. Patients' compliance was also good; 98.6% (3898) of the patients who had fulfilled the admission criteria agreed to participate in the study, and only 4% (158) dropped out. Both of these observations support the feasibility of carrying out prospective studies in general practice. The creation of networks of general practitioners who are prepared to carry out research in their practices would allow treatment and preventive measures to be studied simply and at low cost in the appropriate setting.

Pharmacokinetic and pharmacodynamic modelling of atenolol in rabbits maintained on continuous peritoneal dialysis

The pharmacokinetic and pharmacodynamic profiles of atenolol were studied in adult male rabbits on continuous peritoneal dialysis given 3 mg/kg i.v. before and during renal failure. The average terminal elimination half-life for the drug was 2.5 h calculated from blood, dialysate or urinary data. This value increased about nine times in anuric conditions. Although atenolol was eliminated in the peritoneal fluid, the amount excreted was relatively low both in normal conditions and renal failure, respectively 0.6 and 7% of the administered dose. The pharmacokinetic model was extended by an "effect compartment", which has no influence on the predetermined mass of drug in the body, to analyse the relationship between heart rate fall and changes in atenolol blood concentrations. After drug administration, heart rate fell rapidly about 90 beats in both states. The mean equilibration half-time of atenolol effect and blood concentrations was 0.7 and 1.5 h in normal and pathological states, respectively. The mean blood concentration required to produce 50% of heart rate fall was similar in both conditions, 0.23 mg/l. The nine-fold decrease of atenolol elimination in anuria was in good agreement with the increase in duration of the drug's effect, and was suitably described by the "effect model".

Quality control in antiepileptic drug monitoring in Italy

Measurement of drug concentrations in physiological fluids is increasingly becoming part of the routine management of drug therapy, thus calling for particular care to ensure reliability and avoid misguided management. As part of a long-term national project to set up a network of hospitals where clinical chemists, pharmacists, and physicians could interact and evaluate their activities in connection with therapeutic drug monitoring, the results of a quality control scheme for antiepileptic drugs, which included 50 national hospital laboratories, are described here.

In vitro activities of the spectinomycin analog U-63366 and four quinolone derivatives against Neisseria gonorrhoeae

The in vitro activities of the new spectinomycin analog U-63366 and four new quinolone derivatives, rosoxacin, norfloxacin, ofloxacin, and ciprofloxacin, were compared with those of penicillin, tetracycline, thiamphenicol, cefotaxime, ceftriaxone, and spectinomycin against 222 beta-lactamase-negative and 25 beta-lactamase-positive Neisseria gonorrhoeae strains. U-63366 was more active than spectinomycin, inhibiting 90% of the strains at a concentration of 2 mg/liter. Among the quinolone derivatives, ciprofloxacin was the most active compound in vitro (90% MIC, 0.002 mg/liter), followed by ofloxacin (90% MIC, 0.008 mg/liter), norfloxacin (90% MIC, 0.015 mg/liter), and rosoxacin (90% MIC, 0.03 mg/liter).