The FDA has required manufacturers of propoxyphene-containing products (Darvon, and others) to strengthen boxed warnings to include the potential for overdose.1 This action followed disclosure of fatal overdoses linked to propoxyphene-containing products taken alone or concurrently with other CNS depressants, including alcohol. Many of the overdoses occurred in patients with a history of emotional instability or suicide attempts. Accumulation of metabolites of propoxyphene can lead to central nervous system, cardiac and respiratory depression; convulsions and cardiotoxicity have occurred.

A Schedule IV controlled substance, propoxyphene is a weak full agonist opioid indicated for relief of mild to moderate pain.2 It is often prescribed in combination with acetaminophen (Darvocet, and others). One reasonable alternative would be codeine with acetaminophen; 32 mg of codeine has an analgesic effect similar to that of 65 mg of propoxyphene. Another would be 400 mg of ibuprofen, which may be more effective than either propoxyphene or codeine combined with acetaminophen.

1. FDA News Release. FDA takes actions on Darvon, other pain medications containing propoxyphene. Available at www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm170769.html. Accessed August 23, 2010.

2. Drugs for pain. Treat Guidel Med Lett 2010; 92:25.

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Concerns have surfaced again at the FDA and in the media about the safety of acetaminophen and the multiplicity of products on the market in the US that contain various amounts of it.

The majority of patients with insomnia do not have a predisposing psychiatric disease. Rather, untreated insomnia may be a risk factor for development of psychiatric problems such as depression or anxiety.

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment could also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

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Many drugs are used to treat insomnia, but for some patients nonpharmacological treatments such as changing sleep habits, relaxation training and cognitive therapy may be more effective and durable than treatment with drugs. Hypnotic drugs are generally FDA-approved only for short-term use, but in practice they often are taken much longer.

Acamprosate calcium (Campral - Forest) is now being marketed for oral use to maintain abstinence from alcohol. It has been used in France and other countries since 1989.

With the 2004 Olympics only weeks away, performance-enhancing drugs will once again be receiving a great deal of attention. The US Anti-Doping Agency has published a list of drugs banned in Olympic sports (www.usantidoping.org) that includes, at least for some sports, all but 2 of the drugs reviewed here.

Summer heat waves cause thousands of cases of heat-related illness in the US each year and hundreds of heat-related deaths, especially among the elderly. This review describes the contributing factors, clinical signs, and ways to prevent and treat heat injury.

Testing for drug use has become increasingly common, not only in health care, but also in drug rehabilitation, in the military, at the workplace, after accidents and in the criminal justice system. Performance-enhancing drugs such as anabolic steroids, growth hormone (Genotropin, and others) and erythropoietin (Procrit, Epogen) are not discussed here.

Superseded by Drugs of Choice Handbook
Many drugs are used to treat insomnia, but for some patients nonpharmacological treatments such as changing sleep habits, relaxation training and cognitive therapy may be more effective than drugs.

Superseded by Drugs of Choice Handbook
Insomnia is a commom complaint, particularly among the elderly. Many drugs are approved by the US Food and Drug Administration (FDA) for treatment of insomnia, including five benzodiazepines and zolpidem (Ambien), a non-benzodiazepine that binds to benzodiazepine receptors in the brain. Some drugs marketed for other indications, such as antihistamines, antidepressants and antipsychotics, are also used as hypnotics. For many patients, nonpharmacological treatment of insomnia may be more effective than drugs, especially in the long term (CM Morin et al, Am J Psychiatry, 151:1172, 1994).

In a study of the interaction between alcohol and the calcium-channel blocker felodipine (Plendil), the grapefruit juice vehicle for the alcohol appeared to increase felodipine plasma concentrations. Subsequent studies have found that grapefruit juice increases plasma concentrations of several calcium-channel blockers and of some other drugs as well (DG Bailey et al, Clin Pharmacokinet, 26:91, 1994).

Naltrexone (ReVia -DuPont Pharma), a long-acting oral opioid antagonist previously marketed for treatment of opioid dependence under the trade name Trexan, was recently approved by the US Food and Drug Administration (FDA) for treatment of alcohol dependence. The new trade name will now also be used for the old indication.

Loratadine (Claritin - Schering), a new H 1 -receptor antagonist, has been approved by the U.S. Food and Drug Administration for treatment of seasonal allergic rhinitis in patients more than 12 years old. It will compete with older, relatively sedating drugs such as chlorpheniramine (Chlor-Trimeton, and others) and clemastine (Tavist - Medical Letter, 35:9, 1993) and with newer relatively non-sedating agents such as terfenadine (Seldane) and astemizole (Hismanal).

Percutaneous transluminal coronary angioplasty (PTCA), in which a balloon catheter distends the vessel at the site of obstruction (Medical Letter, 25:97, 1983), is now an established therapeutic option for treatment of patients with coronary artery disease, especially those with single-vessel disease. Major problems related to PTCA include acute occlusion during the procedure (usually caused by dissection), restenosis at the site of angioplasty, and inability to treat complete occlusions and long or ostial lesions. Some cardiologists have tried using lasers during PTCA to deal with these problems.

Cefmetazole sodium (Zefazone - Upjohn), a second-generation parenteral cephalosporin, was recently marketed in the USA for intravenous (IV) treatment of various infections caused by susceptible organisms. Like cefotetan (Cefotan), cefamandole (Mandol), cefoperazone (Cefobid), and moxalactam (Moxam), cefmetazole contains a methylthiotetrazole group that has been associated with prothrombin deficiency.

Summer heat waves cause thousands of cases of heat-related illness in the USA each year and hundreds of heat-related deaths, especially among the elderly. A few principles may be helpful in preventing and treating heat injury.

Astemizole (Hismanal - Janssen), a new antihistamine, was recently marketed in the USA for treatment of seasonal allergic rhinitis and chronic idiopathic urticaria. Like terfenadine (Seldane - Medical Letter, 27:65, 1985), astemizole is claimed to be no more sedating than placebo, but the new drug offers the advantage of a once-daily dosage schedule.

Three benzodiazepines and 16 other compounds are marketed in the USA for treatment of insomnia. Many authorities believe that insomnia is overdiagnosed and overtreated (MK Erman, ed, Sleep Disorders, Psychiatr Clin North Am, Volume 10, Dec 1987).

Since The Medical Letter last reviewed the choice of benzodiazepines (Volume 23, page 41, 1981), several new drugs have been marketed and some old ones are now available generically. Most of the benzodiazepines available for oral use in the USA are listed in the table on page 28.