Table Of Content

eet oenw e pads iy osodes yaw hn’l?h dG. N4. eG ameley eDeea? ttFao s 6 acai 1 sih edMink ATto y We > HH » “oyi.& M e tenayalt) en 14 R” S Reda se ot Oataer A tel AaD ee188r e e1!y aNea sb neMc sy parPea dses Wieeesteidr. Measiy nAe bnite ! Digitized by the Internet Archive in 2022 with funding from Maryland Pharmacists Association Foundation https://archive.org/details/marylandpharmaci6/mary WD ieae nen ie amen \ yy Lie rts { ,\R oss SSS SS ESES=S E AS : { { iLn N{ iSSheScSe eZS eZ SS it # / H EE N NI YjVg VLY SVAtFTs YY Y, iH] ! ' \\r Y, Y ty y | | / Z G ine) | WYY) , | yy hy jiY j} Pa /, 2O2g \ AN i dinye t WV,a TP HT Yj Uy , iGLysrff, i ,a*t WNIi Mae eaWeU:ba isy tu l e aal ll?: Wi i/tN/fh SESS yf/ , i2 iy}| tif! TTTRU US wih Yh pLpyLp, M Yf Uy YY i, /, LL< =/ Y yfJU efn r ifv el / / Wy YY L } /y f Yi/ 1y ] y f { I il Y YW pf) j Yip WAZY { if Yi YY d) WHY | Z| wld } Hh ij Ih? Yj Whiff, y /) My" j Zi Whi Ht f | Hype gi4 ti e WWI y Uy, < y] / i / Wf f/f) f ui { 7S U- fLPeSI1E A , WMALML M: S|s MPhA Mid-Year Educational Seminar February 10,1991 Loews Annapolis Hotel THE MARYLAND PHARMACIST 650 WEST LOMBARD STREET BALTIMORE MARYLAND 21201 TELEPHONE 301/727-0746 Sy JANUARY, 1991 VOL. 67 NO. 1 CONTENTS David G. Miller— Executive Director Richard D. Baylis— Features Editor Maribeth Porter— Production Assistant 3 President’s Commentary Mary Ann Frank— Comptroller : Mel Rubin— Chairman, Publications Committee — Mark Levi Lisa Streib— Production Artist OFFICERS— 1990-1991 New Drugs II: Central Nervous System Agents Hon Presiion — Thomas Gossel Paul Freiman, P.D.— Baltimore — Richard Wuest President c Mark Levi, P.D.—Baltimore ' President-Elect Institutional Forum— Early Diagnosis of Gallstones Ilene Zuckerman, Pharm.D.— Owings Mills —Jim Dickinson Vice-President Brian Sanderoff, P.D.— Baltimore Treasurer Oral Health Problems in the Elderly Ronald Sanford, P.D.—Catonsville — Michelle Andoll Executive Director Emeritus Nathan Gruz, P.D.— Baltimore NARD Resolutions Address Key Practice Issues TRUSTEES Chairman Nathaniel Futeral, P.D.— Baltimore Maryland Pneumonia Vaccination Counseling Gary Magnus, R.Ph. (1991) Materials Silver Spring Howard Schiff, P.D. (1991) Baltimore Arnold Davidov, P.D. (1992) Baltimore Ken Whittemore, Jr., P.D. (1992) DEPARTMENTS 28 Mid-Year Registration Form 2erstown James Tristani, P.D. (1993) Bel Air st) 1G Jee Quiz 29 Products & Promotions Gerald Freedenberg, P.D. (1993) Baltimore : David Chen— ASP (1990) 3] Classifieds UMAB School of Pharmacy EX-OFFICIO MEMBER David Knapp, Ph.D., Acting Dean ADVERTISERS Eli Lilly and Company UMAB School of Pharmacy . Maryland News Distributing HOUSE OF DELEGATES 32. Air Force Health Professions Mayer, Steinberg & Yospe Speaker 26 Alco/Health Services N/E McKeeson— Loewy/District Murhl Flowers— Sunderland 12 Bergen Brunswig Owens and Minor Vice-Speaker 29 District Photo Phillip Marsiglia— Phoenix MARYLAND BOARD OF PHARMACY Roslyn Scheer, M.A.S.—Executive Director Change of address may be made by sending old address (as it appears on your journal) and new address with zip code number. Allow four weeks for changeover. APhA member — Steven Cohen, P.D.—Baltimore tei eae et Sa hn Milton Moskowitz, P.D.—Silver Spring : ote ; : Theodore Litwin, J.D.— Baltimore The Maryland Pharmacist (ISSN 0025-4347) is published monthly by the Maryland Pharmacists Leonard J. DeMino, P D.—Rockville Association, 650 West Lombard Street, Baltimore, Maryland 21201. Annual Subscription — United phic ll PD Bal : States and foreign, $10 a year; single copies, $1.50. Members of the Maryland Pharmacists Associa- Ralph Small, P. i" ee . tion receive The Maryland Pharmacist each month as part of their annual membership dues. Entered George C. Voxakis, P.D.— Baltimore as second class matter at Baltimore, Maryland and additional mailing offices. Postmaster: send ad- Dorothy Levi, P.D.— Baltimore dress changes to: The Maryland Pharmacist, 650 West Lombard Street, Baltimore, Maryland 21201. William Adams, M.Ed.—Baltimore 2 THE MARYLAND PHARMACIST Are We Learning The Right Stuff? Continuing education for pharmacists has long been hailed as the means to assuring continued competence of the profession’s practitioners. In fact, MPhA used this argument in 1986 to secure passage of the mandatory continuing education law in Maryland. But are we really assuring competence or just jumping through regulatory hoops to keep our licenses? We’ ve all attended seminars where half the attendees were asleep and the other half were carrying on conversations with their friends. We’ve all attended seminars where the topic was nothing more than an hour-long **com- mercial’’ for the industry’s latest innovation. Is this education? Is this what pharmacists need? One of my personal goals as President is to assure that the programs sponsored by the Maryland Pharmacists Association are timely and contain information that can be used by pharmacists, MPhA wants to see open eyes at its seminars. That’s why we have been paying special attention to the evaluation forms completed at the end of each of our programs. To meet the goal, our Mid-Year Educational Seminar will have a clini- cally oriented program on new drugs and drug therapies and a personal devel- opment program on understanding your personality and how to work with others. Programs for our Annual Convention include seminars on legal liability of pharmacists and time management in addition to programs on drug and disease issues. I am also pleased to report that one of our affiliates, the Baltimore Metropolitan Pharmaceutical Association, is developing a seminar for young pharmacists on personal financial management. MPhA wants you to learn. We want you to enjoy continuing education, not endure it. Please let us know what you want by calling our office or writing your interests on our evaluation forms. I look forward to seeing each of you at our upcoming Mid-Year! MarksA Levi PeD: President JANUARY, 1991 This continuing education series is provided to MPhA members as a source of continuing education credit. The Maryland Pharmacists Association is approved by the Maryland Board of Pharmacy as a provider of continuing pharmacists’ education in this state. To earn 1.0 contact hours of credit (0.1 CEU) toward relicensure, refer to the instructions and quiz on page 30. Correspondence son’s ability to properly control muscular movement. It is a collection of Course disorders that range from akinesia (ab- normal absence of movements) to New Drugs, Part II: dyskinesia (impairment of the power Central Nervous yX Y > , a offe rrmeuds ctloe as msohvaekmienng t;p alssoy)m .e times re- System Agents The pathologic problem is believed to be an imbalance of neurotransmit- | ters, primarily dopamine and acetyl- by Thomas A. Gossel, R.Ph., Ph.D. choline, that control nerve impulses in Gossel Wuest Professor of Pharmacology the extrapyramidal system, the area in and Toxicology apeutic Classification; the brainstem that coordinates muscu- 2. choose the indications, mecha- lar motor movement. The basic prob- Ohio Northern University nism of action, benefits and limitations lem for many patients is that they do Ada, Ohio of the drugs discussed; not produce sufficient dopamine in 3. identify adverse effects and drug that area. and interactions associated with the drugs; The treatment of choice for Parkin- and sonism is levodopa, given as the com- J. Richard Wuest, R.Ph., 4. demonstrate an ability to counsel bination levodopa/carbidopa (Sine- Pharm.D. patients on these new drugs. met). Dopamine itself cannot be used Professor of Clinical Pharmacy An average of 21.7 new molecular because it does not cross the blood entity drugs were approved each year University of Cincinnati brain barrier from peripheral circula- throughout the 1980s. Drugs that were Cincinnati, Ohio tion to the brainstem where it is need- approved and/or marketed since late ed to correct the problem. 1989, and are active on the central Goals nervous system, are discussed in this Levodopa, which does cross, is the immediate metabolic precursor to The goals of this lesson are to iden- article. The number-letter designation dopamine. It is metabolized into tify and discuss new drugs approved that follows first mention of the gener- dopamine by the enzyme dopa by FDA and/or marketed during late ic name is FDA’s classification, assigned decarboxylase. This can occur in the 1989 and 1990. at the time the manufacturer request- periphery to excessive degree leading ed a New Drug Application. All drugs to irritating and uncomfortable side Objectives in this article are “1” (new chemical effects and inadequate therapeutic ac- entities). The letters include: A (signif- At the conclusion of this lesson, icant therapeutic gain), B (modest tion. successful participants should be able therapeutic gain), and C (little or no Carbidopa is a dopa decarboxylase inhibitor, and prevents peripheral con- to: therapeutic gain), when compared to 1. exhibit knowledge of the drugs previously available therapy for the version of levodopa to dopamine, in- discussed by pharmacologic and ther- same indication. creasing the amount available for trans- port into the central nervous system. in the service Antiparkinson Drugs After several years of therapy, patients may experience a “wearing-off” of pharmacy Pergolide (1B; Permax). Pergolide, effect so that each dose becomes less like bromocriptine (Parlodel), is an active. Others suffer an “on-off” re- agonist for dopamine receptors in the sponse in that symptom relief alter- central nervous system, most specifi- nates with inactivity. Pergolide and cally, the extrapyramidal system. It is selegiline (Eldepryl) are indicated as This continuing education for especially beneficial as adjunctive ther- adjunctive therapy to overcome these Pharmacy article is provided apy in advanced Parkinson’s disease problems, and improve the effective- through a grant from when response to levodopa is deterio- ness of levodopa/carbidopa. rating. Pergolide, like bromocriptine, is an +) MARION MERRELL DOW INC Parkinsonism refers to a number of ergot derivative that is a direct dopa- a neurological disorders that affect a per- mine agonist for receptors in the CNS. THE MARYLAND PHARMACIST This means that these agents, when why, at therapeutic doses, selegiline for OCD. they react with physiologically active does not cause drug interactions char- Chronic obsessive compulsive disor- areas on the nerve cells within the acteristic of other MAO inhibitors (e.g., ders reportedly affect over 4,000,000 CNS, elicit the same response as dopa- Marplan, Nardil, Parnate). These are Americans. Their exact cause is not mine. Pergolide decreases the on-off nonselective inhibitors because they known, but the current theory is that phenomenon of levodopa/carbidopa, act on both types of MAO. obsessions, Compulsions, or both are and may lead to reduction in the Briefly, MAO-A acts in the gut wall caused by imbalances of neurotrans- amount of levodopa needed for some and liver. It exerts its greatest effect on mitters in the brain, most specifically, a patients. endogenous serotonin, and tyramine deficiency of serotonin. There can be significant adverse ef- (as well as other pressor amines) con- Patients with OCD, on the obsessive fects with pergolide. Among these are tained in food. MAO-A blockade can side, undergo repeated, unwanted nausea and indigestion, diarrhea or result in excessive absorption of di- thoughts that intrude into a “normal” constipation, nasal stuffiness, orthostat- etary pressor amines, leading to mas- thought pattern. These lead to distress, ic hypotension, dizziness, Confusion, sive vasoconstriction and death. possibly extreme anxiety, because the insomnia or somnolence, and halluci- MAO-B is most closely associated person usually knows his thoughts are nations. The latter effect is reported to with the metabolism of dopamine in irrational, but cannot change them. be the leading cause of dropout from the brain. An MAO-B selective drug Among the more common compul- therapy. like selegiline decreases dopamine de- sions are washing the hands or clean- While no overt drug interactions struction and increases its availability ing the home repeatedly, hoarding use- have been reported, it can be antici- to overcome symptoms of Parkinson- less items, or incessantly talking and pated that dopamine antagonists, such ism without causing the drug interac- repeating the same words. When these as phenothiazines, haloperidol and tions. In doses higher than recom- interfere with the patient’s occupa- metoclopramide may interfere with mended (5 mg bid) selegiline loses its tional or social functioning, occupy a pergolide. It is also so highly protein selectivity for MAO-B, so these inter- significant amount of time or Cause bound, that pergolide may displace actions can, and have, occurred. undue distress, the person is a candi- other drugs from such binding to in- Much of the research on selegiline date for drug therapy. crease their effects. was conducted in Europe under the The exact mechanism of action for To minimize the chance of ortho- generic name deprenyl, so it is possi- clomipramine is unknown. There is static hypotension during initiation of ble that it may be prescribed by that evidence that its inhibition of seroto- therapy, dosage should be titrated up- name in the U.S. Potential future indi- nin uptake into nerve endings may be ward from a daily dose of 0.05 mg, cations include attention deficit disor- essential to its anti-OCD activity. This possibly to 2 mg over a two- or three- der, narcolepsy, depression, Alzeheim- allows for more serotonin in the syn- week period. Some patients may re- er’s disease and the initial treatment of aptic areas, thus reversing its deficien- quire 1 mg three times a day for Parkinsonism. There is evidence that cy. Clomipramine also blocks the optimal results. To allow for the grad- some patients respond to therapy ear- reuptake of norepinephrine into stor- ual titration, Permax is available in ly in the disease, thus delaying the age areas and increases dopamine me- 0.05, 0.25 and 1 mg tablets. need for levodopa/carbidopa, and re- tabolism. The net result is that obses- ducing its dose when it is needed. sions are eliminated and compulsive Selegiline (1B; Eldepryl). Selegiline The recommended dosage as an ad- activity Ceases. inhibits the enzyme monoamine junct to levodopa/carbidopa in patients The side effect profile is similar to oxidase (MAQ). It acts preferentially with the wearing-off or on-off phe- other tricyclic antidepressants (TCAs) , on one form, termed MAO-B. Selegil- nomena is 5 mg twice daily, with i.e., anticholinergic effects, orthostatic ine can achieve nearly complete inhi- breakfast and lunch to lessen GI tract hypotension, CNS depression and bition of MAO-B with doses insuffi- upset. Eldepryl is available in 5 mg tremor. It causes cardiac arrhythmias, cient to inhibit MAO-A. tablets. like other TCAs, in toxic doses. Due It’s mechanism of action is referred to its high incidence of seizures, if to as “suicide inhibition.” This phar- Clomipramine (1A; Anafranil). Its clomipramine is to be administered to macologic designation refers to drugs manufacturer originally sought approv- patients with a history of seizure dis- that possess a chemically reactive al for clomipramine (a chlorinated de- orders, it must be given with great group which is selectively activated by rivative of imipramine) as an antide- caution. the target enzyme to convert it to a pressant in 1975. The application was The dosage regimen is 25 mg daily, highly reactive intermediate. The con- denied, based on its toxicity profile. gradually increased to 100 mg if need- verted form, then, irreversibly binds to The most significant was seizure activ- ed, over a two-week period. Some and inhibits the enzyme. In other ity reported at 0.7 percent, five times patients may need 200 mg/day for words, selegiline binds with MAO and greater than other antidepressants. symptom control. Doses over 200 mg is converted to its reactive form which Studies were continued outside the daily exhibit increased side effects then renders MAO inactive. Only sub- U.S. including investigation for the without increased therapeutic effect. sequent synthesis of new enzyme can obsessive-compulsive disorder (OCD ). Anafranil is available in 25, 50 and replace it. Since synthesis of MAO is a Currently, clomipramine is marketed 75 mg capsules. slow process, selegiline generally does in approximately 70 countries for de- not lose its effectiveness with pro- pression and/or OCD, and has been Bupropion (1B; Wellbutrin). Bu- longed therapy. available in some for longer than 20 propion, which is therapeutically sim The differentiation of MAO-A from years. On approval in the U.S., clomi- ilar to, but chemically different from MAO-B is important in understanding pramine became the agent of choice the tricyclic antidepressants, was mar- JANUARY, 1991 5 When pharmacists come to Owens & Minor, they find they have a lot of Company. At Owens & Minor, we provide pharmacists with a distributor whose reputation of meeting needs for pharmaceutical, medical, and surgical supplies is unsurpassed. But at Owens & Minor, “Service” is more than a word. It’s our way of doing business: by filling and delivering orders on time; by processing emergency orders immediately and efficiently; by being there when you need us; by providing the personal attention you deserve. As a pharmacist, you can be relied upon. When you P= |z Owens & rely on us, you'll join the many pharmacists that have wwii Minor, Inc. made us one of the leading distributors in the country. T he Company, thal delivers keted in late 1985. It was voluntarily Clozapine (1A; Clozaril). Clozapine Adverse effects of clozapine include withdrawn by its manufacturer in ear- was first synthesized in 1960 and mar- hypersalivation, sedation, dizziness, ly 1986 due to a high occurrence of keted in Europe later that decade. tachycardia, orthostatic hypotension, seizures in bulimic patients enrolled in Clinical trials were initiated in the U.S. fever and constipation. Hypersalivation a clinical trial. Since then, it has been in the 1970s. Reports of mortality due and dizziness usually diminish after evaluated for safety in more than 3000 to agranulocytosis brought U.S. re- the first two weeks of therapy. Seizures patients. It was found that seizures search to an almost complete halt. But were seen in approximately 5 percent resulted from doses higher than rec- interest continued, and the drug was of patients in clinical trials. These were ommended, and are most Common in given Compassionate-use status for se- dose-related and most prevalent in ep- patients prone to them, rather than lected patients who did not improve ileptic patients. While of concern, de- patients without a history of seizures. on traditional therapy (chlorproma- creased seizure control is reported for Because of this, bupropion has been zine, etc. ). After the potential for agran- all antipsychotic drugs. re-released for use in treatment of ulocytosis became known, with proper The dosage of clozapine is 100 to depression. It is contraindicated in pa- monitoring, the occurrence dropped 150 mg once or twice daily initially. tients with a history of seizures, and to 1 percent or less. This can be increased in 25 to 50 mg/ for treatment of bulimia. The manufacturer initially request- day increments over a two-week peri- The exact mechanism of action of ed approval to market the drug in od to reach an optimal dose of 300 to bupropion is not known. It is not an 1983. The request was denied because 450 mg daily. Rarely, patients may MAO inhibitor. It does have weak up- of a high incidence of agranulocytosis, need 900 mg/day for full therapeutic take blocking action on norepine- and insufficient data to establish supe- effects. Clozaril is available in 25 and phrine and serotonin, and it inhibits rior efficacy in light of known toxicity. 100 mg tablets. reuptake of dopamine to some extent. With continued investigation, it was In contrast to traditional tricyclic shown that after six months of therapy, Propofol (1B; Diprivan). Propofol antidepressants, bupropion does not up to 50 percent of schizophrenic is an intravenous anesthetic for induc- block cholinergic, alpha-adrenergic or patients taking clozapine, who were tion and maintenance of general anes- histaminergic receptors. Therefore, it not helped by conventional therapy, thesia for most surgical procedures. causes fewer, if any, anticholinergic improved. With proper WBC monitor- It is used alone or in combination effects, orthostatic hypotension and ing and drug withdrawal when signs of with other anesthetics. It has a rapid drowsiness. agranulocytosis appeared, the death onset of action, usually within 30 to Bupropion causes mild stimulation, rate decreased. None have been re- 40 seconds from start of infusion, including insomnia and headache. In ported in this country. FDA approved and lasts 3 to 10 minutes, depending concert with its action on dopamine, the drug for treatment of patients with on the dose and rate of administra- precipitation of psychosis has been schizophrenia that do not respond to tion, which is monitored throughout reported in a few patients. In contrast conventional therapy in September, surgery. with TCAs, it causes fewer cardiovas- 1939) Propofol shares the adverse effects cular effects. Weight loss is often asso- Clozapine joins loxapine (Loxitane ) of other general anesthetics including ciated with therapy. Patients with mild as a dibenzodiazepine antipsychotic. pain at the site of injection, apnea, congestive heart failure seem able to However, it differs therapeutically in excitement and hypotension during tolerate bupropion, even when they that it does not cause the extrapyra- induction, nausea and vomiting during cannot tolerate other antidepressants. midal (Parkinson-like) symptoms asso- recovery and residual sedation after Bupropion may be involved in sev- ciated with other antipsychotics. surgery (less than previously available eral drug interactions. Because it is Clozapine’s mechanism of action is anesthetics ). metabolized in the liver, drugs that believed to be due to blockade of This last property, i.e., more prompt enhance enzyme production and ac- dopamine in the brain (schizophrenia recovery from anesthesia, is a market- tivity (e.g., carbamazepine, phenytoin, is thought to be caused by excessive ing tool. During clinical trials, patients phenobarbital, rifampin) may decrease dopamine levels). Clozapine has spe- were able to return more quickly to activity. Since both bupropion and cific action on dopamine receptors in self-care, thus requiring less monitor- levodopa affect dopamine activity, to- the limbic area, and this specificity ing by recovery room staff. They were gether they may cause increased side may account for the lack of extrapyra- also able to tolerate orally admin- effects. The above interactions are hy- midal symptoms relative to other istered fluids faster and were alert pothetical rather than proven. Concur- antipsychotics which block dopamine sooner. rent use, or use within 14 days of an in both the limbic and striatal areas. The dosage is individualized, usually MAO inhibitor, is contraindicated. There are no documented cases of 2 to 2.5 mg/kg averaging 40 mg every The recommended dose of bupro- tartive dyskinesia, a condition usually 10 seconds for induction, and 0.1 to pion is 100 mg twice a day, morning seen in about 15 percent of patients 0.2 mg/kg/minute for maintenance of and evening initially, increasing to 150 on other antipsychotic drugs. anesthesia. Diprivan is available in a mg tid. The manufacturer strongly Other antipsychotic-induced afflic- concentration of 10 mg/mL in 20 mL warns against individual doses greater tions not noted with clozapine are glass ampules. than 150 mg, or daily doses greater rigidity, mask-like facial expressions, than 450 mg due to the potential for or slowed movements. These effects Ketorolac (1B; Toradol) This drug seizures. Wellbutrin is available in 75 are causes of discontinuation of thera- has analgesic, anti-inflammatory and and 100 mg tablets. py of other antipsychotic drugs. antipyretic actions characteristic of JANUARY, 199] A surgery and cancer. In equipotent dos- TABLE 1 es, it is comparable to morphine in le Summary of Adverse Events in Two Multiple-Dose Efficacy Studies* | efficacy and safety. Dezocine is claimed to cause fewer side effects than mor- | Toradol Morphine phine with little or no abuse potential. 30 mg 10 & 12 mg Therefore, like ketorolac, it is not a (n = 509) (n = 151) controlled substance. Number of Patients Reporting:** The drug joins butorphanol (Stadol), Any Body System/Any Adverse Event 197 (39%) 106 (70%) nalbuphine (Nubain) and pentazo- caine (Talwin) in the category of anal- Nervous System 116 (23%) 67 (44%) gesics with mixed agonist and antago- Digestive System 66 (13%) 43 (28%) nist effects. Its opioid antagonistic Skin and Appendages 5 ( 1%) 21 (14%) action is greater than pentazocine, but Injection Site 19 ( 4%) 14 ( 7%) less than nalorphine. What little respiratory depression dezocine Causes can Cardiovascular System 18 ( 4%) 4 ( 3%) be reversed with nalorphine. Urogenital System 2 (<1%) 6 ( 4%) The exact mechanism of action for Body as a Whole 8 ( 2%) 5 ( 3%) analgesics has not yet been deter- Musculoskeletal System 2 (<1%) © ( 2%) mpaiinne d.o cTchuer s curirt enits tdhueeo ryt o is cthhaetm iwchaelns | Metabolic/Nutritional Disorders 3 ( 1%) 2 (1%) released from affected cells. These | Respiratory System + ( 1%) 2 ( 1%) stimulate nerve endings to initiate a Special Senses 6 (1%) 2 ( 1%) series of events that the brain inter- Hemic and Lymphatic System 2 (<1%) 1 ( 1%) prets as pain. The discovery that opiates block Number of Patients Terminating receptors was made before the endo- | Early Due to Adverse Events 35 ( 7%) 26 (17%) genous receptor-blocking substances |L * Excludes events considered probably not related to the treatment drug. were elucidated, so they have been **A patient is counted once for a body system if he reports one or more given the name “opiate receptors.” It complaints for that body system. is theorized that opioid analgesics bind at these receptor sites, and prevent the nonsteroidal anti-inflammatory drugs they are incompatible and should not action of pain-inducing neurotransmit- (NSAIDs) in general. Ketorolac inhib- be mixed in the same syringe. ters, thus providing analgesia and also its the action of cyclooxygenase, which Ketorolac is contraindicated in per- potential side effects. Four have been in turn, inhibits prostaglandin synthe- sons with previous hypersensitivity to identified to date: delta, kappa, mu and sis, relieving pain. Pain relief from aspirin or other NSAIDs, or in patients sigma receptors. ketorolac may be evident within 10 who have experienced nasal polyps, Dezocine is claimed to be an ideal minutes of an intramuscular injection. angioedema, or bronchospasm caused analgesic because it has high activity The drug is not an opioid. It there- by aspirin. Use in persons with im- on the mu and delta opioid receptors, fore does not cause typical adverse paired renal function or a history of less activity on kappa receptors, and effects characteristic of opioids. Pa- kidney disease must be undertaken even less on sigma receptors than oth- tients receiving ketorolac have not with caution and in reduced doses. er agonist/antagonist opioids. Since ac- developed tolerance to it, and drug Because it is reported to lead to fluid tion on kappa and sigma receptors is discontinuation does not Cause signs retention and edema, ketorolac should thought to be responsible for CNS of withdrawal. Since it is only ap- be used cautiously in patients with effects associated with narcotic abuse, proved for short-term use, parenteral cardiac or hypertensive disorders. Dalgan will be marketed as the least- ketorolac is not indicated for treat- Since it is not a scheduled drug, likely-to-be-abused opioid analgesic ment of rheumatoid disorders and no nurses and pharmacists are relieved of available. attempt was made to market it for the paperwork of the Controlled Sub- The dosage is 5 to 10 mg intrave- fever reduction. stance Act. This is an important mar- nously or 10 to 15 mg intramuscularly In controlled trials, ketorolac was keting point. every 3 to 4 hours with the dosage associated with fewer adverse effects, The dosage is 30 to 60 mg by intra- titrated to relieve the patient’s pain. and less discontinuance of therapy due muscular injection initially, and 15 to The maximum single dose is 20 mg to adverse effects, than either meperi- 20 mg IM every 6 hours when needed, with a recommended daily dosage lim- dine or morphine (Table 1). Adverse up to 120 mg daily. Toradol is avail- it of 120 mg. Dalgan is available in 5 effects related to nervous and diges- able in 15 mg/mL and 30 mg/mL sy- mg/mL, 10 mg/mL and 15 mg/mL tive symptoms are among the most ringes containing 1 mL, and a 2 mL strengths. common with both ketorolac and nar- syringe with the 30 mg/mL concentra- cotics, but are reported twice as often tion for a 60 mg dose. Summary with morphine than ketorolac. Since ketorolac is an NSAID, it is Dezocine (1C; Dalgan). A new syn- This discussion of new drugs will be synergistic to, and may be used con- thetic opioid agonist/antagonist, dezo- continued and concluded in Part II of comitantly with, opioids. However, cine is an effective analgesic for pain of this series. THE MARYLAND PHARMACIST