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No. of Recommendations: 27
RSH-

I have been lurking on this board for some time now and one thing strikes me about your posts: you tend to discuss topics as an expert with which you are not 100% familiar. You seem to have a deep understanding of pharmokinetics, etc. Your understanding of the clinical or medicolegal side of medicine, particularly from the physician's point of view, is lacking. You garner a great deal of respect on this board. People believe what you write. That respect from the readers REQUIRES a higher level of responsibility with your posting than you demonstrate. For example:

-- When discussing Propulsid (cisapride), you write many of "as I remember" comments concerning the timing of the warnings about the P450 metabolism and the drug's interactions with other medications that go through the P450 pathway. The following is an excerpt from the current package insert for Propulsid:
"Rare cases of cardiac arrhythmias, including ventricular arrhythmias, torsades de points, and QT prolongation, in some cases resulting in death, have been reported. Most of these patients had been receiving multiple other medications and had pre-existing cardiac disease or risk factors for arrhythmias. A causual relationship to PROPULSIDĀ® has not been established. "
Although the insert does say Propulsid is contraindicated for use in patients already taking -azoles, etc., it does not clearly link the two facts. This would tend to place the blame on the company rather than the physician who prescribed the medication.
--It is not GIRD. The disease is GERD or GER (gastro-esophageal reflux)
--Relating the 5-HT agonist action of Propulsid to the 5-HT action of Imitrex is a classic case of fuzzy thinking. Yes, they do both affect the same class of receptors. Imitrex, however is an agonist for 5-HT type 1, which is a vascular receptor found on the blood vessels in and around the central nervous system. It has no effect on the type 4 receptor, the receptor to which Propulsid binds. The type 4 receptor mediates GI motility and heart rate only. To make a blanket statement like the one you made ("...its activity with 5-HT would suggest to me I would not prescribe it for any patient at risk of stroke or cardiac problems, given what's gone on with the 5-HT active drugs such as Imitrex...) is irresponsible. Not only is your suggestion scientifically unsound, but it could potentially cause some readers to discontinue taking a medication for which they have a need. Evidence-based medicine is the standard to which you need to adhere.
--You wrote, "NAC is now available in tablet form and wouldn't be the worst idea for long-term users of APAP-containing drugs to take (Tylox, Vicodin, Tylenol #anything, Fioricet, Percocet, as examples), or else SAM-E (s-adenosylmethionine), "just in case"."
The preceding comment is an even more outrageous example of what I am writing about. You need to keep these little "ideas" to yourself. You pose a risk to people buy suggesting an expensive, potentially harmful medication as long-term preventive therapy for a very low-incidence condition. Tylenol, when taken as directed, is one of the safest drugs on the market. Length of therapy has nothing to do with the toxicity, as long as the dosing is within the standard dosing regimens. The peak of the serum concentrations is related to the toxicity. In other words, taking 100 tablets all at once will stand a good chance of causing fulminant liver failure whereas taking the same number over weeks has a negligible incidence of hepatotoxicity. This should be obvious.
--You wrote, "Physicians, (and NP's and PA's; depending on your state, any of them can prescribe) can be very uninformed (nicest word I could find) about clinical pharmacology, the pharmacokinetics of a drug (meaning where it goes in the body, what happens to it, and how the body gets rid of it), and the dangers of polypharmacy (Pt. seeing 3 different specialists, all ignorant of what each other is prescribing). About the only MD/DOs/etc I talk to that really understand this stuff are oncologists, endocrinologists, cardiologists, neurologists, and anaesthesiologists"
Now this is just plain insulting. You are applying your anecdotal experience to all physicians, further villifying doctors who are seemingly under attack from all sides these days. To lump MDs in with NPs and PAs is pretty damn insulting, as well. NPs and PAs GENERALLY do not know that much about the basic science behind medicine despite the fact that some can be very competent in a clinical setting. Doctors know what they need to know. They do not need to have the volume of distribution memorized for each drug nor do they need to know how soluble a particular medication is in acetone. To imply that this information is critical for prescribing a medication is ridiculous. Doctors DO need to know the dosing/indications/contraindications/side-effects, etc. Watching for polypharmacy is something that is drilled into all U.S. educated/trained physicians. The problem lies in the patients not being able to tell the doctor what they are taking. It is a patient's responsibility to know or to have a list. Otherwise, they put themselves at risk.
--Gent does not affect the "cranial nerve of hearing." It preferentially knocks out the hair cells in the cochlea, thus causing a hearing loss. Gotta get your facts straight. In addition, as stated previously, there is no "Rule" for a pre-Gent audiogram. The financial cost, the opportunity cost, etc. is too high. Please refer to post 3753.
--You wrote, "On admitting, in ER, with no Pt Hx and Pt unconscious or unresponsive):

a) Have blood and other samples drawn for STAT tox screen and for blood chemistry, and start IV's supporting blood volume, continue patient assessment to r/o trauma; admit patient especially if unconscious

b) On evidence of gross septic problems, administer an approved septic shock drug, [as directed],continue investigating the organism causing infection

c) Once supportive therapy, monitoring, and observation have been established, do a DD on just what sort of thing is causing this Pt to be febrile and and unconscious, maintaining supportive treatment

d) When the Lab results don't come back quickly enough, begin antibiotic therapy, antifungal therapy, or whatever your instinct best suggests."
Buy yourself an ATLS (advanced trauma life support) manual and spend some quality time with it. The protocols have already been worked out and are supported in the medical literature. Again, you carry to much weight, you have too much respect on this board to be making up a protocol for an unresponsive patient. You degrade yourself when you attempt to apply your knowledge of pharmacy to clinical medicine.
--You wrote, "Generally, I just tell the physician what to write and it saves a ton of problems." NOW I understand why you have developed your disrespect for the medical community. If you actually have a physician that will pander to your demands, that person is a disgrace to medicine and should have his or her license revoked.

I agree with many of your statements regarding the responsibilities of physicians when prescribing a medication. The problem is often communication. It is hard for a drug company to let every physician know about a change in the labelling.

To sum it up, you should stick to your area of expertise and not branch out. You have a partial knowledge of clinical medicine. To paraphrase a common saying, your partial knowledge is much more dangerous than another reader's absence of knowledge. THIS POST IS ABSOLUTELY NOT INTENDED AS A FLAME - I am offering some constructive criticism only. You have a lot to offer the board and your regular contributions are appreciated. I only ask, for the safety of the readers of this board and in the interest of fostering intelligent discussion rather than promulgation of rumor and heresay, that you discuss what you know, not what you think you know.

Respectfully,
Todd

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