Prescribing in pregnancy: psychotropic drugs Symptomatic ... - NCBI

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Mar 21, 1987 - Drs KIM BILLINGTON and BRIAN HARRIS (Sully. Hospital, South .... 2 Weinstein A, Marlowe S, Kom J, Farouhar F. Low dose methotrexate ...
776 5 Carlston JA. Unilateral dilated pupil from scopolamine disk. YAMA 1982;248:31. 6 Hirch D. Report of a case. Ann Ophihalmol 1984;16:406. 7 Patterson JH, Ives TJ, Greganti MA. Transient bilateral pupillary dilation from scopolamine discs. Drug Intell Clin Phann 1986;20:986-7.

Prescribing in pregnancy: psychotropic drugs Drs KIM BILLINGTON and BRIAN HARRIS (Sully Hospital, South Glamorgan, south Wales) write: Although Dr Loudon's review provided interesting and useful guidelines on a particularly difficult subject (17 January, p 167), he did not mention carbamazepine, which is being used increasingly as prophylaxis against recurrent affective disorders as well as in epilepsy. Its use in young women is particularly likely to cause problems because it reduces the efficiency of oral contraceptives, producing unexpected pregnancies. This can be prevented, however, with the use of a high dose progestogen pill. Carbamazepine does not seem to be associated with an increased rate of teratogenesis when used alone in pregnancy, especially when compared with other antiepileptic drugs. When used in combination with other antiepileptic drugs, however, carbamazepine has been reported to be associated with a pronounced increase in the incidence of congenital defects.

BRITISH MEDICAL JOURNAL

been shown that macrophages may become infected with HIV.6 As Langerhans cells present antigens a similar infection might act as a powerful trigger of psoriatic lesions according to the model we have proposed.5 Though patients with the acquired immune deficiency syndrome become severely depleted in circulating T helper cells, they should at earlier stages in the disease have sufficient T cells to mount an immune reaction against cells infected with HIV that present antigens in the epidermis. 1 GriffithsCEM, PowlesAV,LeonardJN, BakerBS,Valdimarsson H, Fry L. Clearance of psoriasis with low dose cyclosporin. Br MedJ 1986;293:731-2. 2 Baker BS, Swain AF, Fry L, Valdimarsson H. Epidermal T lymphocytes and HLA-DR expression in psoriasis. Br J

Dermatol 1984;110:555-64. 3 Baker BS, Swain AF, Griffiths CEM, Leonard JN, Fry L, Valdimarsson H. Epidermal T lymphocytes and dendritic cells in chronic plaque psoriasis: the effects of PUVA treatment. Clin Exp Immunol 1985;61:526-34. 4 Baker BS, Swain AF, Griffiths CEM, Leonard JN-, Fry L, Valdimarsson H. The effects of topical treatment with steroids or dithranol on epidermal T lymphocytes and dendritic cells in psoriasis. ScandjImmunwol 1985;22:471-7. 5 Valdimarsson H, Baker BS, Jonsdottir I, Fry L. Psoriasis: a disease of abnormal ker.tinocyte proliferation induced by T lymphocytes. Immunology Today 1986;7:256-9. 6 Gyorkey F, Mehick JL, Sinkovics JG, Gyorkey P. Retrovirus resembling HTLV in macrophages of patients with AIDS. Lancet 1985;i: 106.

Methotrexate and non-steroidal Symptomatic hypercalcaemia associated with anti-inflammatory drugs amiodarone Drs ARMANDO GABRIELLI, PIETRO LEONI, and DANIELI (Istituto di Clinica Medica Dr DILIP NATHWANI (Aberdeen Royal Infirmary, GIOVANNIe Terapia Medica, Universita' di Ancona, Aberdeen) writes: A 74 year old woman with chronic Generale 60020 Ancona, Italy) write: Methotrexate has rebronchitis with paroxysmal supraventricular tachy- ceived increased attention for the treatment of patients cardia taking verapamil was admitted witha recurrence rheumatoid arthritis refractory to conventional of supraventricular tachycardia and pseudomonas with is frequent, although mild and chest infection. Amiodarone 400 mg, digoxin 0-125 treatment. 12Toxicity Some reports have, however, emphasised mg, and gentamicin were started. Despite reversal to areversible. possible lifethreatening interaction between methosinus rhythm she developed symptomatic hyperand non-steroidal anti-inflammatory drugs.36 calcaemia and abnormal values on liver function tests. trexate We describe a patient with rheumtoid arthritis who Parathyroid hormone values, bone scan, thyroid func- suffered fatal toxic effects after a single dose of methotion, and protein electrophoresis were normal. A trexate combined with indomethacin and diclofenac. trial of steroids failed to produce improvement. A 71 year old woman with longstanding, aiestructive Amiodarone was stopped, with reversal of the above rheumatoid arthritis and complex was admitted changes. This appears to be a second case of hyper- for evaluation after failingsicca second line therapy with calcaemia associated with amiodarone.1 Again there antimalaria agents, gold salts, and penicillamine. appears to be a possible link with pre-existing mild There was no history ofalcohol consumption, diabetes, renal dysfunction -and concomitant use of digoxin. or renal or hepatic disease. Except for a striking increase of acute all other phase reactants, laboratory 1 McGovern B, Garan H, Kelly E, Ruskin JN. Adverse reactions during treatment with Amiodarone hydrochloride. Br MedJ7 values were normal. On admission treatment was started with 5 prednisone diclofenac 100 mg/day, 1983;287: 175-9. mg/day intravenously, and indomethacin 50 mg/day rectally. On the eighth day 10 mg methotrexate was added intramuscularly as a single dose and repeated Psoriasis, cyclosporin A, and AIDS after 24 hours. Eight hours after the first dose the patient became confused and pyretic. Confusion proDr BARBARA BAKER (St Mary's Hospital, London W2 gressed to coma over the next few days. On the 12th 1NY), Professor H VALDIMARSSON (Landspitalinn, day she developed diarrhoea, leucopenia (1-8 x 109/1), Reykjavik, Iceland), and others write: Dr R C D and anaemia (haemoglobin 88 g/l). Three days later, Staughton and colleagues (10 January, p 125) believe haemoglobin was 67 g/l, white blood cells 04x 109A/, that it is premature to argue that psoriasis is an platelets 30x10971, and creatinine 203 ismol/l. She immunological disease, even though psoriatic lesions died the same day. are infiltrated by T lymphocytes and respond to This case suggests that indomethacin or diclofenac cyclosporin A. They point out that the pharmaco- may have fatal adverse effects if administered conlogical properties of cyclosporin A have not been comitantly with methotrexate. Furthermore, the evaluated fully and that the drug may therefore act rapid onset and the fulminating clinical course after through mechanisms other than the inhibition of T a single dose of methotrexate combined with two helper cells. We decided to set up an open trial of non-steroidal anti-inflammatory drugs imply that cyclosporin A for patients with psoriasis' only after mechanisms other than impaired renal secretion may extensive immunohistochemical studies.24 We realise be operating in this interaction. that our observations and the beneficial effects of cyclosporin A do not prove -formally that psoriasis 1 Kremer JM, Killee J. The safety and efficacy of the use of is a T lymphocyte mediated disease. We believe, methotrexate in long-term therapy for rheumatoid arthritis. Arthritis Rheum 1986;29:822-31. however, that these findings strongly support the 2 Weinstein A, Marlowe S, Kom J, Farouhar F. Low dose notion that T cells directly affect the pathogenesis methotrexate treatment of rheumatoid arthritis: long term of this disease.' Worsening of psoriasis in patients observations. AmJ7Med 1985;79:331-7. infected with human immunodeficiency virus (HIV), 3 Daly HM, Boyle J, Roberts CJC, Scott GL. Interaction between if confirmed, would support the view that psoriatic methotrexate and non-steroidal anti-inflammatory drugs. lesions result from the interaction of T lymphocytes Lancet 19g6;i:557. and Langerhans cells in the epidermis. It has recently 4 Singh RR, Malaviya AN, Pandey JN, Guleria JS. Fatal inter-

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action between methotrexate and naproxen. Lancet 1986;i: 1390. 5 Ellison NM, Servi RJ. Acute renal failure and death following sequential internediate-dose methotrexate and 5-FU: a possible adverse effect due to concomitant indomethacin adminis-

tration. Cancer TreatRep 1985;69:342-3. 6 Thyss A, Milano G, Kubar J, Namer M, Schneider M. Clinical and pharmacokinetic evidence of a life-threatening interaction between methotrexate and ketoprofen. Lancet 1986;i:256-8.

Cephalexin associated pulmonary infiltration with circulating eosinophilia Drs JON H SMITH (Department of Anaesthesia, City Hospital, Nottingham) and V F WEINSTEIN (Warneford Hospital, Leamington Spa, Warwickshire) write: The follQwing case is, we believe, the first description of pulmonary eosinophilia in association with cephalexim. A 44 year old man developed a diffuse maculopapular rash on the seventh day of treatment with oral cephalexin (500 mg three times a day) for an infected cut. The drug was stopped but the rash worsened with formation of bullae on the hands and feet. He developed a cough productive of mucus. Chest radiography showed diffuse consolidation of both lungs, and he was admitted to hospital. He did not smoke and had enjoyed good health. His only known allergy was a contact sensitivity to orange peel. There had been no foreign travel and no other drug treatment. He had undergone cholecystectomy in 1984. Physical examination showed a febrile normotensive man without dyspnoea at rest. He showed the above noted rash and had fine crackles at both lung bases. Investigations showed: haemoglobin 166 g/l, white cell count 20 9x 109/1, eosinophils 9 99x 109/1, neutrophils 9-8x 109/1, lymphocytes 1-03x 109/1, normal urea, electrolyte, and glucose concentrations, albumin 35 g/l, and alkaline phosphatase activity 1083 IU/l (normal