1028 CARDIOPULMONARY EFFECTS OF TIMOLOL EYEDROPS
SiR,—Timolol maleate (’Timoptic’) has recently been marketed for the treatment of glaucoma. Timolol is non-selective, blocking both p, and (3z adrenergic receptors. A 62-year-old man who had congenital heart-disease with atrial fibrillation and chronic congestive heart-failure was well compensated on digoxin and diuretics. Cardiac catherisation in 1967 had revealed an atrial septal defect without obstructive
pulmonary hypertension; this was successfully repaired. In January, 1979, he was found to have open-angle glaucoma and an ophthalmologist prescribed timolol ophthalmic solution 0.5%, one drop in each eye twice a day. In March, 1979, he started to gain weight, became progressively dyspnoeic, and began to have "asthmatic attacks". Examination revealed severe congestive heart-failure and bronchospasm. An ECG showed atrial fibrillation with slow ventricular rate. Timolol was stopped immediately. He was put on pilocarpine and acetazolamide. His serum digoxin was in the therapeutic range. In a few days he lost about 4 kg, became compensated, and his ventricular rate increased to 90/min. Britman’ has described an elderly patient on topical timolol who was found to be in nodal rhythm with a ventricular rate 1. Britman NA. Cardiac effects of 566.
topical timolol.
N
Engl JMed 1979; 300:
Commentary from Westminster Effect
on
N.H.S. of Government’s Expenditure
White-paper first sight that the finances of the N.H.S. had escaped the stringencies of the latest round of public spending cuts. According to the Social Services Secretary, Mr Patrick Jenkin, "planned spending on the N.H.S. will give an increase of about 3% in real terms for the two-year period since 1978-79." But, as the message of the Government’s white-paper on public expenditure sinks in, the nature of the "increase" becomes hard to define. The Conservatives have certainly honoured their pre-election promise to avoid cutting back on the N.H.S. expenditure figure which Labour had planned for 1980-81. Spending on the N.H.S. next year will be 7904 million, about 11% of all Government spending. Increases in various charges are to relieve the Treasury of some of the cost of maintaining this programme. Mr Jenkin affirms that the Government will continue its policy that the user will bear a reasonable share of the cost where he is able to afford it. Prescription charges are to go up from 45p to 70p from April 1 next year-in an attempt to make the charges cover the same proportion of the prescription’s actual cost as they did when the 20p charge was introduced in 1971. No change is to be made in the present list of exemptions. Prepayment certificates, or "season tickets", will continue at "favourable rates." The D.H.S.S. expects the new charges to produce an extra C33 million in the next .financial year. Dental charges, which went up in last June’s Budget by between c2 and jC7, are to rise again, but details have not yet been announced. Mr Jenkin declares that they will "reflect exactly the increase in costs of the services." Another 1’5 million is expected to be raised in 1980-81 by increasing the amount that health authorities recover from the insurers of road accident IT seemed
at
40/min, and another patient’s chronic but stable bronchial asthma became uncontrollable while he was taking timoloI.2 Physicians caring for patients with glaucoma should bear in mind the possible systemic effects of timolol and be more selective in choosing patients for treatment with timolol eyedrops. This drug must be prescribed with caution for patients with known contraindications to the systemic use of beta-blockers.
of
Department of Medicine, Fairmont General Hospital, Fairmont, West Virginia 26554, U.S.A.
SAEED AHMAD
UNUSUAL TEST FOR IRON OVERLOAD
SiR,—A 26-year-old Chinese man with beta-thalassxmia major who had been transfused with 404 units of blood over lifetime set off the signal at an airport security checkpoint. His total body iron, estimated at over 100 g, seems to have been sufficient to trigger a metal detector, an unusual new sign for iron overload. School of Medicine,
University of Hawaii, Honolulu, Hawaii 96814, U.S.A. 2.
ROBERT T. S.
JIM
Jones FL Jr, Ekberg NL. Exacerbation of asthma by topical timolol. N Engl
J Med 1979; 301: 270.
April 1, the limits on inpatient costs be recovered from the insurers will rise from ,E200 to 1250 and on outpatient costs from L20 to 125, while fees for first treatment of the casualty go up from 1-23 to 6-65. In subsequent years the gain from the increase is expected to be ,3 million. Civil Servants expect the effect on car insurance premiums to be marginal. Another ;2 million is to be recouped by reducing some of the entitlements to free welfare milk and vitamins. Mr Jenkin gives assurance that the Government will continue to protect those groups who need help, "but the present subsidies will be withdrawn from large families not needing help on income grounds." In all, these changes are expected to yield z84 million next
victims. From
which
can
year.
Mr Jenkin does not expect the increased prescription charges-the element of the cuts that causes the most indignation among the Opposition-to reduce overall demand for prescriptions. "The usual pattern when prescription charges go up is a small drop followed by a normal." His greatest worry is that health authorities will make economies they will later regret, in order to satisfy cash limits. He appreciates how authorities are being "squeezed", but he blames it on the postdated cheques for pay claims he inherited from the Labour Government. Nevertheless he hopes health authorities will not make "spending decisions that will have long-term consequences they would not otherwise want to have." Closures should be avoided where cash can be saved by other means. Mr Jenkin points out that many authorities have been "extremely skilful" in avoiding closures. He promises that cash limits will be "fixed at a realistic level." But a choice will nevertheless have to be made "between pay and services." Making himself quite clear, Mr Jenkin adds: "If too much is taken out in pay, that must mean a cutback in services. There is no sadder sight than to see trade unionists striking for and winning higher pay, then marching in the streets against the closures that are made to pay for it."
return to
SiR,—Timolol maleate (’Timoptic’) has recently been marketed for the treatment of glaucoma. Timolol is non-selective, blocking both p, and (3z adrenergic receptors. A 62-year-old man who had congenital heart-disease with atrial fibrillation and chronic congestive heart-failure was well compensated on digoxin and diuretics. Cardiac catherisation in 1967 had revealed an atrial septal defect without obstructive
pulmonary hypertension; this was successfully repaired. In January, 1979, he was found to have open-angle glaucoma and an ophthalmologist prescribed timolol ophthalmic solution 0.5%, one drop in each eye twice a day. In March, 1979, he started to gain weight, became progressively dyspnoeic, and began to have "asthmatic attacks". Examination revealed severe congestive heart-failure and bronchospasm. An ECG showed atrial fibrillation with slow ventricular rate. Timolol was stopped immediately. He was put on pilocarpine and acetazolamide. His serum digoxin was in the therapeutic range. In a few days he lost about 4 kg, became compensated, and his ventricular rate increased to 90/min. Britman’ has described an elderly patient on topical timolol who was found to be in nodal rhythm with a ventricular rate 1. Britman NA. Cardiac effects of 566.
topical timolol.
N
Engl JMed 1979; 300:
Commentary from Westminster Effect
on
N.H.S. of Government’s Expenditure
White-paper first sight that the finances of the N.H.S. had escaped the stringencies of the latest round of public spending cuts. According to the Social Services Secretary, Mr Patrick Jenkin, "planned spending on the N.H.S. will give an increase of about 3% in real terms for the two-year period since 1978-79." But, as the message of the Government’s white-paper on public expenditure sinks in, the nature of the "increase" becomes hard to define. The Conservatives have certainly honoured their pre-election promise to avoid cutting back on the N.H.S. expenditure figure which Labour had planned for 1980-81. Spending on the N.H.S. next year will be 7904 million, about 11% of all Government spending. Increases in various charges are to relieve the Treasury of some of the cost of maintaining this programme. Mr Jenkin affirms that the Government will continue its policy that the user will bear a reasonable share of the cost where he is able to afford it. Prescription charges are to go up from 45p to 70p from April 1 next year-in an attempt to make the charges cover the same proportion of the prescription’s actual cost as they did when the 20p charge was introduced in 1971. No change is to be made in the present list of exemptions. Prepayment certificates, or "season tickets", will continue at "favourable rates." The D.H.S.S. expects the new charges to produce an extra C33 million in the next .financial year. Dental charges, which went up in last June’s Budget by between c2 and jC7, are to rise again, but details have not yet been announced. Mr Jenkin declares that they will "reflect exactly the increase in costs of the services." Another 1’5 million is expected to be raised in 1980-81 by increasing the amount that health authorities recover from the insurers of road accident IT seemed
at
40/min, and another patient’s chronic but stable bronchial asthma became uncontrollable while he was taking timoloI.2 Physicians caring for patients with glaucoma should bear in mind the possible systemic effects of timolol and be more selective in choosing patients for treatment with timolol eyedrops. This drug must be prescribed with caution for patients with known contraindications to the systemic use of beta-blockers.
of
Department of Medicine, Fairmont General Hospital, Fairmont, West Virginia 26554, U.S.A.
SAEED AHMAD
UNUSUAL TEST FOR IRON OVERLOAD
SiR,—A 26-year-old Chinese man with beta-thalassxmia major who had been transfused with 404 units of blood over lifetime set off the signal at an airport security checkpoint. His total body iron, estimated at over 100 g, seems to have been sufficient to trigger a metal detector, an unusual new sign for iron overload. School of Medicine,
University of Hawaii, Honolulu, Hawaii 96814, U.S.A. 2.
ROBERT T. S.
JIM
Jones FL Jr, Ekberg NL. Exacerbation of asthma by topical timolol. N Engl
J Med 1979; 301: 270.
April 1, the limits on inpatient costs be recovered from the insurers will rise from ,E200 to 1250 and on outpatient costs from L20 to 125, while fees for first treatment of the casualty go up from 1-23 to 6-65. In subsequent years the gain from the increase is expected to be ,3 million. Civil Servants expect the effect on car insurance premiums to be marginal. Another ;2 million is to be recouped by reducing some of the entitlements to free welfare milk and vitamins. Mr Jenkin gives assurance that the Government will continue to protect those groups who need help, "but the present subsidies will be withdrawn from large families not needing help on income grounds." In all, these changes are expected to yield z84 million next
victims. From
which
can
year.
Mr Jenkin does not expect the increased prescription charges-the element of the cuts that causes the most indignation among the Opposition-to reduce overall demand for prescriptions. "The usual pattern when prescription charges go up is a small drop followed by a normal." His greatest worry is that health authorities will make economies they will later regret, in order to satisfy cash limits. He appreciates how authorities are being "squeezed", but he blames it on the postdated cheques for pay claims he inherited from the Labour Government. Nevertheless he hopes health authorities will not make "spending decisions that will have long-term consequences they would not otherwise want to have." Closures should be avoided where cash can be saved by other means. Mr Jenkin points out that many authorities have been "extremely skilful" in avoiding closures. He promises that cash limits will be "fixed at a realistic level." But a choice will nevertheless have to be made "between pay and services." Making himself quite clear, Mr Jenkin adds: "If too much is taken out in pay, that must mean a cutback in services. There is no sadder sight than to see trade unionists striking for and winning higher pay, then marching in the streets against the closures that are made to pay for it."
return to
