Letters Although total phenytoin concentrations are routinely used to correlate dose with therapeutic effect or toxicity, free phenytoin concentrations provide a better guide for both effect and toxicity.' Concurrent use of highly protein-bound drugs can potentially predispose patients to displacement interactions, which may increase the unbound fraction of phenytoin. Several drugs are known to displace phenytoin from its albumin binding sites. Most reports have involved weakly acidic drugs (e.g., phenylbutazone, salicylic acid, valproic acid)' and, although cisapride is a basic drug, we were unsure whether its high degree of protein binding (>98 percent) might still have an effect on unbound phenytoin fraction. Our concern was that withdrawal of cisapride might alter the free fraction of phenytoin in a patient with seizures that were difficult to control. We found no difference in the free phenytoin fraction before and four days after cisapride administration had ceased (unbound fractions 10.5 percent before cessation of cisapride, 10.3 percent after cessation). Cisapride had no appreciable effect on unbound phenytoin fraction in this patient. GREGORY W. ROBERTS, B.Pharm. Senior Pharmacist STEFAN R. KOWALSKI, M.App.Sc. Senior Pharmacist Pharmacy Department Adelaide Children's Hospital King William St. North Adelaide, Australia, 5006 JEAN PIERRE CALABRETTO, B.Pharm. Deputy Chief Pharmacist REFERENCES 1. Nation RL, Evans AM, Milne RW. Pharmacokinetic interactions with phenytoin (part I). Clin Pharmacokinet 1990;18:37-60. 2. Milne RW, Coulthard KP, Nation RL, Penna AC, Roberts G, Sansom LN. Lack of effect of erythromycin on the pharmacokinetics of single oral doses of phenytoin. Br J Clin PharmacoI1988;26:33D-3. 3. Peterson GM, Khoo BHC, Von Witt RJ. Clinical response in epilepsy in relation to total and free serum levels of phenytoin. Ther Drug Monit 1991;13:415-9. 4. Winter ME, Tozer TN. Phenytoin. In: Evans WE, Schentag JJ, Jusko WJ, eds. Applied pharmacokinetics. Spokane. WA: Applied Therapeutics, 1986:493-539.

How much is the Pharm.D. worth to a student? TO THEEDITOR: For the majority of students graduating from pharmacy school, their main concern is the amount of money they will be able to eam. The additional year in college to obtain a Pharm.D. degree not only is a significant extra expense for a student, but it also means a delay in getting into an income-producing situation. The large number of students who each year consider a job in a chain drug store must wonder if it is a wise investment to spend one more year to be called "doctor." What would be your answer if someone asked you this question: Would you spend one extra year in college, earn the same payor less than those who graduated from a five-year program, and pay $15 000 more in tuition? For those few students who think the Pharm.D. is a worthwhile investment because they plan to practice in a clinical setting, how would you answer this question from a physician: Are you sure this is what you eam after six years of college, two years of residency, and two years of fellowship? I have to alert the deans of pharmacy colleges, pharmacy professors, and the pharmacy leaders to pay more attention to the pay scale of the new Pharm.D. graduates. They are not being paid much more than staff pharmacists in the institutional setting where intensive clinical services are being practiced. In fact, most pharmacy directors and managers are having a hard time convincing administrators to pay more for the new six-year Pharm.D. graduates. The response from administrators is something like this: "Everyone is earning the same degree now, so why should I pay more?" Prior to the all-Pharm.D. programs, pharmacists with the advanced degree (post-B.S. Pharm.D.) were offered a higher pay scale because few pharmacists had the same advanced degree. It appears to me that the first-degree Pharm.D. makes the pay situation (earning power) worse, not better, in the areas around our institution.

Very few new graduates go into the hospital setting for two reasons: (1) retail pharmacies pay more, and (2) not enough clinical positions are available for new graduates. The new six-year Pharm.D. graduates are being hired as staff pharmacists in hospitals with the same pay scale as other five-year graduates unless they have completed residencies or fellowships. We have to consider this: What are the benefits of spending another year in college, besides getting on paper the title "Doctor of Pharmacy"? If the degree cannot get the person more money or prestige, the value of spending more time to get the degree is questionable. Society is not ready to call us doctors. Nurses are not willing to call us doctors. The medical doctors may respect us and call good clinical pharmacists doctor if they work in an institution or college and practice what they learn, but the physicians will not call retail pharmacists doctor even if they have a doctoral degree. Podiatrists, physical therapists, and chiropractors have worked through a common goal of promoting themselves for higher pay and more prestige, and they have been very successful in the past ten years. I have not seen much pharmacy public image change since the 1970s from the "druggist" image to the "clinical pharmacy doctor" image. I think the pharmacy leaders should stop fighting for the Pharm.D. issue and instead, work hard to promote the clinical practitioner image to the public, nurses, and physicians; move the pay scale up to match those of the physical therapists or podiatrists; and finally people will call us doctors. What do you think students will do when they are told to consider suggestions like: Why don't you go back and study for a master's degree in nursing? You can get a job as a nurse specialist that pays much more than what a Pharm.D. earns. If 90 percent of the doctors who graduate from colleges of pharmacy and who work in retail drug stores as druggists are not being called doctor, or being honored as doctors of pharmacy, and are not able to use more than 20 percent of their clinical skills, I do not believe it is worth the extra year or the extra tuition that they spent. C.S. TEDTSE,Pharm.D. Clinical Pharmacy Manager St. James Hospital and Health Centers Chicago Heights, Illinois 60411 Clinical pharmacology in two scientific medical journals TO THE EDITOR: The Lancet (TL) and the New England Journal of Medicine (NEJM) are two general medicine journals with international prestige. This is shown by their inclusion in the main medical literature databases and their high "impact factor" (placings of 17 and 7, respectively, in Journal Citation Reports of 1988).14 We chose to analyze the presence of an interdisciplinary specialty (clinical pharmacology) in these two journals and to compare their situations in Europe and the US. The studies appearing in Tl: and NEJM between 1983 and 1989 that had been performed by clinical pharmacology services and/or in which a clinical pharmacologist took part were reviewed. For each work, the number of authors and the nationality of the clinical pharmacologist were recorded. In Tl.; 402 clinical pharmacology works were published, with a minimum of 48 (12 percent) in 1985 and a maximum of 67 (16.7 percent) in 1984. In NEJM, the number of works was 58, with a minimum of 5 (8.6 percent) in 1985 and a maximum of 15 (25.9 percent) in 1983. The number of authors in TL was 919, of whom 711 (77.3 percent) were clinical pharmacologists, with a uniform distribution throughout the period studied. In NEJM, the number of authors was 243, with 147 (60.5 percent) being clinical pharmacologists. That number progressively decreased during the period studied. There were statistically significant differences between the two journals regarding the nationality of the clinical pharmacologists (p

Clinical pharmacology in two scientific medical journals.

Letters Although total phenytoin concentrations are routinely used to correlate dose with therapeutic effect or toxicity, free phenytoin concentration...
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