2. Why drug prices are an issue again. Am Drug 1991;204(November):13-4. 3. Navarro RP. Pharmacy cost increases: the effect of Pryor II. MedInterface 1991;(March):14-7. 4. Rosenthal E. As costs of new drugs rise, hospitals stick by old ones. New York Times 1991 Dec 18; Sect. A:l (col. 1). 5. Angaran DM. Medication use task force draft performance indicators: a first look. Partners in Pharmaceutical Care 1991;(June):7-12. 6. Klopfer JD, Einarson TR. Acceptance of pharmacist's suggestions by prescribers:a literaturereview. Hosp Pharm 1990;25:830-2,834-6. 7. Rooks WH n, Maloney PJ, Shott LD, Schuler ME, Sevelius H, Strosberg AM, et aL The analgesic and anti-inflammatoryprofile of ketorolac and its ttomethamine salt. Drugs Exp ClinRes 1985;11:479-92. 8. Ketorolac ttomethamine. MedLett Drugs Ther 1990;32:79-81. Correction: sumatriptan TO THE EDITOR: I am writing to call your attention to a mistake that appeared in the published version of our manuscript "Sumatriptan: A Selective 5-Hydroxytryptamine Receptor Agonist for the Acute Treatment of Migraine" (Ann Pharmacother 1992;26:800-8). Figure 2 was incorrectly referenced as "Adapted from Reference 12, with permission," when, in fact, it should have read "Adapted from Reference 10, with permission." Although we tried to be as careful as possible, we, regrettably, missed this error when perusing the galley proofs of the manuscript. TERENCE RJLLERTON, Pharm.D., BCPS
ClinicalResearchFellow Divisionof Neuropharmacology The Dent Neurologic Institute MillardFillmoreHospital 3 GatesCircle Buffalo, New York 14209
lO-mL ampules) and sodium thiosulfate 25% (two 50-mL ampules). Step I for treatment of acute cyanide toxicity consists of crushing an amyl nitrite ampul in the enclosed gauze and holding this under the patient's nostril for 15-30 seconds every two to three minutes until the sodium nitrite is administered. An intravenous line should be placed during this process so that the remaining drugs can be administered. Step 2 consists of administering sodium nitrite 300 mg intravenously (10 mL of 3% solution) over two to four minutes. The pediatric dose is 6-8 mUm2 or 0.2 mL/kg body weight, not to exceed 10 mL per injection. Step 3 consists of administering sodium thiosulfate 12.5 g intravenously (50 mL of 25% solution) immediately after the administration of sodium nitrite. The pediatric dose is 7 g/m2, not to exceed 12.5 g. Steps 2 and 3 can be repeated at one-half the dose if symptoms reappear,'> Chronic cyanide toxicity secondary to sodium nitroprusside administration is treated by discontinuing the nitroprusside infusion and placing the patient on 100% oxygen. The patient should then receive sodium nitrite and sodium thiosulfate as described above. However, some patients, such as those who are mildly symptomatic or those who may not tolerate clinically significant methemoglobin concentrations, may do well with the discontinuation of the sodium nitroprusside infusion followed by administration of sodium thiosulfate alone.' MICHAEL L. PICCOLO, Pharm.D.
ClinicalPharmacokinetics Resident Departmentof PharmacyServices University ofPennsylvania MedicalCenter 3400 SpruceStreet Philadelphia. Pennsylvania 19104 REFERENCES
Correction: cyanide toxicity from sodium nitroprusside TO THE EDITOR: I am writing in reference to the article on the risks and management of cyanide toxicity from sodium nitroprusside (Ann Pharmacother 1992;26:515-9). An error exists regarding the administration of the cyanide antidote kit. Following the inhalation of amyl nitrite, intravenous sodium nitrite should be administered, not intravenous amyl nitrite as indicated in steps I and 2 of Table 3.
DANJ. HALBERSTADT, B.Pharm.
CriticalCare PharmacySupervisor AbingtonMemorialHospital Clinical1nstructor Philadelphia CollegeofPharmacyand Science Abington,Pennsylvania 19001
1. Vogel SN, Sultan TR, Ten Eyck TR. Cyanide poisoning. ClinToxicol 1981;18:367-83. 2. Package insert. Cyanide antidote package. Indianapolis: Eli Lilly, February 1986. 3. Curry SC, Capell-Arnold P. Toxic effects of drugs used in the ICU: nitroprusside, nitroglycerin, and angiotensin-converting enzyme inhibitors. CritCareClin 1991;7:555-81.
AUTHOR'SREPLY: I appreciate Halberstadt and Piccolo's discovery of this error. Sodium nitrite, not amyl nitrite, should be administered intravenously. Piccolo also notes that for less severe intoxications, sodium thiosulfate alone can be administered, which may be reasonable in view of its low toxicity and cost. This has been advocated by some authors,' although there are no clinical data comparing the efficacy of this treatment with stopping nitroprusside therapy alone.
JOSEPH P. RlNDONE, Pharm.D. TO THE EDITOR: I am writing to point out an error in the article on cyanide toxicity. In the second step of Table 3, the recommendations for administration of the contents of the cyanide antidote kit incorrectly list "amyl nitrite 300 mg iv... over 2-4 min." The correct drug for this dose is sodium nitrite. The statement should read " ... administer sodium nitrite 300 mg iv over 2-4 min." The Cyanide Antidote Package (Eli Lilly, Indianapolis) contains amyl nitrite inhalant (0.3 mL, 12 ampules) along with sodium nitrite 3% (two
1160 •
ClinicalPharmacist DepartmentofVeterans AffairsMedicalCenter (119) Tucson, Arizona85723 REFERENCE 1. Curry SC, Capell-Arnold P. Toxic effects of drugs used in the ICU: nitroprusside, nitroglycerin, and angiotensin-convening enzyme inhibitors. CritCareClin 1991;7:555-81.
The AnnalsofPharmacotherapy • 1992 September, Volume26
ClinicalResearchFellow Divisionof Neuropharmacology The Dent Neurologic Institute MillardFillmoreHospital 3 GatesCircle Buffalo, New York 14209
lO-mL ampules) and sodium thiosulfate 25% (two 50-mL ampules). Step I for treatment of acute cyanide toxicity consists of crushing an amyl nitrite ampul in the enclosed gauze and holding this under the patient's nostril for 15-30 seconds every two to three minutes until the sodium nitrite is administered. An intravenous line should be placed during this process so that the remaining drugs can be administered. Step 2 consists of administering sodium nitrite 300 mg intravenously (10 mL of 3% solution) over two to four minutes. The pediatric dose is 6-8 mUm2 or 0.2 mL/kg body weight, not to exceed 10 mL per injection. Step 3 consists of administering sodium thiosulfate 12.5 g intravenously (50 mL of 25% solution) immediately after the administration of sodium nitrite. The pediatric dose is 7 g/m2, not to exceed 12.5 g. Steps 2 and 3 can be repeated at one-half the dose if symptoms reappear,'> Chronic cyanide toxicity secondary to sodium nitroprusside administration is treated by discontinuing the nitroprusside infusion and placing the patient on 100% oxygen. The patient should then receive sodium nitrite and sodium thiosulfate as described above. However, some patients, such as those who are mildly symptomatic or those who may not tolerate clinically significant methemoglobin concentrations, may do well with the discontinuation of the sodium nitroprusside infusion followed by administration of sodium thiosulfate alone.' MICHAEL L. PICCOLO, Pharm.D.
ClinicalPharmacokinetics Resident Departmentof PharmacyServices University ofPennsylvania MedicalCenter 3400 SpruceStreet Philadelphia. Pennsylvania 19104 REFERENCES
Correction: cyanide toxicity from sodium nitroprusside TO THE EDITOR: I am writing in reference to the article on the risks and management of cyanide toxicity from sodium nitroprusside (Ann Pharmacother 1992;26:515-9). An error exists regarding the administration of the cyanide antidote kit. Following the inhalation of amyl nitrite, intravenous sodium nitrite should be administered, not intravenous amyl nitrite as indicated in steps I and 2 of Table 3.
DANJ. HALBERSTADT, B.Pharm.
CriticalCare PharmacySupervisor AbingtonMemorialHospital Clinical1nstructor Philadelphia CollegeofPharmacyand Science Abington,Pennsylvania 19001
1. Vogel SN, Sultan TR, Ten Eyck TR. Cyanide poisoning. ClinToxicol 1981;18:367-83. 2. Package insert. Cyanide antidote package. Indianapolis: Eli Lilly, February 1986. 3. Curry SC, Capell-Arnold P. Toxic effects of drugs used in the ICU: nitroprusside, nitroglycerin, and angiotensin-converting enzyme inhibitors. CritCareClin 1991;7:555-81.
AUTHOR'SREPLY: I appreciate Halberstadt and Piccolo's discovery of this error. Sodium nitrite, not amyl nitrite, should be administered intravenously. Piccolo also notes that for less severe intoxications, sodium thiosulfate alone can be administered, which may be reasonable in view of its low toxicity and cost. This has been advocated by some authors,' although there are no clinical data comparing the efficacy of this treatment with stopping nitroprusside therapy alone.
JOSEPH P. RlNDONE, Pharm.D. TO THE EDITOR: I am writing to point out an error in the article on cyanide toxicity. In the second step of Table 3, the recommendations for administration of the contents of the cyanide antidote kit incorrectly list "amyl nitrite 300 mg iv... over 2-4 min." The correct drug for this dose is sodium nitrite. The statement should read " ... administer sodium nitrite 300 mg iv over 2-4 min." The Cyanide Antidote Package (Eli Lilly, Indianapolis) contains amyl nitrite inhalant (0.3 mL, 12 ampules) along with sodium nitrite 3% (two
1160 •
ClinicalPharmacist DepartmentofVeterans AffairsMedicalCenter (119) Tucson, Arizona85723 REFERENCE 1. Curry SC, Capell-Arnold P. Toxic effects of drugs used in the ICU: nitroprusside, nitroglycerin, and angiotensin-convening enzyme inhibitors. CritCareClin 1991;7:555-81.
The AnnalsofPharmacotherapy • 1992 September, Volume26
