Tin modifier of digestive behaviour
Classification: MAXERAN5 (metoclopramide monohyd rochioride) is a modifier of upper gastrointestinal tract motility. Indications: Sub-acute gastritis, chronic gastritis, gastriG sequellae of surgical procedures such as vagotomy and pyloroplasty. Under these conditions, when gastric emptying is delayed, Maxeran may relieve such symptoms as nausea, vomiting, epigastric distress, bloating, etc. Small bowel ,ntubation: Maxeran may facilitate and accelerate small bowel intubation. Side-effects: Drowsiness and, more rarely, insomnia, fatigue, headaches, dizziness and bowel disturbances have been reported. Parkinsonism and other extra-pyramidal syndromes have been reported infrequently. An increase in the frequency and severity of seizures has been reported in conjunction with the administration of Maxeran to epileptic patients. Precautions: Drugs with atropine-like action should not be used simultaneously with Maxeran since they have a tendency to antagonize effect of this drug on gastrointestinal motility. Maxeran should not be used in conjunction with potent ganglioplegic or neuroleptic drugs since potentiation of effects might occur. Maxeran should not be used in patients with epilepsy and extrapyramidal syndromes, unless its expected benefits outweigh the risk of aggravating these symptoms. In view of the risk of extrapyramidal manifestations, metoclopramide should not be used in children unless a clear indication has been established. The recommended dosage of Maxeran should not be exceeded since a further increase in dosage will not produce a corresponding increase in the clinical response. The dosage recommended for children should not be exceeded. Contraindications: Maxeran should not be administered to patients in combination with MAO inhibitors, tricyclic antidepressants, sympathomimetics and fcods with high tyramine content, since safety of such an association has not yet been established. As a safety measure, a twoweek period should elapse between using Maxeran and administration of any of these drugs. The safety of use of Maxeran in pregnancy has not been established. Therefore Maxeran should not be used in pregnant women, unless in the opinion of the physician the expected benefits to the patient outweigh the potential risks to the fetus. Dosage and administration: For delayed gastric emptying Adults
'/2 to 1 tablet (5 - 10 mg) three or four times a day before meals. 5-10m1(5-lOmg)threeorfour
times a day before meals. When parenteral administration is required, 1 ampoule (10 mg) IM. or IV. (slowly) to be repeated 2 or 3 times a day if necessary. (5 to 14 years):
For small bowel intubation: Adults: One ampoule (10 mg) l.V. - 15
minutes before intubetion. Other
routes (oral or IM.) may be used but with a greater period of latency. (5 to 14 years):
2.StoSml(2.5-Smg) Availability: Tablets: Each white scored compressed tablet
contains 10 mg of Meto.lopramide Monohydrochloride. Bottles of 50 & 500 tablets. Each ml contains 1 mg of Metoclo-
pramide Monohydrochloride. Available in bottles of 110 ml and 450 ml. Each 2 ml ampoule contains 10 mg of Metoclopramide Monohydrochloride in a clear colourless solution. Keep away from light and heat.
Available in boxes of 5 and 50 ampoules.
Product monograph available upon request.
gjf.JORDIC Biochemicals Ltd. Laval, Que.
Marlene Hunter states that "it seems unreasonable and, in the author's opinion, irresponsible to continue an active sexual life without attempting to ensure that pregnancy will not occur" if pregnancy is not desired. I wonder what is Dr. Hunter's opinion of physicians who have their patients discontinue their oral contraceptives for a few months every 2 or 3 years to re-establish their cycles - an unnecessary practice, in my opinion - but do not ensure that these women have an adequate replacement method of contraception. If such a woman, used to relying on effective contraception, becomes pregnant during her "rest period", who is irresponsible, the patient or her physician? Lou E. MASON, MD
Women's College Hospital Toronto, Ont.
The physician and Canadian law To the editor: In his review of the book "The Physician and Canadian Law" (Can Med Assoc 1 111: 1279, 1974), Dr. T. L. Fisher has weighed the evidence and, as one might expect from someone of his experience and position, has acted as a fair and impartial judge of its content. But when he begins to pass sentence on the book's syntax his wig is decidedly askew. In noting, for example, that "twice in the book 'transpires' is - to quote the 'Shorter Oxford English Dictionary - 'misused for: to occur, happen'" and that "these are the kind of things that... are annoying", Dr. Fisher lays himself open not only to the charge of misinterpreting the laws of language, but to that of negligence in using it. My dictionary, published by Random House, offers as its first definition of transpire "to occur, happen", while acknowledging that many (including, one assumes, Dr. Fisher) regard this definition as "incorrect or vulgar". The "Oxford English Dictionary", on the other hand, dismisses Dr. Fisher's "these kind of things" as being "grammatically incorrect" and Fowler's "Modem English Usage" rates the expression a "sturdy indefensible". For the defence, M'Lud, I merely point out that a reviewer, especially one well versed in the law, should not use faulty evidence to make his case in this instance, that the book is "annoying" to read. When he does it more than once (and Dr. Fisher also appears to be unaware that "practice" can be spelled that way even as a verb) maybe it's time to call for a retrial. DAVID Wooos
Medical Communication Services 8849 Roosevelt Ave. Niagara Falls, Ont.
More on the cold war To the editor: As the name implies, the common cold is probably the most frequently seen entity in a physician's office. But I daresay our knowledge of this condition has very little in common with the treatment it receives. By way of review, "common respiratory disease" includes the common cold, grippe, acute bronchitis and tracheobronchitis. There are over 200 antigenically different causative agents known and rhinovirus alone has 30 serologic types. This certainly explains the frequent recurrences. According to Conn's "Current Therapy", 1974 edition, the treatment is symptomatic, and antibiotics should be used only to prevent secondary infection in patients with low pulmonary and cardiac reserves, and to treat complicating secondary infections when they occur; secondary bacterial invasions are uncommon and the routine use of antibiotics should be avoided. However, there are probably more antibiotics prescribed for the upper respiratory infection than for any other disease entity! And we all know that the number of symptomatic remedies for it is almost limitless; the common cold has generated a multimillion dollar pharmaceutical industry! In a survey I conducted at one of our university health services, staffed by conscientious physicians, 24 out of 33 different visits for upper respiratory infections resulted in treatment with antibiotics - 13 with penicillin and 11 with tetracycline! How common this is in a busy general practitioner's office can only be guessed, but 50% would be a conservative estimate. What are we actually propagating with this kind of therapy? The drug industry, for one thing. We are also exposing patients to drugs to which most of their illnesses won't respond. These people become susceptible to all the potential side effects and idiosyncratic reactions of the antibiotic family. Physicians are promoting return visits for a self-limiting disease to give patients a prescription that is in most cases valueless and possibly harmful. Certainly there is a good case to be made for giving some kind of treatment to please the patient as well as the physician. This may take the form of information about the problem, vitamin C, 4 to 6 g/d (which has been shown to have some effect on the severity and duration of symptoms), inquiry into dietary habits and emotional circumstances, especially in cases that have been lingering for more than a week, and finally, simple symptomatic relief if not a ripe old woollen sock. If this letter encourages just a few physicians to rethink their treatment
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 147
pattern for this commonest of all ailments, then it has accomplished its purpose. GERD SCHNEIDER, MD
1303 Richmond Rd. Ottawa, Ont.
What is a specialist? To the editor: I wonder what the opinions of my colleagues are about the criteria needed to call oneself a specialist. Is it simpiy interest in a specialty? Or special training? Or having completed an approved training program and then successfully completing a series of examinations? In the United States any physician who has successfully completed an approved training program becomes a "board-eligible" specialist in that discipline, e.g. pediatrics. Only after he has passed the examinations offered by the American Board of Pediatrics Inc. can he call himself a "board-certified" pediatrician. If he subspecializes the same is true, e.g. for pediatric cardiology. Only if he has passed the written and oral examinations of the appropriate board can he call himself a "certified" specialist. In the US, however, one can charge specialist fees even when one is only "board-eligible" and not "board-certified". There are no exceptions to this rule; even famous university professors must complete written and oral examinations successfully to attain "certified" specialist status. Traditionally in Canada a specialist is one who is certified by examination, both Written and oral, by the Royal College of Physicians and Surgeons of Canada (or by the Province of Quebec). One who has failed these examinations may not practise his specialty, or if he does (at the discretion of the community where he works) he usually charges fees at a generalist's rates. However, there are some interesting perturbations. Some university professors who have not written Canadian examinations have 'been given Royal College fellowships. They are not certified by examination but can call themselves specialists - and collect specialist fees. Why shouldn't a community hospital remote from a teaching centre be able to hire someone on the same basis? Would they wish to? Or would they prefer to maintain higher standards than universities do? As already noted, in the US even full professors must take board examinations to have a "certified" specialist status. I believe there is a need to discuss current procedures for granting and recognizing specialty status. The current system is inconsistent and therefore unjust. I know of individuals who, hay-
ing completed approved training programs but having failed the Canadian specialty examinations, cannot practise their specialty. I know of individuals who, not having tried the Canadian examinations, are given "specialist" status by the Royal College and therefore automatically by the provincial college of physicians and surgeons (and also by government insurance schemes). Surely this is inappropriate. Perhaps we should abandon the present system and adopt the American system, which is fairer and more equitable. KEITH L. MELOFF, MD 123 Edward St. Toronto, Ont.
Hallucinations associated with dantrolene sodium therapy To the editor: We wish to draw attention to hallucinations as a possible side effect of dantrolene sodium (Dantrium) therapy. A 37-year-old man with spastic paraplegia was started on a small dosage of dantrolene, 25 mg bid. This was gradually increased to 75 mg qid over a 17-day period, at which time the first symptoms appeared. He complained of drowsiness and was noted to be slightly confused and disorientated. The dantrolene was decreased to 50 mg qid and he appeared to improve over the next 12 hours. Thereafter he developed acute auditory and visual hallucinations. Dantrolene was discontinued and he was treated with chlorpromazine. The hallucinations persisted for 36 hours. It required a further 24 hours for him to return to his former mental state and alertness. The manufacturer's literature makes no reference to hallucinations being associated with dantrolene therapy. Another physician has personally told us of hallucinations associated with the use of this drug in one of his patients; these subsided on its withdrawal. LESLIE G. ANDREWS, FRCP[CJ ASHOK S. MUZUMDAR, MB A. C. PINKERTON, FRCP[C] G. F. Strong Rehabilitation Centre Vancouver, BC
Graduates of BJ. Medical College To the editor: I am interested in organizing a reunion of B.J. Medical College graduates. Through the Journal I would like to invite all those who have graduated from B.J. Medical College, Ahmadabad, India since 1955 to contact me with a view to establishing an "Overseas B.J. Medical Club".
148 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
PRAFUL A. PATEL, MD 192 Union St. Junction Newcastle, NSW 2291 Australia
Pro-BanthTne for more than peptic ulcer INDICATIONS Pro-Banthine is indicated in peptic ulcer, functional gastrointestinal disturbances, ulcerative colitis, bil iary dyskinesia, chronic hypertrophic gastritis, pylorospasm, acute and chronic pancreatitis, hypermotility of the small intestine not associated with organic change, ileostomies, irritable colon syndrome, diverticulitis, ureteral and urinary bladder spasm, hyperhidrosis.
CONTRAINDICATIONS Gtaucoma Obstructive disease of the gastrointestinal tract Obstructive uropathy due to prostatism Intestinal atony of elderly or debilitated patients Toxic megacolon complicating ulcerative colitis Hiatal hernia associated with reflux esophagitis Unstable cardiovascular adjustment in acute hemorrhage
PRECAUTIONS Patients with severe cardiac disease should be given this medication with caution if even a slight increase in heart rate is undesirable. Fever and heat stroke may occur due to anhidrosis. Varying degrees of urinary hesitancy may occur in elderly patients with prostatic hypertrophy. In such patients urinary retention may be avoided if they are advised to micturate at the lime of taking the medication. A decrease in bronchial secretion may lead to inspissation by these secretions and formation of mucus plugs especially in the elderly or debilitated with chronic pulmonary disease.
ADVERSE EFFECTS Varying degrees of drying of salivary secretions may occur as well as mydriasis and blurred vision. In addition the following adverse reactions have been reported: nervousness, drowsiness, dizziness, insomnia, headache, loss of the sense of taste, nausea, vomiting, constipation, impotence and allergic dermatitis. Some of these effects are dose related.
DOSAGE AND ADMINISTRATION Oral: Dosage should be individualized Pro-Banthine tablets (7.5 mg and 15 mg): the usual adult dosage is 7.5 mg to 15 mg of propantheline bromide with meals and 15 mg to 30 mg at bedtime. Patients with severe manifestations may require increased dosage up to 30 mg four limes a day. Pro-Banthine PA. (30 mg): the usual adult dosage is one tablet in the morning and one at night. Occasionally patients may require one tablet every 8 hours. Parenteral: Initial parenteral dose may be 30 mg or more every 6 hours intramuscularly or intravenously, depending on the condition for which it is administered and the requirements for prompt action. IM. solution - prepared by sterilizing the rubber cap with alcohol and injecting 1 ml of U.S.P. sterile water for injection into the ampoule. IV. solution - recommended that the contents of the 30 mg ampoule be dissolved in 10 ml of U.S.P. sodium chloride injection.
COMPOSITION AND AVAILABILITY Pro-Banthine 7.5 mg: each white, round, convex,
sugar-coaled tablet imprinted "Searle" on one side and "611" on the other contains 7.5 mg of propantheline bromide. In bottles of 100 tablets. Pro-Banthine 15 mg: each peach-coloured, sugarcoated tablet imprinted "Searle" on one side and '601" on the other contains 15 mg of propantheline bromide. In bottles of 100, 1000 and 2500 tablets. Pro-Banthlne P.A. (Prolonged ActIng): the core of each capsule-shaped, compression-coated, peach-coloured tablet, impressed "Searle" on one side and '651" on the other contains 30 mg of propantheline bromide in the form of sustainedrelease beads, about half being released within one hour of ingestion and the remainder released slowly as earlier increments are metabolized. In bottles of 50 and 500 tablets. Pro-Banthine VIALS: each vial contains 30 mg of propantheline bromide as a dry sterile powder for parenteral therapy following reconstitution. In boxes of 10 vials. Full prescribing information available on request or in C.P.S.
Searle Pharmaceuticals Oakville. Ontario