Dyazide® To keep blood pressure down and potassium levels up. Before prescribing, see complete prescribing information in CPS. The following is a brief summary. ADULT DOSAGE: Hypertension: Startingdosage is one tablet twice daily after meals. Dosage can be subsequently increasedpr decreased according to patient's need. If two or more tablets per day are needed, they should be given in divided doses. Edema: Starting dosage is one tablet twice daily after meals. When dry weight is reached, the patient may be maintained on one tablet daily. Maximum dosage four tablets daily. INDICATIONS: Mild to moderate hypertension in hypokalemic patients and in patients in whom potassium depletion is considered especially dangerous. Edema of congestive heart failure, cirrhosis, nephrotic syndrome, steroid-induced edema and idiopathic edema. 'Dyazide' is useful in patients whose response to other diuretics is inadequate. CONTRAINDICATIONS: Further use in progressive renal dysfunction (including increasing oliguria and azotemia) or increasing hepatic dysfunction. Hypersensitivity. Elevated serum potassium. Nursing mothers. WARNINGS: Do not use potassium supplementation or other potassium-conserving agents with 'Dyazide' since hyperkalemia may result. Rare cases have been associated with cardiac irregularities. Make periodic serum potassium determinations, particularly in the elderly, in diabetics, and in suspected or confirmed renal insufficiency. If hyperkalemia develops, withdraw Dyazide and substitute a thiazide alone. Hypokalemia is less common than with thiazides alone, but if it occurs it may precipitate digitalis intoxication. PRECAUTIONS: Check laboratory data (e.g. BUN, serum electrolytes) and ECGs periodically, especially in the elderly, in diabetics, in renal insufficiency, and in those who have developed hyperkalemia on .Dyazide' previously. Electrolyte imbalance may occur, especially where saltrestricted diets or prolonged high-dose therapy is used. Observe acutely ill cirrhotic patients for early signs of impending coma. Reversible nitrogen retention may be seen. Observe patients regularly for blood dyscrasias, liver damage or other idiosyncratic reactions; perform appropriate laboratory studies asrequired. Sensitivity reactions may occur in patients with history of allergy or bronchial asthma. Periodic blood studies are recommended in cirrhotics with splenomegaly. Adjust dosage of other antihypertensive agents given concomitantly. Antihypertensive effects of 'Dyazide may be enhanced in the postsympathectomy patient Hyperglycemia and glycosuria may occur. Insulin requirement may be altered in diabetics. Hyperuricemia and gout may occur. Thiazides have been reported to exacerbate or activate systemic lupus erythematosus. Pathological changes in the parathyroid glands have been reported with prolongedthiazide therapy. Triamterene may cause a decreasing alkali reserve, with the possibility of metabolic acidosis. Serum transaminase elevations sometimes occur with 'Dyazide'. Thiazides can decrease arterial responsiveness to norepinephrine and increase tubocurarine's paralyzing effect; exercise caution in patients undergoing surgery. Use in pregnant patients only whendeemed necessary forthe patient's welfare. ADVERSE EFFECTS: Certain gastro-intestinal, central nervous system, dermatological, hypersensitivity, hematological, cardiovascular and other side effects have been reported with the use of thiazide diuretics or triamterene. Electrolyte imbalance may occur (see Precautions). SUPPLY: Scored light orange compressed tablets monogrammed SKF E93 in bottles of 100, 500, 1,000 and 2,500.
Dyazide DIN 181528
25 mg hydrochlorothiazide 50 mg triamterene
makes sense
ated urinary estrogen output in two males with mastitis and in a 73-year-old man with Addison's disease, who tends to be hypotensive and is taking one 5-mg tablet of prednisone once a day. Dr. O'Regan emphasizes the purpose of my letter by stating that he can find little in the literature on urinary estrogen output in men. In fact, I wrote the previous letter for the following reasons: 1. To suggest that there may be an etiologic relation between estrogen production and impotence in some patients. 2. Because the determination of urinary estrogen output is a simple test that may lead us to a more complete understanding of impotence. For example, in two of my patients there was a tendency to gynecomastia as well, which brings to mind a variant of Klinefelter's syndrome. 3. Because, as Dr. McSherry suggests, we may be referring patients with impotence to psychiatrists before adequate investigation has been done, and determination of urinary estrogen output may prove to be a useful part of such investigation. My patients were referred to internists, surgeons and psychiatrists, without any effective result. None were, to my knowledge, ingesting estrogen at the time of examination. J.C. EDWARDS, SM, S
Community Health Centre 3765 Sherwood Dr. Regina, SK
Self-induced water intoxication To the editor: In a recent issue of the Journal (Can Med Assoc 1 114: 438, 1976) Rae described a suspected case of self-induced water intoxication. Part of the evidence for the diagnosis was a reported average intake of 8 pints of water a day and an observed intake during 1 day of 11 pints. Liquid consumption at the lower rate may not be uncommon. In an unpublished, careful survey of the liquid intake of Ontario adults in 1969, the Addiction Research Foundation determined that 37 of 1883 representative individuals reported ingesting more than 8 imperial pints of fluid during the previous 24 hours; S respondents claimed to have drunk more than 11 pints. Given the apparent relatively low incidence of water intoxication, it must be suggested that the poorly controlled diabetes in Dr. Rae's patient was an important factor in her intoxication, if such existed.
S K Smith Kline & French Canada Ltd.
. Montreal, Quebec H4M 2L6
1094 CMA JOURNAL/JUNE 19, 1976/VOL. 114
R.M. GILBERT, PH D
Addiction Research Foundation 33 Russell St. Toronto, ON
To the editor: Dr. Gilbert's interesting figures from the Addiction Research Foundation survey refer, I presume, to intake of water plus beverages. My patient drank a measured 11 pints of water in 1 day 5 months before her acute illness, yet her immediate water loss after this illness (urine output minus intravenous intake) was 2.5 1. That a person can drink one day with impunity an amount of water that another day causes water intoxication, and that this intake is approached every day by some normal people (compulsive water drinkers?) is not surprising; presumably it is the handling of the water rather than the volume itself that matters. A 36-hour illness with coma, convulsions, fever, neurologic signs and hyponatremia, reversed by administration of 3% sodium chloride, points, I think, to a metabolic encephalopathy due to hyponatremia, which in turn was due, in this patient, to self-induced water intoxication. I cannot agree that her poorly controlled diabetes was an important factor in the intoxication; neither prior to nor during this bizarre incident was her diabetes severe and, aside from the clinical picture, her hyponatremia (serum sodium value, 111 mmol/l) was more striking than her hyperglycemia (blood glucose value, 308 mg/dl) on admission to hospital. I would guess that her schizophrenia was much more important in the establishment of her water-drinking habit - to which, incidentally, she has still not returned than was her diabetes. I am sure Dr. Gilbert will echo my wish that she long remain thus unaddicted and, so to speak, off the water wagon. Joi. RAE, EM, B CH (oxoN) Box 130 Moose Creek, ON
WHO repudiates 1:650 To the editor: When preparing the paper "How accurate and relevant are physician manpower statistics?" (Can Med Assoc J 114: 835, 1976) I searched the literature carefully to find the source of the frequently quoted World Health Organization (WHO) standard of 1 physician for 600 to 650 persons. This standard is frequently referred to in Canadian publications. Unable to locate the exact reference I wrote to the headquarters of WHO in Geneva. I received a reply, which referred to the report of a WHO scientific group on the development of studies in health manpower (technical report series no. 481); this states: "If the ratio is not based on conditions in the country or area concerned but is continued on page 1126
Dyazide DIN 181528
25 mg hydrochlorothiazide 50 mg triamterene
makes sense
ated urinary estrogen output in two males with mastitis and in a 73-year-old man with Addison's disease, who tends to be hypotensive and is taking one 5-mg tablet of prednisone once a day. Dr. O'Regan emphasizes the purpose of my letter by stating that he can find little in the literature on urinary estrogen output in men. In fact, I wrote the previous letter for the following reasons: 1. To suggest that there may be an etiologic relation between estrogen production and impotence in some patients. 2. Because the determination of urinary estrogen output is a simple test that may lead us to a more complete understanding of impotence. For example, in two of my patients there was a tendency to gynecomastia as well, which brings to mind a variant of Klinefelter's syndrome. 3. Because, as Dr. McSherry suggests, we may be referring patients with impotence to psychiatrists before adequate investigation has been done, and determination of urinary estrogen output may prove to be a useful part of such investigation. My patients were referred to internists, surgeons and psychiatrists, without any effective result. None were, to my knowledge, ingesting estrogen at the time of examination. J.C. EDWARDS, SM, S
Community Health Centre 3765 Sherwood Dr. Regina, SK
Self-induced water intoxication To the editor: In a recent issue of the Journal (Can Med Assoc 1 114: 438, 1976) Rae described a suspected case of self-induced water intoxication. Part of the evidence for the diagnosis was a reported average intake of 8 pints of water a day and an observed intake during 1 day of 11 pints. Liquid consumption at the lower rate may not be uncommon. In an unpublished, careful survey of the liquid intake of Ontario adults in 1969, the Addiction Research Foundation determined that 37 of 1883 representative individuals reported ingesting more than 8 imperial pints of fluid during the previous 24 hours; S respondents claimed to have drunk more than 11 pints. Given the apparent relatively low incidence of water intoxication, it must be suggested that the poorly controlled diabetes in Dr. Rae's patient was an important factor in her intoxication, if such existed.
S K Smith Kline & French Canada Ltd.
. Montreal, Quebec H4M 2L6
1094 CMA JOURNAL/JUNE 19, 1976/VOL. 114
R.M. GILBERT, PH D
Addiction Research Foundation 33 Russell St. Toronto, ON
To the editor: Dr. Gilbert's interesting figures from the Addiction Research Foundation survey refer, I presume, to intake of water plus beverages. My patient drank a measured 11 pints of water in 1 day 5 months before her acute illness, yet her immediate water loss after this illness (urine output minus intravenous intake) was 2.5 1. That a person can drink one day with impunity an amount of water that another day causes water intoxication, and that this intake is approached every day by some normal people (compulsive water drinkers?) is not surprising; presumably it is the handling of the water rather than the volume itself that matters. A 36-hour illness with coma, convulsions, fever, neurologic signs and hyponatremia, reversed by administration of 3% sodium chloride, points, I think, to a metabolic encephalopathy due to hyponatremia, which in turn was due, in this patient, to self-induced water intoxication. I cannot agree that her poorly controlled diabetes was an important factor in the intoxication; neither prior to nor during this bizarre incident was her diabetes severe and, aside from the clinical picture, her hyponatremia (serum sodium value, 111 mmol/l) was more striking than her hyperglycemia (blood glucose value, 308 mg/dl) on admission to hospital. I would guess that her schizophrenia was much more important in the establishment of her water-drinking habit - to which, incidentally, she has still not returned than was her diabetes. I am sure Dr. Gilbert will echo my wish that she long remain thus unaddicted and, so to speak, off the water wagon. Joi. RAE, EM, B CH (oxoN) Box 130 Moose Creek, ON
WHO repudiates 1:650 To the editor: When preparing the paper "How accurate and relevant are physician manpower statistics?" (Can Med Assoc J 114: 835, 1976) I searched the literature carefully to find the source of the frequently quoted World Health Organization (WHO) standard of 1 physician for 600 to 650 persons. This standard is frequently referred to in Canadian publications. Unable to locate the exact reference I wrote to the headquarters of WHO in Geneva. I received a reply, which referred to the report of a WHO scientific group on the development of studies in health manpower (technical report series no. 481); this states: "If the ratio is not based on conditions in the country or area concerned but is continued on page 1126
