Micrnae Tablets (glyburide) 2m95mg daday
LETTERS TO THE EDITOR
CONTRAINDICATIONS: MICRONASE Tablets are contraindicated in patients with: 1. Known hypersensitivity or allergy to the drug. 2. Diabetic ketoacidosis, with or without coma. This condition should be treated with insulin. 3. Type diabetes mellitus, as sole therapy. d SPECIAL WARNING ON INCREASED RISK OF CARDIOVASCULAR MORTAUTY: Thes a eireeaderIl hypoglyemic drp ha hm reported to he associated with lcrasd carnd ascular mortlty as compard tetamoMtwth die alm or diet plus lsuHnm. Thswarnilg is bas on thestd coeduc by the Unimrslt Group DIabetes Prgram (UGOP), a Ig-trm prospectIv enical tbIal designed to evalua the slecIene o ghues-eowering drngs In pvuteg er delang vascular compatbons In patts with nonimuln-dependnt dIabetes The study hweled 323 patet who wr ranombly asgeed to ol teur tretmeb tgreps (Dlabets, 19 [Suppl 21: 747-3,41970). e plus a UW ed d butanubl (1.5 grams UGDPreported that paffle itstated ter5tb y w hdid et t w perday) hada ratbfd cardt claremortality apprximably2 timesthNteopatiestsatdwlth aloe. AslgNcant lnleC nitotl mortality was etoebrved, butthm d dttamide wa dsetIaed base a the Increase In cardlescular morbaty, thu umlin te oepperbtu for th dsdy t show an ier en ea mertilty. Despite ceereversyrepgrdingthe etpretllel ethse result, di I d the JUGPDPd preidenas adeuatebaleorthl e g The peenIoud be Inferme MICRONASE aed olaltIv medeetherapy. doth Ntlldeliskmed Advan Alhugh eey - drug In the suleeytorea s (elbetabmle) was Inciude I this stdy, N is pu t
fom assbttapeontteoee_dthatthkswamngayapplytuothworelhypoglycemledrugplthis bc#la view temir cs simIlrtIes In mode of actoe a chomieml stbu. PRECAUTIONS: Geeeral-I4yolycemia: All sulfonylureas are capable of producing severe hypoglycemia.
Proper patient selection and dosage and instructions are important to avoid hypoglycemic episodes. Renal or hepatic insufficiency may increase the risk of serious hypoglycemic reactions. Elderly, debilitated or malnourished patients, and those with adrertal or pituitary insufficiency, are particularly susceptible to the hypoglycemic action of glucose-lowering drugs. Hypoglycemia may be difficult to recognize in the elderly and in people who are taking beta-adrenergic blocking drugs. Hypoglycemia is more likely to occur when caloric intake is deficient, after severe or prolonged exercise, when alcohol is ingested, or when more than one glucose-lowering drug is used. Loss of Control of Blood Glucose: In diabetic patients exposed to stress such as fever, trauma, infection or surgery, a loss of control may occur. It may then be necessary to discontinue MICRONASE and administer insulin. Adequate adjustment of dose and adherence to diet should be assessed before classifying a patient as a secondary failure. Information for Patients: Patients should be informed of the potential risks and advantages of MICRONASE and of alternative modes of therapy. They also should be informed about the importance of adherence to dietary instructions, of a regularexercise program, and of regulartesting of urine and/or blood glucose. The risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members. Primary and secondary failure should also be explained. Laboraty Test Response to MICRONASE Tablets should be monitored by frequent urine glucose tests and periodic blood glucose tests. Measurement of glycosylated hemoglobin levels may be helpful in some patients. Dru InteracIo: The hypoglycemic action of sulfonylureas may be potentiated by certain drugs including nonsteroidal anti-infammatory agents and other drugs that are highly protein bound, salicylates, sulfonamides, chloramphenicol, probenecid, coumarins, monoamine oxidase inhibitors, and beta adrenergic blocking agents. Certain drugs tend to produce hyperglycemia and may lead to loss of control. These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. A potential interaction between oral miconazole and oral hypoglycemic agents leading to severe hypoglycemia has been reported. Carcolngoe s, Mubgen*es, and Impairmentld FertIlity: Studies in rats at doses up to 300 mg/kg/day for 18 months showed no carcinogenic effects. Glyburide is nonmutagenic when studied in the Salmonella microsome test (Ames test) and in the DNA damage/alkaline elution assay. Pregnsan. Teratogenic effects: Pregnancy Category B. Reproduction studies in rats and rabbits have revaled no evidence of impaired fertility or harm to the fetus due to glyburide. There are no adequate and well controlled studies in pregnant women. This drug should be used during pregnancy only i clearly needed. Insulin should be used during pregnancy to maintain blood glucose as close to normal as possible. Nonteratogenic Effects: Prolonged severe hypoglycemia (4 to 10 days) has been reported in neonates bom to mothers who were receiving a sulfonylurea drug at the time of delivery. MICRONASE should be discontinued at least two weeks before the expected delivery date. Nuring Mothers: Some sulfonylurea drugs are known to be excreted in human milk. Insulin therapy should be considered. Pediatric Use: Safety and effectiveness in children have not been established. ADVERSE REACTIONS: HypoglycemIa: See Precautions and Overdosage sections. Gastrointestinal ReaclIn: Cholestatic jaundice and hepatitis may occur rarely: MICRONASE Tablets should be discontinued if this occurs. Gastrointestinal disturbances (nausea, epigastric fullness, and heartburn) occurred in 1.8% of patients during clinical trials. They were the most commonly reported adverse reactions. They tend to be dose related and may disappear when dosage is reduced. Liver function abnormalities have been reported. Dermatologic Reactlon: Allergic skin reactions, e.g., pruritus, erythema, urticaria, and morbilliform or maculopapular eruptions occurred in 1.5% of patients during trials. These may be transient and 'may disappear despite continued use of MICRONASE; if skin reactions persist, the drug should be discontinued. Porphyria cutanea tarda and photosensitivity reactions have been reported with sulfonylureas. Hematlogic ReactIons: Leukopenia, agranulocytosis, thrombocytopenia, hemolytic anemia, aplastic anemia, and pancytopenia have been reported with sulfonylureas. MobbolIe Retlsont: Hepatic porphyria and disulfiramlike reactions have been reported with sulfonylureas; however, hepatic porphyria has not been reported with MICRONASE and disulfiram-like reactions have been reported very rarely. Cases of hyponatremia have been reported with glyburide and all other sulfonylureas, most often in patients who are on other medications or have medical conditions known to cause hyponatremia or increase release of antidiuretic hormone. (SIADH) secretion has been reported with certain other sulfonylureas, and it has been suggested that these sulfonylureas may augmentthe peripheral (antidiuretic) action of ADH and/or increase release of ADH. OVERDOSAGE: Overdosage of sulfonylureas, including MICRONASE Tablets, can produce hypoglycemia. If hypoglycemic coma is diagnosed or suspected, the patient should be given a rapid intravenous injection of concentrated (50%) glucose solution. This should be followed by a continuous infusion of a more dilute (10%) glucose solution at a rate which will maintain the blood glucose at a level above 100 mg/dL. Patients should be closely monitored for a minimum of 24 to 48 hours, since hypoglycemia may recur after apparent clinical recovery. Maximum Dose: Daily doses of more than 20 mg are not recommended. Dosage Inteal: Once-a-day therapy is usually satisfactory. Some patients, particularly those receiving more than 10 mg daily, may have a more satisfactory response with twice-a-day dosage. SpeIfi PatIen Popolatlees: MICRONASE is not recommended for use in pregnancy orfor use in children. In elderly patients, debilitated ormalnourished patients, and patients with impaired renal or hepaticfunction, the initial and maintenance dosing should be conservative to avoid hypoglycemic reactions. (See Precautions Section). foradditional product informnation seeyour Upjohn representative.
THE UPJOHN COMPANY, Kalamazoo, Ml 49001
B-S-S
continued from page 690 carcinoma of the breast. Surg Gynecol Obstet. 1981;153:660-664. 5. Bonadonna G, Valagussa P, Rossi A, et al. Ten-year experience with CMF-based on adjuvant chemotherapy in resectable breast cancer. Breast Cancer Res Treat. 1985;5:95-115.
Minorities in the Health Professions To the Editor: I was appalled by Betty C. Jung's Letter to the Editor in the October 1990 issue. Apparently, she has a distorted view about the problems with minorities in the health professions. African, Hispanic, and Native Americans have been underrepresented in the health professions, especially the medical profession, for a long time. They continue to be underrepresented. It is inappropriate to attribute their lesser numbers in college to the idea that, since they are minorities, their numbers are expected to be smaller. If the ratio of minorities in colleges and graduate schools to those not in said institutions were compared with the same ratio for nonminorities, the ratio for minorities would be much smaller. Furthermore, poor living conditions, health problems, and poor educational systems are indeed factors. Schools are obligated to provide motivation and nurturing for students. This is sorely lacking in most inner-city schools. In addition, poverty and poor living conditions are not an excuse for those who cannot succeed in life-they are a real hinderance. In able to succeed in today's society, one needs money to attend private schools, money to attend college, money to attend graduate and professional schools, and money to start a business. I myself come from a low-income continued on page 729 720
APRIL 1990
J-3146
LETTERS TO THE EDITOR
The following have been reported in about 0.5 to 2 percent of patients but did not appear at increased frequency compared to placebo or other treatments used in controlled trials: gastric irritation, abdominal pain, nausea, vomiting, diarrhea, anorexia, constipation, aphthous ulcers, peptic ulcer, dizziness, headache, malaise, fatigue, insomnia, dry mouth, dyspnea, cough, alopecia, paresthesias. Other clinical adverse effects reported since the drug was marketed are listed below by body system. In this setting, an incidence or causal relationship cannot be accurately determined.
General: Asthenia, gynecomastia. Cardiovascular: Cardiac arrest, cerebrovascular accident/insufficiency, rhythm disturbances, orthostatic hypotension, syncope. Dermatologic: Bullous pemphigus,erythema multiforme (including Stevens-Johnson syndrome), exfoliative dermatitis.
Gastrointestinal: Pancreatitis, glossitis, dyspepsia. Hematologic: Anemia, including aplastic and hemolytic. Hepatobiliary: Jaundice, hepatitis, including rare cases of necrosis, cholestasis. Metabolic: Symptomatic hyponatremia. Musculoskeletal: Myalgia, myasthenia. Nervous/Psychiatric: Ataxia, confusion, depression, nervousness, somnolence. Respiratory: Bronchospasm, eosinophilic pneumonitis,
rhinitis. Special Senses: Blurred vision. Urogenital: Impotence. As with other ACE inhibitors, a syndrome has been reported which may include: fever, myalgia, arthralgia, interstitial nephritis, vasculitis, rash or other dermatologic manifestations, eosinophilia and an elevated ESR. Findings have usually resolved with discontinuation of treatment. Hydrochlorothiazide-GastrointestinaI System- anorexia, gastric irritation, nausea, vomiting, cramping, diarrhea, constipation, jaundice (intrahepatic cholestatic jaundice), pancreatitis, and sialadenitis. Central Nervous System-dizziness, vertigo, paresthesias, headache, and xanthopsia. Hematologic-leukopenia, agranulocytosis, thrombocytopenia, aplastic anemia, and hemolytic anemia. Cardiovascularorthostatic hypotension. Hypersensitivity-purpura, photosensitivity, rash, urticaria, necrotizing angiitis (vasculitis; cutaneous vasculitis), fever, respiratory distress including pneumonitis, and anaphylactic reactions. Other-hyperglycemia, glycosuria,
hyperuricemia, muscle spasm, weakness, restlessness, and transient blurred vision. Whenever adverse reactions are moderate or severe, reduce or withdraw therapy. Altered Laboratory Findings: Serum Electrolytes: Hyperkalemia: small increases in serum potassium, especially in patients with renal impairment (see PRECAUTIONS:Captopril). Hyponatremia: particularly in patients receiving a low sodium diet or concomitant diuretics. BUN/Serum Creatinine: Transient elevations of BUN or serum creatinine especially in volume or salt depleted patients or those with renovascular hypertension may occur. Rapid reduction of longstanding or markedly elevated blood pressure can result in decreases in the glomerular filtration rate and, in turn, lead to increases in BUN or serum creatinine. Hematologic: A positive ANA has been reported. Liver Function Tests: Elevations of liver transaminases, alkaline phosphatase, and serum bilirubin have occurred. OVERDOSAGE: Captopril-Primary concern is correction of hypotension. Volume expansion with an I.V. infusion of normal saline is the treatment of choice for restoration of blood pressure. Captopril may be removed from the general circulation
by hemodialysis. Hydrochlorothiazide-In addition to diuresis, overdosage of thiazides may produce varying degrees of lethargy which may progress to coma within a few hours, with minimal respiratory and cardiovascular depression and without evidence of serum electrolyte changes or dehydration. The mechanism of thiazide-induced CNS depression is unknown. Gastrointestinal irritation and hypermotility may occur. Transitory increase in BUN has been reported, and serum electrolyte changes may occur, especially in patients with impaired renal function. In addition to gastric lavage and supportive therapy for stupor or coma, symptomatic treatment of gastrointestinal effects may be needed. Degree of removal by hemodialysis has not been clearly established. Measures to maintain hydration, electrolyte balance, respiration, and cardiovascular and renal function should be instituted. DOSAGE AND ADMINISTRATION: DOSAGE MUST BE INDIVIDUALIZED (SEE INDICATIONS AND USAGE). CAPOZIDE (Captopril-Hydrochlorothiazide Tablets) should be taken one hour before meals. CAPOZIDE may be dosed bid ot tid. Because captopril and hydrochlorothiazide are excreted primarily by the kidneys, dosage adjustments are recommended for patients with impaired renal function. Consult package insert before prescribing CAPOZIDE (Captopril-Hydrochlorothiazide Tablets). Available in tablets of 25 mg captopril combined with 15 mg hydrochlorothiazide, 25 mg captopril combined with 25 mg hydrochlorothiazide, 50 mg captopril combined with 15 mg hydrochlorothiazide, and 50mg captopril combined with 25 mg hydrochlorothiazide in bottles of 100. (J4-005L)
©1991 E.R. Squibb & Sons, Inc., Princeton, NJ 530-502 Issued: January 1991
continued from page 720
household headed by my mother. My college and medical education was funded largely through student loans. I am presently on a fixed salary as a resident and am attempting to repay these loans (which amount to $100,000). I am continuously harrassed by loan officers, collection agencies, and even attorneys because of my limited ability to repay loans. Further, inner-city communities cannot afford the additional taxing necessary to upgrade schools. Certainly, redistribution of taxes from other areas is necessary. As for Ms Jung's comment on alumni from minority colleges, how many alumni actually have sufficient funds to make significant contributions? Has she researched the number of alumni who are repaying excessive amounts in student loans? Ms Jung is severely misguided in stating that "No one who has ability, initiative, and motivation has been denied a chance in the American educational system." African-Americans have been suppressed and even punished for learning for over 200 years. The educational system has been "tilted" in favor of nonminorities for years. To balance this, it is necessary to offer advantages for minority students and to improve their educational systems.
The issues here are comparable to the problems that women have experienced in the professions, both medical and nonmedical. They have experienced and continue to experience discrimination. However, the feminist movement has brought about a number of women's colleges. The scale of the educational system has had to be "tipped" in favor of educating women. At present, there are significant numbers of women in medical schools (504 in the freshman class at my alma mater). I acknowledge the fact that there is still no equality between the sexes regarding opportunities. However, there is still no equality among different races. Racism is on the uprise today. We must strive toward educating minorities and encouraging their entry into the health (and other) professions. Would you rather carry the financial burden of improving inner-city schools and educating young minority students to become successful, productive, tax-paying citizens or would you rather carry the financial burden of paying for police to protect you from muggers, burglars, drug dealers, and addicts? Would you rather pay for the strain on the judicial system and penal institutions by young people who never had a chance to succeed? Joel B. Burrell, MD New York, New York
729
LETTERS TO THE EDITOR
CONTRAINDICATIONS: MICRONASE Tablets are contraindicated in patients with: 1. Known hypersensitivity or allergy to the drug. 2. Diabetic ketoacidosis, with or without coma. This condition should be treated with insulin. 3. Type diabetes mellitus, as sole therapy. d SPECIAL WARNING ON INCREASED RISK OF CARDIOVASCULAR MORTAUTY: Thes a eireeaderIl hypoglyemic drp ha hm reported to he associated with lcrasd carnd ascular mortlty as compard tetamoMtwth die alm or diet plus lsuHnm. Thswarnilg is bas on thestd coeduc by the Unimrslt Group DIabetes Prgram (UGOP), a Ig-trm prospectIv enical tbIal designed to evalua the slecIene o ghues-eowering drngs In pvuteg er delang vascular compatbons In patts with nonimuln-dependnt dIabetes The study hweled 323 patet who wr ranombly asgeed to ol teur tretmeb tgreps (Dlabets, 19 [Suppl 21: 747-3,41970). e plus a UW ed d butanubl (1.5 grams UGDPreported that paffle itstated ter5tb y w hdid et t w perday) hada ratbfd cardt claremortality apprximably2 timesthNteopatiestsatdwlth aloe. AslgNcant lnleC nitotl mortality was etoebrved, butthm d dttamide wa dsetIaed base a the Increase In cardlescular morbaty, thu umlin te oepperbtu for th dsdy t show an ier en ea mertilty. Despite ceereversyrepgrdingthe etpretllel ethse result, di I d the JUGPDPd preidenas adeuatebaleorthl e g The peenIoud be Inferme MICRONASE aed olaltIv medeetherapy. doth Ntlldeliskmed Advan Alhugh eey - drug In the suleeytorea s (elbetabmle) was Inciude I this stdy, N is pu t
fom assbttapeontteoee_dthatthkswamngayapplytuothworelhypoglycemledrugplthis bc#la view temir cs simIlrtIes In mode of actoe a chomieml stbu. PRECAUTIONS: Geeeral-I4yolycemia: All sulfonylureas are capable of producing severe hypoglycemia.
Proper patient selection and dosage and instructions are important to avoid hypoglycemic episodes. Renal or hepatic insufficiency may increase the risk of serious hypoglycemic reactions. Elderly, debilitated or malnourished patients, and those with adrertal or pituitary insufficiency, are particularly susceptible to the hypoglycemic action of glucose-lowering drugs. Hypoglycemia may be difficult to recognize in the elderly and in people who are taking beta-adrenergic blocking drugs. Hypoglycemia is more likely to occur when caloric intake is deficient, after severe or prolonged exercise, when alcohol is ingested, or when more than one glucose-lowering drug is used. Loss of Control of Blood Glucose: In diabetic patients exposed to stress such as fever, trauma, infection or surgery, a loss of control may occur. It may then be necessary to discontinue MICRONASE and administer insulin. Adequate adjustment of dose and adherence to diet should be assessed before classifying a patient as a secondary failure. Information for Patients: Patients should be informed of the potential risks and advantages of MICRONASE and of alternative modes of therapy. They also should be informed about the importance of adherence to dietary instructions, of a regularexercise program, and of regulartesting of urine and/or blood glucose. The risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members. Primary and secondary failure should also be explained. Laboraty Test Response to MICRONASE Tablets should be monitored by frequent urine glucose tests and periodic blood glucose tests. Measurement of glycosylated hemoglobin levels may be helpful in some patients. Dru InteracIo: The hypoglycemic action of sulfonylureas may be potentiated by certain drugs including nonsteroidal anti-infammatory agents and other drugs that are highly protein bound, salicylates, sulfonamides, chloramphenicol, probenecid, coumarins, monoamine oxidase inhibitors, and beta adrenergic blocking agents. Certain drugs tend to produce hyperglycemia and may lead to loss of control. These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. A potential interaction between oral miconazole and oral hypoglycemic agents leading to severe hypoglycemia has been reported. Carcolngoe s, Mubgen*es, and Impairmentld FertIlity: Studies in rats at doses up to 300 mg/kg/day for 18 months showed no carcinogenic effects. Glyburide is nonmutagenic when studied in the Salmonella microsome test (Ames test) and in the DNA damage/alkaline elution assay. Pregnsan. Teratogenic effects: Pregnancy Category B. Reproduction studies in rats and rabbits have revaled no evidence of impaired fertility or harm to the fetus due to glyburide. There are no adequate and well controlled studies in pregnant women. This drug should be used during pregnancy only i clearly needed. Insulin should be used during pregnancy to maintain blood glucose as close to normal as possible. Nonteratogenic Effects: Prolonged severe hypoglycemia (4 to 10 days) has been reported in neonates bom to mothers who were receiving a sulfonylurea drug at the time of delivery. MICRONASE should be discontinued at least two weeks before the expected delivery date. Nuring Mothers: Some sulfonylurea drugs are known to be excreted in human milk. Insulin therapy should be considered. Pediatric Use: Safety and effectiveness in children have not been established. ADVERSE REACTIONS: HypoglycemIa: See Precautions and Overdosage sections. Gastrointestinal ReaclIn: Cholestatic jaundice and hepatitis may occur rarely: MICRONASE Tablets should be discontinued if this occurs. Gastrointestinal disturbances (nausea, epigastric fullness, and heartburn) occurred in 1.8% of patients during clinical trials. They were the most commonly reported adverse reactions. They tend to be dose related and may disappear when dosage is reduced. Liver function abnormalities have been reported. Dermatologic Reactlon: Allergic skin reactions, e.g., pruritus, erythema, urticaria, and morbilliform or maculopapular eruptions occurred in 1.5% of patients during trials. These may be transient and 'may disappear despite continued use of MICRONASE; if skin reactions persist, the drug should be discontinued. Porphyria cutanea tarda and photosensitivity reactions have been reported with sulfonylureas. Hematlogic ReactIons: Leukopenia, agranulocytosis, thrombocytopenia, hemolytic anemia, aplastic anemia, and pancytopenia have been reported with sulfonylureas. MobbolIe Retlsont: Hepatic porphyria and disulfiramlike reactions have been reported with sulfonylureas; however, hepatic porphyria has not been reported with MICRONASE and disulfiram-like reactions have been reported very rarely. Cases of hyponatremia have been reported with glyburide and all other sulfonylureas, most often in patients who are on other medications or have medical conditions known to cause hyponatremia or increase release of antidiuretic hormone. (SIADH) secretion has been reported with certain other sulfonylureas, and it has been suggested that these sulfonylureas may augmentthe peripheral (antidiuretic) action of ADH and/or increase release of ADH. OVERDOSAGE: Overdosage of sulfonylureas, including MICRONASE Tablets, can produce hypoglycemia. If hypoglycemic coma is diagnosed or suspected, the patient should be given a rapid intravenous injection of concentrated (50%) glucose solution. This should be followed by a continuous infusion of a more dilute (10%) glucose solution at a rate which will maintain the blood glucose at a level above 100 mg/dL. Patients should be closely monitored for a minimum of 24 to 48 hours, since hypoglycemia may recur after apparent clinical recovery. Maximum Dose: Daily doses of more than 20 mg are not recommended. Dosage Inteal: Once-a-day therapy is usually satisfactory. Some patients, particularly those receiving more than 10 mg daily, may have a more satisfactory response with twice-a-day dosage. SpeIfi PatIen Popolatlees: MICRONASE is not recommended for use in pregnancy orfor use in children. In elderly patients, debilitated ormalnourished patients, and patients with impaired renal or hepaticfunction, the initial and maintenance dosing should be conservative to avoid hypoglycemic reactions. (See Precautions Section). foradditional product informnation seeyour Upjohn representative.
THE UPJOHN COMPANY, Kalamazoo, Ml 49001
B-S-S
continued from page 690 carcinoma of the breast. Surg Gynecol Obstet. 1981;153:660-664. 5. Bonadonna G, Valagussa P, Rossi A, et al. Ten-year experience with CMF-based on adjuvant chemotherapy in resectable breast cancer. Breast Cancer Res Treat. 1985;5:95-115.
Minorities in the Health Professions To the Editor: I was appalled by Betty C. Jung's Letter to the Editor in the October 1990 issue. Apparently, she has a distorted view about the problems with minorities in the health professions. African, Hispanic, and Native Americans have been underrepresented in the health professions, especially the medical profession, for a long time. They continue to be underrepresented. It is inappropriate to attribute their lesser numbers in college to the idea that, since they are minorities, their numbers are expected to be smaller. If the ratio of minorities in colleges and graduate schools to those not in said institutions were compared with the same ratio for nonminorities, the ratio for minorities would be much smaller. Furthermore, poor living conditions, health problems, and poor educational systems are indeed factors. Schools are obligated to provide motivation and nurturing for students. This is sorely lacking in most inner-city schools. In addition, poverty and poor living conditions are not an excuse for those who cannot succeed in life-they are a real hinderance. In able to succeed in today's society, one needs money to attend private schools, money to attend college, money to attend graduate and professional schools, and money to start a business. I myself come from a low-income continued on page 729 720
APRIL 1990
J-3146
LETTERS TO THE EDITOR
The following have been reported in about 0.5 to 2 percent of patients but did not appear at increased frequency compared to placebo or other treatments used in controlled trials: gastric irritation, abdominal pain, nausea, vomiting, diarrhea, anorexia, constipation, aphthous ulcers, peptic ulcer, dizziness, headache, malaise, fatigue, insomnia, dry mouth, dyspnea, cough, alopecia, paresthesias. Other clinical adverse effects reported since the drug was marketed are listed below by body system. In this setting, an incidence or causal relationship cannot be accurately determined.
General: Asthenia, gynecomastia. Cardiovascular: Cardiac arrest, cerebrovascular accident/insufficiency, rhythm disturbances, orthostatic hypotension, syncope. Dermatologic: Bullous pemphigus,erythema multiforme (including Stevens-Johnson syndrome), exfoliative dermatitis.
Gastrointestinal: Pancreatitis, glossitis, dyspepsia. Hematologic: Anemia, including aplastic and hemolytic. Hepatobiliary: Jaundice, hepatitis, including rare cases of necrosis, cholestasis. Metabolic: Symptomatic hyponatremia. Musculoskeletal: Myalgia, myasthenia. Nervous/Psychiatric: Ataxia, confusion, depression, nervousness, somnolence. Respiratory: Bronchospasm, eosinophilic pneumonitis,
rhinitis. Special Senses: Blurred vision. Urogenital: Impotence. As with other ACE inhibitors, a syndrome has been reported which may include: fever, myalgia, arthralgia, interstitial nephritis, vasculitis, rash or other dermatologic manifestations, eosinophilia and an elevated ESR. Findings have usually resolved with discontinuation of treatment. Hydrochlorothiazide-GastrointestinaI System- anorexia, gastric irritation, nausea, vomiting, cramping, diarrhea, constipation, jaundice (intrahepatic cholestatic jaundice), pancreatitis, and sialadenitis. Central Nervous System-dizziness, vertigo, paresthesias, headache, and xanthopsia. Hematologic-leukopenia, agranulocytosis, thrombocytopenia, aplastic anemia, and hemolytic anemia. Cardiovascularorthostatic hypotension. Hypersensitivity-purpura, photosensitivity, rash, urticaria, necrotizing angiitis (vasculitis; cutaneous vasculitis), fever, respiratory distress including pneumonitis, and anaphylactic reactions. Other-hyperglycemia, glycosuria,
hyperuricemia, muscle spasm, weakness, restlessness, and transient blurred vision. Whenever adverse reactions are moderate or severe, reduce or withdraw therapy. Altered Laboratory Findings: Serum Electrolytes: Hyperkalemia: small increases in serum potassium, especially in patients with renal impairment (see PRECAUTIONS:Captopril). Hyponatremia: particularly in patients receiving a low sodium diet or concomitant diuretics. BUN/Serum Creatinine: Transient elevations of BUN or serum creatinine especially in volume or salt depleted patients or those with renovascular hypertension may occur. Rapid reduction of longstanding or markedly elevated blood pressure can result in decreases in the glomerular filtration rate and, in turn, lead to increases in BUN or serum creatinine. Hematologic: A positive ANA has been reported. Liver Function Tests: Elevations of liver transaminases, alkaline phosphatase, and serum bilirubin have occurred. OVERDOSAGE: Captopril-Primary concern is correction of hypotension. Volume expansion with an I.V. infusion of normal saline is the treatment of choice for restoration of blood pressure. Captopril may be removed from the general circulation
by hemodialysis. Hydrochlorothiazide-In addition to diuresis, overdosage of thiazides may produce varying degrees of lethargy which may progress to coma within a few hours, with minimal respiratory and cardiovascular depression and without evidence of serum electrolyte changes or dehydration. The mechanism of thiazide-induced CNS depression is unknown. Gastrointestinal irritation and hypermotility may occur. Transitory increase in BUN has been reported, and serum electrolyte changes may occur, especially in patients with impaired renal function. In addition to gastric lavage and supportive therapy for stupor or coma, symptomatic treatment of gastrointestinal effects may be needed. Degree of removal by hemodialysis has not been clearly established. Measures to maintain hydration, electrolyte balance, respiration, and cardiovascular and renal function should be instituted. DOSAGE AND ADMINISTRATION: DOSAGE MUST BE INDIVIDUALIZED (SEE INDICATIONS AND USAGE). CAPOZIDE (Captopril-Hydrochlorothiazide Tablets) should be taken one hour before meals. CAPOZIDE may be dosed bid ot tid. Because captopril and hydrochlorothiazide are excreted primarily by the kidneys, dosage adjustments are recommended for patients with impaired renal function. Consult package insert before prescribing CAPOZIDE (Captopril-Hydrochlorothiazide Tablets). Available in tablets of 25 mg captopril combined with 15 mg hydrochlorothiazide, 25 mg captopril combined with 25 mg hydrochlorothiazide, 50 mg captopril combined with 15 mg hydrochlorothiazide, and 50mg captopril combined with 25 mg hydrochlorothiazide in bottles of 100. (J4-005L)
©1991 E.R. Squibb & Sons, Inc., Princeton, NJ 530-502 Issued: January 1991
continued from page 720
household headed by my mother. My college and medical education was funded largely through student loans. I am presently on a fixed salary as a resident and am attempting to repay these loans (which amount to $100,000). I am continuously harrassed by loan officers, collection agencies, and even attorneys because of my limited ability to repay loans. Further, inner-city communities cannot afford the additional taxing necessary to upgrade schools. Certainly, redistribution of taxes from other areas is necessary. As for Ms Jung's comment on alumni from minority colleges, how many alumni actually have sufficient funds to make significant contributions? Has she researched the number of alumni who are repaying excessive amounts in student loans? Ms Jung is severely misguided in stating that "No one who has ability, initiative, and motivation has been denied a chance in the American educational system." African-Americans have been suppressed and even punished for learning for over 200 years. The educational system has been "tilted" in favor of nonminorities for years. To balance this, it is necessary to offer advantages for minority students and to improve their educational systems.
The issues here are comparable to the problems that women have experienced in the professions, both medical and nonmedical. They have experienced and continue to experience discrimination. However, the feminist movement has brought about a number of women's colleges. The scale of the educational system has had to be "tipped" in favor of educating women. At present, there are significant numbers of women in medical schools (504 in the freshman class at my alma mater). I acknowledge the fact that there is still no equality between the sexes regarding opportunities. However, there is still no equality among different races. Racism is on the uprise today. We must strive toward educating minorities and encouraging their entry into the health (and other) professions. Would you rather carry the financial burden of improving inner-city schools and educating young minority students to become successful, productive, tax-paying citizens or would you rather carry the financial burden of paying for police to protect you from muggers, burglars, drug dealers, and addicts? Would you rather pay for the strain on the judicial system and penal institutions by young people who never had a chance to succeed? Joel B. Burrell, MD New York, New York
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