Pharmacology

Off-label prescribing (to patient groups or for indications not listed in a medicine's product information) is okay if supported by evidence

J Paul Seale MB BS, PhD, FRACP

Consider the evidence before prescribing medications off-label and use non-pharmacological treatments where possible

Ian B Hickie MD

To the Editor: I would like to thank Rintoul and colleagues for bringing together data from varied sources to highlight an important public health issue.1 The 1426% increase in supply of alprazolam they identified over the 20-year period from 1990 to 2010 was particularly striking. Alprazolam is indicated as a second-line treatment for panic disorder where other therapies are ineffective, or for short-term treatment of anxiety disorder. As ...

Tracy W Soh

To the Editor: Rintoul and colleagues showed that alprazolam is being increasingly detected in heroin-related deaths.1 One explanation provided is increased rates of alprazolam misuse among people who inject drugs. My colleagues and I recently reviewed the role of alprazolam in Australian clinical practice,2 focusing on the sole supported Pharmaceutical Benefits Scheme (PBS) indication: treatment of “panic disorder where other treatments have failed or are inappropriate”. ...

Steven Moylan

In reply: We thank Soh for her letter providing further evidence of harm relating to alprazolam misuse, which highlights deficiencies in postmarketing surveillance systems for pharmaceutical drugs. Reports of adverse drug reactions typically originate from therapeutic use; they seldom identify problems arising from misuse. Detection of misuse-related harm currently relies on ad-hoc epidemiological studies such as ours and that of Frei and colleagues, who documented ...

Angela C Rintoul · Malcolm D H Dobbin

The increasing use of psychotropic medicines has led to a need to understand the safety of antipsychotics in pregnancy.

Roisin N Worsley · Heather Gilbert · Jayashri Kulkarni

The case of a woman who developed severe rhabdomyolysis shortly after the addition of pregabalin to a stable atorvastatin regimen serves as a reminder to clinicians to be aware of possible adverse drug reactions.

Roshan Gunathilake MB BS, MD · Laura E Boyce BPharm · Anne T Knight MB BS(Hons), FRACP

We report a case of khat-associated hepatitis in a 32-year-old Somali man living in Australia. This is the first case of hepatoxicity related to khat ingestion reported in Australia.Clinical recordA 32-year-old Somali man with no prior medical history presented to the emergency department with a 1-week history of dark urine, pruritus and jaundice, on a background of a month of malaise and reduced appetite. He ...

Malcolm P Forbes MB BS · Ashok S Raj MB ChB, FRACP · Jennifer Martin MB ChB, FRACP, PhD · Guy Lampe MB BS, FRCPA · Elizabeth E Powell FRACP, FRCP, PhD

It is time that the environmental cost of doing medicine is brought into the whole equation; that Big Pharma are brought on board; and that doctors are educated to give this some priority.

Peter M J Fisher BSc(Hons), PhD · David A Smith BSc · Peter J Collignon MB BS(Hons), BSc(Med)

Vitamin D3 in oral supplements is derived from animal sources, so it is important to address this when recommending vitamin D supplementation to a person who adheres to a vegetarian diet.

Bettina Douglas

In reply: People requiring a purely vegetarian source of vitamin D should use vitamin D2 (ergocalciferol), which is produced by ultraviolet irradiation of the plant sterol ergosterol, and not vitamin D3 (cholecalciferol), which is derived from animal sources. As cholecalciferol is derived from sheep’s wool, which does not involve the sheep being killed, several cholecalciferol supplements are certified as halal. Some capsules contain gelatine (an animal ...

Caryl A Nowson · Rebecca S Mason

Does the appeal process against TGA decisions appropriately serve the Australian public interest?

Nick A Buckley MD, FRACP · Thomas A Faunce BA/LLB(Hons), BMed, PhD

With very few new antibiotics in the pipeline, promoting their development is important, as is balancing priorities when treating patients

Allen C Cheng FRACP, MPH, PhD · Roger L Nation PhC, MS, PhD

The problem of excessive psychotropic drug use in Australian nursing homes is well known, but where are the solutions?

Juanita L Westbury · Gregory M Peterson

To the Editor: The article by Hilmer and Gnjidic1 raises issues about the management of behavioural and psychological symptoms of dementia (BPSD)2 in residential aged care facilities (RACFs). It is important to remember the context in which RACF residents’ care is provided. The federally managed aged care system is politically and organisationally perceived as supported accommodation, which is geared toward supporting or substituting for residents’ performance ...

Ludomyr J Mykyta

In reply: We thank Westbury and Peterson, and Mykyta for highlighting some of the issues raised in our article.1 While we acknowledge the important contribution of providing education programs to existing staff, staff education alone is insufficient to address the complex issues affecting psychotropic drug use in nursing homes.1 Better access to appropriately trained staff in nursing homes, including general practitioners, geriatricians, psychogeriatricians, psychologists, pharmacists, nurses ...

Sarah N Hilmer · Danijela Gnjidic

THIS BOOK is by a doctor with an abiding interest in the philosophy of medicine. Paul Biegler is an Australian Research Council Postdoctoral Fellow at the Centre for Human Bioethics, Monash University, and a recipient of the 2011 Australian Museum Eureka Prize for Research in Ethics.The book describes the therapeutic use of antidepressant medication (ADM) versus cognitive behaviour therapy (CBT), and concludes that it is unethical ...

Kay A Wilhelm