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PHARMACY NEWS Importance of Sunscreens Reaffirmed only 9% of teenagers always use them, according to a survey of Virginia teenagers reported by the ...

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Importance of Sunscreens Reaffirmed

only 9% of teenagers always use them, according to a survey of Virginia teenagers reported by the Skin Cancer Foundation. Although 81 % of the respondents spent most weekends in the sun, one-third of them said they never use a sunscreen. Even attending a sun-safety lecture at school did not improve their sunning habits. "They still equated a tan with health, glamour, and affluence," according to Beth Goldstein, MD, clinical assistant professor of dermatology at the University of North Carolina at Chapel Hill. More than half of those who used sunscreens said it was to prevent sunburn; only 8% used them to prevent cancer. A trend that should help protect teens and adultsespecially women -is the addition of sunscreens to make-up, skin lotions, and lip balms. According to the Skin Cancer Foundation, these products can be as

Staying out of the sun is the best way to prevent most skin cancers, but it is not a practical approach for most people-especially now that warm, sunny days are here. The American Academy of Dermatology recently reaffirmed its recommendation that everyone routinely use sunscreens with a SlID protection factor (SPF) of at least 15. The academy has refuted the claims of three California epidemiologists who suggested in the January 1993 issue of the Annals of Epidemiology that sunscreens may increase the risk of developing malignant melanoma because their use gives people a "false sense of security" that encourages them to stay in the sun longer. In a separate statement, the Skin Cancer Foundation also supported the routine use of sunscreens. It noted that unrestricted sunbathing is never advisable-with or without sunscreen-and emphasized the importance of avoiding the sun between 10:00 am and 3:00 pm and using protective clothing, sunglasses, and shade devices. Despite concerted efforts over the past several years to convince the public about the benefits of sunscreens, Vol. NS33, No.6

June 1993

effective as stand-alone sunscreens as long as they have an SPF of 15 or higher. Also, they do not have the "beachy" scent that ordinary sunscreens have, which may encourage year-round use. Because they tend to be lighter than sunscreens and not formulated to be waterproof or "sweatproof," however, they should be reapplied often, especially after exercise or swimming.

Heart Group Issues Guidelines for Aspirin Use Expanded use of aspirinalready the most commonly used drug today-could help prevent a host of cardiovascular diseases, according to a position statement from the American Heart Association. The landmark statement, published in the journal Circulation (1993;87:659-74), was released "to serve as a guideline for the use of aspirin in the primary and secondary prevention of cardiovascular disease," the

Aspirin and Health Summarizes Finding§ dean

e overview

on aspirin,: aspirin works, cardiovascular benefits, uncertainties about preventive aspirin use, and potential benefits under study, such as prevention of cataracts, periodontal disease, and colon cancer. For itlformation on hgw to order the publis~tion, availab~~ i~0r;$3.8~per COPY~iF~i~~actthe America~ ' Council on Seienc d Health, me., l~~'5Broadway, 2nd Floor, New York, NY 10023-5860. (212) 362-7044.





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report says. Among situations in which aspirin could be beneficial are myocardial infarction- regardless of whether the patient is a candidate for thrombolysis; treatment of ischemic stroke, transient ischemic attacks, and unstable angina; and the prevention of early occlusion of saphenous vein grafts in bypass surgery. According to Charles Hennekens, MD, a coauthor of the statement and professor of medicine at Harvard University, "there is a far wider

range of patients who would benefit from aspirin than the indications currently show." He said that unless the drug is contraindicated, "everyone should take aspirin who is having a heart attack, or survives a heart attack or stroke, whether the patient is male or female, elderly or middle aged, or a diabetic or hypertensive. " Although the report recommends aspirin use for preventing heart attacks in older men with established risk factors, enough data is not yet available to issue definitive recommendations for women. The guidelines recom-

mend low doses of75 mg to 325 mg per day. "However, if the lowest dose (75 mg/day) is considered, the evidence suggests that for a prompt antiplatelet effect patients should receive an initial loading dose of 160-325 mg aspirin." Certain subsets of patients that can also benefit from taking aspirin, the report says, are those with nonvalvular atrial fibrillation, peripheral vascular disease, prosthetic heart valves, arteriovenous cannulas for hemodialysis, pre-eclampsia, and venous thrombosis. The report synthesizes research spanning 25 years.

It stresses the need for patients to contact a physician before initiating aspirin use because of the risk of developing side effects such as gastrointestinal upset, gastrointestinal hemorrhage, and hemorrhagic stroke.

The Ne\N Self-Tanning Products The new sunless tanning products on the market are safe as long as users do not assume that the reSUlting chemical tan protects them against the sun's harmful rays, according to Stanley B.

Clinical Trials of Aspirin and Cardiovascular Disease Aspirin Effects Number of Subjects

Nonfatal Heart Attacks

Nonfatal Strokes

Cardiovascular Fatalities

Men and women with prior history of heart attack, stroke, transient ischemic attacks, or unstable angina


320/0 decrease

270/0 decrease

150/0 decrease

ISIS-2 Study, 1988

Men and women admitted to hospitals with suspected heart attacks


490/0 decrease

460/0 decrease

230/0 decrease

U.S. Physicians' Health Study, 1988-89

Men over 40 with no prior history of heart disease


410/0 decrease



British Doctors' Study, 1988

Men over 50 with no prior history of heart disease





U.S. Physicians' Health Study and the British Doctors' Study, 1988

Men over 40 with no prior history of heart disease


330/0 decrease



Study, Year Published

Characteristics of Subjects

Antiplatelet Trialists' Collaboration (combined results of 25 separate trials), 1988

* No statistically significant effect. Adapted from Aspirin and Health, American Council on Science and Health, Inc., New York, N.Y. Used with permission.


June 1993

Vol. NS33, No.6

Levy, MD, clinical professor of dermatology at the University of North Carolina at Chapel Hill. Levy reported on the latest crop of self-tanning products at a recent meeting of the American Academy of Dermatology. He explained that they contain a colorless dye-dihydroxyacetone (DHA)-that stains skin a light brown when it reacts with amino acids occurring naturally in skin cell proteins or in sweat. DHA appears to work only in the outermost layer of the skin and does not damage the skin or change the amount of pigment. When researchers tried injecting DHA into deeper skin layers, it had no effect, he said. According to Levy, many previous tanning products containing DHA turned skin an unacceptable "off-color orange." The latest generation was formulated to provide a light brown or golden shade, especially for people with fair and medium complexions. To get the best look, the product should be applied two to four times in one day, and should be reapplied every few days as the color starts to fade. Because a compact, smooth outer-skin layer provides the deepest color, it is best to buff the skin lightly and then shower before applying a self-tanning lotion. Other tips: • Apply the cream with the palm, not the fmgertips, and wash hands immediately afterwards. • To avoid fabric stains, Vol. NS33, No.6

June 1993

apply the lotion at least 30 minutes before getting dressed or going to bed. • Apply two hours before exercising because sweat may cause streaking. • If the self-tanning product does not contain a sunscreen with an SPF of 15 or higher, apply an SPF 15 sunscreen at least a half hour before going into the sun. Allow the self-tanner to dry for several hours before applying sunscreen.

Helping Practitioners Spot Depression Family physicians and other primary care providers should be more aggressive about detecting and treating depression, according to guidelines released in April by the Agency for Health Care Policy and Research (AHCPR), part of the U.S. Department of Health and Human Services. Congress created AHCPR in 1989 to improve the quality, appropriateness, and effectiveness of health care. A panel of psychiatrists, primary care phYSicians, and others who examined thousands of studies developed the guidelines. A. John Rush, MD, chairman of the panel and a psychiatrist at the University of Texas Southwestern Medical Center, explained that the guidelines' purpose is to distill "the explosion of knowledge" on the disorder into a document that is accessible

to primary care practitioners, who are typically in the best position to identify depressed patients. "Through information from meta-analyses, we can say, 'here's what we know,'" Rush said. "We'll be disseminating the information over the next several months, and we hope it will make a difference quickly." According to the panel, more than 11 million people in the United States suffer from depression and one in eight Americans will be affected during their lifetime. In 1989 major depression cost the nation at least $27 billion in medical care, worker absenteeism, and related costs. "Our concept of depres-

sive illness has radically shifted," Rush said. "We used to think depression was just feeling down -bad things happen to you. Now we know it's a syndrome." The gravest outcome is suicide, which occurs in 15% of untreated serious depressions. The panel stressed that early detection and treatment can help shorten the depression, thus lessening disability and cutting costs. They urged physicians to explore patients' initial complaints of headaches, body pain, low energy, apathy, or anxiety to determine if depression is the cause. Rush explained that depression can almost always be treated successful-

Symptoms of Depression Patients with major depression typically have five or more of the following symptoms, including at least one of the first two symptoms, all day nearly every day for at least two weeks. • Feeling sad, blue, or down in the dumps. • Diminished interest or pleasure in nearly all activities. • Significant weight loss or gain. • Trouble sleeping or sleeping too much. • Fatigue, loss of energy. • Feelings of guilt or worthlessness. • Indecisiveness or impaired thinking, concentrating, and memory. .. Feeling slow wn, orrestless a:Q;~{hrtable to sit still. • Recurrent thoughts of death or suicide.

• • • • • •

Other symptoms to watch for include: Headaches Other aches and pains Digestive probl~ms Sexual problems Feeling pessimistic or hopeless Being anxious or worried.




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ly with psychotherapy, medication, or a combination of both. "From 50 to 60 percent of patients will respond to the first medication prescribed," he said. Time-limited psychotherapy-cognitive, behavioral, or interpersonal approachesof eight to 20 sessions is effective in 50-60% of less severe cases, he said. "The combination of both medication and psychotherapy is recommended for more complex, chronic, or complicated cases." Although the guidelines discuss symptoms and types of treatment, they do not give detailed information about specillc therapeutic agents. They note that treatment of depression consists of three phases: • Acute treatment of six to 12 weeks aims at remission of symptoms. A partial response (not complete remission) is associated with a poorer prognosis. • Continuation treatment of four to nine months aims at preventing relapse. Medication should be continued at the full dosage; psychotherapy may be helpful. • Maintenance treatment aims to prevent a new episode of depression (recurrence) in patients who have had previous episodes. Only medication prevents a recurrence, but psychotherapy may delay a recurrence.


Make diagnosis

Clearly better


Somewhat better

Continue treatment (adjust dosage)

Augment or change treatment

Continue treatment for 6 more weeks Monitor treatment (every 1-2 weeks)

Complete remission?


Medication continued for 4-9 months. Consider maintenance treatment

Refer or consult a psychiatrist or other mental health professional

Change treatment


* Note: Times of assessment (weeks 6anCl (12) rest very'moClest d~ita. liJinay be"'nE¥cessa'r y to revise the treatment plan earlier for patients who fail to respond. ff

June 1993

Vol. NS33, No.6

Campaign Combats Medication Tampering An ongoing campaign to educate consumers about the signs of medication tampering was recently lalillched by the COlillcil on Family Health in cooperation with the Food and Dnlg Administration and the Nonprescription Dnlg Manufacturers Association. Since 1984, 36 people have been convicted for real or threatened tampering. Nine people have died from nledication tampering since 1982. Through public service alIDOlmcements and pamphlets, the campaign tells conSUlners to: • Read the label, which identifies the package's seals and protective features. • Inspect the outer packaging for signs of tampering. • Examine the medicine before taking it to see if any tablets or capsules differ from others in appearance. Do not take the medicine if the package has tears, cuts, or other imperfections. • Never take medicine in the dark. • Examine the label and the medicine at every dose. • Inform the store manager if any products look suspicious. For copies of the brochure Buying Medicine? Stop, Look, Look Again

(540z), contact the Consumer Information Center, Pueblo, CO 81009. (719) 948-3334.

Vol. NS33, No.6

June 1993

Health Resources The USP DI Drug Information for the Health Care Professional will soon be available as an electronic pocket-sized book. The hand-held data retrieval system, which will weigh less than five Olillces, will be distributed by Franklin Electronic Publishers, Inc. For more information contact Mitchell A. Lapides, product manager at the United States Pharmacopeial Convention, at (301) 881-0666. Standards for Pediatric Immunization Practices, a publication intended to increase immunization among preschoolers, is available from the Centers for Disease Control and Prevention (CDC). The standards give health providers guidance about implementing or changing poliCies to overcome barriers to immunization. Single copies are available from the Information Services Office, National Center for Prevention Services, CDC, Mail Stop E06, Atlanta, GA 30333. (404) 639-1838. The Calcium Information Center Toll-Free Number, sponsored by Oregon Health Sciences and Cornell University, has been established to answer questions from the public and health professionals. The information line gives callers the option of listening to pre-recorded messages, leaving an address to receive printed information, or recording a specific question

that a menlber of the Calcium Information Center will call back to answer. Health professionals can ask to speak with a staff member. Examples of questions the center has received include: How can I get enough calcium when I'nl dieting to lose weight? and Which medications and foods interfere with calcium absorption? The toll-free number is (800) 321-2681. Lyme Disease: The Facts, The ChaUenge is a 20-page brochure available fronl the U.S. Department of Health and Human Services. It discusses symptoms of the disease, current diagnostic tests, and treatments available for various stages of the disease. Single free copies are available by writing: Lyme Disease Booklet, NIAMS/NIH, Box AMS, 9000 Rockville Pike, Bethesda, MD 20892. "lllV and the Health Care Worker" is a two-part videotape and monograph that addresses the concerns of health care workers in a variety of settings, such as hospitals, health maintenance organizations, laboratories, and general practices. It includes the latest regulations from the Occupational Safety and Health Administration on universal precautions and post-exposure management programs. CE credit is available for pharmacists, physicians, and nurses. The program is available from any Glaxo sales representative or by calling the Glaxo Video Library tollfree at (800) 824-2896.


Pharmaceutical Frontiers: Research on Stroke is a brochure containing information on stroke medications lmder development; descriptions of approaches researchers are taking to fmd ways to treat and prevent stroke; and information about warning signs, risk factors, and effects of stroke. Free copies are available by writing to Pharmaceutical Frontiers: Research on Stroke, Pharmaceutical Manufacturers Association, 1100 15th St., Washington, DC 20005. The Alzheimer's Disease Education and Referral (ADEAR) Center, a service of the National Institute on Aging, provides answers to questions about Alzheimer's disease, gives information on the latest research fmdings, and helps identify services for patients and their families. To talk with an information specialist call (800) 438-4380. When Diabetes Complicates Your Life is written by an endocrinologist and research scientist with diabetes. It provides medical facts, discusses emotional side-effects of the disease, and gives advice to help avoid or minimize complications. The 150-page paperback is available in bookstores or can be ordered for $9.95 plus $3 postage and handling from Chronimed Publishing, P.O. Box 47945, Minneapolis, MN 55447. (800) 848-2793. Patient Drug Facts--PC, a new software program for IBM-compatible computers, AMERICAN PHARMACY