No Shortage in Sight for Tetanus-Diphtheria Vaccine 
Pharmacology Watch

The number of vaccine shortages has been unprecedented in the last year, but at least one vaccine, tetanus-diphtheria (Td), is back in full production. The Centers for Disease Control and Prevention (CDC) has announced that they are removing restrictions on the Td booster. Despite the fact that there is only one manufacturer of the vaccine, supplies are large enough to resume routine vaccination. The news is also good for childhood vaccines that have been in short supply, including MMR, varicella, and PCV-7 (pneumococcal) vaccine. All are expected to be in full supply by the end of the year.

Cholesterol-Lowering Therapy OK for Seniors

What to do with the 75-year-old patient with a cholesterol of 300, but no history of heart disease? Primary prevention studies have shown a benefit for treatment of younger patients, but there have been few studies of primary prevention studies in the elderly. Now data from the Cardiovascular Health Study of patients age 65 or older suggest that cholesterol-lowering therapy is useful in older patients as well. After nearly 7.5 years of follow-up, elderly patients with elevated cholesterol levels clearly benefited from cholesterol-lowering treatment. Compared with no drug therapy, statin use was associated with a decreased risk of cardiovascular events (multivariate hazard ratio [HR], 0.44; 95% CI, 0.27-0.71) and all-cause mortality (HR, 0.56; 95% CI, 0.36-0.8). This translates into a relative risk reduction of 56% of incident cardiovascular events and a 44% reduction in all-cause mortality. This was a prospective study, as pointed out in an accompanying editorial; however, it does add to the body of medical literature that suggests that the recent National Cholesterol Education Program (NCEP) guidelines should apply to those aged 65 or older (Arch Intern Med. 2002;162:1395-1400; editorial 1329-1331).

Beta-Blockers and CABG Patients

Preoperative beta-blockers have been shown to reduce operative complications and mortality in noncardiac surgery, and now 2 studies confirm the importance of beta blockade in patients undergoing coronary artery bypass grafting (CABG). In a large observational analysis of more than 600,000 patients undergoing CABG, preoperative beta-blocker therapy was associated with a small but consistent survival benefit in all patients except those with a preoperative left ventricular ejection fraction of less than 30% (JAMA. 2002;287:2221-2227). The most common postoperative complication of CABG is atrial fibrillation. A recent meta-analysis compares beta-blockers, sotalol, amiodarone, and biatrial pacing to prevent atrial fibrillation after heart surgery. All 4 modalities were effective (odds ratio compared to placebo—beta-blockers 0.39, sotalol 0.35, amiodarone 0.48, biatrial pacing 0.46). Each of the 4 drug modalities also significantly reduced length of stay. Significantly, beta-blockers, which are safe and easily administered were as effective as other treatment modalities (Circulation. 2002;106:75-80).

Asthma Sufferers: Use Clarithromycin

Asthmatics with evidence of infection with Mycoplasma pneumoniae or Chlamydia pneumoniae benefit from a 6-week course of the macrolide antibiotic clarithromycin, according to a new study. In 55 patients with stable asthma in the Denver community, 31 were found to have evidence of mycoplasma or chlamydia infections by PCR and culture. All 55 patients were randomly assigned to treatment with either placebo or clarithromycin 500 mg p.o. b.i.d. 6 weeks. Patients who were PCR-positive and received clarithromycin were found to have a significant improvement in FEV1 (2.50 pretreatment, 2.69 posttreatment; P = 0.05), while those who were PCR negative and those who did not receive antibiotic showed no change (Chest. 2002; 121:1782-1788). In a related study, Turkish researchers administered azithromycin 250 mg twice weekly to a group of 11 asthmatics for 8 weeks. No change in FEV1 was noted, but patients had a marked reduction in bronchial hyperresponsiveness as measured by histamine challenge tests. These patients were not evaluated for evidence of infection prior to initiating therapy (J Asthma. 2002;39:181-185).

Good News: Antibiotic Use in Children Down

Meanwhile, efforts by the CDC and others to curb the use of antibiotics in children seem to have paid off. Researchers compared antibiotic prescription rates from 1999-2000 to data from 1989-1990. The number of prescriptions per 1000 individuals age 15 and younger decreased from 838 to 503 a decade later (P < 0.001). Prescriptions per 1000 office visits also fell during the same period of time (JAMA. 2002;287:3096-3102).

Linezolid Successful in Treatment of MRSA

Methicillin-resistant Staphylococcus aureus (MRSA), the bane of hospitals coast-to-coast, is effectively treated with linezolid. Previously vancomycin has been the standard of care for treating MRSA. A new study compares linezolid with vancomycin in 460 patients with known or suspected MRSA infections. Patients were treated with either linezolid 600 mg twice daily (n= 240) or vancomycin 1 g twice daily (n = 220) for 7-28 days. Clinical cure rates and microbiological success rates were similar for both groups, and both regiments were well tolerated with similar rates of adverse events. It is suggestive that linezolid is a reasonable alternative to vancomycin for MRSA infections and adds the additional option of oral therapy (Clin Infect Dis. 2002;34:1481-1490). The study is timely, as the CDC has reported the first isolate of fully vancomycin resistant S aureus in a Michigan man. Several cases of intermediate vancomycin-resistant staph have been reported, but this represents the first case of full resistance (Morb Mortal Wkly Rep MMWR. 2002;51:565-567).

SSRIs Relieve Dizziness in Psychiatric Patients

General internists and family practitioners will be delighted to learn that selective serotonin reuptake inhibitors (SSRIs) have been shown to effectively relieve dizziness in patients with psychiatric symptoms, a common office complaint. A group of 60 patients at University of Pennsylvania with psychogenic dizziness, dizziness due to a neurotologic condition (with psychiatric symptoms), or idiopathic dizziness were treated with an SSRI for at least 20 weeks. Two thirds of patients had been treated previously with either meclizine or a benzodiazepine. Twenty-five percent of the patients did not tolerate SSRIs. Of those who finished at least 20 weeks of therapy, 84% improved substantially with no difference between patients with major psychiatric disorders and those with lesser psychiatric symptoms. Patients with peripheral vestibular conditions and migraine also improved with SSRIs (Arch Otolaryngol Head Neck Surg. 2002;128:554-560).

DEET-Based Mosquito Repellents Just in Time for Vacation

Just in time for summer vacation, the New England Journal of Medicine has published a report showing that DEET-based mosquito repellents are superior to non-DEET-based repellants. DEET is the most common compound found in commercial insect repellents. Recently, several botanical repellents have come on the market as well as 3 repellant-impregnated wristbands. These were tested against DEET containing repellents as well as one other chemical repellent containing IR3535. The worst performers were the wristbands, which offered no protection. The IR 3535-based repellents offer minimal protection while the soybean oil-based botanical repellents work for an average of 95 minutes. In comparison, the formulation containing 23.8% DEET offers complete protection for more than 300 minutes (N Engl J Med. 2002;347:13-18).

FDA Actions

Risedronate (Actonel), P&G Pharmaceuticals’ bisphosphonate for the treatment of osteoporosis, has been approved in a 35 mg once-a-week form. The drug has been available as a 5-mg daily tablet. As with other bisphosphonates, the drug needs to be taken 30 minutes before meals, and patients must remain upright for at least 30 minutes following administration. 

This supplement was written by William T. Elliott, MD, FACP, Chair, Formulary Committee, Kaiser Permanente, California Division; Assistant Clinical Professor of Medicine, University of California-San Francisco. Telephone: (404) 262-5517. E-mail: In order to reveal any potential bias in this publication, we disclose that Dr. Elliott reports no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.