Clinical Briefs



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Am Fam Physician. 1998 Sep 15;58(4):1009-1014.

Neonatal Drug Withdrawal

The American Academy of Pediatrics (AAP) has issued a position statement on neonatal drug withdrawal. The statement, published in the June 1998 issue of Pediatrics, has current information about the clinical presentation, differential diagnosis, therapeutic options and outcomes for infants with intrauterine drug exposure. Specific agents used for opioid withdrawal are discussed in the statement. These include tincture of opium, paregoric, morphine, methadone, clonidine, chlorpromazine, phenobarbital and diazepam.

The following recommendations are from the AAP statement:

  • Screening for maternal substance abuse should involve multiple forms, including maternal history, maternal urine testing, and testing of newborn urine and newborn meconium specimens.

  • Drug withdrawal should be considered as a diagnosis in infants in whom compatible signs develop. Physicians should be aware of other potential diagnoses that should be evaluated and treated.

  • Drug withdrawal should be assessed using an appropriate scoring tool.

  • Pharmacologic therapy of withdrawal-associated seizures is indicated. Other causes of neonatal seizures also must be evaluated.

  • Vomiting or diarrhea associated with dehydration and poor weight gain, in the absence of other diagnoses, are relative indications for treatment, even in the absence of high total withdrawal scores.

  • Treatment drug selection should match the type of agent causing withdrawal.

  • Physicians should be aware that the severity of withdrawal signs, including seizures, has not been proved to be associated with long-term outcome. Treatment may also not change the long-term outcome.

  • Naloxone should not be used in infants whose mothers are known to be opioid-dependent. In the absence of a specific history of opioid abuse, naloxone treatment is a reasonable option in the delivery room management of an infant with respiratory depression whose mother recently received a narcotic.

Mammography Screening Aid

A new computer system designed to double-check mammogram readings has been approved by the U.S. Food and Drug Administration (FDA) and, according to the FDA, has the potential to reduce the number of women who have delayed diagnosis of breast cancer because of missed abnormalities in screening mammograms.

The new device, M1000 Image-Checker, analyzes the content of mammograms and highlights suspicious areas on the images after the radiologist has done the initial evaluation. The radiologist then reviews those same areas on the original mammogram to see if any were not noticed and, if so, whether they require further evaluation.

In studies of more than 40,000 mammograms, the device showed that it improved cancer detection rates by approximately 8 percent. ImageChecker is made by R2 Technology Inc., Los Altos, Calif.

Salt Intake and Hypertension

At the 13th International Interdisciplinary Conference on Hypertension in Blacks, the International Society on Hypertension in Blacks (ISHIB) reiterated its position statement that modest dietary salt avoidance is almost always helpful and is of no health risk. The position is in concurrence with recommendations from the American Heart Association and the National High Blood Pressure Education Program of the National Heart, Lung, and Blood Institute. According to ISHIB, persons who are black, have diabetes, are older or are overweight experience higher blood pressure with increased salt consumption.

Numerous studies have demonstrated the importance of reduced or moderate salt intake, especially for populations at risk. There is also clinical evidence that “high” dietary salt consumption is associated with the enlargement of the heart and damage to the kidneys and to the brain. In blacks, these findings are particularly important because of the increased frequency of hypertensive target organ damage.

The ISHIB notes that with increasing age and obesity, most Americans become more salt-sensitive, resulting in a predictable increase in blood pressure. Moreover, this is seen more often in persons with diabetes and in blacks. Thus, the ISHIB believes that ethnic minority persons, particularly as they get older, have a greater propensity for increases in blood pressure with increasing dietary salt consumption.

Micronized Progesterone

The first oral dosage form of micronized progesterone (Prometrium capsules) has been approved by the U.S. Food and Drug Administration for the treatment of secondary amenorrhea.

Prometrium is a progesterone synthesized from yams that is structurally identical to the natural progesterone found in a woman's body. Patients who may be allergic to peanuts, who have severe liver disease, who have known or suspected breast cancer, or who are pregnant should not take Prometrium capsules. The most common side effects are dizziness, abdominal cramping, headache and breast pain.

Alcohol and Aging

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published a report on alcohol and aging (Alcohol Alert No. 40, April 1998). The report discusses drinking prevalence and patterns among the elderly; combined effects of alcohol and aging; aging and sensitivity to alcohol; aging, alcohol and the brain; and the treatment of alcoholism in the elderly. Elderly is generally defined in the report as persons older than age 65.

The report states that the sensitivity to the health effects of alcoholism may increase with age. One reason is that the blood alcohol concentration in elderly persons is usually higher than that in younger persons after consumption of similar amounts of alcohol, placing elderly persons at increased risk for intoxication and adverse effects. Older persons have less water in the body in which to dilute the alcohol. Even if a person's drinking pattern stays the same over the years, this decreased tolerance for alcohol can cause alcohol problems.

“Health care providers should discuss alcohol use with their older patients as a part of routine care,” according to NIAAA Director Enoch Gordis, M.D.“Advice to older patients should include the medical conditions common to older people, such as high blood pressure and ulcers, that can be worsened by drinking and over-the-counter and prescription drugs that can be dangerous, or fatal, when mixed with alcohol,” he stated in the report. Finally, the report notes that elderly persons with alcohol problems can benefit from treatment.

The text on this report on alcohol and aging can be found on the NIAAA Web site at http://www.niaaa.nih.gov. Copies of the Alcohol Alert are available free of charge from the NIAAA, Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849-0686.

New Drug for Tuberculosis

The U.S. Food and Drug Administration (FDA) has granted accelerated approval of rifapentine (Priftin) to be used in combination with other antituberculosis agents in the treatment of pulmonary tuberculosis. The drug is the first antituberculosis agent approved in 25 years. It has been designated an orphan drug.

With rifapentine, the first course of therapy is two months of daily isoniazid, pyrazinamide and ethambutol combined with twice-weekly rifapentine. The dosing schedule is then reduced to rifapentine plus isoniazid taken once a week. The FDA believes that the dosing schedule with rifapentine will improve compliance, therefore improving patient outcomes and helping to deter drug resistance associated with the use of antibiotics. While the relapse rate with rifapentine is higher than that with rifampin, neither rate is alarmingly high (10 percent versus 5 percent).

According to the FDA, the safety profile of rifapentine appears to be similar to that of rifampin. Patients receiving rifapentine should be monitored for increased liver enzyme levels, which can be a precursor to liver damage, and increased uric acid levels, which can be a precursor to gout. One of the most common side effects is discolored, orange-reddish urine.



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