Letters to the Editor

Interstitial Cystitis Is a Legitimate and Serious Condition

TO THE EDITOR: On behalf of the Interstitial Cystitis Association (ICA) and the hundreds of thousands of patients with interstitial cystitis (IC) that ICA represents, I would like to express our gratitude for the article, "Interstitial cystitis: Urgency and Frequency Syndrome,"¹ in American Family Physician. We are gratified that your family practice readership has the opportunity to review a comprehensive description of interstitial cystitis, its diagnosis, and the variety of treatment options that are available. Since many new patients with IC may not see a urologist right away, it is crucial that family physicians become more aware of this condition.

We would like to point out the omission in the article¹ of any serious discussion of pain treatment for IC. For many patients with IC, the most debilitating aspect is the chronic, unrelenting pain that leads to an exceptionally poor quality of life and, in some cases, even suicide. Because IC is not fatal or malignant, some physicians are reluctant to prescribe strong analgesics, including narcotics. Research documents that patients with chronic pain can receive great benefit from the use of opioid and nonopioid analgesics, and many patients with IC have regained their quality of life through effective pain management.^2-4 Additionally, for certain patients whose symptoms do not respond well to conventional treatments, experimental therapies (including several new medications and neuromodulation) may prove effective in pain management. The ICA has numerous informative fact sheets on IC that can be found on the ICA Web site at www.ichelp.org.

Additionally, the author's¹ discussion of intravesical therapies commonly used for treatment in IC mentions silver nitrate, which is considered an outmoded therapy of questionable therapeutic value, and oxychlorosene, 0.4 percent, which can be very painful for patients. Physicians should be discouraged from considering these two treatments.

In closing, I would like to add a note of historical perspective to this discussion. When the ICA was founded in 1984, there was little recognition of IC in the medical literature and even less recognition in clinical practice. Interstitial cystitis was considered to be a rare, postmenopausal condition. Even after 17 years of public education and millions of research dollars, some physicians still believe that IC is not a true disease, but some sort of "female complaint" that is not worthy of serious consideration. We appreciate your article because it allows your readers to have a clear understanding of the fact that IC is a legitimate illness that occurs not just in adult women, but in adult men and children as well. When patients present with urinary urgency, frequency and/or pain, in the absence of infection, we urge family practitioners to consider the diagnosis of IC.⁵

VICKI RATNER, M.D.
Interstitial Cystitis Association
110 N. Washington St, Ste. 340
Rockville, MD 20850

REFERENCES

1. Metts JF. Interstitial cystitis: urgency and frequency syndrome. Am Fam Physician 2001;64:1199-206, 1212-4.
2. Brookoff D. The causes and treatment of pain in interstitial cystitis. In: Sant GR, ed. Interstitial cystitis. Philadelphia: Lippincott-Raven, 1997.
3. Brookoff D. Chronic Pain: 2. The case for opioids. Hosp Prac (Off Ed) 2000;35:69-72, 75-6, 81-4.
4. Brookoff, D. Chronic Pain: 1. A new disease? Hosp Pract (Off ed) 2000;35:45-52,59.
5. Ratner V. Current controversies that adversely affect interstitial cystitis patients. Urology 2001; 57(6 Suppl 1):89-94.

IN REPLY: I would like to thank Dr. Ratner for her comments on my article "Interstitial Cystitis: Urgency and Frequency Syndrome."¹ All interstitial cystitis patients should be made aware of the Interstitial Cystitis Association, which she represents.

The article¹ does mention the use of tricyclics, nonsteroidal anti-inflammatory drugs and, possibly, gabapentin (Neurontin) for pain relief in patients with interstitial cystitis. Although not mentioned in my article¹, I agree that strong analgesics including narcotics may need to be used to control pain and improve the quality of life in these patients.^2,3 Opioids along with other pain control measures including physical therapy with biofeedback may be warranted in some patients.

While the article¹ does mention the intravesicular treatments silver nitrate and oxychlorosene only in Table 2 and not in the body of the text, both treatments were footnoted as having no studies which showed their efficacy.⁴ Given the lack of efficacy and potential side effects, I would therefore also discourage patients from considering these two treatments.

JULIUS METTS, M.D.
University of California-Davis
Davis, CA 95616

REFERENCES

1. Metts JF. Interstitial cystitis: urgency and frequency syndrome. Am Fam Physician 2001;64:1199-206, 1212-4.
2. Brookoff D. The causes and treatment of pain in interstitial cystitis. In: Sant GR, ed. Interstitial cystitis. Philadelphia: Lippincott-Raven, 1997.
3. Brookoff D. Chronic Pain: 2. The case for opioids. Hosp Prac (Off Ed) 2000;35:69-72, 75-6, 81-4.
4. Sant GR, Meares EN. Interstitial cystitis: pathogenesis, diagnosis, and treatment. Infections in Urology Jan/Feb 1990:24-30.

Should Perindopril Be Used to Treat Patients with Heart Failure?

TO THE EDITOR: We read with great interest the review article entitled "Spironolactone in Left-Sided Heart Failure: How Does it Fit in?"¹ However, we were surprised by the notable omission of perindopril (Aceon) in Table 4 ("Agents used to decrease mortality in patients with heart failure") and by the equally notable appearance of moexipril (Univasc) in the context of heart failure. The majority of review articles relating to pharmacotherapy that have appeared in American Family Physician are balanced and accurate; although the review by Margo and colleagues¹ is generally informative, we feel that a brief comment is warranted.

A thorough review of the biomedical literature (Ovid Technologies, Medline 1963 through September 2001) regarding the role of moexipril in heart failure yields a single citation of moexipril use in induced ischemic heart failure in rats.² Conversely, although perindopril is not labeled by the U.S. Food and Drug Administration for the treatment of congestive heart failure, its ability to ameliorate mild to moderate or severe³ heart failure⁴ of both ischemic and nonischemic origin is well established in fairly large randomized placebo-controlled trials. Further, determining the most effective angiotensin-converting enzyme (ACE) inhibitor in heart failure requires a critical assessment of these data because the biology of ACE inhibition in the setting of heart failure⁵ varies within the ACE-inhibitor drug class.⁶

We agree with the authors¹ that spironolactone can be beneficial in improving the neurohormonal and biophysical properties of the peripheral vasculature in the physiopathology of heart failure, and may exhibit synergy with tissue type ACE inhibitors. However, the disparity in the evidence base for individual ACE inhibitors should be considered by authors and practicing physicians.

DEMETRIOS A. PERDIKIS, M.D.
Department of Family Medicine
University of Medicine and Dentistry of New Jersey­
Robert Wood Johnson Medical School
New Brunswick, NJ 08901

GIACOMO MANGIARACINA, M.D.
Department of Internal Medicine, Seton Hall University School of Medicine

Dr. Perdikis is a member of the Lecture Bureau for Solvay Pharmaceuticals.

REFERENCES

1. Margo KL, Luttermoser G, Shaughnessy AF. Spironolactone in left-sided heart failure: how does it fit in? Am Fam Physician 2001;64:1393-9, 1399.
2. Stauss HM, Zhu YC, Redlich T, Adamiak D, Mott A, Kregel KC, et al. Angiotensin-converting enzyme inhibition in infarct-induced heart failure in rats: bradykinin versus angiotensin II. J Cardiovasc Risk 1994;1:255-62.
3. Flammang D, Waynberger M, Chassing A. Acute and long-term efficacy of perindopril in severe chronic congestive heart failure. Am J Cardiol 1993;71:48E-56E.
4. Cleland JG, Tendera M, Adamus J, Freemantle N, Gray CS, Lye M, et al. Perindopril for elderly people with chronic heart failure: the PEP-CHF study. The PEP investigators. Eur J Heart Fail 1999;1:211-7.
5. Sami MH. Distinctive properties of perindopril among converting enzyme inhibitors in congestive heart failure. Can J Cardiol 1994;10(Suppl D):13D-6D.
6. Thuillez C, Richard C, Loueslati H, Auzepy P, Giudicelli JF. Systemic and regional hemodynamic effects of perindopril in congestive heart failure. J Cardiovasc Pharmacol 1990;15:527-35.

EDITOR'S NOTE: This letter was sent to the authors of "Spironolactone in left-sided heart failure: how does it fit in?," who declined to reply.

Cervical Cancer Screening

TO THE EDITOR: The debate over implementing new tests for cervical cancer screening parallels the controversy over legislating a patients' Bill of Rights for persons covered by health maintenance organizations. Proponents of both pursue questionable improvements in services that, if they materialize at all, may come at the expense of the most vulnerable segment of the population.

It is unclear whether a patients' Bill of Rights would benefit or harm the patients it appears to protect, but it is obvious that all the current proposals neglect persons without the means to obtain health care in the first place. Likewise, since the newer tests for cervical cancer screening presuppose a Papanicolaou (Pap) smear as an initial screen, they will provide no benefit to patients at highest risk for cervical cancer--women with inadequate health care access that seldom or never receive Pap smears.

Whereas the cost of a patients' Bill of Rights is unknown, the cost of supplementary cervical cancer screening ranges from $7,777 to $166,000 per life-year saved.¹ Marginal cervical cancer reductions gained from employing these expensive tests potentially displace substantial reductions in cervical cancer rates that could be achieved by using routine Pap smears to screen the uninsured.

These debates, profound in appearance, distract us from the problem at hand--providing proven, cost-effective care to the patients who need it. Let us recapture our priorities. We should turn our attention from proposing legislation and pursuing new technologies that might guard the privileged, to legislating basic health promotion and disease prevention that will protect the vulnerable.

PETER TEICHMAN, M.D., M.P.A.
West Virginia University
Harpers Ferry Rural Family Practice Residency
31 Taylor St.
Harpers Ferry, WV 25425

REFERENCE

1. Brown, AD, Garber AM. Cost-effectiveness of 3 methods to enhance the sensitivity of Papanicolaou testing. JAMA 1999;281:347-53.

Corrections

Figure 3 of the article "Diagnosis and Management of Osteomyelitis" (June 15, 2001, page 2413) was misidentified in the figure legend as a magnetic resonance image. Figure 3, which appears on page 2416, is actually a computed tomographic scan.

The article "Evaluating the Child with Purpura" (August 1, 2001, page 419) contained an error on page 422. In the fourth paragraph of the left-hand column, the condition described should have been referred to as Fanconi anemia, not Fanconi's syndrome.

The article "Recognizing Spinal Cord Emergencies" (August 15, 2001, page 631) contained an error on page 638. The final paragraph refers to stenosis of the cervical spine but should have referred to stenosis of the lumbar spine.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.