*,:

KENACOMB, PREPARATIONS ID
Triamcinolone Acetonide - Neomycin Nystatin - Gramicidin Compound Indications: Corticosteroid-responsive inflammatory or pruntic dermatoses caused, threatened or complicated by infection due
to bacteria and/or candida. Pruritus ani and pruritus vulvae (cream only). The 0.025% formulations are for use on extensive lesions, or dermatoses which are chronic, mild, or highly susceptible to topical corticosteroid therapy, or for maintenance therapy of dermatoses previously controlled by a 0.1% formulation. Contraindications: Tuberculous and most viral lesions of the skin, including herpes simplex, vaccinia and varicella. Fungal lesions of the skin, except candidiasis. Patients with a history of hypersensitivity to any of the components. Not for ophthalmic use; not to be applied to the external auditory canal of patients with perforated eardrums or patients with otitis media. Occlusive therapy contraindicated in patients with atopic dermatits. Precautions: Because of the potential hazard of nephrotoxicity and ototoxicity, avoid prolonged use or use of large amounts in the treatment of skin infections following bums, trophic ulceration and other conditions where absorption of neomycin is possible. As with any antibiotic preparation, prolonged use may result in overgrowth of nonsusceptible organisms, including fungi other than Candida. Constant observation of the patient is essential. Should superinfection due to nonsusceptible organisms occur, Kenacomb should be discontinued and appropriate therapy instituted. Although adrenal suppression and other systemic adverse effects are rare with topical corticosteroid preparations, their possible occurrence must be kept in mind, particularly when these preparations are used over large areas or for an extended period of time. Occasionally, a patient who has been on prolonged therapy may develop symptoms of steroid withdrawal when the medication is stopped. The use of occlusive dressings is not recommended with products containing anti-infective agents. If local irritation or sensitization develops, the preparation should be discontinued and appropriate therapy instituted. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. When applied to moist intertriginous areas, oleaginous ointments in general may be irritating and are not recommended. Pregnancy and Lactation: The safety of topical steroid preparations during pregnancy and lactation has not been absolutely established; therefore, the potential benefit of use should be weighed against possible hazard to the fetus or the nursing infant. Articles in current medical literature indicate an increase in the incidence of patients allergic to neomycin. Neomycin itself may cause an allergic otitis extema. Systemic neomycin toxicity has occurred rarely following topical administration; tinnitus and deafness have been reported. The possibility of such a reaction should be bome in mind. Topical steroids should be used with caution on lesions close to the eye. Prolonged use of topical corticosteroid products may produce atrophy of the skin and subcutaneous tissues, particularly on flexor surfaces and on the face. If this is noted, discontinue use of the corticosteroid. Topical corticosteroids should be used with caution in patients with stasis dermatitis and other skin diseases associated with impaired circulation. If a symptomatic response is not noted within a week, discontinue the local application of coricosteroids and re-evaluate the patient. Gramicidin absorption following topical administration is unlikely; however, hemolysis may occur should the drug enter the blood. If gramicidin is allowed to come in close proximity to the sub-arachnoid space, a chemical arachnoiditis may occur. The possibility of hypersensitivity to ethylenediamine, a constituent of Kenacomb cream, should be bome in mind. Adverse Effects: Hypersensitivity to nystatin is extremely uncommon. Sensitivity reactions following the topical use of gramicidin or triamcinolone acetonide are rarely encountered. Neomycin: see Precautions. Buming, itching, irritation, dryness, erythema, folliculitis, hypertrichosis, acneiform eruptions, tinnitus, deafness and hypopigmentation have been reported with topical corticosteroids. When steroid preparations are used for long periods in intertriginous areas or under occlusive dressings, striae may occur Damage to collagen, which constitutes a middle layer of the tympanic membrane, may occur Delayed healing and systemic effects, including adrenal suppression and subcapsular cataracts, may occur if absorbed in appreciable amounts. Dosage: Cream: rub into affected areas 2 to 3 times daily. Ointment: Apply a thin film to the affected areas 2 to 3 times daily. Mild Cream & Ointment: 3 or 4 times daily. Supplied: Cream and Ointment: Each g contains: trimcinolone acetonide 1 mg, neomycin base (as sulfate) 2.5 mg, gramicidin 250 Ag, nystatin 100 000 units. The cream is formulated in a perfumed aqueous vanishing cream base which permits its use even in moist intertriginous areas. It also contains polysorbate 60, alcohol, aluminum hydroxide concentrated wet gel, titanium dioxide, silicone fluid, propylene glycol, ethylenediamine, hydrochloric acid, white petroleum, polyoxyethylene fatty alcohol ether, methyl and propyl parabens and sorbitol solution. Tubes of 15, 30 and 60 g. The ointment is formulated in protective Plastibase (Squibb plasticized hydrocarbon gel), a polyethylene and mineral oil gel base. Tubes of 15, 30 and 60 g. Kenacomb Mild: Kenacomb formula as above but with triamcinolone acetonide concentration of 0.025%. Tubes of 30 g (cream and ointment). Ue-- J o
PRESCRIBING INFORMATION floctafenine 200 mg and 400 mg tablets. THERAPEUTIC CLASSIFICATION: Analgesic. ACTIONS: IDARAC (floctafenine) is an anthranilic acid derivative which has analgesic and anti-inflammatory properties. The analgesic activity is comparable to that of other mild analgesics in the relief of acute pain. Floctafenine has been shown to inhibit in vitro biosynthesis of prostaglandins PGE2and PGF2a. Gastrointestinal bleeding determined by daily fecal blood loss, was shown in one clinical trial to be approximately 1.2 mL after 1600 mg/day of floctafenine compared to 10.4 mL after2400 mg/day of acetylsalicylic acid. In normal volunteers, IDARAC was well absorbed after oral administration and peak plasma levels were attained 1-2 hours after administration and declined in a biphasic manner, with an initial (a phase) half-life of approximately 1 hour and a later (, phase) half-life of approximately 8 hours. Floctafenine and its metabolites do not accumulate following oral administration of multiple doses. After oral and intravenous administration of '4C-labelled IDARAC, urinary excretion accounted for 40% and fecal and biliary excretion accounted for 60% of the recovered radioactivity. The main urinary metabolites are floctafenic acid and its conjugate with minimal amounts of free floctafenine. INDICATIONS: IDARAC (floctafenine) is indicated for short-term use in acute pain of mild and moderate severity. CONTRAINDICATIONS: IDARAC (floctafenine) is contraindicated in patients with peptic ulcer or any other active inflammatory disease of the gastrointestinal tract, and in patients who have demonstrated a hypersensitivity to the drug. WARNINGS: Use In Pregnancy: The use of IDARAC (floctafenine) in women of child-bearing potential requires that the likely benefit of the drug be weighed against the possible risk to the mother and fetus. Since there is no information on the excretion of floctafenine in breast milk, use of the drug in women who are nursing is not recommended. Use In Children: The safety and efficacy of IDARAC in children have not been established and therefore its use in this age group is not recommended. The safety and efficacy of long-term use of IDARAC have not been established. PRECAUTIONS: IDARAC (floctafenine) should be used with caution in patients with impaired renal function. In clinical trials with IDARAC dysuria, without apparent changes in renal function, was reported. The incidence of dysuria was greater in males than in females and occurred primarily in the first morning voiding. It has not been established whether dysuria is related to dose and/or duration of drug administration. Patients taking anticoagulant medication may be given IDARAC with caution. Alterations in prothrombin time have been observed only in clinical trials where the administration of IDARAC was extended beyond two weeks. IDARAC should be used with caution in patients with a history of peptic ulcer or other gastrointestinal lesions. ADVERSE REACTIONS: The most commonly occurring side effects reported during IDARAC (floctafenine) therapy were: Central Nervous System: Drowsiness, dizziness, headache, insomnia, nervousness, irritability. Gastrointestinal System: Nausea, diarrhea, abdominal pain or discomfort, heartburn, constipation, abnormal liver function, gastrointestinal bleeding. Urogenital System: Dysuria, burning micturition, polyuria, strong smelling urine, urethritis and cystitis. Other less frequently occurring side effects were: tinnitus, blurred vision, dry mouth, thirst, bitter taste, anorexia, stomach cramps, flatulence, hot flushes and sweating, tachycardia, weakness and tiredness. Allergictype Reactions: Maculopapular skin rash, pruritis, urticaria, redness and itching of the face and neck. SYMPTOMS AND TREATMENT OF OVERDOSE: No cases of overdose have been reported with IDARAC (floctafenine), therefore no specific information on symptoms or treatment is available. Standard procedures to evacuate gastric contents, maintain urinary output and provide general supportive care should be employed. DOSAGE AND ADMINISTRATION: The usual adult dose of IDARAC (floctafenine) is 200 to 400 mg every 6 to 8 hours as required. The maximum recommended daily dose is 1200 mg. IDARAC is recommended for short-term management of acute pain. The tablets should be taken with a glass of water. IDARAC is not recommended for use in children. AVAILABILITY: IDARAC tablets are available as round, biconvex, creamy white tablets containing 200 mg floctafenine with the markings "W" on one side and on the other side "I" with "200" below; and as round, biconvex, creamy white tablets containing 400 mg floctafenine with the markings "W" on one side and on the other side "I" with "400" below. IDARAC is available in bottles of 100 tablets. Store at room temperature, protected from light. IDARAC is a Schedule F (prescription) drug. Product monograph available upon request.

vous eablissez avec vos patientes est important. Montrez-vous attentif et encouragez vos patientes A participer A la prise de decisions de facon A ce qu'elles restent maitresses de la situation. ,askatoon

Of Time and Talk

Rejictions on relationships
C linical psychologist Dr Nina Woulff has been teaching assertiveness training for 15 years, wading daily into the treacherous waters of relationships - between spouses and between parents and teenagers. Director of the Dartmouth Branch of the Atlantic Child Guidance Centre, and lecturer with the Department of Psychiatry at Dalhousie, Woulff spoke at the 25th Maritime Conjoint in Charlottetown, sharing opinion, insight, and experience in an informal lecture. Her "Can Assertiveness Be Unhealthy For Families" launched discussion on a host ofissues and contradictions in modern relationships. Reflections follow.
* * 0

"There are more than 1000 hours yearly ofinformation on relationships on television. With such a glut of information, why do people request speakers such as me?" A partial definition of assertiveness: "To present a balanced view of your strengths as well as your vulnerabilities; to make clear statements with relatively little anxiety about your values and ideas." Aggression implies yell-

ing, assertiveness implies coherence:

Division of Sterling Drug Ltd." Aurora, Ontario L4G 3H6 Reg. Trade Markt ( **Registered User

"It is a lot easier to be aggressive than assertive."

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In taking the step from unassertive to assertive: "You can teach people all

Division of/de Bristol-Myers Squibb Canada Inc.

Belleville. Ontano K8N 5E9

those outer external tricks: sitting authoritatively, making eye contact, using the word 'I,' and making declarative statements instead of asking vague questions. After being taught these skills, we noticed a higher level of anxiety." Why? "Far more important than teaching people assertiveness skills is teaching them what to do with all that anxiety. It is a matter of limiting it, not eradicating it." The 'end result? "You will experience anxiety, but you will control and manage it."

"What causes the anxiety is a change of a set of beliefs. Individuals live by certain commandments, learned in childhood; and we are only half aware of them: many of them were not overtly stated or written down on a tablet so that you can analyze them. They are implicit rules rather than explicit."

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For doctors only: "Your training and your role is to respond and to respond "Start rewriting the rules." * * . quickly. That is appropriate in a med"Compromise is an interesting word ical emergency. I am suggesting that because it means different things to at home, treating a situation like a different people." medical emergency is overreacting."
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"Rules are only rule

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-SR

~N izoaraI
(ketoconazole 2%)
shampoo
TOPICAL ANTIFUNGAL AGENT ACTIONS In vitro studies suggest that the antifungal properties of NIZORAL (ketoconazole) may be related to its ability to impair the synthesis of ergosterol, a component of fungal and yeast cell membranes. Without the availability of this essential sterol, there are morphological alterations of thefungal and yeast cell membranes manifested as abnormal membranous inclusions between the cell wall and the plasma membrane. The inhibition of ergosterol synthesis has been attributed to interference with the reactions involved in the removal of the 14-a-methyl group of the precursor of ergosterol, lanosterol. Except for its specific pharmacologic effect, i.e., a sporocidal orfungi-

Anti-inflammatory, analgesic agent

Brief prescribing information:

applied topically on the skin INDICATIONS

cidal activity, ketoconazole when formulated in a 2% shampoo is not expected to exert any other pharmacodynamic effect when or hair.
NIZORAL (ketoconazole) 2% shampoo is indicated for the topical

treatment and prophylaxis of pityriasis capitis infections (dandruff)

in which the yeast Pityrosporum is involved. CONTRAINDICATIONS NIZORAL (ketoconazole) 2% shampoo is contraindicated in persons who have shown hypersensitivity to the active or excipient ingredients of this formulation. WARNINGS Irritation may occur when NIZORAL shampoo is used immediately after prolonged treatment with topical corticosteroids. Therefore, it is recommended to wait for about 2 weeks after treatment with topical corticosteroids before using NIZORAL shampoo.

PRECAUTIONS
If a reaction suggesting sensiivity or chemical irritation should occur, use of NIZORAL shampoo should be discontinued. NIZORAL shampoo does not produce detectable blood levels after topical application. However due to the teratogenic nature of the active ingredient, ketoconazole, the use of NIZORAL shampoo is not recommended in pregnant or nursing women.

ADVERSE REACTIONS
NIZORAL (ketoconazole) 2% shampoo causes minimal skin and scalp irritation. During clinical trials, 11 (2.1%) of 532 patientstreated with active shampoo reported side effects: Dry, brittle hair (4), greasy hair (2), hair loss (1), irritation (1), exfoliative dermatitis (1), tiny

Actions and Clinical Pharmacology: SURGAM SR, a propionic acid derivative, is a NSAI agent that inhibits prostaglandin synthetase enzymes but whose mechanism of action is not completely known. In vitro and ex vivo studies in different experimental models with cartilage and cultures of human chondrocytes obtained from biopsy specimens have shown that exposure to tiaprofenic acid did not depress the biosynthesis of proteoglycans nor alter the differentiation of proteoglycans secreted. The degradation of proteoglycan aggregates was inhibited. These in vitro results suggest a positive effect of tiaprofenic acid on the joint cartilage under experimental conditions. The clinical significance of these findings is not known and will be further investigated. Indications and clinical use: Relief of signs and symptoms of rheumatoid arthritis and osteoarthritis. Contraindications: Peptic ulcer or active inflammatory disease of the GI system. Known or suspected hypersensitivity to the drug. Patients in whom acute asthmatic attacks, urticaria, rhinitis or other allergic reactions are precipitated by ASA or NSAIDs, as fatal anaphylactoid reactions have occurred in such individuals. Warnings: SURGAM SR should be given under close medical supervision to patients prone to GI tract irritation. Patients should immediately contact a physician if they experience symptoms or signs suggestive of peptic ulceration or GI bleeding. For elderly, frail and debilitated patients, consideration should be given to a lower starting dose, with individual adjustment when necessary and under close supervision. Not recommended in pregnancy and lactation, or in children. Precautions: If peptic ulcer is suspected or confirmed or GI bleeding occurs, tiaprofenic acid should be discontinued, appropriate treatment and monitoring instituted. Tiaprofenic acid should be used with caution in patients with cardiac decompensation, hypertension and renal diseases. Tiaprofenic acid should be used with caution in patients with impaired renal function, and the dosage should be adjusted accordingly. Renal function should be monitored periodically in patients on longterm treatment. SURGAM SR should be discontinued if symptoms of vesical irritation should develop. Liver function
should be monitored during long-term treatment with this drug.

"People in the helping profession and those who are attracted to them tend to be over-responsible."
*

-9

"A parent's role is to define clearly what you stand for and send a message of where you stand. You are not responsible for someone else's happiness.

"All the energy put into changing other people is wasted energy. It is better to put the emphasis on changing yourself." Do not force people to change: "Allow that others have choices after you have taken a stand."
* *

pustules on scalp (1) and dryness and itching of forehead and cheeks (1). SYMPTOMS AND TREATMENT OF OVERDOSAGE
Oral ingestion is usually followed by nausea and vomiting due to the detergent. In the event of accidental overdosage, induce vomiting or consider gastric lavage with sodium bicarbonate, with general supportive measures as required. It has been reported that keto-

Safety of SURGAM SR in patients with liver disease has not been established. SURGAM SR should be used with caution in patients with potential for abnormal bleeding. Therapy should be discontinued if a patient develops blurred and/or diminished vision and an ophthalmological examination carried out. Tiaprofenic acid should be used with caution in the elderly, and
the dosage adjusted individually. Physician should be alert to the

"I want people to stop and think instead of constantly reacting. That is why they are dysfunctional, why they are in therapy. Think about models and past behavior patterns."
*
*

conazole cannot be removed by hemodialysis. DOSAGE AND ADMINISTRATION NIZORAL shampoo should be applied to the wet scalp, worked into a lather and left on for 3-5 minutes before rinsing with water. As
with other shampoos, care should be taken to keep the shampoo out of the eyes and off the eyelids. Treatment: Twice weekly for 4 weeks. Prophylaxis: Once every one or two weeks. DOSAGE FORM Availability: NIZORAL (ketoconazole) 2% shampoo is supplied in HDPE flasks with 100 mL shampoo containing 20mg ketoconazole
per gram.

Storage: NIZORAL 2% shampoo should be stored at

perature. Product Monograph available
on

room

tem-

request.

REFERENCES: 1. Degreef H, Rosenberg EW.: Seborrhoeic dermatitis and dandruff: a place for antifungals. Proceedings of a satellite symposium to the Second International Skin Therapy Symposium, Antwerp, Belgium, May 5, 1988. Data on file at Janssen Pharmaceutica Inc. 2. Degreef H, Jacobs PH, Rosenberg EW, et al (eds).: Ketoconazole in seborrhoeic dermatitis and dandruff. A Review. Data on file at Janssen Pharmaceutica Inc. 3. Green CA et al.: Treatment of seborrhoeic dermatitis with ketoconazole: II. Response of seborrhoeic dermatitis of the face, scalp and trunk to topical ketoconazole. Br J Dermatol 1987; 116:217-221.

development of infection in patients receiving this drug. Drug Interactions: May interact with anticoagulants, sulfonylurea, hypoglycemic agents, sulfonamides, phenytoin, lithium and certain chemotherapeutic agents such as methotrexate, therefore, caution should be observed when these drugs are used concurrently. Could interfere with diuretics in hypertension. Adverse reactions: Gastrointestinal (16%); indigestion, nausea, heartburn, epigastric pain, vomiting, abdominal pain, constipation, flatulence, diarrhea, enterocolitis, melena, rare incidents of gastric or duodenal ulceration. Central Nervous System (6.2%); dizziness, drowsiness, headache, depression, disorientation, insomnia, tinnitus, anxiety, tiredness/weakness. Cutaneous (2.1%); rash, erythema, pruritis, dry skin, onycholysis. Cardiovascular (1.1%); hot flushes, chest pain, angina, bruising. Renal (1.1%); oedema, incontinence, polyuria, oliguria. Hepatic function tests less than 1%. Miscellaneous (2.20/); dry mouth/tongue, stomatitis, nosebleeds. Others (0.1 to 0.5%); eye itching/ conjunctivitis/red eyes, minor eye ulcers, blurred vision, anorexia, weight gain, cramps, dyspnea, intermenstrual bleeding/vaginal spotting, paresthesia of fingers,
-

Why the recent obsession with relationships? "People have more time, fewer children, and work fewer hours. Also the advent of washing machines and microwaves allow a lot more free time, particularly for women."
*
* 0

"I don't think relationships are worse. People just talk about them more."
*

Ketoconazole Shampoo, Seminars in Dermatology1987; 6(1):66-67. Thulliez M.: In: "Janssen in touch with the skin." Abstract of Satellite Symposium to the 17th World Congress of Dermatology, Berlin, 1987,47.7. TanewA.: A randomized study with ketoconazole shampoo 2% or Selsun (selenium sulphide 2.5%) in the treatment of seborrhoeic dermatitis and/or dandruff. Clinical Research Report R41 400/172, November 1987. Data on file at Janssen Pharmaceutica Inc. 8. Schrooten P, De Doncker P.: 2% ketoconazole shampoo in seborrhoeic dermatitis and dandruff, Abstract of the International Society for Human and Animal Mycology, Barcelona; In: Revista /bdrica de Micologia 1988; 5(1):62. 9. Shuster S, Blatchford, N.: Seborrhoeic dermatitis and dandruff: Afungal disease. A Symposium, Royal Society of Medicine, London, December1987. Data on file at Janssen Pharmaceutica Inc. 10. Jacobs PH.: Seborrhoeic Dermatitis: Causes and Management. CUT/S March 1988; 41 :182-186. 11. Nizoral shampoo product monograph.

Pityrosporum orbiculare in vitroand in vivo. Annals of the New York Academy of Sciences 1988; 544:348-353. 5. Smith EB.:

4. Faergemann J.: Activity of triazole derivatives against

sneezing, sweating, palpebral oedema, palpitations, vertigo, tremor, cystalgia, dysuria, pollakiuria, hematuria and cystitis. Dosage and Administration for Rheumatoid Arthritis or Osteoarthritis: The initial and maintenance dose is 2 Surgam SR capsules of 300 mg once daily at bedtime. Surgam SR capsules should be swallowed whole. Availability: SURGAM SR is available as 300 mg hard gelatin capsules with a transparent pink body and opaque maroon cap printed with SURGAM SR on one side and the Roussel logo on the other, each containing off-white spheroidal pellets. Product monograph available on request. References: 1. Phillips, G., et al. Curr. Med. Res. and Opin., Vol. 10, No. 7, 486-493, 1987. 2. Bernstein, R., et al. Data on file. 3. Hazleman, B.L., et al. Data on file. 4. Calin, A., et al. Drugs 35 (suppl 1). 57-63, 1988. 5. Essigman, W., et al. Int JClin Pharm Res VlI (4) 251-257, 1987. 6. Warrington, S.J., et al. Drugs 35 (suppl 1). 90-94, 1988.
Registered trademark of Roussel

On the proliferation of talk shows about relationships and the spectator society that feeds them: "I don't think it is all that bad. People have always been curious about life, about other people, and been interested in people who are different. If they are watching, they are tolerating and accepting. It can be positive if you show people who have struggled and survived." On self-help books on relationships, of which she counted 60 in a local bookstore: "Some self-help books are good but more often than not, they confuse people. They can make superficial changes in a person rather than building-block changes."

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Remember

* JANSSEN PHARMACEUTICA
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Canadian Family Physician VOL 37: Febmary 1991

Why do women spend more time on the quality of relationships? "It is the socialized mandate of women whether there have been books or not."
* *

management, including, "Do not read the handbook at one sitting; read what you need when you need it." * On average, rent and staff consume some 60% of the overhead costs; other costs are incidental. her rules." "Every therapist has "Ifyou have a high overhead, you GCharlotetoum are on a treadmill. You must see more patients to meet that overhead, must delegate to staff as a result, and consequently require staff with specific skills," says du Bois. * "Do more with staff, space, and equipment and in turn become more cost-efficient." H Xow do you organize to provide * In the waiting room, accent walls, hang local art, install track lighting, care to patients? Gerd du Bois, and include children's toys. "These author of The Business ofMedical Pracare minor changes, made for esthettice, has developed a thorough and ic reasons and for comfort." systematic approach to the problem. At the 1990 Maritime Conjoint, du * Give your staff privacy and adeBois offered a few pointers on practice quate workspace. "With comput-0

The Business of Medicine

Staying cost-efficient

erization, more work is delegated to the front office staff." Train the telephone staff. "The telephone is the crucial instrument. If you believe your staff members represent you in person, they also represent you on the phone. It is the entry point into the practice." * Charts often carry useless information and consequently need to be rewritten or reorganized. "If you are not an organized person, the computer will not do it for you," du Bois warns. He developed his charts in consultation with a group of physicians and a filing company, a process that took the better part of a year. The charts list patient problems on the left and progress notes on the right. "An average family physician has over 2000 charts. Do not rewrite old charts; start with new patients.

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----~~~~~~