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Background: Although the corticosteroids are valuable anti-inflammatory and immunosuppressive agents, they also possess many potential adverse effects, especially with continued use. In particular, long-term corticosteroid exposure carries a significant risk of osteoporosis., Aim: To review the use of corticosteroids in patients presenting to the major teaching hospital in Tasmania, Australia; principally to determine whether patients receiving long-term corticosteroid therapy were being monitored for loss of bone mineral density and offered preventive therapy for osteoporosis., Methods: A retrospective review of the medical records for 212 consecutive patients admitted to the medical wards of the hospital over a 5-month period and receiving treatment with either oral or inhaled corticosteroids, was performed. An extensive range of demographic and clinical variables was recorded for each patient. Patients were also questioned about diet and exercise, and whether they had undergone tests for measuring bone mineral density or blood glucose., Results: The median age of the patients was 69 years (range: 15-90 years) and 58% were female. Over half (53%) of the patients were on oral corticosteroids only, with 26% using inhaled corticosteroids only, and 21% on both oral and inhaled corticosteroid therapy. The most common conditions for which patients were receiving corticosteroid therapy were asthma (37% of patients), chronic obstructive pulmonary disease (33%) and rheumatoid arthritis (17%). The most commonly used oral corticosteroid was prednisolone (93%), the median daily dose was 10 mg prednisolone equivalent, and the median duration of oral corticosteroid treatment was 50 weeks. Disregarding short courses, the median duration of oral corticosteroid treatment was 104 weeks. Almost one-third (31%) of the patients receiving oral corticosteroid treatment had been taking the equivalent of 7.5 mg prednisolone daily for at least 6 months. Only 11% of all patients on oral corticosteroids and 21% of those who had been taking oral corticosteroids for at least one year had documented evidence of bone mineral density testing being performed in the past in the hospital. Only 21% of all patients on oral corticosteroids and 31% of those who had been taking oral corticosteroids for at least one year were receiving medication for osteoporosis prevention, and only 15% of women over 45 years of age and on oral corticosteroid therapy were taking hormone replacement therapy. Only about half of the patients on long-term systemic corticosteroid therapy had either documented evidence in their hospital medical records, or were aware, of having undergone blood glucose testing in the preceding 12 months., Conclusion: More attention to the prevention and monitoring of possible adverse effects of long-term corticosteroid therapy is warranted. Guidelines covering preventive measures and treatment options for corticosteroid-induced osteoporosis need to be considered routinely when using these agents.

Background: Commonly used drugs for type 2 diabetes are not ideal. The sulphonylureas, especially potent and long-acting agents such as glibenclamide, can induce hypoglycaemia, while metformin carries the risk of lactic acidosis., Aim: To review the management of type 2 diabetes at the major teaching hospital in Tasmania, Australia, principally to determine the extent of use of glibenclamide and metformin in the elderly and patients where published contraindications are present., Methods: A retrospective review of the medical records for 150 consecutive patients with type 2 diabetes admitted to the hospital in mid-1997, was performed. An extensive range of demographic and clinical variables was recorded for each patient. These included the duration of type 2 diabetes, the presence of other medical conditions, medication history, presence of any contraindications to the use of metformin or sulphonylureas, biochemical measures of diabetic control, and the presence of any diabetic complications., Results: The mean (+/-SD) age of the 150 patients included in the study was 70.1+/-11.8 years. The mean body mass index was 28.7+/-6.2 kg/m2 and the mean recent HbA1c level was 86+/-21%; only 24.7% of patients had a HbA1c level of 7% or lower. Of the 45 patients using glibenclamide, 40 (88.9%) had one or more risk factors for hypoglycaemia: over 65 years of age, renal impairment, or cognitive impairment and living alone. The study also found an extensive use of metformin in patients with contraindications and at highest risk of developing lactic acidosis. Sixty-six out of 70 patients (94%) using metformin had at least one contraindication according to the manufacturer's prescribing information, 57% of patients had two or three contraindications and 14% of patients had more than three contraindications. More than 20% of the patients had a renal function below published exclusion criteria., Conclusions: There was evidence of over-utilization of metformin and glibenclamide in type 2 diabetes patients most at risk of adverse reactions. Insulin therapy could be a safer and more effective management strategy in many of these patients.

There is growing evidence that renally-impaired patients receiving morphine therapy are at greater risk of developing opiate toxicity, due to the accumulation of an active metabolite, morphine-6-glucuronide (M6G), which is usually excreted by the kidneys. This study examined the relationships between morphine dosage, renal function, and trough plasma concentrations of morphine and its glucuronide metabolites in 21 patients (aged mean: 68.5 years: 11 males) receiving either oral or subcutaneous morphine for terminal cancer pain. The median daily morphine dosages (mg.kg-1) were: orally 1.87 (range 0.37-6.82) and subcutaneously 1.64 (range 0.22-3.60). The median plasma concentrations of morphine, morphine-3-glucuronide (M3G), and M6G (ng.ml-1) were: 36.0, 1035.2, and 142.3, respectively. The plasma concentrations of morphine, M3G and M6G were each significantly related to the daily morphine dosage (n = 21, Spearman r = 0.79, 0.91, and 0.88 respectively). Accumulation of the morphine glucuronides was dependent on renal function. The plasma concentrations of M3G and M6G, when divided by the morphine concentration, were significantly related to the calculated creatinine clearance of the patient. Patients receiving oral morphine had higher plasma concentration ratios of glucuronide/morphine than those receiving subcutaneous therapy, presumably due to first-pass glucuronidation. The results of this study confirm that accumulation of the pharmacologically active M6G is related to renal function, which probably explains the observation that morphine dosage requirements are generally reduced in patients with renal impairment.