Anatomy of a First Aid Kit

A well-stocked first aid kit is a handy thing to have. To be prepared for emergencies, keep a first aid kit in your home and in your car. Carry a first aid kit with you or know where you can find one. Find out the location of first aid kits where you work. First aid kits come in many shapes and sizes. You can purchase one from the RedCross.org store or your local American Red Cross chapter. Your local drug store may sell them.

You may also make your own. Some kits are designed for specific activities, such as hiking, camping or boating. Whether you buy a first aid kit or put one together, make sure it has all the items you may need. Include any personal items such as medications and emergency phone numbers or other items your health-care provider may suggest. Check the kit regularly. Make sure the flashlight batteries work. Check expiration dates and replace any used or out-of-date contents. The Red Cross recommends that all first aid kits for a family of four include the following:

• 2 absorbent compress dressings (5 x 9 inches)
  
• 25 adhesive bandages (assorted sizes)
  
• 1 adhesive cloth tape (10 yards x 1 inch)
  
• 5 antibiotic ointment packets (approximately 1 gram)
  
• 5 antiseptic wipe packets
  
• 2 packets of aspirin (81 mg each)
  
• 1 blanket (space blanket)
  
• 1 breathing barrier (with one-way valve)
  
• 1 instant cold compress
  
• 2 pair of nonlatex gloves (size: large)
  
• 2 hydrocortisone ointment packets (approximately 1 gram each)
  
• Scissors
  
• 1 roller bandage (3 inches wide)
  
• 1 roller bandage (4 inches wide)
  
• 5 sterile gauze pads (3 x 3 inches)
  
• 5 sterile gauze pads (4 x 4 inches)
  
• Oral thermometer (non-mercury/nonglass)
  
• 2 triangular bandages
  
• Tweezers
  
• First aid instruction booklet
  

Unusual side effects of HIV drugs pose challenge

Good news followed by bad increasingly plagues America's 2.1 million HIV patients. Updated studies show the greater the use of life-enhancing highly active antiretroviral therapy (HAART), the greater the number of unusual side effects—lipodystrophy (redistribution of fat), lactic acidosis, insulin resistance, and even male osteoporosis.

Dyslipidemia—elevations in triglycerides, LDL, and total cholesterol—is fast becoming commonplace in HIV patients, intensifying concerns about heart attacks and strokes in 30- to 40-year-olds. However, dyslipidemia in these patients has been treated successfully with standard diet modifications and oral drugs such as gemfibrozil and the statins. Also, the protease inhibitor (PI) atazanavir (Reyataz, Bristol-Myers Squibb) may cause less dyslipidemia than any other drug in its class.

Some new findings show that lipodystrophy seems to occur most frequently in patients who thrive on HAART; other data suggest that blood lipid levels normally return to baseline levels when patients stop taking certain nucleoside reverse transcriptase inhibitors (NRTIs), e.g., stavudine (Zerit, BMS), or quit taking all PIs. The third class of HIV drugs—the non-nucleoside reverse transcriptase inhibitors (NNRTIs)—is associ-ated with potentially deadly skin rashes, e.g., the Stevens-Johnson syndrome.

Patients find the disfigurement due to lipodystrophy very distressing and thus the disease is sometimes accompanied by depression. Typically with the lipodystrophy syndrome, fat accumulates at the back of the neck ("buffalo hump") and the abdomen ("protease paunch"), while it disappears from the face, buttocks, and extremities, leaving a gaunt look that even plastic surgery cannot long conceal.

The pathophysiologic mechanisms of these changes are not well understood, according to James A. Jorgenson, R.Ph., M.S., director of pharmacy services, University of Utah Hospitals, Salt Lake City, and other investigators. He told Drug Topics, "Several potent new HIV drugs received accelerated Food & Drug Administration approval due to the critical need for these agents. The benefit for patients outweighed the risk associated with less testing prior to approval. As more patients continue to use these drugs, however, more side effects could reveal themselves."

Some investigators report both drug- and drug class-specific similarities and differences in the impact of antiretroviral drugs. For example, in a 2006 update of his report "Adverse Events of Antiretroviral Drugs" in HIVinSite, Ian McNicholl, Pharm.D., BCBS, pointed out: "Of the NRTIs, stavudine appears to convey the greatest risk of lipodystrophy and other mitochondrial toxicity.... When stavudine is combined with didanosine, there's also an increased risk of lactic acidosis ... and therefore pregnant women ... should avoid this combination. Additionally, studies link stavudine to the fat-depletion component of the HIV-associated lipodystrophy syndrome."
Christine Jamjian, Pharm.D., infectious disease/HIV pharmacist, University Health Care, University of Utah, said in an interview, "Several recent reports show that partial improvement in fat depletion occurred after HIV patients on HAART were switched from stavudine to zi-dovudine, abacavir (Ziagen, GlaxoSmithKine), or tenofovir (Viread, Gilead)." Further, Australian researchers note that patients taking combined PI and NRTI treatment develop fat depletion about twice as fast as with NRTI alone. Their data show, too, that the risk of lipodystrophy rises sharply with the duration of treatment with either of these drug classes or with combinations of them.

McNicholl said, "All PIs are associated with metabolic abnormalities, including dyslipidemia, hyperglycemia, and insulin resistance, as well as lipodystrophy. In addition, PIs may increase the risk of bleeding in hemophiliacs ... and [pharmacists should note] PIs may have significant interactions with other drugs ... which calls for dosage adjustments."
Using atazanavir as an example of the complexity of current drug therapy, McNicholl noted that proton pump inhibitors interfere with absorption and thus are contraindicated in patients receiving this PI. But "other antacids and H2 blockers also interfere with atazanavir absorption and should be used cautiously in patients receiving this approved antiretroviral.... To add to the difficulty of choosing the right drug, some studies show that atazanavir may have less effect on lipid levels than do other PIs."

The new PI tipranavir (Aptivus, Boehringer Ingelheim) also has many drug-drug interactions and should not be used without ritonavir boosting or taken without food, said McNicholl. "New adverse reactions continuously appear as HAART regimens are used increasingly in new combinations of drugs for longer periods."

Lactic acidosis is another, potentially fatal, metabolic disorder encountered in HIV-infected people receiving HAART. A documented adverse effect of nucleoside analog treatment, lactic acidosis is a disease of the mitochondria. Elevated blood levels of lactate warn of the development of lactic acidosis. High-energy tissues such as muscle, heart, and brain are particularly vulnerable to mitochondrial toxicity, but the pancreas and liver are also at risk. Said Jamjian, "Patients should be switched to an NRTI-sparing regimen or to an NRTI with less potential for causing mitochondrial toxicity.... Case reports show patient improvement when antioxidants or vitamin B supplements are introduced."

Other side effects of HAART drugs involving blood sugar levels include hyperglycemia and insulin resistance. The FDA urges clinicians to monitor the blood sugar levels of their HAART patients monthly in months one to three, then once every three to six months. The danger lies in insulin resistance, which brings together obesity, hypertension, hyperlipidemia, and coronary artery disease.

At recent AIDS conferences, researchers have been presenting studies in which osteopenia/osteoporosis occur in young HIV men receiving HAART. However, some studies have suggested that HIV itself may be a cause of osteopenia/osteoporosis in adults and children without any HIV treatment. Commented Jamjian, "Despite the fact that antiretrovirals are associated with a variety of side effects, these drugs have decreased morbidity and mortality associated with HIV infection and restored hope to patients."

SLUGGISH FDA APPROVES ONLY 18 NEW DRUGS DURING 2006

The pace of new drug approvals remained sluggish last year, with only 18 "new molecular entities" cleared for US marketing by the FDA during 2006. Last year's total is down from an average of 26 new drug approvals recorded during the past 6 years, and the slowdown has prompted speculation among pharmaceutical manufacturers, regulators, and health care professionals.

The number of drug approvals may vary from year to year for many reasons, and even a substantial rise or fall in the approval rate during any one year may be unrelated to the pace of industry research or government regulation. Since last year's slow-footed approval pace came at a time when many observers believe that the FDA is growing more cautious in its new drug review and approval process, however, questions are already being raised about whether the government officials are becoming "risk averse."

For their part, government researchers attributed last year's approval decline to the fact that the pharmaceutical industry is placing more of its research and development (R & D) emphasis on complex medicines for difficult-to-treat conditions.

Although the industry is spending more than ever on new product R & D, the failure rate of drugs in testing has risen, as companies target these increasingly intractable diseases, concluded FDA researchers.

Others, however, attribute the relatively slow rate of new drug approvals to the fact that the FDA has been without a permanent full-time commissioner for much of the past year.

In December 2006, the Senate finally confirmed Andrew von Eschenbach, MD, as FDA commissioner, and some observers believe his leadership will result in a higher number of new drug approvals during 2007.