munication has existed, it takes initia- labors have not been subsidized by one It simply has not been subject to the tive and sometimes courage for one or or other of the great cartels. advertising pressures of the pharma- the other to begin to communicate. Every product of the pharmaceutical ceutical industry. The Canadian Pediatric Society and industry comes with a long list of hor- In my opinion there is nothing the College of Family Physicians of rible possibilities. These lists are re- "infra dig" about nature. Some sheet- Canada have established a joint com- quired by law. Despite all the well- anchor treatment in modern medicine mittee to act as a forum for the identifi- known tragedies that have resulted was based on the practices of cation and possible solution of prob- from widespread usage of modern housewives and herbalists! Bella- lems that exist, or may arise, between drugs, physicians often readily con- donna, digitalis, salix bark (aspirin), family physicians and pediatricians demn their colleagues for using water- curare, limes (ascorbic acid), rauwol- who jointly care for Canadian chil- soluble vitamins which have not been fia, hypnotism, acupuncture and a host dren. In addition to the problems of shown to produce any tissue injury. of other worthy treatment modalities practice, a survey of the educational Doctors who condemn the use of these derived from less prestigious fountains needs for both the family physician natural substances, but feel at ease than the modern molecule-jugglers! and the pediatrician is being under- when they prescribe foreign chemi- I submit that the pronouncement taken so that a progressive updating of cals, are in effect puppets of the phar- quoted above is completely irresponsi- both disciplines may continue. Ques- maceutical industry. They can swal- ble and lacking in forethought. I would tions or comments about either prac- low a camel, but they choke on a like to know why the gentleman in tice or medical training of family phy- gnat! question did not take action to stop the sicians and pediatricians relative to the Many of the beneficial effects of marketing of Mandrax in Canada. It health care of Canadian children are any medication can be achieved by has been declared illegal and toxic in sought. These communications can be inert placebos. Indeed, whenever a Europe ten years ago, but remains the forwarded either to Dr. Donald Rice, new product is promoted by the phar- most popular hypnotic in Canada. Yet Executive Director of the College of maceutical industry, an interesting sta- the makers of Mandrax have replaced Family Physicians of Canada, 4000 tistic comparing the value of the new it in Europe with a safer substitute Leslie Street, Willowdale, ON., drug with an inert placebo shows that called Mogadon. This drug is not im- M2K 2R9, or to Dr. Victor Marches- the placebo often achieved 70% of the ported into Canada. sault, Secretary of The Canadian Pe- result obtained with the potentially The Chairman of the Health Com- diatric Society, Centre Hospitalier [dangerous new chemical! The placebo mittee, filling his quixotic role as well Universitaire, Universite du Sher- value of water-soluble vitamins should as he does, ought to turn on his horse brooke, PQ, JIH 5N4. not be deprecated. and aim for the other windmill! Workers in the prestigious Harvard D. Appavoo J. B. McKendry, Medical Research Centre have re- Kerrobert. SK. Coordinator, Family Practice cently debunked the long-held theory Teaching Program, The Hospitalfor Sick Children, that cholesterol and triglycerides are Toronto directly related to arterial and cardiac Entente Not disease. They correctly point out that a R. L. Perkin very small percentage of myocardial So Cordiale Coordinator, Family Practice from Residency Program, infarction patients will be found to In September we printed a letter University of Toronto have unusually high blood lipid levels. a reader who is unhappy with our pol- The same holds true for arteriosclero- icy of running some articles in French tics. The real culprit, they believe, is ("Pas en francais, s'il vous plait" homocysteine. This toxic amino acid CFP 25:987). Below are some of the Megavitamin is rapidly deaminated by pyridoxine. replies. Similar research carried out by Therapy workers in the reputable Minnesota In- Just as C.R.S. Dawes of Winchester, Those who have half a mind to "speak stitute of Technology has adduced evi- Ontario, is probably only one of many out" usually do so! dence to show that large doses of pyri- anglophones who are "frustrated" In a statement to the press, the Na- doxine have a protective action on the when they see French in CANADIAN tional Chairman of the Consumer As- arterial intima. FAMILY PHYSICIAN, I am sure I am sociation of Canada Health Committee Studies carried out in UCLA (San only one of the many bilingual readers warned the public to be careful of doc- Diego) indicate that cognitive skills who enjoy articles in both the French tors who practice megavitamin injec- were recordably enhanced by frequent and in the English languages. tion therapy. I feel certain that he is and prolonged treatment with massive The quotation from Harrowsmith not alone, and realize that in the argot doses of pyridoxine. that "mixing French and English in of rigid-minded colleagues "such We know that pyruvic acid is the one volume . . . would be intolerably therapy is the hallmark of charlatans most toxic of all metabolites, and is re- maddening to readers in both lan- and quacks". sponsible for cardiomyopathies, hepa- guages" implies that there are only Physicians who denounce the use of tocellular damage, cerebral cortical unilingual citizens in Canada, whether large doses of injectable water-soluble and peripheral nerve lesions. Diabe- anglophone or francophone. vitamins are merely expressing their tics, food faddists and alcoholics couldl Since there is no French publication blind, fanatic commitment to the phar- be spared a great deal of damage if we of family medicine, I would be greatly maceutical industry. They have not gave injections of thiamine instead of disappointed should you alter your concerned themselves with findings of Valium! The fact that thiamine detox- present enlightened policy which rec- independent research workers whose ifiLes pyruvate is not. new informsation. ognizes that through various combina-

1432 CAN. FAM. PHYSICIAN Vol. 25: DECEMBER 1979 tions of opportunity, motivation and determination, some of us have be- come bilingual. J'en profite pour vous feliciter sur le Mbtrin fond et la forme des articles publies (ibuprofen) mensuellement. Bravo egalement 'a Action: Ibuprofen has demonstrated anti-inflammatory, and vomiting, indigestion, constipation, abdominal analgesic and antipyretic activity in animal studies cramps or pain, fullness of the gastrointestinal tract l'artiste Bill Woods, pour avoir si joli- designed to specifically demonstrate these effects. (bloating or flatulence) ment rafraichi Ibuprofen has no demonstrable glucocorticoid effect. Incidence less than 1%: gastric or duodenal ulcer with le visage de la revue. Ibuprofen has been found to be less likely to cause bleeding and/or perforation, gastrointestinal By the way, I am not a displaced or gastro-intestinal bleeding in doses usually used than is hemorrhage, melena, hepatitis, jaundice, abnormal liver acetylsalicylic acid. function (SGOT, serum bilirubin and alkaline misplaced "Quebecker", but an Clinical trials in man have shown activity of a dose of phosphatase). Alberta-born Canadian. 1200-1800 mg of ibuprofen daily to be similar to that of Central Nervous System: Jean-Paul Bugeaud 3.6 grams of acetylsalicylic acid daily. Incidence 3 to 9%: dizziness Indications and Clinical Uses: Ibuprofen is indicated for Incidence 1 to 3%: headache, nervousness Bonnyville, AB. the treatment of rheumatoid arthritis and osteoarthritis. Incidence less than 1%: depression, insomnia Causal relationship unknown: paresthesias, hallucina- Contraindications: Ibuprofen should not be used in tions, dream abnormalities. patients who have previously exhibited hypersensitivity I note with keen interest the letter of to it, or in individuals with the syndrome of nasal polyps, Dermatologic: Dr. Dawes, in which he confesses his angioedema and bronchospastic reactivity to acetyl- Incidence 3 to 9%: rash (including maculopapular type) salicylic acid or other nonsteroidal anti-inflammatory Incidence 1 to 3%: pruritis ignorance of the French language, re- agents. (see WARNINGS). Incidence less than 1%: vesiculobullous eruptions, Ibuprofen should not be used during pregnancy, in urticaria, erythema multiforme veals his willingness to speak for "the nursing mothers or in pediatric patients because its Causal relationship unknown: alopecia, Stevens- anglophone" and assumes that "a safety under these conditions has not been established. Johnson syndrome. Warnings: Anaphylactoid reactions have occurred in Special Senses: francophone who reads no English" patients with known A.S.A. hypersensitivity (see Incidence 1 to 3%: tinnitus will blithely continue forever to read CONTRAINDICATIONS). Incidence less than 1%: amblyopia (blurred and/or Peptic ulceration and gastrointestinal bleeding, some- diminished vision, scotomata and/or changes in colour no English! times severe, have been reported in patients receiving vision). Any patient with eye complaints during ibuprofen. Peptic ulceration, perforation, or severe ibuprofen therapy should have an ophthalmological Are options really limited to "one gastrointestinal bleeding can have a fatal outcome, and examination (see PRECAUTIONS). in althougb few such reports have been received with Causal relationship unknown: conjunctivitis, diplopia, or two articles French" or no ibuprofen, a cause and effect relationship has not been optic neuritis. French at all? If the present policy is established. Ibuprofen should be given under close supervision to patients with a history of upper gastro- Metabolic: intestinal tract disease. Incidence 1 to 3%: decreased appetite, edema, fluid "tokenism" why not advocate in- retention. Fluid retention generally responds promptly to creased French content? Perhaps that Precautions: Blurred and/or diminished vision, scoto- drug discontinuation (see PRECAUTIONS). mata, and/or changes in colour vision have been reported. would provide an adequate stimulus If a patient develops such complaints while receiving Hematologic: ibuprofen, the drug should be discontinued and the Incidence less than 1%: leukopenia and decreases in for learning French-and broadening patient should have an ophthalmologic examination. hemoglobin and hematocrit Fluid retention and edema have been reported in Causal relationship unknown: hemolytic anemia, throm- horizons. association with ibuprofen, therefore, the drug should be bocytopenia, granulocytopenia, bleeding episodes (e.g. Morris H. Schwartz used with caution in patients with a history of cardiac purpura, epistaxis, hematuria, menorrhagia). Montreal, PQ. decompensation or renal disease. Cardiovascular: Ibuprofen, like other nonsteroidal anti-inflammatory Incidence less than 1%: congestive heart failure in agents, can inhibit platelet aggregation but the effect is patients with marginal cardiac function, elevated blood quantitatively less and of shorter duration than that seen pressure J'ai apprecie votre note signee Ed, qui with acetylsalicylic acid. Ibuprofen has been shown to Causal relationship unknown: arrhythmias (sinus tachy- adoucit mon ecoeurement suscite par prolong bleeding time (but within the normal range) in cardia, sinus bradycardia, palpitations). normal subjects. Because this prolonged bleeding effect Allergic: la lecture de la lettre du Dr. Dawes de- may be exaggerated in patients with underlying hemo- Incidence less than 1%: anaphylaxis (see CONTRA- static defects, ibuprofen should be used with caution in INDICATIONS). mandant qu'aucun article franqais persons with intrinsic coagulation defects and those on Causal relationship unknown: fever, serum sickness, vous anticoagulant therapy. lupus erythematosus syndrome. n'apparaisse dans votre revue. Je Patients on ibuprofen should be cautioned to report to felicite de la parution d'articles fort their physicians signs or symptoms of gastrointestinal Endocrine: ulceration or bleeding, blurred vision or other eye Causal relationship unknown: gynecomastia, hypo- interessants publies en langue symptoms, skin rash, weight gain, or edema. glycemic reaction. When ibuprofen is added to the treatment program of Renal: franqaise et en langue anglaise: cela patients who have been on prolonged corticosteroid Causal relationship unknown: decreased creatinine montre que cette revue tient compte therapy, and it is decided to discontinue this therapy, the clearance, polyuria, azotemia. corticosteroid should be tapered slowly to avoid Symptoms and Treatment of Overdosage: A nineteen d'un public potentiel d'environ 12,000 exacerbation of disease or adrenal insufficiency. month old child weighing 12 kg ingested from 2800 to Aseptic meningitis has been reported in connection with 4000 mg and presented with apnea, cyanosis and medecins canadiens qui parlent, tra- ibuprofen therapy in patients with systemic lupus responded only to painful stimuli. Oxygen and paren- erythematosus. Such patients may also develop hyper- teral fluids were given and at 12 hours she appeared vaillent et aiment lire en franqais et sensitivity reactions to ibuprofen such as fever, rash or completely recovered. Two other children (10 kg each) n'ont pas l'esprit borne tel qu'illustre abnormal liver function more often than those with other ingested 1200 mg of ibuprofen each and there were no disorders. Caution should therefore be exercised when signs of acute intoxication or late sequelae. A 19 year old par la lettre du Dr. Dawes car la plu- considering ibuprofen therapy for patients with male who had ingested 8000 mg of ibuprofen reported systemic lupus erythematosus. dizziness, and nystagmus was noted. He recovered with part comprennent les deux langues. no reported sequelae after parenteral hydration and Drug Interactions three days' bed rest. Permettez de poser l'hypothese sui- Coumarin-type anticoagulants: Several short-term con- In cases of acute overdosage, the stomach should be vante: au Canada, les citoyens les plus trolled studies failed to show that ibuprofen significantly emptied by vomiting or lavage, though little drug will affected prothrombin times or a variety of other clotting likely be recovered if more than an hour has elapsed separatistes ne se trouvent-ils pas en factors when administered to individuals on coumarin- since ingestion. Because the drug is acidic and is type anticoagulants. However, because bleeding has excreted in the urine, it is theoretically beneficial to dehors de la communaute franco- been reported when ibuprofen and other nonsteroidal administer alkali and induce diuresis. anti-inflammatory agents have been administered to phone? patients on coumarin-type anticoagulants, the physician Dosage and Administration: The initial daily dosage in should be cautious when administering ibuprofen to adults is 1200 mg divided into 3 or 4 equal doses. Claire Laberge Nadeau patients on anticoagulants. Depending on the therapeutic response, the dose may Montreal, PQ. be adjusted downward or upward. The daily dosage A.S.A.: Animal studies show that A.S.A. given with non- should not exceed 2400 mg. steroidal anti-inflammatory agents including ibuprofen Maintenance therapy, once maximum response is yields a net decrease in anti-inflammatory activity with will range from 800 to 1200 mg per day. In response to Dr. Dawes' letter, I lowered blood levels of the non-A.S.A. drug. Single dose obtained, bioavailability studies in normal volunteers have failed Children: Due to the lack of clinical experience, ibu- would like to support your policy of to show an effect of A.S.A. on ibuprofen blood levels. profen is not indicated for use in children under 12 years publishing French articles in our jour- Correlative clinical studies have not been done. of age. Adverse Reactions: The following adverse reactions Supplied: 200 mg yellow coated tablets, 300 mg white nal. This is not only a question of my have been noted in patients treated with ibuprofen: coated tablets, and 400 mg orange coated tablets in "langue maternelle", or my Cana- Note: Reactions listed below under Caus ,l Relationship bottles of 100 and 1000. Unknown are those which occurred under circum- Product monograph available on request. dian-unity political views but also a stances where a causal relationship could not be established. However, in these rarely reported events, matter of basic Canadian language the possibility of a relationship to ibuprofen cannot be rights. excluded. 7811 REGISTERED TRADEMARK: MOTRIN CE 1030.2 [ " Gastrointestina/:The adverse reactions most frequently As to your comments following the seen with ibuprofen therapy involve the gastrointestinal system. letter, I would point out that it may be Incidence 3 to 9%: nausea, epigastric pain, heartburn THE UPJOHN COMPANY OF CANADA easier for us to learn English as a se- Incidence ito30/0: diarrhea, abdominal distress, nausea 865 YORK MILLS ROAD / DON MILLS, ONTARIO CAN. FAM. PHYSICIAN Vol. 25: DECEMBER 1979 1433