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Frenetic Pharmaceuticals.

"Good morning, Dr Fine. Would you like some Psychocort playing cards?"

I turned around. I couldn't help myself. I had been on my way to secure a seat in the cafeteria after a particularly grueling call night, one in which refractory hypotension seemed to be as contagious as the common cold. Perhaps my dilapidated condition left me unable to resist the bait.

Dave, a pharmaceutical representative who looked suspiciously like Bob Costas, felt the tug on his opening line and began to reel me in. "Psychocort," he explained expansively, "is a true breakthrough, a combination of prednisone and Haldol for patients who experience unwanted and embarrassing psychotic effects from prednisone therapy." I glanced down at the slogan that decorated the cards: Play the prednisone game with a full deck.

"That's certainly a unique blend of medications," I admitted. "And I've never seen a deck of cards in which the Queen and King were quite so cushingoid."

"Well, we here at Frenetic Pharmaceuticals believe strongly in offering our clients convenient products that combine two or more medications. Our company motto is Compliance instead of complaints."

I must have looked dubious, because he continued as if answering an unspoken objection. "Conclusive studies have demonstrated the efficacy of such combinations. For example, let me give you this monograph on our Panaceabid formulation. Panaceabid is a combination of ciprofloxacin, trimethoprim-sulfamethoxazole, and doxycycline--definitive twice-a-dah therapy for patients whose doctors are concerned about infection but cannot find a source. As you can see here, 88% of the doctors prescribing Panaceabid in this series reported 'significant relief' of their anxiety. The P value was less than .01."

"But what about the patients? Did they--"

"Here, doctor, have a doughunt. The cinnamon glaze is conveniently combined with a tart lemon filling. You know, we're very excited about another new product, Impactocard. It intermingles quinidine and Imodium for patients who find that the retention of normal sinus rhythm is not sufficiently rewarding to offset the frequent visits to the restroom. I was just chatting with Dr Intimidating Expertise of your cardiology division, and he thinks Impactocard will be of great value."

"What does it cost?"

"Let me pour you a cup of coffee, doctor. No, you don't need to add cream. We mix it in as part of the recipe. Over here, we have samples of Omnipatch, which contains transdermal preparations of estrogen, clonidine, nitroglycerine, nicotine, and scopolamine. It is the only patch approved by the FDA for postmenopausal women with hypertension and angina who plan to quit smoking while on a cruise."

"I really have to go now," I said quickly. "I think I feel my pager vibrating."

"Sure, doctor. Thanks for your time. Let me quickly remind you that Prilopril, a combination of captopril, enalapril, lisinopril and quinapril, is now on formulary here and is indicated especially for hypertensive patients whose doctors can't decide which advertisements to believe. We also throw in some dextromethorphan for cough suppression."

What could one say in response? I started to suggest that his company promote Prilopril by distributing decks of playing cards from which all of the aces had been removed, but Dave appeared so earnest that I changed my mind. Instead, I mumbled some thanks for the doughnut and coffee, slumped into a chair, and proceeded to enjoy a delicious combination of breakfast and slumber.

The next day was Saturday, and I was able to get my work done expeditiously and slip out of the hospital in time to do some shopping at the local Discount Drugstore. I was looking, in particular, for a container of detergent sufficiently large to conquer the 10 loads of laundry that had accumulated during my foray into intensive care.

"Hello, Dr Fine. How nice to see you." It was Dave. He had exchanged his three-piece suit for the full regalia of a Discount Drugstore employee, including a badge that read I'm Dave. Ask me about our contraceptives. With an abrupt motion he grabbed my hand and forced a can of soup into it. "Did you know that Frenetic Pharmaceuticals is a leader in the pharmacologic supplementation of common household products? We're working very closely with a number of retail stores," he bragged. "That, for example, is a can of our innovative Chicken Noodle 'n' Lasix Soup, a tasty treat for patients with severe congestive heart failure who would like to enjoy a hot bowl of soup without committing themselves to a weeklong stay in intensive care. There's also a chunky variety, with K-Dur tablets."

Dave led me a little farther down the aisle and gave me what appeared to be a candy bar. "Over here," he continued, "let me show you Hershey's Euglycemia Bar, made with creamy milk chocolate, nougat, caramel, and delicious morsels of glyburide. For only $5, patients with type II diabetes can relish a tasty chocolate treat and still control their glucose levels. In fact, our study showed that an incredible 50% of the patients in a group consuming two Euglycemia Bars each day fell below the group's median level of glycosylated hemoglobin."

"But 50% always fall below any median, by defin--"

"And the packaging is so convenient! See how the paper wrapper can be detached and used as a urinary glucose test strip?"

There was clearly no point in debating a man who responded to a statistical challenge by advocating the desecration of candy wrappers, so I murmured something vaguely congratulatory and attempted to escape into the personal hygiene area. Unfortunately, Dave loped after me, and I noticed that his speech was beginning to sound pressured. "We have several products in this section that are doing extraordinarily well. First, there's Amoxifloss, a dental floss with an amoxicillin coating, for patients with rheumatic heart disease. It allows them to care adequately for their teeth and gums without having to worry about endocarditis. And speaking of dental hygiene, we also have a toothpaste that is really--"

"I know, I know," I interjected. "It has fluoride in it. They all do."

"Sure it has fluoride," he snapped impatiently. "But it also has a potent sublingual nitroglycerine formulation, for patients with severe coronary artery disease. When angina demands urgent medical attention, Nitrodent relieves the chest pain and keeps your breath fresh and minty for the trip to the emergency room. Wouldn't you say that it fights plaque in a much more effective manner than other toothpastes?" Before I could answer, he emitted a nervous giggle and began to hop up and down in an agitated manner, glancing repeatedly at my receding hairline. "You should also be interested in our latest product for the, uh, uh, follicularly challenged," he prattled. "It's a hair-styling gel with minoxidil called 'Groom & Grow.' Not only will your hair still look great at the end of a busy day, but there will be more of it!"

Dave's eyes were becoming glazed, and I detected a slight intention tremor. In desperation, I grabbed the largest container of laundry detergent I could find and made a run for the checkout aisle. Dave seemed confused and upset. "On your way out," he yelled after me, "be sure to notice the E-Z Breathe Cigarettes behind the counter. They have special heat-labile formulations of Proventil and Vanceril for patients with COPD who can't stop smoking long enough to use their inhalers."

Don't look back, I thought to myself. Just get out as quickly as possible and never go near the hospital cafeteria again. I had paid for my detergent and was just putting my wallet back into my pocket when a small projectile hit me squarely on the back of the head. "That's a package of Addictochew," Dave called out as he ducked behind the deodorant display, "a snappy spearmint gum supplemented with Antabuse, nicotine, and methadone. It's ideal for the man who used to have everything!"

Dave was clearly out of control and he knew it. After he managed to calm himself, he jogged up to the checkout counter to apologize. "I'm very sorry, doctor, but sometimes my manic disorder gets the better of me when I have forgotten to take my Litho-cells." He was just reaching over the counter for a package of lithium batteries when I hurried out of the store.

Submitted January 19, 1994.

From the Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor. Requests for reprints should be addressed to Paul L. Fine, MD, 42836 Saxony, Canton, MI 48187.
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Title Annotation:combination drug therapy gone awry
Author:Fine, Paul L.
Publication:Journal of Family Practice
Date:Jun 1, 1994
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