Adverse Drug Reactions: The Great Masqueraders
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M)92-8615/98 Copyright 0 1998 Drug Infomation Association Inc.
ADVERSE DRUG REACTIONS: THE GREAT MASQUERADERS P.A. ROUTLEDGE AND M.
c. BIALAS
Department of Pharmacology, Therapeutics & Toxicology, University of Wales College of Medicine, Cardiff, South Glamorgan, United Kingdom
J. E. HOUGHTON Senior ADR Pharmacist
F. WOODS Principal Pharmacist Department of Pharmacy, University Hospital of Wales, Cardiff, South Glamorgan, United Kingdom
“It is the first quality of a criminal investigator that he should see through a disguise.” Hounds of the Baskervilles, Sir Arthur ConanDoyle
IN 1976, VERE FIRST described the propensity of drug adverse reactions to masquerade as natural illness (1). He gave five main reasons why so many adverse reactions escape unnoticed: 1. The reaction may be so odd or bizarre that
an often used and apparently innocent drug escapes suspicion, 2. The drug-induced disorder can closely mimic a common natural disease, 3. There is a long delay in the appearance of the adverse effect, 4. The drug evokes a relapse of natural disease or may evoke a disorder in a naturally susceptible subject, and 5 . The clinical situation may be so complex
that its drug-related components pass unnoticed. Twenty years later, iatrogenic disease still regularly goes unrecognized. Vere concluded his article by stating that although many new discoveries are made by national and international adverse reaction monitoring agencies, many of the important new observations are still made by individual doctors. The health professional today, faced with the same difficulties, could do well to emulate the great fictional detective Sherlock Holmes and use the same skills in pharmacovigilance as Holmes applied to criminology.
ADVERSE DRUG REACTIONS ARE WELL-DISGUISED “Accustomed as I was to my friend’s amazing powers in the use of disguises, I had to look three times before I was certain it was indeed Holmes.” Scandal in Bohemia, Sir Arthur Conan-Doyle
The body has only a limited number of responses to noxious stimuli, whether these be viruses, bacteria, or xenobiotics (including drugs)* It is, not surprising that the pathological changes caused by adverse reactions to some drugs may be indistin-
Presented at the DIA Workshop “ADE and Causality Assessment,” December 4-61995. New Orleans, Lotisiana. Reprint address: Professor P. A. Routledge, Department of Pharmacology, Therapeutics & Toxicology, University of Wales College of Medicine, Heath Park, Cardiff, South Glamorgan, CF4 4XN, United Kingdom.
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P. A. Routledge, M. C. Bialas, J. E. Houghton, and F. Woods
guishable from those from idiopathic disease or disease caused by other agents. Idiopathic interstitial cystitis is typically a disease of middle-aged women in which the bladder wall shows inflammatory infiltration, mucosal ulceration, and scarring, resulting ultimately in contraction of smooth muscle, diminished bladder capacity, and symptoms of frequency dysuria and haematuria. The aetiolo
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