No abstract

Luteinising hormone releasing hormone (LHRH) analogues are routinely used in the treatment of patients with advanced prostate cancer. This randomised crossover trial was conducted to compare patient comfort and tolerability between two commonly used LHRH analogues: goserelin acetate and leuprorelin acetate. A total of 50 patients were randomised into two groups, each receiving 6-monthly injections of leuprorelin acetate (a liquid presentation) and goserelin acetate (a depot pellet) and crossing over between treatments. Patients completed a simple visual analogue score for the discomfort felt from the injections. An analysis of variance model was used, and the results found that patients do tolerate leuprorelin acetate (0.589) better than goserelin acetate (1.343) (Po0.001, CI ¼ 95%).

Sir, Amlodipine as a cause of mucous membrane pemphigoid: first report of amlodipine as a causative agent in MMP Cicatricial Pemphigoid is an autoimmune sub-epithelial blistering disease, which affects skin and mucous membranes. It is characterised by depositions of IgG and C3 at the lamina lucida of epithelial basement membrane. 1 Several medications, including topical glaucoma medications, are implicated in the aetiology of pseudo-pemphigoid, in which ocular manifestations are similar but histology not diagnostic. 2 Lisinopril, atenolol, and spironolactone have been implicated in causing drug reactions mimicking mucous membrane pemphigoid. 3 Amlodipine, used for the treatment of hypertension, has been known to cause linear IgA dermatosis 4 as well as bullous pemphigoid, 5 but has not been previously linked to ocular pseudo-pemphigoid. Case reportWe present the case of a 78-year-old Caucasian gentleman referred with suspected mucous membrane pemphigoid. He was on topical tafluprost to both eyes as treatment for low pressure glaucoma. Systemic medications consisted of amlodipine, atenolol, and simvastatin. Clinical features included shortening of the lower fornices of both eyes and marked symblepharon. Immunofluorecence studies of the conjunctival biopsy showed scattered intercellular IgG positivity alone in the epithelium, suggestive of either paraneoplastic or drug-induced pemphigus. Biopsies from inflammed skin plaques and normal-looking adjacent skin revealed weakly positive linear IgA and IgG deposition and granular arrangement of C3 at the basement membrane. The skin histology was thought to be consistent with Lupus, drug-related disease, or possible eczema. The patient was started on topical and a tapering course of systemic steroids. Examination and investigation excluded occult malignancy. As the clinical picture was one of mucus membrane pemphigoid, a review of treatment was undertaken. Amlodipine was stopped, as this was the most recently started antihypertensive and closest temporally to the start of symptoms. Alternative treatment for hypertension has been instituted. Within 6 months of stopping Amlodipine and after 18 months of progressive deterioration, the eyes settled with no sign of activity or progression. The patient is now off all ocular treatment apart from tafluprost for glaucoma. CommentPseudo-pemphigoid associated with topical glaucoma medications is not associated with skin lesions, making tafluprost an unlikely candidate. Oral medications for hypertension and angina are rarely associated with ulcerative disease. However, it is important to bear the association in mind when faced with such a patient. The disease process may arrest on withdrawal of precipitating medication but this is not always the case. This case highlights the importance of enquiring about systemic medication and reporting these rare associations. Conflict of interestThe authors declare no conflict of interest. References1 Helander SD, Rogers RS. The sensitivity and specificity of direct immunofluorescence testing in ...