caseSTUDIES

CASEONE: EN, a 45-year-old man with along history of depression, presentsto XYZ Pharmacy on aSunday afternoon. Although heis well-known by the pharmacistwho regularly works at thepharmacy, the pharmacist andthe technician working thisweekend do not recognize him.

EN places a bottle of St. John's wort on the counter. Heexplains to the technician that he has heard from friends thatthis product will help "lift his spirits." He asks the technician ifthis is true. Noticing that the pharmacist is busy helping anotherpatient in the cough-and-cold aisle, the technician explainsthat she is not the pharmacist, but if he would like to wait amoment, the pharmacist will be right back. The technician continuesto say that her mother uses St. John's wort and that "sheswears by it and says she would not be able to get through theday without it." EN decides that the technician's statement isenough to convince him, so he purchases the bottle.

Two days later, EN returns to the pharmacy to purchase anOTC sleep aid. When he approaches the counter, the pharmacist,recognizing EN and assuming he is there to pick uphis prescription, grabs the prescription bag. The prescriptionis for venlafaxine XR. EN quickly explains that he will notneed the prescription because he has decided to stop taking"those chemicals," and he has switched himself to a "natural,safe product." He says that he only came to purchasesomething to help him sleep better because he is having"crazy dreams."

Upon further discussion, the pharmacist learns that EN'sdoctor is unaware of this medication change. The pharmacistalso learns that, along with vivid dreams, EN is experiencingdysphoria and paresthesias. EN believes these problems aredue to stress in his life.

Should the pharmacist be convinced that the dreams,dysphoria, and paresthesias are due to stress? Or arethey due to some other factor, such as the suddendiscontinuation of venlafaxine or the recent initiation ofSt. John's wort?

CASE TWO: KW, a 28-year-old womanwho works as a horticulturistin southern New England,presents to the walk-in cliniccomplaining of joint pain, muscleaches, low-grade fever,stiff neck, fatigue, and feelingas though she has the "flu,"even though it is the middle of the summer. Although she is5 months pregnant, KW says that she cannot imagine thatthese symptoms are due to her pregnancy since she neverhad problems with her first pregnancy. While KW is explainingher symptoms, the medical resident notices that she hasa large red circular area on her left leg.

After a complete examination and blood work, the medicalresident diagnoses KW with Lyme disease. He wants to starther on an antibiotic but has a limited supply in his medicinecabinet. Unfortunately, the only pharmacy in town is closedfor the evening, so the medical resident calls a friend who isa pharmacist. He asks him which of the antibiotics in his medicinecabinet would be safe for a pregnant woman but effectivefor treating early, uncomplicated Lyme disease. Heexplains to his friend that he has the following antibiotics:

• 40 doxycycline tablets, 100 mg
• 90 amoxicillin capsules, 500 mg
• 60 sulfamethoxazole/trimethoprim tablets, single-strength

Which antibiotic, at what dose, and for how long, should thepharmacist suggest?

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.

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CASE ONE: Rapid discontinuation of venlafaxine, a serotonergic and norepinephrine reuptake inhibitor, is associated with vividdreams, dysphoria, and paresthesias. Its short half-life makes the timeline appropriate. Although stress and St. John's wort can induce adverse effects, thetimeline and symptoms are more likely with venlafaxine withdrawal than these factors.

CASETWO: The pharmacist should recommend amoxicillin 500-mg capsules, the drug of choice in women who are pregnant or breastfeeding. The recommendeddosage is 500 mg 3 times daily for 20 to 30 days. For patients who are not pregnant or breastfeeding, doxycycline 100 mg twice daily for 20to 30 days would be an option.

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