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Dr. Schlesselman is an assistant clinical professor at the University of Connecticut (UConn) School of Pharmacy. Ms. Grgas is a PharmD candidate at the UConn School of Pharmacy
While working in the ambulatory care clinic, PJ, a pharmacy student completing an experiential rotation, is handed a patient chart by the attending physician. The physician asks PJ to review the chart and make a recommendation to him on how to treat the patient.
As PJ reviews the chart, he sees that the patient, a 40-year-old woman, has a history of perennial rhinitis symptoms with paroxysmal episodes, including sneezing, watery rhinorrhea, and nasal pruritus. The onset of these symptoms did not occur until after age 35. The patient reports increased symptoms following exposure to strong odors, temperature changes, and smoke. The patient also experiences a loss of the sense of smell. According to the laboratory work, the patient lacks a clinically significant positive skin test or serum immunoglobulin E antibodies to a specific allergen. The patient has previously used antihistamines with poor response.
At the end of the visit note, PJ sees that the physician scribbled a note that he diagnosed the patient as having rhinitis, but he is unable to read the word before ?rhinitis.? He cannot determine if it says ?allergic? or ?nonallergic.?
From the description of the symptoms, is the patient more likely to have allergic or nonallergic rhinitis?
RH, a 32-year-old woman, calls her local pharmacy?s automated system to refill her Risperdal Consta. Before refilling the prescription, the pharmacist checks RH?s profile. The pharmacist notices that RH has not filled this prescription in over 2 months. Luckily, the pharmacist is precepting a 6th-year pharmacy student on rotation. She asks the student to call RH and ask her how often she is using her Risperdal Consta.
After speaking with the patient, the student informs the pharmacist that RH stopped taking the medication more than 2 months ago, as the profile shows. RH told the student that she "was feeling better; the voices went away" and that she was feeling "normal" again. RH informed the student that she was requesting a refill because she is not "feeling right," and she is ?seeing people in the room even though they are not really there.?
Having heard this information from the student, the pharmacist decides that it is best to not fill the medication until she speaks with the physician who prescribed the medication. The student is confused by this decision, since RH is obviously in need of therapy.
Even though RH is having symptoms, what is the pharmacist?s rationale for not filling the medication and calling the physician instead?
The symptoms described in the patient?s chart are consistent with nonallergic rhinitis. Nonallergic rhinitis often has an onset after age 35 with persistent symptoms and exacerbations during winter months. Patients with nonallergic rhinitis exhibit a hyperreactivity to nonspecific stimuli, including odors, temperature change, smoke, or spicy foods. In these patients, response to antihistamines is poor. In contrast, allergic rhinitis usually has childhood onset with a family history of allergic rhinitis, eczema, or atopy. Allergic rhinitis typically has seasonal exacerbations to indoor or outdoor allergens and will respond well to antihistamine therapy.
Risperdal Consta contains extended-release microspheres, providing effects that last 4 to 6 weeks. Due to a delayed onset of activity (3 weeks), oral antipsychotic therapy is necessary to provide therapeutic levels of antipsychotic therapy and control symptoms during that time. Because RH is already experiencing symptoms, she needs oral antipsychotic therapy to control her symptoms until a dose of Risperdal Consta takes effect.