Craig I. Coleman, PharmD, and Andrew A. Perugini, PharmD Candidate
Case One
CB is a 35-year-old man who comes to your pharmacy with a question concerning his migraine treatment. He states he experiences migraine headaches and has been treating them with sumatriptan 100 mg at the onset of migraine. In the past month he experienced 4 migraines, and the sumatriptan was not completely effective in treating the attack. He tells you that the last migraine he experienced was extremely painful and he had to call out of work. He is curious if there are any preventive treatment options that he can try. You notice in his profile that CB has hypertension but is not currently being treated for it.
As his pharmacist, what advice would you give CB?
Case Two
CO, a 27-year-old woman and new mother, comes to your pharmacy appearing very nervous. Her son is currently 1 month old, and she tells you that she has an appointment with his pediatrician in a month to receive his scheduled vaccinations. CO states she is worried about her son receiving vaccinations. She has heard that vaccinations contain mercury, which has been linked to autism.
As her pharmacist, what advice should you give CO?
ANSWERS
Case 1: Migraine prophylaxis can be considered in patients who experience 3 or more severe migraine attacks without adequate response to therapy, or in patients whose migraine attacks impair their quality of life. Several classes of medications are used for preventive treatment, such as beta-blockers (ie, propranolol), calcium channel blockers (ie, verapamil), antidepressants (ie, amitriptyline), and anticonvulsants (ie, topiramate); however, not all have an FDA-approved indication for migraine prophylaxis. The pharmacist might suggest that CB discuss prophylactic medications with his prescriber. However, it should be made clear to CB that if he is prescribed a prophylactic medication, it may take up to 2 or 3 months before he sees some benefit. Goals of therapy would be to reduce the severity and frequency of migraine attacks, enhance the patient’s response to acute drugs, and - decrease emergency department visits. The specific medication chosen should be based on mul tiple factors, including side effect profile, comorbidities, and drug interactions. Because CB has untreated hypertension, he might benefit from a beta-blocker, as it would treat his condition in addition to preventing migraine attacks.
Case 2: Thimerosal is a mercury-containing organic compound that has been used as a preservative in many vaccines since the 1930s. Thimerosal is metabolized to ethylmercury and thiosalicylate. Ethylmercury should be distinguished from methylmercury, the organic form, which is sometimes consumed by humans by eating seafood. Methylmercury is thought to be more neurotoxic that ethylmercury. The pharmacist should reassure CO that the Institute of Medicine has concluded that there is no causal relationship between thimerosal-containing vaccines and autism. Further, it should be - explained to CO that many manufacturers have reduced or eliminated thimerosal from their vac cines at the urging of the FDA. Currently, there are numerous pediatric vaccines that have either no thimerosal (ie, hepatitis B vaccine Recombivax-HB) or contain only trace amounts (ie, seasonal trivalent influenza vaccine Fluvirin <1 mcg Hg/0.5-mL dose). Finally, the pharmacist should stress to CO that the benefits from vaccines are proven, and without them, her son will be at a higher risk of developing serious infections.
Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy. Mr. Perugini is a PharmD candidate from the University of Connecticut School of Pharmacy.
