OCTOBER 01, 2004
Lauren S. Schlesselman, PharmD

Case ONE: When the patient brought this prescription into the pharmacy, Don Lavasseur, RPh, of Publix Pharmacy in Jupiter, Fla, studied it for a few minutes. Unable to understand the prescription order, Lavasseur asked the patient if she knew what medication the physician was giving her. The patient gave Lavasseur the name of the drug. Can you figure out this prescription? RM, a 35-year-old mother of 2 children, presents to her local pharmacy with a prescription for propranolol 20 mg 4 times daily. She immediately asks to speak with the pharmacist, before having the prescription filled. She expresses concern that the physician must have given her the wrong prescription. She explains that she has read about propranolol because her husband takes it for migraines, although she knows it is usually prescribed for high blood pressure. RM did not go to the physician for high blood pressure, or even migraines, so she does not understand why she would be taking this medication.

When the pharmacist asks RM why she went to the doctor and what he told her, RM says she remembers him explaining that something was wrong with her thyroid. She admits that she does not remember much of what the doctor said.

Because RM's diagnosis is unclear, the pharmacist asks RM to describe the symptoms she has been experiencing. RM explains that she has been fatigued and unable to lift her children for the past few months. She also has noticed that she often feels short of breath and nervous. She even notices that her hands shake. RM has been concerned that she might be approaching menopause since she sweats a lot, is intolerant to heat, and has intermittent rapid heartbeats, but she does not think that it is likely since she just had a baby 6 months ago. Although she is happy to lose extra pounds after pregnancy, she also thinks that she is losing weight too fast.

From RM's symptoms and her statement about her thyroid, the pharmacist suspects that RM has postpartum thyroid dysfunction. The pharmacist explains that postpartum thyroid dysfunction is a transient hyperthyroidism, lasting 1 to 4 months, and occurring in the first 8 months postpartum. He assures RM that propranolol is sometimes used in patients with hyperthyroidism.

RM does not understand how a blood pressure medication will cure her hyperthyroidism. What should the pharmacist tell RM about the use of propranolol in hyperthyroidism?

Case TWO: While en route to a nearby pharmaceutical company, a tractor-trailer truck carrying potassium cyanide crashes into a bridge. The driver opens the trailer to inspect the cargo. Unfortunately, one of the boxes has been severely crushed, breaking the bottles inside.

When the police and paramedics arrive at the scene, the driver complains of shortness of breath, rapid heartbeats, and confusion. As the paramedic examines the driver, he notices that the driver's mental status is rapidly becoming depressed.

The paramedic rushes the driver to the local hospital. On the way to the hospital, the paramedic contacts the Emergency Department (ED). He gives a list of medications that will be needed to treat the driver to the ED staff.

Unfortunately, no one writes down the list of necessary medications. When an ED staff member calls the pharmacy to have the medications delivered, the staff member simply tells the pharmacist to bring whatever is needed to treat cyanide poisoning.

What medications should the pharmacist bring to the ED?

Dr. Schlesselman is a clinical pharmacist based in Niantic, Conn.

Click Here For The Answer -----------> [-]

CASE 1: The pharmacist should explain to RM that propranolol will not "cure" her hyperthyroidism, but rather it will control the symptoms while inflammation of the thyroid resolves. Betablockers will blunt some of the somatic symptoms, such as palpitations, tremor, and anxiety, thus providing symptomatic relief.

CASE 2: The focus of treating cyanide poisoning is the conversion of hemoglobin to methemoglobin, binding the cyanide ion. The pharmacist should bring amyl nitrite, sodium nitrite, and sodium thiosulfate. The amyl nitrite and sodium nitrite are necessary to increase methemoglobin levels, whereas the sodium thiosulfate converts the cyanide to thiocyanate, which can be excreted in the urine.