OCTOBER 01, 2005
Lauren S. Schlesselman, PharmD

CASE ONE: BT, a 65-year-old woman, is brought by her daughter for an appointment with her primary care physician. The daughter informs the physician that the mother has been confused, disoriented, and exhibiting memory loss.

Although BT has a history of Alzheimer's-type dementia, she had been stable on rivastigmine until a few months ago.

The physician explains to BT and her daughter that they should not be surprised by declines in BT's condition over time. To be sure that the change in BT's condition is not due to a precipitating reason, the physician gives her a full examination and reviews all of her medications. When the physician looks at all of the prescription bottles that BT's daughter has brought with her, he notices that there is no bottle of rivastigmine. He asks if she has forgotten another bottle. She confirms that she has brought all of the bottles.

The physician is concerned that BT has not been taking the rivastigmine. He calls the pharmacy to determine the refill history of BT's rivastigmine prescription. He learns that she has not filled it in 4 months.

He wants to restart her on rivastigmine. He tells the pharmacist to refill the rivastigmine and that the daughter will be picking it shortly. Before hanging up, he remembers that he had originally titrated BT's dose. Does he need to initiate her at a low dose again and titrate up?

CASE TWO: SA, a pharmacy student in his final year of school, is spending a month at PRN Pharmacy for his community experience rotation. Although PRN Pharmacy also dispenses manufactured medications, it is known for its compounded products. Because this is SA's first day, he is a little nervous about compounding medications for patients. The pharmacy manager reassures him that all of his work will be double-checked by one of the pharmacists. For whatever work SA does, he should write down all of his calculations to assist in the double-checking process.

After SA compounds a liquid required to fill a prescription, he brings all of the ingredients to the pharmacist for verification. He explains that he made 500 mL of the solution because the pharmacy received 2 prescriptions for the same medication for twin sisters. Each twin needs to receive 250 mL. According to SA's calculations, he mixed 62.5 g of medication into the liquid base.

According to the label and the hard copy of the prescription, the twins require a 1.25% solution of the medication. Is the product formulated by SA appropriate?

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

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CASE ONE: The physician should restart BT's rivastigmine at the lowest daily dose and titrate it. Despite having been on rivastigmine previously, BT has been off the drug for a few months, and therefore she needs to have the medicine titrated again. Four-week titration intervals are recommended between dose increases. Higher doses are associated with increased incidence of side effects, particularly during dose titration. If side effects occur during titration, dose reductions are recommended.

CASE TWO: The preparation made by SA actually is a 12.5% solution. The concentration of weight/volume dilutions are based on grams per each 100 mL. Because the twins need a 1.25% solution, it should contain 1.25 g for each 100 mL. For 500 mL, he should have added 6.25 g, rather than 62.5 g.