Case 1:
AR presents new onset blurred vision, sleeplessness, poor coordination and slurred speech to the emergency room. The 20-year-old lives with her father, who told the health care team that she struggles with alcoholism and has previously taken hand sanitizer, mouthwash, and vanilla extract to her diet. He said he found an empty windshield wiper fluid in the ER room an hour after she felt unwell. Laboratory results for AR show metabolic acidosis, elevated anion and osmolality gap.
What is the best treatment option?
AR is showing signs and symptoms of poisoning. An empty bottle of windshield wiper fluid indicates that this is probably what she drank. This solution contains a large amount of methanol. Fomepizole and supportive measures such as intravenous (IV) fluids and antiemetics are used to treat methanol poisoning patients. Fomepizole inhibits the enzyme alcohol dehydrogenase, which converts alcohol into the highly toxic substance acetaldehyde. Without this enzyme, the parent compound remains in the blood and is eventually excreted in the urine. Since fomepizole has few side effects, its administration is usually less harmful. The loading dose of IV fomepizole is 15 mg/kg. This is followed by a dose of 10 mg/kg every 12 hours (for a total of 4 doses) and then a dose of 15 mg/kg every 12 hours until the methanol level is below 20 mg/dL and the patient is asymptomatic. And it has a normal pH.
Case 2:
Two weeks ago, the pharmacy dispensed a partial fill of oxycodone 5 mg every 12 hours as needed for AF for postoperative bariatric surgery pain. The 43-year-old man is still in pain, but the medicine is helping him, and he came to the pharmacy to refill his balance. The pharmacist noted that AF had difficulty passing stool and had experienced abdominal pain, cramping, and rectal bleeding for the past week. AF asks if he should take biscodyl or calcium polycarbophil. Reviewing the profile, the pharmacist will see that AFF carries amlodipine, lisinopril, and omeprazole, but no other OTC medications.
Should the pharmacist recommend an OTC medication for AF?
AF appears to be experiencing constipation secondary to oxycodone use. Opioids decrease gastric motility by decreasing intestinal tone and contractility. Although most constipation problems are easily treated with OTC medications, rectal bleeding indicates that AF should not be self-medicated. Intra-abdominal bleeding and/or postoperative complications should be ruled out prior to administration of OTC for management of constipation. The pharmacist should refer the AF to the primary care provider for further evaluation.
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