Pharmaceutical Postline

Pharmaceutical Postline

Salicylate Intoxication Dear Sir: Salicylate intoxication is the most common type of drug poisoning (Harrison's Principles of Internal Medicine, 7th ed., M.M. Wintrobe et al., Eds., McGraw-Hili, New York, NY, 1974, p. 660) and aspirin overdose is often considered in suicide attempts (JAMA, 213: 1186, 1970; Arch. Intern. Med., 119: 399, 1967; Glin. Pediat., 9: 658, 1970). Children may be intoxicated as the result of misdosing by a parent (Glin. Pediat., 9: 658, 1970; J. Pediat., 77: 156, 1970). Since aspirin can be very dangerous if misused, and since the drug is sold over-the-counter, the pharmacist can perform a valuable function by supplementing package label information with sound advice and also by referring patients, and parents of patients, for medical care when early signs of salicylate toxicity develop. Early signs of salicylate toxicity include1. Fever. Some patients have become febrile following salicylate ingestion (Glin. Pediat., 9: 658, 1970; unpublished case history, author). Attempting to reduce the fever, these patients have taken aspirin thereby contributing to the salicylate toxici-

ty. 2. Mild confusion which may be mistaken for malaise. 3. Nausea and vomiting more severe than that due to local gastrointestinal upset. 4. Hyperventilation, tinnitus, excessive . sweating. It is important to emphasize that salicy. late toxicity may frequently be the result of a cumulative overdose taken over a number of days rather than in one dose. Patients with a history of recent salicylate intake who exhibit any of the above signs should be referred to a physician or a hospital at once. In cases of large, single overdoses gas. tric lavage should be initiated with extreme caution because of the possibility of increasing absorption of salicylates from a large tablet/capsule mass. In such cases emesis induced with syrup of ipecae may be more appropriate than lavage if the patient is awake and alert to preclude aspiration of vomitus. Infants have been reported to aspirate children's aspirin tablets resulting in permanent brain damage and death (J. Pediat., 83: 266, 1973). Obviously, parents should be counseled to give liquid preparations to very young children. Knowing how unpredictable and deadly

salicylate toxicity can be even with intensive hospital care, I feel that pharmacists should help prevent salicylate toxicity by proper counseling and I hope this information will be of some value. Len A. Billingsley Detroit, Michigan Editors Note: Dr. Billingsley's comments underscore the need for effective patient counseling by pharmacists and other health care providers. We would therefore like to remind our readers of the "Statement on Prescription Writing and Prescription Labeling" developed by APhA and the American Society of Internal Medicine. The statement, published in the December 1974 issue of the Journal of the American Pharmaceutical Association, contains prescription writing and prescription labeling guidelines for prescribers and pharmacists. Implementation of these guidelines on a cooperative basis at the local level will help eliminate problems. such as the ones described by Dr. Billingsley. Back to Basics Dear Sir: I can remember when I was a boy going down to the corner pharmacy with mother on those infrequent occasions when a member of the family had to see a physician and was given a prescription order. "Doc" Reynolds would take the prescription order after a pleasant greeting and in fifteen or twenty minutes would emerge from his mysterious laboratory behind the swinging doors with our medication. "Be sure to take this after you eat; it might upset your stomach otherwise," he would say; or "Keep this away from the window sill; maybe in your medicine cabinet away from the sun and heat." There was always an admonition or comment that seemed to go with each prescription. "Doc" never seemed to be in a hurry and invited questions, even on over-the-counter remedies. Those were the "good old days." But with the helter-skelter pace of today and the increasing size and volume of the modern pharmacy, we seem to have lost that personal touch. The patient now sometimes never directly communicates with the pharmacist. A clerk takes the prescription order, hands it to the pharmacist or "technician" and after going through the assembly line the prescription medication goes back to a clerk who hands it to the patient. At least that was the way it was done in some pharmacies until a year or so

Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

ago. Isn't this short-changing the patient to say nothing of the profession of pharmacy? This transition came about because most pharmacists were dispensing far more prescriptions than 30 to 40 years ago. The pharmacist simply did not have the time, he thought, to chat with his patients. After all, the more prescriptions dispensed per day per pharmacist, the more money the pharmacy made. In September 1973, the pharmacy union in Seattle introduced a "Code of Ethics" as part of their proposed contract. One of the parts of this code required the pharmacist to personally hand the prescription medication to the patient with appropriate instructions and recommendations. There were objections from some employers that the union was interfering in the conduct of their practice, but the code was eventually adopted as part of the contract. Shortly thereafter it was found that some pharmacies were letting clerks hand out renewals since the word "prescription" in the code was being interpreted as referring only to new prescriptions. It was subsequently determined that all prescriptions were to be given to the patient by the pharmacist. The other day I was dispensing tetracycline on a renewal and reminded the patient about certain precautions. She thanked me for reminding her and said that she had remembered the "no dairy products" rule but had forgotten that she should take the capsules on an empty stomach. Even on such often renewed drugs as digitoxin it's a good idea to remind the patient to take the medication every day. On January 1, 1974, the state board regulation became effective requiring the pharmacist to give certain patient information, but only on new prescriptions. Most of us thought it should also cover renewals. In our pharmacy world of today, with fewer pharmacies dispensing more and more prescriptions, it is certainly more economically productive for the pharmacist to hand over the prescription medication to a clerk and go quickly on to the next waiting prescription order or answer the constantly ringing telephone. But today's pharmacist must take the time to go over each prescription with the patient. It is indeed unfortunate that we must be told by rules and regulations to do what clearly is an essential part of our responsibility. Even more important, the welfare of the patient is at stake and after all, isn't that what pharmacy is all about ... to dispense the right medication to the right patient with the

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Pharmaceutical Postline

More than anointment

proper instructions so that the end result will be the improvement and well-being of the patient? For many years some of us have been neglecting this part of our profession, much to the detriment of our patients' health, to say nothing of the down-grading . of the profession of pharmacy. It's to our mutual benefit-the profession and the general public-to bring back to pharmacy this very essential part of the "good old days." Let's get back to basics! Phillip E. Siedler Seattle, Washington

Drug Selection Correction Dear Sir: In John C. Otchy's May 1975 article entitled "Development and Use of an Emergency Kit for the Hospital," an addition or substitution should be made in the drug selection. The use of Neostigmine methylsulfate (# t7) for atropine poisoning will be ineffective. Since neostigmine methylsulfate is a quaternary compound it does not cross the blood brain barrier and will not reverse central anticholinergic symptoms. Physostigmine salicylate, a tertiary anticholinesterase, does penetrate the blood brain barrier and is effective for anticholinergic intoxication. Physostigmine salicylate is available in 2ml ampules in a concentration of 1mg/ml. (Facts and Comparisons.) A 2mg challenge dose of physostigmine in adults administered intravenously over two minutes is effective for atropine poisoning. (Rumal, et al., Poislndex, National Center for Poison Information, Rocky Mountain Poison Center, University of Colorado Medical Center and Denver General Hospital, Feb. 1975.) It should be noted that atropine should be available for IV administration of physostigmine due to possible overdosage or hypersensitivity.

Neo-Polydti zinc bacitracin-neomycin sulfate-polymyxin B sulfate ointment

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Joe Fallon Baltimore, Maryland

Pills, Prunes and Praise Dear Sir: Gene White's article, "Pills, Prunes and Perils," which appeared in the March issue of JAPhA is a must for pharmacy practitioners around the country.

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R. K. Johnson Milwaukee, Wisconsin

Vol. NS15, No.7, July 1975

The Dow Chemical Company Indianapolis, Indiana 46268

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