caseSTUDIES

CASE ONE: NA, a pharmacy student atTake Your Medicine University,is completing an experientialrotation in the emergencydepartment at the local hospital.During the rotation, he isworking with a family practiceintern to assist with medicationrecommendations and patientcounseling.

During a particularly busy day, a 17-year-old girl is brought tothe hospital accompanied by her mother, who found her unconsciousin her bedroom. Her mother informs the intern that herdaughter has a history of depression, for which she has receivedcounseling for 3 years and has been taking amitriptyline for 1year. She says that her daughter has struggled for years with herfeelings of "not fitting in." Her daughter is insecure about herappearance and keeps only a small circle of friends.

The mother has brought an empty prescription bottle foramitriptyline, explaining that she found the bottle next to herdaughter. According to the prescription bottle, it was filled 2 daysago for 100 tablets of amitriptyline 50 mg.

On examination, the intern finds the unresponsive teenager tohave an erratic and extremely rapid pulse. Her skin is dry andflushed. Her pupils are constricted and fixed. The electrocardiogramreveals supraventricular tachycardia with a prolonged PRand QT interval, widened QRS complex, and an inverted T wave.

As the intern begins writing orders for treating the teenager'sapparent suicidal attempt with amitriptyline, he turns to NA andcomments, "This day has been so crazy! I feel like I can't rememberanything. Could you tell me how much activated charcoal togive this girl?"

How much activated charcoal should NA recommend for theteenager?

CASE TWO: The following month, NA, thepharmacy student from TakeYour Medicine University, isassigned to an internal medicineteam at the local hospital. Prior tomorning rounds with the team,NA begins his initial workup of anewly admitted patient.

The patient is an elderlywoman admitted with multiplemedical problems. Upon review of the patient's laboratoryresults, NA notices that the woman's renal function is impaired.According to his calculations, her estimated creatinine clearanceis 40 mL/min.

NA reviews the medication administration record, notingthat the patient is scheduled to receive losartan 50 mg every12 hours, felodipine 10 mg daily, ticlopidine 250 mg twice daily,gabapentin 600 mg 3 times daily, famotidine 40 mg twice daily,cefazolin 1 g intravenously every 6 hours, clindamycin 300 mgevery 6 hours, and ciprofloxacin 400 mg intravenously every12 hours.

As NA finishes reviewing the medication administrationrecord, his preceptor approaches and reminds NA that the teamwill need recommendations on adjusting the patient's medicationdoses due to her impaired renal function.

Which medications will need adjusting?

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

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CASEONE: The recommended dose of activated charcoal for a patient over 12 years old is 50 to 100 g (1-2 g/kg). For the first dose,activated charcoal with sorbitol is often given to increase gastrointestinal (GI) motility. The use of sorbitol is usually not recommended for subsequent dosesdue to the risk of severe GI side effects. Multiple doses of activated charcoal are necessary when treating tricyclic antidepressant overdoses because thesemedications are enterohepatically circulated. Medication that was already absorbed may reenter the GI tract via biliary excretion and be reabsorbed, resultingin prolonged toxicity. CASE TWO: The gabapentin, famotidine, cefazolin, and ciprofloxacin doses should be adjusted due to the patient's poor renalfunction. The famotidine and ciprofloxacin doses should be reduced, while the dosing interval for cefazolin should be increased. The recommended dose offamotidine for patients with creatinine clearance (CrCl) 10 to 50 mL/min is 25% of the normal dose. The recommended dose of ciprofloxacin is 50% to75% of the normal dose. The recommended cefazolin dosing interval for patients with CrCl 10 to 50 mL/min is every 12 hours. As for gabapentin, the recommendeddose is 300 mg every 12 to 24 hours. The doses of losartan, felodipine, ticlopidine, and clindamycin will not need adjusting.

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