Interactive Case Studies: May 2023

Case 1:

AR presents to the emergency department with new onset blurry vision, drowsiness, poor coordination, and slurred speech. She is 20 years old and is accompanied by her father, who informs the health care team that she struggles with alcohol abuse and in the past has ingested hand sanitizer, mouthwash, and vanilla extract to become inebriated. He says that he found an empty bottle of windshield wiper fluid in AR’s room approximately an hour after she began to feel unwell. AR’s laboratory results reveal metabolic acidosis, elevated anion, and osmolality gap.

What is the best treatment option?

AR is displaying signs and symptoms of intoxication. The empty bottle of windshield wiper liquid indicates that this is most likely what she drank. This solution contains a high amount of methanol. Fomepizole and supportive measures such as intravenous (IV) fluids and antiemetics are used to treat patients with methanol poisoning. Fomepizole inhibits alcohol dehydrogenase, an enzyme that metabolizes alcohol to the highly toxic substance acetaldehyde. Without this enzyme, the parent compound stays in the bloodstream and is eventually excreted in the urine. Because fomepizole has minimal adverse effects, the benefits of administering it most often outweigh the risks. The loading dose of IV fomepizole is 15 mg/kg. This is followed by doses of 10 mg/kg every 12 hours (for a total of 4 doses) and subsequently by doses of 15 mg/kg every 12 hours until the concentrations of methanol are less than 20 mg/dL and the patient is asymptomatic and has a normal pH.

Case 2:

Two weeks ago, the pharmacy dispensed a partial fill of oxycodone 5 mg every 12 hours as needed to AF for postoperative bariatric surgery pain. The 43-year-old man is still experiencing pain but says that the medication is helping, and he has come to the pharmacy to fill the balance. The pharmacist learns that AF is having difficulty passing stool and that during the past week he has experienced abdominal pain, cramping, and rectal bleeding. AF asks whether he should take bisacodyl or calcium polycarbophil. Reviewing his profile, the pharmacist sees that AF takes amlodipine, lisinopril, and omeprazole but no OTC medications.Should the pharmacist recommend an OTC laxative to AF?

Should the pharmacist recommend an OTC laxative to AF?

AF appears to be experiencing constipation secondary to oxycodone use. Opioids slow gastric motility by reducing bowel tone and contractility. Although most cases of constipation are easily managed with OTC drugs, the rectal bleeding indicates AF should not self-medicate. Gastrointestinal bleeding and/or a postsurgical complication should be ruled out before an OTC is recommended for the management of constipation. The pharmacist should refer AF to his primary care provider for further evaluation.