Journal of Pharmacy Technology

To report a case of paralytic ileus possibly associated with nebulized ipratropium bromide.

A 43-year-old man fell from a wall and was admitted to the intensive care unit (ICU) for the resulting thoracic trauma. An epidural thoracic catheter was placed for pain control using bupivacaine 0.25% and methadone 0.2 mg/mL. On hospital day 4, he developed purulent bronchiole constriction, and treatment with nebulized mesna and ipratropium bromide was started. Six hours after the first nebulization, the patient developed abdominal pain and bowel distension. An abdominal X-ray showed intestinal gas retention and dilated loops of large bowel. Paralytic ileus was diagnosed. Nebulized ipratropium bromide treatment was stopped and, during the following 24 hours, the patient gradually improved.

Nebulized ipratropium bromide–induced paralytic ileus is an uncommon adverse event that may be of considerable clinical relevance. Nebulized ipratropium bromide is predominantly deposited in the oropharynx, but some amount of the drug may be swallowed with resultant systemic adverse effects. Ipratropium bromide is a nonselective muscarinic antagonist and may inhibit contraction of the gastrointestinal tract. Paralytic ileus could not be attributed to an electrolyte disturbance or abdominal injury. The patient's paralytic ileus resolved when nebulized ipratropium bromide was stopped. An objective causality assessment showed that the paralytic ileus was possibly associated with this drug.

This case report indicates that ipratropium bromide should be considered capable of inducing paralytic ileus.

To describe the occurrence of a subdural hematoma in a woman undergoing chemotherapy with cyclophosphamide, methotrexate, and fluorouracil combined with warfarin therapy.

A 60-year-old white woman with atrial fibrillation underwent radical mastectomy for primary breast cancer with histologically positive axillary lymph nodes. Following surgery, the patient received adjuvant chemotherapy with a CMF 1–8 regimen consisting of cyclophosphamide 100 mg/m² orally on days 1–14, methotrexate 40 mg/m² intravenously, and fluorouracil 600 mg/m² by intravenous bolus on days 1 and 8 every 4 weeks. Warfarin 5 mg/day was administered concomitantly due to atrial fibrillation. Following the second course of concomitant therapy, the patient developed a headache, hemiparesis, and an international normalized ratio (INR) of 7.6, which was highly suggestive of a drug interaction between fluorouracil and warfarin. A computed tomography scan of the brain revealed a left parieto-occipital subdural hematoma.

This case emphasizes the importance of the potentially fatal drug interaction involving warfarin and fluorouracil.

Several adverse interactions between warfarin and fluorouracil have been reported. Considering the severity of this interaction, close monitoring of the INR is recommended in patients receiving these agents concomitantly.

To report blood pressure elevation associated with rofecoxib use in 2 older adults.

Two patients, aged 75 and 94 years, were prescribed rofecoxib for osteoarthritis pain. After the initiation of therapy, an elevation in systolic blood pressure measurement ≥17 mm Hg was observed. Upon withdrawal of rofecoxib, blood pressure in one patient returned to baseline measurements. In the second patient, sustained rofecoxib use resulted in blood pressure elevation and change in antihypertensive therapy.

It is well known that even a small elevation in blood pressure can significantly increase a person's risk for cardiovascular events. However, little is known about the potential magnitude of blood pressure elevation with the use of cyclooxygenase-2 inhibitors in the older adult population. In 2 older adults with osteoarthritis and hypertension, rofecoxib potentially led to a substantial elevation in blood pressure. In each case, adjustments of respective therapeutic regimens were made. The Naranjo probability scale indicates a probable relationship in both cases between the rofecoxib and blood pressure elevation.

These reports suggest that rofecoxib could produce greater elevation in blood pressure in older hypertensive adults than has been previously reported. Therefore, close monitoring of blood pressure for 1–2 months after initiation of rofecoxib therapy is advisable. Further study is needed to determine the true clinical significance of these findings in older hypertensive adults.

To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of common cardiology and general medications during breast-feeding.

Primary texts used by the breast-feeding community (Medications and Mothers' Milk, Drugs in Pregnancy and Lactation, Drugs and Human Lactation) were searched, as well as Micromedex, MEDLINE, PubMed, EMBASE, and EMBASE2 (1984–February 2004).

Multiple sources were used wherever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast-feeding, lactation, nursing, and medications, as well as specific drug names.

Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are drugs that can be harmful to nursing infants, breast milk concentrations of most drugs are insufficient to cause any harm.

Having objective and reliable information on medications enables pharmacists, pharmacy technicians, healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.

Legal definitions of “pharmacy technician” vary by state. Also, many pharmacy organizations have definitions of “pharmacy technician.” There is no consensus on the definition.

To explore the legal definitions of a pharmacy technician and use of the term “professional judgment” in those definitions and develop an empirically and theoretically based definition of a pharmacy technician.

Definitions of a pharmacy technician from the state statutes and regulations were found using LexisNexis State Capital and entered into an N-4 Classic database. The database was then coded through an iterative process of content analysis. A definition was developed using the content analysis and literature-based theory.

Definitions were found for 42 states (84%). Five main concepts were found to exist in the definitions: credentialing, designation, functions, practice site, and supervision. An empiric and theoretically based definition of a pharmacy technician was developed.

Statutory and regulatory definitions of a pharmacy technician tend to define technicians in terms that preserve the dispensing role for pharmacists. Definitions of a pharmacy technician should focus on the types of services pharmacy technicians provide and the types of credentials they must have, rather than what they may not do and who they are not. The use of the term “professional judgment” in defining a pharmacy technician lacks precision and is therefore not helpful in defining “pharmacy technician.”

To compile and evaluate health information Web sites to aid healthcare professionals in locating information on select therapeutic categories.

Therapeutic categories were chosen based on questions that pharmacists may receive in the community and institutional setting for which they might lack adequate resources to answer. Categories included adverse drug reactions, alternative medicine, cardiology, drug dosing in renal failure, drug interactions, foreign drug identification, geriatrics, immunology/vaccines, intravenous stability/compatibility, investigational drugs, oncology, pediatrics, pregnancy/lactation, legal and regulatory, monographs/medication usage evaluations, new drug approvals, shortages, tablet/capsule identification, therapy/therapeutics, and toxicology/poisoning. Web sites were chosen by searching www.google.com, as this search engine currently indexes over 3 billion Web pages.

Resulting Web sites were reviewed, selected, and evaluated using published criteria to assess the quality of each Web site, focusing on the authorship, disclosure, currency, and content.

The top Web sites in each category are presented, with details on their quality rating, sponsor, content, and special features or directions.