Tamiflu: Prepared From Tamiflu Capsules

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Extemporaneously Prepared

TamifluIf the commercially prepared oral suspension is not available, the manufacturer provides the following compounding information to prepare a 6 mg/mLsuspension in emergency situations.

1. Place the specified amount of water into a polyethyleneterephthalate (PET) or glass bottle.

2. Carefully separate the capsule body and cap and pour the contents of the required number of 75 mg capsules into the PET or glass bottle.

3. Gently swirl the suspension to ensure adequate wetting of the powder for at least 2 minutes.

4. Slowly add the specified amount of vehicle to the bottle.

5. Close the bottle using a child-resistant cap and shake well for 30 seconds to completely dissolve the active drug.

6. Label “Shake Well Before Use.”

Stable for 35 days refrigerated or 5 days at room temperature. Shake gently prior to use. Do not dispense with dosing device provided with commercially-available product.

Preparation of Oseltamivir 6 mg/mL Suspension
Body Weight Total Volume per Patient1 # of 75 mg Capsules2 Required Volume of Water Required Volume of Vehicle2,3 Treatment Dose (wt based)4 Prophylactic Dose (wt based)4
1Entire course of therapy.
2Based on total volume per patient.
3Acceptable vehicles are cherry syrup, Ora-Sweet® SF, or simple syrup.
4Using 6 mg/mL suspension.
≤15 kg 75 mL 6 5 mL 69 mL 5 mL (30 mg) twice daily for 5 days 5 mL (30 mg) once daily for 10 days
16-23 kg 100 mL 8 7 mL 91 mL 7.5 mL (45 mg) twice daily for 5 days 7.5 mL (45 mg) once daily for 10 days
24-40 kg 125 mL 10 8 mL 115 mL 10 mL (60 mg) twice daily for 5 days 10 mL (60 mg) once daily for 10 days
≥41 kg 150 mL 12 10 mL 137 mL 12.5 mL (75 mg) twice daily for 5 days 12.5 mL (75 mg) once daily for 10 days
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Flu Arrives Early This Year: Just in Time for the Holidays!

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Ever seen the flu map?  It is pretty neat.  So is Google's Flu Trends.  Alabama, Louisiana, Mississippi, Tennessee and Texas are seeing the most flu activity, the level of influenza activity in Georgia is picking up, according to the U.S. Centers for Disease Control and Prevention. flu-vaccineFlu season typically peaks in January; however this year the flu is making an earlier start thus logically giving the possibility of an earlier peak.  I am hoping my flu shot will keep this nasty virus away!

I love what this doctor says:

“This year’s vaccine appears to be right on target with the circulating virus,” said Dr. William Schaffner, chair of preventive medicine at Vanderbilt University Medical Center in Nashville, Tenn. “Treat it as a holiday gift to yourself and everyone around you. Don’t be a Grinch by spreading the flu.”

The CDC Director says:

“We’re seeing the beginning of the uptick start at least a month before we’d generally see it,” said the CDC director, Dr. Thomas Frieden. “It looks like it’s shaping up to be a bad flu season.”

And last a great article:  12 Flu Myths Debunked

5-Hour Energy Drink and Death

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My heart raced when I saw this.  No pun intended.  I tend to down one prior to a run.  Maybe something I will reconsider, but I also drink a lot of coffee daily so maybe I have tolerance like an alcoholic to alcohol?

Thirteen deaths have been linked to the consumption of 5-Hour energy drinks according to a report by the Food and Drug Administration.  With the fatalities the energy 'shot' has been also linked to heart attacks, convulsions and in one case a spontaneous abortion according to 90 filings with the FDA released to the New York Times this week.  Question:  Um, yeah, avoid caffeine when you are pregnant, mmm kay?

Add also Monster Energy Drink, which I'm almost positive is the official drink of the retail and hospital pharmacist, to the list with the parents of Anais Fournier suing the company over her death.  Only 14-years-old, the parents allege she only drank two in a 24 hour period before becoming ill.

HAGERSTOWN, Md. -

The U.S. Food and Drug Administration is investigating reports of five deaths that may be associated with Monster Beverage Corp.'s energy drink.

The agency acknowledged the adverse reports Monday, but FDA spokeswoman Shelly Burgess says the reports don't prove that the drinks caused the deaths.

This follows news that the parents of Hagerstown, Md. teen Anais Fournier filed a lawsuit in California on Friday against Monster Beverage Corp. for failing to warn about the product's dangers.

The 14-year-old's family says she went into cardiac arrest last December after drinking two 24-ounce cans of Monster Energy Drink in 24 hours.

An autopsy concluded she died of cardiac arrhythmia due to caffeine toxicity. She had an inherited disorder that can weaken blood vessels.

Monster says it doesn't believe its products caused any deaths.

Pertussis and New Recommendation

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It is a well know fact that I support vaccinations. I become irritated when I think about the cases of pertussis that takes the life of an infant because herd immunity is losing its protection. These gaps allow these vaccine preventable diseases to find their way back into the general population. Just the other day on my Facebook wall, there was a comment from someone who is against vaccines. They were told their insurance would no longer cover well visits because she doesn't vaccinate her children. I believe this is the directions insurance companies will go. Vaccinate or no coverage. I do not agree with taking away choice. But truly, if we didn't need insurance and paid for our own healthcare (who does that?) we could make our own decisions.

The CDC now recommends that pregnant women get a dose of the Tdap every time they are pregnant rather than the one time booster if they had not previously received the vaccine. Dr. William Schaffner, who is the chair of the department of preventative medicine at Vanderbilt School of Medicine, suspects that a proportion of babies who die of Sudden Infant Death Syndrome are caused by pertussis.

Just Take Care of Yourself

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Sitting in the waiting room of a pain clinic is more uncomfortable to me than seeing a cop's blue lights in my rear view mirror. Not only is it fairly evident that people in my area do not take care of themselves, I wonder why in the heck do I have to visit this place every six months or so? I have a very shoddy lower lumbar. The rest of my back is great, but for some reason God saw it fit for me to have some crappy genetics coupled with a severe love of running. I use the word severe because it is no secret that eventually most runners will have joint problems, and a severe love so great that it is worth the pain is nuts. There, I said it. I like to run. Even when it hurts. So I use radio frequency lesioning (RFL) to burn the nerves (they grow back) so I don't feel the pain in my lower back.

I watched a woman roll into the waiting room this morning still dressed in pajamas. She looked to be around 400 lbs, and I wonder, how have we allowed ourselves to get to the point where a donut or ten is worth being on a ton of medicine? How can we look in the mirror every day and know we are slowly poisoning ourselves? I'm preaching to the choir here because my diet is crap. Another patient limped in. He hadn't taken care of himself. I sort of stuck out like a sore thumb. This is a good thing.

These pain clinic docs would be out of a job if people took care of themselves!

A good friend of mine sent me this link: Why You Should Not Go to Medical School. Basically it really settled some things that my subconscious mind already knew. Although my dad wanted me to be a doctor, he had no idea what kind of life that would entail. It would mean telling someone to lose that weight so you could get off all the pain and hypertension meds. It would mean knowing that most wouldn't give a rats' ass and keep on stuffing their face with processed sugary foods contributing to diabetes and the like. I'm glad I didn't go to medical school. I'm not so sure I'm glad I chose pharmacy, but I seem to be pretty good at it.

Fungal Meningitis and the End of Lackadaisical FDA Involvement in Compound Pharmacies

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New England Compounding Center (NECC) is at the center of this quite horrific tragedy that has affected the lives of many with fourteen already dead. I cannot personally fathom such a loss over something so seemingly accidental. As a pharmacist my thoughts immediately go to sterile technique and the FDA's regulation of our industry. You see, the states oversee the pharmacies compounding and normally that should be enough. However, something went terribly wrong here. But what is coming out lately is the role of compounding pharmacies and how in this case, there was a grey area they were working in. Basically compound pharmacies can make patient specific medications, what is not allowed is these compounding pharmacies acting as manufacturing and bulk shipping repackaged medications without FDA oversight.

It's all about the dollar, but in this case many priceless lives have been lost.

There are two fungi involved: aspergillus and Exserohilum rostratum.

In the past, these pharmacies have been the heroes making things like bioidentical hormones and other specialty concoctions.

Under the FDA's definition, compounding pharmacies are supposed to mix drugs to order only on a specific patient in response to a prescription from a doctor. Under this definition NECC was not operating as a compounding pharmacy but as a large-scale production of a drug. The FDa should have stepped in before these lives were lost.

Donating a Kidney to a Complete Stranger

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I sat at dinner with some friends a few years back, actually friends of my husband that I met through him, and the husband told his tale of needing a kidney transplant.  He had had a family member donate a kidney only for the transplant to be botched during the transplant.  What a waste, not only for my friend, but also for the living donor who didn't get to see her selfless donation be wasted.  He later did get another successful transplant and is doing well. I remember sitting there at dinner thinking about how I wish I could get to the place in life to donate a kidney to someone, to totally revolutionize their life.  It is a huge undertaking, one that I cannot quite get to.  Wonder if I need both?  Wonder if one of my children or husband need a kidney in the future?  (Though I'm the only one in my family of four with my bloodtype...).

U.S. woman's altruism starts chain of five kidney swaps, extending lives

"I'm not losing nothing," Honica Brittman said this week, sitting in a blue and white hospital gown before surgery in which she would give, for free, the initial kidney in a chain of five kidney transplants at the New York-Presbyterian Hospital/Columbia University Medical Center.

"To actually help somebody live a little bit, a lot longer, that's an awesome thing," she said.

The series of operation on Wednesday and Thursday, which required 10 separate surgical teams and weeks of coordination, was made up of a series of swaps within a group of men and women between the ages of 23 and 68 and with compatible blood types, all motivated by a mix of compassion and commitment to their loved ones.

The chain started with Brittman, who donated a kidney to a 39-year-old television producer whose fiancée and partner of more than 10 years donated to a businessman from upstate New York.

In turn, the businessman's son, a college-age student who felt that for being healthy and the youngest of four sons, he should step up on behalf of his father and donate one of his kidneys to another young man, a 23-year-old originally from Haiti.

His father then donated to a retired teacher from New Jersey.

Can you imagine the lives that would be changed setting off a chain like this?  I have thought about it.  I wonder if there is a special place on the transplant list if something were to happen with your remaining kidney that would make it worth your while?

Who is David Matthew Kwiatkowski?

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Exeter, NH – Exeter Hospital worker David Matthew Kwiatkowski, who officials say had hepatitis C and spread the disease to 30 unsuspecting patients by stealing drugs, has been arrested, the U.S. Attorney's office in New Hampshire announced Thursday. Kwiatkowsi, 32, of Exeter, was arrested this morning at a hospital in Massachusetts, where he's receiving treatment for hepatitis C. He's charged with fraud and tampering.

He faces up to 24 years in prison and a $250,000 fine.

That is it?  A life sentence would be more appropriate.  Let us delve into the world which is Hepatitis C.  What future will these patients and any others that he so selfishly infected face?

Thomas Wharton, MD, FACC, medical director of the Cardiac Catheterization Unit at Exeter Hospital, now views Kwiatkowski as “the ultimate con artist and an extremely good cardiac technologist who pulled the wool over everyone's eyes.”

Of the isolated incidents that fellow Cardiac Catheterization Unit employees began reporting in the spring, Dr. Wharton said, “David had stories for everything that pulled at your heart-strings and we had no reason to disbelieve him. David claimed to have several important medical conditions, and we had no reason to challenge this. The day he reportedly arrived to work with red eyes he told us his aunt had died the night before and he had been up all night crying.”

And the kicker really is his response to investigators about the people he spread the virus to:

"You know, I'm more concerned about myself, my own well being," he told investigators. "That's all I'm really concerned about and I've learned here to just worry about myself and that's all I really care about now."

From http://www.epidemic.org:

Although few prospective long-term survival and health care cost studies are available for hepatitis C, it has been possible to estimate the life-long economic impact of the disease for both the individual patient and for the U.S. population with chronic hepatitis B. Lifetime health care costs for a patient with chronic hepatitis B has been estimated at $65,000 in the absence of liver transplantation. For the 150,000 HBV carriers with significant liver damage, the lifetime health care costs in the U.S. have been estimated to be $9 billion. Assuming an estimated survival of 25 years, the annual health care costs for the affected U.S. population with chronic hepatitis B is $360 million. Based on the same economic analysis, treatment of chronic hepatitis B with interferon is projected to increase life expectancy by about three years and cut the total health care costs.

Hepatitis C can only represent a far greater economic cost. While it infects about 3 and a half more times as many people in the United States than does hepatitis B, more than 80% of hepatitis C patients will develop chronic liver disease, as compared to only 20% of hepatitis B patients. Limited data suggest that 15-20% of those with chronic hepatitis C will develop cirrhosis within a five-year period, and as many as 25% may have cirrhosis by 10-20 years. The risk of developing liver cancer is uncertain, but may approach or exceed 1% during the first 20 years of infection and increase afterwards. Hepatitis C is responsible for about one-third of all liver transplants in the United States.

Approximately 1,000 patients are transplanted each year for liver disease due to hepatitis C. With the cost per liver transplantation in the range of $280,000 for one year, liver transplantation for hepatitis C alone reaches a cost of nearly $300 million per year.

Moreover, the average lifetime cost for hepatitis C, in the absence of liver transplant, has been estimated to be about $100,000 for individual patients. Assuming that 80% of the 4.5 million Americans believed to be infected develop chronic liver disease, the total lifetime cost for this group (3.6 million) will be a staggering $360 billion in today's dollars. Assuming an estimated survival of 40 years, the annual health care costs for the affected U.S. population with chronic hepatitis C may be as high as $9 billion.

It would be prudent to consider that every single person that he has infected would at the VERY least receive $100,000 up front PLUS the cost of transplant and the cost of the emotional toll.  He should never be able to walk in society again and spend the rest of his time working to pay this debt.

I also believe that the hospital should cover the rest of the cost considering the signs were there for him being under the influence.  All it would have taken would be ONE person, ONE coworker, ONE physician to take the chance and get this guy tested.  Also, pharmacists should have a bigger role in a cath lab like this to prevent nurses and staff from having such access to be able to hide something like this.  I'm just appalled at this man's evil behavior coupled with the lack of safe policy at the hospital(s) in question.

This is just my opinion.

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Whooping Cough

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So this is the year where the glorious United States reaches the highest levels of pertussis (whooping cough) in 50 years! Is that enough to stop the crazy anti acclimation rhetoric that continues to flow? Sadly, no. So far the CDC has recorded nearly 18,000 cases this year alone. Pertussis is caused by the bacteria Bordetella pertussis. It is highly contagious and spreads from person to person by coughing or sneezing. Young children are the highest at risk and can lead to death as it has with nine children this year.

It is preventable. So,please stop listening to Jenny McCarthy and protect your children!

Oxycontin Reformulation and the Heroin Effect

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According to multiple news agencies and a letter published by New England Journal of Medicine, former Oxycontin addicts are moving over to a cheaper readily available illegal substance to get high -- heroin.

Effect of Abuse-Deterrent Formulation of OxyContin

N Engl J Med 2012; 367:187-189July 12, 2012

Article

TO THE EDITOR:

In August 2010, an abuse-deterrent formulation of the widely abused prescription opioid OxyContin was introduced. The intent was to make OxyContin more difficult to solubilize or crush, thus discouraging abuse through injection and inhalation. We examined the effect of the abuse-deterrent formulation on the abuse of OxyContin and other opioids.

Data were collected quarterly from July 1, 2009, through March 31, 2012, with the use of self-administered surveys that were completed anonymously by independent cohorts of 2566 patients with opioid dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders,4th edition, who were entering treatment programs around the United States and for whom a prescription opioid was the primary drug of abuse (i.e., heroin use was acceptable but could not be the patient's primary drug). Of these patients, 103 agreed to online or telephone interviews to gather qualitative information in order to amplify and interpret findings from the structured national survey.

Effect of Abuse-Deterrent OxyContin., the selection of OxyContin as a primary drug of abuse decreased from 35.6% of respondents before the release of the abuse-deterrent formulation to just 12.8% 21 months later (P<0.001). Simultaneously, selection of hydrocodone and other oxycodone agents increased slightly, whereas for other opioids, including high-potency fentanyl and hydromorphone, selection rose markedly, from 20.1% to 32.3% (P=0.005). Of all opioids used to “get high in the past 30 days at least once” OxyContin fell from 47.4% of respondents to 30.0% (P<0.001), whereas heroin use nearly doubled.

Interviews with patients who abused both formulations of OxyContin indicated a unanimous preference for the older version. Although 24% found a way to defeat the tamper-resistant properties of the abuse-deterrent formulation, 66% indicated a switch to another opioid, with “heroin” the most common response. These changes appear to be causally linked, as typified by one response: “Most people that I know don't use OxyContin to get high anymore. They have moved on to heroin [because] it is easier to use, much cheaper, and easily available.” It is important to note that there was no evidence that OxyContin abusers ceased their drug abuse as a result of the abuse-deterrent formulation. Rather, it appears that they simply shifted their drug of choice.

Our data show that an abuse-deterrent formulation successfully reduced abuse of a specific drug but also generated an unanticipated outcome: replacement of the abuse-deterrent formulation with alternative opioid medications and heroin, a drug that may pose a much greater overall risk to public health than OxyContin. Thus, abuse-deterrent formulations may not be the “magic bullets” that many hoped they would be in solving the growing problem of opioid abuse.

Theodore J. Cicero, Ph.D. Matthew S. Ellis, M.P.E. Washington University in St. Louis, St. Louis, MO cicerot@wustl.edu

Hilary L. Surratt, Ph.D. Nova Southeastern University, Coral Gables, FL

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