Interesting patients

A lot of my job has the potential to be quite monotonous. Most diabetics, hypertensives and asthmatics are managed according to national guidelines, for example. Every now and then though you get a really interesting patient. I've had a couple of these patients over the last few months.


One lady, lets call her Jennifer, has a complicated pain management regimen. Not only is Jennifer on modified release oxycodone and immediate release morphine, which is strange enough, she is also on fentanyl lozenges. I had never dispensed fentanyl lozenges before, so had to make some phone calls to find out some information about the equivalence between fentanyl lozenges and oral morphine. I have no idea why Jennifer is on three different opioid painkillers - patients are normally on a prolonged release and immediate release version of only one, as it makes adjusting the dose a lot easier.

Another lady, lets call her Emma, is being treated for toxoplasmosis. Toxoplasmosis is caused by a parasite found in undercooked meat and in cat faeces. Normally infection does not cause any problems and is dealt with by the body's immune system. However, the infection can sometimes spread to the eye and cause problems. It looks like this is what happened in Emma's case, as the prescription for her treatment was written by a consultant opthalmologist, who helpfully left his mobile phone number on the prescription. Toxoplasmosis is normally treated using a combination of pyrimethamine and sulfadiazine, neither of which are common stock in community pharmacy. Patients are also given folinic acid, to reduce the side effects of the treatment. I also had someone on the phone from the hospital pharmacy department a few days later wanting to check whether the prescription was for folic acid. I seriously hope it was a technician and not a pharmacist, but don't hospitals have copies of Martindale?

I've also had another patient, James, who has been off somewhere exotic and come back with schistosomiasis, a nice little parasitic infection caused by flukes. Now we don't get too many cases of this in the UK, and there is not actually a medicine on the UK market to treat it. The recomended treatment is with praziquantel, which has to be ordered directly from Merck, the manufacturers. James needed six tablets. Praziquantel comes in a pack of 90, costing over £300, and although I can claim payment for the whole pack I am now left with 84 of these tablets sitting on my shelf until they go out of date.

Oh, and I also have a couple of patients on Glivec, at a cost of about £1500 per month each to the NHS. Glivec is a very good and groundbreaking drug, but it is not cheap.