The greatest irony of this year’s influenza epidemic is the gulf between dire messages urging us to protect vulnerable children and the reality of our actual options. One of our best weapons against pediatric influenza is oseltamivir (Tamiflu) suspension, but you might as well be prescribing platypus blood. Nobody has it.
Explore This IssueACEP News: Vol 32 – No 02 – February 2013
On a recent Friday night, a single mother brought in a 4-year-old girl who developed a fever and cough over the previous 12 hours. The girl had a history of pneumonia and moderately severe asthma requiring two hospitalizations. Her test swab was positive for influenza A, but she did not appear gravely ill and had no findings that warranted hospitalization at that time.
I explained to her mother that she had a good chance of an uncomplicated recovery, but risk factors for severe disease made starting oseltamivir an important safeguard. Her mother was appropriately concerned and promised to fill the child’s weight-based prescription for oseltamivir suspension (45 mg orally twice a day for 5 days). Three hours later, she came back, frustrated and exhausted, having tried five local pharmacies. None of them had any oseltamivir suspension in stock; only the adult-strength 75-mg capsules were available. The child was crying, her pediatrician wasn’t calling back, the mother was exasperated and wanted to leave, and to make matters worse she was working the next 2 days. It was clear that if this child didn’t get the suspension tonight, she probably wasn’t going to get it at all.
Winging it wisely
I rarely recommend compounding medications in the emergency department. It’s time consuming, it makes the nursing staff fretful, and you don’t always have the ingredients you need. And there’s that whole “skill and training” thing.
If you have a pharmacist in-house (or a good relationship with one in your area) a simple phone call usually can remove this burden. Exceptions are necessary when the patient has a great deal to lose, time is a factor, options are limited, and your instincts tell you sending the exhausted parent out to “try harder” is unlikely to succeed. Sometimes the confluence of medical risk, social realities, and weekend inertia means that you have to do your best on your own.
The oseltamivir package insert provides detailed compounding information for pharmacists. It involves adding a small amount of water to adult capsules and then combining a flavored base to create a suspension of 6 mg/mL. Because I didn’t have any flavored base available, I calculated the total dose of oseltamivir the child would take over standard 5-day course (45 mg by mouth twice a day for 5 days, for a total dose of 450 mg). Then I figured out how many of the adult-dose 75-mg oseltamivir capsules would add up to the same total dosage (six of them) and emptied them all into a sterile specimen cup. I added 30 mL of normal saline and gave the whole thing a shake.