Month: July 2017

Crazy Clinical Corner July 2017 – Epilepsy

[English]

Jason Summers is a 7 year-old boy weighing 22 kilograms, members of his family are regular customers at your pharmacy. One day his mother Jane comes. She explains that he had had a  seizure at school where he stiffened, fell off his chair and started to, as his classmates described it, twitch. She also explains that this is not the first time this has happened. The first potential seizure had been eight months ago when he had fallen off his bike. As no one had seen him and he couldn’t remember they had thought it had just been him falling off his bike and twisting his ankle. The first confirmed seizure had happened about three months ago at a family diner but the doctor said that there was no certain history of seizures, so there wasn’t much they could do about it. This time, he was diagnosed with epilepsy and Jane gives you a prescription for sodium valproate syrup 15 mg/kg/day, divided into three doses.

 

Questions:

1: What kind of seizure did Jason likely have ?

 

  • Simple partial seizure
  • Complex partial seizure
  • Tonic-clonic seizure
  • Myoclonic seizure

  • Absence seizure

2: Why didn’t they treat the epilepsy at the first seizure?

3: What are some of the specific adverse effects of sodium valproate?

4a: What dose of sodium valproate (in mg) should Jason have per dose?

4b: What volume of a 200 mg/5 mL syrup should he be given for this dose?


[Spanish]

Jason Summers es un niño de 7 años que pesa 22 kg, su familia son clientes regulares en su farmacia. Un día su madre Jane viene. Ella explica que él había tenido la incautación en la escuela donde se puso rígido se cayó de su silla y comenzó a, como los otros niños lo describieron, ha contraerse. Ella también explica que esta no es la primera vez que esto ha sucedido. La primera crisis potencial había sido hace ocho meses cuando se había caído de su bicicleta. Como nadie lo había visto y él no podía recordar que habían pensado ellos pensaron que sólo era que había caído de su bicicleta y donde de torció su tobillo. La primera convulsión confirmada había ocurrido hace unos tres meses en un una cena entre familia, pero el médico dijo que no había una cierta historial de convulsiones, así que no había mucho que pudieran hacer al respecto. Esta vez, le diagnosticaron epilepsia y Jane le da una receta de jarabe de valproato de sodio 15 mg/ kg/día, dividido en tres dosis.

 

1: ¿Qué tipo de incautación Jason probablemente tiene?

  • Convulsión parcial simple
  • Convulsiones parciales complejas
  • Convulsión tónico-clónica
  • Convulsión mioclónica
  • Ataque de ausencia

2: ¿Por qué no trataron la epilepsia en la primera convulsión?

3: ¿Cuáles son algunos de los efectos adversos específicos del valproato sódico?

4a: ¿Qué dosis de valproato de sodio (en mg) debe tener Jason por dosis?
4b: ¿Qué volumen de un jarabe de 200 mg/5 ml debe administrarse para esta dosis?


[Arabic]

جايسون سامرز هو صبي يبلغ من العمر 7 سنوات ويزن 22 كيلوغرام، أفراد عائلته هم زبائن منتظمين في صيدليتك. تأتي إليك أمه جاين في يوم من الأيام وتشرح لك أنه قد تعرض لنوبة صرع في المدرسة أدت إلى تيبس في عضلاته، حيث سقط من كرسيه وأخذ يرتعش، كما وصفه زملاؤه. وتوضح لك أن هذه ليست المرة الأولى التي يحدث فيها ذلك. وكانت أول نوبة محتملة قبل ثمانية أشهر عندما سقط من دراجته. وبما أنه لم يره أحد عند سقوطه،ولم يتمكن من تذكر ما حدث فإنهم ظنوا أنه كان مجرد حادث سقوط من  الدراجة تسبب في التواء كاحله. ووقعت أول نوبة مؤكدة قبل ثلاثة أشهر أثناء عشاء عائلي لكن الطبيب قال أنه ليس هناك سيرة طبية للنوبات، لذلك لم يكن هناك ما يمكن القيام به. هذه المرة، تم تشخيصه بالصرع وتسلمك جاين وصفة طبية لشراب فالبروات الصوديوم 15 ملغ / كغ / يوم، موزعة على ثلاث جرعات.

1: ما هو نوع النوبة التي من المحتمل أن جايسون يعاني منها؟

نوبة جزئية بسيطة

نوبة جزئية معقدة

نوبة الصرع الكبرى

رمع عضلي

الصَّرْع الصغير

2: لماذا لم يعالج المرض من أول نوبة؟

3: ما هي بعض الآثار السلبية الخاصة بفالبروات الصوديوم؟

4.أ: ما هي جرعة فالبروات الصوديوم (ب الميليغرام) التي يجب أن يأخذها جيسون لكل جرعة؟

4.ب: ما هو الحجم من شراب 200 ملجم / 5 مل الذي يجب أن يعطى لهذه الجرعة؟


[French]

Jason Summers est un garçon de 7 ans pesant 22 kilos, les membres de sa famille sont des clients réguliers dans votre pharmacie. Un jour, sa mère Jane vient. Elle explique qu’il a eu une crise d’épilepsie à l’école où il s’est raidi, est tombé de sa chaise et a commencé à, comme ses camarades de classe l’ont décrit, se tordre. Elle explique également que ce n’est pas la première fois que cela s’est produit. La première crise potentielle avait eu lieu il y a huit mois lorsqu’il était tombé de son vélo. Comme personne ne l’avait vu et il ne se souvenait pas de ce qui s’est passé, ils avaient pensé qu’il venait juste de tomber de son vélo et s’est tordu la cheville. La première crise confirmée s’est produite il y a environ trois mois lors d’un dîner familial, mais le médecin a déclaré qu’il n’y avait pas d’antécédents de crises, donc il n’y avait pas grand chose à faire à ce sujet. Cette fois, il a été diagnostiqué d’une épilepsie et Jane vous donne une ordonnance pour le sirop de valproate de sodium 15 mg / kg / jour, répartis en trois doses.

1: Quel type de crise a probablement eu Jason?

  • Crises partielles simples
  • Crises partielles complexes
  • Crise d’épilepsie généralisée tonico-clonique
  • Crise d’épilepsie myoclonique juvénile
  • Absence épileptique

2: Pourquoi n’ont-ils pas traité l’épilepsie lors de la première crise?

3: Quels sont les effets indésirables spécifiques du valproate de sodium?

4a: Quelle dose de valproate de sodium (en mg) devrait avoir Jason par prise?

4b: Quel volume d’un sirop de 200 mg / 5 mL devrait-il être administré pour cette dose?

 

June Compounding Corner – Cremor leniens

Below is the formula of a softening cream called “Cremor leniens”:

White beeswax ………………………………………………….7.0 g

Cetyl palmitate ………………………………………………….9.0 g

Refined sunflower oil ………………………………………53.5 g

Virgin castor oil ………………………………………………….5.0 g

Glycerol monostearate 40-50 ………………………….5.5 g

Purified water …………………………………………………20.0 g

Methylparaben ……………………………………………….0.04 g

Propylparaben ………………………………………………..0.01 g

Propyl gallate ………………………………………………….0.02 g

Geranium essential oil ……………………………………0.3 ml

 

Questions:

  1. Creams are semisolid emulsions for topical use. How would you proceed when preparing this cream? Three methods of emulsion preparation are described below. Which one would you use in the case of Cremor leniens?
    • Methods of preparation of emulsions:
      • Wet gum method (English method): emulsion is formed by mixing the emulsifying agent with a dispersion medium in which it dissolves. This is then mixed with a dispersed phase.
      • Dry gum method (continental method): order of mixing is different; emulsion is formed by mixing the emulsifying agent with the dispersed phase in which it dissolves; and this is then mixed with the dispersion medium.
      • In situ soap method: emulsifying agent is produced during the preparation of emulsion (not added from outside).
  2. Emulsion are generally two-phase systems with an internal phase and an external phase such as oil-in-water (o/w) and water-in-oil (w/o). Emulsifier is used to maintain physical stability of emulsion. Please identify the emulsifier in the preparation of Cremor leniens and describe its mechanism of action. Based on the used emulsifier, which type of emulsion is it?
  3. Two more components can help maintain the physical stability. Their mechanism of action differs from the one employed by the emulsifier. Please indicate the general name of this kind of substances, their mechanism of stabilisation and identify them in the composition of the Cremor leniens.
  4. Which components are used to ensure microbial stability of the cream? Are there any antioxidants?
  5. In the formula of Cremor leniens, could the total amount of purified water and both parabens be replaced with the same amount of paraben preserved water (composition shown below)? Why? 
    • Paraben preserved water
    • Metylparaben                                  0.67 g
    • Propylaparaben                              0.33 g
    • Purified water               up to 1 000.0 g
  6. Two oils are used in the preparation. Which one is more hydrophilic and why?

 

   
Structure of major triglyceride present in castor oil
(source: wikipedia.org)
Structure of major triglyceride present in sunflower oil

(source: wikipedia.org)

7.    Contrary to Ungentum leniens (softening ointment), Cremor leniens does not have a cooling effect. Based on the composition of Ungentum leniens below, could you explain why it has a cooling effect after application on the skin?

Composition of Ungentum leniens : borax (sodium borate), white beeswax, cetyl palmitate, refined sunflower oil, virgin castor oil, geranium essential oil, purified water

 

Answers:

  1. The cream is prepared by wet gum method (English method) as the emulsifier is firstly dissolved in oil phase (the soluble phase).
    • A hot solution of parabens in water is prepared.
    • Beeswax, cetyl palmitate, both oils and glycerol monostearate are melted in the mortar. Propyl gallate is then dissolved in the melted mixture.
    • The solution of parabens is added to the melting step by step. The emulsified system is homogenised until cold.
    • The amount of evaporated water is used to adjust the weight of the cream.
    • Finally, geranium essential oil is added to the cool cream.
  2. Glycerol monostearate is an emulsifier. It acts on the interface by decreasing the interfacial tension. This cream is water-in-oil (W/O), it´s an hydrophobic cream.
  3. Besides emulsifier, quasi emulsifiers increases viscosity of the outer oil phase and thus helps to maintain the system stability. In Cremor leniens, these are white beeswax and cetyl palmitate.
  4. Both parabens are antimicrobial components and propyl gallate is an antioxidant.
  5. Parabens preserved water contains lower amount of parabens compared to what is required for compounding Cremor leniens. The increased amount of parabens is due to the fact that parabens are lipophilic substances and thus have some affinity to oil phase. Part of the entire amount can then pass to the oil phase. In order to ensure sufficient concentration of parabens in water phase, we should use the prescribed amount of parabens, not Parabens preserved water.
  6. Castor oil is more hydrophilic. Both oils are triglycerides, however, esterified with different fatty acids. Sunflower oil contains mainly triglycerides derived from linoleic and oleic acid. Castor oil has usually three ricinoleic fatty acids. Ricinoleic acid differs from other fatty acids because of hydroxyl functional group on C12 that increases its hydrophilicity.
  7. Ungentum leniens does not contain emulsifier, only two quasi emulsifiers, so the system is not stable enough. After application, the emulsified system disrupts and the released water has a cooling effect while evaporating.

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