Jogger's leukocytes

Hypoglycemia from a look-alike, sound-alike medication error

Objective

To describe the effects of a look-alike, sound-alike medication error on the glycemic control and psychiatric well-being of a 23-year-old man.

Case Summary

A 23-year-old man presented to the university-based Integrated Multidisciplinary Program of Assertive Community Treatment (IMPACT) team with a diagnosis of schizoaffective disorder, most recent episode manic, and hypertension. The patient was prescribed chlorpromazine 100 mg daily to treat symptoms of psychosis and anxiety. The anxiety, however, persisted and escalated over the following 2 weeks. Upon physical examination of the patient's medications, it was discovered that the patient was inadvertently given chlorpropamide in place of the chlorpromazine. Evaluations, clinical presentation, the medication list, and criteria for an adverse drug event indicated a probable relationship (7 of 12) between the use of chlorpropamide and a hypoglycemic episode. The medication error was noted and corrective actions were taken. Within 1 week of the corrective actions, the patient's anxiety improved.

Discussion

When working with psychiatric patients, it is important to physically review all medications when expected responses are not achieved or when new psychiatric or physiological symptoms present. Approximately one-fourth of medication errors in the United States are drug name confusion errors. These errors must be universally addressed by all parties involved in the medication process. Effective safeguards are available and must be implemented by manufacturers, physicians, pharmacists, nurses, and all health care professionals to prevent look-alike, sound-alike medication errors.

Inflammatory response to strenuous muscular exercise in man

Based on the humoral and cellular changes occurring during strenuous muscular work in humans, the concept of inflammatory response to exercise (IRE) is developed. The main indices of IRE consist of signs of an acute phase response, leucocytosis and leucocyte activation, release of inflammatory mediators, tissue damage and cellular infiltrates, production of free radicals, activation of complement, and coagulation and fibrinolytic pathways. Depending on exercise intensity and duration, it seems likely that muscle and/or associated connective tissue damage, contact system activation due to shear stress on endothelium and endotoxaemia could be the triggering mechanisms of IRE. Although this phenomenon can be considered in most cases as a physiological process associated with tissue repair, exaggerated IRE could have physiopathological consequences. On the other hand, the influence of several factors such as age, sex, training, hormonal status, nutrition, anti-inflammatory drugs, and the extent to which IRE could be a potential risk for subjects undergoing intense physical training require further study.

Profound Hypoglycemia in a Mail-Order Pharmacy Customer as a Result of a Dispensing Error

Accidental hypoglycemia is most commonly associated with the inadvertent ingestion of oral hypoglycemic drugs, and profound hypoglycemia can result in significant morbidity and mortality. Dispensing errors involving sulfonylureas are usually cited as the cause, and these errors have historically been related to sound-alike compounds or proximity errors. We present the case of a patient who received sulfonylureas meant for a different patient through the mail and simply complied with the instructions on the medication bottle, with the result of severe hypoglycemia. This case demonstrates the need for clinicians to properly assess all patients with profound hypoglycemia, evaluating them for inadvertent ingestion of hypoglycemic agents. Furthermore, pharmacies that provide mail-order prescription services must ensure patient safety through quality-control mechanisms.

Hypoglycemic Adverse Reactions to Insulin and Sulfonylureas

The physiology and pathophysiology of hypoglycemia secondary to insulin and oral hypoglycemics are reviewed. Literature and clinical experiences, as well as litigated experiences, are discussed, and pharmacists are cautioned to exercise extreme caution when working with these agents, lest permanent brain damage or death result from their inappropriate use and monitoring.

The leucocytosis of exercise. A review and model

Exercise is known to induce an immediate leucocytosis, the magnitude of which is related, in most instances, to the intensity and duration of the work. On finishing exercise, however, the leucocyte count may change in any one of several different ways. The pattern of postexercise changes in the leucocyte count is determined mainly by the time which has elapsed since beginning exercise, rather than the work intensity or the total work done, if, for example, exercise has been intermittent. Consideration of, firstly, the circumstances under which the plasma concentrations of catecholamines and cortisol have been found separately to correlate with the leucocyte count at the finish of exercise, and, secondly, the effects on the leucocyte count of exogenous administration of these substances has led us to develop a model which can satisfactorily account for all of the principal changes in the leucocyte count that have been noted during and after exercise. It is proposed that catecholamines produced during exercise act to increase the ratio of circulating to non-circulating leucocytes, while cortisol acts, by a mechanism which involves a time lag, to increase the total number of leucocytes in the vascular compartment. Examination of previously published reports shows that many contain results which support this model. Using the model as a basis, some predictions are made that can be tested experimentally, and some experiments are suggested which should help elucidate the mode of action of catecholamines and cortisol.

Oral hypoglycemic agents

The sulfonylureas remain the most important oral agents, although their chronic hypoglycemic actions are still unexplained and the evidence on their relative efficacy is inconclusive. Data on relative safety suggest that chlorpropamide is the most toxic sulfonylurea but glyburide causes dangerous hypoglycemia as often as chlorpropamide. For many patients, good blood glucose control will be achieved by taking tolbutamide or another sulfonylurea 30 minutes before breakfast and the main evening meal. The biguanide metformin, which is as safe as glyburide, is of use in treating overweight diabetic patients who do not have cardiovascular, hepatic, or renal dysfunction.

Association of hyperinsulinemia with chlorpropamide toxicity

Clinical and metabolic features of chlorpropamide toxicity are described in two patients with diabetes mellitus and accidental chlorpropamide overdosage. Elevated serum insulin levels were found during hypoglycemia in both patients. The world's literature was reviewed for other cases of chlorpropamide toxicity in which insulin levels have been measured during hypoglycemia. A consistent feature of chlorpropamide toxicity is hyperinsulinemia. It is concluded that stimulation of the pancreatic beta cells during chlorpropamide toxicity leads to hyperinsulinemia and hypoglycemia.