Not long ago, we have issued an Urgent Notice on Suspected Wrongly Dispensed Drugs on 8th June 2005 as an advice to members to safeguard wrong dispensing subsequent to a mishap in early 2005 leading to few casualties out of 150 odd involved patients. We are of the opinion that the pharmacists would fight fiercely for Complete Separation of Consultation and Dispensing this time when the coroner court on the mishap case is to be held later in the coming months.
While we wish that no further dispensing mishap in the mean time would help to cool down the pharmacistsˇ¦ wish, unfortunately we have three individual mishaps again in the last few months which appear in the headlines of news media. So, no matter how strong our arguments are to protect the wish and choice of the patients, it seems that we have to fight this time a tough uphill war.
The first case in May 2006 concerned suspected abuse of psychiatric agents for Mood disorders and the recent one in October 2006 involved dispensing codeine containing agents to kid less than 6 months old. And the most drastic one involved cases of paediatric patients prescribed medicine syrup with alcohol mistakenly mixed which stirred up heated discussions by media on whether a proper division of labour between doctors and pharmacists would provide a better system of checks and balances and minimize the possibility of dispensing errors. Some media even stressed that it is time Hong Kong should consider adopting a strict separation between the medical and pharmaceutical professions and ending doctorsˇ¦ domination of the local health scene.
What should we do then? Give way or try to retain our right? I do think that our colleagues would favour the second option. But the right to dispense by our Profession would be taken away very soon without further correction and improvement on our part.
About a month ago, my patient handed to me a medicine bottle containing syrup for his child from a renounced Paediatrician. I was astonished to note that the bottle as labeled contained two drugs, namely, Tamiflu syrup and Xidanef (an antihistamine) syrup. I wonder if there is any interaction between the two drugs, not to say the ingredients. Even this is practiced by a number of colleagues, I believe compounding (mixing two or more commercial liquid preparation into a single product for a particular patient as described in General Chapter <1075> Good Compounding Practices, U.S. Pharmacopoeia) should not be taken lightly. According to the guidelines in the Good Dispensing Practice Manual published by the Department of Health, compounding process should be checked by a Senior Dispenser or Dispenser. To ensure the quality of all medicines compounded, the following details for each preparation: the formula, the name and quantity of each ingredient and the method of production should be entered into a log book for inspection.
The reason for the aforesaid measures is that the compounder is responsible for ensuring that the quality is built into the compounded preparations of products since the quality of compounded preparations can be adversely affected for a number of reasons. Some examples are stated below:-
Drugs that are soluble in a certain pH range may result in precipitation if the pH of the compounded preparation shifts out of the range. An example would be promethazine hydrochloride, which is incompatible with alkaline materials;
Preservatives, like potassium sorbate, works only in a defined pH range. Change in pH may lead to loss of antimicrobial activity and affect the safety of the compounded preparation;
Change in pH may also affect the swelling of suspending agents, thus the physical stability of the compounded preparation may be impaired;
Acacia is a commonly used suspending agent. An oxidizing enzyme is present in acacia, which may cause chemical instability of the compounded preparation if oxidisable drug from another commercial preparation is added to the system;
Butylated hydroxyanisole is an antioxidant, which is necessary to maintain the stability of certain oxidisable drugs. Addition of trace quantities of metal ions, and exposure to light cause discoloration and loss of activity, leading to ineffectiveness of the compounded preparations.
These are just few examples that I would like to share with you on the danger of Compounding. Should we from now on forget about Compounding in our clinics? To prevent medicine syrup mixing with alcohol again? For diluting medicine syrup, the advice from the Chief Pharmacist of the Department of Health is to use sterile plain water only. Using simple syrup, which also contains preservatives, from commercial firm for diluting drugs is also not advisable.
The Complete Separation of Consultation and Dispensing has been debated in Hong Kong for over 30 years. We can still defend our right does not mean that this will be forever. With the increasing demand from our patients, I think we should tackle the problem wisely with the change of time. Last word I would like to remind our members is to report as many illegal practice in the Community Pharmacies as possible so that we can have our last weapon when the time comes. Good luck, comrades!
Dr. Yeung Chiu Fat Henry