 |
 |
 |
 |
 |
 |
 |
|
|
|
|||||||||
|
|||||||||||
College of Pharmacy University of Iowa Iowa City, Iowa
Assistant Professor (Clinical) College of Pharmacy University of Iowa Clinical Pharmacist Northeast Iowa Family Practice Residency Program 2055 Kimball Avenue Waterloo, Iowa 50702-5047 FAX 319/272-2527 jhoehns{at}neimef.org
Program Director Emeritus Northeast Iowa Family Practice Residency Program Clinical Professor of Medicine College of Medicine University of Iowa
Resident Physician Northeast Iowa Family Practice Residency Program
Published Online, August 1, 2003. www.theannals.com, DOI 10.1345/aph.1D176
Case Report. A 40-year-old white woman presented to the emergency department with severe tetany-type spasm and marked contortion of the limbs, jaw, and neck. She was located on the floor at home, where she had been unable to move for the previous 9 hours. On examination, she was strikingly contorted with her left arm and leg raised and her right arm stretched in front of her while lying on her right side. Her neck was hyperextended and rigid. The patient was able to open her eyes and make contact, but unable to move. She was empirically treated for tetanus with tetanus immune globulin and intravenous penicillin G and also received intravenous lorazepam 3 mg, which resolved the spasm. Vital signs included BP 154/98 mm Hg, HR 126 beats/min, RR 53 breaths/min, and T 38.2 °C. Urine, blood, and cerebral spinal fluid cultures, in addition to head computed tomography, were negative. Upon resolution of the spasm, the woman reported taking several medications obtained from the Internet. She reported ingesting haloperidol 20 mg, bentazepam 50 mg (a benzodiazepine not approved in the US, usual dose 25 mg 3 times daily), and several tablets of acetaminophen/codeine 300/30 mg approximately 15 hours before onset of the spasm. A urine drug screen also revealed methamphetamine use. She recovered well and was admitted to an inpatient drug rehabilitation clinic.
The patient reported purchasing the haloperidol and bentazepam because they were listed under "sleep aids" on the Internet site. The Naranjo probability scale rated the likelihood that the severe dystonia was caused by haloperidol as probable.2
Discussion. Because there was initially no knowledge of her haloperidol use, the evaluation and treatment of her condition were more involved than necessary had the treating physician known she had taken haloperidol.
The medications were ordered from a site that also offers many controlled substances and anabolic steroids. The company claims to ship from many different cities, uses unlabeled small packages, and will ship large orders in multiple packages from different cities on different dates. The Web site claims these efforts are to "ensure maximum discretion and highest probability of successful delivery." Previously, this company had been cited by the Food and Drug Administration (FDA) for selling ciprofloxacin without a prescription in the US.3
That company is one of many Internet sites selling prescription and unapproved drugs without a prescription. The potential danger for consumers is remarkable. Several states have attempted legal action against sites that illegally ship prescription drugs across state lines without registration.4 Unfortunately, these companies are often international, have unknown locations, and are not easily regulated. The FDA recently began issuing "cyber" warning letters to online companies selling drugs without a prescription and encourages reporting of suspected illegal online drug sales.5
Clinicians need to remain aware of the wide availability of prescription drugs online without a prescription and should encourage further regulation of Internet pharmacies.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
 |
 |
 |
 |
 |
 |
