Pharmacist Natasha Hill spent an entire year during her training learning how to compound unusual prescriptions. But one she never practiced is now a daily part of her job: making an antiviral medication used to treat flu.
The special pharmacy mixture is being given to children with swine flu who are too young to take pills, an age group shown to be among the most vulnerable to the new H1N1 virus.
Normally, the drug's Swiss manufacturer makes plenty of the liquid version. But Roche pharmaceuticals says it can produce 25 times more of medication, which is in high demand since the pandemic grabbed hold, if it sticks mostly to pills.
That leaves children who cannot take pills relying on pharmacists such as Natasha Hill.
Compounding means patients sometimes have to wait longer for a prescription, and some have faced extra paperwork or delays because of how compounded prescriptions are reimbursed by insurance companies.
Mixing by hand also introduces the possibility that a pharmacist will make a mistake.
About one of every four liquid Tamiflu prescriptions nationally is being compounded by a pharmacist, said Hill, the head pharmacist at Sarasota's Walgreens compounding center. In Southwest Florida and across most of the state, the manufactured liquid has been unavailable for weeks.
"We were told in September there would be a limited supply and it was depleted quickly," Hill said, while working in the Bee Ridge Road pharmacy. "It was just a couple of weeks after that before we ran out."
The last of the federal government's stockpile of liquid Tamiflu was released to pharmacies nearly two weeks ago, after the number of children who have died from swine flu so far, 95, surpassed those who die from seasonal flu each year. The drug can cut the length of illness by one day, enough in some cases to stave off death.
The government's supply of children's Tamiflu is not expected to be replenished until next year, and a survey this month by the National Community Pharmacists Association showed 97 percent of pharmacies are reporting trouble getting it.
Meanwhile, pharmacists are following the government's instructions for liquefying the pills during an emergency.
On a scale of difficulty, compounding Tamiflu falls somewhere in the middle, Hill said. It does not need to be melted with a heat gun like some medications, but it is not as easy as, for example, shaking up the three ingredients used to make a pain-relieving mouthwash.
The instructions are detailed and inflexible. They prescribe down to the flavor of the syrup the medicine must be mixed with (cherry) to the color of the bottle that must encase it (amber).
Because the homemade version of children's Tamiflu comes out more potent than the manufactured version, the dosage has to be converted. If the doctor forgets to do it, the pharmacist does the math.
"It's a simple calculation," Hill said. "This is what we're trained to do."
Hill graduated from pharmacy school at the University of Wisconsin three years ago and is now head of the Walgreens central compounding pharmacy in Sarasota County. She takes calls from any other pharmacists in the chain with questions about what to do.
First, Hill twists a Tamiflu capsule in half and drops the powder into a mixing mortar. She crushes it with a pestle and slowly adds cherry syrup until it has been finely crushed.
The cherry syrup required is made by Humco company, which has a single plant on the border of Texas and Arkansas where production has been stepped up by seven times this fall. In addition to a sugar-free mix that can be used for children who cannot have sugar, this is the only base allowed.
The pH has been tested by the Food and Drug Administration and is shown to be just right, and the flavor balances the bitterness of the pill. At first the company had to limit the amount of syrup a pharmacy was allowed to have, to make sure everyone could have some, but now it is meeting demand.
All the major pharmacy chains, including Publix and CVS in Florida, say they are making their own liquid Tamiflu.
Hill pours the mixture into a bottle, amber to block the light and prevent it from causing an unintended chemical reaction. She keeps adding more syrup to the remaining granules until there are none left.
"We wouldn't have thought it would be such a bad flu season and demand would be so high," she said.
The special pharmacy mixture is being given to children with swine flu who are too young to take pills, an age group shown to be among the most vulnerable to the new H1N1 virus.
Normally, the drug's Swiss manufacturer makes plenty of the liquid version. But Roche pharmaceuticals says it can produce 25 times more of medication, which is in high demand since the pandemic grabbed hold, if it sticks mostly to pills.
That leaves children who cannot take pills relying on pharmacists such as Natasha Hill.
Compounding means patients sometimes have to wait longer for a prescription, and some have faced extra paperwork or delays because of how compounded prescriptions are reimbursed by insurance companies.
Mixing by hand also introduces the possibility that a pharmacist will make a mistake.
About one of every four liquid Tamiflu prescriptions nationally is being compounded by a pharmacist, said Hill, the head pharmacist at Sarasota's Walgreens compounding center. In Southwest Florida and across most of the state, the manufactured liquid has been unavailable for weeks.
"We were told in September there would be a limited supply and it was depleted quickly," Hill said, while working in the Bee Ridge Road pharmacy. "It was just a couple of weeks after that before we ran out."
The last of the federal government's stockpile of liquid Tamiflu was released to pharmacies nearly two weeks ago, after the number of children who have died from swine flu so far, 95, surpassed those who die from seasonal flu each year. The drug can cut the length of illness by one day, enough in some cases to stave off death.
The government's supply of children's Tamiflu is not expected to be replenished until next year, and a survey this month by the National Community Pharmacists Association showed 97 percent of pharmacies are reporting trouble getting it.
Meanwhile, pharmacists are following the government's instructions for liquefying the pills during an emergency.
On a scale of difficulty, compounding Tamiflu falls somewhere in the middle, Hill said. It does not need to be melted with a heat gun like some medications, but it is not as easy as, for example, shaking up the three ingredients used to make a pain-relieving mouthwash.
The instructions are detailed and inflexible. They prescribe down to the flavor of the syrup the medicine must be mixed with (cherry) to the color of the bottle that must encase it (amber).
Because the homemade version of children's Tamiflu comes out more potent than the manufactured version, the dosage has to be converted. If the doctor forgets to do it, the pharmacist does the math.
"It's a simple calculation," Hill said. "This is what we're trained to do."
Hill graduated from pharmacy school at the University of Wisconsin three years ago and is now head of the Walgreens central compounding pharmacy in Sarasota County. She takes calls from any other pharmacists in the chain with questions about what to do.
First, Hill twists a Tamiflu capsule in half and drops the powder into a mixing mortar. She crushes it with a pestle and slowly adds cherry syrup until it has been finely crushed.
The cherry syrup required is made by Humco company, which has a single plant on the border of Texas and Arkansas where production has been stepped up by seven times this fall. In addition to a sugar-free mix that can be used for children who cannot have sugar, this is the only base allowed.
The pH has been tested by the Food and Drug Administration and is shown to be just right, and the flavor balances the bitterness of the pill. At first the company had to limit the amount of syrup a pharmacy was allowed to have, to make sure everyone could have some, but now it is meeting demand.
All the major pharmacy chains, including Publix and CVS in Florida, say they are making their own liquid Tamiflu.
Hill pours the mixture into a bottle, amber to block the light and prevent it from causing an unintended chemical reaction. She keeps adding more syrup to the remaining granules until there are none left.
"We wouldn't have thought it would be such a bad flu season and demand would be so high," she said.
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