Some Indiana pharmacists are using a couple of the tools apothecaries used centuries ago - the common mortar and pestle - to bring some relief to children suffering the symptoms of H1N1 and the more common seasonal flu.Health officials have been warning that the Americans most at risk from swine flu are the youngest ones, children from 6 months to 24 months old. The flu danger has been complicated for weeks by a national scarcity of prescription liquid Tamiflu, favored by many doctors for patients too young to swallow capsules.
At right, Jim Kodman compounds a batch of liquid Tamiflu at Gatti Compounding Pharmacy in Indiana
Tamiflu is often prescribed to reduce the severity and duration of a flu infection. To get the most out of the medicine, patients need to take it as soon as possible after flu symptoms appear.
According to Jim Kodman, an Indiana pharmacist and owner of Gatti Compounding Pharmacy in Indiana, Tamiflu was never a blockbuster drug until this fall. But it's been in demand this autumn with the presence of swine flu and seasonal flu simultaneously.
Compounding is a process in which a physician and pharmacist work together to develop customized medications for one particular patient, frequently using raw ingredients in the pharmacy.
"The idea of compounding is to meet one individual patient's needs,'' often based on the patient's weight, Kodman said. Compounding usually becomes more common when large medicine manufacturing companies can't meet the demand. And the unsatisfied demand now is for liquid Tamiflu.
"There is no supply of the liquid. That's a national problem,'' Kodman said.
What Kodman and other compounding pharmacists are doing is using Tamiflu capsules, which are readily available, to make a liquid version of the medicine that is easier for small children to swallow.
"It's one of the simpler compounds to make,'' but it takes time, Kodman said.
The compounding pharmacist must open the capsule by hand, pour the powdered medicine into a mortar and grind it with a pestle. The pharmacist then blends the medicine with a syrup and the resulting mixture has a viscosity between water and the syrup that tops an ice cream sundae. A flavoring is also added to make the medicine more palatable to children.
A critical aspect of compounding is knowing how much of the medicine to use.
Tamiflu capsules are manufactured in the 75-mg size, but young children typically need only 30 to 60 mg, depending on their body weight, Kodman said.
"Usually a fraction of the capsule is used,'' he said.
One Web site suggests that parents can crush Tamiflu capsules themselves and mix the medicine with chocolate syrup for their children.
Kodman said he would not recommend that to a parent.
"The last thing you'd want to do is give your child the wrong dose,'' he said.
Most of the prescriptions Kodman has been receiving for compounding liquid Tamiflu are coming from emergency room physicians at Indiana Regional Medical Center.
Adam Kochman, director of pharmacy at IRMC, said the hospital's own compounding pharmacists have been following the recommendations of the Centers for Disease Control and Prevention to make the hospital's liquid form of Tamiflu.
The IRMC pharmacists compound the first dose of liquid Tamiflu for an ill patient to take even before he or she leaves the emergency room, and a prescription is sent out to one of the local retail pharmacies for more doses the patient can take at home, Kochman said.
Vicky Coark, pharmacy manager at the Giant Eagle Pharmacy in Indiana, said her staff has been compounding a few prescriptions each week for Tamiflu liquid, mainly from physicians in the Indiana area.
She said she hasn't received any news about when commercially manufactured Tamiflu liquid will be available again.
And Robert Kasisky, a pharmacist and owner of the Eaglescripts pharmacy in Indiana, also stands ready to compound liquid Tamiflu if needed.
From his vantage point, Kasisky believes the number of local flu cases may have peaked about one month ago.
But based on his observations as a pharmacist for 17 years, he said, "I don't think we're out of the woods yet.''
He anticipates another spike in local flu cases in mid-winter.
At right, Jim Kodman compounds a batch of liquid Tamiflu at Gatti Compounding Pharmacy in Indiana
Tamiflu is often prescribed to reduce the severity and duration of a flu infection. To get the most out of the medicine, patients need to take it as soon as possible after flu symptoms appear.
According to Jim Kodman, an Indiana pharmacist and owner of Gatti Compounding Pharmacy in Indiana, Tamiflu was never a blockbuster drug until this fall. But it's been in demand this autumn with the presence of swine flu and seasonal flu simultaneously.
Compounding is a process in which a physician and pharmacist work together to develop customized medications for one particular patient, frequently using raw ingredients in the pharmacy.
"The idea of compounding is to meet one individual patient's needs,'' often based on the patient's weight, Kodman said. Compounding usually becomes more common when large medicine manufacturing companies can't meet the demand. And the unsatisfied demand now is for liquid Tamiflu.
"There is no supply of the liquid. That's a national problem,'' Kodman said.
What Kodman and other compounding pharmacists are doing is using Tamiflu capsules, which are readily available, to make a liquid version of the medicine that is easier for small children to swallow.
"It's one of the simpler compounds to make,'' but it takes time, Kodman said.
The compounding pharmacist must open the capsule by hand, pour the powdered medicine into a mortar and grind it with a pestle. The pharmacist then blends the medicine with a syrup and the resulting mixture has a viscosity between water and the syrup that tops an ice cream sundae. A flavoring is also added to make the medicine more palatable to children.
A critical aspect of compounding is knowing how much of the medicine to use.
Tamiflu capsules are manufactured in the 75-mg size, but young children typically need only 30 to 60 mg, depending on their body weight, Kodman said.
"Usually a fraction of the capsule is used,'' he said.
One Web site suggests that parents can crush Tamiflu capsules themselves and mix the medicine with chocolate syrup for their children.
Kodman said he would not recommend that to a parent.
"The last thing you'd want to do is give your child the wrong dose,'' he said.
Most of the prescriptions Kodman has been receiving for compounding liquid Tamiflu are coming from emergency room physicians at Indiana Regional Medical Center.
Adam Kochman, director of pharmacy at IRMC, said the hospital's own compounding pharmacists have been following the recommendations of the Centers for Disease Control and Prevention to make the hospital's liquid form of Tamiflu.
The IRMC pharmacists compound the first dose of liquid Tamiflu for an ill patient to take even before he or she leaves the emergency room, and a prescription is sent out to one of the local retail pharmacies for more doses the patient can take at home, Kochman said.
Vicky Coark, pharmacy manager at the Giant Eagle Pharmacy in Indiana, said her staff has been compounding a few prescriptions each week for Tamiflu liquid, mainly from physicians in the Indiana area.
She said she hasn't received any news about when commercially manufactured Tamiflu liquid will be available again.
And Robert Kasisky, a pharmacist and owner of the Eaglescripts pharmacy in Indiana, also stands ready to compound liquid Tamiflu if needed.
From his vantage point, Kasisky believes the number of local flu cases may have peaked about one month ago.
But based on his observations as a pharmacist for 17 years, he said, "I don't think we're out of the woods yet.''
He anticipates another spike in local flu cases in mid-winter.
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