Routes of Drug administration: The Curious Case of 800mg Flagyl and a Baby

It is impossible to be prepared for everything! There’s always a joker to trump anything you have ever experienced and the community pharmacy experience is no exception.

It was a lovely day at work and I was having a great time as the newest pharmacist in the building; especially considering the fact that just two days before, I had set a new record of the highest daily sales ever made by a locum pharmacist in their first week. This made me popular with the other pharmacists and support staff, everyone liked me and I was literally walking on air; well, on 18°C air-conditioned air and oblivious of the fact that each day comes with its own troubles.

I was still in a reverie, enjoying all my accolades when this average height figure charging in my direction jostled me back to reality. It was a woman in her mid-thirties with a baby carefully strapped to her back and I could tell she had trekked a few miles under the hot afternoon sun, as her dark-complexioned face was brimming with sweat which I was sure would be dried up by the air-con in no time. The three perfectly lined tribal marks on both of her cheeks gave her away as being from the western part of Nigeria.

“Please, give me Flagyl tablets”, she requested.

Usually, whenever a patient requests for Flagyl (a brand of Metronidazole), I’m always excited like, “Yes! Another opportunity to show pharmaceutical care and preach rational drug use”.

It usually involves a request for the drug for the purpose of arresting bouts of diarrhea, to be used as a one-time dose, sometimes in combination with another drug – you guessed right – Tetracycline, popularly called “red and yellow capsule” in this part of the world. Then, I get to explain that diarrhea, besides being caused by microorganisms, may simply be a result of increased movement within the stomach, and a drug that will help slow down this movement, consequently stopping diarrhea may just be appropriate. And this drug will achieve its purpose in a single dose, unlike Flagyl which ideally should be taken every 8 hours for a few days for best outcomes.

I had all of that information at the back of my mind, as though carefully rehearsed, ready to be “dispensed”. However, based on my professional training, I wasn’t going to jump to conclusions about who the drug was for, or why the drug was being requested. So, my WWHAM came in handy.
With a smile on my face, I politely asked, “Are you getting the drug for yourself ma?”

“Ehn, yes and no, somehow” Her eyes darted to and fro while the baby on her back kept making baby noises.

That was definitely not the response I was expecting so proceeding to the “what are the symptoms?” questions was obviously not the appropriate thing to do. I had to ask her what she meant by that response.

People of God! I wasn’t prepared for what I heard next!

The woman, explained that she intended to take 2 tablets of 400mg Flagyl (making 800mg) so that her baby could get the drug via breast milk when she feeds him. She went on to say that her baby had been having watery stools since the day before and needed the drugs. She therefore needed to take the tablets – enough of it – so that when she was going to breastfeed the child, he would get the drug from her breast milk. Normally, she would take one tablet for herself, but since her baby was in the picture, two 400mg tablets would suffice.

I never experrerit……I died; I was stupefied.

Thinking about it now though, I’m sure I wasn’t so shocked by the level of misinformation she exhibited as I was by her spectacular display of a mastery of pharmacokinetics! I mean, she was “moving stuff” about drug distribution, drug secretion into breast milk, adult and paediatric dosing considerations, drug crossing barriers etc.

Shoot! I should have asked what pharmacy school she trained in.

I quickly shook it off like nothing happened in the past 2 minutes, and with as straight a face as I could gather, I gently explained to her that drugs do not work that way. You cannot absolutely determine what amount of drugs is finally available for babies in breast milk, let alone decide the amount of the drug that will be appropriate for therapy. Drugs are simply not administered to babies that way. In addition, she had not need of the Flagyl at the time and was only exposing herself to the potential side effects of the drug.

Thankfully, she saw the light and I subsequently gave her paediatric zinc tablets and a pack of ORS for her baby.

One can only imagine what would have happened if she had gotten the drugs elsewhere from a non-professional. Boy! was I glad she came to a pharmacy!

-Story Submitted by Pharm. Oluwabiyi Oyekanmi from Nigeria’s Megacity, Lagos.
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