The *Angriest* Pharmacist You want your prescription filled when? Eat shit…

Alcohol, tobacco, and other necessities for fun

I filled a prescription today for ~4 pints of Lactulose. Guess what it was for? That's right, some poor schmuck with hepatic encephalopathy. "Take one tablespoonful by mouth four times a day." For our non-medical people out there, HE is a complication of liver disease (mainly cirrhosis). This man's body is unable to clear nitrogen waste products from his body. They build up, and his mind goes AWOL. Confusion, agitation, euphoria, insomnia/sleep disturbances, and occasionally coma can be attributed to HE. There's also my favorite symptom: asterixis -- uncontrolable shaking of the hands when they are extended and dorsiflexed (not to be confused with supinated). The personality changes can also be very severe. Brain waves are screwed up as well. Now that we've had our lesson for today, I pose a question. What disease states could cause such a complication?

Well, there's only a few that I learned: Hepatitis and cirrhosis (perhaps Mononucleosis as well)

The lactulose is great for helping the body cope with this. By acidifying the gut (moreso than is already there) it convers the ammonia (NH3) to ammonium (NH4+) with the abundance of protons (H+) around. The charged ammonium cannot cross the gut wall because it is charged, and it gets eliminated in the feces. Coincedentally, this is the primary goal of lactulose: pooping. On average, lactulose in these high doses will cause 4 or more loose stools each day. It's a crappy side effect, but it's much better than being in a coma because you have an ammonia level of 150.

What other drugs should we expect on this man's profile? A Beta blocker to prevent peritonitis and variceal production. Furosemide and spironolactone to reduce fluid build up in the abdomen (ascites). Perhaps even metronidazole to kill urea splitting bacteria in the GI tract.

What should this person avoid? ALCOHOL!

God damnit! It's highly likely this schmuck did this to himself by drinking gallons of gin each day for 15 years. Why in the fuck is this guy buying a case of Bud Light when he's picking up his lactulose? Go ahead, drink yourself into a grave in 2 months rather than a year or two. Put yourself in the hospital with hepatorenal syndrome or severe SBP that will kill you in days. Choke on the blood from a variceal bleed. See if I give a shit anymore.

I asked him if he knew that drinking on these meds was a bad idea. He knew. He agreed with me that "it got him in this mess" but he didn't care. "The way I see it, I don't have too much longer anyway. I might as well enjoy my time left."

That's the exact way I want to be remembered by my kids and grandkids as I fade into a hepatic encephalopathy induced coma -- a drunken idiot.

Walgreen's stopped selling booze because of "ethical dilemmas," yet still sells cigarettes and Spiriva. My store still sells booze and cigarettes. I'm glad they do -- I don't wanna make another stop to get some beer after work. But, I would expect a responsible person with cirrhosis to not purchase alcohol and a person with COPD or emphysema to not purchase another pack of Marlboro Reds.

A mistake is only a mistake if you refuse to correct it.

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