ABSTRACT
BACKGROUND: Medication is not always delivered in a safe dosing format. Up to 33% of medication errors can be attributed to confusing packaging or labelling. CASE DESCRIPTION: A 6-year-old boy with ADHD, for which he was being treated with methylphenidate and pipamperone drops, was brought to the A&E department with signs of severe encephalopathy. He had apparently been given pipamperone in streams rather than in drops in the previous months. The pipamperone level in his blood was raised to toxic levels. The pipamperone drops were delivered in a plastic squeeze bottle (LDPE bottle), which makes correct dosing almost impossible. The treating psychiatrist and the prescribing GP had not noticed this medication error. The incident was reported to the Netherlands Pharmacovigilance Centre Lareb, the Netherlands Medicines Evaluation Board and the Portal for Patient Safety. A warning was also added to the Netherlands paediatric medication prescription website about pipamperone in a squeeze bottle. CONCLUSION: Drug packaging can be a cause of intoxication. The treatment provider should be aware of this in cases of drug intoxication.
Subject(s)
Attention Deficit Disorder with Hyperactivity/drug therapy , Butyrophenones , Drug Overdose , Drug Packaging , Drug-Related Side Effects and Adverse Reactions , Neurotoxicity Syndromes , Patient Safety/standards , Butyrophenones/administration & dosage , Butyrophenones/adverse effects , Child , Drug Overdose/etiology , Drug Overdose/prevention & control , Drug Packaging/methods , Drug Packaging/standards , Drug-Related Side Effects and Adverse Reactions/etiology , Drug-Related Side Effects and Adverse Reactions/prevention & control , Humans , Male , Netherlands , Neurotoxicity Syndromes/etiology , Neurotoxicity Syndromes/prevention & control , Pharmacovigilance , Serotonin Antagonists/administration & dosage , Serotonin Antagonists/adverse effectsABSTRACT
We presented the cases of three children with coeliac disease who despite good adherence to a glutenfree diet remained non-responsive to treatment. Two patients, one of them with IgA deficiency, were successfully treated by complete gluten exclusion with enteral nutrition. However the third child with a severe coeliac disease did not achieve clinical and histologic improvement, even on immunosuppressive treatment. If no hidden sources of gluten can be identified, other causes of persistent villous atrophy, dierent from coeliac disease, have to be considered. They include e.g. inflammatory, immune and endocrine diseases of the digestive tract. In severe cases of childhood coeliac disease not responding to a gluten free diet, autoimmune enteropathy and refractory coeliac disease must be taken into account.
