Febrile neutropenia (FN) is a critical condition in outpatient docetaxel chemotherapy. Many studies have provided evidence for the benefit of oral antibiotics in low risk FN patients and in December 2007, the National Cancer Center Hospital East started to use oral antibiotics routinely for the initial management of such patients. However, it is unclear whether oral antibiotics are being taken properly as initial treatment in the outpatient chemotherapy setting. In this study using patient records, we retrospectively investigated adherence in patients who had been prescribed oral antibiotics as needed during outpatient docetaxel chemotherapy between December 2007 and November 2009. Among the 335 subjects in our study, 87 (26%) developed fevers of above 38 degrees Celsius. Of these patients, 74 (85%) started taking oral antibiotics, and 60 patients finished the course of antibiotics as instructed. The frequency of proper use of oral antibiotics was significantly higher in patients who consulted the hospital by telephone than those who did not (88% vs. 51%, p < 0.001).
The findings of this study show that most patients started taking oral antibiotics when they developed a fever of above 38 degrees Celsius, but many stopped taking them after the fever was resolved, and that telephone consultation could be beneficial in increasing adherence. However, few patients had to be admitted to the emergency department for treatment.

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The relationship between drug loss and humidity in the dispensing and taking processes of digoxin (DX) powder was examined. We used a commercially available 0.1% DX powder, 0.01% and 0.0333% DX powders prepared by mixing the 0.1% DX powder and the excipient EFC lactose, and powders prepared by adding 1% of either hydrated silicon dioxide or titanium dioxide as a lubricant to the 0.01% and 0.0333% DX powders. For comparison, 0.01% DX granules were also prepared.
While the drug loss rates of the DX powders in the taking process were not affected by humidity, loss in the mixing and dividing processes increased significantly when humidity was 50% or lower. At a humidity of 20%, the total drug loss for the commercially available 0.1% DX powder, 0.0333% DX powder, and 0.01% DX powder before taking were 66%, 42%, and 20%, respectively. Total drug loss was decreased by 3-5% through the addition of lubricants to the DX powders. On the other hand, the total drug loss rate for DX granules before taking was 1%, which was lower than that of the powders.
The results of this study indicated that the amounts of the principal ingredient of DX powder taken varied widely with humidity for the same prescribed dose. Also the drug loss was not greatly improved by adding an excipient or lubricants to the DX powders. There was little drug loss for the granular form in the course of the dispensing and taking procedures, suggesting that its use would be a useful way of preventing drug loss with DX.

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Cetuximab, a therapeutic agent for metastatic colorectal cancer, is a chimeric monoclonal antibody that binds and inhibits the epidermal growth factor receptor (EGFR). Adverse events associated with cetuximab include skin disorders, which occur at a high incidence, infusion reactions, and electrolyte disorders, such as hypomagnesemia. The incidence and time of onset of hypomagnesemia following the start of cetuximab treatment were investigated retrospectively. The efficacy of oral magnesium preparations in preventing hypomagnesemia was also examined.
At The Cancer Institute Hospital of Japanese Foundation For Cancer Research, the incidence of hypomagnesemia in patients treated with cetuximab was 39.3%. However, there was no clear trend in the time of onset. In addition, there was no difference in the incidence of hypomagnesemia as a function of whether oral magnesium preparations were administered (p=0.097). Some patients developed severe hypomagnesemia and an intravenous magnesium preparation was not very effective in bringing about recovery, necessitating discontinuation of cetuximab therapy.
Mild hypomagnesemia may be overlooked because subjective symptoms are not readily apparent. However, if it worsens, hypomagnesemia may lead to serious adverse events, such as arrhythmias, which would require discontinuation of cetuximab treatment. In pa tients receiving cetuximab, therefore, serum magnesium levels must be monitored regularly since early detection and treatment of hypomagnesemia are very important.

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This study was designed to evaluate the persistence and safety of topiramate therapy in children and adults with epilepsy. It was a retrospective cohort study undertaken from October 2007 in which we analyzed the clinical records of 726 patients (216 children and 510 adults) who received topiramate for the treatment of epilepsy at the National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders. Factors associated with discontinuation of topiramate therapy determined from the results of the log-rank test (p<0.1) were subjected to multivariate Cox regression analysis in order to calculate hazard ratios and 95% confidence intervals (95% CI).
Suspension (Discontinuation) or dose reduction of topiramate were necessary due to adverse effects in 85 children (39%), of which the major ones were drowsiness (16.2%), anorexia (10.7%), hypohidrosis (4.7%), and irritability (4.2%). There was a higher incidence of hypohidrosis and a lower incidence of speech disorders in children as compared with adults (both p < 0.05). According to Cox proportional hazards analysis, the adjusted hazard ratio for discontinuation of topiramate therapy in children was 0.92 (95% CI : 0.75-1.23 ; p=0.76). In conclusion, this comparative study showed that the persistence and safety of topiramate therapy were similar in children and adults.

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Precision is important in the preparation of liquid mixtures of cancer chemotherapeutic agents because the clinically achievable dose levels of these agents are determined by the weight, body surface area and renal function of patients. We devised a checking procedure to determine if preparation was being done precisely. It involves measurement of the weights of vials and ampules before and after preparation of the drugs and then comparing the net weight difference with the theoretical weight difference. The theoretical weight difference is calculated from the preparation amount and specific gravity of the liquid cancer chemotherapeutic agent and the residual amount in the needle used for preparation.
Through this checking procedure, we were able to determine that the net weight difference was outside the tolerance level when it varied by +4% or -8% from the theoretical weight difference. As the procedure requires only an electronic weighing machine and a preparation calculation sheet we created using the Microsoft Excel computer program, its use would be inexpensive. Though the increase in preparation time due to the procedure was significant, it was actually not so great. We therefore consider it to be a useful means of checking precision in the preparation of liquid cancer chemotherapeutic agents.

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The pulverization of tablets for the preparation of pediatric medicines causes problems with respect to content uniformity and amount of the main ingredient. We compared these 2 factors in a pediatric medicine prepared by 2 methods: tablet grinding and tablet dilution. We also investigated causes of drug loss by means of high-performance liquid chromatography (HPLC).
Three pharmacists prepared cortril powder by each method. When the main ingredient content was calculated by quantitative analysis by means of HPLC, there was no significant difference between the 2 methods, and adhesion to the mortar and the package were considered to be major reasons for drug loss.
We also examined the effect of the amount of diluent on the loss of the main ingredient in the grinding process, finding that increasing the amount of diluent minimized the loss of the main ingredient content. When the amount of diluent per package was 1.5g, the main ingredient content was 90.8% (n=3).
These results suggest that when dispensing small amounts of ground tablets, more attention should be paid to the amount of diluting agents than to the grinding technique.

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Thirty percent of medical mistakes are drug-related. In order to prevent malpractice involving drugs, at Nara Medical University Hospital we had been working on a wide range of measures to prevent dispensing errors, for example, printing shelf numbers on prescriptions and cautions for shelves. However, we were unable to completely avoid dispensing errors.
In view of this we have been using a dedicated dispensing paper since 2007, giving the shelf number and quantity only, which we print out. For efficient dispensing, shelf numbers are printed in order, and the printing procedure was improved for efficiency in the use of the dispensing paper.
As a result, dispensing errors have decreased and we have been able to maintain this for more than three years. We therefore consider that the dispensing paper is useful in preventing dispensing errors.

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Few studies have been done on the use of opioids or psychotropic drugs by cancer patients in Japan. In view of this, we investigated patient records for a total of 2,044 patients, brought by themselves to our pharmacy between September 2009 and March 2010. Their median age was 67 (range 16-93) yrs, and there were 1,402 males (68.5%). The median number of prescriptions they brought with them was 4 (range: 0-23, median number of maintenance drugs = 3, median number of temporary acute therapy drugs = 0). One hundred and eighty seven patients (9.1%) had narcotic analgesic drugs other than codeine phosphate hydrate, and their median morphine-equivalent daily dose was 25mg (range 3.8-265). Six hundred and thirty four patients (31.0%) had psychotropic drugs. Among these drugs, hypnotics accounted for 17.6% (359/2044), anxiolytics 11.0% (224/2044), antipsychotics 7.4% (151/2044), antiepileptics 3.0% (61/2044), and antidepressants 2.3% (47/2044).
Our survey revealed that approximately 10% of cancer patients brought in narcotic analgesic drugs and approximately 30% of them had several psychotropics to be used as supportive medication in cancer treatment.

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