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Scenario

Dispensing assistant Tanya comes to pharmacy technician Vicky with a query on a prescription.

“The dose of this nystatin suspension is written as 4ml four times a day. The child it is for is only two years old, so that can’t be right, can it? I checked the information leaflet inside the box, and it says 1ml qds for a week, which kind of ties in with my assumption that the bottle is 30ml so it covers the course with a little bit extra included in case of spillages.

“I’ve checked with the little boy’s mum and she says it is for oral thrush, so nothing unusual there, and he’s otherwise healthy, she says, so I can’t think of anything there that would mean an increased dose. The strength of the actual product hasn’t changed, it’s still 100,000 units per ml. But the computer hasn’t flagged up the high dose as a problem. Am I missing something or has the doctor got it wrong?”

Answer

The situation regarding nystatin oral suspension is a little confusing, with different information given depending on the source that is referred to. Tanya is presumably dispensing a generic bottle of the antifungal agent, which states the dose as 1ml four times a day. However, the British National Formulary (and the BNF for Children) and the summary of product characteristics (SPC) for Nystan Oral Suspension – the branded version of the product – states the dose in oral candidiasis (thrush) as 1ml qds for babies up to one month old, 2ml qds for infants aged one month to two years, and 4-6ml qds for children aged over two years and adults.

The Nystan SPC was updated in September 2015, with both editions of the BNF changed to reflect the new dosing instructions the following summer. The alteration reflected the opinion of experts in the field, as there is little direct evidence supporting the use of several antifungal agents in the treatment of oral candidiasis. It also brought the UK in line with the US, where higher doses have been used for many years as the 1ml dose has been considered insufficient to coat the inside of the mouth and therefore exert its effect.

Tanya’s most sensible course of action is to phone the medical information department of the pharmaceutical company that makes the product she is dispensing for further advice.

The bigger picture

This scenario illustrates the importance of staying up to date with changes to medicines and practice, as the smallest thing can have a significant impact on patient care and safety. Tanya is right to have queried the prescription; if there is ever any doubt at all, it is always better to check. However, as this scenario also demonstrates, keeping up to date is not always easy, and in some cases the information available will be inconsistent, despite all sources used being reliable. If this happens, checking with Medicines Information – either the department at the relevant pharmaceutical company or your local service – is the best option.

Extend your learning

• Does your local primary care organisation and/or head office send updates on changes to medicines, services and any other matters that may affect community pharmacy? What happens to this information? Find out and see if the in-pharmacy process can be improved in any way (e.g. by making sure it is discussed at staff meetings and prominently displayed on a noticeboard or as a pop-up on the computer) so that nobody is left in the dark
• Another way of keeping abreast of changes is to regularly check the BNF “What’s New?” page and by signing up for BNF email newsletters
• See how SPC updates are logged and tracked by looking at historical data for the Nystan Oral Suspension SPC
• Read the information in the BNF or BNFC about using nystatin suspension and the information under “How do I take it?” from Netdoctor. Do you counsel patients and their parents or carers on all the points mentioned?
• Do you have the contact details of your local Medicines Information department?