BMJ  2003;327:923 (18 October), doi:10.1136/bmj.327.7420.923

Filler

Doesn't it make you sick

An elderly Serbian woman recently presented to the hospice with symptoms of persistent nausea. She had developed breast cancer in 1980 and had undergone a mastectomy. Her disease had relapsed in 1993 and 1997. She had a history of hypothyroidism and asthma. She had been taking regular inhalers, thyroxine, and slow release aminophylline for many years.

In December 2002 she was admitted to a London teaching hospital with nausea and vomiting; trial treatment with cyclizine, levomepromazine, and metoclopramide met with limited success. Her thyroid function tests were normal, as were her renal function, liver function, and bone profile. A brain scan had ruled out brain metastases; an abdominal ultrasound ruled out liver metastases.

She was discharged from hospital in mid-January, but her symptoms had not improved. She was admitted to the hospice two weeks later. Again, we tried various combinations of antiemetics by subcutaneous infusion, we treated her constipation, and started a trial of dexamethasone. She even had a psychiatric review to rule out depression. (We found it hard to make a psychological assessment because her grasp of English was not good, and we wondered whether her symptoms might be a form of somatisation—after all, her homeland was ravaged by war.) However, her symptoms remained frustratingly unresolved.

At the hospice, we have an on-site pharmacist, Jo, who is experienced in palliative drug prescribing and is part of our multidisciplinary team. She suggested checking the patient's aminophylline levels, pointing out that this drug is notorious for its side effects and its narrow therapeutic range. The patient's drug concentration turned out to be 24 mg/l (therapeutic range 10-20 mg/l). We reduced her aminophylline dose, and within 24 hours her nausea and vomiting resolved. It was only after eight weeks of symptoms, being an inpatient at two different units, and numerous investigations and drug combinations that her drugs on admission were finally scrutinised.

We slowly reduced her aminophylline dose and finally stopped it. She was successfully discharged home a few days later. This case illustrates two points—firstly, as we already know but often forget, always consider what other drugs or other conditions a "cancer patient" has, and, secondly, the value of a sharp eyed pharmacist.

Pembridge Palliative Care Unit, St Charles Hospital, London

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