Lack of knowledge and negligence regarding medication use, their dosing and indications, among the majority of the population, has culminated to deal with critical situations due to overdosing of drugs and adverse events. Domperidone is used to treat nausea and vomiting. It acts as an antagonist for peripheral D2 receptor with selective activity restricted to the upper gastro intestinal tract. Here we present a brief case of a 30year old female patient who consumed overdose of a common anti-emetic drug, domperidone, which resulted in an uncommon adverse effect of this drug that is galactorrhea. To prevent these types of adverse effects and complications, it is necessary to educate patient about disease and medications and also to promote awareness among the common people about the use of over-the-counter drugs.
Keywords: Patient education, Domperidone, Awareness, Galactorrhea.
Lack of knowledge and negligence regarding medication use, their dosing and indications, among the majority of the population, has culminated to deal with critical situations due to overdosing of drugs and adverse events. There have been many cases of adverse events pertaining to overdose of prescription drugs reported so far. While most of the studies are focusing on drug, its interaction and side effects, here, we report a case in which, lack of knowledge regarding use of medications with respect to its brand name and generic name, overdose of a common anti emetic drug has occurred. With advancement in medical field number of brands on similar generic drug can be found in market. It is mainly because people only focus at the brand name of the drug, many such cases are observed which have turned out to tackle more severe circumstances than for which an individual was being treated. Brand name has been considered as the identification of the drug by common people and is judged based on colour, size and appearance of the strip or tablets. Developing countries like India where drug distribution system and drug dispensing system is not well strictly regulated, possibility of irrational use of drug increases. Galactorrhea is reported in 5%-32% percent of women. Galactorrhea or galactorrhoea is the spontaneous lactation, un-associated with childbirth or nursing.  The case discussed below is of a commonly used anti-emetic drug, domperidone, which is also available as over-the-counter drug, causing an uncommon adverse effect that is galactorrhea, spontaneous flow of milk from the breast. Standard dose is 10-20mg thrice daily, to be consumed 15-30 minutes before meal.  It can be used for maximum of 12 weeks. It is to be taken only as prescribed by the physician and dose and duration of therapy vary from person to person based on his/her severity of the symptoms of emesis. Lack of sufficient information regarding the disease and drugs results in many medication errors. Such errors can be minimized if every individual on therapy is given concise explanation of his/her disease and prescribed medications including schedule and duration of therapy with prescription. Proper instructions with preferably written format should be provided and counselling must be undertaken as a must for every patient irrespective of education status before prescribing any medication as well as while dispensing over-the-counter drugs by the pharmacists/health care professional. Prompt follow up should be encouraged and previous medications or prescriptions should be preserved so that can be verified by the physician during next follow up; or in case approaching other physician depicting a clear picture of past medications record and evading medication errors. One such case of overdosing of a drug resulting in an adverse effect is discussed further.
A 30 year old female with a history of discharge from breast from last 15 days, pain in both breast, spotting during menstrual period and nausea and vomiting. She had irregular menses and had past medication history of oral medications including Pantaprazole, Metronidazole, Dicyclomine, Mefamenic Acid, Gastracid (Antacid) and Domperidone. Vital signs were normal at the time of admission that is BP 110/80 and pulse 80 beats/ minutes. With high eosinophil value 8.5%. On discussion with the patient, she was counselled about her past illness and medication, which revealed medication overdose. Patient had experienced epigastric pain, nausea and vomiting for couple of days for which she consumed a medication bought from a local shop. Though symptoms subsided, she continued with medication unaware of long term effects. After few days she experienced gastric disturbances again though on medication and consulted a nearby government hospital and started to consume the prescribed drug, domeperidone with antacids, along with the previous medication. She had the same complaints for the third time and consulted a local nursing home and also initiated the administration of prescribed drug, domeperidone with antacids, along with drugs prescribed earlier. Though basic initial complaints were alleviated, after about a year she had fresh complaints of discharge from the breast (galactorrhea).
She had been hospitalized outside her locality in a private hospital where she had been prescribed domperidone 10mg as a prophylaxis for stomach discomfort. Improper patient knowledge about her past medications, patient continues to take all the current prescribed drugs with previous medications. As symptoms of galactorrhea did not subside, it was after a quiet time during the hospital stay where her past medications was taken into account, patient was counselled and the reason was disclosed. Patient had been consuming four times the standard dose of domperidone, as previous medications was observed to be the same drugs with different brand names. The causative agent, domperidone, was withdrawn and the symptoms subsided and patient was discharged.
Domperidone acts as anti-dopaminergic drug and thus leads to increase in lactation. Lactation is promoted by prolactine which is inhibited by dopamine but in case of overdose of domperidone there is decreased activity of dopamine and thus increased activity of prolactine and thus leading to uncontrolled lactation. Half-life of domperidone is 7 hours and 97% is excreted in a period of 4days on administration of 10mg per day (i.e., renal excretion and fecal excretion is approximately 31% and 66% respectively). So on chronic consumption of this drug, accumulation of about 3% every 4 days, can result in severe adverse effect like galactorrhea.
The case discussed above clearly implies the negligence not only among the common people but also among the health care professionals. Lack of knowledge can be considered as one of the cause among the common people especially in rural areas and on the other hand it is the inefficient system to provide proper counselling to every individual being treated for any ailments. It is very necessary in present scenario to provide necessary information regarding drugs-their dosing, frequency, schedule, duration of therapy in particular apart from route of administration, use and side effects of the prescribed drugs to every individual, to obviate any serious adverse reactions related to over dosage and create awareness among the people about giving sole importance to the contents of the medication. Also retrieving of past medications or patient history of every patient being treated for particular disease is essential, prior to prescribing of any medications to avert overlapping of prescriptions. In the case discussed above patient, unawareness has led to serious side effect owing to concomitant administration of the same drugs with different brand names on daily basis for long-term. Such serious errors can be minimized to a certain extent by informing the patient about ceasing or continuing the past medications with current prescribed drugs and necessary patient education should be provided. These are the few steps which can be taken into account to prevent over dosage, leading to adverse reactions and adverse events. Taking into account the busy schedule of the health care professionals, this can be achieved by framing a system, solely to counsel the patient and creating awareness among the common people including in rural areas. Patient information leaflets can be prepared so as to provide information about prescribed drugs as wells as about the over the counter drugs, printed in local languages to enhance the patient compliance. Seminars and workshops on commonly used drugs must be conducted by the health care professionals and spread the word among the common people especially in the rural areas where poverty and illiteracy is the root cause. A well work oriented, skilled and governed health care system must be established to impart proficient patient care. These are the few measures which may lay a foundation to a healthy living and can be a minute step to safe nation.
For better health care services, patient education is an important aspect which not only help in reducing the adverse events but also help in the effective management of the disease. So patient education regarding the disease and about the treatment should be the prime focus in health care set-up which increases the awareness among the patient with proper usage of the drug.
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