Faculty Bibliography

The epidemic of prescription opioid-related morbidity and mortality demonstrates the need for a fresh, open, and balanced approach to managing pain while minimizing adverse personal and public health outcomes. Interventions by pharmacists in situations in which prescriptions are felt to be inappropriate have raised the ire of prescribers who feel their professional judgment is being questioned and their time is being usurped from patient care. Pharmacists, however, represent an important check and balance in the opioid analgesic prescribing chain, and prescribers should embrace their involvement and recognize that the time and effort of the pharmacist are directed at improving care of individual patients and keeping a watchful eye on the public health. Pharmacies need to keep a mindful eye toward professional practices of physicians and use noninvasive means, such as database inquiries, prior to directly contacting a prescriber. Collaboration is the most professional approach that can be taken to assure that our joint priority of caring for patients in distress will be accomplished effectively and safely.

CONTEXT: Donepezil is a centrally-acting, reversible acetylcholinesterase inhibitor that is used in the treatment of Alzheimer disease. Altered mental status, nausea, vomiting, and bradycardia have been reported in therapeutic and supratherapeutic ingestions of donepezil, though pediatric exposures have not been well-described. We report a case of prolonged altered mental status and recurrent bradycardia in a child with a single-pill ingestion of donepezil. CASE DETAILS: A 14-month-old boy was brought to the Emergency Department 3 hours after ingesting one of his grandfather's donepezil tablets (10 mg). Upon arrival, he was somnolent and drooling, with multiple episodes of vomiting and diarrhea. Pupils were normal. Initial vitals: temperature, 36.8 degrees C; blood pressure, 103/56 mmHg; heart rate, 140/min; respiratory rate, 36/min; oxygen saturation, 97%. His drooling, vomiting, and diarrhea resolved, but he remained intermittently agitated. Over the course of the following four days, he had intermittent, episodes of asymptomatic bradycardia to a low of 55/min, primarily when sleeping. A transient episode of junctional rhythm was observed. Serum donepezil level 97 hours post-ingestion was 10 ng/ml. He did not require atropine treatment, and was discharged in stable condition on hospital day 5. DISCUSSION: Donepezil has a prolonged elimination of half-life in adults of approximately 70 hours. Despite its relative specificity for central AChEs, peripheral cholinergic symptoms have been described. We report a case of a symptomatic ingestion of donepezil in a child. CONCLUSIONS: Even after a single-tablet ingestion, donepezil may cause prolonged altered mental status and bradycardia in young children.