MODULE 3│PHARM CARE 4

DISPENSING – ADR
DISPENSING (AO 63 s.1989) 1. Prescriber info
2. Date – valid for 1 month
• Is the act by a validity-registered pharmacist of filling a 3. Patient info
prescription or doctor’s order on the patient’s chart. 4. Superscription – recipe
• Requirements in RA 6675 5. Inscription
• AO 62 – prescribing 6. Subscription
• AO 65 – labeling 7. Transcription
• Taking od order 8. Prescriber signature and license
• Compounding/ preparation
• Provision of medication advice Commonly Used Abbreviation in Prescription & Medication
• OTC drugs vs prescription drugs/ ethical drugs Order

General Steps in Dispensing 1. aa - of each

2. abd -Abdomen
1. Receiving and validating 3. ac - before meals
2. Interpreting the prescription and filling 4. ad - To, up to
3. Packaging and labeling 5. a.d - Right ear
4. Rechecking 6. ad lib - At pleasure, freely
5. Dispensing 7. AM - morning
6. Medication Advice or Patient Counselling 8. amp - Ampule of medication
7. Recording and Filling 9. aq - water
10. a.s - left ear
GPP 11.ASA - Aspirin
• Good Pharmacy Practice 12. ATC - around the clock
•Practice of pharmacy that responds to the needs of the 13. au - each ear
people who use the pharmacists’ services to provide 14. BCP - Birth Control Pill
optimal, evidence-based care. – FIP/WHO 15. bid - Twice a day
• Mission of pharmacy practice: to contribute to health 16. BM - Bowel movement
improvement and to help patients with health problems 17. BP - Blood Pressure
to make the best use of their medicines 18. BPH - Benign prostatic hypertrophy
PhilPSP 19. BS - Blood sugar
• Philippine Practice Standards for Pharmacists 20. BSA - Body Surface Area
“ARMChiP” 21. c - with
• Academe 22. Ca - Calcium
• Regulatory 23. CAD - Coronary Artery Diseases
• Manufacturing 24. DJD - Degenerative joint disease
• Community, Hospital, Institutional 25. DM - Diabetes mellitus
• Public Health 26. DO - Doctor of osteopathy
• Highlight’s role of RPh in NHCD – National Health Care 27. DW - Distilled water
Delivery 28. Dx - Diagnosis
29. elix - Elixir
PRESCRIPTION (AO 63 s.1989) 30.EtOH - Ethanol
31. Ft - Make, let it b made
• Written order and instruction of a validity registered 32. g - Gram
physician, dentist or veterinarian for the use of a specific 33. GERD - Gastro esophageal reflux Disease
drug product (or medical device) for a specific patient 34. GI - Gastrointestinal
35. GU - Genitourinary
36. gr - grain
37. gtt - a drop
38. HA - Headache
1
39. HBP - High blood pressure
.
40. HCTZ - Hydrochlorothiazide
41. HR - Heart rate
42. HRT - Hormone replacement therapy
43. hs- at bed time
3
44. HTN - hypertension
.
2 45. inj - an injection
. 46. IV - Intravenous injection
4 47. IM - Intramuscular injection
. 48. ID- Intradermal injection
49. IU - International unit
50. JRA - Juvenile rheumatoid arthritis
51. KCl - Potassium Chloride
5 52. kg - kilogram
.
53. L - liter
6 54. mcg - microgram
. 55. mEq - milliequivalent
7 56. mg - milligram
. 57. mg/kg - milligrams/kilogram
58.mg/m2 - milligrams/square meter
59. ml - milliliter
60. mOsmol - milliosmole
61.min - minimum
62. MOM - Milk of Magnesia
8 63. MS - Morphine Sulfate
. 64. MTX - Methotrexate

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65. MVI - multivitamins MEDICATION ERROR
66. m - mix
67. N&V - Nausea and vomiting • In hospital, institutional settings
68. non rep/NR - Do not repeat • Patient info (including room number)
69. noct - at night • Date (including time)
70. NS - Normal Saline • Medication prescribes
71. NTG - Nitroglycerine • Prescriber’s name
72. OA - Osteoarthritis • Transcriber’s signature
73. OCD - Obsessive compulsive disorder
74. OJ - Orange Juice DANGEROUS DRUGS PRESCRIPTION
75. O2 - Oxygen
76. ou - Each eye • Issued by PDEA
77. od - Right eye • Requires S2 license
78. os - Left eye • For dangerous drugs
79. P - Pulse • Partial filling allowed
80. pc - after eating • NO REFILLS
81. PEFR - Peak expiratory flow rate • Triplicate
82. pm - evening • Yellow – Pharmacist
92. qid - four times daily • White – Physician
93. qod - every other day • Green – Patient
94. qs - as much as is sufficient
95. qs ad - a sufficient quantity to (prepare) S2 License
96. qh - every hour
97. RA - rheumatoid arthritis
98. RN - Registered Nurse
99. Rect - use rectally
100. s - without
101. ss - one-half
102. SC - Subcutaneous injection
103. Sig - write on label
104. SL - Sublingual
105. SLE - Systemic lupus erythematous
106. SOB - Shortness of breath
107. sol - Solution
108. SQ or SubQ - Subcutaneous injection
109. stat - immediately
110. sup - Suppository
111. Susp - Suspension LIST OF DANGEROUS DRUGS PREPARATIONS INCLUDED IN
112. Sx - Symptom THE PNF
113. syr - Syrup
114. T - temperature Drugs requiring S2 License using DDB Prescription Form:
115. TB - tuberculosis 1. Alprazolam
116. TCN - Tetracycline 2. Bromazepam
117. TED - Thromboembolic disease 3. Clonazepam
118. TIA - Transient ischemic attack 4. Codeine (as phosphate)
119. tid - three times a day 5. Diazepam
120. tiw - three times a week 6. Fentanyl (as citrate)
121. tbsp. - tablespoon 7. Ketamine
122. TMP-SMX - Trimethoprim-sulfamethoxazole 8. Methylphenidate
123.tsp - teaspoon 9. Midazolam
124. top - (use) topical 10. Morphine (as sulfate)
125. Tx - treatment 11. Nalbuphine
126. U - unit 12. Oxycodone
127. UA - Uric acid, urinalysis 13. Phenobarbital
128. UC - Ulcerative colitis 14. Pethidine (meperidine)
129. ud - as directed 15. Remifentanil
130. ung - ointment 16. Zolpidem
131. URI - Upper respiratory infection Mainly:
132. ut dict - as directed • Barbiturates
133. UTI - Urinary tract infection • Benzodiazepines
134. WA - while awake • Opioids
135. wk - week
136. caps- Capsule Schedule I – has no currently accepted medical use in treatment in
137. cc - cubic centimeter (ml) the Philippines; has lack of accepted safety for use of the drug under
138. CHF - Congestive heart failure medical supervision
139. COPD - Chronic obstructive pulmonary disease
140. CP - Chest pain Schedule II – These drugs have high potential for abuse, currently
141. dil - dilute accepted w/ medical use but with some restrictions. Substance in
142. dtd - let such doses be given this schedule can lead to severe psychological or physical
143. DC - Discontinue medication dependence
145. DES - Diethylstilbestrol 1. Fentanyl (Duragesic)
146. disp - Dispense 2. Morphine (Duramorph)
147. div – Divide 3. Nabilone (Cesamet)
4. Oxycodone (Oxytoncin)
5. Dextroamphetamine (Dextrostat)
6. Dexmethylphenidate (Focolin)
7. Methylphenidate (Pitalin)
8. Aspirin (aspirin)
9. Pethidine (Demerol)
10. Hydrocodone (Vicodin)

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Schedule III – Substances in this schedule have potential for abuse • Reconstitution
less than Schedule II or/and abuse may lead to moderate or low • Mixing
physical dependence or high psychological dependence • Medication counselling in dispensing
1. Testosterone (Andriol Testocaps) • Use of medical devices
2. Phendimetrazine ( Obezine)
3. Codeine (Codipront) Tall-man Lettering
4. Oxandrolone (Oxandrin) • From US FDA, ISMP – Institute for Safe Medication
5. Buprenorphine (Buprenex) Practices
6. Buprenorphine/Naloxone (Zubsolv) • acetaZOLAMIDE vs. acetoHEXAMIDE
7. Butabarbital (Butisol) • buPROPion vs. busPIRone
8. Oxymetholone (Anadrol-50) • chlorproMAZINE vs. chlorproPAMIDE
9. Dronabinol (Marinol) • cycloSERINE vs. cycloSPORINE
10. Ketamine (Ketamax) • DOBUTamine vs. DOPamine
• hydrALAzine vs. hydrOXYzine
Schedule IV – These drugs have low potential for abuse relative to
drugs in Schedule III. Abuse of the drug may lead to limited physical Extemporaneous compounding
dependence or psychological dependence, relative to drugs in • Label
Schedule III. • Content
1. Alprazolam (Xanor) • Name of components
2. Zolpidem (Stilnox) • Quantity
3. Tramadol (Tramal) • As written in the Prescription
4. Diazepam (Valium) • Expiry date
5. Clonazepam (Rovotril) • Auxiliary label
6. Phetermine (Duromine 1/30) • Prepared by
7. Enflurane (Endurane) • Date of preparation
8. Sertraline (Zoloft)
9. Phenobarbital (Luminal Na) Sterile compounding
10. Lorazepam (Ativan)
Aseptic techniques
Schedule V – Has low potential of abuse than Schedule IV and • Laminar airflow hood
consist primarily and preparations containing limited quantities of • Vertical LAF – do not stack
certain narcotics. These are generally used as antitussive, • Horizontal LAF – do not block
antidiarrheal and analgesic purposes
1. Pregabalin (Lyrica) Terminal sterilization
2. Brompheniramine/Codeine (Nelex Ac) MOA Method
3. Locosamide (Vimpat) Moist heat Protein coagulation Autoclave (121°C,
4. Atropine/ Diphenoxylate (Vi-Atro) 15psi, 15-30mins)
5. Codeine/Phenylephrine (Ala-Hist) Dry heat Oxidation Oven (160°C., 2-4hrs)
6. Codeine/Phenylephrine/Pyralamine (Codimal PH) Membrane filtration Physical separation 0.2-micron filter
“cold sterilization”
7. Codeine/Phenylephrine/Tripolidium (Arislex Ac)
Gas Alkylation Ethylene oxide
8. Brompheniramine/ Codeine/ Phenylephrine (Brovex PBC) (carboxide: 10% EtO
9. Chlorpheniramine/Codeine/Pseudophedrine (Co-Histine OH) + 90% CO2)
10. Codeine/Guiafenesin/Phenypropanolamine (Enditussin Exp) Ionizing radiation DNA mutation Gamma rays

GENERIC PRESCRIBING OFFENSES INTERPRETING ORDER:

CHECKING FOR INCOMPATIBILITIES/ INTERACTIONS
Erroneous
• Brand name comes before generic name Drug Incompatibility
• Generic name is the one in parenthesis • Problem that may arise when two or more drugs are
• Brand name not in parenthesis combined during compounding, dispensing or administration
• Dispense, report • Physicochemical Incompatibility
Violative • Outside the body
• Only brand name is written • Directly observable
• Brand name is more legible/ prominent than the generic • Therapeutic Incompatibility/ Drug interaction
name • Inside the body
• Brand name is also written, but with instructions that prevent
other brands to be used (ex. “no substitution”) PHYSICOCHEMICAL INCOMPATIBILITY
• Do not dispense, report
Impossible Manifestation
• Generic name and/ or brand name is written, and both are • Formation of precipitate
not legible • Change in color or odor
• Generic name does not correspond to the brand name • Formation of gas
• Drug prescribes is not registered with Philippine FDA • Change of physical state from solid to liquid
• Do not dispense, report
PHYSICAL
RECORDING AND FILLING
• drug is same but physical state is altered
• Prescription record book – keep for 2 years
• Dangerous drug record book – kept for 1 year Physical: Immiscibility/ insolubility
• Poison book – keep for 5 years
• Precipitation
Filling the Order: Compounding/ Dispensing
• Often caused by dehydration/ salting out
• Electrolyte + nonelectrolyte = ppt of nonelectrolyte
Retrieval
• Electrolyte + hydroalcoholic solution = separation
• Be careful with SALAD/ HAM
of alcohol
• sound alike look alike
• Temperature change
• high alert medications: (narrow Therapeutic Index)
• Endothermic dissolution
• “Tall man lettering”
• More heat, more dissolution
• Extemporaneous compounding
• Less heat, less dissolution
• Tablet counter
• Exothermic dissolution
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 • Less heat, more dissolution Chemical: Photochemical degradation
• E.g., Ca(OH)2 solution
• Happens through photooxidation or photolysis
Physical: Liquefaction • E.g., nifedipine, nitroprusside, riboflavin

• Hygroscopic Chemical: Optical isomerism

• Absorbs moisture
• E.g., NaCl • Change in optical activity leading to change in biological
• Deliquescent effect
• Absorbs moisture, dissolves • Racemization
• E.g., NaOH, KOH, NH4Cl • Epimerization
• Efflorescent • E.g., thalidomide
• Release moisture • R – sedative
• E.g., CuSO4 • 5H2O (Roman vitriol) • S – teratogenic
Na2CO3 • 10H2O (washing soda) • Undergoes conversions in vivo
CaSO4 • 2H2O (gypsum)
• Eutexia Chemical: Others
• Melting point depression when two solids are in contact
with one another • Gelatinization/ gel formation
• Camphor + methanol • Acacia + Fe salts
• EMLA: lidocaine + prilocaine
• Cementation/ cake formation
• Acacia + Bi salts
Physical: Polymorphism
THERAPEUTIC INCOMPATIBILITY/ DRUG INTERACTION
• Changes in crystalline structure
• Cubic e.g., NaCl • When 2 or more drugs are administered and response is
• Monoclinic e.g., sucrose different from intended
• Triclinic e.g., boric acid • Precipitant drug: causes interaction
• Tetragonal e.g., urea • Object drug: affected by interaction
• Hexagonal e.g., iodoform
• Rhombic e.g., iodine DRUG – HERBAL INTERACTIONS
• Cause changes in Physical properties
• E.g., Theobroma oil • St. John’s wort + digoxin = decrease digoxin concentration
• Garlic + warfarin, heparin = increase bleeding
Physical: Sorption • Valerian + benzodiazepine = increased sedation

• Movement of drug solution to container, holder Herbal Preparations

• Related: leaching (container to solution)
• Ginseng – adaptogen
Physical: Volatilization • Echinacea – for cold symptoms
• Ginkgo – memory aid
• Happens to volatile liquids • Milk thistle – hepatoprotectant
• E.g., NTG, alcohols, aldehydes, ketones, esters • St. John’s wort – uplifts mood
Physical: Loss of water • Valerian – sleeping aid
• Saw palmetto – for enlarged prostate
• Dehydration of dosage forms
• Gritty, powdery paste DRUG – LABORATORY TEST INTERACTIONS
• Ointments – crumbling
• Emulsions – cracking • Rifampicin in urinalysis = masked color of urine
• Gels – syneresis • Ascorbic acid in glucose test = false increase in glucose
• Allopurinol in cholesterol test = false increase in
CHEMICAL cholesterol

• Drug altered DRUG – FOOD INTERACTIONS

Chemical: Redox Increased absorption

• Fatty food + griseofulvin
• From exposure to oxygen, metals
• Fats – rancidity Decreased absorption
• Ca rich food + quinolones/ tetracyclines
• Volatile oils – resinification
• Catecholamines (e.g., epinephrine – pink coloration • Any food, drink + biphosphates
• Take with plain water 30 mins before breakfast and
• Aminophylline – crystals of theophylline
remain upright for NLT 30 mins
Chemical: Acid-base reaction
Modified Metabolism
• Grapefruit – enzyme inhibitor
• Precipitation • Alcohol + metronidazole, (some) cephalosporins
• Cation drug + anion drug (methylthiotetrazole) = hangover effects
• Weakly acidic drug in acidic solution → unionized • “Disulfiram-like reactions
• Weakly basic drug in basic solution → unionized
• Evolution of gas Additive
• Acid + carbonate ion = effervescence (CO2 gas) • Tyramine rich (cheese, wine) + MAOI = HTN crisis
• K rich + spironolactone = hyperkalemia
Chemical: Hydrolysis
Antagonism
• Most common incompatibility, cause of drug degradation • Green leafy vegetables + warfarin = clotting
• Happens in the presence of water
• Esters (procaine, tetracaine, aspirin)
• Lactams (penicillin, cephalosporin)

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 DRUG – DRUG INTERACTIONS • Osmotic/ saline – NA phosphates (Fleet), lactulose,
Epsom salt (MgSO4)
PHARMACODYNAMIC • Lubricants – mineral oil, glycerin
• Anticholinergics – decreased motility = delayed absorption
Pharmacodynamic: Addition
Altered GI flora
• 1+1=2 • Antibiotic + anticoagulant = bleeding
• BZD + antihistamine = sedation • Loss of Vit. K2 (menaquinone)
• Beta blocker + non DHP CCB = bradycardia • Lesser clotting factors
• TCA + antihistamine = anticholinergic effects • Antibiotic + OCP = lower concentration
• Antidepressant + azithromycin = QT prolongation • Loss of OCP activation
• ACEi + K sparing diuretic = hyperkalemia
Pharmacokinetic: Distribution
Pharmacodynamic: Synergism
Protein binding
• 1+1>2 • Valproic acid + phenytoin = higher phenytoin conc.
• Sulfonamide (-static) + dihydrofolate reductase inhibitor (- • Aspirin + warfarin = higher warfarin conc.
static) = bactericidal • Sulfonamides + tolbutamide = more hypoglycemia
• SMX-TMP/ cotrimoxazole
• Sulfadoxine-pyrimethamine (Fansidar®) – antimalarial Altered blood flow
• Epinephrine + lidocaine = more localized effect (adrenergic
Pharmacodynamic: Antagonism vasoconstriction)

• 1+1=0 Pharmacokinetic: Metabolism

• Pharmacologic: same receptor
• Physiologic: different receptor ENZYME INHIBITORS ENZYME INDUCERS
“SICKFACES.COM GQ” “CRAPGPT S”
• Opioid agonist + Naloxone – pharmacologic
• Glucocorticoid + OHA – physiologic ↑ enzyme activity ↓ enzyme activity
↑ drug metabolism ↓ drug metabolism
• Antipsychotic + Levodopa – pharmacologic ↓ drug effect ↑ drug effect
• Epinephrine + Ach – physiologic Sodium valproate Carbamazepine
• Epinephrine + histamine – physiologic Isoniazid Rifampicin
Cimetidine Alcohol (chronic)
Pharmacodynamic: Potentiation Ketoconazole Phenytoin
Fluconazole Griseofulvin
• 1+0=2 Alcohol (Acute) Phenobarbital (Barbiturates)
• Beta lactam + Beta lactamase inhibitor Ciprofloxacin Tolbutamide (Sulfonylurea)
• Amoxicillin + Clavulanic acid (Augmentin) Erythromycin St. John’s wort
Sulfonamide
• Piperacillin + Tazobactam (Tazocin)
Disulfiram
• Ampicillin + Sulbactam (Unasyn) Chloramphenicol
• Aminoglycosides + loop diuretic (esp. ethacrynic acid) Omeprazole
ototoxicity Metronidazole
Grape fruit
Pharmacodynamic: Electrolyte Changes Quinidine

• Diuretic + Digoxin = digoxin sensitization Pharmacokinetic: Excretion

• Digoxin toxicity more probable in hypokalemia
• S/sx: N/V, xanthopsia, cardiac arrythmia Alteration of urine pH
• Low sodium + Li = Li toxicity • NaHCO3 + aspirin (acidic) = excretion
• S/sx: coarse tremors • NH4Cl + amphetamine (basic) = excretion

PHARMACOKINETIC Alteration of active tubular secretion

• Penicillin + probenecid = increase penicillin
Pharmacokinetic: Absorption • Imipenem + cilastatin = increase imipenem
• Li + NSAIDs = increase Li toxicity
Alteration of pH • Methotrexate + NSAIDs = increase MTX toxicity
• ↓ pKa acids • Digoxin + quinidine = increase digoxin toxicity
• ↑ pKa bases
• LUNA: Lipophilic Unionized Nonpolar Absorbed DRUG INTERACTION ASSESSMENT
• pH<pKa: protonated
• pH>pKa: deprotonated • Level of documentation describes degree of confidence in
• Recall: dissolution prior to absorption the occurrence of interaction
• Ketoconazole (weakly basic) + antacid = lower absorption
[unionized – low dissolution] Established
• Bisacodyl + antacid = stomach irritation [premature release] • Proven to occur in clinical studies

Complexion/ adsorption Probable

• Quinolone/ Tetracyclines + divalent, trivalent metals = • Very likely but not proven clinically
lower absorption
• Penicillamine + metals = lower absorption Suspected
• Cholestyramine, Colestipol + lipophilic drug (thyroid • Might occur, with some data available
hormone, digoxin, warfarin, vit. ADEK) = lower absorption
Possible
Altered GI motility • Could occur, but has limited data
• Laxatives, cathartics – increased motility = lower
Bioavailability for slowly absorbed drugs Unlikely
• Stimulant/ irritant – bisacodyl, senna, castor oil • Doubtful, no-good evidence
• Bulk forming – psyllium
• Surfactant/ stool softeners – docusate, PEG

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 MONITORING AFTER DISPENSING: ADE/ADRs Bizarre ADRs
Type I IgE – mediated Allergies
ADE – Adverse Drug Effects anaphylactic reaction (e.g., penicillin)
• Any toward occurrence during the use of a drug, with or Type II IgG or IgM – mediated cytotoxic Body dyscrasias
without correlation/ causality reaction (e.g., methyldopa,
chloramphenicol)
• ADR
Type III IgG – mediated Multi-system
• Toxicity immune complex reaction involvement
• Medication Error (e.g., HIPS)
Type IV T cell – mediated Dermatitis
ADR – Adverse Drug Reactions delayed reaction (e.g., urushiol,
• Any response to a drug that is noxious and unintended, tuberculin)
which occurs at doses normally used (vs toxicity) in man
for prophylaxis, diagnosis, or therapy of disease, or for the Type C – Continuous
modification of physiologic function • Related to dose and duration of drug use
• Examples
Side-effect • Steroid – Cushing’s
• Any unintended effect of a drug occurring at normal doses • Substance for abuse including caffeine – dependence/
and is related to the pharmacological properties of the habituation/ addiction
drug • Isoproterenol – tachyphylaxis
• Nitrates – tolerance (Monday sickness)
Toxicity
• Any response to a drug that is noxious and unintended or Type D – Delayed
intended, which occurs at doses higher than normally • Manifests long after exposure
used in man. • Teratogenicity, carcinogenicity
• Teratogens:
Medication error • Retinoids – heart and brain anomalies
• Preventable event that may lead to inappropriate medication • Phenytoin – fetal hydantoin syndrome
use or cause harm to the patient while the medication is in • Valproic acid – spina bifida
control of health care professional, patient or consumer • ACE inhibitor – renal dysgenesis
• Lithium – Ebstein’s anomaly
Pharmacovigilance (WHO) • Methimazole – aplasia cutis
• Science and activities relating to the detection, • Warfarin – fetal warfarin syndrome
assessment, understanding and prevention of adverse • Alcohol – fetal alcohol syndrome
effects or any other possible drug-related problems. • Thalidomide – phocomelia

Risk factors Pregnancy Safety Categories

• Age – very young and very old
• Polypharmacy Pregnant Animals Example
• Duration of use women
• Sex Category A Safe
• Comorbidities Category B Safe Unsafe Paracetamol,
No studies Safe Amoxicillin
• Therapeutic Index of drug used
Category C No studies Unsafe Rifampicin,
• Genetics
Theophylline (dose-
• N-acetyltransferase polymorphism dependent)
• Fast acetylators: Asians, Eskimos Category D Unsafe Phenytoin,
• Slow acetylators: Caucasians (benefits>risk) Tetracycline
• Drug-induced lupus: HIPSQ: hydralazine, Category E/X Unsafe Thalidomide,
isoniazid, procainamide, sulfonamide, quinidine (benefits<risk) Isotretinoin
• G6PD deficiency – Pentose Phosphate Path. (NADPH)
• Prone to hemolytic anemia from oxidative drugs Type E – End of use
• Antibiotics (sulfonamides, chloramphenicol), • From termination, sudden discontinuation
antimalarials, large dose vit. C, naphthalene, • Managed with dose tapering
methylene blue • Substances of abuse, opioids – withdrawal
• Clonidine – rebound HTN
TYPES OF ADR • Steroids – Addison’s

Type A – Augmented Type F – Failure of therapy

• Related to drug’s pharmacology • Unexpected loss of drug efficacy, mainly due to AMR
• Side effects
• Toxicity
• Common, predictable, dose-dependent reproducible
• BZD – sedation
• Opioid – constipation
• OHA – hypoglycemia
• Loop diuretic – hypokalemia
• SSRI + MAOi – serotonin syndrome

Type B – Bizarre
• Bizarre a.k.a. idiosyncratic reaction
• Unrelated to drug’s pharmacology
• Uncommon, unpredictable, dose-independent, not
reproducible

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