[Author Affiliation]Dean Elbe. 1 Children's & Women's Mental Health Programs, BC Mental Health & Substance Use Services, Vancouver, British Columbia. 2 Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia.Leslie Wicholas. 1 Children's & Women's Mental Health Programs, BC Mental Health & Substance Use Services, Vancouver, British Columbia. 3 Department of Psychiatry, University of British Columbia, Vancouver, British Columbia.Address correspondence to: Dean Elbe, PharmD, BCPP, Mental Health Building, P2-229, Children's & Women's Health Centre of British Columbia, Box 141-4500 Oak Street, Vancouver, BC, Canada V6H 3N1, E-mail: delbe@cw.bc.caTo the Editor:An 8-year-old boy with a history of attention-deficit/hyperactivity disorder (ADHD) combined subtype, complex partial epilepsy, pediatric migraine, nonverbal learning disorder, and anxiety disorder not otherwise specified was admitted to the inpatient child psychiatry unit of British Columbia's Children's Hospital in September 2012 for assessment and treatment. Admission medications included valproic acid (liquid) 250 mg twice daily, lisdexamfetamine 20 mg daily (dispersed in liquid), melatonin (sublingual) 5 mg at bedtime as needed, and fluoxetine 20 mg daily administered via topical application to alternating wrists every morning. The patient was extremely fearful of taking oral medications. This aversion developed after the family dog was euthanized. The patient feared that he would also die if he took oral medications. His parents had been restraining him and forcing him to take medically necessary oral medications, such as valproic acid for seizure prophylaxis.Upon learning of the topical fluoxetine prescription, the clinical pharmacist contacted the dispensing community pharmacy for details of the product. Topical fluoxetine had been dispensed since February 2012 for ∼7 months prior to admission. The product was compounded to contain fluoxetine 100 mg/mL in Lipoderm® , a proprietary permeation enhancer produced by the Pharmaceutical Compounding Centers of America.A literature search for data regarding topical absorption of fluoxetine in humans did not reveal any relevant articles. Data obtained from veterinary literature indicated that transdermal fluoxetine absorption was likely to be low (Ciribassi et al. 2003; Trepanier 2011). The patient's mother described a pattern of response consistent with what may be typically expected following administration of oral fluoxetine for treatment of anxiety, including a reduction in symptoms that was delayed in onset by 3-4 weeks following the start of topical fluoxetine administration. No adverse effects were reported. The clinical pharmacist recommended checking a serum fluoxetine level to assess whether any of the fluoxetine was reaching the systemic circulation. The patient was also very fearful of needles, and the family initially refused to consent to having bloodwork drawn. The patient's family did not want to stop topical fluoxetine administration, even following a conversation with the treating psychiatrist and clinical pharmacist about the likely low rate of transdermal absorption. Continued use of this product was considered to likely be ineffective for treatment of the patient's anxiety disorder, but very unlikely to be directly harmful to the patient.During the 1 month admission he was switched from liquid valproic acid to a divalproex sprinkle formulation (obtained via the Health Canada Special Access Program) which was consistently administered in hospital. With teaching and a rewards program implemented by unit staff, the patient became more amenable to taking medications orally. He no longer had to be restrained by his parents for medication administration. His parents consented to bloodwork to assess serum valproate and fluoxetine levels. …
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