MD vent

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I work at a large teaching hospital.

One doctor yesterday ordered amoxil 1,000 mg po q12 hours however the patient was an HD patient. I called to change it to 500 mg q 24 and he actually didn't understand why I wanted to decrease the schedule. he actually said "her kidneys are already gone so it doesn't matter if we renally adjust". sigh

Another doctor had ordered heparin 5,000 units subq q8 hours however the patient was on warfarin with an INR of 2.5. I called to get the heparin d/c'd and the doctor said "I was taught that a patient on warfarin even with a therapeutic INR still needs dvt ppx because warfarin doesn't prevent dvt's". double sigh. I did an ADE on that one.

Originally Posted by MackandBlues

One doctor yesterday ordered amoxil 1,000 mg po q12 hours however the patient was an HD patient. I called to change it to 500 mg q 24 and he actually didn't understand why I wanted to decrease the schedule. he actually said "her kidneys are already gone so it doesn't matter if we renally adjust". sigh

For B-lactams, they have time dependent killing, so wouldn't you lower the dose but keep the interval? If concentration dependent, keep the strength and lower the interval. Maybe I'm thinking of adjustment for renal impairment, not HD adjustment?

Originally Posted by Ackj

For B-lactams, they have time dependent killing, so wouldn't you lower the dose but keep the interval? If concentration dependent, keep the strength and lower the interval. Maybe I'm thinking of adjustment for renal impairment, not HD adjustment?

Hint- how are most beta lactams eliminated?

Re: heparin, isn't that when you pull out the fact that warfarin inhibits factors 2,7,9,10 and then ask what factors heparin inhibits? Knowing the cascade is hard but this is basic knowledge. Then again if this happened to be idk whether to chit or go blind due to the absurd nature of this statement.

Now what I'm really interested in is what service they are...I'm guessing surgery.

bleh it's not like too much amoxicillin ever hurt anybody

Originally Posted by meister

bleh it's not like too much amoxicillin ever hurt anybody

But we must adjust!

If you think about it, how many prescriptions are dispensed in community to patients with poor kidney function with no adjustments and they do just fine.

I work in long term care and I do adjust many drugs but at the end of the day its all good.

If you work at CVS or Walgreens you will fill macrobid for 70 and 80 yo patients all the time with no knowledge of the renal function. You are lucky if the docotor even writes out the full first name on the script.

Originally Posted by Pharmer187

If you think about it, how many prescriptions are dispensed in community to patients with poor kidney function with no adjustments and they do just fine.

I work in long term care and I do adjust many drugs but at the end of the day its all good.

Sometimes, I like that pharmacists correct my scripts or orders in the ER. It makes me feel secure that someone is checking on me.

However, I recall one time in which the pharmacist called me and asked me to change my macrobid script because the GFR was 58 instead of 60. I was like... let's keep it. She's allergic to everything else.

Btw, what's the main concern with macro bid and poor renal function? Is it worsening renal function and is it neuropathy?

Originally Posted by pinipig523

Btw, what's the main concern with macro bid and poor renal function? Is it worsening renal function and is it neuropathy?

It doesn't work below a CrCl of ~50 (some people say 60, some people say 40). It's activity is dependent on reaching adequate urinary concentrations, and without adequate renal function, you'll never get there. The corollary to this is that whatever drug isn't being excreted into the urine is still floating around causing the adverse drug reactions (neuropathy, neuropsychiatric, pulmonary fibrosis, etc.).

Nitrofurantoin is a great drug in the right population for short-term use, but more often I see it being used in the wrong populations (re: elderly) for chronic UTI suppression. Probably the most cut-and-dry intervention from our perspective, yet it's often one that we get a ton of pushback on.

Originally Posted by Praziquantel86

It doesn't work below a CrCl of ~50 (some people say 60, some people say 40). It's activity is dependent on reaching adequate urinary concentrations, and without adequate renal function, you'll never get there. The corollary to this is that whatever drug isn't being excreted into the urine is still floating around causing the adverse drug reactions (neuropathy, neuropsychiatric, pulmonary fibrosis, etc.).

Nitrofurantoin is a great drug in the right population for short-term use, but more often I see it being used in the wrong populations (re: elderly) for chronic UTI suppression. Probably the most cut-and-dry intervention from our perspective, yet it's often one that we get a ton of pushback on.

Gotcha... another lesson learned. Thanks!

You should see it from the PBM side. Seeing all the ways they can f-up a simple three question form or the completely ridiculous letters they send in.

Originally Posted by MountainPharmD

You should see it from the PBM side. Seeing all the ways they can f-up a simple three question form or the completely ridiculous letters they send in.

My favorite MD response of all time: We faxed a prior auth form, he faxed back the same form to us, his ONLY modification was to write "OK x3" across the front. Gee, thanks, very helpful.

For most Wisconsin Medicaid PA requests, the forms have to be sent to the pharmacy and called into an automated system. It is a rather simple form. It asks has the patient tried a preferred drug, have allergies to a preferred drug, and a few other things. So many times they cannot fill out this form correctly. They will answer yes to trying a preferred drug but not say which one. They will not sign the form. It is really frustrating.

I think this thread runs the risk of attracting disgruntled med students and residents from the medical forums to defend their honor... how long before someone tells us to shut up and count the pills?

That said, I used to review non-forumlary requests at the VA and it was hilarious. We're talking "clinical justifications" gems like, "Because I want it," and "the patient wants it," and "it's the best," and "patient allergic to generic" (when our FORMULARY is the brand name) and *blank*. It was great.

[QUOTE=All4MyDaughter;12452642]I think this thread runs the risk of attracting disgruntled med students and residents from the medical forums to defend their honor... how long before someone tells us to shut up and count the pills?

QUOTE]

Lol - bring it on! How can they defend a resident that doesn't understand why renally adjusting a medication is necessary or another resident saying that warfarin and a therapeutic INR do not prevent DVTs?

Originally Posted by All4MyDaughter

I think this thread runs the risk of attracting disgruntled med students and residents from the medical forums to defend their honor... how long before someone tells us to shut up and count the pills?

That said, I used to review non-forumlary requests at the VA and it was hilarious. We're talking "clinical justifications" gems like, "Because I want it," and "the patient wants it," and "it's the best," and "patient allergic to generic" (when our FORMULARY is the brand name) and *blank*. It was great.

I see stuff like this all day. Or how about a form with three questions is faxed back in blank except for this at the bottom scribbled in angry hand writting - "I am board certified in blah, blah, blah and when I prescribe drug xzy YOU (you is always in caps) need to pay for it."

Originally Posted by pinipig523

Sometimes, I like that pharmacists correct my scripts or orders in the ER. It makes me feel secure that someone is checking on me.

However, I recall one time in which the pharmacist called me and asked me to change my macrobid script because the GFR was 58 instead of 60. I was like... let's keep it. She's allergic to everything else.

Btw, what's the main concern with macro bid and poor renal function? Is it worsening renal function and is it neuropathy?

I'm sure you meant CrCl. Since when do we dose by GFR?

Originally Posted by aznkukuboi

I'm sure you meant CrCl. Since when do we dose by GFR?

since CrCl is used as an estimator of GFR

Originally Posted by PharmaTope

since CrCl is used as an estimator of GFR

I demand inulin Cl before adjusting doses!

Originally Posted by npage148

I demand inulin Cl before adjusting doses!

Originally Posted by PharmaTope

since CrCl is used as an estimator of GFR

GFR should never be used to adjust any renally excreted drugs...ever!!!

http://www.watag.org.au/wamsg/docs/W...DrugDosing.pdf

[QUOTE=MackandBlues;12454400]

Originally Posted by All4MyDaughter

I think this thread runs the risk of attracting disgruntled med students and residents from the medical forums to defend their honor... how long before someone tells us to shut up and count the pills?

QUOTE]

Lol - bring it on! How can they defend a resident that doesn't understand why renally adjusting a medication is necessary or another resident saying that warfarin and a therapeutic INR do not prevent DVTs?

I, for one, would never tell a pharmacist to "shut up & count the pills," but sometimes I get such pushback that it's tempting. Yes, I'm giving the patient 100 units of insulin. No, I'm not dumb. I'm treating an overdose. Yes, I want glucagon at 10mg/hour. Again, overdose management...

Yes, I want that dose of vanc. Renal function? They're on HD, who cares? It'll come off the next time they dialyze... Or they'll just throw it in with HD. Renally dosing is wholly appropriate in the proper clinical setting, but is also sometimes moot. GFR < 60 if prerenal and I'm hydrating... consider it a loading dose & adjust subsequently. [yadda]^3

As to your warfarin/therapeutic INR issue; one of the indications for filter placement is recurrent DVT *despite* a therapeutic INR... We wouldn't need filters if this didn't happen. It's called Virchow's Triad, and DVT is just a sign of some other problem; not the problem itself. Anticoagulation only modifies 1/3 of the triad...

Go here: http://www.ncbi.nlm.nih.gov/pubmed/11112236

It's not about honor; and I like the check/balance system, as we all have our different approaches to health care. But if I can clinically justify it, please gimme the drug. Oh, and do some reading on DVT and anticoagulation before spouting off on how the concept of recurrent DVT in the face of therapeutic anticoagulation isn't an issue.

Cheers!
-d

Acyclovir 200 mg. Take 1 tablet by mouth every 4 hours (5 times a day). No refills. Dispense quantity sufficient.

That's how the script was written. Called to see first what the dosing was (q 4, 5x, or 5 times separated by 4 hours?) and to find out the duration. The doctor asks what's the usual dosing on it. I'm like what are you treating?? Why not ask before writing the script instead of just writing it however, having the patient come to the pharmacy, make me page you, and then help you write it. What if the doctor had left the ER after that patient and went home? They'd yell at me! In Spanish! I don't understand Spanish!

Originally Posted by Wheresmyaricept

Acyclovir 200 mg. Take 1 tablet by mouth every 4 hours (5 times a day). No refills. Dispense quantity sufficient.

That is how acyclorvir 200mg is dosed, The only thing missing is the days supply.

Originally Posted by npage148

That is how acyclorvir 200mg is dosed, The only thing missing is the days supply.

You're missing that q4h and 5x/day are not the same thing...

Originally Posted by npage148

That is how acyclorvir 200mg is dosed, The only thing missing is the days supply.

Yes, but working next door to Yale, I try to be cautious with all the students there. It could have been they were trying to use it for an off label use because there isn't a diagnosis listed on the script. But when I called to verify that it was supposed to be every four hours five times a day and the duration, he wasn't too confident and wasn't sure how long to give it for.

Originally Posted by Carboxide

You're missing that q4h and 5x/day are not the same thing...

No I'm not. It's very typically dosed q4h 5x a day while awake (you'd skip the overnight night dose). You can find it this specified in multiple references (I just checked lexi and Clinical Pharmacology and it's there).

Originally Posted by Daiphon

I, for one, would never tell a pharmacist to "shut up & count the pills," but sometimes I get such pushback that it's tempting. Yes, I'm giving the patient 100 units of insulin. No, I'm not dumb. I'm treating an overdose. Yes, I want glucagon at 10mg/hour. Again, overdose management...

Yes, I want that dose of vanc. Renal function? They're on HD, who cares? It'll come off the next time they dialyze... Or they'll just throw it in with HD. Renally dosing is wholly appropriate in the proper clinical setting, but is also sometimes moot. GFR < 60 if prerenal and I'm hydrating... consider it a loading dose & adjust subsequently. [yadda]^3

As to your warfarin/therapeutic INR issue; one of the indications for filter placement is recurrent DVT *despite* a therapeutic INR... We wouldn't need filters if this didn't happen. It's called Virchow's Triad, and DVT is just a sign of some other problem; not the problem itself. Anticoagulation only modifies 1/3 of the triad...

Go here: http://www.ncbi.nlm.nih.gov/pubmed/11112236

It's not about honor; and I like the check/balance system, as we all have our different approaches to health care. But if I can clinically justify it, please gimme the drug. Oh, and do some reading on DVT and anticoagulation before spouting off on how the concept of recurrent DVT in the face of therapeutic anticoagulation isn't an issue.

Cheers!
-d

Thanks for the chirpy reply, but you're quoting someone else's post. I didn't post anything about warfarin or DVTs. But thanks for the tip about reading and for teaching me about Virchow's Triad. LOL

A4MD -

I responded to both, using the subsequent post to yours; the snippiness was toward Mack - not you.

In regards to your original post, I'm actually ashamed that anyone from my side of medicine would ever tell a pharmacist to shut up. Idiots like that are just that - idiots.

My beef with Mack was with the uninformed sleight against residents. Simply meant as an exhortation to fact check before tossing stones.

Any perceived sleight against you is truly unintended, and I apologize. d=)

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

I agree completely with you in regards to filter placement and recurrent dvt's, but if you read my original post the attending (she isn't a resident but an attending) actually told me "warfarin does not prevent dvt's so therefore a patient still needs dvt ppx if they are on warfarin". I was NOT talking about "recurrent DVT in the face of therapeutic anticoagulation". And in regards to vanc - an average 3-4 hour HD only removes around 50% of vanc (plus 10% removal by nonrenal elimination) so if its not renally adjusted (I love a 20 mg/kg load then around 0.5-1 gram after each HD session depending on patient weight) - it will accumulate and even though the patient's kidneys are already gone it can still cause serious adverse effects such as ototoxicity, neutropenia and thrombocytopenia.

Originally Posted by Pharmer187

GFR should never be used to adjust any renally excreted drugs...ever!!!

http://www.watag.org.au/wamsg/docs/W...DrugDosing.pdf

Well actually... there are cases where you do use GFR for adjustment.

Originally Posted by PharMed2016

Well actually... there are cases where you do use GFR for adjustment.

I think Pharmer187 means the eGFR because dose adjustment always depends on the GFR and creatinine clearance. He must mean that eGFR through MDRD calculations shouldn't be used.

This is what Sparda would do:

Originally Posted by Wheresmyaricept

Acyclovir 200 mg. Take 1 tablet by mouth every 4 hours (5 times a day). No refills. Dispense quantity sufficient. #50 Dr contacted

Now fill this script stat!

Originally Posted by pezdispenser

This is what Sparda would do:

Now fill this script stat!

Now that's a different story.