question about night float and phenergan

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tum

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just a quick question for some of the residents on here

when you're on float, and you get a call for phenergan for nausea, are there any contraindications? (if the guy's vitals are stable and he looks comfortable)

just looking it up online i found the listed contraindications (liver dysfunction, BPH, angle closure glaucoma, etoh).

are these clinically accepted contraindications? ie. what would make you jump straight to zofran? that seems like it would be contraindicated in impaired hepatic function as well

i have my first night float coming up and trying to avoid over/underthinking everything (although i might have already lost that battle)
 
tum said:
just a quick question for some of the residents on here

when you're on float, and you get a call for phenergan for nausea, are there any contraindications? (if the guy's vitals are stable and he looks comfortable)
Click to expand...

I prefer to use phenergan for nausea as a first line before going to zofran due to the cost difference. Why go for the new drugs if the cheaper generic drugs will work?

You will need to keep in mind that this is metabolized by the liver when you give it to someone with hepatic failure. And probably more important, [SIZE=-1]Promethazine[/SIZE] has strong anticholinergic properties. So you very well could turn the nauseous old pt into a combative old delirious pt. Also keep in mind that you can not give it IV or SubQ. So be careful in the older population.

Always keep in mind, if you do not think you should give it, you probably shouldn't. You can ask another resident or your attending if you're concerned about giving it to a particular pt.
 
JayneCobb said:
I prefer to use phenergan for nausea as a first line before going to zofran due to the cost difference. Why go for the new drugs if the cheaper generic drugs will work?

You will need to keep in mind that this is metabolized by the liver when you give it to someone with hepatic failure. And probably more important, [SIZE=-1]Promethazine[/SIZE] has strong anticholinergic properties. So you very well could turn the nauseous old pt into a combative old delirious pt. Also keep in mind that you can not give it IV or SubQ. So be careful in the older population.

Always keep in mind, if you do not think you should give it, you probably shouldn't. You can ask another resident or your attending if you're concerned about giving it to a particular pt.
Click to expand...

Zofran is generic now. It's cheap. Go ahead and use it!
 
JayneCobb said:
Isn't it still upwards of $25 per 4mg dose? That may be a quarter of what it was, but still no Promethazine . I'll have to double check those numbers.
Click to expand...

Per drugstore.com (which is as good a source as any I guess):
Ondansetron (generic) ~$18/4mg tablet
Promethazine (generic) ~$0.30/25mg tablet

Just for fun, I checked our VA pricing (I challenge you to get better pricing inside the US at a legit pharmacy):

Ondansetron (generic) ~$5.30/4mg tablet
Promethazine (generic) ~$0.15/25mg tablet

So...it's a whole lot cheaper than it used to be but Zofran's still >30x more expensive than Phenergan. That said, I know that my own threshold for prescribing it is lower given the price breaks. But I still try either compazine or phenergan first (assuming no contraindications of course)...if they work, problem solved for a fraction of the price.
 
brooklyneric said:
Per drugstore.com (which is as good a source as any I guess):
Ondansetron (generic) ~$18/4mg tablet
Promethazine (generic) ~$0.30/25mg tablet

Just for fun, I checked our VA pricing (I challenge you to get better pricing inside the US at a legit pharmacy):

Ondansetron (generic) ~$5.30/4mg tablet
Promethazine (generic) ~$0.15/25mg tablet

So...it's a whole lot cheaper than it used to be but Zofran's still >30x more expensive than Phenergan. That said, I know that my own threshold for prescribing it is lower given the price breaks. But I still try either compazine or phenergan first (assuming no contraindications of course)...if they work, problem solved for a fraction of the price.
Click to expand...

That's better than the last time I checked on the pricing. I'll have to call down to pharmacy and see what the hospital's cost is currently. I give Zofran, and I have no issues about zofran but I almost always start with promethazine first. I'm trying to learn to be more cost effective and efficient in my rx habits.
 
JayneCobb said:
That's better than the last time I checked on the pricing. I'll have to call down to pharmacy and see what the hospital's cost is currently. I give Zofran, and I have no issues about zofran but I almost always start with promethazine first. I'm trying to learn to be more cost effective and efficient in my rx habits.
Click to expand...

Plus, they work in different ways and phenergan may actually be more effective except in cases of anesthetic or chemo-induced nausea. Also, for our night float intern, GO SEE THE PATIENT. Always. Phenergan or Zofran for nausea is fine but neither is a very good drug for ACS, GI Bleed, SBO etc. If the primary team hasn't written for prn antiemetics, then this might be a new, important change in the patient's condition. If they should have written for prn antiemetics, but the new intern didn't know better, write a one time dose and ask your fellow intern to write for all the meds he anticipates his patient needing overnight.
 
Gastrapathy said:
Plus, they work in different ways and phenergan may actually be more effective except in cases of anesthetic or chemo-induced nausea. .
Click to expand...


Good points. I'd completely forgotten about the anesthetic & chemo nausea being one place to consider starting with Zofran over promethazine.

JayneCobb said:
. Also keep in mind that you can not give it IV or SubQ. .
Click to expand...

And just another quick learning point here. Why do we not give it IV? You can, but you can not give the 50mg/ml formulation, and even the lower concentration doses tend to cause a decent amount of discomfort, in addition to thrombo-phlebitis and tissue necrosis. The reason I bring this is up, is I frequently see promethazine ordered IV instead of IM/PO.
 
powermd said:
Zofran is generic now. It's cheap. Go ahead and use it!
Click to expand...

Some insurances will still only give your patients 6 tablets/prescription, since it is still really expensive.
 
yep. i agree with all of the above 🙂 Now the nurses here cannot even give phenergan IV anymore... They can only give po or IM. WTF right? We need h/o approval here for Zofran as it is very expensive...more appropriate for cancer peeps and kids...
 
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