Do you dispense if individual dose exceeds recommendations?

[Curiousone1111]

Hi! When it comes to dosing variations... do you guys call MD to switch to recommended dose/frequency or get the okay, or do you just dispense without calling so long as it’s within max DAILY dose? I.e. promethazine with CODEINE. Suggested dose is 5 ml po q4-6h prn. Max 30ml/24 hrs.

Let’s say you got rx for 10 ml po q6. If u go by that, pt will possibly take up to 40 ml per day which exceeds 30ml per day AND also exceeds the individual dose of 5mL. Do we really have to be super stringent on it matching recommended doses like 10 ml per dose vs 5 ml per dose? Like if it was 10 ml(instead of 5ml) but q8h so it comes out to the same 30mL per day max, would you fill it or speak to MD since 10>5?

similar situation, I got an rx for a 13 year old. It was ibuprofen 600mg q6-8h so total 2400 mg a day, and thats the max for age 12+. However, epocrates app shows the dosing for fever as 400mg q4-6 h (1200 mg max for fever, 2400mg max for pain). Would you fill as is since its within max DAILY dose regardless of indication even if rx says fever (which should actually be a max of 1200)? Also, is it an issue that the recommendation is using 400mg tablets but MD sent for 600? I’m having a hard time determining these things and whether I should waste my energy or just fill.

Really appreciate it

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[ValeRx]

I would call on prometh/codeine and not the ibuprofen.

 

[Curiousone1111]

I would call on prometh/codeine and not the ibuprofen.

@ValeRx Would you just call on the 40 mL a day (10ml q6) since it exceeds individual and daily dose, or even if it was 10 ml q8h which would still stay within 30mL daily dose but the individual dose exceeds 5ml? Thanks a lot!

 

[ValeRx]

@ValeRx Would you just call on the 40 mL a day (10ml q6) since it exceeds individual and daily dose, or even if it was 10 ml q8h which would still stay within 30mL daily dose but the individual dose exceeds 5ml? Thanks a lot!

It would be over the recommended max daily dose, so that's why I'd call. Q8 dosing also wouldn't make any sense so I don't think you'd even see that type of situation because that drug is q4-6h.

 

[JustFillIt]

How about zolpidem 10mg for women. Call the doc on that one and see what happens.

if your lucky you may speak to the actual waiting room receptionist and/or the medical assistant.

 

[Curiousone1111]

It would be over the recommended max daily dose, so that's why I'd call. Q8 dosing also wouldn't make any sense so I don't think you'd even see that type of situation because that drug is q4-6h.

@ValeRx
There are situations like guaifenesin/dxm where dosing is 10 ml po q4h so 60mL max but the docs in my area always prescribe a higher individual dose like 20 mL po tid… it stays within max daily dose but the individual dose is double the recommended dose. Would you call or just dispense? These rxs get so annoying having to get a hold of the doc to switch the dose or get an ok if they’re really persistent for whatever reason

 

[Curiousone1111]

How about zolpidem 10mg for women. Call the doc on that one and see what happens.

if your lucky you may speak to the actual waiting room receptionist and/or the medical assistant.

@JustFillIt
Max is still 10mg/day for females even though 5mg starting dose is recommended so I never really called lol. Also, like your username. Do you just fill everything? 🤪

 

[Sparda29]

Wouldn't call for either one. 10 extra mL a day isn't gonna do any harm.

 

[JustFillIt]

@JustFillIt
Max is still 10mg/day for females even though 5mg starting dose is recommended so I never really called lol. Also, like your username. Do you just fill everything? 🤪

pretty much

 

[Curiousone1111]

Wouldn't call for either one. 10 extra mL a day isn't gonna do any harm.

@Sparda29 How about if single individual dose exceeds the recommendation? You’re talking about if overall daily dose is exceeded by 10 mL. I used to just focus more on daily dose as opposed to the individual dose too but someone brought it to my attention and now I overthink everything lmao

 

[Curiousone1111]

pretty much

@JustFillIt lmao do you ever worry about liability? I’m trying to learn how to chill but paranoid even with malpractice insurance 💀

 

[Sparda29]

@Sparda29 How about if single individual dose exceeds the recommendation? You’re talking about if overall daily dose is exceeded by 10 mL. I used to just focus more on daily dose as opposed to the individual dose too but someone brought it to my attention and now I overthink everything lmao

It really depends on the patient and their tolerance.

 

[JustFillIt]

@JustFillIt lmao do you ever worry about liability? I’m trying to learn how to chill but paranoid even with malpractice insurance 💀

Haha - well, I do joke a little. I won’t just “fill anything”. For example, I can remember refusing codeine for children, excessive opioid fills (early fills etc), and maybe something that I perceive as a severe interaction.

But In general - yes - I got over all that little stuff that just creates roadblocks. I would not loose any time over the majority of dur interactions. But I don’t make it my mission to go out of my way to refuse fills because I know someone is abusing their controlled substance. As long as they played by the rules (stuck to their fill dates, don’t have overlapping rx, etc) I would not make it my business to make a big thing about it.

But - I have not worked retail for a few years now so…. I dunno what I would fill anymore to be honest

 

[KidPharmD]

Ignoring your specific examples, I am going to say that deciding to call is a risk/benefit decision for you and the patient. How likely is this to actually hurt the patient? Are you good enough with that risk to decide not to call? Is this dose EVER appropriate for this patient (if not, I would probably call), and can you reasonably tell yourself that you can see why the doc ordered it this way.

After a while you will start to see where things are worth it and where they are not. You will also start to see that there are docs that just fundamentally disagree with what is in your reference or on the label and you will know when it isn't worth asking.

 

[Curiousone1111]

Haha - well, I do joke a little. I won’t just “fill anything”. For example, I can remember refusing codeine for children, excessive opioid fills (early fills etc), and maybe something that I perceive as a severe interaction.

But In general - yes - I got over all that little stuff that just creates roadblocks. I would not loose any time over the majority of dur interactions. But I don’t make it my mission to go out of my way to refuse fills because I know someone is abusing their controlled substance. As long as they played by the rules (stuck to their fill dates, don’t have overlapping rx, etc) I would not make it my business to make a big thing about it.

But - I have not worked retail for a few years now so…. I dunno what I would fill anymore to be honest

@JustFillIt yeah if they play by the books there isn’t much else you can do. How do you refuse to fill if other rphs have been filling early and you don’t want to do the same? The patient expects it at that point and I don’t know how to truthfully tell them it’s just against the law without them going nuts

 

[Curiousone1111]

Ignoring your specific examples, I am going to say that deciding to call is a risk/benefit decision for you and the patient. How likely is this to actually hurt the patient? Are you good enough with that risk to decide not to call? Is this dose EVER appropriate for this patient (if not, I would probably call), and can you reasonably tell yourself that you can see why the doc ordered it this way.

After a while you will start to see where things are worth it and where they are not. You will also start to see that there are docs that just fundamentally disagree with what is in your reference or on the label and you will know when it isn't worth asking.

@KidPharmD thanks a lot for your advice.

 

[Sparda29]

@JustFillIt yeah if they play by the books there isn’t much else you can do. How do you refuse to fill if other rphs have been filling early and you don’t want to do the same? The patient expects it at that point and I don’t know how to truthfully tell them it’s just against the law without them going nuts

You just tell them "they aren't supposed to give it to you early and I'm not gonna risk my license."

 

[Sine Cura]

similar situation, I got an rx for a 13 year old. It was ibuprofen 600mg q6-8h so total 2400 mg a day, and thats the max for age 12+. However, epocrates app shows the dosing for fever as 400mg q4-6 h (1200 mg max for fever, 2400mg max for pain). Would you fill as is since its within max DAILY dose regardless of indication even if rx says fever (which should actually be a max of 1200)? Also, is it an issue that the recommendation is using 400mg tablets but MD sent for 600? I’m having a hard time determining these things and whether I should waste my energy or just fill.

Really appreciate it

In the U.S. we have a fatty culture where it's socially acceptable to be 5'6" and 300+ lbs (I guess people think they are strong like Samoans, a % of which literally have an 'obesity gene', when they bulk up on junk food) and ride scooters 'cause muh knees, so that spreads to the kids who are basically adult weight.