- SSRIs/SNRIs: People will often ask if they can drink alcohol while starting on these. Definitely some people may experience decreased tolerance to alcohol. Package insert tells you to avoid alcohol all together. Of course people are still going to drink - I just tell them to take it slow at first if they're going to drink and see how they're effected. What do you tell your patients?
Actually, *increased* tolerance to alcohol is not that uncommon with the SSRI's. I would tell the person that drinking alcohol while on these drugs is not recommended (because alcohol can worsen the effects of depression, or worsen/precipitate migraines, or worsen nerve pain....depending on what the person is taking the SSRI for.) If they are going to drink anyway, then I would recommend that they abstain for 4 - 6 week while the drug is building up in their system, before adding in moderate drinking to the mix. I would be honest that for many people, moderate drinking can be done while on these drugs.
- Missed doses: printed recommendations are vague. It just says if you forget your dose take it ASAP but if it's almost time for your next dose skip the forgotten dose. What would you consider "almost time for your next dose"?
It really depends on the drug, but the general rule of thumb is if it's more than half-way to your next dose wait, if it's less than half-way, take the missed dose. IE, if the drug is dosed once a day at 08:00am, then you would take the dose as soon as you remember, up until 08:00pm, after 08:00pm you would just wait until the next day. This rule works for many drugs, but use your pharmaceutical knowledge to know when you should suggest otherwise.
- Missed doses of meds that shouldn't be stopped abruptly: Like beta-blockers or clonidine? If it's a lower dose, I say fine - but if it's a mid or higher dose and patient says he forgot his meds and is going to miss a dose of two?
Patients do miss does, even when they shouldn't. Then they often end up in the ER, because they've missed a week of doses. Obviously, recommend the patient take his medicines, why are his medicines unavailable? No money to replace the meds? No refills available? Give advice based on the patient's particular scenario.
- Antibiotics: of course best to spread doses out evenly best you can, but people still have to sleep. What are your recommendation on something that's taken Q8h or Q6h?
Q6 hours, spread it through out the waking hours as much as possible. Q8h is easier to do, if the patient oversleeps and takes it an hour late, that is not a big deal.
- Ketorolac: 5 days of continuous use is the recommended limit but when can they start taking it again?
This should generally be avoided. People shouldn't need more than 5 days of continuous use of ketorolac, after the 5 days, they need to be switched to an alternative pain control. Or just taking the ketorolac on an episodic basis (ie like maybe 2 or 3 doses for a migraine, but they shouldn't be having migraines that often, if they are, then preventative treatments should be used. I'm hard pressed to think of a situation where a patient would need 5 days of ketorolac, and then immediately need 5 days more. But in such a rare situation, then it would be the physician's call, based on the patient's condition, as far as I'm aware, there is no official recommendation for wait times between 5 day courses. Bear in mind, ketorolac has been taken off the market in many other countries, due to it's fatality rate. But when ketorolac was first approved in the US, there was no 5 day minimum, so many people did take it for far longer than that, and most of them lived (but not all of them did, and the fatality rate was unacceptable, which is why the 5 day limit was then put on.)
