An ethical dilemma?

[Old Timer]

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Patient comes into your pharmacy with a prescription from their psychiatrist with several medications and says she will be back later. The patient has never been to your store before. The prescriptions include:

• Geodon 80 mg BID
• Chlorpromazine 50mg tid.

This is considered a contraindication according to the package insert, Facts and Comparisons and First Data Bank. The physician is contacted and is out of the office until the next day. You fax the relevant information to the physician so he can review same and call back.

The patient returns to the pharmacy and you inform the patient of the situation. The patient becomes agitated and begins yelling that she has been on this combination of medication for years. You explain the danger of taking these two medications and further explain the doctor will call back tomorrow. The patient leaves.

Two hours later another pharmacy calls and asks for a copy of the missing RX. You explain to the other pharmacist what the issue is and ask if they are aware of the interaction, yes "since it's from the same doctor it's OK"🙄

Do you give the copy?

 

[PharmDstudent]

Patient comes into your pharmacy with a prescription from their psychiatrist with several medications and says she will be back later. The patient has never been to your store before. The prescriptions include:

• Geodon 80 mg BID
• Chlorpromazine 50mg tid.

This is considered a contraindication according to the package insert, Facts and Comparisons and First Data Bank. The physician is contacted and is out of the office until the next day. You fax the relevant information to the physician so he can review same and call back.

The patient returns to the pharmacy and you inform the patient of the situation. The patient becomes agitated and begins yelling that she has been on this combination of medication for years. You explain the danger of taking these two medications and further explain the doctor will call back tomorrow. The patient leaves.

Two hours later another pharmacy calls and asks for a copy of the missing RX. You explain to the other pharmacist what the issue is and ask if they are aware of the interaction, yes "since it's from the same doctor it's OK"🙄

Do you give the copy?

No. You ask the patient to pick up their prescription. I wouldn't want my hands stained for giving out a copy.

 

[OUTexan]

I think this is situation should teach a patient to try and always fill rx at the same pharmacy. If she has been getting it for years at Pharmacy X, then why not keep going there? Why go to Pharmacy Y when Pharmacy X was filling it for years and had already contacted the doctor and had monitored her on the two drugs?

I probably would have given it to the other pharmacy if it was her original pharmacy that she has filled both of them there before.

 

[binghamkid]

Patient comes into your pharmacy with a prescription from their psychiatrist with several medications and says she will be back later. The patient has never been to your store before. The prescriptions include:

• Geodon 80 mg BID
• Chlorpromazine 50mg tid.

This is considered a contraindication according to the package insert, Facts and Comparisons and First Data Bank. The physician is contacted and is out of the office until the next day. You fax the relevant information to the physician so he can review same and call back.

The patient returns to the pharmacy and you inform the patient of the situation. The patient becomes agitated and begins yelling that she has been on this combination of medication for years. You explain the danger of taking these two medications and further explain the doctor will call back tomorrow. The patient leaves.

Two hours later another pharmacy calls and asks for a copy of the missing RX. You explain to the other pharmacist what the issue is and ask if they are aware of the interaction, yes "since it's from the same doctor it's OK"🙄

Do you give the copy?

By all means, no! The other pharmacist at the other store should definitely be firmly reminded that professionalism requires us to put the patient's well-being first and foremost. Just because the physician wrote both prescriptions does not mean it's ok. (You learn this like first day of professionalism class at pharmacy school.) Now, I don't pretend to know what these two medications do (since i"m just a P1 and haven't had much in-house pharmacy experience), but if there are contraindications listed in three different sites, it can't be good for you and precautions should be taken. Just because there are no symptoms doesn't mean something harmful isn't happening. From the case, we see that these prescriptions came from the patient's psychiatrist, so it's most likely that the symptoms are not life-threatening (i.e. drastic blood pH changes, etc. etc.). Barring a critical emergency (like these medications are necessary to treat angina or something, which they're not), these medications should not be dispensed until its been clarified with the physician. (Plus, what if they're controlled II substances? Again, I have no idea and it's 2 am here and I have an exam tomorrow at 7:30 am so I'm not going to look it up at this point in time, but I will later)

As pharmacists, we can't just be the robot in the middle. We paid lots of money to go to school to learn to think like professionals and evaluate situations.

Nice case scenario though, Old Timer 👍

 

[PharmaSynergy]

The chlorpromazine/ziprasidone interaction clearly carries the risk of QTc prolongation which could possibly lead to cardiac arrhythmias. However, in practice I've observed similar phenothiazine/atypical antipsychotic combination regimens which was usually part of a gradual switch strategy whereby the first-gen antipsychotic is gradually withdrawn while the new agent is being titrated up to full therapeutic dose. It looks like in this case the Geodon is at the max dose, and the chlorpromazine is at a relatively low dose. It could be that the patient indeed has been on this regimen for a while (maybe not *years*, but possibly several months) and is near the tail end of the titration schedule and should soon be off the chlorpromazine.

Since the psychiatrist wasn't available, I would have asked the patient at which pharmacy she usually has these meds filled. Then I'd call that pharmacy and hopefully there wouldn't be a problem confirming the Rx history, since it clearly involves a patient safety issue. Perhaps this could have prevented the patient from storming out upset and going to another pharmacy in the first place. I hope. 🙂

 

[Old Timer]

Why go to Pharmacy Y when Pharmacy X was filling it for years and had already contacted the doctor and had monitored her on the two drugs?

Read carefully, I didn't say the other pharmacy checked with the doctor. Only that since it was from the same doctor it was OK.

I also have NOT YET divulged what happened when the MD returned my call the next day, the plot thickens...

 

[PharmaSynergy]

Read carefully, I didn't say the other pharmacy checked with the doctor. Only that since it was from the same doctor it was OK.

I also have NOT YET divulged what happened when the MD returned my call the next day, the plot thickens...

The plot thickens? Ooh, even more intriguing! Was this a real case, btw? One thing we don't know is the legitimacy of the Rx in the first place, and the veracity of the patient's assertion that she "has been taking this drug combo for years".

I'm going to use my imagination here on the possibilities...

1. The MD called back and said he/she never prescribed Geodon for that patient. The Rx must have been forged whereby the patient added Geodon on it herself (b/c she saw an ad for it in a magazine 😱). (True, it's unlikely that a patient would ever forge an Rx for a psychotropic med -- if anything, they probably wish they didn't have to take *any* meds due to the side effects). The MD says that Ms. X has been on chlorpromazine for years and has been stable; he's appalled to learn of the forgery, and thanks you for being on the alert and possibly saving the patient's life. The patient probably went to a different pharmacy instead of her usual one, hoping that the "new" pharmacy wouldn't catch the abnormality.

2. The MD called back and said in fact it is a legit Rx and Ms. X has been taking that particular drug combination for quite some time and is stable on that regimen. Her cardiac function/ECG is being monitored regularly. He tells you thank you for your concern, but is not appreciative of the fact that you turned the patient away.

I wonder what really happened ...

Thanks for sharing this interesting case, OldTimer. 👍

 

[Old Timer]

The plot thickens? Ooh, even more intriguing! Was this a real case, btw?

Yes, this is a true story.

One thing we don't know is the legitimacy of the Rx in the first place, and the veracity of the patient's assertion that she "has been taking this drug combo for years".

The Prescription is valid from a known local prescriber. We do know she has taken them in the past after the phone call from the other pharmacy.

1. The MD called back and said he/she never prescribed Geodon for that patient. The Rx must have been forged whereby the patient added Geodon on it herself (b/c she saw an ad for it in a magazine 😱). (True, it's unlikely that a patient would ever forge an Rx for a psychotropic med -- if anything, they probably wish they didn't have to take *any* meds due to the side effects). The MD says that Ms. X has been on chlorpromazine for years and has been stable; he's appalled to learn of the forgery, and thanks you for being on the alert and possibly saving the patient's life. The patient probably went to a different pharmacy instead of her usual one, hoping that the "new" pharmacy wouldn't catch the abnormality.

Nice try, but that will be for the Lifetime TV version. Real life is more mundane.

2. The MD called back and said in fact it is a legit Rx and Ms. X has been taking that particular drug combination for quite some time and is stable on that regimen. Her cardiac function/ECG is being monitored regularly. He tells you thank you for your concern, but is not appreciative of the fact that you turned the patient away.

Closer to what happened, but that is not how the story ended.

I wonder what really happened ...

The patient took the prescription. In Pennsylvania, I had nor legal grounds to hold the prescription. Since all of the drugs were written on one blank, I did indicate which were filled so wherever she took the RX it both drugs would be noted. The other store has been filling this combination of drugs for an undetermined period of time. The doctor called back the next day and was unaware of the interaction and asked that it not be filled. I informed him of the situation with the other pharmacy. We discussed the need to monitor the EKG and possible have a cardiology consult. He said he would contact the patient and thanked me for my efforts.

The moral of the story is just because you have engaged in risky behavior before without incident, does not mean you can continue to engage in this behavior forever without incident.

For more information.
http://psy.psychiatryonline.org/cgi/content/full/47/3/264

http://www.torsades.org/medical-pros/drug-lists/drug-lists.htm

 

[alwaystired]

Thanks very much for the wonderful education!

Out of curiousity, what level did your computer system rank this interaction? What was the computer's recommendation.

That is one thing I wonder about how to handle sometimes and have a feeling I will be wondering TONS more when I'm on my own, I know the computer and literature gives you info, but when at quick glance, it makes me nervous to be under the pressure to decide.

I know you sometimes have to use your judgement where to draw the line on fill or not fill, but it's one of the few things I am apprehensive about for when I'm done next year.

 

[Doctor M]

Very informative! Thank you!

 

[Old Timer]

Thanks very much for the wonderful education!

Out of curiousity, what level did your computer system rank this interaction? What was the computer's recommendation.

The computer rated it as Level 1, contraindicated, these drugs should not be given together.

That is one thing I wonder about how to handle sometimes and have a feeling I will be wondering TONS more when I'm on my own, I know the computer and literature gives you info, but when at quick glance, it makes me nervous to be under the pressure to decide.

This is the hardest part of making the jump from student to pharmacist.

I know you sometimes have to use your judgement where to draw the line on fill or not fill, but it's one of the few things I am apprehensive about for when I'm done next year.

There are no hard and fast rules. Each case rests on it's own merits. That's why pharmacists get the big bucks. You have to decide or know when to make someone else (the prescriber) decide.

 

[BMBiology]

According to micromedex, the contraindication between geodon and chlorpromazine is only theoretical but lets assume it's a true contraindication.

What if she has bipolar and she harms herself because you refused to fill her geodon? Why not just give the patient her geodon and not fill chlorpromazine until you talk to the MD?

 

[CaliCPhT]

VERY interesting... I can say that I learned something today! 🙂

So, what do you think of a managed care company placing limitations on a level 1 interaction where it will not allow the medications to be filled concurrently without an authorization?

 

[Old Timer]

According to micromedex, the contraindication between geodon and chlorpromazine is only theoretical but lets assume it's a true contraindication.

What if she has bipolar and she harms herself because you refused to fill her geodon? Why not just give the patient her geodon and not fill chlorpromazine until you talk to the MD?

That's exactly what was done. If you read the link I posted it is more than theoretical. This is one case but the evidence is pretty conclusive the Geodon caused the the QT interval prolongation.

 

[Old Timer]

VERY interesting... I can say that I learned something today! 🙂

So, what do you think of a managed care company placing limitations on a level 1 interaction where it will not allow the medications to be filled concurrently without an authorization?

It depends on the level of authorization required. If they allow the pharmacist to consult with MD, document consultation and enter DUR and intervention codes, I have no problem. There are too many pharmacists like one in this case that would push it through.

 

[no-see-um]

Great thread. I'd have done the exact same thing. No way in hell I'd transfer out a prescription that involves a level 1 interaction, when I am waiting for correspondance with the prescriber. Ethics (patient well-being) and professionalism (interacting with other health providers to provide safe and effective patient care) say no. Another pharmacy has no right to come between these important relationships for the sake of expediency in filling. This is your patient.

 

[OUTexan]

One of our teachers yesterday pointed out that you cannot keep a script if a patient asks for it. It is not yours, the patient just trusted you with it. Now, how much trust are you given if the patient won't let you practice pharmacy?

 

[BMBiology]

If you read the link I posted it is more than theoretical. This is one case but the evidence is pretty conclusive the Geodon caused the the QT interval prolongation.

I am not questioning if geodon caused QT interval prolongation. I will let you re-read my post. No one is rushing you. You are not at CVS.

 

[PharmaSynergy]

According to micromedex, the contraindication between geodon and chlorpromazine is only theoretical but lets assume it's a true contraindication.

What if she has bipolar and she harms herself because you refused to fill her geodon? Why not just give the patient her geodon and not fill chlorpromazine until you talk to the MD?

I think that's a great question. It accentuates the true ethical dilemma of the case -- to fill or not to fill. In other words, is more harm done by denying the patient's psych meds and risking destabilization ... or by filling the Rx and risking the serious cardiac sequelae. If I followed OldTimer's story correctly, it sounds like neither the Geodon nor chlorpromazine were filled, but the rest of the meds listed on the same Rx blank were filled... and the patient ultimately came back and took the Rx (to supposedly have the psych meds filled elsewhere).

The idea of filling Geodon but not chlorpromazine sounds like a reasonable option, i.e, to give the patient at least one med to keep her condition stable. However, I think ultimately the safest route was to withhold both because 1) What if the patient still had some chlorpromazine at home? Dispensing Geodon would still put the patient at risk of the interaction; 2) I think it may also be going a bit out of our scope of practice to decide to fill one but not the other since both are antipsychotics - which one to give? I think the Geodon might even carry greater risk of QT prolongation in itself, independent of the chlorpromazine; 3) The MD would be in the next day to discuss the situation, so 24 hours is a *relatively* reasonable period of time to withhold such meds. After all, a bona fide effort was made to prevent a possibly serious cardiac effect which was clearly documented by multiple sources. I'm totally speculating on OldTimer's rationale in this case, so please correct me if I'm way off base. 🙂

 

[Old Timer]

The Geodon was filled and the Chlorpromazine was held until the MD called back. That was not clear in the original presentation. In any event just so you know what happens in retail, she will never come back to my store and will go to the store that gives her the prescriptions whether it is safe or not. Just the way it is. And is she were to suffer a serious cardiac event, she would sue the other store.....

 

[PharmaSynergy]

The Geodon was filled and the Chlorpromazine was held until the MD called back. That was not clear in the original presentation. In any event just so you know what happens in retail, she will never come back to my store and will go to the store that gives her the prescriptions whether it is safe or not. Just the way it is. And is she were to suffer a serious cardiac event, she would sue the other store.....

Ah, I see. Thank you for the clarification. Yep, no doubt if heaven forbid the patient were to suffer that cardiac event she'd be suing the pharmacy and pharmacist who filled the Geodon/chlorpromazine combo. And in this case, surely there'd be accountability on the part of the psychiatrist, the one who prescribed the drugs in the first place.

Btw, were there specific reasons for choosing to fill the Geodon rather than the chlorpromazine? Was it simply because it's the newer atypical antipsychotic and therefore you figured it makes more sense to fill that vs. the first-generation chlorpromazine? Or are there specific guidelines/protocols you go by to fill one vs. the other?

I guess another good moral of the story is to have adequate professional malpractice insurance coverage, right? 😉

 

[psurocks]

to be honest, id give them the copy and let em fill it...they then bear the responsibililty, not me.

 

[no-see-um]

to be honest, id give them the copy and let em fill it...they then bear the responsibililty, not me.

Transferring a medication that you have already contacted the doctor's office on with notice of a major interaction- could make you a Defendant party to such a malpractice lawsuit as well.

Just stand your ground. What's the worst the lady could do to you if you refuse to because it would cause her harm (short of a punch in the nose)- but professionally? As long as you are acting in the best interest of the patient by contacting the doctor and following up before any transfer that would have your name on it, there is absolutely NOTHING that could happen.

[Hypothetically] She irked you a little, so you'd let her die if there were a way to not have liability on your hands? Doesn't work that way, even legally. And ethically, it's obvious.

No transfer.

 

[psurocks]

Transferring a medication that you have already contacted the doctor's office on with notice of a major interaction- could make you a Defendant party to such a malpractice lawsuit as well.

Just stand your ground. What's the worst the lady could do to you if you refuse to because it would cause her harm (short of a punch in the nose)- but professionally? As long as you are acting in the best interest of the patient by contacting the doctor and following up before any transfer that would have your name on it, there is absolutely NOTHING that could happen.

[Hypothetically] She irked you a little, so you'd let her die if there were a way to not have liability on your hands? Doesn't work that way, even legally. And ethically, it's obvious.

No transfer.

but the script legally belongs to the pt, so if she wants it back, i have to give it back to her right? (unless of course the doc tells me to destroy it or something, which isnt the case here)

 

[Old Timer]

Pennsylvania law prohibits the refusal to return the prescription to the patient and also prohibits the refusal to transfer a valid order. The order was valid under PA law. I can always refuse to fill an order, but I can't keep it unless it is fake or I am instructed to do so by the provider.

I did inform the other pharmacist of the interaction, the seriousness of the interaction, my refusal to fill the prescription w/o consulting the prescriber, and that the physician was consulted. They had already filled it multiple times w/o catching or paying attention to the interaction.

Just wanted to give you guys and gals something to think about. This is a real life decision you might have to make in the retail world.