Coumadin & Plavix

[b*rizzle]

So a man comes in yesterday and drops off a script for Plavix for his elderly father. In the process of filling, one of the pharmacists on duty finds out that the patient is on warfarin 2.5 mg daily. Both scripts are from cardiologists within the same practice. This particular pharmacist flips out (stating that it's too dangerous for anyone to be on both clopidogrel & warfarin) and refuses to fill it until after she speaks with the doctor on call. (Whom I will mention, by the way, was none too pleased to speak with her about it, and said: "Of course I know about it, just fill it anyway.")

While waiting for the MD to call us back, the son returns to pick up the prescription. Though apparently understanding of the RPh's concern, he appears irritated because he already knew about the issue, and was able to explain to the RPh why his dad was on both.

[In the meantime, myself and the other pharmacist on duty had agreed that, though risky, there are legitimate reasons for being on both at the same time. The other RPh on duty said she would have rather spoken to the son about it first, then either filled the Rx and documented the discussion (if he was definitely aware of the issue) or called the MD (if he had no clue what the big whoop was about).]

Definitely an issue of individual judgment. How would you have handled this?

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[VCU07]

So a man comes in yesterday and drops off a script for Plavix for his elderly father. In the process of filling, one of the pharmacists on duty finds out that the patient is on warfarin 2.5 mg daily. Both scripts are from cardiologists within the same practice. This particular pharmacist flips out (stating that it's too dangerous for anyone to be on both clopidogrel & warfarin) and refuses to fill it until after she speaks with the doctor on call. (Whom I will mention, by the way, was none too pleased to speak with her about it, and said: "Of course I know about it, just fill it anyway.")

While waiting for the MD to call us back, the son returns to pick up the prescription. Though apparently understanding of the RPh's concern, he appears irritated because he already knew about the issue, and was able to explain to the RPh why his dad was on both.

[In the meantime, myself and the other pharmacist on duty had agreed that, though risky, there are legitimate reasons for being on both at the same time. The other RPh on duty said she would have rather spoken to the son about it first, then either filled the Rx and documented the discussion (if he was definitely aware of the issue) or called the MD (if he had no clue what the big whoop was about).]

Definitely an issue of individual judgment. How would you have handled this?

It is ok to be on both as long as pt. is being monitored. If it came from the same practice then I let it go.

 

[ItsOverZyvox]

So a man comes in yesterday and drops off a script for Plavix for his elderly father. In the process of filling, one of the pharmacists on duty finds out that the patient is on warfarin 2.5 mg daily. Both scripts are from cardiologists within the same practice. This particular pharmacist flips out (stating that it's too dangerous for anyone to be on both clopidogrel & warfarin) and refuses to fill it until after she speaks with the doctor on call. (Whom I will mention, by the way, was none too pleased to speak with her about it, and said: "Of course I know about it, just fill it anyway.")

While waiting for the MD to call us back, the son returns to pick up the prescription. Though apparently understanding of the RPh's concern, he appears irritated because he already knew about the issue, and was able to explain to the RPh why his dad was on both.

[In the meantime, myself and the other pharmacist on duty had agreed that, though risky, there are legitimate reasons for being on both at the same time. The other RPh on duty said she would have rather spoken to the son about it first, then either filled the Rx and documented the discussion (if he was definitely aware of the issue) or called the MD (if he had no clue what the big whoop was about).]

Definitely an issue of individual judgment. How would you have handled this?

So the patient, otherwise well controlled and monitored by the cardiology practice, listens to the pharmacist and stops coumadin. He strokes but doesn't die yet is now paralyzed. I hope the pharmacist has a good mal-practice insurance.

 

[BMBiology]

Considering the pt is only on 2.5mg of coumadin, it is not too bad. Another life saved by the pharmacist.

 

[ItsOverZyvox]

Considering the pt is only on 2.5mg of coumadin, it is not too bad. Another life saved by the pharmacist.

1. How does 2.5mg being small make any difference? So it's ok for a patient on low dose warfarin to stop taking it while patient on high dose warfarin is more affected by discontinuation?

2. How did the pharmacist save another life?

 

[Priapism321]

Considering the pt is only on 2.5mg of coumadin, it is not too bad. Another life saved by the pharmacist.

I have had patients on 1 mg warfarin daily (minus clopidogrel) admitted with and INR of 7 and severe hemorrhagic complications......and conversely, patients on 15 mg daily with an INR of 1.4. This reply makes no sense at all to me.

 

[MountainPharmD]

Come on...its very simple....Big is bad and small is good. Simple concept lets get with the program

 

[BMBiology]

1. How does 2.5mg being small make any difference? So it's ok for a patient on low dose warfarin to stop taking it while patient on high dose warfarin is more affected by discontinuation?

2. How did the pharmacist save another life?

I guess I am the only one with a sense of humor today. You guys are just bitter that you did not save anybody today.

 

[BMBiology]

I have had patients on 1 mg warfarin daily (minus clopidogrel) admitted with and INR of 7 and severe hemorrhagic complications......and conversely, patients on 15 mg daily with an INR of 1.4. This reply makes no sense at all to me.

You have ruined another life. I told you to monitor the patient's INR.

 

[Old Timer]

Moral of the story:

1) Get all of the facts before you speak to the prescriber.
2) Speak with prescriber in a non-accusatory tone.

I have never had a physician yell at me for double checking something. Better safe than sorry.

Don't say "I wont dispense this combination." and then dispense it 2 hours later....

This particular pharmacist flips out (stating that it's too dangerous for anyone to be on both clopidogrel & warfarin)

If it's too dangerous for anyone to be on both why would it matter what the doctor says?

 

[WVUPharm2007]

I wonder what he'd think of some of the stuff you casually see in hospitals. A guy getting heparin with plavix!!! And then some sort of post-op Integrillin drip all at the same time?!?! My God, the patient will surely bleed all over the place like a guy in Central Africa with ebola.

 

[pkpd]

So a man comes in yesterday and drops off a script for Plavix for his elderly father. In the process of filling, one of the pharmacists on duty finds out that the patient is on warfarin 2.5 mg daily. Both scripts are from cardiologists within the same practice. This particular pharmacist flips out (stating that it's too dangerous for anyone to be on both clopidogrel & warfarin) and refuses to fill it until after she speaks with the doctor on call. (Whom I will mention, by the way, was none too pleased to speak with her about it, and said: "Of course I know about it, just fill it anyway.")

While waiting for the MD to call us back, the son returns to pick up the prescription. Though apparently understanding of the RPh's concern, he appears irritated because he already knew about the issue, and was able to explain to the RPh why his dad was on both.

[In the meantime, myself and the other pharmacist on duty had agreed that, though risky, there are legitimate reasons for being on both at the same time. The other RPh on duty said she would have rather spoken to the son about it first, then either filled the Rx and documented the discussion (if he was definitely aware of the issue) or called the MD (if he had no clue what the big whoop was about).]

Definitely an issue of individual judgment. How would you have handled this?

Every RPH is different...as for me, I'll definitely call the doctor when it comes to certain medications (example warfarin) and if the patient is a new customer or this is the first time u r filling both warfarin & plavix. I am sure the cardiologist knows very well about the DI and it is not uncommon for patients to be on both. Just be nice on the phone and tell the physician that u r just double checking with him/her so u can counsel the patient. Who cares if the son or anyone is upset because he/she has to wait. If nothing happens when the patient takes the two meds u r fine but if something bad happens...(who knows what...maybe his diet/dna leading to increase inr) then u cannot cover your ***. When bad things happen, it is natural for human beings to find someone to blame.

Always remember, protect urself...protect ur own license!

 

[GatorRxGirl]

I've seen several pts. on both and are well monitored and are post-ischemic stroke. It's great the pharmacist caught the interaction but it sounds like it was handled all wrong.