Dispensing HIV meds

[Curiousone1111]

Hey everyone!

it’s a well known fact that HIV meds, more often than not, have a lot of DDIs. Do you just dispense, or are there any specific DDIs or concerns important enough for you to call the prescriber? I haven’t worked with a lot of HIV meds so I’ve forgotten most of my knowledge in terms of different classes and drug combination therapies. I know in retail pharmacies, clinical knowledge isn’t emphasized much. Do you just fill as is, or do you ensure it’s an appropriate dose (i.e. if a med is usually BID but md wrote for once daily, do you call?), proper combination of drug classes etc? Or is it really just patient specific? Thanks!

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[BidingMyTime]

A good question. HIV meds quickly get complicated. Whenever I do a CE on them, I'm left thinking that it definitely not my speciality.
For the most part, patients with HIV will be seeing an HIV specialist and their meds will be coming from that doctor. Unless it is something really egregious, I'd assume that the HIV specialist is aware of the drug-drug or drug-condition interactions, so I would fill and not call.

However, if the script is, say an antibiotic coming from a walk-in clinic, then I would be more concerned about any interactions, since likely the practitioner at the walk-in clinic, even if an actual physician, is not going to know much about HIV meds and interactions. At that point, if the interaction is a clear contraindication, call the physician and suggest an acceptable alternative. If the interaction is a concern, but not a clear contraindication (as is usually the case)......then considering the patient condition, what is being treated, and the interaction, you have to make the call as the pharmacist. You could dispense and counsel the patient on the interaction and encourage them to call their HIV doc on Monday, you could call the walk-in doc and suggest a change, or you could try to contact the HIV doc and refuse to dispense until you are able to make contact with the doc. When uncertain, talk to the patient, because they are likely to give you further information, to help you make a decision.

 

[Sabril]

Not that it is something to be taken lightly but I have not yet seen anyone getting into trouble due to not catching drug interactions, at least not in retail setting. Dispensing wrong drugs, wrong patients, failure to warn or counsel, even inappropriate containers yes but not DI. I think most people only act when there is a hard DUR reject.

 

[Dred Pirate]

I work hospital, so my perspective is a little different. But what you need to be aware of is when things change (HIV meds or other meds that are added by other MD's that may interact). Those you need to call on. Where it becomes relevant to me in a hospital is if there are therapeutic subs that could cause issue (PPI, fluticasone, etc)

From a retail perspective - things you should be aware of is the patient needs to be on three active agents (not counting a booster agent) unless they are on Dovato (which I think is the only approved dual agent therapy and ironically there is now a pop up add in SDN for as I type) - there may be times were a pt is only on two agents, but 99% of the time this is an error. Not necessarily by the MD, but by the pt not understanding their regimen - they make stop taking on med because there was a change and they didn't realize there were to continue it, etc.

Many agents require renal dosing, but then there is some (lamivudine for example) that technically requires renal dosing, but it is essentially non-toxic and some ID MD's just don't care to reduce, but others do

 

[Curiousone1111]

Not that it is something to be taken lightly but I have not yet seen anyone getting into trouble due to not catching drug interactions, at least not in retail setting. Dispensing wrong drugs, wrong patients, failure to warn or counsel, even inappropriate containers yes but not DI. I think most people only act when there is a hard DUR reject.

@Sabril do you pay attention to the drug combination being dispensed, the doses etc or since all that is very patient specific you just dispense as is? I’m not sure why I’m more concerned with HIV, it’s not like I try to be in control of other disease state’s therapy. Perhaps since the disease is so much more serious to keep under control? I definitely didn’t explain myself properly but hopefully you get what I meant

 

[Curiousone1111]

A good question. HIV meds quickly get complicated. Whenever I do a CE on them, I'm left thinking that it definitely not my speciality.
For the most part, patients with HIV will be seeing an HIV specialist and their meds will be coming from that doctor. Unless it is something really egregious, I'd assume that the HIV specialist is aware of the drug-drug or drug-condition interactions, so I would fill and not call.

However, if the script is, say an antibiotic coming from a walk-in clinic, then I would be more concerned about any interactions, since likely the practitioner at the walk-in clinic, even if an actual physician, is not going to know much about HIV meds and interactions. At that point, if the interaction is a clear contraindication, call the physician and suggest an acceptable alternative. If the interaction is a concern, but not a clear contraindication (as is usually the case)......then considering the patient condition, what is being treated, and the interaction, you have to make the call as the pharmacist. You could dispense and counsel the patient on the interaction and encourage them to call their HIV doc on Monday, you could call the walk-in doc and suggest a change, or you could try to contact the HIV doc and refuse to dispense until you are able to make contact with the doc. When uncertain, talk to the patient, because they are likely to give you further information, to help you make a decision.

@BidingMyTime ok, thanks for all of that! I guess I will be doing the same as you for HIV meds that come in regardless if its from a specialist or regular MD. I will fill and counsel, and only really call the doctor if a new script comes in from a different doctor. HIV definitely is not my specialty either but that’s why when i do get scripts, I find myself looking up doses and putting the meds into an interaction checker to make sure there’s no duplicate therapy. I feel like I forgot all the different classes and recommended combinations. Do you bother looking up doses/frequency? One time I was dispensing a medication which I don’t recall, and it’s supposed to be taken bid. It was written for qd and the only way I knew that was by looking up the dosing info. I called and they said it was a mistake and should be bid. Makes me wonder if I should always be looking at all that stuff or just dispense as is.

 

[Curiousone1111]

I work hospital, so my perspective is a little different. But what you need to be aware of is when things change (HIV meds or other meds that are added by other MD's that may interact). Those you need to call on. Where it becomes relevant to me in a hospital is if there are therapeutic subs that could cause issue (PPI, fluticasone, etc)

From a retail perspective - things you should be aware of is the patient needs to be on three active agents (not counting a booster agent) unless they are on Dovato (which I think is the only approved dual agent therapy and ironically there is now a pop up add in SDN for as I type) - there may be times were a pt is only on two agents, but 99% of the time this is an error. Not necessarily by the MD, but by the pt not understanding their regimen - they make stop taking on med because there was a change and they didn't realize there were to continue it, etc.

Many agents require renal dosing, but then there is some (lamivudine for example) that technically requires renal dosing, but it is essentially non-toxic and some ID MD's just don't care to reduce, but others do

Thanks so much for your thorough response!

 

[Sabril]

@Sabril do you pay attention to the drug combination being dispensed, the doses etc or since all that is very patient specific you just dispense as is? I’m not sure why I’m more concerned with HIV, it’s not like I try to be in control of other disease state’s therapy. Perhaps since the disease is so much more serious to keep under control? I definitely didn’t explain myself properly but hopefully you get what I meant

I don't usually see a lot of HIV meds so I can't comment on HIV meds specifically, but if I find myself checking meds I don't know about, I will need to slow down and pay attention to all the DUR prompts. The system won't warn me of everything but I think it's a good start. Certainly if I start to dispense a lot of these meds then I'll need to do more serious homework.

As far as dosing, I mean don't most HIV meds come as unit-of-use bottles? I would question why is something given BID if the bottle comes in as 30 tabs.

I am just saying that if I have a million things going on, then I would focus on giving the right med per prescription to the right patient first, and learn to fit everything else in with time. Again not to say to ignore DI but I don't think you'll encounter acute issues very often in a retail setting.

I wish there is a thread where people would chime in what they consider "must act" issues. Of the top of my head there're entresto and ACEI, and high dose lamotrigine for a naive patient.

 

[WorthlessOxygen]

I wish there is a thread where people would chime in what they consider "must act" issues.

Sounds like a simple enough thing to start, if one were so inclined

 

[Sine Cura]

Apparently 2x DRV/c + EVG/COBI/FTC/TAF is the new hotness for salvage

FQHC NPs insist "it's what the ID doctor wrote for"

 

[Rockinacoustic]

I don't work retail, but you should at the very least know what drugs are renally dose adjusted (so you're not always calling to verify a lower dose of 3TC or FTC in a patient who also fills a phosphate binder), and what drugs are dosed higher when patients are on inducers (i.e. DTG twice daily in patients on rifampin or phenytoin). CDC guidelines are the gold standard, but I'm sure there are CEs you can easily find for more engaging learning.

HIV has become a relatively easy disease state to control with adherence to modern HAART. Probably the biggest intervention you can make is questioning if a patient is filling the appropriate therapy or adherent if they're also filling standing orders for Bactrim, atovaquone, azithro, fluconazole, or other treatments suggestive of opportunistic infections, which in turn suggests lack of viral suppression.