dose equivalence

[aryad]

Pt was.on glipizide 10mg 2 tabs twice daily.(max.dose is.40mg/day).somewhere down the lane as the rx was e - prescribed it got switched to the er version with same dosing.now max dose for er is 20mg/day. A new rx was e prescribed today , I noted the discrepancy and Called the doc ofc and got it switched to max.dose.so now the pt is on glipi 10mg er 2 qd.
I am confused now, shouldn't it have been glipi 10mg 2 bid .
What is the equivalence factor for er dosing ?
Is 20mg er QD = 20 mg IR BID?
And now that the pt had been on 20mg er bid what is a right switch -----
20 mg IR BID OR 20 MG ER QD?
I am.sorry if that's confusing as I write from my phone at mid night,.but can't sleep without hoping I wud get an answer soon.
Thanks guys!

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[rxlea]

ER is once daily dosing.

20mg ER

 

[Old Timer]

The question asked is, did you mean to decrease the Glipizide from 40mg/day to 20 mg/day?

 

[All4MyDaughter]

ER is once daily dosing.

20mg ER

Like Old Timer alluded, the real issue is does the patient need 20 mg or 40 mg of Glipizide per day?

20 mg ER may be the max *recommended* ER dose, but I don't think it's equivalent to what the patient was taking (20 mg IR BID). I'd be worried about halving someone's sulfonylurea dose without making any other changes to their regimen. Can you see why this could be problematic?

How long was the patient on 20 mg ER BID? I would have asked the patient how he or she was tolerating that dose and what their blood sugar readings looked like. If the patient was doing well on this dose then the OP had two options. Leave things the way they are or get it switched back to 20 mg IR (if the OP is really worried about exceeding the max *recommended* ER dose). The only way I'd be comfortable cutting the dose by 50% is if the patient wasn't tolerating the higher dose and it needed to be reduced for safety reasons. In either case, the action taken should be documented and the patient counseled.

 

[girlrx]

I wouldn't worry too much about it. Not much benefit is seen of doses over 20mg per day whether it is ir or er form. Make sure you discuss this with the patient and have them monitor their blood sugar.

 

[rxlea]

I didn't read that far into the question because the OP spoke to the doctor. I thought the question was asking if the 20mg er should be QD or if it should be 10mg er BID.

 

[All4MyDaughter]

I didn't read that far into the question because the OP spoke to the doctor. I thought the question was asking if the 20mg er should be QD or if it should be 10mg er BID.

Well, yeah. ER is once daily dosing. But this is what he was asking:

What is the equivalence factor for er dosing ?
Is 20mg er QD = 20 mg IR BID?

No.

And now that the pt had been on 20mg er bid what is a right switch ----- 20 mg IR BID OR 20 MG ER QD?

Of those two options I'd pick 20 mg IR BID. I am not comfortable cutting the dose of a stable patient by 50%. But I've also seen 40 mg ER QD so I would be ok with that too.

Since he was looking for an equivalence factor, the answer is that it's 1:1. I think he was just getting hung up on 20 mg ER being the max recommended dose. I don't think that matters too much.

We have a lot of patients on 40 mg/day in our clinic. We tend to max it out as part of our regimens before we switch the patient to insulin, because so many of our patients are vehemently opposed to insulin.

As far as the doctor agreeing to it, well... weird things happen. I've known doctors who thought you were supposed to cut the dose in half when switching from BID Lopressor to Toprol XL. That actually happened to a family member and the outcome was very poor... Another reason we need to be sure of our recommendations BEFORE we make them to the doctor.

 

[rxlea]

Well, yeah. ER is once daily dosing. But this is what he was asking:



No.



Of those two options I'd pick 20 mg IR BID. I am not comfortable cutting the dose of a stable patient by 50%. But I've also seen 40 mg ER QD so I would be ok with that too.

Since he was looking for an equivalence factor, the answer is that it's 1:1. I think he was just getting hung up on 20 mg ER being the max recommended dose. I don't think that matters too much.

We have a lot of patients on 40 mg/day in our clinic. We tend to max it out as part of our regimens before we switch the patient to insulin, because so many of our patients are vehemently opposed to insulin.

As far as the doctor agreeing to it, well... weird things happen. I've known doctors who thought you were supposed to cut the dose in half when switching from BID Lopressor to Toprol XL. That actually happened to a family member and the outcome was very poor... Another reason we need to be sure of our recommendations BEFORE we make them to the doctor.

I see that now... granted it was late and I had a beast of a week. My bad... Yeah, I have seen the 40mg/day before too because, as you stated, patients don't like to be switched to insulin.

 

[All4MyDaughter]

I see that now... granted it was late and I had a beast of a week. My bad... Yeah, I have seen the 40mg/day before too because, as you stated, patients don't like to be switched to insulin.

The stigma against it is huge. I sort of understand why, but then again, it is the most effective treatment. I have a lot of patients who need to be on insulin, but wouldn't comply if we pushed the issue.

 

[owlegrad]

The stigma against it is huge. I sort of understand why, but then again, it is the most effective treatment. I have a lot of patients who need to be on insulin, but wouldn't comply if we pushed the issue.

It's kinda weird because patients hate the idea of insulin (I would too), but compliance is a huge issue before you ever get to insulin. It's like, if you hate insulin so much, why aren't you taking your meds!? Taking your meds = delaying/preventing needing insulin! I think this is one area where education could go a long way.

 

[All4MyDaughter]

It's kinda weird because patients hate the idea of insulin (I would too), but compliance is a huge issue before you ever get to insulin. It's like, if you hate insulin so much, why aren't you taking your meds!? Taking your meds = delaying/preventing needing insulin! I think this is one area where education could go a long way.

Yeah, all kinds of compliance issues in DM management. We really should start with, "Step away from the 48 oz Coke and Twinkies, sir!"

 

[owlegrad]

Yeah, all kinds of compliance issues in DM management. We really should start with, "Step away from the 48 oz Coke and Twinkies, sir!"

Oh, God forbid diet or exercise be considered!

Side Note: My spell checker wants me to change All4MyDaughter to "Almighty". How did you program it to do that?

 

[All4MyDaughter]

Oh, God forbid diet or exercise be considered!

Side Note: My spell checker wants me to change All4MyDaughter to "Almighty". How did you program it to do that?

I have ways, my dear. I have ways!!!

 

[rxlea]

So much goes into DM management. I was talking to one of my preceptors at length on this very topic because my mother has been warned by her doctor about being put on insulin. In addition to the "take your meds", there is the need for increased exercise and changes in diet, all while keeping cultural factors in mind (like how my mother loves to cook beans with lard). Some people just don't have time to increase their exercise nor have the desire to eat healthier (cooking takes time, ya know!). It's much more complex than that, of course... those are only minor examples. I would consider going into a position, say in a clinic or ambulatory setting, where I would work with patients with DM, HTN, obesity, etc. I imagine that sort of work takes patience...

 

[npage148]

if I was type II, I would be jumping to insulin as soon as I fail metformin.