Drug-Drug Interaction Acceptable?

[BME103]

Advertisement - Members don't see this ad

Is drug-drug interaction an acceptable medical risk?

I have worked in a community pharmacy for the last 3 years and I don't ever recall a doctor changing a drug he prescribed because it interacts with another drug the patient is taking. I have seen (or should I say heard) pharmacists desperately telling doctors of the interaction but the usual response is "I know of the interaction, just fill it". What do you guys think?

 

[Outcastrx]

Is drug-drug interaction an acceptable medical risk?

I have worked in a community pharmacy for the last 3 years and I don't ever recall a doctor changing a drug he prescribed because it interacts with another drug the patient is taking. I have seen (or should I say heard) pharmacists desperately telling doctors of the interaction but the usual response is "I know of the interaction, just fill it". What do you guys think?

Are you asking an interview questions? this sounds like one...

well, it depends on the situation, patients, time, place, nature of diagnosis, law, state, where it applied

if, generally speaking, the well-being of the patient comes first...do no harm!
screw the pharmacist and physician

 

[sdn1977]

Sure it is! So much depends upon the circumstance. For example, if you have an interacting drug with warfarin, lets say trazodone....and the pt has been taking & stable on trazodone for years but presents with requiring tx for a DVT. Now, you have to add warfarin. You just titrate it to the existing physiologic circumstance, which has trazodone.

Now, that is different from the pt who is stable on warfarin for a fib. Now the pt has to be treated for a sinus infection with augmentin for 3 weeks. So...you now have to monitor the INR closer since the amoxicillin may affect metabolism or platelet function.

Thats why you need a pharmacist & not just someone who reads the DUR alerts on the computer!

 

[sdn1977]

I should have added.....by informing the prescriber, he/she may approach subsequent therapy differently. You may not know you were the facilitator of that change, but it may be there nonetheless.

 

[Sosumi]

As sdn1977 said, it all depends on the situation and severity of the interaction as to whether or not an intervention is required. The fancy clinical review and alerts are only used as a screen. It's up to the pharmacist's professional judgment whether the interaction is severe enough to justify it. In community pharmacy, it doesn't get mentioned a lot because often pharmacists don't feel like they have much time nor know the circumstances enough to intervene. That's a shame since a lot of resulting subtherapy or toxicities may occur and go unnoticed since the pharmacist and prescriber aren't interacting.

Warfarin therapy is the biggest culprit which is why most patients usually go to AC clinic to have their doses adjusted because of all the drug-drug and drug-food interactions that do occur on warfarin.

 

[BME103]

I am not exactly sure why we are learning all of these drug-drug interactions in school but yet they are hardly use in regular practice. It makes me wonder if we are learning things that are practical.

 

[meg]

It's like the people who work in a nuclear reactor training for a meltdown. You hope it's not going to happen and it probably doesn't happen very often... but when you finally get that prescription which has two drugs that are horribly contraindicated.. aren't you going to be glad that you were trained to see it? Better than killing people.

 

[Trancelucent1]

My professor was recently telling us a story about a pharmacist that filled a Rx that seriously interacted with another medication they were on. The interaction ended up being fatal for the patient and as a result both the physician and the pharmacist were sued and both lost their licenses.

I think it depends where you work. In some hospitals, pharmacists go on rounds and the physicians make their recommendations based on what the pharmacist says. I think it's very important to know these things. I also think it's important that if the doctor doesn't change the med, that you counsel the patient and let them decide if they want to take the drug. Either way you're covering all your bases and then it's up to the patient to decide.

 

[BME103]

It's like the people who work in a nuclear reactor training for a meltdown. You hope it's not going to happen and it probably doesn't happen very often... but when you finally get that prescription which has two drugs that are horribly contraindicated.. aren't you going to be glad that you were trained to see it? Better than killing people.

Don't we have computer system that would warn us of severe interaction?

 

[BME103]

In some hospitals, pharmacists go on rounds and the physicians make their recommendations based on what the pharmacist says.

In most hospitals, pharmacists do not go on rounds with physicians. They only do at a few selected hospitals such as university hospitals. It is difficult to believe that after 40 years of pushing "clinical" pharmacy, only little progress has been made.

 

[Aznfarmerboi]

Don't we have computer system that would warn us of severe interaction?

The computers do warn us about most of them. However its more complicated than that as each patient is unique.

 

[Requiem]

In most hospitals, pharmacists do not go on rounds with physicians. They only do at a few selected hospitals such as university hospitals. It is difficult to believe that after 40 years of pushing "clinical" pharmacy, only little progress has been made.

You seem to troll a lot, especially for a "pharmacy student".

 

[All4MyDaughter]

Don't we have computer system that would warn us of severe interaction?

Yes, and artificial intelligence is always better than human intelligence.


Case in point, I filled a script today for Metformin. I got a red screen (major interaction/absolute contraindication) for Metformin with Congestive Heart Failure (because the patient is on Lisinopril and HCTZ).
Should I have refused to fill? What would you have done? Do you think the computer gave enough information for you to decide?

There is way more to pharmacy than reading information from a computer. It is both an art and a science.

 

[BME103]

Case in point, I filled a script today for Metformin. I got a red screen (major interaction/absolute contraindication) for Metformin with Congestive Heart Failure (because the patient is on Lisinopril and HCTZ).
Should I have refused to fill? What would you have done? Do you think the computer gave enough information for you to decide?

Let me take a guess, you decided to ask the pharmacist and he/she told you to fill it anyways because the physician wouldn't change it.

 

[All4MyDaughter]

Let me take a guess, you decided to ask the pharmacist and he/she told you to fill it anyways because the physician wouldn't change it.

Nope.

I asked the patient why they were taking Lisinopril and HCTZ.
When they indicated that it was for HBP, I specifically asked them if they had CHF.
The patient did not have CHF so I noted this in the DUR, then I used the manual override function to finish processing the script. This requires a password. As always, I printed the screen so the pharmacist could review my work when checking the prescription.

The computer is great, but lacks the ability of discernment that humans have. The computer sees Lisinopril and HCTZ (which are used for CHF), assumes the person has CHF and kicks out the metformin script. It doesn't see the alternatives or process any shades of gray.

This is a very simple example (I as an intern was able to handle it easily) but there are many more complicated scenarios where human intelligence is needed.

Technology is an important tool but it will never replaced the judgement of a trained, educated professional.

 

[BME103]

You are lucky that the computer system told you that there may be a major contraindication.

 

[All4MyDaughter]

You are lucky that the computer system told you that there may be a major contraindication.

Like I said, technology is an important tool.

 

[bananaface]

Don't we have computer system that would warn us of severe interaction?

Not necessarily. The databases aren't guaranteed comprehensive and usually update every 3 months or so. When a new interaction becomes known, it may not screen right away. For example, for the first couple of months after we discovered that patients with sulfa allergies sometimes reacted to Bextra as well, we had to check the patient's allergy history by hand because our database wasn't set up to catch the scenario.

Computer systems aren't enough. You need to know the conceptual basis for a wide variety of drug interactions to be a competent practitioner. When you call a physician on a drug interaction "my computer says this is bad" is not going to cut it. Also, your training will help you to determine which alerts are most likely to be significant and which are BS. Technology is not a replacement for a clinician.

 

[kwizard]

Is drug-drug interaction an acceptable medical risk?

I have worked in a community pharmacy for the last 3 years and I don't ever recall a doctor changing a drug he prescribed because it interacts with another drug the patient is taking. I have seen (or should I say heard) pharmacists desperately telling doctors of the interaction but the usual response is "I know of the interaction, just fill it". What do you guys think?

Please correct me if I am wrong, but I do believe the most recent Walgreens lawsuit (http://www.miami.com/mld/miamiherald/news/state/14320866.htm) is due to a pt not being informed about a "potential drug interaction". I believe the pt was on an oral contraceptive (OC) but was also on tegretol (classic enzyme inducer) for bipolar disorder. The pt is therefore suing b/c she feels that she wasn't warned about the interaction thus resulting in her pregnancy. Never mind the other potential drug interactions b/w OC and antibiotics which may produce similar results as the case cited above.

Other examples...as many have already pointed out, no the computer databases aren't perfect nor do they pick up every potential interaction. Most databases still don't pick up interactions b/w benadryl and cholinesterase inhibitors even though their mechanisms counter each other in regards to their effect on acetylcholine potentially resulting in a further decline in mental status/dementia. One of the reasons you go to pharmacy school is to be able to asess which interactions are pertinent in the pt population you serve.

Pharmacists rounding in hospitals...Yes it is true that in most hospitals pharmacists don't round; however, the reason for this is that "rounding w/ a team of various health care practitioners" in the traditional sense is typically an activity reserved for teaching hospitals b/c the purpose is to engage in a learning and educational/academic environment for everyone, but most importantly for the students/residents (medical, pharmacy, nursing, etc). Since most hospitals aren't teaching hospitals then the medical service will be provided by private practice MDs w/ supplmental care from NP/PA or by the MD paid by the hospital (i.e. hospitalists). So in this non-academic environment, the clinicians round when they have time as opposed to gathering the team on a daily basis. In this non-teaching environment some facilities often do weekly care plans w/ all of the clinicians to review the status and discharge planning of the pts on that unit/ward.

 

[npage148]

Please correct me if I am wrong, but I do believe the most recent Walgreens lawsuit (http://www.miami.com/mld/miamiherald/news/state/14320866.htm) is due to a pt not being informed about a "potential drug interaction". I believe the pt was on an oral contraceptive (OC) but was also on tegretol (classic enzyme inducer) for bipolar disorder. The pt is therefore suing b/c she feels that she wasn't warned about the interaction thus resulting in her pregnancy. Never mind the other potential drug interactions b/w OC and antibiotics which may produce similar results as the case cited above.

There is a big difference between the well defined effect of enzyme inducers like carbimazipine and rifampin casueing OC failure veruses the maybe possible we got 5 case reports that other AB will cause OC failure. If a person is on carb/rifampin they HAVE to use a different method while if they take a regular AB they maybe should use a back up method

 

[kwizard]

There is a big difference between the well defined effect of enzyme inducers like carbimazipne and rifampin casueing OC failure veruses the maybe possible we got 5 case reports that other AB will cause OC failure. If a person is on carb/rifampin they HAVE to use a different method while if they take a regular AB they maybe should use a back up method[/QUOTE]

Not to get into a debate over semantics, but the intent in the post was to draw focus to a case where a drug interactions would be significant as opposed to drawing a comparison in probability of OC failure due to enzyme inducers vs antibiotic use (esp given variability depending on antibiotics used as the anecdotal case reports you described are w/ mostly PCN and tetracycline derivatives). Although I would agree that the literature is much more definitive in regards to the interaction b/w enzyme inducers w/ OC and the literature for antibiotics w/ OCs is much more skeptical. Thanks for the further clarification.

 

[BME103]

Please correct me if I am wrong, but I do believe the most recent Walgreens lawsuit (http://www.miami.com/mld/miamiherald/news/state/14320866.htm) is due to a pt not being informed about a "potential drug interaction". I believe the pt was on an oral contraceptive (OC) but was also on tegretol (classic enzyme inducer) for bipolar disorder. The pt is therefore suing b/c she feels that she wasn't warned about the interaction thus resulting in her pregnancy.

Isn't this the same patient who is already suing Walgreens for something else?

Patient: You didn't warn me about drug-drug interactions
Pharmacist: Yes, I did.
Patient: No, you didn't.
Pharmacist: Yes, I did.

 

[kwizard]

Isn't this the same patient who is already suing Walgreens for something else?

Patient: You didn't warn me about drug-drug interactions
Pharmacist: Yes, I did.
Patient: No, you didn't.
Pharmacist: Yes, I did.

Honestly I'm not sure, but even if it does come down to a "he/she said vs he/she said" an important factor may be whether the pt checked the box saying they "refused consultation" to cover the pharmacist from liability and/or the pharmacist documented in the computer system or possibly on the order filed in the pharmacy that counseling was provided to the pt and/or prescriber was notified. Honestly even if pt refused consultation in this case the pharmacist should still make attempt to provide consultation and document that such efforts were refused by pt. Eitherway in the event that the pharmacist didn't take any of these necessary steps AND DOCUMENTED THE INFO DISCUSSED then they (the pharmacist) may find themself in an unfortunate situation. Not being too familiar w/ the specifics of the case, I really can't say for sure.

 

[BME103]

^^Just because a customer clicked on the "consultation" box doesn't mean the pharmacist didn't tell her about the interaction. It comes down to what you can prove and in this case, it is very difficult to hold the pharmacist accountable (even if he didn't tell the patient of the drug interaction).

That is why our liability insurance is so cheap!

 

[kwizard]

^^Just because a customer clicked on the "consultation" box doesn't mean the pharmacist didn't tell her about the interaction. It comes down to what you can prove and in this case, it is very difficult to hold the pharmacist accountable (even if he didn't tell the patient of the drug interaction).

That is why our liability insurance is so cheap!

Well you certainly have interesting perspectives which I don't completely agree w/ but time will tell how the case turns out. Nice debate though

 

[BME103]

Well you certainly have interesting perspectives which I don't completely agree w/ but time will tell how the case turns out. Nice debate though

I predict that Walgreens will give her a $50.00 coupon booklet and she will decide to drop the charges.