Duplicate Therapy- SSRI+SSRI/SSRI+SNRI

[josh6718]

How often do you encounter this combination working in retail and how do you resolve it? I have seen numerous patients that have prescriptions for escitalopram 10 mg + escitalopram 20 mg from the same prescriber, in addition to something like venlafaxine/duloxetine or fluoxetine and/or amitriptyline from another.

To make it worse, most of these all are usually a (re)fill 05 and only have DUR comments that only contain 'dose ok' or 'patient on both' without providing any more information.

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[Lnsean]

Huh? Escitalopram 10 + 20 from the same prescriber obviously means that they are trying to give the patient 30mg and do not want the pt to have to cut tablets. I always ask them on the first fill if they are taking both doses to equal 30mg and that's the end of that.

Venlafaxine/Duloxetine---you need to monitor these a bit more---they're more generally prescribed for nerve pain than really for depression. I'd make sure that they are not duplicating on these for sure.

Fluoxetine and Elavil: I see this combo common enough from the doctors around my area. As long as its from the same doctor, I'd be fine with filling these. Elavil is often used to help with insomnia as well and some doctors will write for a small dose at bedtime for the patient. It would be okay with me on these.

 

[Rockinacoustic]

You need to speak to the patient- and if their answer doesn't satisfy you then the prescriber. For all you know the patient should be titrating up or down on their dose or switching antidepressants entirely.

 

[Monsterdaddy]

I work part time in a behavioral health hospital and let me tell you, almost every time I verify a medication I get multiple duplicate and major contraindication warnings!!!!! And it's OK, seriously. Many mental health MD's start regimens trying one and then adding another and so on, it's like trial and error (this is from the clinical pharmacist at that hospital). As long as the patient can tolerate side effects the duplications will continue and in many cases it works.

You can always ask the patient to double check nothing was supposed to discontinue.

 

[ZakMeister]

How often do you encounter this combination working in retail and how do you resolve it? I have seen numerous patients that have prescriptions for escitalopram 10 mg + escitalopram 20 mg from the same prescriber, in addition to something like venlafaxine/duloxetine or fluoxetine and/or amitriptyline from another.

To make it worse, most of these all are usually a (re)fill 05 and only have DUR comments that only contain 'dose ok' or 'patient on both' without providing any more information.

different doses of the same med almost always means that the MD wants to give a total dose which otherwise would have to be attained by splitting. While I am not that comfortable with a total dose of LExapro 30 mg...in a pt with no cardiac issues I would pass on contacting the MD but I would still document it on the rx

However, it's a duplication and MD attention needs to be drawn if different med of the same class has been prescribed.

 

[owlegrad]

different doses of the same med almost always means that the MD wants to give a total dose which otherwise would have to be attained by splitting. While I am not that comfortable with a total dose of LExapro 30 mg...in a pt with no cardiac issues I would pass on contacting the MD but I would still document it on the rx

However, it's a duplication and MD attention needs to be drawn if different med of the same class has been prescribed.

What would you document on the RX?

 

[josh6718]

What would you document on the RX?

This I think is the biggest problem. Most of these prescriptions are ReadyFill, so there isn't an opportunity to speak to the patient prior to dispensing. You could 'force a counsel', but even if you are able to ask a patient if they're taking both they will almost always respond yes, not understanding the pharmacology and that being taking 3 SSRI's and or 2 SNRI's may not be in their best interest.

 

[ZakMeister]

What would you document on the RX?

I would document on the back of or below the initial rx (depending on if it's hard copy of an erx or written tamper resistant form) that it's a part of a regimen totalling x mg. It's best to print the DUR msg and attaching it to the rx but then I won't be able to fill 600 rxs a day

For that Lexapro 30 mg, I would note after consulting with the MD and pt that Ok'd with MD to dispense the rx and there are no obivous contraindication

 

[npage148]

Nothing is logical in psych and the risks of these drugs are exaggerated. You can push doses and 5-ht syndrome might as well be a myth. If your worried about 30 mg of lexapro I hope you never work next to a major psych hospital

 

[owlegrad]

I would document on the back of or below the initial rx (depending on if it's hard copy of an erx or written tamper resistant form) that it's a part of a regimen totalling x mg. It's best to print the DUR msg and attaching it to the rx but then I won't be able to fill 600 rxs a day

For that Lexapro 30 mg, I would note after consulting with the MD and pt that Ok'd with MD to dispense the rx and there are no obivous contraindication

I'm truly impressed that you can fill 600 a day and call about Lexapro 30 mg.

 

[owlegrad]

Nothing is logical in psych and the risks of these drugs are exaggerated. You can push doses and 5-ht syndrome might as well be a myth. If your worried about 30 mg of lexapro I hope you never work next to a major psych hospital

Yeah that's what I learned too that serotonin syndrome with less than three serotonergic agents of high doses just doesn't happen.

 

[lord999]

Nothing is logical in psych and the risks of these drugs are exaggerated. You can push doses and 5-ht syndrome might as well be a myth. If your worried about 30 mg of lexapro I hope you never work next to a major psych hospital

Except, I've actually seen a serotonin storm patient twice (one that had it during the shift and one that I dealt with at peer review), and both with fatal results from hyperthermia refractive to dantrolene and dialysis. This is VA though, and they are aggressive about medicating. 5-HT syndrome is real, but rare and fairly unpredictable to someone like me. During the one that was on shift, we did the homework afterwards and it really is as weird as the aplastic anemia effect in chloramphenicol, unpredictable but happens.

As stated by others, there really isn't much of a science around psychiatric medicines and most of the MOA's that say "centrally acting" is codespeak for "we don't know what the hell is really going on but it works". Figuring out the physiology how certain psychotropics actually work beyond the obvious chemical pathways is Nobel Prize winning work when it is done. There might be a science to prescribing, but I've seen more "try something different until it works" than any particular predefined strategy besides initial treatment.

 

[deleted820760]

I think a big problem is the fact that pharmacists verify and dispense meds, but we are not the ones seeing the patient in follow-up appointment or the hospital when something goes wrong.

My fellow pharmacists who work in the ED may see more, but we still don't see as much as physicians. This leads some of us to minimize the likelihood of serious adverse effects, because we haven't personally seen it. I know I've minimized things, too.

The percentages of various side effects to a medication in Lexi-comp do not always represent what is seen in real life. I definitely think if we were present when things went wrong and the patient sought medical care because of it, it would sink in more.

Serotonin syndrome and prolonged QT and subsequent torsades are perfect examples. I've seen someone's QTc jump up to 611 on Levaquin. It was from working in the ICU and following up on the patient. If I just worked in the basement and verified the initial order, I would have never found out about it.

 

[Sine Cura]

When someone gets TdP and you dispense knowing that the patient is actually taking multiple QTc prolongers, even though you "documented" the prescriber "said it was ok" neither you or the prescriber are likely to evade accountability if the affected patient or family pushes for it

 

[npage148]

I think a big problem is the fact that pharmacists verify and dispense meds, but we are not the ones seeing the patient in follow-up appointment or the hospital when something goes wrong.

My fellow pharmacists who work in the ED may see more, but we still don't see as much as physicians. This leads some of us to minimize the likelihood of serious adverse effects, because we haven't personally seen it. I know I've minimized things, too.

The percentages of various side effects to a medication in Lexi-comp do not always represent what is seen in real life. I definitely think if we were present when things went wrong and the patient sought medical care because of it, it would sink in more.

Serotonin syndrome and prolonged QT and subsequent torsades are perfect examples. I've seen someone's QTc jump up to 611 on Levaquin. It was from working in the ICU and following up on the patient. If I just worked in the basement and verified the initial order, I would have never found out about it.

Yes, they do happen and are real events that cause significant AE but there is no rational way to handle these rare, not always dose mediated reactions.

Unless it's obvious ddi or contraindications or dosing errors what is there to do? You call the prescriber to express your concern over 30 mg of lexapro or giving a ssri together with something like trazadone/ultram/Triptan and waste people's time and you look like a fool. Of course 5ht syndrome could happen but it so rare it's cant be rationally dealt with other than counseling the patient . Same with Qt prolongation drugs. You know patients are not getting an ekg in the office? Never dispense Levaquin? Ibu can cause SJS and yet i recommend it dozens of times a day.

Like others said, you can document you spoke with the Doctor but it won't save you in a lawsuit or from the BOP.

 

[sosoo]

depressant meds take awhile to kick in. im guessing some doctors like to start out with multiple meds to keep them alive for those more severely depressed ppl. though im actually more concern with bupropion lowering seizure threshold. i left a script aside and not verify it and so when the patient comes and its not bagged up and ready for sale they got mad. super mad when i attempt to counsel them. and yea they're picking it up for someone else who have seizure so they didn't care.. and then there's also the clueless pharmacist manager. he stood by listening and questioning me where i got my info from. he's like a clueless idiot who never knew bupropion can lower seizure threshold and got frustrated when i explain it to him.

 

[Abby Atwood]

depressant meds take awhile to kick in. im guessing some doctors like to start out with multiple meds to keep them alive for those more severely depressed ppl. though im actually more concern with bupropion lowering seizure threshold. i left a script aside and not verify it and so when the patient comes and its not bagged up and ready for sale they got mad. super mad when i attempt to counsel them. and yea they're picking it up for someone else who have seizure so they didn't care.. and then there's also the clueless pharmacist manager. he stood by listening and questioning me where i got my info from. he's like a clueless idiot who never knew bupropion can lower seizure threshold and got frustrated when i explain it to him.

Did the patient have risk factors that made you concerned about the seizure threshold being lowered?

 

[owlegrad]

Did the patient have risk factors that made you concerned about the seizure threshold being lowered?

I'm beginning to suspect that he doesn't dispense any medications. Or perhaps he prefers homeopathic medications since they don't have side effects.

 

[sosoo]

Did the patient have risk factors that made you concerned about the seizure threshold being lowered?

the patient has history of taking seizure meds. / my concern though is the pharmacy manager didn't even know that bupropion can lower seizure threshold. it was a really awkward moment.

 

[npage148]

the patient has history of taking seizure meds. / my concern though is the pharmacy manager didn't even know that bupropion can lower seizure threshold. it was a really awkward moment.

Probably was gabapentin or tegretol or another "seizure drug" that's primarily used for mood disorders and not actually seizures. Probably written buy the patients psychiatrist to boot

 

[Old]

Yes, they do happen and are real events that cause significant AE but there is no rational way to handle these rare, not always dose mediated reactions.

Unless it's obvious ddi or contraindications or dosing errors what is there to do? You call the prescriber to express your concern over 30 mg of lexapro or giving a ssri together with something like trazadone/ultram/Triptan and waste people's time and you look like a fool. Of course 5ht syndrome could happen but it so rare it's cant be rationally dealt with other than counseling the patient . Same with Qt prolongation drugs. You know patients are not getting an ekg in the office? Never dispense Levaquin? Ibu can cause SJS and yet i recommend it dozens of times a day.

Like others said, you can document you spoke with the Doctor but it won't save you in a lawsuit or from the BOP.

There is a lot of truth in the above statements. I sometimes work with the newer grads that their education was very clinically based which can be a good thing. However, in a retail setting its virtually impossible to call about every possible interaction problem that are very rare to ever occur. Yet, they do it. The other patients suffer as does the customer service because of it. When you come back the next day you hear customer complaints, tech complaints and doctors offices complaining to you about the silly calls they received the day before. Its not unusual for them to leave several pages of rxs that should have been done when they were there. In a hospital setting you are better able to determine what is correct and what is not since you would have more patient data. Perhaps with experience they will be able to be better able to determine what is a real threat to the patient and what is not.

 

[BidingMyTime]

There is a lot of truth in the above statements. I sometimes work with the newer grads that their education was very clinically based which can be a good thing. However, in a retail setting its virtually impossible to call about every possible interaction problem that are very rare to ever occur. Yet, they do it. The other patients suffer as does the customer service because of it. When you come back the next day you hear customer complaints, tech complaints and doctors offices complaining to you about the silly calls they received the day before. Its not unusual for them to leave several pages of rxs that should have been done when they were there. In a hospital setting you are better able to determine what is correct and what is not since you would have more patient data. Perhaps with experience they will be able to be better able to determine what is a real threat to the patient and what is not.

I once followed a pharmacist who, I kid you not, called on every interaction/warning/precaution that popped up in the computer. This pharmacist even left a BCP prescribed by an OB/GYN....because the pt was 12 and an age warning had popped up. Seriously.

In the grand scheme of things, life is filled with risks, and medication is no different. A pharmacist needs to be able to make an educated call on whether the benefits of a med are worth the risks, especially if the risks are very rare.

 

[deleted820760]

Yes, they do happen and are real events that cause significant AE but there is no rational way to handle these rare, not always dose mediated reactions.

Unless it's obvious ddi or contraindications or dosing errors what is there to do? You call the prescriber to express your concern over 30 mg of lexapro or giving a ssri together with something like trazadone/ultram/Triptan and waste people's time and you look like a fool. Of course 5ht syndrome could happen but it so rare it's cant be rationally dealt with other than counseling the patient . Same with Qt prolongation drugs. You know patients are not getting an ekg in the office? Never dispense Levaquin? Ibu can cause SJS and yet i recommend it dozens of times a day.

Like others said, you can document you spoke with the Doctor but it won't save you in a lawsuit or from the BOP.

Uh dude, you've got the wrong person. I think you meant to respond to OP. Lol. I know how to handle interactions and what to call on.

 

[deleted820760]

I once followed a pharmacist who, I kid you not, called on every interaction/warning/precaution that popped up in the computer. This pharmacist even left a BCP prescribed by an OB/GYN....because the pt was 12 and an age warning had popped up. Seriously.

In the grand scheme of things, life is filled with risks, and medication is no different. A pharmacist needs to be able to make an educated call on whether the benefits of a med are worth the risks, especially if the risks are very rare.

Yes, that's really annoying. I've worked with people like that, too. It's usually a new grad, but sometimes you'll find people who've been practicing for years who do that.

This one pharmacist would page the doctor over the dumbest things and then leave to go to lunch or the bathroom. The doctor would call back, and we'd be forced to ask the dumb question on her behalf. Lol.

One time I got tired of it. When the doctor called back, I said someone must have paged him by mistake. Lmao. I just verified the order myself because there wasn't a legitimate issue with it.

 

[deleted820760]

Then, there are the opposite types of pharmacists who don't evaluate anything and just click the verify button. Sigh.

I love the people who aren't one extreme or the other. Those are the best pharmacists in my opinion. They call on the right stuff.

 

[npage148]

Uh dude, you've got the wrong person. I think you meant to respond to OP. Lol. I know how to handle interactions and what to call on.

No, you just implied that pharmacists don't take these reactions seriously because we don't get to see the consequences.

 

[deleted820760]

No, you just implied that pharmacists don't take these reactions seriously because we don't get to see the consequences.

Then you made some stupid assumptions.

"You call the prescriber to express your concern over 30 mg of lexapro or giving a ssri together with something like trazadone/ultram/Triptan and waste people's time and you look like a fool. Of course 5ht syndrome could happen but it so rare it's cant be rationally dealt with other than counseling the patient . Same with Qt prolongation drugs. You know patients are not getting an ekg in the office? Never dispense Levaquin? Ibu can cause SJS and yet i recommend it dozens of times a day."

I never said any of the above examples, and I have never called the doctor on idiotic things. Are you for real right now? Lol. Read my post before you say silly things.

My post was just a general observation of pharmacists acting like side effects don't happen because we don't really see it. If someone wants to know the true likelihood of experiencing certain side effects, I think doctors would know better than pharmacists. We read about it in references, but they see it. I never said I overreact and call on everything, and I never suggested others do so. Don't read more into things that aren't written.