DUR scenarios for new RPH's

[chicagoboy1984]

Hey guys. I just started working as a new RPH at CVS but have come across DUR scenarios that I did not receive sufficient training for in pharmacy school and during graduate intern training since my preceptors rarely let me verify. So here are 2 scenarios which I would appreciate some input on:

1) If you were refilling a prescription for gabapentin and the dose was extremely high (4800mg per day) and you could not find any documentation that the MD was ever called (nothing in active notes or forced notes), would you call the MD? I find that a lot of pharmacists at CVS do not document that they called the MD.

a. Or should you just assume that the original RPH who filled the gabapentin must have consulted the prescriber?

b. Also, is there a way to see how the original RPH got past the DUR (whether they clicked on prescriber consulted or patient consulted)?

c. If you assumed the original RPH actually consulted the prescriber before filling the first fill, if an ADR resulted in the future from the high dose, would you as an RPH who refilled the high dose be liable? Or does liability mainly rest with the original RPH?




2) What if you encountered a major drug interaction (say, diltiazem and simvastatin 80mg) when refilling a patient's diltiazem? If both drugs were refills but were from different MD's, I would want to see an active note documented that the MD was consulted. However, if I do not find one, should I call the MD?

a. Or should I assume the original RPH did his/her job by calling MD but forgot to document (although the RPH must have clicked on "prescriber consulted" to get past the DUR; therefore, that would technically serve as documentation that MD was consulted, correct?)




Any input would be greatly appreciated. Thanks.

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[chuckle beast]

If patient has been on gabapentin awhile or its been gradual increase I wouldn't call

Simvastatin/dilt combo it's reasonable to call to get authorization then make note. It's your license.

 

[pezdispenser]

The Walgreens system has a third option that says "Reviewed patient history" which is the one I would use on a refill. I'm comfortable with this, but it's really up to you. If you want to call the doctor and document, go right ahead

 

[Sparda29]

Hey guys. I just started working as a new RPH at CVS but have come across DUR scenarios that I did not receive sufficient training for in pharmacy school and during graduate intern training since my preceptors rarely let me verify. So here are 2 scenarios which I would appreciate some input on:

1) If you were refilling a prescription for gabapentin and the dose was extremely high (4800mg per day) and you could not find any documentation that the MD was ever called (nothing in active notes or forced notes), would you call the MD? I find that a lot of pharmacists at CVS do not document that they called the MD.

a. Or should you just assume that the original RPH who filled the gabapentin must have consulted the prescriber?

b. Also, is there a way to see how the original RPH got past the DUR (whether they clicked on prescriber consulted or patient consulted)?

c. If you assumed the original RPH actually consulted the prescriber before filling the first fill, if an ADR resulted in the future from the high dose, would you as an RPH who refilled the high dose be liable? Or does liability mainly rest with the original RPH?




2) What if you encountered a major drug interaction (say, diltiazem and simvastatin 80mg) when refilling a patient’s diltiazem? If both drugs were refills but were from different MD’s, I would want to see an active note documented that the MD was consulted. However, if I do not find one, should I call the MD?

a. Or should I assume the original RPH did his/her job by calling MD but forgot to document (although the RPH must have clicked on “prescriber consulted” to get past the DUR; therefore, that would technically serve as documentation that MD was consulted, correct?)




Any input would be greatly appreciated. Thanks.

Gabapentin scenario, yeah call to verify. Simvastatin/diltiazem scenario, screw verifying it, just tell the asshat physician to get them off simvastatin and onto atorvastatin or Crestor.

 

[All4MyDaughter]

Gabapentin scenario, yeah call to verify. Simvastatin/diltiazem scenario, screw verifying it, just tell the asshat physician to get them off simvastatin and onto atorvastatin or Crestor.

FYI, atorvastatin also interacts with diltiazem. If the patient has been on the combination for a long time without incident, I would probably document that I counseled the patient and fill.

As far as gabapentin, I'd ask the patient how long he or she has been on the dose, if they are having any adverse effects and how well it seems to be working for them. I'd look at the profile to verify history of dose escalation and I'd recheck that the original hard copy RX was filled completely.

 

[chicagoboy1984]

For gabapentin, I think it was just the patient's 3rd refill. It was super busy at the pharmacy that day (surprise surprise), and the patient's boyfriend was waiting. So, as a rookie pharmacist who didn't want to make others wait and ruin my wait time, I just filled it and counseled the pt's boyfriend to follow up with MD to monitor renal function. I also asked if she was getting excessive dizziness/drowsiness from gabapentin, which he said she didn't. I then documented my counseling session with the boyfriend in the computer system. How much of myself did I cover? LOL

For dilt/simva, I passed it onto another pharmacist who made the MD call since I had a lot of waiters and had to verify quickly. The PIC tried to convince me to just fill it anyway, but I did not feel comfortable, so he told me to give it to another pharmacist.

 

[Sparda29]

FYI, atorvastatin also interacts with diltiazem. If the patient has been on the combination for a long time without incident, I would probably document that I counseled the patient and fill.

As far as gabapentin, I'd ask the patient how long he or she has been on the dose, if they are having any adverse effects and how well it seems to be working for them. I'd look at the profile to verify history of dose escalation and I'd recheck that the original hard copy RX was filled completely.

It does, but at least you'd be able to have a lower dose of the atorvastatin.

I wonder though, since atorvastatin is more potent, does it also have a higher risk of muscle injury? It would be an interesting study, max dose of Simvastatin Vs max dose of Atorvastatin Vs max dose of Rosuvastatin.

 

[BidingMyTime]

Hey guys. I just started working as a new RPH at CVS but have come across DUR scenarios that I did not receive sufficient training for in pharmacy school and during graduate intern training since my preceptors rarely let me verify. So here are 2 scenarios which I would appreciate some input on:

1) If you were refilling a prescription for gabapentin and the dose was extremely high (4800mg per day) and you could not find any documentation that the MD was ever called (nothing in active notes or forced notes), would you call the MD? I find that a lot of pharmacists at CVS do not document that they called the MD.

a. Or should you just assume that the original RPH who filled the gabapentin must have consulted the prescriber?

b. Also, is there a way to see how the original RPH got past the DUR (whether they clicked on prescriber consulted or patient consulted)?

c. If you assumed the original RPH actually consulted the prescriber before filling the first fill, if an ADR resulted in the future from the high dose, would you as an RPH who refilled the high dose be liable? Or does liability mainly rest with the original RPH?




2) What if you encountered a major drug interaction (say, diltiazem and simvastatin 80mg) when refilling a patient’s diltiazem? If both drugs were refills but were from different MD’s, I would want to see an active note documented that the MD was consulted. However, if I do not find one, should I call the MD?

a. Or should I assume the original RPH did his/her job by calling MD but forgot to document (although the RPH must have clicked on “prescriber consulted” to get past the DUR; therefore, that would technically serve as documentation that MD was consulted, correct?)




Any input would be greatly appreciated. Thanks.

Good questions. It's hard first starting out....with experience, you will have a better idea of your local prescribers habits, and which interactions are unlikely to be clinically significant. When I first went back to retail after many years away, I called doctors on a lot more stuff then, than I do today (either because I've realized the interaction is rarely going to be clinically significant, or because I know the prescriber isn't going to change it anyway)

Refills are especially tricky...in general, I usually assume any problems were handled by the original filling pharmacist (either by talking with the pt or the doctor). Especially if the pt has been on the therapy for a long time. But ultimately, you are legally responsible for each prescription you fill, so you must be comfortable with it. With a refill, I would probably consult with the pt, make sure they are aware of the possible interaction/problems and see if they know if the doctor has ever talked about their therapy with either the pt or a pharmacist. It's important to remember that there will always be anomalies, I saw a hospital patient once who said she was on 0.5mg Synthroid, I thought that had to be wrong, that it must be 0.05mg. No way was I going to sign off on that order. But I was able to contact her family doctor who verified it. I think its prudent to always verify high dosages--its important to remember that there is the possibility that a particular individual does require those doses.

I don't have any advice on the computer system you are working with. But in the examples you gave, I would talk to the patient, if you are comfortable with their answers, then document what they told you and fill the prescriptions. If not, explain to them the issues involved and let them know you are going to call their doctor to make sure that the doctor is aware of side effects/problems from these dosages/combinations.

In general, I am much more likely to question a family doctor then a specialist. If it was a cardiologist prescribing the diltiazem/simvastatin or a neurologist the high dose gabapentin, I would be less likely to call the doctor, then if it was a family doctor prescribing the same. If it was a specialist prescribing something outside of his expected range, ie the neurologist prescribing diltiazem/simvastatin or the cardiologist prescribing the gabapentin, I would definitely call and be more likely to refuse to fill that prescription. And it depends on how informed the patient is of why they are getting their treatment, and their history that led to the current treatment.

So ultimately its a judgement call, based on different issues.

 

[Ackj]

I saw a hospital patient once who said she was on 0.5mg Synthroid

Whoa. S/p thyroidectomy? Crazy dose.

Great advice in this thread. This stuff is definitely something you don't get a ton of exposure to as an intern, because the experienced pharmacist won't bother showing you the non-issues. How often does a pharmacist say "hey, look at this interaction. It's completely insignificant and okay to fill"? You usually get to see the significant things to call on, but making the determination to call or not isn't often explained.

 

[All4MyDaughter]

Whoa. S/p thyroidectomy? Crazy dose.

Great advice in this thread. This stuff is definitely something you don't get a ton of exposure to as an intern, because the experienced pharmacist won't bother showing you the non-issues. How often does a pharmacist say "hey, look at this interaction. It's completely insignificant and okay to fill"? You usually get to see the significant things to call on, but making the determination to call or not isn't often explained.

That does makes me suspect non-compliance. There are three women in my family who have zero endogenous thyroid function and the highest any of us has ever been on is 250 mcg.

 

[BidingMyTime]

That does makes me suspect non-compliance. There are three women in my family who have zero endogenous thyroid function and the highest any of us has ever been on is 250 mcg.

That's a good point, that I never considered at the time. She was in and out of the hospital for issues non-related to her thyroid, at least in the hospital she was getting that dosage. She had had a thyroidectomy and her doctor said she had been on that dosage for nearly 20 years. At the time I chalked it up to her having some unknown genetic abnormality. Thinking of that, reminds me of a patient who was on 30mg Coumadin a day--he did have a diagnosed genetic problem, although that was long enough ago I don't remember the details.

 

[All4MyDaughter]

That's a good point, that I never considered at the time. She was in and out of the hospital for issues non-related to her thyroid, at least in the hospital she was getting that dosage. She had had a thyroidectomy and her doctor said she had been on that dosage for nearly 20 years. At the time I chalked it up to her having some unknown genetic abnormality. Thinking of that, reminds me of a patient who was on 30mg Coumadin a day--he did have a diagnosed genetic problem, although that was long enough ago I don't remember the details.

Yeah, doses above 300 mg are pretty rare. We usually look at compliance, absorption issues or drug interactions. But if she had been on that dose for 20 years, it's probably not worth worrying about.

 

[BidingMyTime]

Great advice in this thread. This stuff is definitely something you don't get a ton of exposure to as an intern, because the experienced pharmacist won't bother showing you the non-issues. How often does a pharmacist say "hey, look at this interaction. It's completely insignificant and okay to fill"? You usually get to see the significant things to call on, but making the determination to call or not isn't often explained.

Another piece of advice, don't always trust the middleman (ie nurse, medical assistant, office receptionist.) If you can't read the doctor's writing and you call them to clarify, you can probably trust them to tell you what it says. But if you are calling because of a potentially dangerous interaction or crazy dosing, and they come back with something like "I asked the doctor and he said to go ahead and fill it".....tell them you will have to talk to the doctor personally, because many times their "asking the doctor" means they looked in the chart and verified it was written there, not that they passed on the concerns with the doctor and verified that he didn't make a typo. Almost always, the doctor will either make a change when the problem is explained to her/him, or will be able to give a reasonable medical explanation for the prescription.

It's very, very rare that I've refused to fill a prescription after talking with a doctor, I can only think of a couple of times, those cases involved extremely high narcotic doses in narcotic-naive/non-narcotic depedent patients, being prescribed by a non-specialist doctor who....I don't know, because he wanted to kill the patient? It was incomprehensible to me that the doctor would not change the dosage which went against all common sense/medical guidelines/black box warnings. I gave the script back to the patients and told them flat out that I believed the dosage would be fatal, that there doctor refused to change it, and I urged them to seek a second opinion from a different doctor.

Sometimes people will throw a fit because they want you to "just fill their prescription" and not check on stuff, but remember the more upset people get about waiting directly corresponds with the speed with which they will sue you if their prescription is mixed up or if they have a reaction/problem with it.

 

[BidingMyTime]

Yeah, doses above 300 mg are pretty rare. We usually look at compliance, absorption issues or drug interactions. But if she had been on that dose for 20 years, it's probably not worth worrying about.

It was a crazy dosage, I've never seen anything higher than 250mcg except for that pt.

 

[Farmercyst]

Had a viagra 50mg for a 90yo on Digoxin. Didn't kick up a DUR, but called because we were worried about overexetion on a 90 with known cardiac issues. Per MD ok to fill. :?

 

[chicagoboy1984]

Thanks for your input guys. So in general, is counseling the patient on monitoring for side effects of the drug interaction/excessive dose sufficient to protect our licenses (provided we have documentation of the counseling session), provided….

1) You are filling a refill, so you assume the original RPH did his/her job by clarifying with prescriber or patient
OR
2) One of the drugs is a new RX, but the 2 interacting drugs are not an absolute contraindication (e.g. simvasatin and diltiazem) AND were prescribed by same MD (I would say to not call MD since we have to assume the MD is not stupid and recognizes the drug interaction…..)]
OR
3) It is a new RX, the dose is excessively high BUT the patient has a history of dose escalation on the drug (Viagra 25mg-->50mg for 90yo or gabapentin 1800mg--> 4800mg/day)

Whereas you would most likely call the MD if…
1) It is a new RX, both of the 2 interacting drugs were prescribed by same MD, and the drug interaction IS an absolute contraindication (simvastatin and gemfibrozil)
OR
2) It is a new RX, the 2 interacting drugs are NOT an absolute contraindication but are considered a severe interaction (e.g., amlodipine and simvastatin) and the drugs were written by different MD's (I would call since you cannot assume one MD knew all the drugs the patient was taking, including drugs written by a different MD….)
OR
3) it is a new RX, the dose of drug is excessively high and the patient has no history of dose escalation over time on the drug (eg., Viagra 50mg for a 90yo or gabapentin 4800mg/day)

Thanks.

 

[chicagoboy1984]

Although I will say that even filling refills of excessive doses should be done cautiously depending on the potential side effects. For example (and correct me if I am wrong), I would be content with counseling a patient who is getting a refill of gabapentin 4800mg/day since the worst that can probably happen is the patient becomes excessively sedated (especially if her renal function worsened). However, when I was a student on my community APPE, I was filling a refill for metformin 4000mg/day, and I ended up calling the MD. As it turns out, the MD meant 2000mg/day, but he accidentally wrote metformin 1000mg take 2 tabs po bid instead of take 1 tab po bid. I guess the original RPH accidentally ignored that DUR, but I was able to catch it and correct it (luckily, the patient was Spanish-speaking and was taking the metformin the same way she was always taking it [regardless of what the RX bottle told her], which was 1 tab po bid). In the case of metformin, I felt obligated to call since the worst that can happen is lactic acidosis, which is much more severe than CNS depression….

 

[Chris co2012]

Had a viagra 50mg for a 90yo on Digoxin. Didn't kick up a DUR, but called because we were worried about overexetion on a 90 with known cardiac issues. Per MD ok to fill. :?

So either he has BPH, pulmonary HTN, or... Get it, grandpa!

 

[pezdispenser]

Gabapentin is absorbed by a saturable transport system. Clinical Pharmacology says the bioavailability is 60% for a 300mg dose and 35% for a 1,600mg dose, so higher doses are not even getting absorbed and so I wouldn't worry about it.

 

[owlegrad]

Gabapentin is absorbed by a saturable transport system. Clinical Pharmacology says the bioavailability is 60% for a 300mg dose and 35% for a 1,200mg dose, so higher doses are not even getting absorbed and so I wouldn't worry about it.

60% of 300mg = 180mg

35% of 1200mg = 420mg

I must be missing something, because that seems like a pretty large difference to me?

 

[pezdispenser]

60% of 300mg = 180mg

35% of 1200mg = 420mg

I must be missing something, because that seems like a pretty large difference to me?

Damn I typed it wrong.
It's 60% of 300mg = 180mg
and 35% of 1600mg = 560mg

So you increase the dose 5.3x but the amount absorbed only increases 3.1x. Diminishing returns and the transport will eventually get saturated. Official max dose is 3600mg/day. 4800mg is 1.3x this but not as bad as it looks because of the saturable absorption.

To me, a doctor prescribing over the official max dose is still fair game because they may think it is worth the risk, just like a doctor prescribing off label is fair game.

 

[owlegrad]

Damn I typed it wrong.
It's 60% of 300mg = 180mg
and 35% of 1600mg = 560mg

So you increase the dose 5.3x but the amount absorbed only increases 3.1x. Diminishing returns and the transport will eventually get saturated. Official max dose is 3600mg/day. 4800mg is 1.3x this but not as bad as it looks because of the saturable absorption.

To me, a doctor prescribing over the official max dose is still fair game because they may think it is worth the risk, just like a doctor prescribing off label is fair game.

AHHH gotcha, thanks

 

[txpharmguy]

Had a viagra 50mg for a 90yo on Digoxin. Didn't kick up a DUR, but called because we were worried about overexetion on a 90 with known cardiac issues. Per MD ok to fill. :?

Don't c*ck block Grandpa. Let him go out in glory!