Emergency Supply for NitroStat

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thisoneorthat

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I work in a big chain, and a 3-day supply of a 'life-sustaining medication' can be given if patient has no more refills.

Patient came in yesterday, and while waiting for a transfer prescription of NitroStat SL tab from a different pharmacy, we were told the prescription had expired just a day ago. He was visibly sweating & slightly exhausted. I told him I would phone call an ambulance to come here, but he said since he's part of the VA system, the closest ER was in a city 2 hours away and a local ER wouldn't accept him (or perhaps it was a cost issue).

With NitroStat SL, once you open a vial of 25-tabs, the rest can't be used again for another patient, so I was hesitant to give him a 3-day supply. I asked if he had any chewable ASA on him, and he said yes. Got on the phone to call a local pharmacy to see what I should do but after a few moments, he had left the store.

I couldn't sleep last night, because I knew I could've prevented something from happening (if anything did). Should I have simply given him the whole vial of the NitroStat?

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We probably would have filled it for the full 25 and just called dr first thing to get a refill approval.
 
I've encountered the same situation in the past and I just wrote up a prescription under his primary doctor's name and dispensed the 25 qty bottle.
I can't see any reasonable doctors denying patient's access to NitroStat especially when the pharmacist confirms that patient is in need of nitrostat ASAP.

On a similar note, I used to have arguments with my partner back in the days when she would not switch Zofran to Zofran ODT unless she heard from the doctor.
My argument was (and still is) that no doctor will say "NO, I want the patient to keep trying until they can swallow the tablet in between their vomiting," but her argument was that what I wanted to do was illegal and since the SL bypasses first pass metabolism, it might have different effect that the prescriber did not intend by prescribing the oral version.

I guess we are both entitled to our professional judgment but yeah, I would've just given it to the man if I was in your shoes.
 
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I appreciate the replies.

I'm recent grad RPh, and I was so hung up on the "fill only 3 days worth" rule, tablet sustainability issue, and no prescription on file technicalities that I didn't think to use my professional judgement. I pray that the patient did not end up having an MI, because of my lack of common sense....
 
Whenever you are in sticky situation just remember these two things:

1) What would a reasonable pharmacist in your position do? (The most common test that the courts use in most jurisdictions during malpractice cases.)
2) Will I feel comfortable defending my actions and judgment in front of the state board of pharmacy?

If you consider above two factors before you make a judgment call, you can sleep at night with some peace of mind.
 
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First, cut yourself some slack. It's not your fault he didn't have it.

Next time consider writing the order and having the doctor approve it afterwards. That's probably what I would have done.
 
I've encountered the same situation in the past and I just wrote up a prescription under his primary doctor's name and dispensed the 25 qty bottle.
I can't see any reasonable doctors denying patient's access to NitroStat especially when the pharmacist confirms that patient is in need of nitrostat ASAP.

On a similar note, I used to have arguments with my partner back in the days when she would not switch Zofran to Zofran ODT unless she heard from the doctor.
My argument was (and still is) that no doctor will say "NO, I want the patient to keep trying until they can swallow the tablet in between their vomiting," but her argument was that what I wanted to do was illegal and since the SL bypasses first pass metabolism, it might have different effect that the prescriber did not intend by prescribing the oral version.

I guess we are both entitled to our professional judgment but yeah, I would've just given it to the man if I was in your shoes.


ODT zofran doesn't bipass first pass because it's not absorbed bucally, it's still swallowed. So...

But regards to the SL NTG, what if they are getting a PDE-I via samples from their MD? Giving him a bottle to hold him w/o verification could kill him. You are basing it off of an expired transfer from a different pharmacy, so the script is over a year old (a lifetime clinically)
 
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On a similar note, I used to have arguments with my partner back in the days when she would not switch Zofran to Zofran ODT unless she heard from the doctor.
My argument was (and still is) that no doctor will say "NO, I want the patient to keep trying until they can swallow the tablet in between their vomiting," but her argument was that what I wanted to do was illegal and since the SL bypasses first pass metabolism, it might have different effect that the prescriber did not intend by prescribing the oral version.

Well they are not AB rated so...

But yeah, who cares? It's like Ventolin vs Proair. Give me a break.
 
Yeah, it was a situation where the woman was begging for the melting ones cuz she couldn't keep anything down.
I told my tech to change it to the ODT but that's when my partner intervened.
I was the "lenient" one and my partner played the "strict" rph role but we worked well as a team.
Now those days are gone with the company scheduling only one pharmacist per day but those were the good days.
 
ODT zofran doesn't bipass first pass because it's not absorbed bucally, it's still swallowed. So...
So what's really the point if you're puking your guts out? It won't matter if it was a whole tablet, dissolved tablet, liquid, powder, etc when your stomach is trying to empty itself. Am I missing something here, or was the whole product just some magic pharma marketing?
 
ODT zofran doesn't bipass first pass because it's not absorbed bucally, it's still swallowed. So...

But regards to the SL NTG, what if they are getting a PDE-I via samples from their MD? Giving him a bottle to hold him w/o verification could kill him. You are basing it off of an expired transfer from a different pharmacy, so the script is over a year old (a lifetime clinically)

When is the last time you knew of someone who un-needed nitro they needed a year ago?
 
When is the last time you knew of someone who un-needed nitro they needed a year ago?

When was the last time some cardiac patient scrounged up some Viagra from a sympathic urologist w/o telling their gp or cardiologist?

Or someone hasn't been to the heart doctor since they got their original rx and been booted from the practices and has relied on sympathic pharmacists for emergency supplies
 
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So what's really the point if you're puking your guts out? It won't matter if it was a whole tablet, dissolved tablet, liquid, powder, etc when your stomach is trying to empty itself. Am I missing something here, or was the whole product just some magic pharma marketing?

Takes less liquid to swallow, thus the stomach stays emptier.
 
I worked with a pharmacist who would give out Viagra emergency supplies. :laugh::laugh::laugh: He said he would consider it an emergency if he were out.


3 days is meh....what if its a 4 day holiday weekend? I've given out vials of insulin before as E/S, I'm not going to measure out syringes for them.

The think with emergency supplies, the idea is to fill a prescription to keep a patient from needing immediate medical care until their doctor can be contacted.

With the nitro...the thing is, the guy was very symptomatic, and had never filled it at the pharmacy he was at. I would tell him no, too many unknowns, and I think at that point the guy needed to go to the emergency room--legally the local ER is not going to turn him away because of his insurance, they would stabilize and transport if necessary. And even if he got a big bill, his insurance surely has a non-preferred provider clause for emergencies and would still pick up a good portion of the bill.
 
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If I'm ever having symptoms of an MI, I hope I have the wits about me to go to a hospital instead of a pharmacy.

On a similar note, I had a guy come in a few weeks ago who only spoke Polish and was complaining of what appeared to be a headache. I took him to the blood pressure machine and it came back 230/150. Repeated it with the same results. Speaking through my Google translate app, I told him I was going to call the ambulance because that is way too high, and he took off. Never heard what happened to him. Hope he's ok.
 
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I didn't even think of calling his current doctor for a possible refill request *sigh* I also didn't understand it either when the patient seemed hesitant for me to call an ambulance or even obtain the address to the local ER since he was so adamant to drive himself...

As a newbie, I'm trying to not let the craziness of the situation get to me whether it be in this type of situation or any other time (ie. being pressured to fill a confrontational patient's controlled drug during busy hours). I need to take a second to step back & determine how I can fulfill the patient's best interest while not breaking any laws/company rules, if that's even possible. I just felt so terrible after the incident initially, because I was solely hung up on the technicalities w/out regards to the patient's outcome until after I got home.
 
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I didn't even think of calling his current doctor for a possible refill request *sigh* I also didn't understand it either when the patient seemed hesitant for me to call an ambulance or even obtain the address to the local ER since he was so adamant to drive himself...

.

Most vets, myself included, have it drilled into their heads to not use the ambulance service and only go to the VA emergency room. Any outside use would have to be paid for out of pocket. I was told numerous times if you break your leg, better hope it is not the one you use to drive with.
 
Most vets, myself included, have it drilled into their heads to not use the ambulance service and only go to the VA emergency room. Any outside use would have to be paid for out of pocket. I was told numerous times if you break your leg, better hope it is not the one you use to drive with.

Ahhh I see... When I asked him a second time if I could assist him in getting local help, he repeated yet again that the closest VA emergency room was about 2 hours away. I should've picked up on that.
 
I didn't even think of calling his current doctor for a possible refill request *sigh* I also didn't understand it either when the patient seemed hesitant for me to call an ambulance or even obtain the address to the local ER since he was so adamant to drive himself....


If that patient was a VA patient (vet), then good luck reaching his VA doctors/PAs/NPs after hours (or even during working hours) :bang:

I wonder if he also gets most of his meds through the VA pharmacy as well (which only a VA doctor/PA/NP can prescribe)?

Referring him to the emergency department is the right thing. I don't think giving him an emergency supply of NTG would have prevented a MI. If he is that symptomatic, he either has unstable angina, or having ACS ... either way, it needs to be worked up (and depending on what's going on, time may be essential, ie door-to-balloon time)

And there are a lot of "what-ifs" - what if he was on Viagra through the VA pharmacy (and not listed in your computer system). What if he's having a Right Ventricular MI? What would giving NTG do in that situation? What if his dyspnea is not an MI but RV strain from a PE? What would NTG do in that situation? What if it's actually a bad pneumonia developing, or a COPD exacerbation? What if it's actually an arrhythmia (like afib with RVR, or SVT, or VTach)?

You did the right thing by referring him to the nearest ER (and offering to call 911). The fact that he refuses - the responsibility and onus is on him, and no longer on you.


*I have patients all the time paging me in the middle of the night because they can't breath. Sometimes they can't even speak due to severity of their dyspnea. I always tell them to go to the ED. The differential is too broad and the consequences too severe to treat over the phone. I don't know if they are hypoxic, septic, or about to crash and needs intubatio, etc.

**if I was the on-call physician for this patient, not sure if I would authorized NTG refill if he is that acutely symptomatic unless I know this patient very well (and reasonably confident that he's not sick). If I'm cross-covering, or if there is any doubt that he could be sick, I would refer him to the nearest ED.

Just my 2¢
 
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I wouldn't worry about it, patients need to take responsibility for their own actions.

1) It's expired
2) it was at ANOTHER pharmacy, why are you left to deal with it?
3) I would have told him to go to the ER
 
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