How far do you go with OTC recommendations?

[crossurfingers]

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For example, someone comes into your pharmacy looking for something to give a 2 month old baby for fever. Do you calculate the weight based dosage for Tylenol or refer him to the pediatrician? Or a pregnant woman comes in wondering what she can take for cough and congestion. Her OB/GYN did not give her a list of medications that were safe for her to take during pregnancy. Do you refer her to her doctor?

I've seen some pharmacists do their own risk/benefit assessment and make recommendations off of that, but I'm wondering about our liability.

 

[Vitamin K]

For example, someone comes into your pharmacy looking for something to give a 2 month old baby for fever. Do you calculate the weight based dosage for Tylenol or refer him to the pediatrician? Or a pregnant woman comes in wondering what she can take for cough and congestion. Her OB/GYN did not give her a list of medications that were safe for her to take during pregnancy. Do you refer her to her doctor?

I've seen some pharmacists do their own risk/benefit assessment and make recommendations off of that, but I'm wondering about our liability.

Everybody has to take their own stance on this one based on their comfort level. I personally never make recommendations for children under 5 or pregnant women with the exception of "no duh" stuff like humidifiers, saline nasal sprays, and topicals. I'll almost always refer them to their pediatrician or OB/GYN for anything other than that. However, if their doc already recommended that their baby get tylenol, I'll definitely give them a weight-based dosage. I'm comfortable dosing things with a doc's approval, but I wouldn't stick my neck out and make the recommendation myself. There's no need to because every pediatrician or OB/GYN office I've every heard of has an on-call physician for that patient/parent to talk to.

 

[PharmDstudent]

If I make a recommendation, I will guide the patient with the manufacturer's directions; I don't do weight-based dosing, though, because I don't have any way to determine if the child really weighs XX lbs. Sudafed PE, Delsym, and Tylenol/Advil have recommendations for under 6. Tylenol/Advil, laxative suppositories, and homeopathic garbage (which I never recommend) have dosing guidelines for infants.

This lady had to buy 3 bottles of medications for her sick kid, because they've removed the combination products for under 6. I guess that's just how the cookie has to crumble...

Pregnant women are much harder, in my opinion, than infants/children, because the only agent that I know of that is not teratogenic is Tylenol. Most of the other pharmacological agents are up for debate, you know.

I don't stray out of the guidelines, for any reason, but I've seen it done. I would probably be more comfortable if I could get some experience with a pediatrician or OB/Gyn, but even still, I honestly don't know if that would be enough.

 

[MountainPharmD]

For example, someone comes into your pharmacy looking for something to give a 2 month old baby for fever. Do you calculate the weight based dosage for Tylenol or refer him to the pediatrician? Or a pregnant woman comes in wondering what she can take for cough and congestion. Her OB/GYN did not give her a list of medications that were safe for her to take during pregnancy. Do you refer her to her doctor?

I've seen some pharmacists do their own risk/benefit assessment and make recommendations off of that, but I'm wondering about our liability.

You should not recommend any dosing other than what the manufacturer states on the label. If you do you are liable for anything that goes wrong.

A wise old poster on here called SDN1977 summed it up nicely. I am paraphrasing on course but she said she never recommends any otc medication. She merely explains the options and lets the customer decide.
Thats what I do as well.

 

[Hels2007]

You should not recommend any dosing other than what the manufacturer states on the label. If you do you are liable for anything that goes wrong.

A wise old poster on here called SDN1977 summed it up nicely. I am paraphrasing on course but she said she never recommends any otc medication. She merely explains the options and lets the customer decide.
Thats what I do as well.

Strongly agree with everything you said here. 🙂

 

[dangerdog]

when in doubt, cover your ass first?

 

[Hels2007]

when in doubt, cover your ass first?

Yep, because ultimately no one but you cares about your ass.

 

[evilolive]

Yep, because ultimately no one but you cares about your ass.

What are you supposed to do if someone sues you? Does the hospital or the corporation protect you?

 

[acetyl]

You should not recommend any dosing other than what the manufacturer states on the label. If you do you are liable for anything that goes wrong.

A wise old poster on here called SDN1977 summed it up nicely. I am paraphrasing on course but she said she never recommends any otc medication. She merely explains the options and lets the customer decide.
Thats what I do as well.

I miss her. She would always write the longest posts, and if someone responded with a long post....her next one would be longer! It was great.

About OTC recommendations I feel the same, go with the label. The one drug I think would be okay to deviate would be acetaminophen...I found it odd that it's indicated for only >2 yo, but Ibuprofen is >6 months.

 

[simon11]

WHERE IS THE VOICE OF SDN1977

I TRULY miss her!! This forum has never recovered from her absence. We miss the valuable voice of experience.

 

[dangerdog]

What are you supposed to do if someone sues you? Does the hospital or the corporation protect you?

some chains and hospital will cover you under their malpractice insurance. But my school teaches us that it's better to get your own as well. It's dirt cheap for pharmacists anyway. 😀

 

[Hels2007]

What are you supposed to do if someone sues you? Does the hospital or the corporation protect you?

The answer, as with anything involving legal, is "it depends". 🙂 The best advice is to remember that the corporate lawyers are there to protect the corporation, not you. 😉

 

[Sparda29]

In the cases you provided there, we would tell them to contact the pediatrician or OBGYN, if they tell us "but its the weekend, I don't want to bother them.", we'll just tell them that those fools signed into those specialties knowing well that they are on-call 24/7.

 

[Old Timer]

There are several issues here:

1) Cold medications don't work. There is not one single study that shows they are safe and effective for children under six. If you want to recommend something, recommend a vaporizer and saline nasal spray. If you are adventurous and the patient is not diabetic or an infant, you can recommend honey: half a teaspoon for children between two to five years, one teaspoon for children six to 11 years, and two teaspoons for children 12 to 18 years.

1. Paul IM, Beiler J, McMonagle A, et al. Effect of Honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007;161:1140-6.

2) I have no problem if you want to calculate the appropriate dosage of acetaminophen if you are sure you have an accurate weight.

3) Every pregnant woman is given a list of medications they are permitted to take. Ask if they have the list. It is safe to recommend acetaminophen as long as the patient does not have a liver problem.

4) You need to know when to refer and when you can help the patient self treat. If a two year old has fever but is eating, playing and otherwise OK, it is fine to treat their fever. If they are not eating or lethargic, it's time to refer.

You can't hide behind call your doctor because your are interested in protecting your posterior. You are or about to become pharmacists to help people, not protect your own ass. I don't think you will find a legal case where a pharmacist has been sued for recommending acetaminophen.

 

[Pharmavixen]

There are several issues here:

1) Cold medications don't work. There is not one single study that shows they are safe and effective for children under six. If you want to recommend something, recommend a vaporizer and saline nasal spray. If you are adventurous and the patient is not diabetic or an infant, you can recommend honey: half a teaspoon for children between two to five years, one teaspoon for children six to 11 years, and two teaspoons for children 12 to 18 years.

1. Paul IM, Beiler J, McMonagle A, et al. Effect of Honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents. Arch Pediatr Adolesc Med 2007;161:1140-6.

2) I have no problem if you want to calculate the appropriate dosage of acetaminophen if you are sure you have an accurate weight.

3) Every pregnant woman is given a list of medications they are permitted to take. Ask if they have the list. It is safe to recommend acetaminophen as long as the patient does not have a liver problem.

4) You need to know when to refer and when you can help the patient self treat. If a two year old has fever but is eating, playing and otherwise OK, it is fine to treat their fever. If they are not eating or lethargic, it's time to refer.

You can't hide behind call your doctor because your are interested in protecting your posterior. You are or about to become pharmacists to help people, not protect your own ass. I don't think you will find a legal case where a pharmacist has been sued for recommending acetaminophen.

👍

I would add, with experience you get more comfortable with when to refer to the ER or the FD. And in 22 years, I've not known a single pharmacist who has been sued or even disciplined over an OTC recommendation.

 

[meister]

I'm going to have to agree with Old Timer here and say that cold/cough medication for pretty much any adolescent has never really been shown to be effective. The danger of those medications outweighs their benefit.

I work in a pediatrics office every other week and none of the docs there recommend anything other than ibuprofen and acetaminophen for fever (if indicated), humidifiers, and saline nasal spray. The parents always beg for cough syrups or decongestants but none of that OTC stuff has ever been shown to work for kids.

I am 100% positive that a lot of these parents walk to you guys after they talk to their kid's doc who has recommended against medicating and ask you what you think without telling you that piece of information. People just want to hear what they want to hear.

 

[Vitamin K]

I agree 100% with Old Timer. I do think that OTC recommendations are an important part of being a pharmacist and serving your community. However, I also think that you have to be careful of what you are recommending and to whom. That's part of what pharmacy school prepares you for - knowing what questions to ask, when to ask them, and what decisions/recommendations to make based on the answers. It's not good enough to follow "What's a good cough medicine?" with "Delsym. It's on aisle 5." You have to ask questions, know who the patient is (it's not always the person you're talking to) and understand the reasons why this person should or should not be treating with OTC. We're medical professionals...we get to exercise that type of judgement.

 

[nikkai]

Yep, because ultimately no one but you cares about your ass.

Actually, my wife cares a lot about my ass. 😍

 

[PharmDstudent]

I miss her. She would always write the longest posts, and if someone responded with a long post....her next one would be longer! It was great.

About OTC recommendations I feel the same, go with the label. The one drug I think would be okay to deviate would be acetaminophen...I found it odd that it's indicated for only >2 yo, but Ibuprofen is >6 months.

You're right about the "Infants" Tylenol drops. That is absolute garbage! I've never had to give or read the directions, because people will already know what to give their infant based on their pediatrician's recommendation, but the fact that it says "Infants" on the label really ****** me off. Why? Infants are classified so, because they have to be under 1 year of age. How stupid is that? It says that it is "Infants" drops, but it does not include infant dosing. 😡 I can't help it... the marketing agents for Tylenol are ******s! 🙄

 

[28657]

You're right about the "Infants" Tylenol drops. That is absolute garbage! I've never had to give or read the directions, because people will already know what to give their infant based on their pediatrician's recommendation, but the fact that it says "Infants" on the label really ****** me off. Why? Infants are classified so, because they have to be under 1 year of age. How stupid is that? It says that it is "Infants" drops, but it does not include infant dosing. 😡 I can't help it... the marketing agents for Tylenol are ******s! 🙄

In the hospital I work at a 2 year old patient's mom was upset that we only had Tylenol Infant Drops and not Children's Tylenol......she says her doctor said Infant Drops are harder on the liver! ***Oh that statement is wrong in more than one way! 😉****

 

[buckm]

I agree 100% with Old Timers advise. Not only do cold medications not work for children, there is no good evidence that they will work on adults infected with cold or flu virus. Secondly, consider having a resource like the Broselow-Luten color coding dosing chart for pediatric dosing. It's great for when you call a prescriber that doses out to the 0.25 ml.

 

[dangerdog]

Actually, my wife cares a lot about my ass. 😍

So does my girlfriend. But I always feel kind of weird when girls go after guy's asses. I mean, shouldn't oogling the asses of the opposite sex be a male dominated activity? bwahahahaa