I hate peds meds! Help on dosing!

[Curiousone1111]

---

Members don't see this ad.

Hi guys.

For pediatric rxs, if it is for a medicine that is not approved in that age group, do you make sure the dose is similar to the approved dosing (lets say 9 month old child and albuterol syrup rx is approved for 2+). Make sure dosing is around that amount or less by getting patient weight from parent or office, or do u always call office and confirm that they’re aware this wasn’t approved in the age group? I asked the office for patient weight and the dose came out to a little more than 0.1 mg/dose but basically they went by the dosing amount for a child who is at least 2 yrs of age. Do u call to tell them it isnt approved in <2 so this dose is a little high considering it is for 2+, or do you just leave it?

What about peds rxs in general with regards to dosing? I am doing refills and see levetiracetam 750 mg bid for 13 year old girl. I asked her for her weight she said she doesn’t know (lol) then said about 120 lbs. all the different seizure indications seem to have a dose range of 10 mg/kg BID and can be increased up to 30 mg/kg bid. If she is 54 kg she should be getting 500 mg bid... but if you consider up to 30 mg/kg bid, then it is fine. It was a hospital that wouldnt answer so i couldnt confirm dose with md but dispensed because dose is within range if u go up to 30mg/kg bid.


What do u guys do? Always call to verify dose with md for kids, or if unapproved in that age? Or do you use their weight multiplied by a dosing range (even tho u might not know exact dose they’re going by, eyeball if it looks ok for that unapproved age)?

Thanks!

 

[Rouelle]

1. Not much is explicitly approved for a 9 month old. If you’re planning to call on every “dose not approved for age group” you’re going to have a tough row to hoe. Keep an eye open for things that are known to not be safe for an age group (ie you generally don’t routinely give IBU to a kid under 6 months, etc).

2. A pediatrician who routinely prescribes albuterol syrup is likely too old and out of touch to listen to any suggestions you might have.

3a. Keppra was likely titrated to effect. You say that it is under the weight based max, so don’t think twice about it.

3b. You generally don’t dose by weight a teenager who weighs 120 pounds. They’re “adult-sized.” Weight based dosing (of “normal” drugs) can take them over the adult max. [Imagine treating otitis media in a 54 kg patient with 90 mg/kg/day of amoxicillin...crazy.] They get adult doses.

 

[DOOM N GLOOM]

What do u guys do? Always call to verify dose with md for kids, or if unapproved in that age? Or do you use their weight multiplied by a dosing range (even tho u might not know exact dose they’re going by, eyeball if it looks ok for that unapproved age)?

Since you asked for my opinion, I’ll go with option c: Throw a hissy fit, flip the table, quit my job and get out of pharmacy altogether.

 

[radio frequency]

I’ve rarely had a prescriber intentionally prescribe albuterol syrup. Call on it, especially if it’s a new resident. They were likely trying to order nebs and couldn’t find it in the computer.

I always had a normal weight for age chart and would calculate that out, then when parents came to pick up I’d ask weight and compare.

Some stuff just isn’t tested in kids, so you have to be realistic. Always counsel. And watch for doses of ranitidine much greater than 1 mL in babies. That calculation seems to always get screwed up by providers...and is still fairly common.

 

[Curiousone1111]

I used to google the average weight of a child and use that for amoxicillin, ibu/apap etc but since every kid is different I just call the office or parent for their weight. The issue was not knowing what dose to multiply by for let’s say prednisolone that has a variety of dosing regimens based on indications. For amox i still just go by 90mg/kg/day lol.

Thanks for your help!

I’ve rarely had a prescriber intentionally prescribe albuterol syrup. Call on it, especially if it’s a new resident. They were likely trying to order nebs and couldn’t find it in the computer.

I always had a normal weight for age chart and would calculate that out, then when parents came to pick up I’d ask weight and compare.

Some stuff just isn’t tested in kids, so you have to be realistic. Always counsel. And watch for doses of ranitidine much greater than 1 mL in babies. That calculation seems to always get screwed up by providers...and is still fairly common.

I’ve rarely had a prescriber intentionally prescribe albuterol syrup. Call on it, especially if it’s a new resident. They were likely trying to order nebs and couldn’t find it in the computer.

I always had a normal weight for age chart and would calculate that out, then when parents came to pick up I’d ask weight and compare.

Some stuff just isn’t tested in kids, so you have to be realistic. Always counsel. And watch for doses of ranitidine much greater than 1 mL in babies. That calculation seems to always get screwed up by providers...and is still fairly common.

 

[Curiousone1111]

That’s true! Let’s say they get a topical steroid and there’s one that is okay for their age group, wouldn’t you call and see if they still want what was prescribed or if they’ll consider switching? I.e. rx for clobetasol for <12 yr old

1. Not much is explicitly approved for a 9 month old. If you’re planning to call on every “dose not approved for age group” you’re going to have a tough row to hoe. Keep an eye open for things that are known to not be safe for an age group (ie you generally don’t routinely give IBU to a kid under 6 months, etc).

2. A pediatrician who routinely prescribes albuterol syrup is likely too old and out of touch to listen to any suggestions you might have.

3a. Keppra was likely titrated to effect. You say that it is under the weight based max, so don’t think twice about it.

3b. You generally don’t dose by weight a teenager who weighs 120 pounds. They’re “adult-sized.” Weight based dosing (of “normal” drugs) can take them over the adult max. [Imagine treating otitis media in a 54 kg patient with 90 mg/kg/day of amoxicillin...crazy.] They get adult doses.

 

[CountByFives]

The only thing I absolutely refuse to fill is Codeine(in any form/combination) in people 12 and under. Anything else in a Ped, I defer to the pediatrician unless it is absurdly wrong.

Anything remotely close and reasonable I allow and counsel if necessary.

 

[radio frequency]

That’s true! Let’s say they get a topical steroid and there’s one that is okay for their age group, wouldn’t you call and see if they still want what was prescribed or if they’ll consider switching? I.e. rx for clobetasol for <12 yr old

I generally wouldn’t call on a topical product unless it was known to be harmful. Many are used in peds even though they don’t have dosing for that. Look at ketoconazole tooicals. Yet you can give oral tablets of the same with peds dosing. Does that mean the topical formulation is somehow less safe in peds? Probably not. More like the manufacturer didn’t want to spend the money for pediatric safety studies.

 

[Curiousone1111]

Good point, that’s because it’s contraindicated in <12. I’m still surprised at rphs who fill things that are clearly listed as “contraindicated” in the package insert, just bc the md said its ok lol.

I love all the helpful responses! Maybe this is the ocd in me but i saw a rx for ipratropium bromide 0.02% (0.5 mg vial)- 1 vial q4 hrs. Pt is 14 yrs old. Lexi lists the dose as 1 vial q6-8 hrs. I guess q4 is ok the dr wants it less spaced apart so i probably wouldnt call, but the issue is its supposed to be four times a day max. Would u just add *max four times a day* at the end of the label and counsel, or refuse to fill til u speak to md about whether u should add that limit or not? The other rph filled as is, and it rejected saying max quantity 11 ml per day (its 2.5 ml in a vial so basically only four times a day). She changed the days supply to make it go thru. Would you bill correct days supply and leave sig as is but add to limit it to four times a day... or is that considered changing directions, which shouldnt be done til u talk to md? Its hard to get a hold of hospital doctors and it seems crazy to call on every little thing but it is a higher than usual dose if the dr expects them to take it q4 around the clock=6 times a day.

The only thing I absolutely refuse to fill is Codeine(in any form/combination) in people 12 and under. Anything else in a Ped, I defer to the pediatrician unless it is absurdly wrong.

Anything remotely close and reasonable I allow and counsel if necessary.

 

[Curiousone1111]

Yeah its just topical but i think studies have shown even topical steroids can affect a child’s growth? Not sure completely.

I generally wouldn’t call on a topical product unless it was known to be harmful. Many are used in peds even though they don’t have dosing for that. Look at ketoconazole tooicals. Yet you can give oral tablets of the same with peds dosing. Does that mean the topical formulation is somehow less safe in peds? Probably not. More like the manufacturer didn’t want to spend the money for pediatric safety studies.

 

[radio frequency]

Yeah its just topical but i think studies have shown even topical steroids can affect a child’s growth? Not sure completely.

Don’t ever call unless you’re sure.

 

[RxPreceptor]

Pretty sure that's with inhaled corticosteroids & even then, it's an extremely minor stunt in growth in the grand scheme of final height

 

[Rouelle]

Pretty sure that's with inhaled corticosteroids & even then, it's an extremely minor stunt in growth in the grand scheme of final height

If I’m not mistaken, growth velocity is slowed but final height is unaffected in these kids.

 

[RxPreceptor]

Just wanted to throw this out there, but Pharmacists Letter usually has some pretty specific topics on such matters under their "resources" section. I usually read & reread these throughout my off week as a boredom killer (cardio reading material).

 

[dmd20000]

If you are in retail and doing this constantly you will get screwed lol. It is better if you know which doses are usual and which doses are unusual so even if you don't have the weight you don't waste time calling the doctor.

 

[Sine Cura]

I check ranitidine and hydroxyzine and atypical Rx like MTX. TBH why does anyone working retail for more than 6 months need a weight for antibiotics... usually RPH have a good sense of normal dose ranges by then comparing to patient age

I laugh at atypical antipsych scripts for anyone 4 or younger. Yes even peds offices write wacky ****. I'm sure someday I'll get real justification so we can submit dat TAR (a type of PA for California Medicaid)

I call only if it's wrong like TDD dose exceeding adult dosing