Lunesta 9mg QHS?

[MountainPharmD]

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Has anyone seen this before? I got a script for it today for a lady who has been on 6 mg for a few months. My partner saw that I filled it and freaked out ands said he would have refused to fill it.

 

[Thoughtfulsinner]

I would never have filled that.

 

[Aznfarmerboi]

In clinical trials with eszopiclone, one case of overdose with up to 36 mg of eszopiclone was reported in which the subject fully recovered. Individuals have fully recovered from racemic zopiclone overdoses up to 340 mg (56 times the maximum recommended dose of eszopiclone).

Clinically, I think that 9mg will cause a lot of side effects such as psychomotor problems. The 3mg's side effect profile is statisically and clinically sig. versus the 2 and 1 mg so I cant imagine the 9mg. Most trials did up to 7.5 mg as dose...

 

[Aznfarmerboi]

Just wondering, ur title says 9mg.. but you filled it for 6. My theory is if any script more than the 2nd refill has a mistake, I'll let it pass. I figured if the patient is not bitching, still alive, and awake... it should be okay. Of course, I'll still tell the patient and document.

 

[WagsTale]

Has anyone seen this before? I got a script for it today for a lady who has been on 6 mg for a few months. My partner saw that I filled it and freaked out ands said he would have refused to fill it.

Unfortunately, it's very easy to "armchair-quarterback" this scenario right now. Because I am naturally a cautious pharmacist, I like to say that I probably would have called to verify this dose. However, realistically if I came across this during a frantic and busy part of my day, and I had quickly reviewed this patient's profile, I may too have let this go through.

On a somewhat related note, today I had a prescription handed to me for 3 patches of fentanyl 100mcg to be applied every 3 days, quantity of 90. I nearly fell over. After I reviewed the patient's profile, I found that she had previously been getting a script for 2 patches of 100mcg every 3 days....still an incredibly high dose, at least from what I've ever seen/read about. I called the Dr. to see what was up, and it turns out that the 3 patches was a TYPO!! WOAH!! Anyone else ever actually see a dose this high before?

 

[Phlame217]

As a tech yes.

Just today, we had a heavy narc patient return becuase wal-mart declared her a seeker and refused any further scripts.

Her regimen currently consists of:
2 fentanyl 100 mcg patches changed every 3 days
oxycontin 60, 1 po q4 ppa
oxycontin 30, 1 po prn btp max 4/day

Now the back story after the shock...

Shes been a regular patient for years, but left after we couldnt keep enough narcs in stock to fill. She was involved in a car wreck about a year ago where a fleeing criminal hit her head on @ 120mph while she was travelling at 70 mph. Her entire and C spine is now fused, and she had 3 L Spine fused. She had severe internal trauma along with other injuries.

 

[Vitamin K]

I would not have filled it. There's technically no "max dose" in the literature, but I'd be really concerned about someone taking 3 times the "usual" high dose of a sleeping med. I wouldn't be comfortable with it. I'd consider it after talking to the MD, but with LOTS of documentation.

 

[MountainPharmD]

Just wondering, ur title says 9mg.. but you filled it for 6. My theory is if any script more than the 2nd refill has a mistake, I let it past. I figured if the patient is not bitching, still alive, and awake... it should be okay. Of course, I'll still tell the patient and document.

She has been taking 6mg for a couple of months. I got the script a few days ago for 9mg (3 - 3 mg QHS) and just filled it. This patient is on several narcs as well as the Lunesta. We have called many times to verify other medications as well as to verify the 6 mg prescrition when we received it a few months ago.

I of course did a search and could not find any documentaion listing a max dose. I read some case reports where people have taken 12 mg and had hallucinations. I was wondering if anyone had some documentaion or experience with higher doses being used for certain conditions.

 

[Doctor M]

Has anyone seen this before? I got a script for it today for a lady who has been on 6 mg for a few months. My partner saw that I filled it and freaked out ands said he would have refused to fill it.

You made a judgment call...Obviously the script was written by the same physician...and the patient was not responsive to 6mg. So i wouldnt have refused to fill the rx, but i would at least speak to the patient...if that did not satisfy me, then a quick call to the physician would have sufficed. If it was a weekend, then i would have counseled her to keep taking 6mg until i could confirm the 9mg dose... Perhaps this pt metabolized the drug quickly...who knows...Either way, she tolerated 6mg so the pt will probably tolerate 9mg...

 

[JackBeanstalk]

As a tech yes.

Just today, we had a heavy narc patient return becuase wal-mart declared her a seeker and refused any further scripts.

Her regimen currently consists of:
2 fentanyl 100 mcg patches changed every 3 days
oxycontin 60, 1 po q4 ppa
oxycontin 30, 1 po prn btp max 4/day

Now the back story after the shock...

Shes been a regular patient for years, but left after we couldnt keep enough narcs in stock to fill. She was involved in a car wreck about a year ago where a fleeing criminal hit her head on @ 120mph while she was travelling at 70 mph. Her entire and C spine is now fused, and she had 3 L Spine fused. She had severe internal trauma along with other injuries.

Oxycontin prn for breakthrough pain? is this typical in retail because in my hospital newbie docs will sometimes write for oxycontin prn BTP and I'll have them change it to oxycodone or percs or t3 etc...

 

[Old Timer]

Depends on who the doctor is. Is he/she a specialist? Does this prescriber have other patients on multiple controlled medications? Too many variables. Based on the information provided, I would have either filled the prescription or dispensed enough to get through until I could contact the prescriber. My decision would be based on my knowledge of the patient and his/her history.

 

[RhinoRX]

I see some crazy prescriptions, too, as a tech... one doctor specifically is a mental health professional in my area, and this is what I've seen from him:

1. pt taking 11 (yes, eleven) methylphenidate 20mg QD
2. an 8 year old on 4 methylphenidates QD, 1 aricept QD, and 1 bupropion bid... (isn't this doc ****ing this kid up for life??)

 

[vardenafil]

i just started at a new pharmacy and apparently there is some lady taking 120mg of restoril hs. her profile shows this going back several years.

 

[Sparda29]

My aunt has a really bad case of lupus, already had to go total hip replacement. She's been on a really crazy regimen. I gotta check her medication bag to see what she's on.

 

[Sparda29]

Oxycontin prn for breakthrough pain? is this typical in retail because in my hospital newbie docs will sometimes write for oxycontin prn BTP and I'll have them change it to oxycodone or percs or t3 etc...

I usually see the Oxycodone Immediate Release used for breakthrough pain and the Oxycontin as the regular one.

 

[The Sonoran]

Anyone else ever actually see a dose this high before?

Yes, plus breakthrough meds.

 

[Old Timer]

Best ever MS-Contin 100 mg 18 tablets q12h. With MSIR 30 mg 10 tablets q3h prn breakthrough pain.

Called MD. Pt hat end stage pancreatic cancer with bone mets and wait for it.... He was a heroin addict. Normal doses did not apply to him.

 

[Sparda29]

Best ever MS-Contin 100 mg 18 tablets q12h. With MSIR 30 mg 10 tablets q3h prn breakthrough pain.

Called MD. Pt hat end stage pancreatic cancer with bone mets and wait for it.... He was a heroin addict. Normal doses did not apply to him.

😱

I bet you were the one stuck explaining this to the insurance company when the DUR came back.

 

[Pharmavixen]

Best ever MS-Contin 100 mg 18 tablets q12h. With MSIR 30 mg 10 tablets q3h prn breakthrough pain.

Called MD. Pt hat end stage pancreatic cancer with bone mets and wait for it.... He was a heroin addict. Normal doses did not apply to him.

This would be a valid, IMV. Opioid addicts potentially have down-regulated their pain receptors such that they feel pain more intensely, and they have increased tolerance such that you provide a background of LT opioid, and you may have to offer IR more frequently.

We had a guy at the jail (I've discussed him before) who was receiving the equivalent of morphine 1000 mg daily from his PCP, and there was nothing wrong with him (other than addiction).

1. pt taking 11 (yes, eleven) methylphenidate 20mg QD
2. an 8 year old on 4 methylphenidates QD, 1 aricept QD, and 1 bupropion bid...

Now THAT is not right. The psychiatrists at the jail, who come from a large research psychiatric/addiction facility and are totally into EBM, don't give more than 40 mg methylphenidate to our guys with severe ADD - tons of impulsivity problems that put them in jail.

And Aricept in a kid? WTF??

And there's the street value. I switched the jail over from Ritalin SR to regular Ritalin tablets that the nurses could crush and mix with water to foil their diversion efforts (they were hiding those little SR tablets in holes in their teeth, etc). One day after I instituted this, 3 inmates asked to be d/ced from the Ritalin because it was "too strong."

I think sometimes they'll use psych meds to try and substitute for therapy that is more time-consuming, and probably less lucrative, like CBT.

Back on topic: we don't have Lunesta in Canada; I googled, and it looks like it's just a "me too" Imovane, and when I see dose escalations of Imovane, it's substance abuse.

 

[Monalyce]

And Aricept in a kid? WTF??

I've heard of Namenda being used for bedwetting. Perhaps something along these lines? I haven't found any literature on off-label pediatric use of Aricept, though.

 

[Phlame217]

Oxycontin prn for breakthrough pain? is this typical in retail because in my hospital newbie docs will sometimes write for oxycontin prn BTP and I'll have them change it to oxycodone or percs or t3 etc...

doubled checked today and it was actually :
As previously listed but with "oxycontin 30's q3h" and "Oxy IR 10 q3 prn btp"

Got those two mixed up.

 

[Zenman1]

I inherited a Soldier on Lunesta 6 mg. 3 mg did absolutely nothing and 6 works great. However, he wants to deploy and probably won't be allowed to on that dose so we'll be looking at options.

 

[wagrxm2000]

6 years later I'm sure the OP patient is on 18 mg by now

 

[MountainPharmD]

The OP is still here. This post was from 4 jobs ago. Wow, pulling one from deep in the archives!

 

[BidingMyTime]

People do end up needing crazy doses sometimes, but 6mg - 9mg seems like a huge jump. Why wouldn't the physician just step up to 7mg?

 

[Cren]

I would not assume that an increased requirement for these types of medication until and unless the prescribing physician genetic testing on the patient to test any possible definciencies in metabolizing medications.

It is an easy thing to do; even only uses saliva instead of a blood draw in most cases.

There's an ER doc in a hospital who, the moment she sees a recent rx for Norco in the system, refuses to prescribe anything more than tramadol.

There's a patient with recurrent miscarriage (seven in less than a year and a half, including 2 tubals terminated with methatrexate), and a lot of pain issues.

Her genetic testing results tell us that codeine and tramadol need to be avoided, where fentanyl, hydrocone, morphine, and oxycodone help some, but aren't ideal. The opiods with the least genetic impact based on the report include butorphanol, hydromorphone, meperidine, methadone, oxymorphone, and tapentadol.

This doctor has given her such a hard time about the hydtocodone, that she's scared to go to the ER because she's afraid of being treated like an addict, even with solid evidence in her corner. With her medical state, trying for a pregnancy with long history and high risk for ectopic pregnancy, this is more dangerous than denying the script when miscarriage is an easy diagnosis and genetic testing is even easier to accomplish.

 

[owlegrad]

I would not assume that an increased requirement for these types of medication until and unless the prescribing physician genetic testing on the patient to test any possible definciencies in metabolizing medications.

It is an easy thing to do; even only uses saliva instead of a blood draw in most cases.

There's an ER doc in a hospital who, the moment she sees a recent rx for Norco in the system, refuses to prescribe anything more than tramadol.

There's a patient with recurrent miscarriage (seven in less than a year and a half, including 2 tubals terminated with methatrexate), and a lot of pain issues.

Her genetic testing results tell us that codeine and tramadol need to be avoided, where fentanyl, hydrocone, morphine, and oxycodone help some, but aren't ideal. The opiods with the least genetic impact based on the report include butorphanol, hydromorphone, meperidine, methadone, oxymorphone, and tapentadol.

This doctor has given her such a hard time about the hydtocodone, that she's scared to go to the ER because she's afraid of being treated like an addict, even with solid evidence in her corner. With her medical state, trying for a pregnancy with long history and high risk for ectopic pregnancy, this is more dangerous than denying the script when miscarriage is an easy diagnosis and genetic testing is even easier to accomplish.

Why should the ER manage her pain rather than her OB-GYN or Primary Care?

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[FarmD711]

I would not assume that an increased requirement for these types of medication until and unless the prescribing physician genetic testing on the patient to test any possible definciencies in metabolizing medications.

It is an easy thing to do; even only uses saliva instead of a blood draw in most cases.

There's an ER doc in a hospital who, the moment she sees a recent rx for Norco in the system, refuses to prescribe anything more than tramadol.

There's a patient with recurrent miscarriage (seven in less than a year and a half, including 2 tubals terminated with methatrexate), and a lot of pain issues.

Her genetic testing results tell us that codeine and tramadol need to be avoided, where fentanyl, hydrocone, morphine, and oxycodone help some, but aren't ideal. The opiods with the least genetic impact based on the report include butorphanol, hydromorphone, meperidine, methadone, oxymorphone, and tapentadol.

This doctor has given her such a hard time about the hydtocodone, that she's scared to go to the ER because she's afraid of being treated like an addict, even with solid evidence in her corner. With her medical state, trying for a pregnancy with long history and high risk for ectopic pregnancy, this is more dangerous than denying the script when miscarriage is an easy diagnosis and genetic testing is even easier to accomplish.

Yeah why would she be going to the ER for pain management?


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