Max Dose of APAP

[cutiger]

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This is a question regarding what you would do as a pharmacist/intern:
A patient comes in with a script for Lortab, sig says 1-2 q4h prn pain. giving a max of 12 to be taken in a day, thus putting them past the 4 gram limit on APAP in a day. At my non-rotation job, we always at least put a one time comment saying 8 would put them at the max level.

I did this at my rotation site, and my preceptor asked me where I saw the comment on the script. I replied that it's not on there, but that sig gives them more than the max. She said that she/they never add anything to the script and dispense as is because the Pt COULD have a tolerance.

I think it's our responsibility to at least make them aware of it in some way. What is y'alls feelings or how you approach it?

 

[nnguyenc]

anybody have that literature suggesting the 4 gram limit

there's some flaws with the study...but it just something we've just blindly accepted

 

[Brixius]

This is a question regarding what you would do as a pharmacist/intern:
A patient comes in with a script for Lortab, sig says 1-2 q4h prn pain. giving a max of 12 to be taken in a day, thus putting them past the 4 gram limit on APAP in a day. At my non-rotation job, we always at least put a one time comment saying 8 would put them at the max level.

I did this at my rotation site, and my preceptor asked me where I saw the comment on the script. I replied that it's not on there, but that sig gives them more than the max. She said that she/they never add anything to the script and dispense as is because the Pt COULD have a tolerance.

I think it's our responsibility to at least make them aware of it in some way. What is y'alls feelings or how you approach it?

At my pharmacy we put the max dose per 24 hours if the sig warrants it.

I'm sure some person is going to disagree, get mad, call me you and me idiots and start a fight about it. That's the way it goes here.

 

[PumpkinSmasher]

This is a question regarding what you would do as a pharmacist/intern:
A patient comes in with a script for Lortab, sig says 1-2 q4h prn pain. giving a max of 12 to be taken in a day, thus putting them past the 4 gram limit on APAP in a day. At my non-rotation job, we always at least put a one time comment saying 8 would put them at the max level.

I did this at my rotation site, and my preceptor asked me where I saw the comment on the script. I replied that it's not on there, but that sig gives them more than the max. She said that she/they never add anything to the script and dispense as is because the Pt COULD have a tolerance.

I think it's our responsibility to at least make them aware of it in some way. What is y'alls feelings or how you approach it?

You could call and ask if they want to switch to Norco...

 

[Quiksilver]

This is a question regarding what you would do as a pharmacist/intern:
A patient comes in with a script for Lortab, sig says 1-2 q4h prn pain. giving a max of 12 to be taken in a day, thus putting them past the 4 gram limit on APAP in a day. At my non-rotation job, we always at least put a one time comment saying 8 would put them at the max level.

I did this at my rotation site, and my preceptor asked me where I saw the comment on the script. I replied that it's not on there, but that sig gives them more than the max. She said that she/they never add anything to the script and dispense as is because the Pt COULD have a tolerance.

I think it's our responsibility to at least make them aware of it in some way. What is y'alls feelings or how you approach it?

a tolerance? how? its a saturable PK pathway. thats why its hepatotoxic. there is no tolerance, to my knowledge it doesn't inhibit its own metabolic pathway

 

[Aznfarmerboi]

Concerning APAP toxicity, 4 grams is the limit for chronic exposures (2 grams for liver damage). Although I do not have any literature... this is a widely accepted number and you can always look it up in any toxicology textbooks (Goldfranks). They should have references at the end of the chapter where you can then pull up the primary literature.

You wont see any acute toxicity unless the person ingests > 7.5g within a 4 hour limit (mostly seen in suicidal cases).

What I would do and each pharmacist practices differently depending on their experience and state law is call the doctor and document with recommendation to change to another drug. A pharmacist (or pharmacy student)'s job is to optimize drug therapy and this would be a legit intervention.

Tolerance issues do not come into play since APAP is not addictive...

 

[prevacid]

i work a heavy pain med store, and i always put the max on the labels


one of the times i am uneasy is when i dispense vicodin and darvocet to the same elderly patient....i make sure they understand both have APAP in it and all tat, but still, it makes me uneasy

 

[PharmDstudent]

I did this at my rotation site, and my preceptor asked me where I saw the comment on the script. I replied that it's not on there, but that sig gives them more than the max. She said that she/they never add anything to the script and dispense as is because the Pt COULD have a tolerance.

I think it's our responsibility to at least make them aware of it in some way. What is y'alls feelings or how you approach it?

The patient could have a tolerance to what? The hydrocodone or the APAP? (Hopefully they didn't mean the APAP!)

If they have a "tolerance" to opiods, then they should be switched to something with a smaller amount of APAP (to facilitate more-frequent dosing) or maybe even to a low dose of oxycodone/APAP with limited dosing.

Sometimes patients are prescribed Lortab, Lorcet, etc. regimens post-surgery, so the long-term effects of greater than 4 grams of APAP may not be that much of a concern to the physicians since the dosing is limited to fewer days.


*Word to the wise: Never assume that your preceptor will do things the way that you are accustomed to doing things.

 

[Old Timer]

This is a question regarding what you would do as a pharmacist/intern:
A patient comes in with a script for Lortab, sig says 1-2 q4h prn pain. giving a max of 12 to be taken in a day, thus putting them past the 4 gram limit on APAP in a day. At my non-rotation job, we always at least put a one time comment saying 8 would put them at the max level.

This is a appropriate and you would either add it to the label or make a note to speak to the patient when they came in.

I did this at my rotation site, and my preceptor asked me where I saw the comment on the script. I replied that it's not on there, but that sig gives them more than the max. She said that she/they never add anything to the script and dispense as is because the Pt COULD have a tolerance.

You really only have two choices. Either the preceptor misunderstood your intention or she was a total idiot.

I think it's our responsibility to at least make them aware of it in some way. What is y'alls feelings or how you approach it?

I approach it exactly the same way you do.

anybody have that literature suggesting the 4 gram limit

there's some flaws with the study...but it just something we've just blindly accepted

Here is all you need to know:

A recent study reported that increases in ALT (an enzyme found in the blood which originates predominantly from liver cells) were observed in subjects taking the maximum daily dose of acetaminophen (4 grams).

http://tylenol.com/page.jhtml?id=tylenol/news/tylenol_liver_health.inc

The Maximum Recommended Therapeutic Dosage of Acetaminophen is 50mg/kg/day

F.D.A. Maximum Recommended Therapeutic Dose (MRTD) Database


That's all you need to know. Both the FDA and the manufacturer state the dose should not exceed 4 gm per day. You better have a really good study to back up your recommendations on the advisability of safely exceeding this dosage.

 

[johnep34]

In the UK there have been two landmark cases where pharmacist found guilty of dispensing overdose on script.

1) Migril (a product containing ergotamine for migraine)

2) dexamethasone.

These cases established that pharmacist shares guilt with dr on overdoses.
johnep

 

[Pianopooh]

This is a question regarding what you would do as a pharmacist/intern:
A patient comes in with a script for Lortab, sig says 1-2 q4h prn pain. giving a max of 12 to be taken in a day, thus putting them past the 4 gram limit on APAP in a day. At my non-rotation job, we always at least put a one time comment saying 8 would put them at the max level.

I did this at my rotation site, and my preceptor asked me where I saw the comment on the script. I replied that it's not on there, but that sig gives them more than the max. She said that she/they never add anything to the script and dispense as is because the Pt COULD have a tolerance.

I think it's our responsibility to at least make them aware of it in some way. What is y'alls feelings or how you approach it?

Wow, that's unfortunate your preceptor gave you the response of "just follow the script and dispense." I would call the MD just to verify, my preceptors have been very fortunate and kind enough to tell me it's ok to call the MD to ask, even if the MD is upset from such a call. The Tylenol manufacturer bottle says 8 tablets/mdd = 4 grams/day. What did you end up doing?

 

[johnep34]

Paracetamol (acetominophen) is apparently largest cause of liver failure.
Methionine has a protective action on the liver, combination product marketed by Penn.

In UK largest pack size available from non-pharmacies is 16, 32 from pharmacy counter, upto 100 under pharmacist supervision. The 500 packs I saw in Walmart/Sams are just not available in UK.

Public can buy combination products with dihydrocodeine (7.46mg) and codeine (8mg) under pharmacist supervision.

Co-dydramol 500mg/10mg and Co-codamol 500mg/30mg are available on prescription.
johnep

 

[cutiger]

Wow, that's unfortunate your preceptor gave you the response of "just follow the script and dispense." I would call the MD just to verify, my preceptors have been very fortunate and kind enough to tell me it's ok to call the MD to ask, even if the MD is upset from such a call. The Tylenol manufacturer bottle says 8 tablets/mdd = 4 grams/day. What did you end up doing?

I left for the day shortly after that, but on rotation I don't have an ID with the company so anything that goes out is on the pharmacist, because everyone heard me voice my opinion and she made the final edit of my original sig.

 

[DAW2]

personally i would have left the script as is but told them about the limit during counseling. i would have also set the days supply to the limit and if there is a problem later we'll know how much they're taking

 

[Quiksilver]

i would put it in the sig so that its documented and warned.

 

[Aznfarmerboi]

personally i would have left the script as is but told them about the limit during counseling. i would have also set the days supply to the limit and if there is a problem later we'll know how much they're taking

Then you might as well just put the limit on the script in the first place to cover your ass.