Multiple questions regarding pharmacist practice

[MARX22]

Hey guys. Warning beforehand. These are some questions I came across over the past few months. It’s going to be long, and I’m a newbie—an overthinking one especially! so if it seems dumb to you, please don’t waste your time. I thank u all in advance for any help!

1) when i get rxs for like naproxen or ibuprofen and the pt is already on aspirin 81, i never call lol. I call on class D and x interactions. Lexi shows this interaction as D-consider modification for aspirin w/nsaid but i never called bc every rph i speak to says it isnt a big deal. So generally I call on D and X interactions but I don’t for this. A few months ago I called on sertraline and azithro even though lexi showed C-monitor. I guess I got scared bc of the fact that it mentioned qt prolongation epocrates said use an alternative or monitor ecg which i dont think can be done outpatient but the patient can look out for abnormal heart rhythm/beat, right? Basically—When do u find it important to confirm with someone on the doctor’s end before dispensing?


2-If ur doing a refill and see an “important” interaction (which again, at this point I don’t know how to even determine that. Thought D and X but the sertraline/azithro thing which was C throws me off as to whether i should always call on qt), and the original rph didnt annotate anything—would u jus refill it bc pt has gotten it already, or would u delay til u speak to dr/nurse/someone in office?


3) Also idk whydrs send me dextromethorphan 15-guaifenesin 100mg/5 ml idk if it comes that way but my wholesaler shows the 10-100/5. Sometimes doctors dont reply. Do we just not dispense til we speak to someone, or is it ok to assume they’ll ok the change?


4)what do you guys do if you have an rx for ibuprofen or apap for a kid, dose seems high when u go by age so u ask for weight, md office no response, parents give the weight but dose is still too high. Cant get in touch w dr. Do you change and annotate md ok, dispense w/ the high dose as dr wrote, or don’t dispense til u speak to dr even if that means they never get back to u? I had a 6 yr old kid getting singulair 5 mg take 2 tabs qd.... some rph had filled it in the past. I called for months-no response from the office. Montelukast isn’t weight based from what I saw on lexi but even so, parent claimed child was thin.



5)if get new rx with new strength or frequency, just discontinue (dc) the old rx without talkin to md/pt? Sometimes il have gabapentin 300 mg qd then later get 300 bid. Do we assume it replaces the previous rx even tho TID would be within max dose and it could be meant together?


6)If dc’d qd now get an rx for same med and strength but bid, n pt ran out of the bid, our software lets u make the dc’d rx active again. Is it ok to reactivate the qd n give to patient til md resends bid—or once u dc something don’t undo it? Same w test strips. Was bid, now new rx for qid. I discontinued the bid. So if they ever run out of qid and want it that minute, we shouldn’t be reactivating the bid rx just to provide them with strips since itl prly get confusing, right?


7)rx for cal600/d400 comes—not covered. Pt has been on 500/400. Tried to call md to switch back to 500/400 or see if md thinks 600/400 is a must. Nobody answers on doctor’s end. Pt wants to get the one thats covered n has a refill on file. Technically thats supposed to be dc’d so we cant give it cuz new rx came for diff strength, right? Its only cal/d so not a biggie but just clarifying the concept of it


8)max dose of Simvastatin w amlodipine is 20 mg. Sometimes pts are on higher than 20 but dr still says its ok. Lexi says not to exceed/avoid simva>20. When I see avoid I think “never,” but apparently its ok since its not listed as contraindicated? I personally have called n switched to a diff statin but so many rphs dispense the simva>20 w md’s ok. It’s difficult to try to control it all since other rphs practice differently. I’d like some insight from u more experienced folks


9)another annoying thing. Doctors write-Qty 240 but sig says 5 ml q4 x 10 days, which means they need 300 ml. Sometimes its not even worth thr hassle of calling lol or they dont pick up. I just give 240 ‍♀️

10) pt was on omeprazole, gets new rx for esomeprazole. Therapeutic dup. Do u call esomep’s dr to clarify, or just give esomep and discontinue omep? I would say just dispense new rx without callin... but if its not covered and md doesnt answer.. can u still dispense refill of the one on profile (omep) or is it supposed to be stopped since md sent a new one?

11)Finally—if md wrote a specific pen needle gauge/mm, and it isn’t available on the market and md doesn’t answer for days—do u just put md ok and bill/dispense the size that’s available? I doubt they care, and i always put md ok tab or cap without calling bc that’s such a dumb law and if u really called to get an ok on tab vs cap... they’d curse u out lol


If u read this far—thank you for ur patience haha!!!

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[CetiAlphaFive]

Hey guys. Warning beforehand. These are some questions I came across over the past few months. It’s going to be long, and I’m a newbie—an overthinking one especially! so if it seems dumb to you, please don’t waste your time. I thank u all in advance for any help!

1) when i get rxs for like naproxen or ibuprofen and the pt is already on aspirin 81, i never call lol. I call on class D and x interactions. Lexi shows this interaction as D-consider modification for aspirin w/nsaid but i never called bc every rph i speak to says it isnt a big deal. So generally I call on D and X interactions but I don’t for this. A few months ago I called on sertraline and azithro even though lexi showed C-monitor. I guess I got scared bc of the fact that it mentioned qt prolongation epocrates said use an alternative or monitor ecg which i dont think can be done outpatient but the patient can look out for abnormal heart rhythm/beat, right? Basically—When do u find it important to confirm with someone on the doctor’s end before dispensing?


2-If ur doing a refill and see an “important” interaction (which again, at this point I don’t know how to even determine that. Thought D and X but the sertraline/azithro thing which was C throws me off as to whether i should always call on qt), and the original rph didnt annotate anything—would u jus refill it bc pt has gotten it already, or would u delay til u speak to dr/nurse/someone in office?


3) Also idk whydrs send me dextromethorphan 15-guaifenesin 100mg/5 ml idk if it comes that way but my wholesaler shows the 10-100/5. Sometimes doctors dont reply. Do we just not dispense til we speak to someone, or is it ok to assume they’ll ok the change?


4)what do you guys do if you have an rx for ibuprofen or apap for a kid, dose seems high when u go by age so u ask for weight, md office no response, parents give the weight but dose is still too high. Cant get in touch w dr. Do you change and annotate md ok, dispense w/ the high dose as dr wrote, or don’t dispense til u speak to dr even if that means they never get back to u? I had a 6 yr old kid getting singulair 5 mg take 2 tabs qd.... some rph had filled it in the past. I called for months-no response from the office. Montelukast isn’t weight based from what I saw on lexi but even so, parent claimed child was thin.



5)if get new rx with new strength or frequency, just discontinue (dc) the old rx without talkin to md/pt? Sometimes il have gabapentin 300 mg qd then later get 300 bid. Do we assume it replaces the previous rx even tho TID would be within max dose and it could be meant together?


6)If dc’d qd now get an rx for same med and strength but bid, n pt ran out of the bid, our software lets u make the dc’d rx active again. Is it ok to reactivate the qd n give to patient til md resends bid—or once u dc something don’t undo it? Same w test strips. Was bid, now new rx for qid. I discontinued the bid. So if they ever run out of qid and want it that minute, we shouldn’t be reactivating the bid rx just to provide them with strips since itl prly get confusing, right?


7)rx for cal600/d400 comes—not covered. Pt has been on 500/400. Tried to call md to switch back to 500/400 or see if md thinks 600/400 is a must. Nobody answers on doctor’s end. Pt wants to get the one thats covered n has a refill on file. Technically thats supposed to be dc’d so we cant give it cuz new rx came for diff strength, right? Its only cal/d so not a biggie but just clarifying the concept of it


8)max dose of Simvastatin w amlodipine is 20 mg. Sometimes pts are on higher than 20 but dr still says its ok. Lexi says not to exceed/avoid simva>20. When I see avoid I think “never,” but apparently its ok since its not listed as contraindicated? I personally have called n switched to a diff statin but so many rphs dispense the simva>20 w md’s ok. It’s difficult to try to control it all since other rphs practice differently. I’d like some insight from u more experienced folks


9)another annoying thing. Doctors write-Qty 240 but sig says 5 ml q4 x 10 days, which means they need 300 ml. Sometimes its not even worth thr hassle of calling lol or they dont pick up. I just give 240 ‍♀️



10)Finally—if md wrote a specific pen needle gauge/mm, and it isn’t available on the market and md doesn’t answer for days—do u just put md ok and bill/dispense the size that’s available? I doubt they care, and i always put md ok tab or cap without calling bc that’s such a dumb law and if u really called to get an ok on tab vs cap... they’d curse u out lol


If u read this far—thank you for ur patience haha!!!

Jesus wept.

EDIT:

Ill post actual answers to some of these questions later if any of them merit anything besides "what did you do during the 4 years of school?" Answer

 

[Sine Cura]

Not a single one I would take any additional step involving the prescriber's office except montelukast 10 mg

I think one thing all retail pharmacists should do is ask yourself, "Why am I contacting the prescriber's office?" Is it because you actually care for the patient's well being or you just want to cover your ass and think you are by obtaining so-called "documentation." I see most of the time on the latter the vast majority of timid pharmacists fold like a cheap suitcase the moment you get a "ok to fill" like that means anything

 

[MARX22]

I agree with u, and being around timid pharmacists got me questioning everything! I agree on the wanting to cover your ass part. Would u be changing apap/ibu doses on ur own though? We still need to annotate on any changes. Just stuck on the technicalities. Id love to change on my own but legally we still need the “ok.” I would like some genuine advice

Not a single one I would take any additional step involving the prescriber's office except montelukast 10 mg

I think one thing all retail pharmacists should do is ask yourself, "Why am I contacting the prescriber's office?" Is it because you actually care for the patient's well being or you just want to cover your ass and think you are by obtaining so-called "documentation." I see most of the time on the latter the vast majority of timid pharmacists fold like a cheap suitcase the moment you get a "ok to fill" like that means anything

I

 

[Apotheker2015]

Hey guys. Warning beforehand. These are some questions I came across over the past few months. It’s going to be long, and I’m a newbie—an overthinking one especially! so if it seems dumb to you, please don’t waste your time. I thank u all in advance for any help!

1) when i get rxs for like naproxen or ibuprofen and the pt is already on aspirin 81, i never call lol. I call on class D and x interactions. Lexi shows this interaction as D-consider modification for aspirin w/nsaid but i never called bc every rph i speak to says it isnt a big deal. So generally I call on D and X interactions but I don’t for this. A few months ago I called on sertraline and azithro even though lexi showed C-monitor. I guess I got scared bc of the fact that it mentioned qt prolongation epocrates said use an alternative or monitor ecg which i dont think can be done outpatient but the patient can look out for abnormal heart rhythm/beat, right? Basically—When do u find it important to confirm with someone on the doctor’s end before dispensing?


2-If ur doing a refill and see an “important” interaction (which again, at this point I don’t know how to even determine that. Thought D and X but the sertraline/azithro thing which was C throws me off as to whether i should always call on qt), and the original rph didnt annotate anything—would u jus refill it bc pt has gotten it already, or would u delay til u speak to dr/nurse/someone in office?


3) Also idk whydrs send me dextromethorphan 15-guaifenesin 100mg/5 ml idk if it comes that way but my wholesaler shows the 10-100/5. Sometimes doctors dont reply. Do we just not dispense til we speak to someone, or is it ok to assume they’ll ok the change?


4)what do you guys do if you have an rx for ibuprofen or apap for a kid, dose seems high when u go by age so u ask for weight, md office no response, parents give the weight but dose is still too high. Cant get in touch w dr. Do you change and annotate md ok, dispense w/ the high dose as dr wrote, or don’t dispense til u speak to dr even if that means they never get back to u? I had a 6 yr old kid getting singulair 5 mg take 2 tabs qd.... some rph had filled it in the past. I called for months-no response from the office. Montelukast isn’t weight based from what I saw on lexi but even so, parent claimed child was thin.



5)if get new rx with new strength or frequency, just discontinue (dc) the old rx without talkin to md/pt? Sometimes il have gabapentin 300 mg qd then later get 300 bid. Do we assume it replaces the previous rx even tho TID would be within max dose and it could be meant together?


6)If dc’d qd now get an rx for same med and strength but bid, n pt ran out of the bid, our software lets u make the dc’d rx active again. Is it ok to reactivate the qd n give to patient til md resends bid—or once u dc something don’t undo it? Same w test strips. Was bid, now new rx for qid. I discontinued the bid. So if they ever run out of qid and want it that minute, we shouldn’t be reactivating the bid rx just to provide them with strips since itl prly get confusing, right?


7)rx for cal600/d400 comes—not covered. Pt has been on 500/400. Tried to call md to switch back to 500/400 or see if md thinks 600/400 is a must. Nobody answers on doctor’s end. Pt wants to get the one thats covered n has a refill on file. Technically thats supposed to be dc’d so we cant give it cuz new rx came for diff strength, right? Its only cal/d so not a biggie but just clarifying the concept of it


8)max dose of Simvastatin w amlodipine is 20 mg. Sometimes pts are on higher than 20 but dr still says its ok. Lexi says not to exceed/avoid simva>20. When I see avoid I think “never,” but apparently its ok since its not listed as contraindicated? I personally have called n switched to a diff statin but so many rphs dispense the simva>20 w md’s ok. It’s difficult to try to control it all since other rphs practice differently. I’d like some insight from u more experienced folks


9)another annoying thing. Doctors write-Qty 240 but sig says 5 ml q4 x 10 days, which means they need 300 ml. Sometimes its not even worth thr hassle of calling lol or they dont pick up. I just give 240 ‍♀️

10) pt was on omeprazole, gets new rx for esomeprazole. Therapeutic dup. Do u call esomep’s dr to clarify, or just give esomep and discontinue omep? I would say just dispense new rx without callin... but if its not covered and md doesnt answer.. can u still dispense refill of the one on profile (omep) or is it supposed to be stopped since md sent a new one?

11)Finally—if md wrote a specific pen needle gauge/mm, and it isn’t available on the market and md doesn’t answer for days—do u just put md ok and bill/dispense the size that’s available? I doubt they care, and i always put md ok tab or cap without calling bc that’s such a dumb law and if u really called to get an ok on tab vs cap... they’d curse u out lol


If u read this far—thank you for ur patience haha!!!

I mean no disrespect. I see too much lexicomp here. Pull up package inserts. Everything is there. Simvastatin dosing is nicely outlined in the package insert whether online or on paper. 4th year was for you to develop the confidence to discern clinically significant interactions from those that aren't. My suggestion is to try to go through the top 200 drug list and look up and OWN why the drug was given the patent; i.e., approved. If you can recite that, then you're golden.

Azithromycin is fine if your heart is fine. Remember that. When you counsel, you assess whether the patient has a history of heart problems and if they mentioned those to the prescriber. You take it from there and document. It's also a very short course usually and at this point, z-packs are pointless due to drug resistance and poor prescribing practices.

And for fluoroquinolones, the tendon ruptures that everyone likes to freak out patients about was really an issue for older patients (>60), with reduced body mass, compromised kidney function, heart/lung/kidney transplant and/or on long term therapy with corticosteroids. Go figure.

Always D/C rx's that are replaced by new rx which reflects a change in therapy. You should not be reactivating prescriptions and if you MUST, then you need to document why. If something ever happens and it circles back to you, and it will, there is no way that you will remember. Not deactivating such prescriptions is asking for a dispensing error to happen. Patients use the automated system to order their meds and if they're out of fills on the rx which reflects their current therapy, they will press buttons until something goes through. And that is how you get a patient taking a lower/higher dose of whatever with the wrong dosing frequency. The system will present it to you as a refill. Thus, it will go straight to fill, then to visual verification, boom, out the door it goes.
It takes a second to deactivate those prescriptions. Yet, so many pharmacists do not. It's confusing to me. Most systems do not prompt the pharmacist to deactivate those prescriptions or review the fill history.

APAP/Ibuprofen - let me ask you this, whether you can get a hold of anyone, are you going to dispense that excessive dose? Prescribers never override your license. You are the last safety checkpoint. Own it. I am at a very busy place. I usually put a max on anything like that. If they send a prn prescription that if taken scheduled exceeds the max daily dose, I add "Do not exceed 3 tablets per day". I don't want to hold up the patient and tell them that's what the guideline says and they are more than welcome to talk to their prescriber and see if they should do otherwise. Then I have a tech fax the prescriber informing what we dispensed. That;'s usually a fax with a quick note and the prescription label. Done. If they think otherwise, they will call you back and/or call the patient.

Back to reactivating stuff, I would provide a mercy supply - some people do 3 days which is extremely annoying. The patient will be right back. Unless it's something really expensive I give 5 to 7 days worth. Test strips, I ask the patient if they're actually out. Truth is they're rarely compliant and they just love hoarding the stuff. If they're out, just take care of the patient, give them the smallest box you have, put a label on it and done. Document. You're not supposed to but that's life. Or grab it off the OTC section and comp it and document why and then document that when you're able to run it through insurance.

Montelukast is by age. That's that.

Calcium... meh, dispense what goes through even if it means you OK that before the MD says OK and you fax them to inform what you did. The MD is not going to say no.

The 240 mL issue. Well, did they miss PRN and a max per day? You don't know. Is there a max recommended dose?

Pen needle - I tell the patient, my company requires me to call, they're not available and won't be until after the weekend. I Have X Y Z gauge, if you tell me you prefer one of those, i can override it and dispense those. Done.

Cap to Tab Ok but Tab to Cap not OK. You do not know if the person has an allergy to the gelatin. I've heard of that happening to pharmacists and getting into trouble. If it's something that simply isn't available in tabs, and that's common knowledge, well that's life. So you check for allergies. Done. Otherwise, I would rather play with strength and dispense more tabs than switch to caps.

 

[Sabril]

Apotheker gave very good advice. Except that the list of meds that I would feel comfortable switching between tab and cap is very limited, hctz, ranitidine and things like that. I wouldn't switch things like Verapamil Er for example.

And I change things all the time without speaking to the prescriber. For example one PA loves to write alendronate take with food, simvastatin take in the morning etc so I have to change the direction. I also change the quantity, size of syringes, size of eye drop bottles etc. to whatever that makes sense and to avoid third party chargeback. The doc may specifically write for a 10ml bottle of combigan per month, but if the day supply is incorrect, the insurance company can take their money back. No amount of "calling the doctor" would help you then.

As far as how to deal with drug interactions, may I suggest the OP to subscribe to the pharmacist's letter. It is a good read (sometimes) and there is also a forum to ask these kinds of questions. Admittedly I fail to follow about 70% of recommendations so I cannot say it is "life changing" for me but it is a good resource nonetheless.

 

[wagrxm2000]

First off, I barely read this.

My advice doesn't change though, you will hate your job if you question everything. If there's an interaction, you simply tell the customer to watch out for it. If the dosing is wrong for a child, tell them the correct dose. Duplicate therapy? Give the most recent and tell them to stop the other.

I think you should see a trend here. Oh and let the customer do the work for you. This would be for refills, PAs, wrong drug sent, etc. Just send a fax and tell the patient to call.

I just saved you an hour a day, your welcome.

 

[johnpharm01]

First off, I barely read this.

My advice doesn't change though, you will hate your job if you question everything. If there's an interaction, you simply tell the customer to watch out for it. If the dosing is wrong for a child, tell them the correct dose. Duplicate therapy? Give the most recent and tell them to stop the other.

I think you should see a trend here. Oh and let the customer do the work for you. This would be for refills, PAs, wrong drug sent, etc. Just send a fax and tell the patient to call.

I just saved you an hour a day, your welcome.

Well this is really bad advice. Pass all the responsibility on to the patient. Well you can't. Practice like this and when it hits the fan how do you explain it?. I applaud the individual starting this thread for doing so. I would recommend coming up with a framework for your practice.
Mine : Goal is to help patient by providing correctly filled prescriptions to help patients treat medical problems done within the confines of law, rule, policy and good practice. One problem you are running into is assessing drug-drug interactions. This is where pharmacy schools fail, they make us memorize tons of information but don't make it useful. I worked at a major chain and would routinely see other rphs dispense warfarin even with significant drug interactions saying it was the patients responsibility to manage. Wrong, how the hell would they know and if they did how would they?. After working in anticoag, I would not dispense fluconazole with speaking to the prescriber if someone was on warfarin (combo gives 5 or higher INR) but might just counsel if the interaction was Keflex and warfarin. So when you look at drug interactions don't just rely on the software, consider a persons age, general health and possible outcomes. Minor issues maybe ok with a warning, but serious ones will need other action.

 

[wagrxm2000]

Well this is really bad advice. Pass all the responsibility on to the patient. Well you can't. Practice like this and when it hits the fan how do you explain it?. I applaud the individual starting this thread for doing so. I would recommend coming up with a framework for your practice.
Mine : Goal is to help patient by providing correctly filled prescriptions to help patients treat medical problems done within the confines of law, rule, policy and good practice. One problem you are running into is assessing drug-drug interactions. This is where pharmacy schools fail, they make us memorize tons of information but don't make it useful. I worked at a major chain and would routinely see other rphs dispense warfarin even with significant drug interactions saying it was the patients responsibility to manage. Wrong, how the hell would they know and if they did how would they?. After working in anticoag, I would not dispense fluconazole with speaking to the prescriber if someone was on warfarin (combo gives 5 or higher INR) but might just counsel if the interaction was Keflex and warfarin. So when you look at drug interactions don't just rely on the software, consider a persons age, general health and possible outcomes. Minor issues maybe ok with a warning, but serious ones will need other action.

Calm down there buddy, this is why people complain they don't have enough help.

Please tell me how many times you've called on an interaction and the md office said, "so" or "that's what I want" or "why are you telling me this, I know what they are on"?

OP gave an example of sertraline and azithromycin not warfarin.

 

[johnpharm01]

Calm down there buddy, this is why people complain they don't have enough help.

Please tell me how many times you've called on an interaction and the md office said, "so" or "that's what I want" or "why are you telling me this, I know what they are on"?

OP gave an example of sertraline and azithromycin not warfarin.

I agree retail is a nightmare, but these issues come up elsewhere. The best way to deal with them is to really educate ourselves and gather information so we can make good decisions. Minor drug interactions may not need any response, but more severe ones do. If I call the doctor and they are dismissive that can be ok I did my job making sure the dr recognizes the interaction. If its more severe I like to know their plan. If its beyond the course of usual prescribing, likely to cause harm and the dr does not want to discuss it the rx can be filled elsewhere.
Some examples:
Worked in long term care (mental health) . Psychiatrist was on vacation, nurse and md were worried about a resident with bipolar disorder being depressed. They started the resident on an antidepressant. I tried to warn them to use carefully as could flip to mania and documented in his medical record. The dr fought it and sure enough the resident became manic and didn't come down for months.
Worked at a major retailer. NP prescribed serotonergic drug for patient who was on two other serotonin boosting drugs. Called NP who refused to discuss it told me to call other dr (the patient was receiving rxs from multiple mds). Told np that I would not dispense it. She actually came by the pharmacy complained to my boss, but it did get resolved with him.
At major retailer called md, patient was on cat x drug and was pregnant (told staff was preg so could get 0 copay with state medicaid) This rx got canceled immediately after it was filled multiple times

 

[wagrxm2000]

I agree retail is a nightmare, but these issues come up elsewhere. The best way to deal with them is to really educate ourselves and gather information so we can make good decisions. Minor drug interactions may not need any response, but more severe ones do. If I call the doctor and they are dismissive that can be ok I did my job making sure the dr recognizes the interaction. If its more severe I like to know their plan. If its beyond the course of usual prescribing, likely to cause harm and the dr does not want to discuss it the rx can be filled elsewhere.
Some examples:
Worked in long term care (mental health) . Psychiatrist was on vacation, nurse and md were worried about a resident with bipolar disorder being depressed. They started the resident on an antidepressant. I tried to warn them to use carefully as could flip to mania and documented in his medical record. The dr fought it and sure enough the resident became manic and didn't come down for months.
Worked at a major retailer. NP prescribed serotonergic drug for patient who was on two other serotonin boosting drugs. Called NP who refused to discuss it told me to call other dr (the patient was receiving rxs from multiple mds). Told np that I would not dispense it. She actually came by the pharmacy complained to my boss, but it did get resolved with him.
At major retailer called md, patient was on cat x drug and was pregnant (told staff was preg so could get 0 copay with state medicaid) This rx got canceled immediately after it was filled multiple times

I'm perfectly fine with you calling on serious things but the examples the OP gave weren't serious.

 

[johnpharm01]

I'm perfectly fine with you calling on serious things but the examples the OP gave weren't serious.

I am glad you approve.

 

[MARX22]

If u tell them the right dose but dispense with the high one, doesn’t that still trace back to you if anything were to happen and the parent followed the label?

As for discontinuing old med and giving new one—i have no issue doing that. There have jus been a few times where i called n it ended up being a mistake where md wanted the old med-although usually they want the new one. Since not all rphs discontinue as u said... if ur refilling, do u jus give the more recent one and dc the old one then at that point n tell pt u wont fill?

For example i was working as a floater and they had a pt on celebrex and voltaren gel for months. Lexi shows it as contraindicated. Shouldn’t combine celebrex with any nsaid and it showed it for topical in the drug interaction tool as well. Checked voltaren PI-says oral nsaids were prohibited w voltaren gel during clinical trials and that they were not tested together but if pt were to take together theres a higher risk of bleed/ulcers. Do you guys dc the older one even if refilling, or how do u deal with it? Did a quick google search, stated oral nsaid and topical together did not provide added benefit and instead increased risk of bleed, but for naproxen and voltaren it comes up as cat C-monitor. Do u assume the new one replaces the old one even if its diff routes po vs topical and pt has been on it for a while?

First off, I barely read this.

My advice doesn't change though, you will hate your job if you question everything. If there's an interaction, you simply tell the customer to watch out for it. If the dosing is wrong for a child, tell them the correct dose. Duplicate therapy? Give the most recent and tell them to stop the other.

I think you should see a trend here. Oh and let the customer do the work for you. This would be for refills, PAs, wrong drug sent, etc. Just send a fax and tell the patient to call.

I just saved you an hour a day, your welcome.

 

[MARX22]

Hello Apotheker,

No disrespect at all! I look at the package insert when I’m really confused as to why lexi, micromedex show different things but sometimes even then don’t know what to do. For example i was working as a floater and they had a pt on celebrex and voltaren gel for months. Lexi shows it as duplicate therapy, and also contraindicated, mdex shows as major but not c/i. Lexi said-Shouldn’t combine celebrex with any nsaid and it showed it for topical in the drug interaction tool as well. Checked voltaren PI-says oral nsaids were prohibited w voltaren gel during clinical trials and that they were not tested together but if pt were to take together theres a higher risk of bleed/ulcers. Doesnt say c/i. Do you dc the older one even if refilling, or how do u deal with it? Did a quick google search, stated oral nsaid and topical together did not provide added benefit and instead increased risk of bleed, but for naproxen and voltaren it comes up as cat C-monitor. Do u assume the new one replaces the old one even if its diff routes po vs topical and pt has been on it for a while, since the other rph has been dispensing both?if ur the rph working and pt only been on po nsaid and now gets topical or vice versa, do u just dc one n give new one or call since its diff routes?

As for discontinuing old med and giving new one—i have no issue doing that. There have jus been a few times where i called n it ended up being a mistake where md wanted the old med-although usually they want the new one. Since not all rphs discontinue as u said... if ur refilling, do u jus give the more recent one and dc the old one then at that point n tell pt u wont fill both, like the celebrex/voltaren gel scenario above? Theyl probably throw a fit wanting both but if its unacceptable to dispense both, I’d say that. If they request to keep the older med if lets say it was celebrex n worked better than gel, do u still dc celebrex bc voltaren was more recent even tho rph filled both? Not every rph actually dc’s or calls on such DDIs, they may just be filling everything smh.

As for apap or ibu... i never dispense above 4g (yes it should be 3grams but diff boxes state diff maxes so its debatable) and 2.4g ibu. My concern was aspirin with ibuprofen.

Pen needles if the pt wants before u can receive the correct size, you’d get their ok then just give the size you have? Would you annotate anything like md ok, since ur changing the gauge etc? It seems like a minor thing though it’s still a needle lol. If it was a refill though you’d still need to order the same size needle for that rx number

The cough meds they dont put prn sometimes but as long as it doesnt exceed mdd like 30 ml of prometh Dm i just dispense and tell the pt its for cough so it should be prn

As for just dc-ing old med and giving new one... got rx for cellcept 250 bid pt was on 500 bid. U would assume to dc 500mg. Turns out pt said md said take 750 bid. Rx didnt mention combining w the old rx.

Thanks!

I mean no disrespect. I see too much lexicomp here. Pull up package inserts. Everything is there. Simvastatin dosing is nicely outlined in the package insert whether online or on paper. 4th year was for you to develop the confidence to discern clinically significant interactions from those that aren't. My suggestion is to try to go through the top 200 drug list and look up and OWN why the drug was given the patent; i.e., approved. If you can recite that, then you're golden.

Azithromycin is fine if your heart is fine. Remember that. When you counsel, you assess whether the patient has a history of heart problems and if they mentioned those to the prescriber. You take it from there and document. It's also a very short course usually and at this point, z-packs are pointless due to drug resistance and poor prescribing practices.

And for fluoroquinolones, the tendon ruptures that everyone likes to freak out patients about was really an issue for older patients (>60), with reduced body mass, compromised kidney function, heart/lung/kidney transplant and/or on long term therapy with corticosteroids. Go figure.

Always D/C rx's that are replaced by new rx which reflects a change in therapy. You should not be reactivating prescriptions and if you MUST, then you need to document why. If something ever happens and it circles back to you, and it will, there is no way that you will remember. Not deactivating such prescriptions is asking for a dispensing error to happen. Patients use the automated system to order their meds and if they're out of fills on the rx which reflects their current therapy, they will press buttons until something goes through. And that is how you get a patient taking a lower/higher dose of whatever with the wrong dosing frequency. The system will present it to you as a refill. Thus, it will go straight to fill, then to visual verification, boom, out the door it goes.
It takes a second to deactivate those prescriptions. Yet, so many pharmacists do not. It's confusing to me. Most systems do not prompt the pharmacist to deactivate those prescriptions or review the fill history.

APAP/Ibuprofen - let me ask you this, whether you can get a hold of anyone, are you going to dispense that excessive dose? Prescribers never override your license. You are the last safety checkpoint. Own it. I am at a very busy place. I usually put a max on anything like that. If they send a prn prescription that if taken scheduled exceeds the max daily dose, I add "Do not exceed 3 tablets per day". I don't want to hold up the patient and tell them that's what the guideline says and they are more than welcome to talk to their prescriber and see if they should do otherwise. Then I have a tech fax the prescriber informing what we dispensed. That;'s usually a fax with a quick note and the prescription label. Done. If they think otherwise, they will call you back and/or call the patient.

Back to reactivating stuff, I would provide a mercy supply - some people do 3 days which is extremely annoying. The patient will be right back. Unless it's something really expensive I give 5 to 7 days worth. Test strips, I ask the patient if they're actually out. Truth is they're rarely compliant and they just love hoarding the stuff. If they're out, just take care of the patient, give them the smallest box you have, put a label on it and done. Document. You're not supposed to but that's life. Or grab it off the OTC section and comp it and document why and then document that when you're able to run it through insurance.

Montelukast is by age. That's that.

Calcium... meh, dispense what goes through even if it means you OK that before the MD says OK and you fax them to inform what you did. The MD is not going to say no.

The 240 mL issue. Well, did they miss PRN and a max per day? You don't know. Is there a max recommended dose?

Pen needle - I tell the patient, my company requires me to call, they're not available and won't be until after the weekend. I Have X Y Z gauge, if you tell me you prefer one of those, i can override it and dispense those. Done.

Cap to Tab Ok but Tab to Cap not OK. You do not know if the person has an allergy to the gelatin. I've heard of that happening to pharmacists and getting into trouble. If it's something that simply isn't available in tabs, and that's common knowledge, well that's life. So you check for allergies. Done. Otherwise, I would rather play with strength and dispense more tabs than switch to caps.

 

[wagrxm2000]

If u tell them the right dose but dispense with the high one, doesn’t that still trace back to you if anything were to happen and the parent followed the label?

As for discontinuing old med and giving new one—i have no issue doing that. There have jus been a few times where i called n it ended up being a mistake where md wanted the old med-although usually they want the new one. Since not all rphs discontinue as u said... if ur refilling, do u jus give the more recent one and dc the old one then at that point n tell pt u wont fill?

For example i was working as a floater and they had a pt on celebrex and voltaren gel for months. Lexi shows it as contraindicated. Shouldn’t combine celebrex with any nsaid and it showed it for topical in the drug interaction tool as well. Checked voltaren PI-says oral nsaids were prohibited w voltaren gel during clinical trials and that they were not tested together but if pt were to take together theres a higher risk of bleed/ulcers. Do you guys dc the older one even if refilling, or how do u deal with it? Did a quick google search, stated oral nsaid and topical together did not provide added benefit and instead increased risk of bleed, but for naproxen and voltaren it comes up as cat C-monitor. Do u assume the new one replaces the old one even if its diff routes po vs topical and pt has been on it for a while?

You have to do what you're comfortable with. I'm fine giving my recommendation as long as the MD wasn't way off. Obviously just for otc.

There has to be a legitimate reason for me to give duplicate therapy.

 

[KennethCool]

4th year was for you to develop the confidence to discern clinically significant interactions from those that aren't.

Honestly, this is something I wasn't taught in school or on any of my rotations.

 

[MARX22]

Would u fill voltaren gel with po nsaid? Ive done asa and nsaid but feel iffy about two nsaids even if one is topical. They weren’t tested together and technically its duplicate therapy but not c/i in package insert either. Their reasoning for dup therapy is always “this works best for pt” or pt has been on it for yrs lmao

You have to do what you're comfortable with. I'm fine giving my recommendation as long as the MD wasn't way off. Obviously just for otc.

There has to be a legitimate reason for me to give duplicate therapy.

 

[MARX22]

Honestly, this is something I wasn't taught in school or on any of my rotations.

Seriously.... these questions didnt even cross my mind when I was in school/rotations. Just faced them as an rph bc thats when ur actually dispensing/verifying

 

[Apotheker2015]

Hello Apotheker,

(...) Checked voltaren PI-says oral nsaids were prohibited w voltaren gel during clinical trials and that they were not tested together but if pt were to take together theres a higher risk of bleed/ulcers. (...)



As for just dc-ing old med and giving new one... got rx for cellcept 250 bid pt was on 500 bid. U would assume to dc 500mg. Turns out pt said md said take 750 bid. Rx didnt mention combining w the old rx.

Thanks!

I see where you are coming from. We were all trained differently. My school discouraged the use of Lexicomp as your main source because it's basically cliff-notes. We had an amazing pharmacokinetics/biopharmaceutics professor who showed us how to chew through a package insert in 5 minutes or less. Once you develop your own system, you'll be able to get through key points of any package insert in no time.
Google "voltaren gel package insert". The accessdata.fda should be the first one. Go to page 11. There are 3 key points here:
1. Systemic exposure with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is on average 17 times lower than with oral treatment.
2. The amount of diclofenac sodium that is systemically absorbed from Voltaren® Gel is on average 6% of the systemic exposure from an oral form of diclofenac sodium.
3. The average peak plasma concentration with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is 158 times lower than with the oral treatment.

Now after reading through those 3 points, why do you think oral NSAIDs were prohibited during clinical trials?
These are the times when I am glad I took my sweet time to get to pharmacy school after doing research in hard sciences through undergrad. If the average peak plasma concentration of voltaren gel is 158 times lower than with the oral treatment, do you think that you would be able to measure the plasma concentration of voltaren gel if subjects are also taking oral NSAIDs?
The answer is no. The data would be obscured by the concentrations of oral NSAIDs. You would not be able to tell what's what even if you're looking for specific metabolites. And you could do that but that would be highly inefficient and expensive..

The take home message from those 3 points is that topical diclofenac gel will pretty much absorb where you apply and for the most part stay there. ***6% of the systemic exposure from an oral form of diclofenac*** I am not going to venture and say 94% stays in the area where it's applied. It's likely a lot less than that. But for the most part this is a cleaner drug, isn't it? With oral forms, you rely on systemic absorption for that drug to reach its desired therapeutic target.

No math. No complicated PK. Just intuitively reason through the story the package insert is telling you. Lexi gives you facts that are only useful if you've reasoned through package inserts and made that knowledge yours.

So once you get through the PK section, you can approach everything else. Otherwise, every possible adverse effect sounds like a death sentence for your patient. Would voltaren gel be dangerous for an older person with less than ideal kidney function? It's possible, but you have to ask yourself, how much voltaren? Are they going to bathe in a tub of it and stay in there for 6 hours?
Diclofenac is cleared by the kidneys, yes, but the topical route pretty much spares the kidneys. These are not set rules. Every patient is different. I would not mess with extreme cases, of course.
So you see that for voltaren gel to cause a stomach bleed at the recommended dose the patient would need to be at risk for it - taking stupid amounts of X drug- and of course, applying stupid amounts of Voltaren gel. When you get a script, quickly establish whether it's the recommended dose for that population/patient type and go from there.

Are you catching my drift here?

Pen needles if the pt wants before u can receive the correct size, you’d get their ok then just give the size you have? Would you annotate anything like md ok, since ur changing the gauge etc? It seems like a minor thing though it’s still a needle lol. If it was a refill though you’d still need to order the same size needle for that rx number

We are typically caught up and I stress that my techs call patients right away. I always keep the resolution/third party rejection queue on even though I am not required to, simply because it puts me in control of everything. That way techs aren't able to get away with not calling patients or just pushing prescriptions that aren't going through to a later time.
It's as simple as calling the patient and letting them know what you have in stock. If you can speak to them great. Otherwise, leave a message. Use your judgment there. Most patients do not care that much about the gauge. They don't even know what that means. They mostly care about the length. So when I tell them the gauge I tell them the length too and say, "the ones in stock are the same length as the ones you always get but a little thicker/thinner". That gives them a visual.

The cough meds they dont put prn sometimes but as long as it doesnt exceed mdd like 30 ml of prometh Dm i just dispense and tell the pt its for cough so it should be prn
Walmart is very strict with all controlled substances. Do not forget that regardless of what you tell the patient, what you put on the label is what pretty much goes on record. The patient won't get a copy of your counseling points. They're not going to read the medication guide. They are not even paying attention to anything that you are saying. Those should be PRN and per company policy, I am required to clarify that. Thus, I would. But on a Friday night with a sick patient and frantic parent in front of me, I would dispense and add "as needed. Do not exceed X ml in 24 hours".
Then fax the prescriber back, letting them know what you did. If the prescriber feels any different, well, no harm done, right? The patient got the medication and the quantity that was prescribed. He/she can call the patient and override what you did. However, that's the only way I'd bless that with my license.
Others may disagree. And that's fine. It's my license. I am not holding up the patient in any way. I do that with acute pain C-IIs as well. I put a max on them and inform the prescriber via fax and annotate on the script. I even write the MMEs on it. I've had prescribers come up to me and say "Oh, you are John Smith. Glad to meet you. I like how you work. Thank you. We appreciate it in my office"
It's my license and I have loans to pay. If you keep your queue clutter free and teach your techs to do the same, you will have time to do hand write thank you notes. I have seen stores so well run that pharmacists have time to do that.

As for just dc-ing old med and giving new one... got rx for cellcept 250 bid pt was on 500 bid. U would assume to dc 500mg. Turns out pt said md said take 750 bid. Rx didnt mention combining w the old rx.
Never assume anything. And never assume anything with Cellcept. That's just a sloppy prescriber. It would strike me as odd to see a dose decrease without the addition of say, corticosteroids.
You also have to educate your prescribers. You can either do it directly by asking them to state "this prescriptions replaces previous cellcept ..." "Take along with ..."
It's a new prescription and you have to counsel, anyhow. I would definitely check in with the prescriber. Once you call them several times, it gets annoying to them and they'll listen.

Hope this helps. Get out of retail if you get the chance to.

All the best.

 

[MARX22]

First off, you’re very patient and I thank you for all of your help!!!!!! I appreciate you pulling the voltaren PI and making great points!

I guess my issue with pen needles is even if the patient is ok with it, that we’re changing the size the MD sent without getting the md’s ok.

Promethazine dm is not a control in my state, but even for controls, sometimes doctors don’t add the mdd and i add it according to the sig’s directions. For percocet/opioids there’s no ceiling dose but if there’s apap in there then yea u can’t exceed past 4 g. Sometimes theyl send the general max dose like clonazepam 0.5 mg bid. Mdd 20 mg. Lol. I don’t leave it as 20 mg bc pt might thibk they’re allowed to take that much but then they’ll run out and insurance wont pay and blah blah. The sig says bid so bid it is. Anyway about the cough med they don’t add prn sometimes and neither do i since im just paranoid about adding it lol although i add a max for controls. Does your system let u fax a message or are u manually writing something and putting it hru the fax machine? What are u annotating on the script, that ul let md know u added the max dose?


Pt got prednisone, and lower dose of cellcept. Most rphs say just give the new dose and dc the old one, with duplicate therapy the new one replaces the old. I guess if you call md and they don’t answer you could ask the patient? I’m just not sure if i’m making a mistake by trying to run everything thru the md as opposed to taking the patient’s word for it. The problem is this was a hospital resident not my local doctor for me to tell em hey u should have mentioned on the rx to combine w previous cellcept. Its hard to even get a hold of hospital doctors so in those scenarios do you still refuse to fill til you talk to the dr, or do u take patient’s word for it i.e. i’m supposed to take this with the 500 mg from before?

I see where you are coming from. We were all trained differently. My school discouraged the use of Lexicomp as your main source because it's basically cliff-notes. We had an amazing pharmacokinetics/biopharmaceutics professor who showed us how to chew through a package insert in 5 minutes or less. Once you develop your own system, you'll be able to get through key points of any package insert in no time.
Google "voltaren gel package insert". The accessdata.fda should be the first one. Go to page 11. There are 3 key points here:
1. Systemic exposure with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is on average 17 times lower than with oral treatment.
2. The amount of diclofenac sodium that is systemically absorbed from Voltaren® Gel is on average 6% of the systemic exposure from an oral form of diclofenac sodium.
3. The average peak plasma concentration with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is 158 times lower than with the oral treatment.

Now after reading through those 3 points, why do you think oral NSAIDs were prohibited during clinical trials?
These are the times when I am glad I took my sweet time to get to pharmacy school after doing research in hard sciences through undergrad. If the average peak plasma concentration of voltaren gel is 158 times lower than with the oral treatment, do you think that you would be able to measure the plasma concentration of voltaren gel if subjects are also taking oral NSAIDs?
The answer is no. The data would be obscured by the concentrations of oral NSAIDs. You would not be able to tell what's what even if you're looking for specific metabolites. And you could do that but that would be highly inefficient and expensive..

The take home message from those 3 points is that topical diclofenac gel will pretty much absorb where you apply and for the most part stay there. ***6% of the systemic exposure from an oral form of diclofenac*** I am not going to venture and say 94% stays in the area where it's applied. It's likely a lot less than that. But for the most part this is a cleaner drug, isn't it? With oral forms, you rely on systemic absorption for that drug to reach its desired therapeutic target.

No math. No complicated PK. Just intuitively reason through the story the package insert is telling you. Lexi gives you facts that are only useful if you've reasoned through package inserts and made that knowledge yours.

So once you get through the PK section, you can approach everything else. Otherwise, every possible adverse effect sounds like a death sentence for your patient. Would voltaren gel be dangerous for an older person with less than ideal kidney function? It's possible, but you have to ask yourself, how much voltaren? Are they going to bathe in a tub of it and stay in there for 6 hours?
Diclofenac is cleared by the kidneys, yes, but the topical route pretty much spares the kidneys. These are not set rules. Every patient is different. I would not mess with extreme cases, of course.
So you see that for voltaren gel to cause a stomach bleed at the recommended dose the patient would need to be at risk for it - taking stupid amounts of X drug- and of course, applying stupid amounts of Voltaren gel. When you get a script, quickly establish whether it's the recommended dose for that population/patient type and go from there.

Are you catching my drift here?

Pen needles if the pt wants before u can receive the correct size, you’d get their ok then just give the size you have? Would you annotate anything like md ok, since ur changing the gauge etc? It seems like a minor thing though it’s still a needle lol. If it was a refill though you’d still need to order the same size needle for that rx number

We are typically caught up and I stress that my techs call patients right away. I always keep the resolution/third party rejection queue on even though I am not required to, simply because it puts me in control of everything. That way techs aren't able to get away with not calling patients or just pushing prescriptions that aren't going through to a later time.
It's as simple as calling the patient and letting them know what you have in stock. If you can speak to them great. Otherwise, leave a message. Use your judgment there. Most patients do not care that much about the gauge. They don't even know what that means. They mostly care about the length. So when I tell them the gauge I tell them the length too and say, "the ones in stock are the same length as the ones you always get but a little thicker/thinner". That gives them a visual.

The cough meds they dont put prn sometimes but as long as it doesnt exceed mdd like 30 ml of prometh Dm i just dispense and tell the pt its for cough so it should be prn
Walmart is very strict with all controlled substances. Do not forget that regardless of what you tell the patient, what you put on the label is what pretty much goes on record. The patient won't get a copy of your counseling points. They're not going to read the medication guide. They are not even paying attention to anything that you are saying. Those should be PRN and per company policy, I am required to clarify that. Thus, I would. But on a Friday night with a sick patient and frantic parent in front of me, I would dispense and add "as needed. Do not exceed X ml in 24 hours".
Then fax the prescriber back, letting them know what you did. If the prescriber feels any different, well, no harm done, right? The patient got the medication and the quantity that was prescribed. He/she can call the patient and override what you did. However, that's the only way I'd bless that with my license.
Others may disagree. And that's fine. It's my license. I am not holding up the patient in any way. I do that with acute pain C-IIs as well. I put a max on them and inform the prescriber via fax and annotate on the script. I even write the MMEs on it. I've had prescribers come up to me and say "Oh, you are John Smith. Glad to meet you. I like how you work. Thank you. We appreciate it in my office"
It's my license and I have loans to pay. If you keep your queue clutter free and teach your techs to do the same, you will have time to do hand write thank you notes. I have seen stores so well run that pharmacists have time to do that.

As for just dc-ing old med and giving new one... got rx for cellcept 250 bid pt was on 500 bid. U would assume to dc 500mg. Turns out pt said md said take 750 bid. Rx didnt mention combining w the old rx.
Never assume anything. And never assume anything with Cellcept. That's just a sloppy prescriber. It would strike me as odd to see a dose decrease without the addition of say, corticosteroids.
You also have to educate your prescribers. You can either do it directly by asking them to state "this prescriptions replaces previous cellcept ..." "Take along with ..."
It's a new prescription and you have to counsel, anyhow. I would definitely check in with the prescriber. Once you call them several times, it gets annoying to them and they'll listen.

Hope this helps. Get out of retail if you get the chance to.

All the best.

 

[CetiAlphaFive]

I see where you are coming from. We were all trained differently. My school discouraged the use of Lexicomp as your main source because it's basically cliff-notes. We had an amazing pharmacokinetics/biopharmaceutics professor who showed us how to chew through a package insert in 5 minutes or less. Once you develop your own system, you'll be able to get through key points of any package insert in no time.
Google "voltaren gel package insert". The accessdata.fda should be the first one. Go to page 11. There are 3 key points here:
1. Systemic exposure with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is on average 17 times lower than with oral treatment.
2. The amount of diclofenac sodium that is systemically absorbed from Voltaren® Gel is on average 6% of the systemic exposure from an oral form of diclofenac sodium.
3. The average peak plasma concentration with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is 158 times lower than with the oral treatment.

Now after reading through those 3 points, why do you think oral NSAIDs were prohibited during clinical trials?
These are the times when I am glad I took my sweet time to get to pharmacy school after doing research in hard sciences through undergrad. If the average peak plasma concentration of voltaren gel is 158 times lower than with the oral treatment, do you think that you would be able to measure the plasma concentration of voltaren gel if subjects are also taking oral NSAIDs?
The answer is no. The data would be obscured by the concentrations of oral NSAIDs. You would not be able to tell what's what even if you're looking for specific metabolites. And you could do that but that would be highly inefficient and expensive..

The take home message from those 3 points is that topical diclofenac gel will pretty much absorb where you apply and for the most part stay there. ***6% of the systemic exposure from an oral form of diclofenac*** I am not going to venture and say 94% stays in the area where it's applied. It's likely a lot less than that. But for the most part this is a cleaner drug, isn't it? With oral forms, you rely on systemic absorption for that drug to reach its desired therapeutic target.

No math. No complicated PK. Just intuitively reason through the story the package insert is telling you. Lexi gives you facts that are only useful if you've reasoned through package inserts and made that knowledge yours.

So once you get through the PK section, you can approach everything else. Otherwise, every possible adverse effect sounds like a death sentence for your patient. Would voltaren gel be dangerous for an older person with less than ideal kidney function? It's possible, but you have to ask yourself, how much voltaren? Are they going to bathe in a tub of it and stay in there for 6 hours?
Diclofenac is cleared by the kidneys, yes, but the topical route pretty much spares the kidneys. These are not set rules. Every patient is different. I would not mess with extreme cases, of course.
So you see that for voltaren gel to cause a stomach bleed at the recommended dose the patient would need to be at risk for it - taking stupid amounts of X drug- and of course, applying stupid amounts of Voltaren gel. When you get a script, quickly establish whether it's the recommended dose for that population/patient type and go from there.

Are you catching my drift here?

Pen needles if the pt wants before u can receive the correct size, you’d get their ok then just give the size you have? Would you annotate anything like md ok, since ur changing the gauge etc? It seems like a minor thing though it’s still a needle lol. If it was a refill though you’d still need to order the same size needle for that rx number

We are typically caught up and I stress that my techs call patients right away. I always keep the resolution/third party rejection queue on even though I am not required to, simply because it puts me in control of everything. That way techs aren't able to get away with not calling patients or just pushing prescriptions that aren't going through to a later time.
It's as simple as calling the patient and letting them know what you have in stock. If you can speak to them great. Otherwise, leave a message. Use your judgment there. Most patients do not care that much about the gauge. They don't even know what that means. They mostly care about the length. So when I tell them the gauge I tell them the length too and say, "the ones in stock are the same length as the ones you always get but a little thicker/thinner". That gives them a visual.

The cough meds they dont put prn sometimes but as long as it doesnt exceed mdd like 30 ml of prometh Dm i just dispense and tell the pt its for cough so it should be prn
Walmart is very strict with all controlled substances. Do not forget that regardless of what you tell the patient, what you put on the label is what pretty much goes on record. The patient won't get a copy of your counseling points. They're not going to read the medication guide. They are not even paying attention to anything that you are saying. Those should be PRN and per company policy, I am required to clarify that. Thus, I would. But on a Friday night with a sick patient and frantic parent in front of me, I would dispense and add "as needed. Do not exceed X ml in 24 hours".
Then fax the prescriber back, letting them know what you did. If the prescriber feels any different, well, no harm done, right? The patient got the medication and the quantity that was prescribed. He/she can call the patient and override what you did. However, that's the only way I'd bless that with my license.
Others may disagree. And that's fine. It's my license. I am not holding up the patient in any way. I do that with acute pain C-IIs as well. I put a max on them and inform the prescriber via fax and annotate on the script. I even write the MMEs on it. I've had prescribers come up to me and say "Oh, you are John Smith. Glad to meet you. I like how you work. Thank you. We appreciate it in my office"
It's my license and I have loans to pay. If you keep your queue clutter free and teach your techs to do the same, you will have time to do hand write thank you notes. I have seen stores so well run that pharmacists have time to do that.

As for just dc-ing old med and giving new one... got rx for cellcept 250 bid pt was on 500 bid. U would assume to dc 500mg. Turns out pt said md said take 750 bid. Rx didnt mention combining w the old rx.
Never assume anything. And never assume anything with Cellcept. That's just a sloppy prescriber. It would strike me as odd to see a dose decrease without the addition of say, corticosteroids.
You also have to educate your prescribers. You can either do it directly by asking them to state "this prescriptions replaces previous cellcept ..." "Take along with ..."
It's a new prescription and you have to counsel, anyhow. I would definitely check in with the prescriber. Once you call them several times, it gets annoying to them and they'll listen.

Hope this helps. Get out of retail if you get the chance to.

All the best.

Excellent post

 

[Apotheker2015]

First off, you’re very patient and I thank you for all of your help!!!!!! I appreciate you pulling the voltaren PI and making great points!

I guess my issue with pen needles is even if the patient is ok with it, that we’re changing the size the MD sent without getting the md’s ok.

Promethazine dm is not a control in my state, but even for controls, sometimes doctors don’t add the mdd and i add it according to the sig’s directions. For percocet/opioids there’s no ceiling dose but if there’s apap in there then yea u can’t exceed past 4 g. Sometimes theyl send the general max dose like clonazepam 0.5 mg bid. Mdd 20 mg. Lol. I don’t leave it as 20 mg bc pt might thibk they’re allowed to take that much but then they’ll run out and insurance wont pay and blah blah. The sig says bid so bid it is. Anyway about the cough med they don’t add prn sometimes and neither do i since im just paranoid about adding it lol although i add a max for controls. Does your system let u fax a message or are u manually writing something and putting it hru the fax machine? What are u annotating on the script, that ul let md know u added the max dose?


Pt got prednisone, and lower dose of cellcept. Most rphs say just give the new dose and dc the old one, with duplicate therapy the new one replaces the old. I guess if you call md and they don’t answer you could ask the patient? I’m just not sure if i’m making a mistake by trying to run everything thru the md as opposed to taking the patient’s word for it. The problem is this was a hospital resident not my local doctor for me to tell em hey u should have mentioned on the rx to combine w previous cellcept. Its hard to even get a hold of hospital doctors so in those scenarios do you still refuse to fill til you talk to the dr, or do u take patient’s word for it i.e. i’m supposed to take this with the 500 mg from before?

You're welcome! Yes, I expanded the promethazine question and threw codeine in it, sorry. Bottom line is Walmart wants to call and document. I do not always do those in that order. Sometimes, it means I take action, document and then inform the prescriber.

Cellcept - I would not interrupt therapy. Is patient out of the medication at home? You don't want that patient to go without cellcept regardless of how much the patient is taking. I do not rely on patient for much other than their address. Fax the prescriber back asking if that's what they meant to do. They will get back to you. If the prescriber sent the wrong directions, they will follow up with you and the patient. You can call and leave the patient a message. If it's after business hours, I page physicians and they always get back to me. Or whoever picks up the phone, I ask them if they have access to charts. If the answer is no, then ask to be transferred to a charge nurse. They are able to confirm that the script and directions you received matches the treatment plan on the chart.
What happens if you take the patient's word for it? What if the patient misunderstood? There goes your license. You have to set up a communication chain for confirmation to circle back to you.

You ALWAYS educate residents. They don't know what the hell they're doing and we save their behinds every day as it is.
"Be right, be brief, be gone"

Our system allows us to fax prescribers right from the screen but I usually print the rx, write clearly what I need, and give it to a tech. That way the tech follows up on it going through etc.
The system also allows us to annotate on e-scripts. I'll write whatever condition I added to let the script out the door. If it's a manual script, I grab that and write on that. That's what I fax back. I may or may not write a full sentence.

For percocet/opioids there’s no ceiling dose but if there’s apap in there then yea u can’t exceed past 4 g.
With appropriate and careful titration, there is no ceiling dose. The guidelines were updated and it's all MMEs. Morphine Milli-equivalents. CDC opioid guidelines. There is an app that calculates MMEs for you and it's very useful.
For acute pain management, the ceiling is 60 MMEs and for chronic 90 MMEs (+/-, patient characteristics, etc) That's why lexicomp is useless. But that's just my humble opinion.
You can make a small flashcard with the MMEs for oxycodone, hydrocodone, etc and have it handy, too.

 

[MARX22]

You’re right. So you’d give them the 250 even if they said theyre supposed to take it with the 500, and you wouldnt dc the 500 yet but youd try to get in touch w md to see if its supposed to be combined or not? I get what you’re saying abt patients making errors, in that case if they didnt have any 500 at home snd wanted it... how do we know if we should give it or just give the new one only? Sighhhhh. I always feel bad for patients but also always doubt whether they know anythin about their treatment plans haha

What’s the app you’re referring to?

You're welcome! Yes, I expanded the promethazine question and threw codeine in it, sorry. Bottom line is Walmart wants to call and document. I do not always do those in that order. Sometimes, it means I take action, document and then inform the prescriber.

Cellcept - I would not interrupt therapy. Is patient out of the medication at home? You don't want that patient to go without cellcept regardless of how much the patient is taking. I do not rely on patient for much other than their address. Fax the prescriber back asking if that's what they meant to do. They will get back to you. If the prescriber sent the wrong directions, they will follow up with you and the patient. You can call and leave the patient a message. If it's after business hours, I page physicians and they always get back to me. Or whoever picks up the phone, I ask them if they have access to charts. If the answer is no, then ask to be transferred to a charge nurse. They are able to confirm that the script and directions you received matches the treatment plan on the chart.
What happens if you take the patient's word for it? What if the patient misunderstood? There goes your license. You have to set up a communication chain for confirmation to circle back to you.

You ALWAYS educate residents. They don't know what the hell they're doing and we save their behinds every day as it is.
"Be right, be brief, be gone"

Our system allows us to fax prescribers right from the screen but I usually print the rx, write clearly what I need, and give it to a tech. That way the tech follows up on it going through etc.
The system also allows us to annotate on e-scripts. I'll write whatever condition I added to let the script out the door. If it's a manual script, I grab that and write on that. That's what I fax back. I may or may not write a full sentence.

For percocet/opioids there’s no ceiling dose but if there’s apap in there then yea u can’t exceed past 4 g.
With appropriate and careful titration, there is no ceiling dose. The guidelines were updated and it's all MMEs. Morphine Milli-equivalents. CDC opioid guidelines. There is an app that calculates MMEs for you and it's very useful.
For acute pain management, the ceiling is 60 MMEs and for chronic 90 MMEs (+/-, patient characteristics, etc) That's why lexicomp is useless. But that's just my humble opinion.
You can make a small flashcard with the MMEs for oxycodone, hydrocodone, etc and have it handy, too.

 

[Apotheker2015]

You’re right. So you’d give them the 250 even if they said theyre supposed to take it with the 500, and you wouldnt dc the 500 yet but youd try to get in touch w md to see if its supposed to be combined or not? I get what you’re saying abt patients making errors, in that case if they didnt have any 500 at home snd wanted it... how do we know if we should give it or just give the new one only? Sighhhhh. I always feel bad for patients but also always doubt whether they know anythin about their treatment plans haha

What’s the app you’re referring to?

It's cellcept. You do not want that patient to go without it if they're out of it already. All I am saying is that you reach out to the prescriber and also tell the patient do the same. Again, our prescribers are very good about stating clearly changes of therapy, add-ons, titrations. If yours aren't, then educate them. In any case, you dispense the cellcept, you don't want someone rejecting an organ on your watch.
Often times, patient have a visit summary and you can ask for that. I have never been told "no, you can't see it". If they have it on them, they'll give it to you. Some are very techy and have access to their chart online. I would trust those two sources but not the patient's word. They mean well but have no clue.

 

[MARX22]

Yeah sometimes the paper just says start 250 just bc they sent an rx for 250, it says what they literally sent over lol but the patient claimed its supposed to be added to the 500. I wouldnt want to get in trouble for that either so i gave both but wondered if it was meant to be together or not. I guess i could take their word, annotate, and leave msg for md that this is wat was done and call it a day, if the drs office didn’t pick up. Idk if i should be driving myself crazy calling every day til i get a hold of someone though.

It's cellcept. You do not want that patient to go without it if they're out of it already. All I am saying is that you reach out to the prescriber and also tell the patient do the same. Again, our prescribers are very good about stating clearly changes of therapy, add-ons, titrations. If yours aren't, then educate them. In any case, you dispense the cellcept, you don't want someone rejecting an organ on your watch.
Often times, patient have a visit summary and you can ask for that. I have never been told "no, you can't see it". If they have it on them, they'll give it to you. Some are very techy and have access to their chart online. I would trust those two sources but not the patient's word. They mean well but have no clue.

 

[Sabril]

Yeah sometimes the paper just says start 250 just bc they sent an rx for 250, it says what they literally sent over lol but the patient claimed its supposed to be added to the 500. I wouldnt want to get in trouble for that either so i gave both but wondered if it was meant to be together or not. I guess i could take their word, annotate, and leave msg for md that this is wat was done and call it a day, if the drs office didn’t pick up. Idk if i should be driving myself crazy calling every day til i get a hold of someone though.

I don't mean to interrupt the conversation between you and Apotheker as Apotheker is doing an excellent job of explaining it. But in your case of Cellcept and other similar cases, I would look up the maximum dose and decide. The max dose of cellcept for a "typical" adult I believe is 2000mg per day so your guy should be fine. As it stands, the doctor never told you to d/c either strength so what prompts you to do it on your own? Giving pt a lower dose than he needs carries a much worse consequence. After you document that you tried to clarify with the doc and that you counseled the patient, you can call it a day.

 

[Apotheker2015]

Yeah sometimes the paper just says start 250 just bc they sent an rx for 250, it says what they literally sent over lol but the patient claimed its supposed to be added to the 500. I wouldnt want to get in trouble for that either so i gave both but wondered if it was meant to be together or not. I guess i could take their word, annotate, and leave msg for md that this is wat was done and call it a day, if the drs office didn’t pick up. Idk if i should be driving myself crazy calling every day til i get a hold of someone though.

The app is called CDC Opioid Guidelines. There are several CDC apps. Check them out.

 

[Apotheker2015]

Yeah sometimes the paper just says start 250 just bc they sent an rx for 250, it says what they literally sent over lol but the patient claimed its supposed to be added to the 500. I wouldnt want to get in trouble for that either so i gave both but wondered if it was meant to be together or not. I guess i could take their word, annotate, and leave msg for md that this is wat was done and call it a day, if the drs office didn’t pick up. Idk if i should be driving myself crazy calling every day til i get a hold of someone though.

Sabril makes a good point. The prescriber did not tell you to d/c the previous script. However, are you entirely sure? No, you're not. And if that is how you choose to practice pharmacy with YOUR HARD EARNED LICENSE, so be it. At least until you get more comfortable in your own skin, then better safe than sorry.
Again, you have to educated prescribers to communicate clearly. They don't want call backs for clarification? Well, communicate clearly. Same for techs. They're an extension of YOU and they're working under your license. Don't let them forget that without your license they can't be inside the pharmacy.
Teach them to be thorough. If techs do not enter allergies that are clearly listed on a new prescription, I send them back. It counts as an error on their part. Otherwise, the system can't do a decent DUR that you can work with.

 

[MARX22]

Thank you sabril and apotheker!

I figured the same that it didn’t exceed the max dose so I tried calling md, no answer, so asked patient and annotated and gave both. Pt should have an idea of what’s going on with their therapy. I’ve had it happen many times with gabapentin dose increases. Its still within the max if u werre to assume to combine it with previous dose but i’ve kind of assumed that if they wanted to combine, they’d just give the new dose as one that includes the previous one combined. For something like that maybe if dr doesnt answer u jus assume new rx replaces old one.. but for things that are more critical like cellcept id agree to try to reach md n if no answer, don’t refuse to fill it—take pts word and annotate.

When it comes to dosing variations... do you guys refuse to fill or it’s ok so long as it’s within max daily dose? I.e. promethazine with CODEINE. Suggested dose is 5 ml po q4-6h prn. Max 30ml/24 hrs.

Got rx for 10 ml po q6. If u go by that pt will possibly take up to 40 ml per day. Do you guys just add the MDD of 30 ml, or do u refuse to fill it as 10 ml per dose? In other words, do we really have to be super stringent on it matching recommended doses like 10 ml per dose vs 5 ml per dose? Even if it wasn’t a control and was lets say promethazine dm... sig says 10 ml po q6... again the max is 30 ml. Do you just add the max or do u refuse to fill until u speak to office and change to 5 ml q4-6 as recommended? I believe Apotheker mentioned he’d just add the max if it exceeds it so in case of this 10 ml q6 itl be 40 ml, you’d add don’t exceed 30 ml.

Thanks!

Sabril makes a good point. The prescriber did not tell you to d/c the previous script. However, are you entirely sure? No, you're not. And if that is how you choose to practice pharmacy with YOUR HARD EARNED LICENSE, so be it. At least until you get more comfortable in your own skin, then better safe than sorry.
Again, you have to educated prescribers to communicate clearly. They don't want call backs for clarification? Well, communicate clearly. Same for techs. They're an extension of YOU and they're working under your license. Don't let them forget that without your license they can't be inside the pharmacy.
Teach them to be thorough. If techs do not enter allergies that are clearly listed on a new prescription, I send them back. It counts as an error on their part. Otherwise, the system can't do a decent DUR that you can work with.

 

[Sine Cura]

WM technically does not permit you to add annotations (even "discard remainder") but no one gets in trouble for it unless someone's gunning for you.

 

[Apotheker2015]

Thank you sabril and apotheker!

I figured the same that it didn’t exceed the max dose so I tried calling md, no answer, so asked patient and annotated and gave both. Pt should have an idea of what’s going on with their therapy. I’ve had it happen many times with gabapentin dose increases. Its still within the max if u werre to assume to combine it with previous dose but i’ve kind of assumed that if they wanted to combine, they’d just give the new dose as one that includes the previous one combined. For something like that maybe if dr doesnt answer u jus assume new rx replaces old one.. but for things that are more critical like cellcept id agree to try to reach md n if no answer, don’t refuse to fill it—take pts word and annotate.

When it comes to dosing variations... do you guys refuse to fill or it’s ok so long as it’s within max daily dose? I.e. promethazine with CODEINE. Suggested dose is 5 ml po q4-6h prn. Max 30ml/24 hrs.

Got rx for 10 ml po q6. If u go by that pt will possibly take up to 40 ml per day. Do you guys just add the MDD of 30 ml, or do u refuse to fill it as 10 ml per dose? In other words, do we really have to be super stringent on it matching recommended doses like 10 ml per dose vs 5 ml per dose? Even if it wasn’t a control and was lets say promethazine dm... sig says 10 ml po q6... again the max is 30 ml. Do you just add the max or do u refuse to fill until u speak to office and change to 5 ml q4-6 as recommended? I believe Apotheker mentioned he’d just add the max if it exceeds it so in case of this 10 ml q6 itl be 40 ml, you’d add don’t exceed 30 ml.

Thanks!

Let me restate what I think you may be referring to. I put a cap/max -do not exceed X mL in 24 hours- , if the only issue with a PRN is that it exceeds the total maximum daily dose. To be clear, for that to be the case, each single dose has to be within dosing recommendations.
I wouldn't just switch the prescription from 10 mL Q6H to 5 mL Q4-6H prn.
10 mL>> single dose limit of 5mL;
total 40 mL >>total recommended dose of 30 mL (adults)

If you change that prescription from 10mL to 5m without communicating are basically prescribing that. You aren't a prescriber. That's not the way the system is set up.
In your example, 10 mL Q6H, I would call. Adding a max of 30 mL would still mean verifying single doses of 10 mL which exceed the recommended limit for each dose. And like Sine Cura said, at Walmart we are not allowed to add anything. They want you to call for everything. I am willing to make one leap, not 2 or 3. That leap cannot be an assumption. It's always a fact.
Even though we are not supposed to add information to the label, well, there really isn't any other way to do it. I do fax prescribers with whatever max I add. Otherwise, you will continue to get sloppy prescriptions.

 

[MARX22]

Thank you so much Apotheker! By changing to 5 i didnt mean to do it without calling, I meant do u find it necessary to call and change or would you dispense as is. I don’t mind calling but sometimes there’s no answer and I never really held it back as long as it didn’t exceed the max DAILY amount even if it did exceed the single dose. It also sucks cuz if other rph verified n dispensed n pt wants a refill ur still kind of expected to dispense unless u call and get an oral rx for 5ml (even tho these cough meds arent usually with refills i see em sometimes).

For the rest of you, do u really call on 10 ml q6 for lets say promethazine dm when recommended dose is 5ml at a time? I have seen a lot of rxs dispensed that way so long as DAILY max amount isnt exceeded

Let me restate what I think you may be referring to. I put a cap/max -do not exceed X mL in 24 hours- , if the only issue with a PRN is that it exceeds the total maximum daily dose. To be clear, for that to be the case, each single dose has to be within dosing recommendations.
I wouldn't just switch the prescription from 10 mL Q6H to 5 mL Q4-6H prn.
10 mL>> single dose limit of 5mL;
total 40 mL >>total recommended dose of 30 mL (adults)

If you change that prescription from 10mL to 5m without communicating are basically prescribing that. You aren't a prescriber. That's not the way the system is set up.
In your example, 10 mL Q6H, I would call. Adding a max of 30 mL would still mean verifying single doses of 10 mL which exceed the recommended limit for each dose. And like Sine Cura said, at Walmart we are not allowed to add anything. They want you to call for everything. I am willing to make one leap, not 2 or 3. That leap cannot be an assumption. It's always a fact.
Even though we are not supposed to add information to the label, well, there really isn't any other way to do it. I do fax prescribers with whatever max I add. Otherwise, you will continue to get sloppy prescriptions.

 

[BidingMyTime]

The difficult thing with being a new pharmacist is to realize that medicine (and pharmacy) is an art. Yes, there is science behind it, but individual people respond individually, so there are extremely few always/never rules.

1) when i get rxs for like naproxen or ibuprofen and the pt is already on aspirin 81

I wouldn't either, although if the RX's are from 2 different dr's, then I would probably call/fax a note to let them know about the other dr's RX. (rule 1, pt's seldom tell their doctors what other dr's have prescribed them.) If it is a short term RX (like from a dentist or ER) then I wouldn't bother calling or faxing.

2-If ur doing a refill and see an “important” interaction (which again, at this point I don’t know how to even determine that. Thought D and X but the sertraline/azithro thing which was C throws me off as to whether i should always call on qt), and the original rph didnt annotate anything—would u jus refill it bc pt has gotten it already, or would u delay til u speak to dr/nurse/someone in office?

Why is someone refilling azithro? Generally speaking, if a pt has been doing fine for a month with 2 drugs that interact, then I wouldn't do anything else with it (maybe talk with the pt and make sure they aren't having any issues.) Setraline/azithro are seldom going to be a problem, because of the short course of azithro therapy, although I would talk with the pt about it, make sure both dr's are aware of the prescription, that the pt doesn't have already known heart issues, etc.


[quote[Also idk whydrs send me dextromethorphan 15-guaifenesin 100mg/5 ml idk if it comes that way but my wholesaler shows the 10-100/5. Sometimes doctors dont reply. Do we just not dispense til we speak to someone, or is it ok to assume they’ll ok the change?[/quote]

I'd probably call the first time, but after that if the doctor says they don't care, then I would change it for that doctor in the future. If the doctor doesn't reply, then tell the pt they need to call their dr so you can clarify it. Or, they can just use the OTC version.

what do you guys do if you have an rx for ibuprofen or apap for a kid, dose seems high when u go by age so u ask for weight, md office no response, parents give the weight but dose is still too high. Cant get in touch w dr. Do you change and annotate md ok, dispense w/ the high dose as dr wrote, or don’t dispense til u speak to dr even if that means they never get back to u? I had a 6 yr old kid getting singulair 5 mg take 2 tabs qd.... some rph had filled it in the past. I called for months-no response from the office. Montelukast isn’t weight based from what I saw on lexi but even so, parent claimed child was thin.

It depends on how "high" the dose is, and how long is the amount you are giving them. If the dose is just moderately high, but only a 2 day supply ordered from ER, then I wouldn't worry about it. If it's dangerously high, or moderately high with a month's supply being given, I wouldn't dispense without talking with the dr.

5)if get new rx with new strength or frequency, just discontinue (dc) the old rx without talkin to md/pt? Sometimes il have gabapentin 300 mg qd then later get 300 bid. Do we assume it replaces the previous rx even tho TID would be within max dose and it could be meant together?

If the doctor doesn't specify, you would have to ask the pt (and hope they know.) Yes, you should DC old'd RX's, once you have ascertained they are no longer needed. Doctor's often don't annotate for the pharmacist if they are adding on or replacing an old RX. Generally a QD RX, with a new BID RX, would be a replacement (since gabapentin generally wouldn't just be increased from QD to TID.)

Is it ok to reactivate the qd n give to patient til md resends bid—or once u dc something don’t undo it? Same w test strips. Was bid, now new rx for qid. I discontinued the bid. So if they ever run out of qid and want it that minute, we shouldn’t be reactivating the bid rx just to provide them with strips since itl prly get confusing, right?

No, if you know its QID, then you shouldn't reactive the BID RX just because they ran out of the QID. That will cause confusion for the patient and screw up the insurance. You should only reactivate a prescription if you DC'd it in error.

rx for cal600/d400 comes—not covered. Pt has been on 500/400. Tried to call md to switch back to 500/400 or see if md thinks 600/400 is a must. Nobody answers on doctor’s end. Pt wants to get the one thats covered n has a refill on file. Technically thats supposed to be dc’d so we cant give it cuz new rx came for diff strength, right? Its only cal/d so not a biggie but just clarifying the concept of it

As previously, unless you know that particular doctor doesn't care, I would tell the pt it can't be filled until it's clarified. They can buy OTC in the meantime.

When I see avoid I think “never,” but apparently its ok since its not listed as contraindicated?

No, "avoid" does not mean "never." Avoid means, try not to give the 2 together at that dosing, unless the benefits outweigh the risks and other options have failed. "Never" means something like Accutane in a pregnancy, there is NEVER a reason for that combo. "Avoid" does not mean you can't give 40mg simvastatin and amlodipine together, it just means try other options first, and be aware of the risks.

9)another annoying thing. Doctors write-Qty 240 but sig says 5 ml q4 x 10 days, which means they need 300 ml. Sometimes its not even worth thr hassle of calling lol or they dont pick up. I just give 240 ‍♀️p

Is this a PRN or an antibiotic? If it's a PRN, then even if the doctor didn't write that, it can be assumed that the person isn't going to be waking up around the clock to take a PRN medicine, so just give the 240ml. If it's an antibiotic (which in your example it wouldn't be, since what outpatient antibiotic would be given q4), but if it were, then I would assume the doctor can't do math and I would give the full 300ml. One caveat, you might want to double check with the pt first, since maybe they had already had a bottle, lost/spilled it, so the doctor is just ordering enough to replace what they lost/spilled.

pt was on omeprazole, gets new rx for esomeprazole. Therapeutic dup. Do u call esomep’s dr to clarify, or just give esomep and discontinue omep? I would say just dispense new rx without callin... but if its not covered and md doesnt answer.. can u still dispense refill of the one on profile (omep) or is it supposed to be stopped since md sent a new one?

Yes, it's safe to assume the esomeprazole is replacing the omeprazole. If the esomeprazole isn't covered, then I would dispense the omeprazole, then contact the doctor so s/he can do a PA for the esomperazole or change to whatever the insurance will cover.

Finally—if md wrote a specific pen needle gauge/mm, and it isn’t available on the market and md doesn’t answer for days—do u just put md ok and bill/dispense the size that’s available? I doubt they care, and i always put md ok tab or cap without calling bc that’s such a dumb law and if u really called to get an ok on tab vs cap... they’d curse u out lol

If the doctor isn't calling for days, then the pt needs to contact their doctor. Ultimately it's their responsibility. However, in this case, if the patient knows what pen needle they normally use, then I'd just give them that one, it's not going to make a difference in therapy. With changing tabs to caps, these aren't bioequivalent, and while often that really doesn't matter, sometimes it does, that is why they can't be changed without talking with the physician.

 

[Sabril]

Thank you so much Apotheker! By changing to 5 i didnt mean to do it without calling, I meant do u find it necessary to call and change or would you dispense as is. I don’t mind calling but sometimes there’s no answer and I never really held it back as long as it didn’t exceed the max DAILY amount even if it did exceed the single dose. It also sucks cuz if other rph verified n dispensed n pt wants a refill ur still kind of expected to dispense unless u call and get an oral rx for 5ml (even tho these cough meds arent usually with refills i see em sometimes).

For the rest of you, do u really call on 10 ml q6 for lets say promethazine dm when recommended dose is 5ml at a time? I have seen a lot of rxs dispensed that way so long as DAILY max amount isnt exceeded

Should you hold back the med if you see an issue? Why not? You have a legitimate reason. Even if the patient complains. I don't think your DM knows what the max dose is for the med, and is unlikely to go look it up to fire you over it. Firing people is supposed to be fun, easy and enjoyable.

I cannot speak for others but I myself will just counsel the patient and document it. Hey, your doctor originally wrote for a very high dose, but since you have been refilling this med and taking it for a while, you need to limit it to X amount, otherwise the med will accumulate in your system. Oh you think it will not be enough to control your cough? You need to consider the serious consequences of overdosing: diarrhea, confusion, fever, convulsion, hallucination, delirium, Asperger's, Hashimoto's, Quasimodo's (and whatever else you can recall at the end of a drug ad)

All joking aside, since you talked about checking refills, there is a price for trying to make things right. One of my friends got fired for it. While verifying, she also tried to fix/ clarify stuff the previous dispensing pharmacists missed or ignored. Major issues like wrong DEA numbers and things like that. And there were a lot of errors. So my friend slowed down a lot and got axed before her 90 days.

 

[johnpharm01]

Should you hold back the med if you see an issue? Why not? You have a legitimate reason. Even if the patient complains. I don't think your DM knows what the max dose is for the med, and is unlikely to go look it up to fire you over it. Firing people is supposed to be fun, easy and enjoyable.

I cannot speak for others but I myself will just counsel the patient and document it. Hey, your doctor originally wrote for a very high dose, but since you have been refilling this med and taking it for a while, you need to limit it to X amount, otherwise the med will accumulate in your system. Oh you think it will not be enough to control your cough? You need to consider the serious consequences of overdosing: diarrhea, confusion, fever, convulsion, hallucination, delirium, Asperger's, Hashimoto's, Quasimodo's (and whatever else you can recall at the end of a drug ad)

All joking aside, since you talked about checking refills, there is a price for trying to make things right. One of my friends got fired for it. While verifying, she also tried to fix/ clarify stuff the previous dispensing pharmacists missed or ignored. Major issues like wrong DEA numbers and things like that. And there were a lot of errors. So my friend slowed down a lot and got axed before her 90 days.

What was her official reason for termination?

 

[MARX22]

Thanks for ur help. Sometimes pt isnt there and u call and they don’t pick up. Do u just dispense it then and assume next rph will counsel? The rph might not ask abt heart issues for the sertraline n azithro...and most of these pts do have some sort of heart issue but if its not arrythmias i suppose its ok, if arrhythmias then don’t dispense til u speak to the dr. My concern is once its bagged then the pt will want it and u might not be there to make sure/discuss with them

The difficult thing with being a new pharmacist is to realize that medicine (and pharmacy) is an art. Yes, there is science behind it, but individual people respond individually, so there are extremely few always/never rules.



I wouldn't either, although if the RX's are from 2 different dr's, then I would probably call/fax a note to let them know about the other dr's RX. (rule 1, pt's seldom tell their doctors what other dr's have prescribed them.) If it is a short term RX (like from a dentist or ER) then I wouldn't bother calling or faxing.



Why is someone refilling azithro? Generally speaking, if a pt has been doing fine for a month with 2 drugs that interact, then I wouldn't do anything else with it (maybe talk with the pt and make sure they aren't having any issues.) Setraline/azithro are seldom going to be a problem, because of the short course of azithro therapy, although I would talk with the pt about it, make sure both dr's are aware of the prescription, that the pt doesn't have already known heart issues, etc.


[quote[Also idk whydrs send me dextromethorphan 15-guaifenesin 100mg/5 ml idk if it comes that way but my wholesaler shows the 10-100/5. Sometimes doctors dont reply. Do we just not dispense til we speak to someone, or is it ok to assume they’ll ok the change?

I'd probably call the first time, but after that if the doctor says they don't care, then I would change it for that doctor in the future. If the doctor doesn't reply, then tell the pt they need to call their dr so you can clarify it. Or, they can just use the OTC version.




It depends on how "high" the dose is, and how long is the amount you are giving them. If the dose is just moderately high, but only a 2 day supply ordered from ER, then I wouldn't worry about it. If it's dangerously high, or moderately high with a month's supply being given, I wouldn't dispense without talking with the dr.



If the doctor doesn't specify, you would have to ask the pt (and hope they know.) Yes, you should DC old'd RX's, once you have ascertained they are no longer needed. Doctor's often don't annotate for the pharmacist if they are adding on or replacing an old RX. Generally a QD RX, with a new BID RX, would be a replacement (since gabapentin generally wouldn't just be increased from QD to TID.)



No, if you know its QID, then you shouldn't reactive the BID RX just because they ran out of the QID. That will cause confusion for the patient and screw up the insurance. You should only reactivate a prescription if you DC'd it in error.



As previously, unless you know that particular doctor doesn't care, I would tell the pt it can't be filled until it's clarified. They can buy OTC in the meantime.



No, "avoid" does not mean "never." Avoid means, try not to give the 2 together at that dosing, unless the benefits outweigh the risks and other options have failed. "Never" means something like Accutane in a pregnancy, there is NEVER a reason for that combo. "Avoid" does not mean you can't give 40mg simvastatin and amlodipine together, it just means try other options first, and be aware of the risks.[/QUOTE]

 

[MARX22]

Wow. Why did your friend get fired?

As for dispensing but documenting/counseling on high dose... wouldn’t u be afraid theyl overdose or take the high dose on the label and it still falls on you for dispensing it with those directions?

Should you hold back the med if you see an issue? Why not? You have a legitimate reason. Even if the patient complains. I don't think your DM knows what the max dose is for the med, and is unlikely to go look it up to fire you over it. Firing people is supposed to be fun, easy and enjoyable.

I cannot speak for others but I myself will just counsel the patient and document it. Hey, your doctor originally wrote for a very high dose, but since you have been refilling this med and taking it for a while, you need to limit it to X amount, otherwise the med will accumulate in your system. Oh you think it will not be enough to control your cough? You need to consider the serious consequences of overdosing: diarrhea, confusion, fever, convulsion, hallucination, delirium, Asperger's, Hashimoto's, Quasimodo's (and whatever else you can recall at the end of a drug ad)

All joking aside, since you talked about checking refills, there is a price for trying to make things right. One of my friends got fired for it. While verifying, she also tried to fix/ clarify stuff the previous dispensing pharmacists missed or ignored. Major issues like wrong DEA numbers and things like that. And there were a lot of errors. So my friend slowed down a lot and got axed before her 90 days.

 

[CetiAlphaFive]

Thanks for ur help. Sometimes pt isnt there and u call and they don’t pick up. Do u just dispense it then and assume next rph will counsel? The rph might not ask abt heart issues for the sertraline n azithro...and most of these pts do have some sort of heart issue but if its not arrythmias i suppose its ok, if arrhythmias then don’t dispense. My concern is once its bagged then the pt will want it and u might not be there to make sure/discuss with them



I'd probably call the first time, but after that if the doctor says they don't care, then I would change it for that doctor in the future. If the doctor doesn't reply, then tell the pt they need to call their dr so you can clarify it. Or, they can just use the OTC version.




It depends on how "high" the dose is, and how long is the amount you are giving them. If the dose is just moderately high, but only a 2 day supply ordered from ER, then I wouldn't worry about it. If it's dangerously high, or moderately high with a month's supply being given, I wouldn't dispense without talking with the dr.



If the doctor doesn't specify, you would have to ask the pt (and hope they know.) Yes, you should DC old'd RX's, once you have ascertained they are no longer needed. Doctor's often don't annotate for the pharmacist if they are adding on or replacing an old RX. Generally a QD RX, with a new BID RX, would be a replacement (since gabapentin generally wouldn't just be increased from QD to TID.)



No, if you know its QID, then you shouldn't reactive the BID RX just because they ran out of the QID. That will cause confusion for the patient and screw up the insurance. You should only reactivate a prescription if you DC'd it in error.



As previously, unless you know that particular doctor doesn't care, I would tell the pt it can't be filled until it's clarified. They can buy OTC in the meantime.



No, "avoid" does not mean "never." Avoid means, try not to give the 2 together at that dosing, unless the benefits outweigh the risks and other options have failed. "Never" means something like Accutane in a pregnancy, there is NEVER a reason for that combo. "Avoid" does not mean you can't give 40mg simvastatin and amlodipine together, it just means try other options first, and be aware of the risks.

[/QUOTE]

Do you consider azithromycin to be a high risk med for arrhythmias?

 

[Amicable Angora]

I see where you are coming from. We were all trained differently. My school discouraged the use of Lexicomp as your main source because it's basically cliff-notes. We had an amazing pharmacokinetics/biopharmaceutics professor who showed us how to chew through a package insert in 5 minutes or less. Once you develop your own system, you'll be able to get through key points of any package insert in no time.
Google "voltaren gel package insert". The accessdata.fda should be the first one. Go to page 11. There are 3 key points here:
1. Systemic exposure with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is on average 17 times lower than with oral treatment.
2. The amount of diclofenac sodium that is systemically absorbed from Voltaren® Gel is on average 6% of the systemic exposure from an oral form of diclofenac sodium.
3. The average peak plasma concentration with recommended use of Voltaren® Gel (4 x 4 g per day applied to 1 knee) is 158 times lower than with the oral treatment.

Now after reading through those 3 points, why do you think oral NSAIDs were prohibited during clinical trials?
These are the times when I am glad I took my sweet time to get to pharmacy school after doing research in hard sciences through undergrad. If the average peak plasma concentration of voltaren gel is 158 times lower than with the oral treatment, do you think that you would be able to measure the plasma concentration of voltaren gel if subjects are also taking oral NSAIDs?
The answer is no. The data would be obscured by the concentrations of oral NSAIDs. You would not be able to tell what's what even if you're looking for specific metabolites. And you could do that but that would be highly inefficient and expensive..

The take home message from those 3 points is that topical diclofenac gel will pretty much absorb where you apply and for the most part stay there. ***6% of the systemic exposure from an oral form of diclofenac*** I am not going to venture and say 94% stays in the area where it's applied. It's likely a lot less than that. But for the most part this is a cleaner drug, isn't it? With oral forms, you rely on systemic absorption for that drug to reach its desired therapeutic target.

No math. No complicated PK. Just intuitively reason through the story the package insert is telling you. Lexi gives you facts that are only useful if you've reasoned through package inserts and made that knowledge yours.

So once you get through the PK section, you can approach everything else. Otherwise, every possible adverse effect sounds like a death sentence for your patient. Would voltaren gel be dangerous for an older person with less than ideal kidney function? It's possible, but you have to ask yourself, how much voltaren? Are they going to bathe in a tub of it and stay in there for 6 hours?
Diclofenac is cleared by the kidneys, yes, but the topical route pretty much spares the kidneys. These are not set rules. Every patient is different. I would not mess with extreme cases, of course.
So you see that for voltaren gel to cause a stomach bleed at the recommended dose the patient would need to be at risk for it - taking stupid amounts of X drug- and of course, applying stupid amounts of Voltaren gel. When you get a script, quickly establish whether it's the recommended dose for that population/patient type and go from there.

Are you catching my drift here?

Pen needles if the pt wants before u can receive the correct size, you’d get their ok then just give the size you have? Would you annotate anything like md ok, since ur changing the gauge etc? It seems like a minor thing though it’s still a needle lol. If it was a refill though you’d still need to order the same size needle for that rx number

We are typically caught up and I stress that my techs call patients right away. I always keep the resolution/third party rejection queue on even though I am not required to, simply because it puts me in control of everything. That way techs aren't able to get away with not calling patients or just pushing prescriptions that aren't going through to a later time.
It's as simple as calling the patient and letting them know what you have in stock. If you can speak to them great. Otherwise, leave a message. Use your judgment there. Most patients do not care that much about the gauge. They don't even know what that means. They mostly care about the length. So when I tell them the gauge I tell them the length too and say, "the ones in stock are the same length as the ones you always get but a little thicker/thinner". That gives them a visual.

The cough meds they dont put prn sometimes but as long as it doesnt exceed mdd like 30 ml of prometh Dm i just dispense and tell the pt its for cough so it should be prn
Walmart is very strict with all controlled substances. Do not forget that regardless of what you tell the patient, what you put on the label is what pretty much goes on record. The patient won't get a copy of your counseling points. They're not going to read the medication guide. They are not even paying attention to anything that you are saying. Those should be PRN and per company policy, I am required to clarify that. Thus, I would. But on a Friday night with a sick patient and frantic parent in front of me, I would dispense and add "as needed. Do not exceed X ml in 24 hours".
Then fax the prescriber back, letting them know what you did. If the prescriber feels any different, well, no harm done, right? The patient got the medication and the quantity that was prescribed. He/she can call the patient and override what you did. However, that's the only way I'd bless that with my license.
Others may disagree. And that's fine. It's my license. I am not holding up the patient in any way. I do that with acute pain C-IIs as well. I put a max on them and inform the prescriber via fax and annotate on the script. I even write the MMEs on it. I've had prescribers come up to me and say "Oh, you are John Smith. Glad to meet you. I like how you work. Thank you. We appreciate it in my office"
It's my license and I have loans to pay. If you keep your queue clutter free and teach your techs to do the same, you will have time to do hand write thank you notes. I have seen stores so well run that pharmacists have time to do that.

As for just dc-ing old med and giving new one... got rx for cellcept 250 bid pt was on 500 bid. U would assume to dc 500mg. Turns out pt said md said take 750 bid. Rx didnt mention combining w the old rx.
Never assume anything. And never assume anything with Cellcept. That's just a sloppy prescriber. It would strike me as odd to see a dose decrease without the addition of say, corticosteroids.
You also have to educate your prescribers. You can either do it directly by asking them to state "this prescriptions replaces previous cellcept ..." "Take along with ..."
It's a new prescription and you have to counsel, anyhow. I would definitely check in with the prescriber. Once you call them several times, it gets annoying to them and they'll listen.

Hope this helps. Get out of retail if you get the chance to.

All the best.

Would you mind telling (or private messaging) when you graduated and what school you came from? I'm impressed by your advice.

 

[Sabril]

Wow. Why did your friend get fired?

As for dispensing but documenting/counseling on high dose... wouldn’t u be afraid theyl overdose or take the high dose on the label and it still falls on you for dispensing it with those directions?

That is why I cannot speak for other pharmacists. But nothing you can do will absolve you 100%. There will always be a risk. Even with the perfectly correct label, people will choose to overdose themselves and come back to blame you. On your unlucky day, those blames will stick no matter how ridiculous they are. Like I have a label typed up as: methotrexate 2.5mg take one tablet by mouth once a week. A lady took it once a day. If anything happened to her, I am sure it will come back to me somehow.

I am not saying to pass everything to the patients. I just feel that proper consultation and documentation go a long way. It is not a lazy way out as many deem it to be.

 

[Apotheker2015]

That is why I cannot speak for other pharmacists. But nothing you can do will absolve you 100%. There will always be a risk. Even with the perfectly correct label, people will choose to overdose themselves and come back to blame you. On your unlucky day, those blames will stick no matter how ridiculous they are. Like I have a label typed up as: methotrexate 2.5mg take one tablet by mouth once a week. A lady took it once a day. If anything happened to her, I am sure it will come back to me somehow.

I am not saying to pass everything to the patients. I just feel that proper consultation and documentation go a long way. It is not a lazy way out as many deem it to be.

This is so true. It always comes down to the patient's word vs. the pharmacist's word. That's why it's important to document in the counseling notes/profile - wherever your system allows. Something that stuck with me from counseling lab in school that I use every day is to ask patients "what can I do to this label or bottle to help you remember to take this medication only once a week?" they will tell you: - it might be:

• drawing a large asterisk on the bottle with a sharpie - never on the cap.
• Or highlighting the "once a week" part on the label.
• Or giving them a 12 week supply of methotrexate in 3 bottles of 4 pills each and writing with a sharpie a big "MONTH 1" "MONTH 2" "MONTH 3"

I also like to detach the Patient Medication Guide and I tell them "This is your guide. I gave you key points. It is up to you to read through this guide to learn what you can expect from taking this medication". They still won't read it, of course. But then you know you do it consistently, techs see you do that consistently, and the video camera also captures you doing that.
Some might say you won't have time to do all that. If you keep a clutter free queue, you will.

 

[Apotheker2015]

Seriously.... these questions didnt even cross my mind when I was in school/rotations. Just faced them as an rph bc thats when ur actually dispensing/verifying

Third year we had a class -Biopharmaceutics- that focused on issues like the Voltaren & oral NSAIDs issues. They went through most issues that come up with different dosage forms, routes of administration. Sometimes it got into too much detail and you were of course, tested on that, but it sure has proven useful.
So then of course, you get out to 4th year rotations and who are your preceptors? Alumni who went through the same hoops and keep the same expectations.
At the end of the day, I am just another retail pharmacist but very thankful for my training even though I really hated it - couldn't wait to get out. Once you get your techs to think like you do and respond well to your direction, your job becomes a lot easier and even a breeze.

 

[johnpharm01]

That is why I cannot speak for other pharmacists. But nothing you can do will absolve you 100%. There will always be a risk. Even with the perfectly correct label, people will choose to overdose themselves and come back to blame you. On your unlucky day, those blames will stick no matter how ridiculous they are. Like I have a label typed up as: methotrexate 2.5mg take one tablet by mouth once a week. A lady took it once a day. If anything happened to her, I am sure it will come back to me somehow.

I am not saying to pass everything to the patients. I just feel that proper consultation and documentation go a long way. It is not a lazy way out as many deem it to be.

I agree with this 100%. Nothing will stop people from filing board complaints. Everyone makes errors. Patients have bad reactions to medications. But if you have good pharmacy practices you can mitigate the risk. Document. Put safety first, not last. Stay up to date. Patient welfare is priority. Carry malpractice insurance.

I worked at a pharmacy that received a board complaint. The manager and other staffer had to respond, but I was excluded because of my documentation. I have made a mistake, realized it later, and was open with patient and corrected it. I think this went miles as to not being complained about. I also made less mistakes then my peers and never found myself in hot water to begin with.

 

[MARX22]

Do you consider azithromycin to be a high risk med for arrhythmias?[/QUOTE]


Well it is moderate risk, while sertraline is indeterminate so I’m not sure if it’s a significant interaction considering even lexicomp just lists it as C-monitor... but the fact that it mentions qtc prolongation scares me and I feel afraid to dispense without speaking to md. What do you do?

 

[johnpharm01]

Do you consider azithromycin to be a high risk med for arrhythmias?

Well it is moderate risk, while sertraline is indeterminate so I’m not sure if it’s a significant interaction considering even lexicomp just lists it as C-monitor... but the fact that it mentions qtc prolongation scares me and I feel afraid to dispense without speaking to md. What do you do?[/QUOTE]

Gather more information. Filling rxs are risk vs benefit.
1. 22 yo college student, healthy no known cardiac history getting treated by PCP for gonnorrhea got on spring break - FILL
2. 85 yo grandmother in/out hospital on amiodarone, warfarin went to er got treated for possible CAP, refused admission CALL
If benefits outweigh risk, fill, counsel and make other interventions to lessen risk. If risks clearly exceed benefits and the risks are death or serious injury refuse to fill until rationale explained, risks mitigated "this is only drug that would work and disease has serious consequences". If unsatisified with answers given by md, refuse to fill.
Worked overnights at major chain. Customer came in, 20's female, appeared to be pregnant third trimester which she confirmed. She presented an rx for opiates. Reviewed record and she had been taking high dose opiates long term, scheduled, profile never marked for pregnancy, weak indication. Told her would have to call md, did and md was very helpful felt risks of stopping opiate for baby were worse than continuing. Filled and dispensed rx but also clearly explained that baby would be born dependent and would have to go thru detox upon birth.
Another customer came in, allergic to opiates, with rx for tramadol. Interviewed them and stated they have wheezing when takes tramadol, self treats with benadryl. Indication non cancer pain, able to function without. Refused to fill sent back to dr for better treatment.