newbie hello and a question

[hogpharmer]

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Hello everyone! I am a first-time poster but a long-time lurker. I'm currently a P1 and work part-time in a retail pharmacy.

Here's a question about something that happened recently at work:

Patient has been taking Synthroid for years. Patient sees our wonderful $4 generic list and wants to switch to levothyroxine. Script is a DAW 1. I am hesitant about switching it. Pharmacists says "switch it". So, I switch it to levothyroxine.

I know I am a lowly P1, but I was under the impression that it is not good to change thyroid medication. If the doctor starts a patient on Synthroid and puts DAW 1, then the doctor does not want it changed to generic.

What does everyone think?

 

[WVUPharm2007]

Legally you have to call and get the brand necessary moniker off of it. However, the script may have been written in a nonofficial way. In WV, you have to write out "Brand Medically Necessary" on the script. Just writing "DAW:1" isn't good enough. So the pharmacist may be legally in a loophole allowing them to switch it.

About the actual switch - if it's an FDA rated AB drug, it's fine. Drug companies use such exact weighing equipment that differences between companies is typically minute concerning immediate release medications such as levo. Abbott wants everyone to believe a bunch of conjured up junk about how a bioequivalent drug isn't really bioequivalent, blah, blah....it's all a bunch of bull****, IMO. If it were legal for me to make a switch, I would switch it and not think twice.

 

[Old Timer]

There are several things to look at:

1) What does the law of your state say?

2) As pointed by the modest and brilliant WVUPharm2007 it also depends on how the doctor signed the blank. In Pennsylvania, the prescriber must hand write Brand Necessary or Brand Medically Necessary on the blank. No stamps, no DAW, no needs brand, no brand only.

The rub is this. L-Thyroxine is a drug with bizarre kinetics. I personally would not switch a patient who has reached therapeutic levels from the brand to the generic or from the generic to the brand w/o first consulting with the physician. I have seen to many treatment failures each way. Now should the patient present a prescription allowing substitution and they have been on the brand, I would counsel the patient to speak with doctor and have their TFT performed sooner to see how the change affected the levels.

One more thing, argue with the pharmacist, discuss with the pharmacist, ask the pharmacist to explain his/reasoning, but DO WHAT THE PHARMACIST SAYS. They know more than you. Maybe the doctor called 15 minutes before and said the switch was OK. Maybe they already checked the original and the prescription allowed substitution.

 

[Priapism321]

The drug companies would have you believe switching from brand to generic would be detrimental to the patient; however, sound scientific research argues against such a notion. In the early 1990's, a study was completed showing that Synthroid was no different than several other preparations of levothyroxine. However, since the original hypothesis was that a difference would be found, and the makers of Synthroid funded the study, they fought tooth and nail to keep the data suppressed. They were actually successful for four years, most likely leading to unnecessary prescription of Synthroid (which a court also agreed had happened, and for blocking the publication of the study, the drug company paid out over one hundred million dollars in a class action lawsuit settlement).

If anyone has a chance to read the details of this series of events (I have only provided a brief overview), you will truly appreciate how vindictive the pharmaceutical industry really is. The reason I became so interested in this stuff is the lead investigator on the study was a UCSF Pharmacist, and because she would not let the industry compromise the integrity of her research, the study was ultimately published in JAMA on April 16, 1997. In my opinion, this pharmacist has saved patients and the healthcare system hundreds of millions of dollars by demonstrating that generically equivalent formulations of levothyroxine are indeed bioequivalent to Sythroid, despite what Pharma tells anyone.

My short answer: switch the damn drug if it is legally permissible.

 

[hogpharmer]

Just to clarify -- the doctor was not consulted to find out if the switch was OK, nor was the original script pulled to see if substitution was allowed. The patient was simply picking up her Synthroid, complained that it wasn't $4, and the pharmacist told me to switch it. The pharmacist told the patient after the switch that she should get her levels checked because the generic could alter her levels.

I asked the pharmacist for his reasoning afterwards and he said it was the patient's right to switch if they wanted to. While I'm all for generic drugs, I have just always heard that on thyroid drugs that it is not good to switch during treatment. Of course, they used to say the same thing about Coumadin/warfarin, but the opinion seems to have changed on that.

Thanks everyone for your comments. I definitely do what the pharmacist says but I just wanted to get some insight from others.

 

[Priapism321]

While I'm all for generic drugs, I have just always heard that on thyroid drugs that it is not good to switch during treatment.

Is it at all relevant that you have "heard" switching thyroid medications is "not good." Honestly, who cares what you have heard, a lot of people have heard a lot of things. Do you have any data to support the bio-inequivalence of the medications? I am not meaning to attack you, but I don't understand what you are aiming to get out of stating what you have heard. Perhaps someone is going to read your statement above and think "Man, he has heard switching is bad, it must be the case. I mean, he obviously is hearing these things from a reputable sources."

I once heard from a physician that piperacillin/tazobactam was available orally and that it covered MRSA; it's a good thing I learned early not to believe everything that I "heard."

 

[MountainPharmD]

Is it at all relevant at all that you have "heard" switching thyroid medications is "not good." Honestly, who cares what you have heard, a lot of people have heard a lot of things. Do you have any data to support the bio-inequivalence of the medications? I am not meaning to attack you, but I don't understand what you are aiming to get out of stating what you have heard. Perhaps someone is going to read your statement above and think "Man, he has heard switching is bad, it must be the case. I mean, he obviously is hearing these things from a reputable sources."

I once heard from a physician that piperacillin/tazobactam was available orally and that it covered MRSA; it's a good thing I learned early not to believe everything that I "heard."

Take it easy there slick. The newbie is just asking a question and a good one I might add. Old Timer has it correct. It is good to ask questions and good to understand but in the end you do what the pharmacist says.

To be more specific it depends on the laws of your state. A thorough pharmacist would have pulled the hard copy to verify DAW-1 was properly anotated. If it was then a call to the doctor should have been made to get the official okay for the switch. Once you get the okay document it on the script and move on. Sure it takes a little time but so what. I rather spend the time to do soemthing right than to quickly do something wrong.

 

[hogpharmer]

The pharmacists I worked with many years ago used to say it was bad to switch. That is where I "heard" it. That's also why I wanted your opinions on it because we haven't learned anything about it in school yet, and I am open to the fact that what I "heard" may not be true.

And, yes, it does seem like you're attacking me. Why do newbies always seem to get attacked on here? What a nice welcome.

 

[PharmDstudent]

And, yes, it does seem like you're attacking me. Why do newbies always seem to get attacked on here? What a nice welcome.

"Take it easy there slick." You don't know what it's like to be attacked by Priapism; he actually said that he wasn't trying to attack you. Ask WVU. He gets attacked by Priapism all the time!

 

[MountainPharmD]

"Take it easy there slick." You don't know what it's like to be attacked by Priapism; he actually said that he wasn't trying to attack you. Ask WVU. He gets attacked by Priapism all the time!

Wow just wow I would hate to be attacked by a priapism....might hurt.....

 

[hogpharmer]

If you say "not trying to attack you", it usually means you are about to say something that can be taken as an attack. Just like saying "No offense, but ...." usually means you are about to say something that can be taken offensively.

If Priapism wasn't trying to attack me, then what was the purpose of his post?

 

[MountainPharmD]

If you say "not trying to attack you", it usually means you are about to say something that can be taken as an attack. Just like saying "No offense, but ...." usually means you are about to say something that can be taken offensively.

If Priapism wasn't trying to attack me, then what was the purpose of his post?

Let it go dude...You have to have thick skin on this forum. Remember it is an anonymous public forum so people say things they would not normally face to face. Its what makes it fun! Besides its good for you. Teaches you how to handle retail customers who act the same way.

 

[Priapism321]

If you say "not trying to attack you", it usually means you are about to say something that can be taken as an attack. Just like saying "No offense, but ...." usually means you are about to say something that can be taken offensively.

If Priapism wasn't trying to attack me, then what was the purpose of his post?

Here is what inspired my previous post:

1) Indeed, you asked a good question; that sort of thing is encouraged around here.
2) You received several responses from people who probably know more than you on the issue.
3) You post again, after the question has been answered, and are compelled to state the case for why you were hesitant to switch the drug. Here is the problem, you give no acceptable rationale, or scientific evidence to support your stance on the matter.

In my opinion, if you ask a question, you just be quiet other than expressing appreciation to the individuals who take time to offer their thoughts. I don't need you to repeat over and over that you "heard" that switching is "not good," this contributes absolutely nothing to the discussion.

 

[PharmDstudent]

Wow just wow I would hate to be attacked by a priapism....might hurt.....

Yeah. It can hurt a little. He told me that I need to wait a few years before I post in the clinical threads, that hurt. It wasn't necessary. He didn't actually add anything to that thread to begin with.

Retail hurts too. When people make me upset, I'll just make them wait for the pharmacist. Some lady was giving my her date of birth backwards. I asked that she say it correctly so that I wouldn't make a mistake. She tells me that she's French and that's how French people say it. She had a New Orleans accent, and she spoke English. I should have told her that I'm German, that I can't understand French people, and that I can only understand German. I made the pharmacist deal with her!
They think I'm an undereducated tech or something, even though I wear my intern jacket.

If you can't tell, I have a love/hate relationship with people.

FYI newbie- Priapism never says that he isn't trying to attack someone; he'll just do it.

 

[Priapism321]

He didn't actually add anything to that thread to begin with.

Ha. In my opinion, posts 36-41 provide evidence for the contrary (unless you simply mean that I didn't post on the matter before I politely told you to stay in school and study hard; after that I jumped in at Epic's request for the lowly resident to offer his lowly opinion).

 

[PharmDstudent]

Ha. In my opinion, posts 36-41 provide evidence for the contrary (unless you simply mean that I didn't post on the matter before I politely told you to stay in school and study hard; after that I jumped in at Epic's request for the lowly resident to offer his lowly opinion).

Exactly! (I was just joking about that Iranian marriage stuff.)

Even though I study hard, school can be a drag. I like talking about pharmacy stuff outside of school and work. There are a lot of fresh ideas that pop up in this forum- stuff that I would have never thought about otherwise!

I'm sorry that they have to associate resident with the adverb lowly. It's not really fair. Residencies are altruistic if you ask me.
Maybe I'm just selfish or jaded, but I won't do a residency.

 

[WVUPharm2007]

Being that we are suppossed to practice "evidence-based" medicine....


Here is a nice little journal article on the matter.

Yeah, it's a few years old and released before the generic hit AB status, but whatever.

The author's conclusion:

In conclusion, there is no hard, scientific evidence to suggest that the current guideline for bioequivalence for levothyroxine products does not perform as it purports. Evidence, so far, demonstrates that properly powered studies, performed and analyzed as recommended by the FDA, should and do establish bioequivalence for products that differ by less than 20% and differentiate and reject as inequivalent those products that differ by more than 20%.

I would tend to agree....it's bioequivalent, it works, so there.....

I have a feeling that any circumstantial lab evidence showing the generic isn't as good likely has to do with noncompliant patients that want an easy out for their laziness when their levels come back. Notice it's never TOO HIGH..oh no, it's always TOO LOW. Really, why is that....? (That's all just my guess though....)

 

[hogpharmer]

Here is what inspired my previous post:

1) Indeed, you asked a good question; that sort of thing is encouraged around here.

I'm beginning to think otherwise

2) You received several responses from people who probably know more than you on the issue.

True, which is why I asked the question in the first place.

3) You post again, after the question has been answered, and are compelled to state the case for why you were hesitant to switch the drug. Here is the problem, you give no acceptable rationale, or scientific evidence to support your stance on the matter.

My follow-up post was to address Old Timer, who suggested that the doctor had called previously and OK'd the switch or the pharmacist checked the original prescription for substitution, which he did not do. You are right that I don't have any scientific evidence. That is why I was asking the experts on this board. If I have "heard" incorrectly, I was willing to be corrected.

In my opinion, if you ask a question, you just be quiet other than expressing appreciation to the individuals who take time to offer their thoughts.

I did offer my appreciation. Please re-read my second post.

I don't need you to repeat over and over that you "heard" that switching is "not good," this contributes absolutely nothing to the discussion.

I did not "repeat over and over" that I heard that switching was not good. I said it in my original post, then re-stated it in my follow-up to make a point that it used to be the consensus that it was best not to switch, but scientific evidence can change the consensus, as in Coumadin/warfarin.

this contributes absolutely nothing to the discussion

And attacking a newbie does?

I'm done with this

Thanks again everyone who offered your opinions.

 

[PumpkinSmasher]

Here is what inspired my previous post:

I'm beginning to think otherwise
True, which is why I asked the question in the first place.
My follow-up post was to address Old Timer, who suggested that the doctor had called previously and OK'd the switch or the pharmacist checked the original prescription for substitution, which he did not do. You are right that I don't have any scientific evidence. That is why I was asking the experts on this board. If I have "heard" incorrectly, I was willing to be corrected.

I did offer my appreciation. Please re-read my second post. I did not "repeat over and over" that I heard that switching was not good. I said it in my original post, then re-stated it in my follow-up to make a point that it used to be the consensus that it was best not to switch, but scientific evidence can change the consensus, as in Coumadin/warfarin.
And attacking a newbie does?

I'm done with this

Thanks again everyone who offered your opinions.

If you are this sensitive on this message board I really do not image you making it long as a pharmacist, good luck when you switch careers.

 

[Allure]

Are we not allowed to be sensitive and have feelings just because we're behind a computer screen? Does being behind a computer screen give you the right to be rude?

 

[MountainPharmD]

Are we not allowed to be sensitive and have feelings just because we're behind a computer screen? Does being behind a computer screen give you the right to be rude?

I do not know about the "right" but it certainly makes it easier to be rude. This is an anonymous public forum, what do you expect? People will type things on here that they would never say to anyones face. Thats life on an online forum and why it is interesting.

I do agree with the above poster. If your feelings get hurt that easy on a online forum good luck as a pharmacist....