Patient on Diazepam and Clonazepam?

[AmphoTerrible]

Advertisement - Members don't see this ad

So a patient came in to the pharmacy today with scripts for clonazepam 1mg q4 prn anxiety and diazepam 5mg tid and every 6 hours as needed. We call the MD and the MD being a jerk yells at the pharmacist for questioning his prescriptions. Newbie pharmacist backs down and fills it without an explanation. Is there any possible indication for 2 benzos? Even besides being on 2 benzos the doses are pretty high as well. Thoughts?

 

[WVUPharm2007]

Who knows. That's pretty much the answer. The prescribing habits of BZDs are sometimes weird as hell from prescriber to prescriber. Could it be controlled with only one agent? Probably. But if it is legit and works for the patient, I'd be cool with it...though scrutiny should be exercised if something looks sketchy.

 

[Aznfarmerboi]

No possible indications that I can think of. As far as high dosing is concerned, the sky is the limit. From my experience, a nurse would be afraid to administer diazepam 10mg for alcohol withdrawal in one hospital and in the other, doses of diazepam 100mg would go unnoticed. It all depends on your patient population and how frequently they use it.

I would check previous profile to see if he has been on it, document phonecall (and note everything) with MD, and counsel to patient. The patient probably would be controlled on just one of them for whatever reason it is needed. If anything, I would be worried about the long half life of the two drugs.

 

[VancTheTank]

.

 

[Old Timer]

For the community folks - is "duplicate" therapy like this ever a problem as far as insurance is concerned?

Yes, and get's more bizarre by the day. Future Scripts, the PBM owned and operated by Independence Blue Cross started a new edit June 1st. If you received any pain medication in the last 30 days, you may not receive an additional pain medication without the physician calling in a PA. Sorry, the Darvocet or Tramadol didn't work and you need Vicodin, nope PA. If you are on let's say tramadol for moderate pain and Vicodin or Percocet for severe pain, you now need a PA even if you have taken both before.....

 

[Pharmavixen]

Doesn't look right. Strictly speaking, you can't overdose on benzos, but the massive clonazepam dose would totally cover whatever the comparatively wimpy diazepam dose would do.

I wouldn't have filled it without an explanation. Maybe there is one, but in my experience, scripts like this aren't based on appropriate therapeutics. Especially when it's two benzos with street value.

 

[aboveliquidice]

Craziness - but not unheard of - One thing I saw recently that looks strange in a patient on duplicate respiratory medications... As in two corticosteroids (for respiratory maintenance) or two anticholinergics... such as both Tio and Ipra.

Apparently this is common practice at the VA here in town (yet to see it at my current hospital).

 

[Farmercyst]

Yes, and get's more bizarre by the day. Future Scripts, the PBM owned and operated by Independence Blue Cross started a new edit June 1st. If you received any pain medication in the last 30 days, you may not receive an additional pain medication without the physician calling in a PA. Sorry, the Darvocet or Tramadol didn't work and you need Vicodin, nope PA. If you are on let's say tramadol for moderate pain and Vicodin or Percocet for severe pain, you now need a PA even if you have taken both before.....

That is lame. Our pain mgmt docs are gonna hate them. We consistently get Ibu 6/800+ Vic/Norco/Perc for breakthrough, also have several on multiple concentrations of either oxy or MS IR+CR.

 

[nafcillin]

makes sense if the person is weaning from clonazepam as a diazepam taper is relatively common. the klonipin dose concerns me as that is quite high. q4h = a possibility of having a total of 6mg a day. I would have asked the patient what his/her history with the drug was. Tolerance is gradually built up over time and 6mg is a possibility, though not something I would strive for.

 

[Pharmavixen]

I did my residency in addiction medicine, and what we used to do was switch them one benzo (diazepam) and then taper. Diazepam is useful because it's "self-tapering," what with its long t1/2 and active metabolites. But leaving them on 2 benzos doesn't make any sense.

If you see someone on more than one benzo on a chronic basis, generally it's not evidence-based medicine. I have seen docs who prescribe diazepam and oxazepam to the same person at the same time, an ignorance of pharmacology that's up there with discharging pts on IV vanco with a script for po vanco, IMO.

The doc's aggressive defensiveness is a warning sign right there. If a doctor ever throws a hissy when you question his/her script, be very, very careful.

Different from pain medicine, where you may prescribe a LA opioid, say, and another that's IR for breakthrough.

 

[prevacid]

ive seen it

just call to confirm tats what the md wanted, never questioned them on it