Phenytoin 300 tid??

[npage148]

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Saw this from the ER written by a new resident which was the dose a unreliable patient claimed she was stable on. Never seen a dose this high and when I called to confirm a different attending agreed and cancelled the RX. Seriously, I gram a day? Didn't help the patient was stoned out of her mind when I tried to talk to her about it.

 

[Pharmavixen]

Our dr wrote an order like that on the patient's word, saying the guy "swore up and down he took 900mg phenytoin daily." I got him to change it to 300 mg daily & trough levels to start & in 7 days to make further adjustments.

Then the dr asked me this: "What if he has a seizure?" What would you say?

 

[R xxx]

Call his pharmacy and confirm the dose

 

[npage148]

Well, the script was also 3 weeks old so she was out of meds for at least that long adding to the rationale to cancel the script. "If she can go that long w/o it she can wait another 3 days for the neuro clinic"

 

[Pharmavixen]

Call his pharmacy and confirm the dose

Absolutely. The challenge here is pt compliance.

Where I work, we see many folks coming in with, say, really high BP, and several BP meds at maximal doses. So we drop the doses down and monitor BP, and in the vast majority of pts, we stabilize BP at lower doses/fewer meds. Because on the street, the pt's PCP kept piling on meds that the pt wasn't taking.

Similarly, if a pt comes in on phenytoin 300 mg tid, even if I've verified it with the pt's pharmacy, I'd recommend to our physician that we drop the dose to 300 mg daily and adjust the dose according to trough levels. Maybe the pt has a Vm of an elephant, but probably he was just not taking his phenytoin.

Besides which, a shocking number of physicians dose phenytoin as if it had linear kinetics.

 

[BidingMyTime]

Saw this from the ER written by a new resident which was the dose a unreliable patient claimed she was stable on. Never seen a dose this high and when I called to confirm a different attending agreed and cancelled the RX. Seriously, I gram a day? Didn't help the patient was stoned out of her mind when I tried to talk to her about it.

I have seen does that high, but its very rare, and the patient had congenital problems. Yeah, going from a patient history in an ER, I would want to double check the dose.

 

[npage148]

Yeah. All the ER could come up with was her levels were low and she had a seizure. I would bet my house she was just non-complaint with it and was being dose-escalated w/o regard if she was even ever prescribed that dose.

 

[PharmDstudent]

This doesn't surprise me. A lot of patients don't take their meds and refuse to admit it. It's horrible!

 

[confettiflyer]

Maybe the pt has a Vm of an elephant,

I'm at starbucks, and reading this brought out the kinetics geek in me and i actually laughed out loud. hah. thanks, pharmavixen