Question about inhaler scripts and spacer?

[ldiot]

What if the doctor writes a script for proair and the SIG says "use with spacer" but the patient profile has no spacer on it. Can this be considered a script for a spacer as well as an inhaler since it says use with spacer?

I was wondering... it seems like at the pharmacy we hand out inhalers all day long but rarely a spacer.

Is the doctor providing a spacer at the office? Do most people just not use a spacer with plain albuterol? If it says use with spacer but they never send a script for a spacer is it assumed that I'm dispensing one?

Also why are spacers not able to be sold OTC?

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[zelman]

What if the doctor writes a script for proair and the SIG says "use with spacer" but the patient profile has no spacer on it. Can this be considered a script for a spacer as well as an inhaler since it says use with spacer?

I was wondering... it seems like at the pharmacy we hand out inhalers all day long but rarely a spacer.

Is the doctor providing a spacer at the office? Do most people just not use a spacer with plain albuterol? If it says use with spacer but they never send a script for a spacer is it assumed that I'm dispensing one?

Also why are spacers not able to be sold OTC?

If you get a prescription that says "take 1 aspirin tablet daily while sitting in a BMW" do you dispense a luxury car? Mentioning a spacer is not ordering a spacer.

 

[Sine Cura]

It is also common for have orders for insulin or daily GLP-1 pens without corresponding orders for pen needles.

If you have a hard copy for an inhaler in front of you, a smart person would tell the patient/agent that there is no order for a spacer. Sometimes they already have a spacer.

Edit: FDA regulation of medical devices includes determination about Rx status

 

[lord999]

What if the doctor writes a script for proair and the SIG says "use with spacer" but the patient profile has no spacer on it. Can this be considered a script for a spacer as well as an inhaler since it says use with spacer?

I was wondering... it seems like at the pharmacy we hand out inhalers all day long but rarely a spacer.

Is the doctor providing a spacer at the office? Do most people just not use a spacer with plain albuterol? If it says use with spacer but they never send a script for a spacer is it assumed that I'm dispensing one?

Also why are spacers not able to be sold OTC?

Depends on the state, my old state AZ took that to be an implied prescription if the patient did not have a working one (as in you would just copy a new Rx in dicta est), but MN and IL required you call. That's always a simple call to the practice asking "you also meant an order of Spacer UTD with that right?". Dispensing an inhaler and not catching that they didn't have a spacer would probably get you in trouble in both states if the signa mentions one and you didn't verify it with the patient that they had one.

Most people don't use a spacer (which I don't think is a good practice when learning). The technique is fairly tricky to get right on your first inhaler but if you're a lifelong asthmatic, it's probable that they won't need it anymore. I still have one in case I have a problem with technique and I'm sick.

 

[ldiot]

Wow so I can't dispense a spacer without a script but I'll get in trouble for dispensing the inhaler without a spacer if they don't have one and the SIG says to use one? Honestly it's bull**** that I have to play secretary for doctors and insurance all day long and if I tell the patient to take care of it they whine and moan and tell me to do it, and even if the patient does it they usually tell the doctor the wrong thing anyways and I'd probably end up with a second inhaler rx and still no spacer

 

[Mad Jack]

Agree- I don't work retail so I have no idea what the actual workflow is but that seems jacked up. If they want the spacer it's their job to provide with with one or give them an Rx for it. Not the pharmacist job to double check what they intended.

Now if the patient asked, then I would 100% take care of them.

This is all kind of ridiculous, given that all inhalers should be used with a spacer. An inhaler without a spacer is like paint without a paintbrush- sure, you can smear it on with your hands, but it won't work nearly as well as it should, the paintbrush is implied.

 

[Drugsarefun2350]

I wouldn't bother calling the doc for it, if the patient asks just do it and document on the hard copy the reasoning, if a board of pharmacy gets mad about that then I have no hope for the profession

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[trailerpark]

This is all kind of ridiculous, given that all inhalers should be used with a spacer. An inhaler without a spacer is like paint without a paintbrush- sure, you can smear it on with your hands, but it won't work nearly as well as it should, the paintbrush is implied.

Umm no, you can correctly use an inhaler without a spacer as long as you have at least 2 grey cells touching...


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[Mad Jack]

Umm no, you can correctly use an inhaler without a spacer as long as you have at least 2 grey cells touching...


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Medication deposition with a spacer versus without is vastly different, particularly in the portion of the airways that matter.

"The study was conducted at Case Western Reserve University, and University Hospitals of Cleveland, in collaboration with Rhone-Poulenc Rorer
Pharmaceuticals. When comparing drug deposition of triamcinolone acetonide
with the use of Azmacort's built-in spacer versus drug deposition without a
spacer, researchers found on average a 180 percent increase in lung deposition
as well as 333, 142 and 113 percent increases in drug deposition to the
central, intermediate and peripheral regions of the lungs, respectively."

This study was in-vivo using PET scanning.

http://www.ncbi.nlm.nih.gov/pubmed/11037987

Abstract of the final study results, you can dig up the full study yourself if you'd like. The bottom line is that a spacer increases target tissue deposition in the area of the lung you most want steroids to deposit by over 300%. That's a huge amount when we're talking about maintenance therapy. Deposition further down the line is still increased substantially, and coordination is significantly increased in patients that are acutely SOB. Not prescribing a spacer with MDI maintenance meds is, in my opinion, completely irresponsible prescribing, and not prescribing one with rescue therapy is poor care. There is a reason guidelines recommend spacers, even if patients are often too stubborn to carry around and use them.

 

[group_theory]

Up until recently, when I write for a spacer, I would include the Diagnosis and ICD10 (ie Dx: Severe Persistent Asthma, J45.50) in the sig line of my EMR (EPIC)

The question I have is whether doing this is redundant to the retail pharmacist? I also "associate" a diagnosis with the order when I sign the order. When I select the Print Rx option, I see the diagnosis show up under "Diagnosis" on the paper Rx. I do not know if the diagnosis shows up when select the ERx option (and since spacers are equipments, I include the Dx in the sig just in case). Am I being redundant and can I stop doing this?

*I wonder if the associate diagnosis also occurs on the inpatient side at discharge during medication reconciliation since on a few occasions, I've gotten paged by outside pharmacy on a few occasion (about once every 3-4 months) when I'm on call asking to "resend" the Rx since they didn't include the diagnosis and they can't bill under Medicare Part B. (from my end, it's actually real hard to do since the patient is already discharged so the chart has been closed ... I must create a separately new encounter and reorder the medications - always fun when it wasn't your patient and you're just covering, and want 10+ prescriptions ... and was told they can't take a verbal for diagnosis)


To the original thread, for what it's worth - I always ask the patient if he/she have a spacer when I'm writing for an inhaler (except the new proair respiclick and Aerospan) ... if they say yes, I don't include an Rx for a spacer. If they say no, I include a separate Rx for spacer.

 

[zelman]

Up until recently, when I write for a spacer, I would include the Diagnosis and ICD10 (ie Dx: Severe Persistent Asthma, J45.50) in the sig line of my EMR (EPIC)

The question I have is whether doing this is redundant to the retail pharmacist? I also "associate" a diagnosis with the order when I sign the order. When I select the Print Rx option, I see the diagnosis show up under "Diagnosis" on the paper Rx. I do not know if the diagnosis shows up when select the ERx option (and since spacers are equipments, I include the Dx in the sig just in case). Am I being redundant and can I stop doing this?

*I wonder if the associate diagnosis also occurs on the inpatient side at discharge during medication reconciliation since on a few occasions, I've gotten paged by outside pharmacy on a few occasion (about once every 3-4 months) when I'm on call asking to "resend" the Rx since they didn't include the diagnosis and they can't bill under Medicare Part B. (from my end, it's actually real hard to do since the patient is already discharged so the chart has been closed ... I must create a separately new encounter and reorder the medications - always fun when it wasn't your patient and you're just covering, and want 10+ prescriptions ... and was told they can't take a verbal for diagnosis)


To the original thread, for what it's worth - I always ask the patient if he/she have a spacer when I'm writing for an inhaler (except the new proair respiclick and Aerospan) ... if they say yes, I don't include an Rx for a spacer. If they say no, I include a separate Rx for spacer.

Diagnosis is nice to have so we can check the dose is appropriate for the indication. It's only absolutely necessary for Medicare part b claims.

 

[doublehh03]

What if the doctor writes a script for proair and the SIG says "use with spacer" but the patient profile has no spacer on it. Can this be considered a script for a spacer as well as an inhaler since it says use with spacer?

I was wondering... it seems like at the pharmacy we hand out inhalers all day long but rarely a spacer.

Is the doctor providing a spacer at the office? Do most people just not use a spacer with plain albuterol? If it says use with spacer but they never send a script for a spacer is it assumed that I'm dispensing one?

Also why are spacers not able to be sold OTC?

What if the doctor writes a script for proair and the SIG says "use with spacer" but the patient profile has no spacer on it. Can this be considered a script for a spacer as well as an inhaler since it says use with spacer?

I was wondering... it seems like at the pharmacy we hand out inhalers all day long but rarely a spacer.

Is the doctor providing a spacer at the office? Do most people just not use a spacer with plain albuterol? If it says use with spacer but they never send a script for a spacer is it assumed that I'm dispensing one?

Also why are spacers not able to be sold OTC?

It depends. I usually only see MDs write that for pediatrics. And if I don't see one on file, I'll dispense it. You shouldn't worry about things like this. You're taking care of the patient.

 

[owlegrad]

I used to ask the patient if they wanted a spacer. Most insurances in my experience didn't cover it and few patients wanted to pay out of pocket, so in most cases it became a mute point. In the few cases where patients wanted a spacer I just noted on the script that I called and the prescriber authorized a script for a spacer (since it is clear from the directions that is what the prescriber intended).

There is plenty of things to waste time on in pharmacy, why make your job harder?

 

[ldiot]

I used to ask the patient if they wanted a spacer. Most insurances in my experience didn't cover it and few patients wanted to pay out of pocket, so in most cases it became a mute point. In the few cases where patients wanted a spacer I just noted on the script that I called and the prescriber authorized a script for a spacer (since it is clear from the directions that is what the prescriber intended).

There is plenty of things to waste time on in pharmacy, why make your job harder?

It seems like most new grads call on every little detail and become more relaxed on this kind of stuff as they gain experience. My first instinct is to not call on most of this kind of crap and I'm still only a student which kind of scares me that I'm too far on the other end of the spectrum.

 

[cbrons]

Wow so I can't dispense a spacer without a script but I'll get in trouble for dispensing the inhaler without a spacer if they don't have one and the SIG says to use one? Honestly it's bull**** that I have to play secretary for doctors and insurance all day long and if I tell the patient to take care of it they whine and moan and tell me to do it, and even if the patient does it they usually tell the doctor the wrong thing anyways and I'd probably end up with a second inhaler rx and still no spacer

Do you write "dispense with spacer"? Or write an entirely different Rx for the spacer? Im confused

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[cbrons]

Umm no, you can correctly use an inhaler without a spacer as long as you have at least 2 grey cells touching...


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The patient pop near here doesnt universally meet that criteria

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[group_theory]

Umm no, you can correctly use an inhaler without a spacer as long as you have at least 2 grey cells touching...

The patient pop near here doesnt universally meet that criteria

Obligatory video post

 

[owlegrad]

It seems like most new grads call on every little detail and become more relaxed on this kind of stuff as they gain experience. My first instinct is to not call on most of this kind of crap and I'm still only a student which kind of scares me that I'm too far on the other end of the spectrum.

I wouldn't worry about it too much, I am WAY on the other end of that spectrum as well and so far it has been ok. As long as you don't start thinking "OK to substitute" means you can dispense anything you want you should be fine.

 

[maria1oh]

I would only dispense an implied spacer if the patient requests one. Recently filled proair and spacer using the same script and the customer (patients wife) came back saying they didn't need a spacer and wanted a refund. We usually refuse refunding but this was kind of our fault for dispensing a spacer without a direct order/rx. We damaged out the spacer and took a loss since it had already left the pharmacy.