Jul 31, 2016
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Pharmacy Student
Hi everyone! I'm a fairly new graduate, so I wanted to get some opinions from more seasoned pharmacists on a dose increase of a medication for a patient. I know that I'm probably over thinking this, but just wanted to have others throw in their two cents and experience with this.

77 yo patient on glimepiride 4 mg - originally taking 1 tablet BID. Got a new prescription today saying 2 tablets in the morning and 1 tablet at night. I had a DUR saying that the max dose of the medication is 8 mg/day. As far as I know this is the only diabetes medication for the patient.

My question is, would you fill it as is? Or would you contact the doctor and question why the patient isn't on additional therapy since he has maxed out on his glimepiride. I've read in school about sulfonylureas having a decreased effectiveness over time due to over stimulating the pancreas, so I thought the dosing makes sense, but then again it is over the max dose.

I ended up filling it (patient hasn't picked it up yet), but I'm having second thoughts. What would you do in this situation? Thanks in advance for the advice!
 

steveysmith54

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10+ Year Member
Dec 29, 2005
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If your computer is flagging something to be a high dose, you should call the prescriber UNLESS 1. you are absolutely sure that that it's a common practice to go above the recommended dose OR 2. pt has been on that dose forever and it has already been verified.

None of these criteria are met. If it were me and I was an outpatient RPh, i would not care that the pt should be on an additional therapy (which is obviously true in this case), i'd care that the max dose is exceeded and it could cause hypoglycemia, as well as other adverse reactions. Call the doctor.
 

CetiAlphaFive

2+ Year Member
Apr 12, 2016
4,129
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Pharmacist
Hi everyone! I'm a fairly new graduate, so I wanted to get some opinions from more seasoned pharmacists on a dose increase of a medication for a patient. I know that I'm probably over thinking this, but just wanted to have others throw in their two cents and experience with this.

77 yo patient on glimepiride 4 mg - originally taking 1 tablet BID. Got a new prescription today saying 2 tablets in the morning and 1 tablet at night. I had a DUR saying that the max dose of the medication is 8 mg/day. As far as I know this is the only diabetes medication for the patient.

My question is, would you fill it as is? Or would you contact the doctor and question why the patient isn't on additional therapy since he has maxed out on his glimepiride. I've read in school about sulfonylureas having a decreased effectiveness over time due to over stimulating the pancreas, so I thought the dosing makes sense, but then again it is over the max dose.

I ended up filling it (patient hasn't picked it up yet), but I'm having second thoughts. What would you do in this situation? Thanks in advance for the advice!
I mean, it's nothing crazy, but usually, "Home Improvement" dose escalation is indicative of a lazy or stupid MD.
"Hurrrrr, if 8mg didn't do'd it good enough, maybe 12 will do it gooder"

No, definitely wouldn't have filled as is.
I would've called the prescriber and ask why they haven't optimized the metformin dose.

Then I would've told them we need documentation from MD before filling it.
^
This sidesteps the usual "YAh that's how thuh dokter rite it" from the medical assistant on the phone.

Then, document "notified md of risk of hypoglycemia. Notified MD of inappropriate dose. Notified MD of lack of metformin. MD insists that benefit outweighs risks and to fill as-is. CA5 09/24/17
 
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Jul 31, 2016
3
0
Status
Pharmacy Student
I mean, it's nothing crazy, but usually, "Home Improvement" dose escalation is indicative of a lazy or stupid MD.
"Hurrrrr, if 8mg didn't do'd it good enough, maybe 12 will do it gooder"

No, definitely wouldn't have filled as is.
I would've called the prescriber and ask why they haven't optimized the metformin dose.

Then I would've told them we need documentation from MD before filling it.
^
This sidesteps the usual "YAh that's how thuh dokter rite it" from the medical assistant on the phone.

Then, document "notified md of risk of hypoglycemia. Notified MD of inappropriate dose. Notified MD of lack of metformin. MD insists that benefit outweighs risks and to fill as-is. CA5 09/24/17
Got it. Thanks for everyone's advice so far. I'll be sure to contact the MD tomorrow about it.
 

wagrxm2000

A different perspective
5+ Year Member
Sep 17, 2014
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Not saying you shouldn't call but you aren't going to get anything done if you question every DUR.

Just a warning, call when absolutely needed but not for everything. Some things it's better to caution the patient and have them call you to make sure everything is ok. Also learn your doctor's, some won't care what you think.
 

quickpic007

2+ Year Member
Sep 22, 2016
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Is there any kidney meds on this pt?
lots of old school docs do this over max dose bs...amlodipine 20 mg is another popular one
surprising pt didnt yell "give me mah pills the doctor wrote it!!"
 
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