What to dispense when you get a prescription for these drugs? (Different salts)

[gradintern]

Doxycycline: Dispense monohydrate or hyclate?

Prednisolone liquid, could you dispense Prednisolone sodium phosphate?

Forms of erythromycin: I know there are differences in absorption, but which form do you dispense if prescription doesn't specify? Anyone have a good summary of the different forms and what's different about each?

Any other similar drug situations please feel free to post, such as metoprolol succinate being extended release and tartrate being immediate release is an example.

Thanks!

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[crazybob]

metoprolol succinate being extended release and tartrate being immediate release.

I usually assume metoprolol tartrate unless I see succinate or ER written after metoprolol. If it's 200 mg, I'd think the succinate form. Then I'd ask the pharmacist to check the script and then the label, and then the dispensed drug to see that all of it is correct.

Can't you usually look under the refill history? I know that you can't always do that, but that's where I would start.

 

[Ackj]

I'm on IPPE at a Wegmans now, and they have a pharmacist/intern dedicated to calling up doctors and clarifying. They call about EVERYTHING, no guesswork at all. I guess it's good to make sure, but if they didn't have 4 pharmacists on, there's no way that would be possible.

Normally (my Kmart job) I'd look at refill history to see which one they've been getting, or see if I can figure it out based on the dosing (bupropion twice daily would probably be SR, once daily would most likely be the XL).

 

[Farmercyst]

I usually assume metoprolol tartrate unless I see succinate or ER written after metoprolol. If it's 200 mg, I'd think the succinate form. Then I'd ask the pharmacist to check the script and then the label, and then the dispensed drug to see that all of it is correct.

Can't you usually look under the refill history? I know that you can't always do that, but that's where I would start.

At the very least you'll have to watch out for audits if you do that.

 

[pharm B]

At our pharmacy, we have to call on the metoprolol if the doc didn't specify.

 

[rxlea]

A simple google search reveals that the solubilities of the doxy differ which affects absorption and GI side effects. One is also cheaper.

 

[gradintern]

A simple google search reveals that the solubilities of the doxy differ which affects absorption and GI side effects. One is also cheaper.

So if neither is specified, which do you dispense?

 

[rxlea]

If I had the choice, I would pick the cheapest one that has less side effects.

 

[rxlea]

If you can save the patient from some dyspepsia and keep their wallet fatter, do it. Patient needs come first d00d (within reason of course). I would verify on the metoprolol for sure.

 

[Farmercyst]

If I had the choice, I would pick the cheapest one that has less side effects.

Would it be legal?

Things to think about. Therapeutic equivalency (orange book), Clinical efficacy, and legal requirements for substitution (varies by state).

 

[rxlea]

Would it be legal?

Things to think about. Therapeutic equivalency (orange book), Clinical efficacy, and legal requirements for substitution (varies by state).

Let me rephrase....if the doctor gave me the choice.

Would the doc give the choice ever? Like if you're treating acne or something? I guess the issue is whether or not you verify.

 

[gradintern]

Thanks for your replies everyone. My question is if nothing is specified on the Rx, would you dispense either one or are they too different in some way? I am in California. I will guess that they are not interchangeable in the orange book, but if the doctor doesn't specify which salt, is there a "default" salt that most pharmacists will choose? At my pharmacy it seems like we tend to dispense doxy hyclate and I'm just wondering if there is something I am unaware of when choosing to dispense a certain salt.

The metoprolol was just an example I gave, definitely the two salts are very different and obviously not interchangeable, and I was inviting similar examples. So does prednisolone/predisolone sodium phosphate fall into this category of being completely different like the situation with metoprolol for some reason, or if not specified, can either be dispensed?

Also, there's the diltiazems: more than one 24-hour formulation, not interchangeable per the orange book, but let's say you're out of stock on the one with osmotic release mechanism and have the other one in stock, would you consider dispensing another 24-hour formulation or would you actually call a doctor on this?

So to recap, if no additional information is given on the prescription, would you, pharmacists, dispense:

- prednisolone sodium phosphate for the other formulation of prednisolone liquid?
-either form of doxy if only "doxycyline 100mg" is written
-which form of erythromycin for what directions given on the rx? ery-tab, base, enteric etc.

All of the above assuming there is no fill history of these medications for the patient.

Also, would you:

-substitute different release mechanisms of equal duration of action for diltiazem, if patient history shows they've been getting the one you don't have in stock? Would you call the doctor?

 

[Sparda29]

Look at the dosing accompanying the drug. That usually gives away which formulation is needed. Also, find out what it is being used for.

I rarely see the monohydrate version of doxycycline dispensed. For metoprolol, if it's being dosed BID or TID, it's the tartate since the succinate is dosed once daily normally.

 

[genesis09]

If nothing is said for doxycycline, most of the time we'll dispense doxycycline hyclate capsules.

 

[Qwerty Man]

prednisolone sodium phosphate- keep in fridge, not bitter, better compliance especially for kids

regular prednisolone-not in fridge, very bitter, poor compliance especially in kids


so i wouldn't change those two.

 

[gradintern]

prednisolone sodium phosphate- keep in fridge, not bitter, better compliance especially for kids

regular prednisolone-not in fridge, very bitter, poor compliance especially in kids


so i wouldn't change those two.

Thank you! Very valuable info. But if the prescription was written for prednisolone sodium phosphate and it wasn't in stock and the patient needed the medication that day, would it be ok to dispense the regular prednisolone instead and vice versa? They are roughly the same?

 

[daabc]

Doxycycline: Dispense monohydrate or hyclate?

Prednisolone liquid, could you dispense Prednisolone sodium phosphate?

Forms of erythromycin: I know there are differences in absorption, but which form do you dispense if prescription doesn't specify? Anyone have a good summary of the different forms and what's different about each?

Any other similar drug situations please feel free to post, such as metoprolol succinate being extended release and tartrate being immediate release is an example.

Thanks!

I think it depends on the pharmacist.

For the Doxy, most pharmacist just gives the hyclate caps, but some will call the md to clarify and document on EVERY single rx.

Prednisone, I was told that it needs clarification because children don't metabolize it correctly.

Erythromycin, I can never figure out and ask the pharmacist every time. How they decide, I don't really know.

Metoprolol, if the md didn't specify extended release, then its immediate release and they get tartrate. Unless he wrote for a wacky strength, then we clarify.

The diltiazem and bupropion, those get md calls a lot for clarification. Sometimes the nitrofurantoin macro too.

 

[npage148]

I will always call on a dilt/verapamil, metoprolol and wellbutrin. I've seen all forms dosed weird so many time.

Doxy has near 100% BA regardless of salt so I always pick the hycalate becasue it's in our script pro.

 

[phathead]

Look at the dosing accompanying the drug. That usually gives away which formulation is needed. Also, find out what it is being used for.

I rarely see the monohydrate version of doxycycline dispensed. For metoprolol, if it's being dosed BID or TID, it's the tartate since the succinate is dosed once daily normally.

Ding ding ding, we have a winner.

90% of the time you can determine what salt it is by simply reading the directions. Hell, most docs are too lazy to remember what salts are what in my experience.

Don't really see the need to bug them or go more in depth about it right away, a clarification can come later if needed.

That being said, I would not judge patient's history to determine what form they are on. I have seen people switch from Wellbutrin SR to XL and back to SR before. Not always the best choice there.

 

[diastole]

Also, there's the diltiazems: more than one 24-hour formulation, not interchangeable per the orange book, but let's say you're out of stock on the one with osmotic release mechanism and have the other one in stock, would you consider dispensing another 24-hour formulation or would you actually call a doctor on this?

Is this substitution even legal? I seem to remember from law that the pharmacist can't substitute unless it is interchangeable in the orange book. Is that true for all states or are the laws different on this in other places?

 

[gradintern]

Ding ding ding, we have a winner.

90% of the time you can determine what salt it is by simply reading the directions. Hell, most docs are too lazy to remember what salts are what in my experience.

Don't really see the need to bug them or go more in depth about it right away, a clarification can come later if needed.

That being said, I would not judge patient's history to determine what form they are on. I have seen people switch from Wellbutrin SR to XL and back to SR before. Not always the best choice there.

Does the dosing for the monohydrate differ from the hyclate?

 

[RPHTXRE]

If I had the choice, I would pick the cheapest one that has less side effects.

Why don't we organize pills by their color or their size? Jesus christ, I hope you grow up before you graduate...assuming you get that far.

 

[crazybob]

Why don't we organize pills by their color or their size? Jesus christ, I hope you grow up before you graduate...assuming you get that far.

Don't pharmacists tend to order from the cheapest manufacturer?

 

[Sparda29]

From Lexi Comp

Anthrax:

Inhalational (postexposure prophylaxis): Oral, I.V. (use oral route when possible): 100 mg every 12 hours for 60 days (MMWR, 2001, 50:889-93).

Cutaneous (treatment): Oral: 100 mg every 12 hours for 60 days. Note: In the presence of systemic involvement, extensive edema, lesions on head/neck, refer to I.V. dosing for treatment of inhalational/gastrointestinal/oropharyngeal anthrax

Inhalational/gastrointestinal/oropharyngeal (treatment): I.V.: Initial: 100 mg every 12 hours; switch to oral therapy when clinically appropriate; some recommend initial loading dose of 200 mg, followed by 100 mg every 8-12 hours (JAMA, 1997, 278:399-411).

Note: Initial treatment should include two or more agents predicted to be effective (per CDC recommendations). Agents suggested for use in conjunction with doxycycline or ciprofloxacin include rifampin, vancomycin, imipenem, penicillin, ampicillin, chloramphenicol, clindamycin, and clarithromycin. May switch to oral antimicrobial therapy when clinically appropriate. Continue combined therapy for 60 days.

Brucellosis: Oral: 100 mg twice daily for 6 weeks with rifampin or streptomycin

Chlamydial infections, uncomplicated: Oral: 100 mg twice daily for ≥7 days

Community-acquired pneumonia, bronchitis: Oral, I.V.: 100 mg twice daily

Endometritis, salpingitis, parametritis, or peritonitis: I.V.: 100 mg twice daily with cefoxitin 2 g every 6 hours for 4 days and for ≥48 hours after patient improves; then continue with oral therapy 100 mg twice daily to complete a 10- to 14-day course of therapy

Gonococcal infection, acute (PID) in combination with another antibiotic: I.V.: 100 mg every 12 hours until improved, followed by 100 mg orally twice daily to complete 14 days

Lyme disease, Q fever, or Tularemia: Oral: 100 mg twice daily for 14-21 days

Malaria prophylaxis: 100 mg/day. Start 1-2 days prior to travel to endemic area; continue daily during travel and for 4 weeks after leaving endemic area

Nongonococcal urethritis: Oral: 100 mg twice daily for 7 days

Periodontitis: Oral: 20 mg twice daily as an adjunct following scaling and root planing; may be administered for up to 9 months. Safety beyond 12 months of treatment and efficacy beyond 9 months of treatment have not been established.

Tickborne rickettsial disease: Oral, I.V.: 100 mg twice daily for 5-7 days; severe or complicated disease may require longer treatment; human granulocytotropic anaplasmosis (HGA) should be treated for 10-14 days

Rosacea: (Oracea™): Oral: 40 mg once daily in the morning

Sclerosing agent for pleural effusion injection (unlabeled use): Irrigation: 500 mg as a single dose in 30-50 mL of NS or SWFI

Syphilis:

Early syphilis: Oral, I.V.: 200 mg/day in divided doses for 14 days

Late syphilis: Oral, I.V.: 200 mg/day in divided doses for 28 days

Yersinia pestis (plague): Oral: 100 mg twice daily for 7 days

Vibrio cholerae: Oral: 300 mg as a single dose

From Pharmacist's Letter

RUMOR: Doxycycline MONOHYDRATE (Monodox) is better tolerated than doxycycline HYCLATE (Vibramycin).

TRUTH: There are two doxycycline oral solid dosage formulations on the market...doxycycline monohydrate (Monodox) and doxycycline hyclate (Vibramycin, Vibra-Tabs). Pharmacists often get prescriptions written for doxycycline with no specification of which formulation to dispense.

Both doxycyclines are equally effective. But some clinicians prefer the monohydrate salt because it dissolves slower in the stomach...potentially reducing GI effects.

But there is no proof that the monohydrate version is better tolerated...and it's more expensive.

Plus the bioavailability of doxycyline monohydrate may be lower at a high pH. This might be clinically significant in patients on long-term acid suppressive therapy...or those with gastrectomy or gastric bypass surgery.

Recommend using doxycycline hyclate in most cases. Tell patients to take it with food or milk if stomach irritation occurs. Also emphasize the importance of drinking a full glass of water and not lying down right after taking doxycycline to reduce the risk of esophageal irritation.

Keep in mind that you'll need to call the prescriber to substitute one form for the other. The two forms are not generic equivalents...despite their similarities.


Hide References
Bogardus JB, Blackwood RK Jr. Dissolution rates of doxycycline free base and hydrochloride salts. J Pharm Sci 1979;68:1183-4.

Saivin S, Houin G. Clinical pharmacokinetics of doxycycline and minocycline. Clin Pharmacokinet 1988;15:355.

Evaluation of a new antibacterial agent. Doxycycline monohydrate and doxycycline hyclate (Vibramycin). JAMA 1969;209:549.

Grahnen A, Olsson B, Johansson G, Eckernas SA. Doxycycline carrageenate - an improved formulation providing more reliable absorption and plasma concentrations at high gastric pH than doxycycline monohydrate. Eur J Clin Pharmacol 1994;46:143.

 

[rxlea]

Why don't we organize pills by their color or their size? Jesus christ, I hope you grow up before you graduate...assuming you get that far.

Was there a point to this comment?

 

[rxlea]

From Lexi Comp



From Pharmacist's Letter

Thank you, Sparda. Do you have a gif for that?

 

[gradintern]

From Lexi Comp



From Pharmacist's Letter

Thank you!! That info from Pharmacist's Letter is exactly what I needed . I'll do a search there for the prednisolone and erythromycin, but if anyone has similar info for those two drugs, please share!

 

[MindOverMatter]

Pharmacist's Letter is seriously one of the best no-nonsense resources out there.

 

[jmsnyc]

So as a patient, I was given a script for Doxycycline 100mg BID without specifying Monohydrate or Hyclate. At the Sam's Club pharmacy, Doxycycline MonoHydrate is on their list of discounted prescriptions for plus members (which I am) as $10 for 30 pills, Hyclate was not, however with my insurance copay was $15. When I got it filled I was not aware of the difference and I asked the pharmacist to check if it is on the plus list before using my insurance. He said it was not and dispensed the Hyclate. I then looked at the list and noticed the MonoHydrate and googled the difference, and most what I found is that MonoHydrate is easier on the stomach so I wanted that especially since it is generally more expensive but as a Plus member it was cheaper. The pharmacist claimed that if Monohydrate is not specified he must dispense Hyclate or he could lose his license. I asked him to call my physician but it was too late in the day on a Friday and I would have had to wait until Monday to start my antibiotic regimen. Nevertheless, I doubted his claim that he could not dispense the Monohydrate if the script is written for Doxycycline. This is in the state of Georgia.

 

[Sine Cura]

Technically "doxycycline" unspecified is ambiguous because there are two commercially available forms of doxycycline, the hydrated free base ("monohydrate") and the hydrochloride hemiethanolate hemihydrate form (hyclate). There is no anhydrous doxycycline commercially available either.

To say "doxycycline" unspecified must be hyclate is wrong. This is not like amlodipine where there is only one "crystal" form.

 

[ldiot]

So as a patient, I was given a script for Doxycycline 100mg BID without specifying Monohydrate or Hyclate. At the Sam's Club pharmacy, Doxycycline MonoHydrate is on their list of discounted prescriptions for plus members (which I am) as $10 for 30 pills, Hyclate was not, however with my insurance copay was $15. When I got it filled I was not aware of the difference and I asked the pharmacist to check if it is on the plus list before using my insurance. He said it was not and dispensed the Hyclate. I then looked at the list and noticed the MonoHydrate and googled the difference, and most what I found is that MonoHydrate is easier on the stomach so I wanted that especially since it is generally more expensive but as a Plus member it was cheaper. The pharmacist claimed that if Monohydrate is not specified he must dispense Hyclate or he could lose his license. I asked him to call my physician but it was too late in the day on a Friday and I would have had to wait until Monday to start my antibiotic regimen. Nevertheless, I doubted his claim that he could not dispense the Monohydrate if the script is written for Doxycycline. This is in the state of Georgia.

Monohydrate is just absorbed slower, many people assume that because it is absorbed slower that it is easier on the stomach but in reality this hasn't been proven. Both are equally effective and there is no reason to delay treatment over 5 dollars.

 

[waiter]

Monohydrate usually less expensive.
Metoprolol needs to be clarified.

 

[ldiot]

Monohydrate usually less expensive.
Metoprolol needs to be clarified.

So I know that Orapred tastes better and Prelone contains alcohol and tastes worse... so where does prednisolone sodium phosphate come into the picture? Is one of them or both of them prednisolone sodium phosphate or is that a different one all together?

 

[Sine Cura]

Orapred is prednisolone sodium phosphate

 

[HelpfulPharmer1]

So I know that Orapred tastes better and Prelone contains alcohol and tastes worse... so where does prednisolone sodium phosphate come into the picture? Is one of them or both of them prednisolone sodium phosphate or is that a different one all together?

For technical comparison:
Source: Facts Comparison as of 03-2017:
Orapred = PrednisoLONE sodium phosphate
(15 mg/5 mL Oral Solution)
Orapred oral solution contains fructose.

Prelone = PrednisoLONE base
(15 mg/5 mL Oral Syrup)
Prelone oral syrup contains sucrose.

In reality, Orapred which is PrednisoLONE sodium phosphate is prefered because it has better taste and causes less nausea vomiting (based on study published by NIH).

"
RESULTS:
During the study period, 211 eligible children were enrolled, of whom 23 were excluded. Of the remaining 188 subjects, 96 received generic prednisolone and 92 received Orapred. All baseline characteristics were similar in both groups. In the generic prednisolone group, 17 (17.7%) children vomited compared with 5 (5.4%) in the Orapred group (RR = 3.26, 95% CI, 1.25, 8.47). Taste scores were obtained from 18 children in the generic prednisolone group and from 19 children in the Orapred group. The median taste score was 2 for the generic prednisolone group and 4 for the Orapred group (Delta = -2.0, 95% CI, -3.0, -1.0) (P = 0.0001).

CONCLUSIONS:
In our study population, Orapred was associated with a significant less incidence of vomiting and better taste score compared to the generic prednisolone."
Source: https://www.ncbi.nlm.nih.gov/pubmed/16801838

But, if any patient demands BRAND ORAPRED, sorry, BRAND ORAPRED was discontinued in 2014 along with BRAND PRELONE.
(Source: Fact & Comparisons)

So, for 15 mg / 5 ml, we only have generics:
PrednisoLONE sodium phosphate
or
PrednisoLONE

 

[ldiot]

For technical comparison:
Source: Facts Comparison as of 03-2017:
Orapred = PrednisoLONE sodium phosphate
(15 mg/5 mL Oral Solution)
Orapred oral solution contains fructose.

Prelone = PrednisoLONE base
(15 mg/5 mL Oral Syrup)
Prelone oral syrup contains sucrose.

In reality, Orapred which is PrednisoLONE sodium phosphate is prefered because it has better taste and causes less nausea vomiting (based on study published by NIH).

"
RESULTS:
During the study period, 211 eligible children were enrolled, of whom 23 were excluded. Of the remaining 188 subjects, 96 received generic prednisolone and 92 received Orapred. All baseline characteristics were similar in both groups. In the generic prednisolone group, 17 (17.7%) children vomited compared with 5 (5.4%) in the Orapred group (RR = 3.26, 95% CI, 1.25, 8.47). Taste scores were obtained from 18 children in the generic prednisolone group and from 19 children in the Orapred group. The median taste score was 2 for the generic prednisolone group and 4 for the Orapred group (Delta = -2.0, 95% CI, -3.0, -1.0) (P = 0.0001).

CONCLUSIONS:
In our study population, Orapred was associated with a significant less incidence of vomiting and better taste score compared to the generic prednisolone."
Source: https://www.ncbi.nlm.nih.gov/pubmed/16801838

But, if any patient demands BRAND ORAPRED, sorry, BRAND ORAPRED was discontinued in 2014 along with BRAND PRELONE.
(Source: Fact & Comparisons)

So, for 15 mg / 5 ml, we only have generics:
PrednisoLONE sodium phosphate
or
PrednisoLONE

Thanks for the info! So all in all you would just dispense Orapred if the script just said "presnisolone 15mg/5ml"?

Although Orapred might not taste as bad it still smells absolutely terrible; I was filling one today and that's nasty stuff lol.