What to do when prescriber won't budge on dose/drug?

[Pharmacy Kid]

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Pt (>60yo female) comes in with discharge medication orders. There are several meds including 2 blood pressure meds. Amlodipine 10mg TWO tablets daily and clonidine 0.1mg one tablet bid. Previously she was only on amlodipine 10mg one tablet daily as her BP regimen.

Pharmacist doesn't remember the reason for her hospital stay. However, her BP readings in the past month in outpatient clinic were in the 160's/100's. I first tried to find evidence that up to amlodipine 20mg daily can be used, but couldn't. Then the pharmacist called that physician saying 10mg is the max rec'd dose and if he wanted to add another BP med (lisinopril or HCTZ or anything) instead of increasing amlodipine from 10mg to 20mg. He wouldn't change anything.

So do you just document and fill it? If you don't fill it, and pt gets MI/stroke in between now and time they get seen by regular provider, it's on you. If you do fill it and pt gets bad side effect, it's kind of on the physician, right?

 

[JoBreeze]

Would you really consider refusing in this situation given only the information posted?

 

[All4MyDaughter]

Document well, and then dispense.

 

[PumpkinSmasher]

Pt (>60yo female) comes in with discharge medication orders. There are several meds including 2 blood pressure meds. Amlodipine 10mg TWO tablets daily and clonidine 0.1mg one tablet bid. Previously she was only on amlodipine 10mg one tablet daily as her BP regimen.

Pharmacist doesn't remember the reason for her hospital stay. However, her BP readings in the past month in outpatient clinic were in the 160's/100's. I first tried to find evidence that up to amlodipine 20mg daily can be used, but couldn't. Then the pharmacist called that physician saying 10mg is the max rec'd dose and if he wanted to add another BP med (lisinopril or HCTZ or anything) instead of increasing amlodipine from 10mg to 20mg. He wouldn't change anything.

So do you just document and fill it? If you don't fill it, and pt gets MI/stroke in between now and time they get seen by regular provider, it's on you. If you do fill it and pt gets bad side effect, it's kind of on the physician, right?

Anecdotally in less than 5 patients, I have seen noted BP reduction with amlodipine 15mg and 20mg.

You have the professional right to refuse to fill a medication but this instance does not seem like an appropriate time to refuse to fill at all. Do you believe the 20mg is going to harm the patient?

 

[Rockinacoustic]

I had an instance like this the other day. I documented on the hard copy, told the patient's caretakers what side effects (or lack of effect in this case) to watch for, and moved on.

 

[MackandBlues]

I've seen then do amlodipine 10 mg bid tons of times.

 

[Praziquantel86]

Amlodipine 20mg is not something that should keep you up at night.

 

[xiphoid2010]

Amlodipine 20mg is not something that should keep you up at night.

+ 1. Document and move on. There are bigger fish to fry.

 

[confettiflyer]

Amlodipine 20mg is not something that should keep you up at night.

+2, document and move on...i'd spend 30 seconds on this tops, unless i had a student to do all the digging and contact for me.

 

[rph3664]

I've seen amlodipine 20mg daily, whether 20 qd or 10 bid, many times. I wouldn't be too concerned, especially because the patient is also taking clonidine which is NOT a first-line BP agent.

 

[Pharmacy Kid]

In case anyone wanted to know, it was documented and filled.

 

[Sparda29]

+2, document and move on...i'd spend 30 seconds on this tops, unless i had a student to do all the digging and contact for me.

+3

 

[Digsbe]

I was a tech when a situation like this happened. A pediatrician had written an extremely high dose for amox suspension for a little girl to treat an ear infection (the pharmacist said by weight dosing it would be appropriate for a 400lb man). The pharmacist called the pediatrician and alerted her about the dangerously high dose. The pediatrician had an attitude and refused to change so the pharmacist documented on the script that she had called the physician and filled the script (she said documenting would protect her from some liability knowing that she had alerted the pediatrician of the possible danger). The next day the child had a reaction to the high dose and was swapped to ear drops like the pharmacist originally recommended.

To my knowledge there was no legal or malpractice repercussion against my pharmacist, although I'm unsure if the patient went on to sue the pediatrician for malpractice. If I ever work in retail I would probably call prescribers and document things unless I was fairly certain that the patient's health would be seriously compromised. If I felt that a patient's health would be seriously compromised I will refuse to fill and I would tell the patient about my concerns.

 

[Beacon]

Document, then fill.

 

[rx2010]

For norvasc, I would document, fill, counsel and move on. If it's something I obviously know is dangerously high that can harm the patient and physician still insisted on giving it, I would not fill it and explain to the patient why and recommend they get a second physician's opinion.