Merck and Schering-Plough are in bed together, again. (One wonders if a merger will be the climax of their collaborations somewhere down the line?) This time it’s their new combination of loratadine (Claritin) and montelukast (Singulair) which was accepted for review by the FDA on August 28. In my opinion, it’s only a matter of time before the two companies are given the green light to start selling it.

This combo is not unlike their Vytorin arrangement, which is actually a pretty decent combination both therapeutically and financially: Vytorin is no more expensive than Zetia by itself, which makes it a good deal for consumers and insurers alike. (And there’s also the more mundane fact that there’s one less pill to take, and the fact that ezetimibe is of questionable value when prescribed alone.)

Because Claritin is now OTC, it is simultaneously more and less valuable to Schering-Plough. Less valuable because you can’t charge as much for it as you could when it was Rx-only because no one would buy it — and more valuable because you’ve got a potential market limited only by the number of people in the United States. I know I recommend (generic) Claritin pretty regularly. It works well for most people, myself included.

If the pricing is done following in the footsteps of Vytorin — which I suspect it will be — it’ll be a nice little niche drug for the two companies, and it’ll save consumers money, if not insurers. I don’t ever see it being a blockbuster like Vytorin, for obvious reasons.

The inobvious

One thing struck me about this deal after some thought, and it’s the new reciprocity between the two companies: Vytorin is inherently more valuable to Schering-Plough because their drug ezetimibe (Zetia) is still protected by patent, whereas Merck’s contribution — simvastatin — is not. With this new drug, the roles will be reversed. I don’t know what this means in terms of dollars and cents, but Merck’s got to be breathing a bit easier now that they’re on more equal footing with their partner.

[tags]Merck, Schering-Plough, Claritin, Singulair[/tags]

Novartis has gotten their pointless direct renin inhibitor approved by the European equivalent of the FDA.

How utterly snooze-worthy. Now you Europeans can waste your tax dollars money on the drug, too! Hooray!

Bonus Tekturna story:

Doctor writes a prescription for Tekturna for one of his patients. (One of our drug delivery guys, actually.) Gives him a free sample card, even though he doesn’t have insurance and thinks he’s doing him a favor. He gets 30 Tekturna for free, and the next month rolls around. That’ll be $100, please, even with the employee discount I gave him because he amuses me.

He almost shit a brick.

Remember, folks: giving patients a FREE SAMPLE is great, but it’s a complete WASTE OF EVERYONE’S TIME if they are without insurance or if their insurance doesn’t cover it.

Mr. Delivery Guy comes back a week later with a prescription for lisinopril, after I write him a note to give to his bonehead physician.

Sometimes I wonder…

[tags]Tekturna, aliskiren, Rasilez[/tags]

Just in case you need your isoniazid fix:

Seriously, WTF?

Scenario: Person calls up to see if their doctor has responded to the refill request that was sent the day before. We’re going on 24 hours and still we’ve not heard back from the prescriber. (Oh, the horror!)

That first phonecall is okay. But then there’s the second. And the third. And sometimes the eighth.

“WHY HASN’T MY DOCTOR CALLED YOU YET??”

How in the seven hells should I know, lady? Yes, it is almost invariably women that ask this question; men, in general, seem to be more interesting in getting to the root of the problem than complaining about it. (Insert off-topic discussion about gender differences here.)

I DO know one thing, though. If you’ve called us twice, and your doctor hasn’t gotten back to us, and it’s been 24 hours, and oh my god you will absolutely die if you don’t get your simvastatin five minutes ago, you need to start calling the right person. The gatekeeper. The person who — hold onto your socks now — writes your bloody prescription.

I am not your goddamn therapist.

I don’t understand the mental disconnect between dialing the pharmacy versus dialing the doctor’s office. Is it because you’re calling a retail establishment where someone actually answers the phone? Somehow I think the answer is YES. In the last two days, I have waited on hold with a doctor’s office for 10 minutes or longer six times. One of those times was actually 23 minutes(!).

But back to consumer idiocy for a moment: Pharmacies are not required to do refill requests for you. There’s no law saying “Pharmacist must request refills for patient upon request.” It’s just something that’s done as a service to remain competitive with the other retail pharmacy outlets. Way back in the day — before unlimited long-distance phone service — many pharmacies would add the price of that telephone call into the cost of the prescription. Back before there were third parties. The average person would shit a brick today if that was done. (Back in the Good Ol’ Days, there was also the Asshole Tax, which I’d like to reinstate for the habitual offenders.)

Newsflash: the pharmacist doesn’t decide whether or not to refill a prescription — we’d LOVE to fill it for you because you’re being a pain in the ass, and it’ll get you off our back. Not to mention that mo’ scripts = mo’ money. Maybe sometime down the road, when s/he has access to complete medical records and lab results, a one-time refill ability will be within the pharmacist’s scope of practice. But as of now, it’s not.

So why don’t you go bother the person with that authority?

And incidentally, if you’re a provider, I’m not particularly interested in why your customers — yes, customers — wait on hold for eons before they get to talk to someone. I don’t care how busy you are. I don’t care how busy your office staff are. I don’t care that it takes you an hour to get a diagnostic test approved. I don’t care that your reimbursement rates are declining, and gee wouldn’t it be nice if you could bill for time wasted on the friggin telephone.*

I AM interested in not being the cathartic outlet for your patients’ frustration at you and your office’s inadequacy.

…I totally just went there, didn’t I? Feel free to vent your frustrations at and about pharmacists and pharmacies in the comments — and yes, this post was very cathartic. You know I still love all of you.

* Actually, I do care quite a bit about that. Just not within this context.

That’s not a phrase you want to hear a doctor say when you call up and ask if he really wanted $random-obscure-drug-that-no-one-has-ever-heard-of after he’s sent an e-prescription over to you from his fancy-schmancy new EMR. You know, the EMR that lists every single drug ever made from the beginning of time up until now, regardless of whether or not that drug still exists, and doesn’t use any sort of Bayesian analysis — yes, the same technology that sorts your email — to suggest your drug of choice based on past prescribing habits, or to sort drugs based on their probability of usage or (Heaven forbid!) to suggest that just MAYBE, doctor, you really wanted something else when you picked that whacko drug from the drop-down box.

So anyway, the bogus prescription was for extended-release lovastatin. Yeah, it really does exist, but hilariously enough, the prescribing doctor had never heard of it. And neither had the pharmacist, thankfully, because she might have ordered it, and then the patient would have gotten the wrong medication.

Christ, people. Proofread your goddamn prescriptions. To make sure that gibberish that your EMR spits out is REALLY what you want. And that you’ve actually heard of the drug you are prescribing. It ain’t rocket science, and even if it were, I’m sure you’d be equal to the task.

Yeah, yeah. We all make mistakes. Proofreading a friggin’ prescription shouldn’t be one of them. But yet, somehow, I see anywhere from 4-20 crap prescriptions Every. Single. Day. All because they weren’t proof-read before they were handed to the patient or sent to the pharmacy.

What’s the most fun part of all this is that when you get the doctor on the line, he cops an attitude because he thinks he’s the Second Coming of Christ even though he’s the bonehead who made the mistake. Get over yourself, dude. <Internet toughguy>I swear, one of these days, I’m going to drive to a doctor’s office and put my foot up someone’s ass.</Internet toughguy>

No, I don’t hate my job, but I do hate people sometimes. It gets tiresome saving other people’s bacon when all you get is grief for your troubles. Grief from the patient because the prescription took more than 30 seconds to fill (“Well, can you just fill it anyway?”), and grief from the doctor because you deigned to bother him.

And no, not all doctors are like this. Many of them are awesome, nice people. But just as the vocal minority often gives the silent majority a bad name, the types of doctors that are most likely to come to the phone themselves are the ones who want to pick a fight. And they often do everything in their power to make you feel like a piece of shit, even when they are in the wrong. Needless to say, that does neither themselves, nor their profession any favors. The same holds true for bad behavior no matter who you are, or what you do.

In the last couple of weeks, I’ve seen quite a few errors since Toprol XL has gone generic. Usually it’s because prescribers are writing “Metoprolol Succ Xmg” (Or some repetitive bastardization thereof compliments of your friendly EMR which formats prescriptions in bizarre ways.)

Most of the people doing data entry are not pharmacists. They are technicians. And when they see “metoprolol” they immediately pick generic Lopressor, because that is what they are accustomed to. They don’t know that there’s a difference between succinate and tartrate, and if they do know there’s a difference, they don’t know what it means. Most of the time, if this error is made, it is caught by the checking pharmacist. But due to the sheer volume of Toprol scripts dispensed every day, some still slip through the cracks.

I know it’s fun to start writing generic names when generics become available. When Zestril went generic, you all started writing lisinopril. Same for gabapentin and every other generic drug on the planet, I’m sure.

But please don’t do this with Toprol. We’re all on the same team, here, and the goal is to minimize errors regardless of who is technically at fault. And I can guarantee that it will minimize prescribing errors when those refill requests start coming in, and your office staff start leaving incorrect or incomplete voicemails, because they got it wrong, too. ;)

Thank-you.

Remember candy cigarettes? Those sticks of gum done up to look like smokes with a red tip, and the puff of some sort of powder when you blew through it once?

Man those used to make me want to smoke so badly when I was a kid. No joking, either. I couldn’t wait to be old enough to puff on a “real” smoke like all the kids that I thought were cool.

Then the candy cigarettes all but disappeared — I stopped seeing them in stores, and I assumed that they were outlawed as part of the ongoing war against cigarette advertising. But I guess I was just looking in the wrong places. This past weekend I went to an ice cream shop done up in 1950s style with some friends. Lo and behold! Candy cigarettes! “WTF?” I said. “I thought these things were taken off the market!” I haven’t been this excited about candy since my Valium necklace.

(They also had some big-league chew, which I’ve not seen in a while, either. Big league chew never got me interested in dip, for what that’s worth.)

Unfortunately, I didn’t have any cash on me, so I couldn’t buy ’em, but I did open the pack, and they looked decidedly less appetizing than they used to. Amazing what time and experience will do…

For nostalgia’s sake, you can still get candy cigarettes pretty easily. Amazon will happily sell you a wide variety, for example, and they’ve also got Big League Chew. (Actually, I think the only things Amazon doesn’t sell are cars and houses, but that’s what eBay is for.)

Somewhat off-topic: this page is an interesting run-down of the various candy cigarettes over the years and in various parts of the world. I think the type I used to chew as a kid were mostly Mustangs — since re-branded to “Stallions” because RJ Reynolds was too short-sighted to recognize that another company was doing their marketing for them.

In any case, my mom used to be deathly afraid of me getting candy cigarettes for fear that it would lead me to smoking. So I used to have to do it discreetly. I think that added to the allure of both candy cigarettes and smoking in general.

The title of this blog post comes from Family Guy, Season 3, Episode 3 from Baby Smokes a Lot: “Hehe! Tastes like happy!” — which I would upload to share because it’s hilarious and oh so wrong… if only I could find an easy way to export Ogg Media Video files to a more web-friendly format. Argh!

[tags]Candy cigarettes, big league chew, nostalgia[/tags]

Last night I had a prescription that said “2 qd” — it was a phoned-in prescription. I filled it, thinking nothing of it, and low and behold I see it has been edited to some different directions. “WTF?” I say to myself, pulling out the hard copy. Nope, it definitely says “Π qd” (That’s as close to a Unicode approximation to the symbol for 2 that I can come up with.)

“Um, so why did you change this?” I ask, handing the QA pharmacist the hard copy and the edited label.

“Because it was wrong,” she says.

“No, it wasn’t,” I say, handing over the script written by her hand. “2 qd means ‘2 tablets once daily’.”

“You don’t know that,” she says. “What if the doctor means take 1 tablet in the morning and 1 tablet 4 hours later, or 1 tablet twice a day?”

“Well then the doctor should write that.”

“Sometimes they don’t.”

“I see. *pause* I was always taught that 2 qd means ‘2 tablets once daily’ and if the doctor wants twice daily dosing, the script should say ‘BID’ otherwise the doctor — not the pharmacist — has made a mistake. And that 2 qd absolutely means 2 tablets/capsules/whatever once daily, with no ambiguity.”

“Well, I like to put ‘Take 2 tablets every day as directed.'”

We argued a bit after that, but the trouble with sticking “as directed” on there is a nifty way of a pharmacist doing a little CYA, which isn’t necessarily a bad thing. The script technically doesn’t say it, and generally speaking, the patient hasn’t been “directed” in how to do anything, so it’s actually not correct to do that. What if the script is for meloxicam or nabumetone?

To aid in the discussion, here’s a brief Latin recap for those that have forgotten it, or never learned what the abbreviations actually meant in the first place. Unfortunately, they’re not much help, either:

• q: quaque: “every”
• qd: quaque die: “every day” which is generally understood to be “once a day” or “once daily”
• qX°: every X hours
• po: per os: “by mouth”
• od/os/ou: oculus dexter (“right eye”); oculus sinister (“left eye”); oculus uterque (“both eyes”)

And so on.

For me, I will continue to write “Take 2 tablets once daily” when I see “2 qd”. But to others, that means something different, and I think it’s important that prescribers know that that it means something different to each pharmacist. I mentioned this phenomenon in my Chantix prescribing tutorial, and it applies here as well. There is indeed ambiguity, where there should ideally be none.

And it so happens that this presents the perfect opportunity to test out my new polling toy. So I’ve included 2(!) polls for finer-grained results. We’ll pretend we’re dealing with tablets for the sake of simplicity. If you are not in the medical field, please vote “Other medical personnel”. The poll will open a new window for each poll which is annoying, but there doesn’t seem to be a way around this. And feel free to elaborate in the comments — I really had no idea until yesterday that this was something not everyone agreed on.

I think probably the first “real” counseling point any pharmacy student learns is “Don’t drink alcohol with Flagyl!” If it’s not the first thing, it’s easily the second or third. In fact, I’ve seen this hand-written on prescription labels for added emphasis, even though the auxiliary labels that print out already say it. You don’t often see “Take with food” hand-written, even though it would probably provide more real-world benefit to the patient than the standard “Don’t drink alcohol” mantra.

“Heresy!” you shout. Well, hear me out…

You see, there’s almost no data to support the assertion that alcohol and metronidazole combine to create a disulfiram-like reaction. It’s crazy, I know. How could this age-old advice be wrong? The reason this is drilled into pharmacy and med students’ heads is because the conventional wisdom is old. It got here because “everyone knows” that ethanol + metronidazole = A Bad Time. Even though there’s no meaningful evidence to support this conclusion.

Regular readers know my distaste (hah!) for metronidazole. In fact, I missed out on my best friend’s 21st birthday drunkfestcelebration because of it. As it turns out, I missed out for naught. Alas.

Exhibit A is a meta-analysis of published anecdotes, “Do Ethanol and Metronidazole Interact to Produce a Disulfiram-Like Reaction” published in The Annals of Pharmacotherapy. Exhibit B is a double-blind, placebo-controlled study out of Finland, also published in TAOP entitled “Lack of Disulfiram-Like Reaction with Metronidazole and Ethanol” which is a bit more science-y and a little less meta-analysis-y.

This is a long entry, so here’s a ToC.

1. Bits and bobs from Exhibit A
2. Bits and bobs from Exhibit B
3. Final thoughts

Continue reading Alcohol and Flagyl = disulfiram rxn? Where’re the data, dood?! →