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?! →

I’ve idly wondered from time to time how serodiscordant couples maintained a relationship, and how they have children. You see them at the pharmacy, and you know one of them is HIV+ and the other is not, so it does get you thinking. Especially when they have kids.

Wonder no more. Medscape and Viread to the rescue!

All of the couples in the study wanted to have children; the men were already taking antiretrovirals that suppressed their serum HIV below the detectable level.

To further reduce the risk of infection in the female partners, the researchers gave each of them two doses of tenofovir, one to be taken 36 hours before intercourse and another 12 hours before.

After each of the couples had made three attempts, 11 of the 21 couples had conceived, Dr. Vernazza said, and after 10 attempts, 15 were pregnant. These are substantially higher rates than might be expected with artificial reproduction, Vernazza said.

All the women in the study tested negative for HIV, 3 months after the last exposure, the researchers report. “The risk of transmission in a couple with a fully treated male partner is low and can further be reduced by timed intercourse and a short pre-exposure prophylaxis with tenofovir,” Dr. Vernazza said.

[…]

“Persuasion of the patients might sometimes be a problem, in which case we still offer them in vitro fertilization (with sperm washing),” he said. “But in general, an hour to explain all the data is enough.”

An hour, eh? I wonder if there’s a billing code for that?

[tags]HIV, AIDS, conception, tenofovir, Viread[/tags]

This has nothing to do with medicine, and at last count, the F-word is used 22 times in the space of one paragraph. And probably another 22 times outside that paragraph. If that bothers you, go no further.

Continue reading Vespula maculifrons can kiss my arse. Err… →

This is Oscar.

Oscar predicts — with 100% accuracy so far — when people are going to die. The following excerpt is from the NEJM essay mentioned in the AP article, for those who don’t have access.

Oscar takes no notice of the woman and leaps up onto the bed. He surveys Mrs. T. She is clearly in the terminal phase of illness, and her breathing is labored. Oscar’s examination is interrupted by a nurse, who walks in to ask the daughter whether Mrs. T. is uncomfortable and needs more morphine. The daughter shakes her head, and the nurse retreats. Oscar returns to his work. He sniffs the air, gives Mrs. T. one final look, then jumps off the bed and quickly leaves the room. Not today.

Making his way back up the hallway, Oscar arrives at Room 313. The door is open, and he proceeds inside. Mrs. K. is resting peacefully in her bed, her breathing steady but shallow. She is surrounded by photographs of her grandchildren and one from her wedding day. Despite these keepsakes, she is alone. Oscar jumps onto her bed and again sniffs the air. He pauses to consider the situation, and then turns around twice before curling up beside Mrs. K.

One hour passes. Oscar waits. A nurse walks into the room to check on her patient. She pauses to note Oscar’s presence. Concerned, she hurriedly leaves the room and returns to her desk. She grabs Mrs. K.’s chart off the medical-records rack and begins to make phone calls.

Within a half hour the family starts to arrive. Chairs are brought into the room, where the relatives begin their vigil. The priest is called to deliver last rites. And still, Oscar has not budged, instead purring and gently nuzzling Mrs. K. A young grandson asks his mother, “What is the cat doing here?” The mother, fighting back tears, tells him, “He is here to help Grandma get to heaven.” Thirty minutes later, Mrs. K. takes her last earthly breath. With this, Oscar sits up, looks around, then departs the room so quietly that the grieving family barely notices.

I think if I were dying, it might be nice to have an animal next to me. Even if I wasn’t aware of it. Oscar has a plaque dedicated to him, as well, “For his compassionate hospice care, this plaque is awarded to Oscar the Cat.”

Note: Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families. Oscar has also provided companionship to those who would otherwise have died alone. For his work, he is highly regarded by the physicians and staff at Steere House and by the families of the residents whom he serves.

That’s pretty amazing.

And it seems that I Can Has Cheezburger? has made a LOLCAT out of him.

“Hello, may I help you?”

“Hello… my boyfriend is a heroin addict.”

Not exactly the sort of greeting one expects after picking up the telephone.

“OK.”

“Yeah, I was wondering if you could sell him like one needle. I’m worried about him and I don’t want him to get AIDS or something like that.”

“Um, well, we can’t sell you just one syringe. They come in packs of 10. I don’t have any way of selling you just one.”

“Oh. Really.”

“Yeah, I’m sorry.”

“Well, how much are they?”

“They’re about $2.50 or so for ten.”

“Oh. He can’t afford that.” At this point I’m thinking WHAT THE HELL? You can buy HEROIN but you can’t afford $2.50 for some freakin’ syringes?!?! Think of it as an investment in the future, FFS!

“Yeah. I’m sorry. I wish I could help you.” Where help doesn’t necessarily mean “Get you a needle so your SO can shoot up.”

“Well… Do you know where I can get him one?”

“Um, you could try a hospital. Maybe they can give you one.”

“Oh!” she says brightly. “I’ll try that. Thanks!”

*click*

It seems that Massachusetts does not have a clean needle program, and I’m fairly certain that NH doesn’t either, since hypodermic needles require a prescription in that state. I guess she really was SOL. I wonder what happened.

Regular readers already know my feelings about selling needles OTC.

While working in an affluent town the other day — not my normal pharmacy stomping grounds — I was in a pretty good mood. When I’m happy, I get talkative, particularly if I’m somewhat caffeinated, which I was.

Anyway, I rang someone out. Their script was for Imitrex. Since I had done the whole thing from start to finish, I looked at her profile like I always do. (Contrary to popular belief, filling a prescription is NOT a passive activity.) 9x50mg tablets about once every two months. Less than your normal Imitrex user.

She was a nice woman, and (what I assume was) her SO seemed pretty cool, so we were chatting at the register. For some reason, I saw fit to tell this woman that if you take enough Imitrex, your blood will turn green, as it is a bisphosphonate. Useless trivia that I thought was pretty cool. (Cyanosis brought on by sulfhemoglobinemia, where a sulfur atom takes the place of a carbon atom in normal hemoglobin. How green? I don’t know, because I’ve never seen it — though I’d really like to find a picture.)

As soon as I told her, I saw fear come in her eyes, and I knew I had made a mistake. I assured her that this would never happen to her, and that you’d have to be taking huge doses for a long time, but I could see it didn’t matter. The damage was done.

Next time I’ll just keep my mouth shut about what I think is awesome, and useless. I wince every time I think about the conversation. Why did I have to mention this? Why? It served no purpose.

Errors in judgment can be just as damaging as a “technical” error like dispensing the wrong drug.

A woman came up to the counter yesterday to ask about Robitussin as fertility aid. I was at the other end of the counter doing God knows what, but got called over when the pharmacist I was working with didn’t know the answer. Her friend had told her that Robitussin could help her conceive, and she had “read on the Internet” — a statement that always makes me cringe — that this was indeed possible. (This is probably the page she read, btw.)

But she couldn’t remember which type of Robitussin her friend told get, and needed our help.

The pharmacist pulled an answer out of his ass and made it sound really good. Turns out it was the right one. Guaifenesin, of course, thins mucus and he suggested that it might also thin the cervical mucus, allowing sperm to more easily penetrate. Seems this is, in fact, the idea behind using it to aid in fertility.

There is a small body of published literature that supports its use. One article (PDF) from Fertility and Sterility, published in 1982 stands out:

Couples with infertility should not use vaginal lubricants, which can impair sperm motility and activity. Twenty-three out of 40 females taking guaifenesin (200 mg orally three times a day) from day 5 to the day of BBT rise demonstrated improved cervical mucus quality, and 15 out of 23 couples conceived.

A second study published in 1991 (PDF). These findings are only relevant in the case where cervical mucus is abnormal, and can’t be applied outside of this context. I’m not a fan of taking OTC or prescription meds willy-nilly, even if it is “only” Robitussin. Especially if the reason is because a friend told you so, or you “read it on the Internet”.

Talk to your doctor, naturally. But I thought it was pretty interesting. But talk about off-label usage!

Everyone has their own preferred method of dealing with forged prescriptions. Ryan at EclecticEsoteric recently asked what I would do. It so happens that Andrew at PharmCountry has a related post, so it seems an opportune time…

When you’ve got a forged or altered prescription, there are two basic things you SHOULD do.

1) Contact the prescriber. Verify that it has been forged or altered.
2) Initiate a PharmAlert, the details of which can be obtained by contacting your state’s board of pharmacy. I believe this is how such an alert is usually initiated anyway — I’d say “always” but I haven’t worked in every state, so that’s impossible for me to know.

PharmAlerts start a cascading reaction. A notice is typically faxed to the pharmacy at the top of the list in your area, and they, in turn, fax to other pharmacies who fax to other pharmacies. You are also supposed to pick up the telephone, and notify the pharmacist at the receiving pharmacy as well, but we rarely do. I should take a picture of the PharmAlert notification map for my area. It’s kind of nifty because one of my stores is #1 on the list. If I had to guess, I would say that the seed pharmacies at the top of the lists are probably chosen that way because they are lower volume, and it’s thought that they have more time to seed the word along? I have nothing to back this up, I’m only guessing. We are responsible for notifying three pharmacies, whereas everyone lower on the list than us is only responsible for one.

Doctors’ offices can also initiate pharmalerts, and often do if a prescription pad is stolen.

There are a couple of things you COULD do beyond these two steps, depending on how crazy you want to be. These include contacting the police, the DEA, and anyone else you might want to contact. It all depends on how zealous you want to be. Me? I don’t bother because I don’t particularly want to be a law enforcement officer. If I did, I’d work for the DEA. Some pharmacists also take the opportunity to lecture the person about altering a prescription. That’s not really my style either. The person already knows they did it, and they know it’s wrong. I don’t need to beat it into their head, or threaten to call the police on them.

All this changes, though, if you’re a habitual offender and/or I suspect there might be organized crime involved. In that case, I verify the script, call the police very quietly, and keep you waiting until the officer arrives, at which point you are arrested. And yes, it always does seem to fall on me to keep the person waiting and so on. I have no idea why. Apparently my poker face is pretty good.

Assuming no drastic measures are taken, I would also say that you shouldn’t give the prescription back to the person, but I have seen it done. (An act which never ceases to boggle my mind!) By doing this, you are giving the person another chance to take the script elsewhere. This is unacceptable!

Regardless, I believe it’s important to keep whatever action you decide to take low-key and professional. You are not this person’s parent. You aren’t the police. You are the medication gatekeeper. Politely deny them, do what you must do, and keep the ball rolling.

[tags]Pharmacy, pharmalerts, pharmacy practice[/tags]