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]

Chantix is pretty popular these days, and with good reason. It works pretty well. In fact, of all of the people I’ve talked to, there’s not one that’s not had success with it. Anecdotal, but nifty. I was dead wrong in my guess that insurers would balk at paying for it. Even medicaid is paying for it in my area, which is truly mind-blowing given how tight they are with their formulary. Even when it’s not covered, it’s still usually cheaper than buying a month’s worth of cigarettes.

What’s not so nifty about Chantix are the horrific prescriptions we see for it. Directions that make no sense. Or make sense within a certain context, but probably not the context the prescriber was thinking of. This will become clear shortly.

This is a short post, but it’s big because of all of the pictures.

Table of Contents:

1. How does Chantix come?
2. Normal Chantix Use: prescribing a course of Chantix
3. Normal Chantix Use: the first month (photos begin)
4. Normal Chantix Use: Month 2 and beyond
5. Abnormal Chantix Use and common missteps

Continue reading The ins and outs of prescribing Chantix (varenicline): an illustrated How-To guide →

The folks in Tulsa, Oklahoma recently dug up a car that was buried as a time capsule in 1957. They put a few things in the car before they buried it:

In the trunk, workers meticulously pulled out some of the objects buried with the two-door hardtop to celebrate Oklahoma’s 50 years of statehood a 5-gallon can of leaded gasoline, which went for 24 cents a gallon in those days, and rusted cans of Schlitz beer.

The contents of a “typical” woman’s handbag, including 14 bobby pins, lipstick and a bottle of tranquilizers, were supposed to be in the glove box, but all that was found looked like a lump of rotted leather.

Tranquilizers: the solution to all women’s ills in the days before men took them seriously. Dysmenorrhea? Have some Valium. Bad day? Valium. Kids acting up? Valium. Dinner didn’t come out right? Sprinkle some Valium on it.

Valium! Valium! Valium!

So let’s see. If I were a bottle of tranquilizers back in 1957, what would I be?

The first benzo approved was Librium, which was discovered in 1954, and re-discovered again in 1957. So it’s probably not Librium. Valium, of course, is newer, having been approved in 1963.

The other possibility might be methaqualone (Quaalude), which was discovered in 1955, but wasn’t popular until the 60’s.

My guess would have to be phenobarbital which was approved back in 1912. What’s your guess?

[tags]History, women’s issues, tranquilizers[/tags]

The pharm can get pretty wild and crazy sometimes, and Twix aren’t always handy. And let’s face it, candy necklaces are for kids. Valium is SO much more stylish:

You, too, can have your very own Valium necklace for the low, low price of $55.62!

No Valium was harmed during the making of this blog post.

[tags]Valium, candy necklace, humor[/tags]

One of my more popular posts has been “Do we need Tekturna (aliskiren)?“. The comments have been varied, but I still stand by my doubts over its usefulness. Other medbloggers have expressed their doubts as well. And I should state right now that I think Tekturna being on the market is a Good Thing™. I am not against the drug’s existence.

In fact, I’m not arguing how efficacious it is. I’m sure it works. If it didn’t, it wouldn’t be approved. I’m merely questioning its place in current treatment paradigms. To explain what I mean, I’m going to use a crude analogy to compare angiotensin II receptor blockers (ARBs) and aliskiren, the only direct renin inhibitor (DRI).

Think of a sink. For whatever reason, you want to keep liquid from going down the drain. Does it make more sense to keep the sink turned off, or to plug the drain directly?

Well obviously if the goal is keeping the drain dry, you’d plug the drain. This is what ARBs do. They prevent specific and non-specific binding at the angiotensin II receptor sites. Tekturna just keeps the sink from turning on and does nothing to block the drain directly. This means there’s still going to be non-specific binding at the angiotensin II receptor site. (Incidentally, this non-specific binding is not merely theoretical; if it were, ACEis would be more effective as a class than the ARBs, but instead they are merely comparable.)

Back to my point: Tekturna is more expensive than the ARBs, and it will be for a long time. I don’t think having aliskiren as an option is a bad thing. I just question how valuable the drug truly is with less expensive ACE inhibitors and ARBs. Sitting here, it doesn’t seem to have a real niche. Would I try Tekturna if nothing else worked? Of course I would. If I were targeting the RAAS, would I reach for it as first-line therapy? Hell no I wouldn’t. I’d go for an ACE inhibitor in most cases.

I’m not going to delve into the heated debates about reactive renin production and other similar topics because I suspect that the reality lies somewhere in the middle ground, as it usually does.

In the meantime, I think don’t think Tekturna has a meaningful place in current drug therapy. If ARBs do not work, it is unlikely that a DRI will, either. The only time I see it perhaps being useful is if a patient cannot tolerate ACEis or ARBs.

[tags]Medicine, pharmacy, Tekturna, aliskiren, hypertension[/tags]

It looks a little something like this:

Found this thanks to Ars. (Yeah that’s three “i”s in a row.)

Medical resident contracts first reported case of Acute Wiiitis.

From Ars:

The case report reads very tongue-in-cheek, containing a description of the Wii controller that can only be described as clinical, and noting that, unlike in real tennis, the resident’s level of fitness did not preclude his ability to overdo it: “Unlike in the real sport, physical strength and endurance are not limiting factors.”

Apparently, Acute Wiiitis is actually a variant of a disease that was first described in 1990, Nintendinitis, but the presentation is distinct enough to warrant a specific term. Those curious about these sorts of ailments may also want to check out the description of Nintendo elbow and Ulcerative Nintendinitis.

Genius!

Selling syringes is a sore spot for many pharmacy personnel, both technicians and pharmacists alike. I’ve heard technicians say that they wish that they (the drug abusers) would “just die.” I used to have moral qualms about it, too. Why sell something to drug addicts which only facilitates their habit? Why make it easier to abuse illegal substances?

I had an epiphany one day. It occurred to me that selling needles was the lesser of two evils.

Option 1: Withhold clean needles.
Outcome: Person still injects drug of choice, potentially using an unclean needle.

Option 2: Sell clean needles.
Outcome: Person still shoots up, but may avoid infecting or becoming infected with a blood-borne pathogen.

Option 2 is the better option, if for no other reason than it’s more economical. By possibly reducing the spread of infectious disease, we’re possibly saving taxpayer money. Drug abusers are typically uninsured, and wind up in the ER where tax money will pay for the cost of their care. It should go without saying that withholding clean needles isn’t going to stop an addict from getting their fix. Of course drug abuse leads to other medical complications, so there’s no guarantee that they won’t end up there anyway…

Naturally, I play the “Gee I wonder if they’re using it for insulin… or maybe their cat?” game all the time, even though I know it’s unlikely. When they haven’t showered in about a week, look as though they’ve been living in a box under a bridge somewhere, and complain that you’re not snappy enough about selling them their $2.10 bag of syringes, it’s probably a good sign that you’re not using said needles for healthy reasons.

But it’s a comfortable delusion nonetheless.

[tags]Medicine, pharmacy, needles, syringes, drug abuse[/tags]

I don’t often participate in blogosphere or Internet drama, but I do want to briefly add my comments to the general blogosphere reaction to the outcome of Flea’s trial. If for no other reason than Flea was one of my favorite blogs, and its disappearance is a loss for medbloggers and the Internet community at large. I won’t pontificate long. My thoughts boil down to this:

It saddens me when a case is settled not on the facts of the case, but rather on issues that are only tangentially related to the matter at hand, at best. That said, perhaps Flea was confident in his anonymity, but probably shouldn’t have been. Being nearby, I considered going to the courthouse in Boston and asking a court clerk where and when “the malpractice case of the pediatrician” was being heard, simply because most of my days are free, and I would have liked to observe the trial. I wouldn’t have revealed Flea’s identity.

Unfortunately, hindsight is 20-20, and things that are obvious after the fact are often not so obvious while they are occurring. We’ve all done things that were dumb in hindsight — myself especially — so I will refrain from being an armchair jackassexpert and saying that Flea should have known better.

But ultimately we have a legal outcome wasn’t about the truth. The truth — whatever it happens to be — is apparently irrelevant. Unimportant, even. I think that alone is poor commentary on our legal system.

[tags]Medical malpractice, malpractice[/tags]