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]

There’s a bizarre misconception that pharmacies have a Batphone that connects us with The Doctor at the push of a button. Anytime, anywhere.

The Batphone phenomenon generally rears its ugly head on the weekends or after hours when someone inevitably needs a refill on their Allegra, or their kid’s fluoride prescription has run out of fills, or their Patanol copayment is higher than they’d like it to be. Eleventh Law stuff.

I’ve had people literally scream obscenities at me because I won’t give out the doctor’s special phone number. You know, the magic one that all you doctors have to every other doctor on the planet so you can have your secret conversations with one another and that pharmacies can use periodically when there’s a medical emergency. Like that Patanol copayment. That super special phone that’s never busy, and doesn’t get answered by the front desk.

Why oh why are you holding out on us, doctors?? WHY???

We’ve got this one doctor’s office that refuses to accept prescription fax refill requests. This means we have to actually pick up the phone and call — but most of the time the phone is busy, so it takes 3 or 4 tries to actually get through. This is annoying, but not the end of the world — we fill a moderate number of prescriptions for him, but most of them seem to be antibiotics and such, with no refills.

What is disconcerting is that when we do get through to the office, a receptionist answers the phone, looks up the file while you wait, reads the prescription in question back to you, and then invariably authorizes it with two more refills. Every single time. I have no idea who this person is or what their qualifications are, but it makes me uncomfortable. Yeah, I have the refill “authorization” within 90 seconds which is nice and convenient… But who’s doing the authorizing? Is she qualified to make the decision? Is the doctor being notified? Are the charts being updated? Who is doing the monitoring? When was Mr Smith last seen in the office?

Am I going to get a phonecall later asking me how the patient is taking the medication?

Call me old-fashioned, but I prefer the black box method of requesting a refill, where a request goes out electronically, via fax, or by leaving a voicemail, and then comes back some time later either authorized or denied. This delay lets me think that the prescriber is actually, you know, looking at the patient’s chart to see what’s going on before making a decision.

I like my comfortable delusion. Even if it is a fantasy and the med in question is “just” glyburide.

I suspect a great many doctors shoot from the hip when it comes to refills. What makes me think this?

Well there’s this weird little loophole in our automated refill request line where someone can request a refill and trigger an auto-fax to the doctor if the script has expired or run out of refills. It’s all automatic — no pharmacy personnel even see the refill request before it gets sent. Our computer systems aren’t typically smart enough to check and see if there’s a replacement prescription in patient’s profile already.*

What’s amusing is that often this second prescription differs from the first. Not significantly, but where the first might have 5 refills, the second has 3. Or 11. Or maybe zero. Often we’ll get two scripts with the old refill number on it sent back on the same day, each with a different number of refills, usually in the same handwriting. This makes me wonder… how are you guys charting this stuff?

Is this why we get phonecalls asking what strength of a drug a patient is taking? And how are they taking it? And please give them six months worth of refills?

Not to beat the EMR drum — because I don’t think they’re perfect either — but I have never seen this happen with an EMR.

It makes me scratch my head. Shouldn’t the order of operations be something like:

1. Request comes in and is put aside for later perusal.
2. Patient’s file is checked
3. A determination of the appropriateness of a refill is determined.
4. The number of refills is written on the request AND the patients chart — along with any changes.
5. Chart is closed, request form is faxed back to the pharmacy and then thrown away or placed in the patient’s files once you get the confirmation that the fax has gone through successfully.** If not, re-fax periodically until it does go through, or if it’s a constant problem, just CALL it in. That’s what we do when we can’t get a fax through.

Just askin’.

* This seems a good time for a digression. This little loophole, I suspect, is where the aggravation on a prescriber’s part that a prescription refill request has already been responded to, comes from. “I already took care of this, dammit! Why am I seeing it again?” Well now you know that patients can trigger second (and third, and fourth) requests all on their own, with no human intervention. This seems to be popular with elderly people who will often try to call in the same refill four days in a row before they actually come down to the pharmacy “just to make sure it’s there” — and our system isn’t smart enough to catch it and weed it out. It sucks. I hope this loophole is closed, too, because some pharmacy personnel aren’t smart enough to throw those second and third redundant prescriptions away when they come off the fax machine. They’re not real, people. Just toss ’em.

** Another digression: when irate patients come in demanding to know why the pharmacy doesn’t have a prescription because Goddammit-I-spoke-to-Jane-at-DrBob’s-office-this-morning-and-she-said-it-was-faxed-last-Thursday- what-the-fuck-is-wrong-with-you-people and we call the office, and get a sheepish “Oh, it was faxed but it says the line was busy. Sorry. We’ll do it now.” — it really tends to piss us off.

Update: Thanks to Kevin, MD, The Consumerist, and The Wall Street Journal Health blog, this entry is getting a lot of traffic. If you enjoy it, please take the time to Digg it. :)

The first round was popular, so I thought I would share another round of Bad Prescriptions. Answers will be posted tomorrow (Thursday) night around midnight.

Remember there’s more to a prescription than the drug. You need to get:

• Drug name
• strength
• directions
• quantity
• number of refills

The last prescription is totally legible. I have included it so you can cringe along with me. It was for a 6 year old child. And the folks in the Ivory Tower think MinuteClinics are bad…

Exhibit A:

Exhibit B:

Exhibit C:

(Standard disclaimer about electronic prescribing not being the perfect answer applies.)

[tags]Medicine, pharmacy, prescriptions, bad handwriting, doctor’s handwriting[/tags]