Category Archives: Pharmacy

Keep up if you can, Jay Parkinson

Jay Parkinson has a nifty section of his blog where he details the money he has saved his patients. The timeframe spans one month (October). His total is $9,672. Pretty nice; I’ll be watching to see what else you do.

I can speak for pharmacists, technicians, and patients when I say that its really, really nice to see a doctor doing the research to find out how much drugs actually cost. I see so much healthcare inefficiency on a daily basis just as it relates to drug therapy, it makes me want to start knocking heads together. Prescribers going right for the Nexium or Prevacid without EVER trying omeprazole; Lipitor when simvastatin is just as effective and has never been tried; Lescol XL, when pravastatin has never been tried; Avodart when finasteride has never been tried. Right for the ARB when an ACEi has never been tried.

Look, I don’t give a fuck what your pet drug is. I don’t give a damn what the drug rep shoves under your nose on a weekly basis. I don’t care that you’re unaware of the top-of-mind marketing that’s being used on you without your knowledge or consent.

If it’s going to cost an elderly person on a fixed income an extra $594/year because you “like it better”, you need an ass-kicking.

And so on. I’m all for moving from one drug to another if a less expensive drug has been tried and has failed. That makes sense. But the absolute waste of money because less expensive alternatives have never been tried boggles my mind. I can truly understand why prior authorizations were invented, even if I curse them daily for wasting minutes of my precious time.

Back to the topic at hand: this time of year, people make appointments to see me, where we sit down(!), chat, review medications, and then we talk about what can be done for 2008. Most people that see me are happy with their drug therapy, except for one thing: it costs too much. The goal of their visit is to reduce the cost of their drug therapy for 2008, every single time. Without fail.

I have seen 7 people across two days. (An average appointment lasts about 45 minutes.) In that time, I have saved patients $11,831. That’s an average inefficiency of ~$1700 per person. And these are people with drug coverage. The single highest total for one person was ~$3600/year.

In the next couple of days, I’ll try to share some scenarios so you can see how much just one simple switch can save an average person.

Keep up the good work, Jay. Seriously. Pharmacists, technicians, and patients everywhere applaud your good sense and efforts.

[tags]healthcare, inefficiency[/tags]

Evolution of thought processes

Phone rings. “Hello, may I help you?”
“Hi, I was wondering if I can take an Aleve for my shoulder ache? I also take lisinopril.”

7 years ago:
WTF is lisinopril?
Time: instantaneous

6 years ago:
I know how to spell lisinopril!
Time: ~0.5 seconds

5 years ago:
Lisinopril is for blood pressure!
Time: ~1-2 seconds

4 years ago:
Have I seen this before? Yes… I have because Aleve is naproxen sodium, and I’ve seen people take Naprosyn with lisinopril.
Time: ~2-3 seconds

3 years ago:
Lisinopril is an ACE inhibitor, and I see this combination every day.
“Sure, that’s fine.”
Time: ~0.75 seconds

2 years ago:
*Visual, mental review of systems, picturing the RAAS pathway and envisioning how naproxen is metabolized to see where and how the two intersect.*
“Sure, that’s fine.”
Time: ~0.5 seconds or so

Most recently:
How old is she? What’s her creatinine clearance? Might she be better off with diclofenac or celecoxib? Eh, it’s probably okay on a short-term basis, and it’s not a terrible choice, but it’s probably not the best choice, either.
“Sure, that’s fine.”
Time: ~1-2 seconds

What’s the next step, I wonder? Quicker processing? Maybe. Deeper comprehension? Hopefully.

This development of thought processes is the difference between these two residents. The ability to take in a situation in its entirety, process it efficiently, while remaining calm and friendly takes time and exposure, and has very little to do with intelligence or any other innate quality.

* Naproxen is considered an unacceptable agent in geriatric patients even though it is used in the elderly pretty regularly. (My grandmother, for instance.) Probably because most internists, orthopods, and others are often not terribly familiar with geropharmacology, which is why geriatrics is its own specialty both in Medicine and Pharmacy.

How-To: Find the best Medicare Part D prescription drug plan

So we’re in the open enrollment period for Medicare Part D. It started on November 15, and it ends on December 31. I’ve been doing consulting twice a week, and the scramble is in full effect. While I do quite a bit more than plunk in drugs and quantities for my consulting, there is one tool that is the backbone of what I do when running various scenarios. It’s the plan finder.

This guide does not apply if you have a hybrid medicaid-medicare plan through your state. Those folks know who they are, and if you have no idea what I’m talking about, you don’t need to worry about it.

Before you begin you’ll need three things:

  1. A complete drug list of the person you’re doing the research for. This means you’ll need drug names, strengths, and quantities. Calculations are done for a 30-day supply, so if you take something 3 times a day, the quantity for 30 days will be 90.
  2. About five minutes
  3. An Internet connection (har har)

Here’s a walk-through, so you’ll want to open the link in a new window or tab…

Continue reading How-To: Find the best Medicare Part D prescription drug plan

How do you handle stepping on someone else’s toes?

Two recent posts of mine have dealt with bad information, and both times I’ve wondered what the accepted protocol is for addressing it. Obviously “Hey dumbass, go read some medical literature,” doesn’t cut it. I addressed one instance — the cholesterol one — quietly, after it happened. It wasn’t life-threatening misinformation, so immediate intervention didn’t seem necessary.

I didn’t bother to say anything about the antibiotic shenanigans.

The trouble with this is addressing something someone does without stepping on their toes. If I do something stupid, I’d like someone to smack me upside the head and tell me I’m wrong. Pussyfooting around the issue is for people with no self-confidence. I don’t have that problem — after all, I write on the Intarweb, and think people actually care about what I have to say, don’t I? ;) — so just come right out and tell me I’m wrong.*

Not everyone is that resilient, however, and I’m sensitive to this.

Recently I’ve heard a pharmacist say she was going to take lots of Vitamin C and echinacea to get over a cold. I’ve seen pharmacists recommend Airborne for cold on more than one occasion. I’ve heard a pharmacist recommend a homeopathic remedy for migraine. I said nothing — these suggestions aren’t harmful, but they certainly aren’t helpful, either. In these cases, it’s just not worth the effort. Besides, Father Time and the body’s own defenses will clear these problems up on their own. (And in the case of the migraine, I suspect it was psychosomatic anyway.)

When someone says something boneheaded to a patient, how do you handle it? Especially if it’s a pharmacist colleague? I would imagine doctors and nurses run into this problem from time to time as well, even if they practice alone now.

* I’m happy to say that this hasn’t happened in a very long time, which can be viewed as either a good thing (I’m SMRT!) or a bad thing (I work with a bunch of idiots). Which one I lean towards is dependent on where and who I am working with, naturally.

Bacteriostatic doesn’t mean “ineffective”

I hear some wacky stuff come out of the mouths of pharmacists sometimes, and it makes me sad, because they should know better. One recent gem, said to a technician was “Well Zithromax doesn’t actually kill the infection. It’s a bacteriostatic drug, so it doesn’t really do anything. Why waste your money? Amoxicillin’s the same way.”

My blood pressure went up a few points — at least they didn’t say it to a patient.

Bacteriostatic doesn’t mean that it doesn’t work. It also doesn’t mean that you’d be just as well off taking sugar pills. In fact, there are relatively few bactericidal drugs out there, and most of them are the nuclear bombs of the antibacterials: fluouroquinolones, vanco, rifampin, linezolid, and so on. The majority of oral antibiotics that are filled on a daily basis are, in fact, bacteriostatic.

And guess what? It doesn’t matter. Bacteriostatic drugs hold the infection in check while the immune system clears it out. I thought this was common knowledge; I guess I was wrong. Of course there are instances when this isn’t good enough. Those are the minority of circumstances, however. Infections don’t usually need to be killed. That’s why we have an immune system.

Chocolate placebo?

Research from the Nestlé Research Center in Switzerland and published in the Journal of Proteome Research.

In a clinical trial made up of 22 men, half of which described themselves as “chocolate lovers” while the other half were “chocolate indifferent,” participants ate chocolate or placebo over a five-day period. During this time, their blood and urine was monitored for various metabolite levels. The researchers found a “hallmark” profile in the men who described themselves as chocolate lovers: low levels of LDL-cholesterol and slightly raised levels of albumin protein. The same levels were found in the chocolate lovers even when they ate no chocolate. The researchers also noted that the activity of the gut microbes of chocolate lovers was distinctively different from the other subjects.

(They should have used women. :haw: )

But seriously… what the heck is a chocolate placebo? Wouldn’t you know that you’re not eating chocolate?

And thus it begins: Xyzal

The money being wasted on pointless research, that is. Xyzal (levocetirizine), is beginning to have some money spent on research proving that it’s a good drug. I have no doubt it’s a good drug. They’ve isolated the active isomer and decided to market it since the patent on Zyrtec (cetirizine) is running out.

Let’s review, SAT-style:


Expect Zyrtec to go OTC as a means of ensuring continued profitability through marketing. (More people buy brand name Tylenol than the generic — same story for Claritin.)

Here’s the bottom line: everything that Zyrtec works for, Xyzal will work for, and vice versa. Same side effects, too. And because this is so, you will never see a head-to-head study comparing Xyzal with Zyrtec, because the results will prove that it’s just a waste of money. Like Clarinex. Oh sure, there will be a few isolated cases where Xyzal is 0.5% better for 0.1% of the study population, and these studies will be trumpeted, but remember that they’re actually meaningless. You’ll also see studies that show Xyzal is effective for some obscure condition that Zyrtec was never studied for. Just remember that this is done to make Xyzal seem like something more than a me-too drug, and that if someone bothered to spend the money, Zyrtec would work just as well.

So if you like to waste your time doing PAs or you feel an insane need to throw your patients’ money away, prescribe Xyzal. Otherwise keep on using Zyrtec.

“He gets so excited he throws up”

“My son is 7 years old, and whenever something exciting happens, he throws up. We’re supposed to go to the amusement park today if the weather clears up, and he’s afraid — and so am I — that if we go, he’ll throw up while we’re there.

“I don’t know what to do anymore. On the first day of school, he throws up. On the last day of school, he throws up. Waiting in line for a roller coaster, he throws up. If he gets really happy for any reason, he throws up. And he throws up because he throws up and worries that he’s going to throw up again.

“Is there anything I can give him so he stops throwing up?”

Straight Face held firmly in place — with superhuman effort — I stopped to think about the problem.*

And lest you think me an insensitive clod, I can assure you that I did (and still do) feel awful for this kid. I wonder what his home life is like. I wonder if he’s chemically imbalanced. I wonder if it’s a phase he’ll grow out of. I wonder how to help him in the short term, today, hopefully without robbing him entirely of the excitement that an amusement park brings. I wonder about abuse, too. I wonder if this behavior is conditioned in some way, and if it might be self-reinforcing, not unlike that destructive positive feedback loop that plagues those with panic disorder. I wonder if he’ll grow up with anxiety problems. I wonder if he’ll end up a well-adjusted adult, hopefully without the need to be on long-term psych meds.

Most of all, right now, I hope mom has a talk with the pediatrician about it.

Given that my options are severely limited by a lack of prescribing powers, the best solution OTC would be Benadryl to blunt the edge, with the side effect of probably making him very sleepy. Not optimal, for sure, but better than puking before you get on the ride, no? Some would think Emetrol, maybe, but that’s a poor solution because that’s not going after the actual problem. If the child is overexcited, better to take that down a notch than merely cover the side effects of being in that condition in the first place.

What do you guys think? What would you have done?

* When I was in junior high, my friends and I used to talk about the worst, most absurd “super power” to have. We decided it would be the superhuman ability to crap your pants every time you got excited. “Haha! Yay!… ohhhh….” This is where I coined the phrase “My bowels are aquiver with excitement.”

I’d say this child’s difficulty ranks right up there…

If you have Parkinson’s, you probably shouldn’t try to alter your own prescription

This past week, we had a guy gentleman come in with prescriptions written for some usual suspects in the treatment of Parkinson’s, one of them being Klonopin. His symptoms were relatively obvious, too. What was funny in a “Haha, this is really pathetic” sort of way was that the prescriber had signed them in blue ink with rather normal (even neat!) handwriting.

In the no sub box, this guy had scrawled “no substitution” in handwriting that looked like calligraphy done with a squiggle pen. And of course the ink was black.

Yeah okay, buddy. I mean, I don’t really care if you want the brand name, just drive up the road to New Hampshire and request it. Don’t alter the damn prescription and think I’m not going to notice. There are two parties that should be writing things on the prescription, and you are not one of them.

I didn’t rake him over the coals for it. It wasn’t worth the time and emotional energy, and he seemed like a nice enough fellow. I hope it doesn’t happen again.

The ending is that the insurance (Tricare) wouldn’t cover brand name if there was a generic available. Big surprise. So he ended up with his clonazepam, generic Sinemet CR, and generic something else. What a bunch of idiotic hoops to jump through to end up back at square one.

But seriously, what person — who knows they can’t write due to a medical condition — alters their own prescription? In the wrong colored ink, no less?

Never ascribe to malice that which is adequately explained by stupidity.

How do you guys save your knees?

For you folks that stand all day every day, how do you keep your knees from going to shit? I’m in my mid-20s, and my knees hurt so badly after even an hour of standing that I’m considering going to the doctor. What, if anything, he’ll suggest, I don’t know. I’m starting to dread my long days, and I’m starting to get pissed off at people more easily because I’m in pain.

This is not cool, and it’s only come about recently thanks to working 6 on and 1 off.

When I had time to work out regularly, this wasn’t a problem. I just don’t have the time to work out at all right now — and yes, it’s not simply a matter of “making time” — the time does not exist during the day for me to do this.