Please continue to write "Toprol" NOT "metoprolol succinate"
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.
What does "2 qd" actually mean?
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.
Alcohol and Flagyl = disulfiram rxn? Where're the data, dood?!
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.
Conception for HIV+ couples
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]
The "furry harbinger of death"
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.
The Mass Medical Society doesn't get it
Argue from your Ivory towers all you like. It's meaningless in this day and age. Here's why:
1) If you have an illness that probably falls within the conditions treated by MinuteClinics, and you try to go to your normal doctor, you're probably going to be seen by a midlevel.
2) Medicine is a business, as much as we'd like to pretend that it's not. It is subject to the same economic principles as everything else.
3) Bearing in mind point #2, recall that it is virtually impossible to see your primary care doctor for anything but a visit scheduled months in advance. Until you address that problem, your arguments (no matter how well-reasoned) don't count for much.
4) MinuteClinic has ways of sharing records with doctors. This "continuity of care" argument is nothing but a red herring that sounds nice. All providers have to do is sign up. It is also possible to get referrals from MinuteClinic. (And that's good for YOUR business.)
5) MinuteClinics fill a niche that PCPs are not. That they CANNOT fill using a traditional business model. Change your business model or lose your bread-and-butter: your easy in-and-out patients.
6) MinuteClinics are going to keep more people out of EDs. And that, I think you would agree, is a Good Thing.
Blow smoke all you want. You're not going to stop MinuteClinics from coming. You have two options: embrace them or compete with them. Everything else is meaningless. If you want to stop them, educate your doctors on how to better compete with these health-care-in-a-box places. It's not hard. You've got a built-in advantage. You can monologue if it makes you feel better, but trust me, the public doesn't care. And I don't either.
And while we're at it, let's call this what it is: turf protection. You're trying to protect your turf under the guise of patient care, and there's nothing wrong with that. But railing against it is the wrong way to go about it. You need to be smart: protect your turf using business tactics, not monologues.
But since you're apparently uninterested in doing that, you're going to guarantee that MinuteClinic will gain an easy hold, even in Massachusetts where doctors are a dime a dozen. People WANT to see THEIR doctor. They'd much prefer that over going to see someone they have no relationship with at a Minute Clinic. But until doctors start setting aside time for same-day appointments, en masse, these Minute Clinics are going to thrive.
There's a reason moms like drive-throughs in their pharmacies. Think about that.
The ins and outs of prescribing Chantix (varenicline): an illustrated How-To guide
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:
- How does Chantix come?
- Normal Chantix Use: prescribing a course of Chantix
- Normal Chantix Use: the first month (photos begin)
- Normal Chantix Use: Month 2 and beyond
- Abnormal Chantix Use and common missteps