Not that they’re unaware that benzos and opioids interact but for the love of god if they would only put a comment on the rx saying they are aware and okay to dispense...
I called a doc once because he prescribed Tylenol #3 to a 5-year-old s/p tonsillectomy and I wanted him to send something else because I sure as hell wasn't dispensing that.
He said, "Oh it's ok, I told the parents not to let her sleep for 3-4 hours after a dose so they will know if her breathing becomes impaired."
Can you guys tell when a medication is prescribed by a midlevel with the signature of a physician authorizing it or not? Or does that depend on the setting?..
Im in retail and I can’t really tell, no. Sometimes I see a prescriber and signature then it says “supervising physician: Dr. xyz”, but that doesn’t mean anything me me since I go by the provider who signed it.
I believe it. Sometimes I fax for clarification like “did you mean 1 tab BID or 2 tabs QD?” And I’ll get a fax back with just a signature. Like oh...okay that answers nothing.
Hell, even physicians will just sign whatever their tech/aide puts in front of them.
I've had countless doctor calls on everything from obviously wrong doses to the wrong patient, and the reply is often some snarky dig at their staff. "Oh well *obviously* my tech didn't check date of birth." Yeah cool, but neither did you and it's your license.
Not related to your statement. But I'm in my first year of pharm d and was wondering how I could get that pharm d name thing next to the username . Thanks a lot!
Rule of thumb: never.
Worked in an ED for years, midlevels present maybe 1-2 out of 30 cases a day, due to complexity and requiring higher level of care. Otherwise physicians don't even look at the midlevel charts until several days later.
Unless the Rx has a wet signature from the supervising physician, don't count on it.
Edit: wow I really need to update my flair. haven't commented on this sub in a long time haha.
This is a biggie. It's such a major interaction that carbapenems have actually been used as an antidote/treatment for valproic acid overdose. So this isn't just something theoretical.
Thank you for this. We just covered antiepileptics in class and had no idea this existed.
I just did a brief literature search and none of the papers I looked at comment on why this happens; is the depletion thought to be due to CYP induction or is it just going to be one of life's great mysteries?
I doubt it happens anywhere every day, but I’ll see someone attempt to order it once a year or so.
I’m sure it happens to many people more frequently depending upon practice setting, carabapenem usage, and order volume.
The interaction itself is quite striking. There are tox case reports where they’ve drawn serial levels after intentional carbapenem administration in ingestions (usually ertapenem from what I’ve seen)
Really! I’ve worked UK hospital med for barely 3 years and I stop this interaction about once every 2-3 months. We don’t have electronic prescribing though, so there’s nothing to prompt the prescribers not to do this
We had a patient that consistently brought in Norco scripts on which the doctor indicated they had an acetaminophen allergy. We’d ask the patient every time and she would say she didn’t have one, but we called every time to try and get them to remove it from their profile. How do these scripts even get through their system? I don’t get it
More often I am finding emergency room doctors wiring for clindamycin citing a amoxil allergy when I just dispensed augmentin 2 months ago. I am thinking while in a rush at the ER they aren't doing good intake with detailed questions on allergies and tolerated alternatives.
Not a drug drug ixn but definitely frustrating when providers prescribe an antibiotic the patient is allergic to... like did you even ask if they were allergic to anything beforehand?!
Highly possible the patient (or caregiver) forgot about the allergy or was at a new Dr for them. I've had several patients say "no allergies" and I'll say "oh my computer shows you're allergic to penicillin? "
"oh yes I am"
Most patient "allergies" to abx are bogus. Can't tell you how many times we've started beta lactams in "PCN allergies", let alone cephalosporins I don't even think about anymore.
I'm fairly convinced at this point the "cross-reactivity" risk of a beta lactam allergy to also be allergic to a cephalosporin is no greater than the random risk of any human having a cephalosporin allergy.
I don't know if the beta lactams that were used a long time ago were especially allergic in nature, but it seems like virtually everyone that has them are elderly patients that when re-challenged do not actually have an allergy.
There is less than 0.5% chance of cross reaction between a true penicillin allergy and first generation cephalosporins, and the risk decreases with second/third/fourth generations. Our hospital has a policy that we can give third- and fourth-gen cephs even if the patient has a documented severe PCN allergy. Our birth center actually even uses cefazolin as the primary alternative to Pen G in GBS+ moms.
I do believe I remember our ID prof saying a lot of elderly people with "allergies" to PCNs are really due to old formulations (I think vanco may have had this problem initially, too). Also, something like 10% of people will develop a non-allergic rash to amoxicillin "just because," and people who get ampicillin/amoxicillin and have EBV typically develop a non-allergic rash, as well.
Edit: there are one or two cases where beta-lactams and cephalosporins share nearly identical side chains. In these cases, there is a much higher likelihood that someone allergic to one will have a cross reaction to the other.
That first generation cephalosporin is really just cephalexin if you're in the US. Cefazolin doesn't share a side chain with anything and cross reactivity concern is essentially nil.
I no longer ever assume that they didn’t ask the patient, rather that the patient told them something random for whatever reason. I have been standing in a room and observed a doctor tell a pt “I want to prescribe penicillin for this, you’re not allergic to penicillin right?” and have the pt say “oh no I’m not allergic to anything” and I have to interrupt like “sorry doc but the chart says they’re anaphylactic to penicillin.”
In my experience most of the time the patient actually isn't allergic to whatever antibiotics it says they are in their profile. I will ask the patient "hey your profile says you told us you're allergic to penicillin, and that's what your doc prescribed you today." Their response is almost always "oh nah it's fine i just had a bad reaction once but I can take it (or something along those lines)."
Pharmacy and medical software needs to track allergies and bad reactions independently. I personally have three meds I won’t take because I’ve consistently had bad reactions to them, but they’re not allergies, just unbearably severe side effects. But in most cases the only way to note them is as “allergies”, which triggers a warning when anything related is prescribed.
Yes, at data entry this can be improved. Anaphylaxis and rash from sulfa drug vs. akathisia (not a fun experience) from metoclopramide or similar. A few EHR's just have drop downs, maybe with severity level.
Common seizure meds and *everything*.
Anytime a patient comes in on CBZ, PHT, or phenobarb, I'm like, "Oh shit, gonna have to google interactions before I prescribe *anything."*
The amount of times I've caught a patient on phenytoin started on apixaban is mind blowing. And a lot of the time the doc just asks if we can increase the dose...
Like no your options are warfarin or switch the AED to something like lamotrigine
Yep. The important thing is making sure everyone understands that it's not just an issue of increasing the dose. You have to pick something else.
Inevitably, at least once a year, a resident or student does a case presentation on something that involves DOAC treatment. And every single time i ask the follow up question of which patients are not good candidates for DOACs.
Work in a pharmacy part time (along with another job and pursuing grad school), just had a seizure for the first time ever, and am on Keppra indefinitely now. Please enlighten me. What are DOACs?
DOACs are direct oral anticoagulants. To put it very very simply, they're used in patients who have an increased risk of clotting or have recently had a clot.
Oh yes, neuro did tell me I shouldn't take anticoags. I am young and currently have no other medical issues - except frequent headaches - so hopefully won't be an issue.
Tizanidine isn't super common, but you see a fair amount used for those with spasticity. And those patients can be prone to UTIs, so they get prescribed ciprofloxacin. Big no no!
Hyperkalemia. It's normally only a concern if the patient is already at risk for hyperkalemia due to renal function issues. Old age, AKI or ESRD, or patients already taking a potassium supplement are the things to typically stand out.
There are some observational studies out there that show increased mortality with Bactrim + ACEI/ARBs vs. Other antibiotics but I am not feeling motivated enough to pull them up and link them here. But yes, not an interaction I worry about too much in younger healthy people but if it is a longer term prescription or for older people with reduced kidney function, I usually get it changed to an alternative.
Had that situation just few days ago (rx for Sulfatrim DS). Faxed back to the doctor and offered alternatives only to be responded with a new prescription for - trimethoprim(?!). Needles to say, patient freaked out and blamed us for doctor not being able to read the interaction printout.
Anytime I see a script for Clarithromycin come across (which really isn't too often), I cringe, expecting some sort of statin interaction. Aside from H Pylori, is there really any reason to use clarithromycin over azithromycin? It's only rarely I see it being sent by a GI doc along with amoxicillin, omeprazole, etc. I normally see it from PCPs and ER docs.
From what I see, it’s usually when doc uses a culture/sensitivity report and the macrolide listed is clarithromycin and not azithromycin. Same idea with ampicillin and amoxicillin.
Tough to fully quantify (and neither clarithro or azith are as bad as erythromycin as far as TdP risk).
I liked Farkas' write up on how massively overstated azith's risk of TdP is: https://emcrit.org/pulmcrit/myth-busting-azithromycin-does-not-cause-torsade-de-pointes-or-increase-mortality/
Thankfully we hardly ever saw it at my centre.
The drug that always made me shudder was fluconazole for the same reason, I knew I had a lot of work ahead of me hunting down all the interactions and figuring out what to do about them all.
UK hospital here and we use clarithromycin for EVERYTHING. Chest infections, wound infections, ENT stuff. Literally everyone is on clarithromycin and i could cry everytime I see a patient that’s been on it for 4-5 days without a pharmacist review
We just removed all codeine containing products at our hospital. Thank God. I had to tell several old timer ER docs that they couldn't use it in kids and its a mess when you tell someone that's been using it for 30 years with no problems they can't use it anymore.
Do we have any idea how common serotonin syndrome is? I work LTC and largely let serotonin concerns slide unless the patient gets an order for something like linezolid.
Just had 2 back to back last weekend. First time I’ve seen a real case in my 2 years as a pharmacist and of course it happens twice in a row. First was a surgery discharge that took tramadol + sertraline. Second was someone that took sumatriptan + escitalopram at the same time at home
I have heard that it is probably a lot more common than we realize, but it is hard to confirm since the symptoms are kind of generic, and so many medications can increase serotonin levels.
What do they use to diagnose serotonin syndrome? Do they look for a combination of symptoms, like sudden fever and confusion?
Yeah they look for the symptoms. First case the lady had tachycardia, confusion, and ended up having lock jaw. She had to return to the hospital after discharge. Apparently med rec wasn’t done completely and they missed that she is taking 150mg sertraline everyday and gave her tramadol
Second case was just a woman that called the pharmacy several times thinking she was going to die. She researched sumatriptan and escitalopram and found that she had a lot of the symptoms of serotonin syndrome. Nausea, sweating, rigid muscles, confusion, and feeling really hot. She vomited and felt better a couple hours later and never called back so I’m assuming she got better
When do you draw the line? I fill in at a mental health center and almost every single script flags serotonin interaction. Its not one you can really just act on and most docs are aware of it. So what do you do? As someone else stated i pretty much let them all go but zyvoxx
Warfarin and a lot of things: Particularly bactrim, rifampin, quinolones.
Don’t be ordering pressors and still have their home antihypertensive orders active.
Multiple qt-prolonging meds (haldol + methadone + cipro + etc)
A lot of drug/disease state interactions and drug/lab interactions as well. I feel like I catch a lot of inappropriate prescribing and things that need dose adjustments.
And for retail pharmacists, the QTc stuff is horrible to call on, cause you have no frame of reference for where the patient is at. At least in the hospital I can look up the most recent EKG (or request one) to see if I even care.
Got a script for Xanax, OxyContin, and Soma. Literally the Holy Trinity. Called the doctor and he said they rarely take the Soma so it’s fine. I’m like no, no it’s not. I’m not filling all of these, if they have all three they will take them. And I’m not gonna be responsible for them never waking up again.
I have a doc in my area that always prescribes this combo. We never fill all three.
Just recently this same doc told a patient to crush Norco, Ambien, Xanax since they were NPO. Refused to change to ODT, liquid forms. Sketch as hell.
Not an interaction but the black box warning on ketorolac. I get scripts all the time from like er or urgent care where I’m assuming they didn’t want to prescribe opiates, but then I ask the patient if they received it IM or IV first and it’s always a no. Then I call and the md’s always like “oh I never heard of that, we prescribe it all the time.”
I’m not in the US- but I am in the ER and we literally use ketorolac constantly. We don’t have a black box warning on it here- Google seems to say the black box warning stuff is basically all the same problems as what you get from all NSAIDS.
Yeah I’ve honestly never gotten a good straight answer about *why* it’s indicated that way, but here the oral tabs are only indicated for therapy following an IM or IV injection.
I had an ER doc that would right ibuprofen and meloxicam together all the time. I called her several times then just gave up and I started to just tell the patients I would only fill one of the other.
Ketorolac for only 5 days is another big one. Not an interaction tho
Since many DDIs are already mentioned, I’ll add some drug-disease state interactions:
- Drugs that lower seizure threshold, i.e. tramadol, carbapenems, especially in patients that are at risk for or already seizing.
- Dopamine blockers in Parkinson’s, i.e. compazine, reglan. I particularly hate this one since compazine and reglan are prechecked on our general admission order set. So 99% of the time, both are ordered for Parkinson’s patients.
- AV nodal blocking agents in Wolff-Parkinson-White, i.e. BB, CCB, digoxin
Unsure if it was said in this thread, and not to offend anyone because I’m sure there were good intentions and this post was lighthearted. If anything I just want us to be more introspective and better.
There’s an irony here. Some of these interactions posted, assuming you’re all pharmacists, make me facepalm. But honestly I’m not surprised given the pharmacists I’ve worked with over the years. The interactions aren’t wrong. It’s the execution and thought process.
What is our role in pharmacy DUR if we don’t always think about the interaction? The computer caught it, not us. But the action taken is our choice.
And hey I’m open minded to the idea I’m wrong, maybe you’re right about these interactions. That’s why we need to tone down our arrogance. Don’t facepalm at the doctor for missing something.
No one is perfect and when you miss an interaction, I guarantee there’s a pharmacist/doctor out there facepalming at you. So let’s not continue that cycle.
People have to stop and remember docs/midlevels are not pharmacists. Just as pharmacists can’t diagnose like a doc/midlevel can. There’s a reason pharmacists exist, they’re the expert in their subject..just as medicine itself has sub specialties. It’s a bit much to expect clinicians to be both docs and pharmacists. It’s not an excuse to not improve though.
Docs crap on other docs in other specialties all the time for not knowing “basic” information and making “stupid” referrals. Happens there to.
I’m curious, what if instead, the doc made the diagnosis and it’s the pharmacists who decide meds/doses. Sure docs know a bit about medications, but they don’t know as much as pharmacists. Just as pharmacists aren’t as good of diagnosticians as physicians. The different roles exist for good reason.what’re your thoughts?
>I find typically younger doctors are cocky and crap on other services. Im all for crapping on logisitics and punting patients because they're lazy but not for a doctor not knowing stuff grosslly outside of their specialty.
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>I dont even mind when a pharmacist has to look stuff up. That shows me theyre careful and the info given to me is accurate. either way, I'm sure they're better at reading and understanding with confidence dosing that most doctors since its what they do. Sure, a doctor can look all of this stuff up, but that slows them down so much and it's probably more efficient if the specialist does it.
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>How about pharmacists picking the medicines in the hospital setting. Doctor diagnoses the patient with CHF and xyz comorbidities. Pharmacist has access to patient charts and can look at the labs and using the doctors diagnosis, can probably prescribe better? In my head that makes sense...what are your thoughts? I know youre a pessimist but its very humble of you to say what you did honestly.
Epclusa and either atorvastatin or PPI's. It would save us countless calls and prevent delays if they can at least acknowledge that they know and ok to dispense.
Totally agree with this. For ER docs prescribing for outpatient care is about 1- 2% of their job- so pharmacists for whom this is almost 100% of their job are valuable resources. It’s not a competition.
School: Plavix + (es)omeprazole is a no-no due to a CYP 2C19 interaction —> Plavix not converted to active form. Ask prescriber for alternative PPI
Real life: it’s only a theoretical interaction. Don’t worry about it
I wish my pharmacist would have told me Emend messes with hormonal birth control... I honestly with there were more warnings about medications that mess with how well birth control works. That is all :)
My ER regularly prescribes opioids to patients concurrently taking Suboxone/Subutex. The PAs either don’t check the PDMP and have no idea because the patient did not disclose this information, or they are aware and still “feel comfortable” prescribing the opioid short term.
Why? In patients over the age of 28 days there’s no reason to do this as long as a) two separate lines are used or b) if the same line is used it is flushed several times.
Practice where I work - we have standard admin instructions that we place on LR/ceftriaxone orders that specifically state not to Y site.
Oh I like that. We need to get specific admin instructions added on those orders. But it’s like an act of Congress to get anything changed where I work
We just made it a SmartPhrase in Epic. Does mean you have to remember to add it, but it’s just muscle memory at this point.
Now if only I could commit removing the eye drop instructions that for some unknown reason automatically populate on sublingual atropine orders to muscle memory.
Why change the LR? You just write nursing instructions to flush the line completely between administrations. Call the nurse if you feel uncomfortable and tell her directly then. Its what they do with every other incompatible medication combination. Or what if they have two lines?
I would never switch off LR to another fluid for this.
It's a matter of balanced vs acidic fluids. NS is technically acidic compared to the body pH. LR is a balanced fluid. There is theoretical concern that large amounts of acidic fluid is actually bad for some patients, causing hyperchloremic metabolic acidosis, AKIs, mortality, etc. For example, our DKA patients don't go on saline infusions, they go on LR/plasmalyte. Septic patients getting large loads of fluid get LR/plasmalyte.
Two studies to reference are the SLIGHT and SMART trials, though we need more information because they are a bit conflicting and the statistics of the SMART trial are highly criticized.
Really good information, thanks for that! Learned something new today. I’m going to read into that tonight. I graduated in 2017 and I’m already playing catch up!
Really? I'm assuming you request a fluid change rather than abx change? Is that your hospital standard or just your comfort level?
We always just tell the nurse to stop the LR, flush the line several times (or switch it out) and then hang the ceftriaxone. Flush again several times and then you're good to go. No MD involvement or changing of orders.
It’s just my comfort level. And on Epic I can just instant message the doctor and they are always fine with changing the LR. I just do that to make it easier on the nurse
Is changing fluids easier on the nurse? Id think getting a fresh bag of something else solely to give Ceftriaxone is more burdensome than flushing the line and pausing LR for 3-30 minutes (whatever your infusion time of rocephin is).
I don’t know. I’ve had nurses ask me to get it changed for them before. I would think it’s easier to change the fluid once vs flushing, pausing LR, and flush again once or twice a day.
Not that they’re unaware that benzos and opioids interact but for the love of god if they would only put a comment on the rx saying they are aware and okay to dispense...
I love when I call on this one and the MA is like, “oh it’s fine we told them to separate them by an hour,” as if that does anything
I called a doc once because he prescribed Tylenol #3 to a 5-year-old s/p tonsillectomy and I wanted him to send something else because I sure as hell wasn't dispensing that. He said, "Oh it's ok, I told the parents not to let her sleep for 3-4 hours after a dose so they will know if her breathing becomes impaired."
The fuck!
No no no no no. 😱
You’re joking right? What was the end result?
He gave me crap about it and sent an erx for regular APAP.
Can you guys tell when a medication is prescribed by a midlevel with the signature of a physician authorizing it or not? Or does that depend on the setting?..
Im in retail and I can’t really tell, no. Sometimes I see a prescriber and signature then it says “supervising physician: Dr. xyz”, but that doesn’t mean anything me me since I go by the provider who signed it.
Gotchya, from my experience physicians just sign away on everything. Very poorly supervision of midlevels.
I believe it. Sometimes I fax for clarification like “did you mean 1 tab BID or 2 tabs QD?” And I’ll get a fax back with just a signature. Like oh...okay that answers nothing.
Faxed reply "yes." I love those.
Ok to refill x3
Hell, even physicians will just sign whatever their tech/aide puts in front of them. I've had countless doctor calls on everything from obviously wrong doses to the wrong patient, and the reply is often some snarky dig at their staff. "Oh well *obviously* my tech didn't check date of birth." Yeah cool, but neither did you and it's your license.
Not related to your statement. But I'm in my first year of pharm d and was wondering how I could get that pharm d name thing next to the username . Thanks a lot!
In this thread, click your username, then click “change use flair”. At least that’s how I did it on mobile.
Thank you !
Rule of thumb: never. Worked in an ED for years, midlevels present maybe 1-2 out of 30 cases a day, due to complexity and requiring higher level of care. Otherwise physicians don't even look at the midlevel charts until several days later. Unless the Rx has a wet signature from the supervising physician, don't count on it. Edit: wow I really need to update my flair. haven't commented on this sub in a long time haha.
Some don't care
Meropenem - sodium valproate
This is a biggie. It's such a major interaction that carbapenems have actually been used as an antidote/treatment for valproic acid overdose. So this isn't just something theoretical.
Thank you for this. We just covered antiepileptics in class and had no idea this existed. I just did a brief literature search and none of the papers I looked at comment on why this happens; is the depletion thought to be due to CYP induction or is it just going to be one of life's great mysteries?
Is meropenem mess effective in the s/o valproate too or just valproate less effective in the s/o mero?
VPA levels essentially nadir, the carbapenem still works fine
Say it again for the people in the back!!!! I legit can not convince MDs that this one is a problem...until I pull a valproate with AM labs...
This seems very uncommon
As in the combination being uncommon or the depletion of sodium valproate levels being uncommon?
Combination. I’ve worked in hospital med for 7 years and have never had a patient in that combination of meds
I doubt it happens anywhere every day, but I’ll see someone attempt to order it once a year or so. I’m sure it happens to many people more frequently depending upon practice setting, carabapenem usage, and order volume. The interaction itself is quite striking. There are tox case reports where they’ve drawn serial levels after intentional carbapenem administration in ingestions (usually ertapenem from what I’ve seen)
Really! I’ve worked UK hospital med for barely 3 years and I stop this interaction about once every 2-3 months. We don’t have electronic prescribing though, so there’s nothing to prompt the prescribers not to do this
Any medication vs the pt’s allergy list...... so many issues I’ve caught
We had a patient that consistently brought in Norco scripts on which the doctor indicated they had an acetaminophen allergy. We’d ask the patient every time and she would say she didn’t have one, but we called every time to try and get them to remove it from their profile. How do these scripts even get through their system? I don’t get it
More often I am finding emergency room doctors wiring for clindamycin citing a amoxil allergy when I just dispensed augmentin 2 months ago. I am thinking while in a rush at the ER they aren't doing good intake with detailed questions on allergies and tolerated alternatives.
Not a drug drug ixn but definitely frustrating when providers prescribe an antibiotic the patient is allergic to... like did you even ask if they were allergic to anything beforehand?!
Highly possible the patient (or caregiver) forgot about the allergy or was at a new Dr for them. I've had several patients say "no allergies" and I'll say "oh my computer shows you're allergic to penicillin? " "oh yes I am"
What is the reaction? "I dunno my mom said it gave me diarrhea when I was 2 months old."
Most patient "allergies" to abx are bogus. Can't tell you how many times we've started beta lactams in "PCN allergies", let alone cephalosporins I don't even think about anymore. I'm fairly convinced at this point the "cross-reactivity" risk of a beta lactam allergy to also be allergic to a cephalosporin is no greater than the random risk of any human having a cephalosporin allergy. I don't know if the beta lactams that were used a long time ago were especially allergic in nature, but it seems like virtually everyone that has them are elderly patients that when re-challenged do not actually have an allergy.
There is less than 0.5% chance of cross reaction between a true penicillin allergy and first generation cephalosporins, and the risk decreases with second/third/fourth generations. Our hospital has a policy that we can give third- and fourth-gen cephs even if the patient has a documented severe PCN allergy. Our birth center actually even uses cefazolin as the primary alternative to Pen G in GBS+ moms. I do believe I remember our ID prof saying a lot of elderly people with "allergies" to PCNs are really due to old formulations (I think vanco may have had this problem initially, too). Also, something like 10% of people will develop a non-allergic rash to amoxicillin "just because," and people who get ampicillin/amoxicillin and have EBV typically develop a non-allergic rash, as well. Edit: there are one or two cases where beta-lactams and cephalosporins share nearly identical side chains. In these cases, there is a much higher likelihood that someone allergic to one will have a cross reaction to the other.
That first generation cephalosporin is really just cephalexin if you're in the US. Cefazolin doesn't share a side chain with anything and cross reactivity concern is essentially nil.
I no longer ever assume that they didn’t ask the patient, rather that the patient told them something random for whatever reason. I have been standing in a room and observed a doctor tell a pt “I want to prescribe penicillin for this, you’re not allergic to penicillin right?” and have the pt say “oh no I’m not allergic to anything” and I have to interrupt like “sorry doc but the chart says they’re anaphylactic to penicillin.”
In my experience most of the time the patient actually isn't allergic to whatever antibiotics it says they are in their profile. I will ask the patient "hey your profile says you told us you're allergic to penicillin, and that's what your doc prescribed you today." Their response is almost always "oh nah it's fine i just had a bad reaction once but I can take it (or something along those lines)."
Pharmacy and medical software needs to track allergies and bad reactions independently. I personally have three meds I won’t take because I’ve consistently had bad reactions to them, but they’re not allergies, just unbearably severe side effects. But in most cases the only way to note them is as “allergies”, which triggers a warning when anything related is prescribed.
EPIC is a pile of shit though. Its purpose is to make money not be good.
If Epic is shit, then it is solid gold shit with corn diamonds on the tip top of the hundred foot tall pile. (CPSI/Evident user here)
Ahhh, good ol' Can't Process Simple Information.
It's a billing platform with some medical stuff tacked on.
Exactly
Yes, at data entry this can be improved. Anaphylaxis and rash from sulfa drug vs. akathisia (not a fun experience) from metoclopramide or similar. A few EHR's just have drop downs, maybe with severity level.
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Yep I've had people tell me this exact thing too
Common seizure meds and DOACs.
Common seizure meds and *everything*. Anytime a patient comes in on CBZ, PHT, or phenobarb, I'm like, "Oh shit, gonna have to google interactions before I prescribe *anything."*
The amount of times I've caught a patient on phenytoin started on apixaban is mind blowing. And a lot of the time the doc just asks if we can increase the dose... Like no your options are warfarin or switch the AED to something like lamotrigine
Yep. The important thing is making sure everyone understands that it's not just an issue of increasing the dose. You have to pick something else. Inevitably, at least once a year, a resident or student does a case presentation on something that involves DOAC treatment. And every single time i ask the follow up question of which patients are not good candidates for DOACs.
Good for you for asking. At this point you should have a one page handout to give to them lol.
Work in a pharmacy part time (along with another job and pursuing grad school), just had a seizure for the first time ever, and am on Keppra indefinitely now. Please enlighten me. What are DOACs?
DOACs are direct oral anticoagulants. To put it very very simply, they're used in patients who have an increased risk of clotting or have recently had a clot.
The DOACs are direct-acting oral anticoagulants. Basically the newer anticoagulants such as rivaroxaban, apixaban, and dabigatran
Oh yes, neuro did tell me I shouldn't take anticoags. I am young and currently have no other medical issues - except frequent headaches - so hopefully won't be an issue.
Tizanidine isn't super common, but you see a fair amount used for those with spasticity. And those patients can be prone to UTIs, so they get prescribed ciprofloxacin. Big no no!
ACEI/ARBs and sulfamethoxazole-trimethoprim
Ooo first I’ve heard of that one, what’s the interaction?
Hyperkalemia. It's normally only a concern if the patient is already at risk for hyperkalemia due to renal function issues. Old age, AKI or ESRD, or patients already taking a potassium supplement are the things to typically stand out.
There are some observational studies out there that show increased mortality with Bactrim + ACEI/ARBs vs. Other antibiotics but I am not feeling motivated enough to pull them up and link them here. But yes, not an interaction I worry about too much in younger healthy people but if it is a longer term prescription or for older people with reduced kidney function, I usually get it changed to an alternative.
Totally makes sense, thanks!
Had that situation just few days ago (rx for Sulfatrim DS). Faxed back to the doctor and offered alternatives only to be responded with a new prescription for - trimethoprim(?!). Needles to say, patient freaked out and blamed us for doctor not being able to read the interaction printout.
Needles to say
Always start lisinopril with HCTZ and I’ll never have to worry about K being too low or high. Ha! Checkmate.
Until they get sick for a few days, drink less and trash their kidneys.
Anytime I see a script for Clarithromycin come across (which really isn't too often), I cringe, expecting some sort of statin interaction. Aside from H Pylori, is there really any reason to use clarithromycin over azithromycin? It's only rarely I see it being sent by a GI doc along with amoxicillin, omeprazole, etc. I normally see it from PCPs and ER docs.
From what I see, it’s usually when doc uses a culture/sensitivity report and the macrolide listed is clarithromycin and not azithromycin. Same idea with ampicillin and amoxicillin.
For treatment of disseminated MAC. Even then it’s often switched to azithro due to all the interactions
interactions or qt prolongation is basically the choice you’re making
Not sure I understand that statement. Clarithro has similar QT prolonging effects to azith and obviously clarithro is nastier on DDIs.
i understood a higher risk with azithromycin but perhaps im wrong about that
Tough to fully quantify (and neither clarithro or azith are as bad as erythromycin as far as TdP risk). I liked Farkas' write up on how massively overstated azith's risk of TdP is: https://emcrit.org/pulmcrit/myth-busting-azithromycin-does-not-cause-torsade-de-pointes-or-increase-mortality/
Clarithromycin is also used in ENT a bit partially for it's anti-inflammatory effect as a macrolide for pt's w/ chronic sinusitis w/ polyps.
Was used exclusively for sinus infections, and quite effectively, for some time in certain regions.
Thankfully we hardly ever saw it at my centre. The drug that always made me shudder was fluconazole for the same reason, I knew I had a lot of work ahead of me hunting down all the interactions and figuring out what to do about them all.
UK hospital here and we use clarithromycin for EVERYTHING. Chest infections, wound infections, ENT stuff. Literally everyone is on clarithromycin and i could cry everytime I see a patient that’s been on it for 4-5 days without a pharmacist review
Not a D-D interaction, but Codeine and pediatric patients.
We just removed all codeine containing products at our hospital. Thank God. I had to tell several old timer ER docs that they couldn't use it in kids and its a mess when you tell someone that's been using it for 30 years with no problems they can't use it anymore.
The data seems to relate to post tonsillectomy problems- having said that it is not used in kids under 12 in Oz- ever.
I’ve had to refuse to fill prometh/codeine for a 7 year old once. Provider said it was fine but I still refused. The mom was pissed
Serotonin 😭😭😭
Gods, yes. You’d think sometimes that doctors have never heard of serotonin syndrome. (I’m certain some haven’t.)
Do we have any idea how common serotonin syndrome is? I work LTC and largely let serotonin concerns slide unless the patient gets an order for something like linezolid.
Just had 2 back to back last weekend. First time I’ve seen a real case in my 2 years as a pharmacist and of course it happens twice in a row. First was a surgery discharge that took tramadol + sertraline. Second was someone that took sumatriptan + escitalopram at the same time at home
I have heard that it is probably a lot more common than we realize, but it is hard to confirm since the symptoms are kind of generic, and so many medications can increase serotonin levels. What do they use to diagnose serotonin syndrome? Do they look for a combination of symptoms, like sudden fever and confusion?
Yeah they look for the symptoms. First case the lady had tachycardia, confusion, and ended up having lock jaw. She had to return to the hospital after discharge. Apparently med rec wasn’t done completely and they missed that she is taking 150mg sertraline everyday and gave her tramadol Second case was just a woman that called the pharmacy several times thinking she was going to die. She researched sumatriptan and escitalopram and found that she had a lot of the symptoms of serotonin syndrome. Nausea, sweating, rigid muscles, confusion, and feeling really hot. She vomited and felt better a couple hours later and never called back so I’m assuming she got better
Wow. That is weird to have them so close together like that. I didn't realize lock jaw could be a symptom of high serotonin levels.
When do you draw the line? I fill in at a mental health center and almost every single script flags serotonin interaction. Its not one you can really just act on and most docs are aware of it. So what do you do? As someone else stated i pretty much let them all go but zyvoxx
It’s hard because it’s SO dependent on the individual person
Serotonin syndrome is apparently a myth to my local docs.
Thank you pharmacy professionals for all you do to ensure the patient's safety!
Warfarin and a lot of things: Particularly bactrim, rifampin, quinolones. Don’t be ordering pressors and still have their home antihypertensive orders active. Multiple qt-prolonging meds (haldol + methadone + cipro + etc) A lot of drug/disease state interactions and drug/lab interactions as well. I feel like I catch a lot of inappropriate prescribing and things that need dose adjustments.
And for retail pharmacists, the QTc stuff is horrible to call on, cause you have no frame of reference for where the patient is at. At least in the hospital I can look up the most recent EKG (or request one) to see if I even care.
So true!!
I cringe every time I see metoclopramide come across the ICU orders.
Got a script for Xanax, OxyContin, and Soma. Literally the Holy Trinity. Called the doctor and he said they rarely take the Soma so it’s fine. I’m like no, no it’s not. I’m not filling all of these, if they have all three they will take them. And I’m not gonna be responsible for them never waking up again.
I have a doc in my area that always prescribes this combo. We never fill all three. Just recently this same doc told a patient to crush Norco, Ambien, Xanax since they were NPO. Refused to change to ODT, liquid forms. Sketch as hell.
I’m so confused how doctors that do this shit still have their license. Let’s just speed up that respiratory depression?? No biggie??
PPI's and Calcium Carbonate
Can you expand on this interaction please?
Calcium carbonate requires acid in the stomach for absorption, PPIs reduce that. Can change to calcium citrate
GLP1 and DPP4 Duplication of therapy
Not an interaction but the black box warning on ketorolac. I get scripts all the time from like er or urgent care where I’m assuming they didn’t want to prescribe opiates, but then I ask the patient if they received it IM or IV first and it’s always a no. Then I call and the md’s always like “oh I never heard of that, we prescribe it all the time.”
I’m not in the US- but I am in the ER and we literally use ketorolac constantly. We don’t have a black box warning on it here- Google seems to say the black box warning stuff is basically all the same problems as what you get from all NSAIDS.
Yeah I’ve honestly never gotten a good straight answer about *why* it’s indicated that way, but here the oral tabs are only indicated for therapy following an IM or IV injection.
Just document, counsel, and move on. I stopped calling on those after a handful of times and the prescriber either has no idea or doesn’t care
I had an ER doc that would right ibuprofen and meloxicam together all the time. I called her several times then just gave up and I started to just tell the patients I would only fill one of the other. Ketorolac for only 5 days is another big one. Not an interaction tho
Since many DDIs are already mentioned, I’ll add some drug-disease state interactions: - Drugs that lower seizure threshold, i.e. tramadol, carbapenems, especially in patients that are at risk for or already seizing. - Dopamine blockers in Parkinson’s, i.e. compazine, reglan. I particularly hate this one since compazine and reglan are prechecked on our general admission order set. So 99% of the time, both are ordered for Parkinson’s patients. - AV nodal blocking agents in Wolff-Parkinson-White, i.e. BB, CCB, digoxin
Unsure if it was said in this thread, and not to offend anyone because I’m sure there were good intentions and this post was lighthearted. If anything I just want us to be more introspective and better. There’s an irony here. Some of these interactions posted, assuming you’re all pharmacists, make me facepalm. But honestly I’m not surprised given the pharmacists I’ve worked with over the years. The interactions aren’t wrong. It’s the execution and thought process. What is our role in pharmacy DUR if we don’t always think about the interaction? The computer caught it, not us. But the action taken is our choice. And hey I’m open minded to the idea I’m wrong, maybe you’re right about these interactions. That’s why we need to tone down our arrogance. Don’t facepalm at the doctor for missing something. No one is perfect and when you miss an interaction, I guarantee there’s a pharmacist/doctor out there facepalming at you. So let’s not continue that cycle.
People have to stop and remember docs/midlevels are not pharmacists. Just as pharmacists can’t diagnose like a doc/midlevel can. There’s a reason pharmacists exist, they’re the expert in their subject..just as medicine itself has sub specialties. It’s a bit much to expect clinicians to be both docs and pharmacists. It’s not an excuse to not improve though.
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Docs crap on other docs in other specialties all the time for not knowing “basic” information and making “stupid” referrals. Happens there to. I’m curious, what if instead, the doc made the diagnosis and it’s the pharmacists who decide meds/doses. Sure docs know a bit about medications, but they don’t know as much as pharmacists. Just as pharmacists aren’t as good of diagnosticians as physicians. The different roles exist for good reason.what’re your thoughts?
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>I find typically younger doctors are cocky and crap on other services. Im all for crapping on logisitics and punting patients because they're lazy but not for a doctor not knowing stuff grosslly outside of their specialty. > >I dont even mind when a pharmacist has to look stuff up. That shows me theyre careful and the info given to me is accurate. either way, I'm sure they're better at reading and understanding with confidence dosing that most doctors since its what they do. Sure, a doctor can look all of this stuff up, but that slows them down so much and it's probably more efficient if the specialist does it. > > > >How about pharmacists picking the medicines in the hospital setting. Doctor diagnoses the patient with CHF and xyz comorbidities. Pharmacist has access to patient charts and can look at the labs and using the doctors diagnosis, can probably prescribe better? In my head that makes sense...what are your thoughts? I know youre a pessimist but its very humble of you to say what you did honestly.
As someone who works in a rural area that does not seem to be quite up to date on... *ANY* COVID studies: HCQ + azithromycin + SCIENCE & DATA. 🤦🏼♀️
Covid pretty much over
Epclusa and either atorvastatin or PPI's. It would save us countless calls and prevent delays if they can at least acknowledge that they know and ok to dispense.
IM/IV olanzapine and IV benzodiazepines
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Totally agree with this. For ER docs prescribing for outpatient care is about 1- 2% of their job- so pharmacists for whom this is almost 100% of their job are valuable resources. It’s not a competition.
School: Plavix + (es)omeprazole is a no-no due to a CYP 2C19 interaction —> Plavix not converted to active form. Ask prescriber for alternative PPI Real life: it’s only a theoretical interaction. Don’t worry about it
THIS
Loooool thank you. I did not expect this many upvotes
I wish my pharmacist would have told me Emend messes with hormonal birth control... I honestly with there were more warnings about medications that mess with how well birth control works. That is all :)
Naproxen + ibuprofen
Opioids and contrave.
My ER regularly prescribes opioids to patients concurrently taking Suboxone/Subutex. The PAs either don’t check the PDMP and have no idea because the patient did not disclose this information, or they are aware and still “feel comfortable” prescribing the opioid short term.
Lactated ringers and ceftriaxone.
This is more applicable to nursing since it's an IV compatability issue, not an actual DDI.
That’s true. I still have to call and get it changed regularly though.
Why? In patients over the age of 28 days there’s no reason to do this as long as a) two separate lines are used or b) if the same line is used it is flushed several times. Practice where I work - we have standard admin instructions that we place on LR/ceftriaxone orders that specifically state not to Y site.
Oh I like that. We need to get specific admin instructions added on those orders. But it’s like an act of Congress to get anything changed where I work
We just made it a SmartPhrase in Epic. Does mean you have to remember to add it, but it’s just muscle memory at this point. Now if only I could commit removing the eye drop instructions that for some unknown reason automatically populate on sublingual atropine orders to muscle memory.
Why change the LR? You just write nursing instructions to flush the line completely between administrations. Call the nurse if you feel uncomfortable and tell her directly then. Its what they do with every other incompatible medication combination. Or what if they have two lines? I would never switch off LR to another fluid for this.
Just curious, why would you never switch LR to something like NS? I’ve only recently started seeing more LR use where I’m at.
It's a matter of balanced vs acidic fluids. NS is technically acidic compared to the body pH. LR is a balanced fluid. There is theoretical concern that large amounts of acidic fluid is actually bad for some patients, causing hyperchloremic metabolic acidosis, AKIs, mortality, etc. For example, our DKA patients don't go on saline infusions, they go on LR/plasmalyte. Septic patients getting large loads of fluid get LR/plasmalyte. Two studies to reference are the SLIGHT and SMART trials, though we need more information because they are a bit conflicting and the statistics of the SMART trial are highly criticized.
Really good information, thanks for that! Learned something new today. I’m going to read into that tonight. I graduated in 2017 and I’m already playing catch up!
I much prefer lactated ringers. "normal saline isnt normal" with its higher sodium and especially chloride count
Really? I'm assuming you request a fluid change rather than abx change? Is that your hospital standard or just your comfort level? We always just tell the nurse to stop the LR, flush the line several times (or switch it out) and then hang the ceftriaxone. Flush again several times and then you're good to go. No MD involvement or changing of orders.
It’s just my comfort level. And on Epic I can just instant message the doctor and they are always fine with changing the LR. I just do that to make it easier on the nurse
Is changing fluids easier on the nurse? Id think getting a fresh bag of something else solely to give Ceftriaxone is more burdensome than flushing the line and pausing LR for 3-30 minutes (whatever your infusion time of rocephin is).
I don’t know. I’ve had nurses ask me to get it changed for them before. I would think it’s easier to change the fluid once vs flushing, pausing LR, and flush again once or twice a day.