ATAP: Medication changes and how I deal with them

I received this question from a doctor who frequents the site:

I have a question regarding changes in medication. I am a physician.
The way I usually handle it is that I tell the patient the new dose and
then write a prescription to reflect that dose. I then tell them that
they’ll have to go in earlier than usual to get a refill and to use the
new prescription to let the pharmacist know that the dose has been
changed. Is that the best way to handle it?

This is an excellent question. I far far too often have patients tell me (when they are out of medication) that doctor has changed the dose. Usually this is on a Friday night about 10 min before closing.
In the case above, you, Dr, are doing the correct thing. Seriously, I cannot express this enough that writing a new Rx for the patient to bring in (or fax over from your office) is the absolutely best thing to do. Telling the patient about the new dose is like talking to the sky (or filtering piss out of the ocean). I have seen more mistakes with patients getting their pills mixed up and taking double on something they shouldn’t have. Usually things turn alright, but when they get instructions to double up on their HCTZ and instead double up on warfarin, things turn sour really quick. If doctors always assume that their patients cannot wipe their own asses without written instructions, the world would be a better place.
This is what I do with a sig/dose change for which the MD has done “The right thing(tm)”:
When the patient comes in, I get the new Rx in hand, and right then I have verification that the dose has indeed been changed which I input into the computer and fill the Rx (if they are out). If the patient comes in and still has some medication at home I put the changed Rx on file, and if the drug & strength are the same I print out a new label and tell the patient to apply it to their old bottle (I write the Rx number down which to apply the label to). Usually the patient is smart enough to match 2 numbers together and apply a stupid sticker. However this is a huge judgment call, and on more than one occation I have told them to come back with all of their medications so I can do it myself. I instruct the patient to come in when they are out upon which I fill the Rx that was put on file and everything is happy in pharmacyland.
So if you are an MD/NP/PA/DO/CNM/Janitor who is reading this, here is a few tips on how to make your pharmacist love you.

  • Any changes in dosage or sig, write the patient a new Rx. Using a sharpie on my pharmacy label is just going to waste both of our times with a fax over confirming what you wrote.
  • If any medications are DC’d, let us know. Nothing annoys us more than to have to wait for a fax-back asking if the patients Lotensin needs to be DC’d because you wrote an Rx for Diovan. Its not that its a waste of our time, but the patient obviously has no clue what’s going on, and the terms “possible therapy duplication” is like speaking chinese to them. They have to come back to the pharmacy, or wait an unknown period of time until we get an answer.
  • Write down any and all information on the Rx that might save a phone call or fax when switching to formulary alternatives. Unless you really want Protonix for some god-forsaken reason (like the reps are giving you lapdances), writing “or equiv” will save us both a ton of time. A PPI is a PPI for gods sake.
  • If you have any questions about whats covered, a rule of thumb is that if its cheap and generic; its covered. Prilosec vs Aciphex, Lotensin vs Aceon, etc etc etc. Have you tried generic Mobic vs Celebrex? You should! If you don’t really care what NSAID the patient gets, then state “Feldene, but whatever is covered, therapeutic sig”. Any pharmacist worth his salt will take care of your patient and not bother you. We may fax you what we gave so you can keep your records updated, but we’re not going to ask you a bazillion questions if its okay. Remember, we went to school to learn about drugs; have a bit of trust in us.
  • Hate to tell you, but most NEW drugs now days are just knock-off me-too’s that are out because their replacement is going off of patent soon and will be dirt cheap. Look at Paxil CR, Coreg CR, Adderall XR, Lexapro. All came out shortly after Paxil/Coreg/Adderall/Celexa went off patent. You have been using these agents for 10-15 years, and all of a sudden they suck because something new came out? Think of it this way, if they were so “new” and “breakthrough” and “revolutionary”, then why weren’t they out when there was 5 years left on the patent on the drug they are meant to replace?
  • If you have any questions about pricing, call us. Seriously. Nothing makes me happier than churning my workflow to a grinding halt to answer a phone call from a local doctor wanting information vs some crackhead asking for their vicodin a week early. Believe it or not, we’re in the same boat, and we cant exist without each other, so lets actually talk once in a while.

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10 Comments

  1. 2nd Year Pharmacy Student says:

    Great post! I seriously agree, doctors could so so much to make things go smoothly for themselves AND for us if they would follow your advice. One comment though — Mobic isn’t equivalent to Celebrex. Celebrex is COX-2 specific whereas Mobic is significantly less selective for COX-2 versus COX-1 (more concern for ADEs with patients on anticoagulant therapy, etc.)
    Keep giving out the great advice for MDs. I am still convinced they need to have an intensive class in med school on how to properly write a prescription and what happens to the magical piece of paper when it leaves their offices. Believe it or not, pharmacists don’t reside in the Tower of Babel where all indecipherable hieroglyphs/chicken scratch can automatically be interpreted.
    D

  2. RJS says:

    None of the above will ever happen in my neck of the woods, unfortunately.
    It would if FPs as PCPs were more common than internists. IME, internists seem to have a collective stick up their asses.

  3. richmond says:

    i’ve had a doctor that just simply disappeared every so often, so the PA was there instead. with an Rx pad. The Doctors own Rx pad. Presigned. The entire book.
    Not only do I think that is probably illegal, i think it is totally unsafe.
    i stopped going to him because one of the “nurses” was still in school! she is younger than my sister for gods sake! and she just graduated from uni.
    so freaky, him!

  4. RxPower says:

    As a 2nd year pharm student, you will soon learn the practicality of using meloxicam before Celebrex. Altough I’m sure that the highlighted portion in your therapeutics notebook on celecoxib’s COX-2 specificity and NSAIDs Med-Guided potential for ulcers is important for tests, when faced with a $50 copay, most patients/doctors will choose the more COX-2 specific meloxicam. (I know, run-on sentence). I’m sure drug information taught you how to look stuff up. J Med Chem. 1997 Mar 14;40(6):980-9. & Can J Physiol Pharmacol. 1997 Sep;75(9):1088-95. Yea, it’s been a fact since ’97, when you were still playing paintball and trying to finger girls.

  5. http://openid.aol.com/emujane1980 says:

    I would also like for the doc to make some notation on the new script to confirm that it is for a dose change. I’ve had scripts dropped off when the patient has no idea whether their dose has changed, it would be nice not to have to confirm.

  6. Dawn Marie Perry says:

    I love this blog. I started my own pharmacy in 2005 and blogged briefly about my experiences. I stopped blogging because I am inherently lazy. I stopped in to comment because I ran across something interesting today while looking for the contents of a cough and cold product. Have you ever been to cafepharm boards (http://www.cafepharma.com/boards)? It appears to be a site for drug whores. Several companies have message boards where the reps discuss salaries, bonuses, and products. They also insult each other and their rival companies. It is a strange site, but I thought that you might find it interesting! Thank you for your always-entertaining thoughts! I am glad that you are telling our stories.

  7. Pharmacist from Northern Ontario says:

    I just wanted to add that it helps if you can get the doctor to note on the Rx that this is actually a dose change, by using a little arrow pointing up if the dose is increasing or down…what am I saying, no one ever gets their dose decreased! Anyway, it’s just another way to avoid a time waisting phone call to check that this was a dose increase and not just an error, especially when the patient has no idea that the doctor was changing the dose!

  8. N.B. says:

    Great post, TAP. I definitely think you’ve put down some excellent advice for physicians here.
    Just one thing. Is everything you’re suggesting legal? I know that therapeutic interchange without a physician’s consent is a no-no, but is it suddenly acceptable if the physician writes “or equivalent, pharmacy to dose” like you’re suggesting? I’m not 100% clear on the issue, and while I realize it’s highly improbable that you’re going to get busted for it (and you really shouldn’t), the dreaded insurance company audit is still going to loom over you at the end of the day…

  9. AZ Pharmer says:

    I would like to know how this MD learned to do this and if he would like to relocate near me!
    Seriously, this is such basic shit that it completely pisses me off, I convey this to the patient making it known I’m annoyed and that their Dr. should know better than to tell them without somehow telling me, and in the case of one repeat offender scatterbrained/lazy cocksucker MD, implying (strongly) that he is mentally retarded.
    The patient is instructed to call the office themselves and request a new rx be phoned in and ask why this was not done 2 weeks ago when the dose was changed.
    This is not my job and I do not make these calls anymore and my staff is only allowed to fax the request ONCE…I will not waste my time calling. If its after hours I suggest they bother the on call md at home (and secretly hope that he/she is in the middle of the best lay they’ve had in months)
    by the by, is this angry thing contageous? if so I think I’m fucking terminal…

  10. Pharm Guy says:

    Wow! Great entry! We wasted all sorts of time on this. After contacting the docs, it seems like you have to fight with the insurance company next. There needs to be a general physician email!

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