Vancomycin Question!

Heres a very good question that I recieved about Vancomycin (AKA Mississippi Mud) from Ingrid. I actually had this question a few months ago.

So here’s my question: Can IV vancomycin be given orally? Once upon a time a couple of jobs ago, maybe 15 years ago I worked on a peri-op floor of a fairly small hospital. We all know that PO vanco is really expensive and IV vanco is pretty cheap. The pharmacist at our hospital told us that it was perfectly okay, and it was cheaper for the patient (and probably the hospital if we got stuck with reimbursement stuff, I’m thinking). We would draw up whatever the dose, squirt it into a med cup, and the patient would drink it.

Actually, I had this same question about 9 months ago. I actually called up my old coworker at the hospital that I used to work at and asked him. Yes, you can. Vanco is vanco and the capsules aren’t anything special or extended release. Considering that Vancocin Caps are kilo-bucks and Vancomycin IV is dirty cheap, its a good way to save the patient a whole lot of money if they are competent enough to reconstitute and administer it.

NO ONE I have ever worked with since has ever heard of such a thing. MDs don’t believe me, and I don’t know whether or not to believe them. I’m asking because 1. it’s interesting, whether it’s true or not, for lots of reasons, which I’m sure you get.
2. my dad has mrsa (wound) and has been taking some pretty expensive p.o. alternatives at home (&%### medicare D and its wonderful “donut hole”).

Oral Vanco isn’t bioavailable. Meaning that if you take vanco caps, all it will do is just kill everything in the gut and not get absorbed into the rest of the body. Thats a /very/ common mistake that doctors make is they have the patient on IV vanco, then send them home with caps and wonder why its not working. Vancomycin is not like Levaquin or any other IV/Oral antibiotic. Like Neomycin (though Neomycin isn’t given IV anymore. Well, not if the doctor likes your kidneys), the physical molecule is too large for the body to absorb, so its really just GI topical. If he’s taking oral Vancocin for a MRSA wound, then you’re just wasting money and your doctor is a fucking idiot. Oral Vanco is only indicated for C. Diff pseudomembraneous colitis after failure of Flagyl.
People tend to freak out when the word MRSA is thrown around, however when the doctors get off of their butt and do a C&S report, they find that sometimes its not resistant to some really common antibiotics like clindamycin, doxy/tetracycline, or cipro.
But to answer your question, no, there is not any difference between oral/IV chemically. There is a difference between absorption on oral vs IV, and the biggest problem is having the patient be competent enough to reconstitute the proper IV dose to give it to themselves orally.
Wow, I actually impressed myself with how smart I sound.. 🙂 Pretty good for a retail chump.

The Tech Call

On a more lighter side of things, I have noticed a certain phenonemom in my years and years at the pharmacy. Its called, the “Tech Call”. Heres how it goes:
You’re working along after getting a whole 2 min to eat lunch. Obviously you did not have time to chew or even enjoy your food. Compound this with talking all day and swallowing air. You know where this is going, you need to pass some gas.
Thats right, fart. The one joke that never gets old. Nothing is funnier than watching an old man bend over for that bottle of mag-citrate only to rip the loudest fart in the store. You only hope that he didnt shit his pants and have it run down his legs for you to clean up.
Of course while you’re talking with a patient you cant just rip one right there, so you hold it in, and it grows, and grows. Sooner or later it feels like your colon is going to explode and you run the risk of letting it go and having a bit extra come out. The infamous ‘shart’ (which is what they should of named Xenical). So you wait for the opportune time to let loose the beast that is trying to claw its way out. You wait until there is nobody around, spread your legs really fart apart so it doesnt make much noise, and release………. As you feel your bowels deflate….. YOUR TECH WALKS RIGHT BEHIND YOU AND GETS BOTH BARRELS OF POO-POO BUTT DEATH RIGHT IN THE FACE.
Never fails. Its like farting calls your tech/clerk/coworker to walk right behind you at that moment. Its like a dog whisle! Your ass is sending out a supersonic call that says “Hey Tech! Walk across the store and come right behind me for no reason!”
Now a good tech will stifle the whole “oh god” as he/she cuts a swath right through the gaseous death that is hovering right behind you, but a fellow pharmacist coworker usually isn’t that kind. They will say “HOLY SHIT WHAT DIED IN YOUR ASS.” Of course you can do nothing, because you are up to your armpits in work, so you must sit there, hold your breath, and hope it dissapates quickly. All while this is happening the entire store manages to walk right behind you and give you a chuckle or comment about how nasty the fart you just ripped is.
Never fails I tell you, never fails.

I have a fan club!

My fiance’ (yes ladies, i’m taken. Sorry!) has pointed out that I have a fan club that I was unaware of.
On Facebook ( I have a group dedicated to yours truly. Whats even better, is that it has over 300 members. What makes it even better than that is that they actually LIKE ME! It touched me in ways that I thought I could only touch myself. Just search for ‘Angry Pharmacist’ and you’ll find it.
So I caved in, asked my computer friends for help, and created a Facebook account. My name is ‘Ang Pharmacist’. Facebook wouldnt let me have “The Angry Pharmacist” so my first name is now Ang. You can ‘friend’ me or do whatever you facebook people do (it confuses me) to your hearts content.
If I have any other fan clubs let me know. 🙂

Let loose the nurses of war!

One (1), uno, a single person had a complaint about my Nurse vs NA/MA rant.

I am a 17 year old girl in my senior year of high school. Im in the miami
valley career tech center. This is my second year in the MVCTC. I am taking
allied health. I have always wanted to be a nurse as far back as i can
remember. My program has already went on clinicals and everything and we
are trying our best to learn everything as quick as possible. I think that
NA’s and MA’s should be able to call themselves some what of a nurse
because after all thats what we are going to school to be is a nurse. I
also dont think people should run their mouths about people who call
themselves nurses because its none of anyones buisness so leave it alone.
Our teachers that teach us here are all very good RN’s that know what they
are doing!!!!!!!! SO STOP YOUR SHIT AND GET OVER IT!!!!!!!!!!!!

Ah, to be young again. Honey, you’re going to find out later on in life that if you call yourself something that you are not, especially in the medical field, you are going to get in a whole pot of deep hot shit. Comparing your education to someone with a BS degree in nursing is really insulting to those who actually went to college for 4+ years to get an RN. Names and titles are reserved for those who actually earn that title. See, the ‘A’ in your title stands for ASSISTANT. Therefore you are a Nursing ASSISTANT not a NURSE. You can call yourself an NA or a MA until the cows come home, just don’t call yourself a nurse. In fact, you don’t even call yourself a ‘woman’, but a ‘girl’. Afraid someone is going to call you out that you are in fact a girl and not a ‘woman’?
And yes, It is my business to know exactly who I am talking to on the phone, because you may not realize this now, but when I ask you a question, and you guess an answer (because you are not an RN, and you think its okay to just guess) and someone dies, its my ass, not yours. I’m not saying that you all are a bunch of idiots, but my pharmacy techs don’t run around calling themselves Pharmacists, so you shouldn’t call yourselves a nurse. See what your RN teachers think about that.
Now what you should be worried about is the influx of angry nurses who are going to chew your ass a new one when they read this post. Of course its best to have this happen on the internet than in front of everyone in a hospital where they can see you cry.
I’m going to enjoy this. Nurses, you know what to do! Get your friends in on this. Lets make something she can print out and hand to her teachers who think its okay that they call themselves nurses.

Housekeeping Rambling – Year 2

Hi all! Its been a long 2 years since I started this site!
Once in a while I’ll do these housekeeping posts to inform all of the new viewers at home exactly what this site (i hate the word blog) is about, how to contact me, etc.
I am, as you can probably guess, a pharmacist. I work in the very bad part of town. I use this site to vent my frustration at the world and the public in general. I like to think of myself as the patron saint of retail pharmacy. I believe I am the first angry pharmacist on the internet, but that may be a push between myself and the DrugNazi.
To answer some questions you may have:

  • No, I am not this rude to my patients. I may have no problem shitting on the ground, I do have a problem shitting where I sleep.
  • No, I don’t hate doctors. There’s always a few out of the bunch that really piss me off, thats focused on them. Not those of you at home reading this. I know you doctors are spying on me from the comfort of your nice baby seal skin chair.
  • No, I don’t hate drug reps….. okay, thats a lie, i really do hate drug reps. Sorry, they make my life hell. If you’re a drug rep and reading this, I’m sorry, I hate your profession (not you personally). If you were unemployed maybe drugs would be cheaper for the rest of us. Plus doctors would actually have to use professional judgement, common sense, and brains (*gasp*) when looking at new medications rather than spoon feeding them what they want to hear via your large breasts and low cut tops. *shrug* Eat a dick. Should of given me those nice ‘doctor’ pens you hide from us. You know, the heavy ones that come in the little felt sleeve.
  • My email is I’m sure you can guess what ‘thissitename’ is. I get enough junk email making fun of my small penis and tiny breasts so you’ll have to use knowledge to email me (added bonus: weeds out the retards). You can email me pretty much anything. Questions, comments, nude photos you might be considering sending to penthouse but need another opinion, anything!
  • Unlike the DrugNazi, this site is for pharmacy related stuff, not political bantering and soapbox. I may get on the soapbox when it relates to pharmacy, but not on other stuff. I know i’ll piss you off with my views, so i’ll keep them to myself.
  • No, I dont know the DrugNazi. I keep on telling him to email me so we can go out on a drunken angry pharmacist escapade, but he’s too busy being angry at the world as he bends over for one of the corpo-mega-chains.
  • I use bad words. My mother reads this site and is ashamed that I use such foul language. She also doesn’t work with the public. Silly mom.
  • I’m not good with computers. I just click the little “Save” button and magically my words appear on my webpage. Dont ask me computer questions unless it involves Foundation Systems Inc pharmacy software. I’m good at that. If any of you at home work for them, drop me a line, I want to say hi. I might even plug your software here.
    In the past few years, this site has gone from getting about 10 views a day (mostly by me) to a metric (not imperial) buttload of views. What do I think about this? IM FUCKING FAMOUS! HOLLYWOOD HERE I COME-or maybe not. Hell, someone even created a site called theangriestpharmacist! Talk about riding in on my coattails! Sorry pal, unless you make the 10:00 news going on a killing rampage of minority welfare children I have you beat in the anger department hands down.
    I would however like for you to tell your pharmacy friends about this site so they can get a chuckle and realize that they are not alone floating in the sea of stupidity. I know most of you have, but I know a few of you are slow and need a little prodding.. “Go! Shoo! Fax this to your friends.. go now! Its okay! Mush!”

  • I’m sick, batton down the hatches!

    Nothing is more frustrating than having to work when you are sick. Unfortunately I’ve been sick this entire week and (due to my wonderful work ethic) cannot call in sick. Therefore I take my anger and frustration out on other people (much to the joys of you at home).
    First off, a big screw-you to all those people out there who say “oh dear, why is a pharmacist working when he is sick spreading germs to everyone that comes in! Thats horrible!”. First off, I’m not coughing or sneezing into your vial (even though sometimes I’d like to take a dump in it). Second, it helps drum up business. Third, all of your sick asses come and cough on me and get my staff sick. Its payback time, go to hell.
    As I sit here at 1am waiting for my promethazine-DM (no, not the codeine one you crackheads, though the Alpharma made one I heard is quite tasty) to kick in so I can sleep, let me tell you about my week.
    Highlights of the Angry Pharmacist’s Week:

  • Ungrateful welfare people: I get up every morning at 6am and drag my ass into work so your lazy fucking ass can sleep until 11am. Therefore I deserve a little more courtesy than “Give me my Vico-Dans”. Seriously, let me work HARDER so you can be more of a BITCH to me. Why are my tax dollars paying for your stupid ass again? Oh, thats right, because we’re the working serfs and you’re just a welfare scammer. To those at home who want to start an argument with me: Leave your gated communities and 40k SUV’s and drive to the bad part of town and work there for 8 hours a day, 5 days a week. After you clean the turd stains down the back of your legs, you’ll understand why throwing money at a problem does not make it go away.
  • Drug Reps: If you are a drug rep, go shoot yourself. If you are thinking about becoming a drug rep, go into prostitution, you’ll get more respect from me. Some drug rep comes and visits me from Pfizer trying to push Liptor. I’m swamped, sick, tired, and the hoe just stands there and doesn’t take a hint. I angerly stumble down and put on my “im happy” face and see what free shit she has for me. Nothing, just a binder with some papers. She then proceeds to tell me how wonderful Lipitor is vs Zocor. I tell her “Zocor is like $5 vs $100, how do you get off fooling yourself that Lipitor is better?”. She gives me this big hooplah about drug interactions and rabdo (she horribly mangles the whole name), etc etc etc. Basically just trying to spoon feed me the shit that Pfizer filled her head with. After she was done completely making an ass of herself I said “So, %1 of the population cant take Zocor, why should people use Lipitor when 1 month of that will pay for 1 year of Zocor?”. She hands me these stupid little reimbursement cards so you can get “a whopping $15 off of your copay”. Fucking Wee for you! 15 bucks on a 100 dollar drug! Let me dance a fucking jig of joy. She was so excited about this I think she was about to cream her panties. I ruined that by saying “Why doesn’t Pfizer just lower the price of Lipitor rather than hand out these stupid cards? Have you noticed that you’re existence being here is fueled by a similar drug going generic and dirt cheap? Where were you a year ago pushing Liptor when Zocor was trade name? What about Pravachol? Why all of a sudden all the attention to Zocor? Oh, I know, because its dirt cheap”. She gave me this really dirty look as I creamed my panties with that rant and handed me a binder citing all of the studies and told me to read it for myself. I said “Oh, nice, studies funded by Pfizer, go figure, I already know how this is going to end”. She thanked me for my time, and with a huff waltzed off. I think i soiled myself with glee after that. To all of the drug reps out there in internetland: A pharmacist is busy like a doctor. Best thing you can do is wave hello, and leave the stuff with the clerks if you stand there more than 30 seconds without the pharmacist acknowledging your existence. You all have the uncanny ability to come at the absolute wrong time (during lunch) so thats why we (meaning I) am always pissy when I see you. Plus to be honest, we really don’t give a shit what you are pushing, we just like the free pens. The person you should be lap-dancing for is the insurance companies. They run the show, we dont. We’ll switch it to a generic 99% of the time because then we get lube when the insurance companies rape our behinds. Insiders view, take it how you will.
  • “Nurses” who cant speak english: Totally insulted a “nurse” by saying “Im sorry, can you get someone who speaks english? I really cant understand a word you are saying”. Then the person who got on said I was being an asshole! Me? An asshole? NEVAH! I just said that I couldn’t understand the persons english and to just give me the fucking Rx so I can stop wasting more time. I mean it wasn’t anything ambiguous.. Only HYDRALAZINE 25 tid. You know, a totally legit sig for Hydralazine or Hydroxyzine. I’ll just flip a coin on this one. People think that we need correct directions for medications. HA! All of pharmacy is just good guesses and tons of luck! Silly non-english speakers and their bok-bok accents! Seriously, remove the stick from your anus and wake up. People’s lives are at stake and if you cant fucking say the drug names than you shouldn’t be calling in Rx’s.
  • Pharmacy Student Associations: Yanno what really bugs me? These pharmacy school students who are so gung-ho about the profession that they go to all the meetings, and get togethers, and circle jerks, and orgys, etc. They are so proud to be president of some alphabet soup association. They think they are so fucking important “pioneering the way for the future of pharmacy”. Oh, im sorry, us retail folk are busting our ass to serve what you so gleefully verbally masturbate each other about. I’m not saying that the associations are bad, they do a ton of good and I’m a member (yes yes, I know) of them, but the students who go all horny and brag about how they hold an office and put it on their resume. After you have been in the trenches for 15 years, then you can ‘pioneer’ to your hearts content. How do you fucking ‘know’ the profession or what it ‘needs’ when you’re just a fucking two bit student and have never worked a fucking day as a fucking pharmacist. Whew, prometh kicked in when writing that one.
  • Working while Sick: As said before, I’m ill. Yes, I did work due to some people calling in dead or retarded. Yes I have wonderful work ethics that I will only go home if I am on a death bed. Yes, I am every employee an independent pharmacy has wet dreams about. Yes I am fucking awesome and if you knew me in real life you would say “YOU ARE FUCKING AWESOME”. However the awesome-machine that is me tends to gum up and jam when I’m sick. I fucking hate it. I feel like ass, and no matter how much ibuprofen, entex-la, and prometh-dm I guzzle I still feel like ass. I have no urges to try the shit with codeine, or tussionex, or any of that controlled shit. I only took prometh-dm because we didn’t have an open bottle of Robatussin DM hanging around and I didn’t feel like buying it.
  • SHOWERS: For fucks sake! I’m on the verge of throwing up so hard my asshole would suck in air. All I need is for some funky smelling patient coming in and giving me dry heaves. Seriously, go jump in a pond or use the garden hose in the back to bathe. Fortunately my nose is all stuffed up, so I’m partially immune to their evil powers, however I can do that mouth-smell thing. Ew.
    So yes, that has been my week. I left out the parts about crying and early refills, and the other mundane shit that everyone reads on here.

  • Taking the CARE out of WellCare

    This is a directed bitch at WellCare. Yes, WellCare. I hope they read this, and I hope they give me an ‘offical reply’ to their stupid ass policies as you’ll see below. If you have a bitch about WellCare, then comment below. If I’m going to get a subpoena or court order to take this entry down (which I’m not, because its the truth), we mine as well go down swinging.
    Its 5:30, right before closing. One of our terminal cancer patients (11159.2) came in with an Rx for some Duragesic Patches. He is out of oral meds, so doctor figured now would be a good time to put in him on the patch. He has WellCare. So we try to bill the Fentanyl Patches. Not covered. Hm, what about trade name? Nope. No fentanyl patches are covered. So we call the wonderful WellCare customer service number only to be told that there is NO provision for early, lost, or emergency override fills. We pleaded and told the douche that the patient has terminal cancer, and if there was any way to fill the Rx.
    Short answer: No.
    Long answer: No.
    Who the fuck does NOT cover fentanyl patches? Its not like fucking that new quinine thats out. Fentanyl patches are used for one thing: Chronic or cancer pain. I bet they require a prior auth for all HIV medications too (because those arent important)! Anyway, back to the story:
    They would fax to the doctors office a prior auth form which needed to be completed and sent back. This is on a Friday, at 5:30pm. Yeah, snowballs chance in hell of that being done. Even if he doctor did it that very moment it probably wouldn’t be processed until Monday.
    Thats right, this terminal cancer, no pain medication, all because WellCare is ran by a bunch of fucking heartless idiots. The patient ended up shelling out a few hundred bucks for his patches so he wouldnt be hospitalized over the weekend.
    I hope someone from WellCare reads this, and realizes how fucked up they are, what a shitty program they run, and how bad this makes them look. Figures they are processed by WHI AKA Wallgreens. “Pharmacy America Trusts” my ass. So to any of the big CEO’s or important people at WellCare: I, The Angry Pharmacist think you guys are fucking assholes and I hope someday when you get cancer from those $100 cigars and top shelf booze that YOU get to spend the weekend in pain because your insurance company dicked you over like you dicked over my patient.
    Fuck Off and die.
    The Angry Pharmacist

    Drug Disposal Questions

    Once in a while I’ll get a few good questions that I think should be public knowledge. In fact, I even made its very own category for it! I only try to pick questions that a lot of people ask, and something that I can make funny and entertaining to read. As always members of the profession can chime in via comments to add onto the mayhem.

    I have never worked in a pharmacy, so I have to ask…
    Are there really THAT MANY people who are “strung out” on Vicodin (and
    other opioids)? Judging by what I’ve read on this board, it sounds like
    Vicodin prescriptions make up like 75% of all the Rxs filled! Is it really
    this big of a problem? Soma, too?

    Short Answer: Yes
    Long Answer: Oh fuck yes. You are right, depending on your location, you’ll see the number 1 Rx based on pill volume for most community/retail settings will either be Vicodin/ES, Soma, Tyl#3, or Valium. Hands down no question about it. It might not be #1 (I think glyburide is up there pretty good, just because EVERYONE is on #120/month), but i’ll bet your ass the goodies are in the top 5.
    Now strung out. Lets see what stories I have:

  • Phone calls are the best. They sit there in silence, make no sense as they call in their vicodin refills early, and have zero memory of doing so. They’ll call back in 20 min asking the exact same thing. You can tell from their voice that they are gone to Vicodin-Town.
  • When they come into the store, they have that glassy not-there look. Take someone who is really drunk, remove the smell, and have them (and their 5 screaming children) wander up to your counter asking for a refill on an Rx they picked up yesterday.
    Next question, YOU! The blonde with the gynormous boobies in the back!

    You bring up something I have been wanting to ask but didn’t want to
    Now that I am minus a brain tumor, I am off all of my pain meds [Fentanyl
    and Morphine]. What do I do with the extra patches? I haven’t known who to
    trust to hand them over, and you know why.
    Should I turn them in to the pharmacist, really? (Not questioning your
    judgement, just asking for reassurance)

    And your well endowed friend next to you:

    You say that your patients/clients can return unused medications to be
    destroyed, do most pharmacies do this? If not, what is the best way to
    dispose of old medication? Sorry for the questions, my grandmother died in
    April and my family hasn’t done anything with all her medicine yet.

    If ever you have medication that you want destroyed, you should bring it back to the pharmacy it came from. In the fentanyl patch case, yes, you should return it to the pharmacy. We’re not scummy cops who pocket guns and drugs from raids to use/bring home to their kids. We actually care about our license, and our profession so we will dispose of the unused (or used) patches. Especially with the 100mcg fentanyl patches you want to make sure you take them and hand them to the pharmacist directly for disposal. Cutting them up and throwing them away can have really bad results, so dont do it.
    The same goes for unused pills that you bring back. To make it sound official we say that we “Have procedures in place to dispose of all dangerous drugs in an environmentally safe fashion”. Honestly all we really do is dump the pills into a huge sharps container, and the nice lady who does our outdated drug returns takes it to a place where its incinerated. No, they are not dumped into a giant toilet and flushed. Flushing stuff like pills really isn’t a good idea anyways, because stuff like Klor-Con tends to stick together worst than a post-thanksgiving turd and will plug your toilet. Yes, personal experience talking here (the pills, and the thanksgiving turd).
    I’m pretty much free to answer any question you may have about pharmacy, life, etc. If you want liberal political bantering, go to the DrugNazi’s. This is pharmacy-only (which I’m sure you guys appreciate). You can email me at druglord/at/theangrypharmacist/dooooot/com (Stupid spambots). Now I will choose what questions I pick based upon how angry and entertaining I can make the responses, so don’t get your feelings hurt if I don’t answer your question.
    Oh, and happy 1st to all the pharmacists out there. I hope today wasn’t too killer.