Category Archives: Ask The Angry Pharmacist

ATAP (Ask the Angry Pharmacist): Imitrex packaging

Here is my question, though it’s unrelated to today’s post, and it’s not my
pharmacist’s fault in the slightest. Why does Imitrex come in those big,
folding card packages?

Because God and GSK hate you. πŸ™‚
Actually it’s like that for your enjoyment πŸ™‚ I love the Imitrex packaging, because it gives me a damn good excuse to just overrule whatever the doctor writes for in the quantity (#30? gimme a break) and just slap the label on the thing and give it out. Saves me the cost for a bottle, labor for a tech to count, and I can prepare and send it on its way while the techs are busy counting vicodin. Plus I think the pills are really brittle or sensitive to ambient air moisture, so it makes sense to individuality blister pack them.

I can’t easily carry those packages in my purse.
They are also a pain in the ass to open. I use a tweezers to get the first
layer open (try doing that with a migraine). When I pop it through the
next layer, it often breaks and a piece ends up in my carpet.

Get a bigger purse.. πŸ™‚
Or you can just cut out the foil bubbles and keep them in a plastic baggie. You can also rip off the top layer of the bi-fold packaging so you just have the cardboard part that houses the little foil blisters. As long as the tablets stay in the little foil blisters you can do whatever you want. Personally I’d want to keep a copy of the pharmacy label in the plastic baggy so paramedics or other medical personnel can tell what they are if you are found in a ditch somewhere.
For your opening question, its like that to make them ‘childproof’ since they are not in a childproof pharmacy vial. Personally I think childproof caps are bullshit since a kid can get them off anyways, and if you keep your medication where a toddler can get it you shouldn’t be having/taking care of children.
You can also carefully cut the blisters open, but make sure you feel where the pill is first before you go hacking like Conan.

Anyway, I enjoy your blog, and now I understand why it takes time to fill a
prescription.

Thanks! πŸ™‚ I enjoy it when people send me legit questions that I can answer on here.

Woah. I cant believe it.

I am one of those drug reps that you hate see walking through the door but
I have to ask a serious question. Do you think that generic Coreg is
equivalent in efficacy/tolerability to the branded Coreg? Also, since there
will be 14 potential manufacturers of generic Coreg, will they all have the
same effect? Hasn’t there been alot of difference with the generics for
metformin? Maybe not? I would like serious responses because if generic
Coreg is as good as the branded then that will be great for your customers.
They will be getting the best beta blocker at an affordable price. How
about the patients that switch from branded Coreg or Coreg CR to the
generic? Do you see any problems in regard to potential decompensation of
their CHF? I know post MI and HTN patients will be different but the CHF
patient is a little more vulnerable. Also, how about the patient who has
the same co-pay or a little higher for branded or generic- would you
recommend that they switch to generic? This personally happened to me when
I got a script filled. I have the same co-pay and I was given a generic
without being asked. Wasn’t happy about it so asked for the branded that
the doctor wrote on the script.
Thanks for your serious reply.

I love it when drug reps use big words! Its so cute! But seriously, I dont understand how you can believe the stuff that GSK pounds into your brain and you extrude out of your mouth.

  • Tablet making isn’t rocket science. For the “variability” that you talk about, how do you know that the same “variability” isn’t present in the trade name? There isn’t some magical formula that the trade name company in making the tablets, and there isn’t some special machine that GSK has that proves equivalency between invidiual tablets that huge generic manufacturers (Mylan, QT, Watson, Dr Reddy) doesn’t already own. Their ass and reputation rides on their product much like GSK does. So yes, the tolerability and safety will be equivalent. Yes, generic Coreg is great for our patients HOWEVER your employer wants you to switch everyone over to their product so they continue to make a 5.8 zillion dollar profit and screw everyone over. Its business, plain and simple. If Coreg-CR was a superior product from the get-go, then they would of came out with Coreg-CR initally and not the IR. Amazing how GSK did the exact same route that Ambien and Paxil did; release an CR product when (gasp) their product just happened to go off of patent. I bet any money that Avandia-CR is in the works right now. You should of went the Clarinex/Lexapro route and purified an isomer to make doctors cream their panties when they hear about this ‘new discovery’.
  • You know what I’ve found with generic metformin? The patient eating birthday cake the night before he switched. Taking the new brand on an empty stomach vs always taking the old brand on a full stomach. I “don’t like the color” or “This one has the bad smell”. Yeah, totally irrelevant psychosomatic or outside variables that no drug company can compensate for.
  • With decompensation with CHF patient, if they are being treated correctly (meaning a Beta-Blocker, an ACE-I cranked up until cough then reduce by ~10%, Aldactone, lasix/K+) then they shouldn’t have any decompensation problems one bit. Of course Doctors dont want to put their patients on the “proper” CHF regime because its a lot of pills, so they just give them Coreg and some lasix and send them on their way (then wonder why they end up in the hospital).
  • If patients have the same copay between trade and generic (which they don’t), i’ll still fill the generic. Why? Because I dont want a $200 bottle sitting on my shelf when a $5 will do when there is no significant difference between the two. I’m on medication, my boss is on medication, and some of our staff are on medication. They are all generic (and we stock the trade name). Why? Because its cost-effective for the store, for us, and for our insurance companies. We do “the right thing(tm)” of our own free choice. I hate people who are so brainwashed that their doctors are some sort of deities and demand they get trade name Amoxicillin because their doctor wrote it on the prescription.
    So, its time to ask you a few questions:

  • Take like Toprol-XL, Lotrel (Sandoz Brand), Zocor (when it /first/ came out), etc. Know what all of these have in common? Their generics are made by the trade name company. Do you still whine and push your “not equivalent” propaganda when the Sandoz brand of generic Lotrel look exactly the same as trade name Lotrel? I know that GSK probably doesn’t do this yet, but when they do, will you still be pushing some new-product-x and bashing the generic when you fully know that the generic is made by YOUR company?
  • Seriously, how many free trips/dinner/fancy pens/lapdances/kickbacks/bribes/”incentives”/”rebates” do you bring to cardiologists to push your new drug? Do you just throw a bunch of studies in front of him, recite some numbers from a study that GSK funded showing (surprise) Coreg CR superior to God himself and throw schwag at him? Don’t you watch those infomercials on TV and wonder that maybe you are a real-life one? Don’t you believe that to practice “good medicine” the doctor needs to have a un-influenced (meaning no goodies) decision on what agent would be the best and safest for the patient found out on his own free will? If a doctor is “too busy” talk with ME, a licensed professional about his patients health and medication then why would he have enough time to talk with YOU unless you somehow benefit him with free goodies.
  • Do you tell him how expensive this shit is? I mean “I have this wonderful drug that will cure everything” sounds great, until you say “but it costs 34 kerjillion dollars a month”. Seriously, what doctor is going to prescribe something to a patient knowing full well they cant afford it? Oh, because you don’t tell them how much it costs. So I get on the phone, and I tell him “Uh, Mrs Smith has no insurance, and new-drug-x costs $200/month”. He/She goes “Oh, I had no idea, the detail person was just in here”. See that? By you omitting information, you just cost both of us time we did not need to waste.
    So I want you to do something. I want you to take a few hundred bucks, and throw it away every month for no reason. Then you’ll see what its like to have no insurance and have your Doctor refuse to switch from Coreg-CR because of someone like you.
    Told ya I didn’t like drug reps. Im sure you’ll get some colorful comments from other pharmacists who share my view.

  • 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.. πŸ™‚ Pretty good for a retail chump.

    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 (http://www.facebook.com) 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. πŸ™‚

    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
    broach…
    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.