Category Archives: Ask The Angry Pharmacist

ATAP: Ambien for depression?

This was sent from an MD to both the DrugNazi and myself. Here is my take on it.

I know you both probably think Ambien is bad medicine….
If you don’t, I do.

Eh, for occasional use its perfectly fine (especially if the patient just had a traumatic event/surgery/etc). Obviously if the patient needs 30 a month in order to sleep there is something deep underlying that needs to be addressed.

Regardless, today a miniskirted, stilletto heeled prostirep came into my office and tried to tell me that some Doc, which she desribed as a “sleep guru”, is now reccomending Ambien for depression.
Yes, depression.
The premise of the argument is that SSRIs can be activating and that ambien CR (which is magical as opposed to regular ambien which is poison) should be used to combat the insomnia “common” to ALL SSRIs.
Ok. Last I checked, and granted its been awhile, but all SSRIs are not created equal. some sedate, some activate, and those of us who prescribe with half a brain will tell the patient to take the activating ones (i.e. paxil) in the morning. and the occasionally sedating (i.e. zoloft) in the evening.

Ambien for depression? Maybe if you are depressed because your brain cannot recharge its neurotransmitters during sleep. Even that is a stretch. I think that people underestimate the power of a good solid 8+ hours of sleep. However one of the clinical side effects of depression is lethargy/sleeping a ton.
Funny how you mention that Ambien vs Ambien CR. I think you’re on the right track here. People are beginning to realize that they can pay 10 bucks cash for 30 generic ambien vs a $50 copay for trade name Ambien CR. Sinofi must be crapping their pants and trying to come up with new indications.
As far as the SSRI’s go, last I checked Prozac was the most activating (which is why it was initially investigated as a weight loss drug, only to be found to improve mood. Henceforth the SSRI craze was born) while Paxil (and its anticholinergic effects) was the most sedating. Its like Artane is way more activating than Cogentin is. Some people have even resorted to abusing Artane just to get that amped up feeling.
If the patient is responding bad to an SSRI, why not just give him/her Remeron and kill two birds with one stone? Knocks him/her out, and has antidepressant effects. Plus its dirt cheap. Trazodone has been used for years for this, and even though one out of a million men will have an eternally hard pecker, its worked wonderful for the last bazillion years.
Treating the side effects of a medication with another medication (AKA PolyPharmacy) just leads down the road to trouble. Next think you know the patient is on 30 different meds, you cannot switch any of them without a cascading failure as they get out of equilibrium, and when they get hospitalized its a real pain in the ass to treat them.

Oh, and the advisability of giving a patient a clearly addicting medicine (I dont care what the prostirep says) especially when they are depressed and at high risk for overdose seems inadvisable at best, and possibly malpractice at worst.

Yeah, I think something is seriously retarded with this drug rep or some key information was not being relayed to you. Giving a clinically depressed person (who doesn’t want to get out of bed, shows no sign of doing things that would normally make him/her happy, etc) a CNS depressant seems like pouring gasoline on the fire.
Overdosage might or might not be an issue here. Clearly the SSRI’s are tons more dangerous in high doses than Ambien (which is very Benzo like). Actually people don’t realize how hard it is to treat an aspirin overdose, and that kills more people than Rx medication does.

Am I off base here? It seems the reps have a new strategy for pushing off label uses. they just pop up with some “study” and pass them out like they are “educating” me. It seems that this is barely legal. (in the bad sense)

No, actually I’m thrilled that you are questioning what the talking heads are blabbing at you. More doc’s need to do this and show the drug companies (and the hot reps they employ) that doctors are not their little pawns in a money-making scheme.

Anyway I thought I would send this to both of you, TAP and Drugmonkey to see if you had a rant to develop.

Mine wasn’t very rant-a-licious. You had a legit question and deserved a professional answer rather than something with a lot of swear words and foul humor. Sorry if I disappointed you. πŸ™‚

BTW, I am a professor at a family medicine residency, I frequently print out both of your blogs and post for the residents to read. I am pushing for a prostirep free clinc. I am not in charge or it would be.

Ah, we are corrupting the youth of medicine one resident at a time. Excellent.

Also, either of you want to travel to Arkansas and give a cme lecture to a bunch of docs?

I’ll keep your contact info.. πŸ™‚

Why do people still think Marijuana can be prescribed?

As a pharmacist what type of medical marijuana abuse do you see?

I see tons of abuse, and zero Rx’s. MJ is a C-1 narcotic like Heroin, LSD, and PCP. It cannot be “prescribed” or “dispensed” legally in the good ole USA.

I’m in college and I always hear of Doctors illegally prescribing Marijuana to kids who pay a couple hundred bucks. Is this just talk or does it actually happen? How big of a problem is this and how can it effect your pharmacy?

Doctors cant prescribe a C-1 narcotic nor do pharmacies stock C-1 narcotics (research facilities excluded). Regardless of what those fruity fucks in California say, MJ is illegal, and always will be illegal. States cannot make a less-strict law to override federal law (however they can make a state law more strict than federal).
DEA has the final word, and the only reason why there is this MJ Rx bullshit floating around is that they have bigger things to worry about like inspecting pharmacies for vicodin use and making our lives hell than to bust some broke stoned pothead.
So the “Doctor” that is “prescribing” this MJ is just a glorified pusher who should have his license revoked and publically strung up by his peers by propagating this stereotype. The “kids” who are buying this shit for a few hundred bucks are getting ripped off and should just visit their local stoner for a better deal.
MJ is not an Rx drug, and the people who are getting “Rx’s” for it are just rationalizing their abuse and pulling the wool over the retarded eyes of the local law enforcement. If I were a cop, and some douchebag showed me an Rx for MJ, i’d laugh at him and arrest him (if he had some on him). I’d win in court every time.

Can’t feed me that info and expect a serious answer!

This is an honest question.
Every month I call the computer at Walgreens to have my monthly
prescription refilled.
I always give the computer a pickup time that is hopelessly optimistic. I
usually don’t really pick it up until 12 to 36 hours after the time I
entered.
Am I a bad person?

You go to walgreens, so yes, you are a bad person (Come on! How can I pass up a line like that)!
Honestly, I really dont think it matters. They just sit in a drawer waiting for you. Now if you ordered a bunch of expensive stuff then sat on it for a month or two (so the pharmacy had to Return-To-Stock it), THEN came and wanted it (so they had to fill the Rx twice), you are a doubly bad person.
Oh! If you want to ask me questions, please email questions@theangrypharmacist.com. I miss questions in the comments, etc.

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™‚