Wednesday, October 20, 2010

All Tied Up Over Tylenol

Overdosage with Tylenol is the most common cause of acute liver failure, and attempts have recently been made to educate the public that Tylenol (or acetaminophen, or APAP) is not an innocuous drug. People may not be aware that acetaminophen is present in many products other than "Tylenol" leading to doubling-up and inadvertent overdose, and there can be confusion over strengths of different products -- regular strength tabs, extra-strength tabs, chewable tabs, infant drops which are 100mg/ 1ml, and children's liquid which is 160mg per 5ml. For adults, 4000mg per day is the maximum dosage, or 8 tablets of 'extra strength' Tylenol equivalent, and there is talk of lowering that recommendation.

Anyway, the thing that worries me most is the kids, because of the aforementioned strength differences and the lack of faith I have in many of the caregivers who give the doses. You remember when they pulled all those OTC pediatric cough/cold products off the market not long ago? It wasn't because the medications were inherently unsafe, it was because there were too damn many dosage errors to justify leaving them out there. Every time I sold one of those things I attempted to make sure the parent knew how much to give, but they rarely initiated the question themselves.

Getting back to Tylenol, we get a lot of prescriptions for it because it is covered by state assistance for those who are eligible. Pediatric dose, as we all know: 10 to 15 mg per kg every 4-6 hours, maximum 5 doses daily. But after checking the child's weight, we consistently get doses that are written too high. Usually they creep up into the 16-17-18 mg/kg range, sometimes more. Okay, maybe a couple of doses isn't a big deal, but legally as far as that labeling is concerned it's OK for that child to get that dose every 4 hours for the next... well, indefinitely. I'm often nervous about assuming that a non-English speaking parent even remembers what 1.2 mL looks like on that dropper. We always have this conundrum --- should we call and bug the doctors/nurse about it EVERY time and hold up the prescription till they call back? Should we go ahead and change it to a more correct dosage and initiate a phone call or fax back to the office and hope it gets changed in their medical record? Or do we decide we've called them enough times and just tell the parent the correct dose and make sure they know how to give it? Is it worth all the time spent? It happens virtually every day. Are we just getting too wound up about the whole thing?

I'm curious as to how other folks handle prescriptions for OTC items like this.

For the record, I never use those dosing charts that give a weight 'range' and assign a dose for it. I calculate 12mg/kg (right smack in the middle) and then round up or down to the next logical dosage unit (1/2 - 1 - 1 & 1/2 teaspoon, dropperful, etc.) Done.

Sunday, October 10, 2010

The Generic-Go-Round

I'm still surprised by how often customers don't understand what 'generic' means. The ones that do understand are the 'prescription pros' whose eyes actually light up when you tell them their medication is now available as a generic, because they anticipate the price coming down. But many people still look very skeptically at you and ask, "But it's the same thing, right?" I feel as though they think I'm trying to put something over on them.

I've tried out a few different ways of explaining 'generic.' Some of them are:

1. It's the same active ingredient as the brand name drug, it just looks different and is made by a different company. (This one doesn't go over that well. It sounds kind of fishy.)

2. It's exactly the same medication as Zocor, they just can't call it Zocor because that's a
protected trade name. (Sometimes this is met with a nod of understanding.)

3. You know when you buy Del Monte Canned Pears and right next to it on the shelf there is a can of "Great Value" Canned Pears? They're both canned pears. One just has a fancier label. (This one is only used when I'm hitting rock bottom.)

People get funny ideas about generics. We all have the customer who swears, "the generic doesn't work for me," (even though there is no earthly reason why it shouldn't) or "I'm allergic to the generic." I don't dismiss these people out of hand. Generic products can contain different inactive ingredients (colors, flavors, fillers) that theoretically someone could have an allergy to. The lack of effectiveness is a little harder to buy, although again, theoretically a person could absorb the generic product somewhat differently which might affect its action. I recently had a customer beg me for a few tablets of Cardura because since he was switched to the generic, "I can't pee." ( I gave him a few and started the prior auth. procedure -- he did look really uncomfortable).

Other times I think people get it in their head that the generic is not going to work and then proceed to enable that very thing by sheer willpower. I took a call from an exasperated nurse who needed to start a prior auth for Duac Gel because the patient would not use its two --- cheaper---- components separately (Clindamycin gel and Benzoyl Peroxide gel) because she claimed that did NOT work. I'd have a tough time with that. I'm glad to see that occasionally docs will refuse to do prior auths for some of this stuff.

Then there's the flip side of the coin, when someone is presented with a higher-than-expected copay for what is a very pricey brand name drug, and their first question is "Isn't there a GENERIC??" I have to answer, "No, not for this one."

And I get that skeptical look, AGAIN............

Tuesday, October 5, 2010

The Truth Goes Marching On

OK, so the makers of the delicious Sun Chips recently started packaging their product in a compostable bag made of plant-based materials. Better for the environment and a good idea, right?

Wrong. They have decided go back to the old packaging for all but one flavor. Why?
According to news reports:

"But that which makes them compostable also makes them loud. The bags have a different molecular structure from the original packaging, and they're stiffer. So people complained about the noise. Groups on Facebook abound with names such as "I wanted SunChips but my roommate was sleeping..." and "Nothing is louder than a SunChips bag."

Spokeswoman Aurora Gonzalez said the company received complaints about the noise from the bags, although it also received thanks from customers who liked being able to recycle them.

So the decision was made to remove the bulk of the biodegradable line."

Sigh. Some times I worry about this blessed land of ours. Yeah, the environment's important and all, but DO NOT, I REPEAT DO NOT, mess with our salty snacks and our ability to partake of them when the roomie is asleep. There are certain things that are sacred.

Why is this pharmacy-related? It isn't really, except that I often throw a handful of Sun Chips into the pitiful lunch I wolf down back in the stock room. It was a noble try, guys.

Sunday, October 3, 2010

I Have Seen the Enemy and It is Me

There are some days (I repeat, some) when I feel like I can really kick ass in this job. Multitask like crazy. Juggle about 15 balls in the air at once. Make snap decisions. Keep things moving. Everything is humming along pretty well and staying in its groove. I've got notes and pieces of paper everywhere but I know where everything is and what's going on with it.

Then, it happens -- that one interruption, phone call or yelled question that somehow upsets the boat. Someone hands me a prescription and asks me to put it on file for them. A few minutes later I realize I don't know what I did with it.

What the HELL did I DO with it? I JUST HAD it in my HAND. Damn it, where IS IT?, I screech.

God, I hate that. Everyone else looks sympathetic but is really too busy to offer more than meek suggestions ("maybe you left it by the register?") I start to empty the garbage cans. I look under every piece of paper, every computer terminal. I am completely thrown off. I get behind and other things start to pile up. The whole rhythm of the universe has completely gone to hell. I fear that my co-workers are secretly snickering and wondering if I am, y'know, losing it.

It's kind of upsetting when your whole workday can turn bad over one misplaced piece of paper. I never did find the damn thing. I'm still stewing.