Contacting the Prescriber

[manics]

Just interested in others experiences to gain an insight into my own practices.

How often in an average month/year do you have to contact the presriber due to a (potentially) dangerous drug interaction and/or a medical contraindication.

Off the top of my head in the past couple of years

Interactions

Erythromycin - Carbamazepine
Ciprofloxacin -Theothylline
Clarithromycin - Colchicine
Azathioprine - Allopurinol
Warfarin - Ibuprofen

Propranolol in an asthmatic
Diclofenac in heart failure

How do GP's normally react to there prescribing being questioned. Thankfull, angry, dismissive? What to do if you can't contact the prescriber?

[shonap87]

Maybe every couple of days if lucky. Then we seem to go a week with none and have four in a day, or a script!

Most common I think we get is clarithromycin with simvastatin/quinine or antifungals with fentanyl

[Pharmanaut]

Clarithromycin + Simvastatin.
Usually check if the patient has been given any 'special instructions' from the Dr.
If not - try to contact the Dr, if Dr not available, advise them them what 'usually happens'.
Best you can do.
Usually presents on saturday, so most of the time its the latter.
Then ask if Cholesterol is well controlled etc before advising patient to stop simvastatin for course of antibiotic.

[crit care]

for something like a clarithromycin + simvastatin interaction- do we really need to be contacting the prescriber, i can see from an education point so the Dr is informed, but surely we can counsel the patient not to take the statin whilst on the clarithromycin..thats what i do, and in hopsital just cross off the statin whilst on the abx, and then retrospectively tell the dr what i have done and why

[Web Ferret]

In all cases from the OP the prescriber will have over-ridden a computer system warning.
This will have been recorded in the GP computer system audit log.

Then head office moan about the phone bill from contacting GPs.

[hibernia]

for something like a clarithromycin + simvastatin interaction- do we really need to be contacting the prescriber,

I come across it fairly often and NEVER contact the prescriber, doing as you do advising the patient not to take the statin while on the antibiotic and adding a warning label to that efect to remind them.

The question should be do you believe that you are an expert in drugs? If you do then why would you need the approval of a person whose expertise in in another area to pass on your knowledge to the patient and protect them from possible harm? On occasions it is necesary because we don't have the legal authority to alter a prescription but it isn't for this one.
Prescribers and patients would take us more seriously and treat us with more respect if we had a little more confidence in our own abilities.

[crit care]

i believe we are experts in drugs...4 years at uni and all that! we are in better positions than other professions to advise on patients medication. I guess you wouldn't want to under estimate the prescriber in front of the patient.

whenever i interact with drs to get stuff changed or challenge them on decisions, most of the time they take my word for it and then i ahve to spell out to them what to prescribe, so essentially i'm prescribing it, its just their signature next to it!!

[culchie82]

I come across it fairly often and NEVER contact the prescriber, doing as you do advising the patient not to take the statin while on the antibiotic and adding a warning label to that efect to remind them.

The question should be do you believe that you are an expert in drugs? If you do then why would you need the approval of a person whose expertise in in another area to pass on your knowledge to the patient and protect them from possible harm? On occasions it is necesary because we don't have the legal authority to alter a prescription but it isn't for this one.
Prescribers and patients would take us more seriously and treat us with more respect if we had a little more confidence in our own abilities.

Interestingly enough Hibernia, there was a case a few years back, of a patient in the South, who died from Rhabdomyolysis caused from a Statin/Macrolide interaction. I think with the high risk drugs eg Digoxin, Warfarin, Insulins, Lithium, erring on the side of caution is always best and a second opinion from a GP is generally a good thing. Actually getting hold of the GP, with impatient eyes piercing through you, can be a nightmare though.

[hibernia]

[QUOTE]

Interestingly enough Hibernia, there was a case a few years back, of a patient in the South, who died from Rhabdomyolysis caused from a Statin/Macrolide interaction

My memory of that case, which maybe faulty, was that it was high doses of lipitor and fucidin in a hospital in-patient. No clinical pharmacist on the particular ward and the verdict was medical misadventure. If a community pharmacist had dispensed it there might well have been further consequences.

I think with the high risk drugs eg Digoxin, Warfarin, Insulins, Lithium, erring on the side of caution is always best and a second opinion from a GP is generally a good thing.

I agree completely and am often guilty of over-caution but when you are sure of the risks and know how to avoid them, as in the simvastatin-clarithromycin case, then I see no reason to involve the GP.

Actually getting hold of the GP, with impatient eyes piercing through you, can be a nightmare though

Again you have to be assertive, ask the patient to call back because it may be an hour or so before you can clear their prescription. They probably waited longer than that in the surgery. They may complain but other patients have rights too and it is vital not to allow yourself to become flustered, because that's when mistakes happen.

[shonap87]

I think my tutor is trying to make me not lazy about interactions, but I absolutely hatehatehate not engaging my brain when a computer warning pops up!

Some of the "major interactions" I have been told I should contact a gp about -

propranolol (two week course from three months ago) + salbutamol

insulin + fibrates (the patient isn't on insulin, but presumably this flashed because of other antidiabetic drugs)

another which I forget the specifics of but even the computer specifically stated there was interaction with some of the drugs in that group, but no interaction with the particular one they were on.

another example where the patient was taking an antidepressant and antiepileptic (convulsive threshold lowered), but they were taking it for migraine. They did not have epilepsy.

The last one I think you can argue for, obviously if the patient wasn't there or they didn't seem sure why they were taking it, or even just erring on the side of caution with drug types that obviously can be dodgy (even though the doctor then explained to my pharmacist like a child that the anticonvulsive threshold doesn't matter if it's not for epilepsy).

They also want me to advise patients on POPs to be cautious when on antibiotics, which often goes completely contrary to what the doc has said.

Doesn't it make us look stupid if we can't interpret what the computer gives us?