Interaction: Aspirin + Diclofenac....and Beconase Nasal Spray for 4 years old????!!!!

[AmyLondon2010]

Hi everyone!

just a quick question....i'm recently qualified and while i was locuming got these two scenarios....

1) Diclofenac prescribed for a 90 years old lady who has been on Aspirin 75 for a long time....she had ibuprofen occasionally in the past according to her daughter...called the Dr explained the interaction and the age of lady....however was pushed by Dr to dipense it....

2) Beconase nasal spray....prescribed for a 4 years old child...but according to BNF should not be prescribed for a under 6 years...again told by Dr to dispense it

what do u think? are these quite normal? cause im getting lots of these at the moment....i dont know maybe because im newly qualified i'm being too cautious...

[johnep]

Dose of aspirin was originally child formulation. I have taken both for years with no problems. Steroids in children another matter. When first CFC free steroid became available, not for children, but GPs routinely prescribing CFC Free to kids. As long as they know and you have put pc on script, not your problem.
johnep

[Asterix]

1st case did you suggest a ppi?

2nd case about the child...would avoid as steroids can cause all sorts of s/e including growth retardation

[Asterix]

on another note, say if you were still unhappy to dispense after the doc rang you can you refuse to dispense it and ask pt to go somewhere else

[mhb08112]

How would telling her to go elsewhere be appropriate? Make her someone else's problem?

I really despair for this profession sometimes.

I'm not saying that you don't have the right to refuse to dispense, but turning a patient away is rarely ever making their welfare your first concern.

[bobbin]

Hi everyone!

just a quick question....i'm recently qualified and while i was locuming got these two scenarios....

1) Diclofenac prescribed for a 90 years old lady who has been on Aspirin 75 for a long time....she had ibuprofen occasionally in the past according to her daughter...called the Dr explained the interaction and the age of lady....however was pushed by Dr to dipense it....

2) Beconase nasal spray....prescribed for a 4 years old child...but according to BNF should not be prescribed for a under 6 years...again told by Dr to dispense it

what do u think? are these quite normal? cause im getting lots of these at the moment....i dont know maybe because im newly qualified i'm being too cautious...

Potent NSAIDs such as diclofenac are often needed in elderly people, in spite of their adverse effects. It would be great if paracetamol was always sufficient, but it is not. Paracetamol should be tried first for most types of pain, with the exception of conditions such as gout where severe acute inflammation is present.

Diclofenac should be used at the lowest effective dose for the shortest period possible. A 90 year old may not require the standard 50mg tds. Unfortunately, the lowest effective dose can only be found by trial and error. If the doctor prescribed the 25mg tablets, the patient could titrate the dose. She might manage with a small dose such as 25mg bd. Even low doses of paracetamol (500mg qds) could minimise the amount of diclofenac needed in this patient. A proton pump inhibitor should be prescribed for gastro-protection.

Ibuprofen may be somewhat safer than diclofenac but its anti-inflammatory properties are not very strong. Many patients with inflammatory arthritis find ibuprofen inadequate. It is, however, quite a strong analgesic. Naproxen is claimed to be safer for the cardiovascular system than diclofenac. Patients often seem to prefer diclofenac though. I get the impression that it tends to be more effective for arthritis pain, and slightly less likely to cause dyspepsia symptoms.

.............

Beconase is used in children under 6 in some cases. Antihistamines such as cetirizine are only partially effective for allergic rhinitis and some patients do not respond well at all. Steroids are generally much more effective, and for severe symptoms are unsurpassed. If the child has severe symptoms and has not responded to antihistamines, Beconase might be chosen. Look at the medication history and enquire with the mother about the severity of symptoms. Titrate to the lowest effective dose. Consider other steroids being used eg. inhalers and creams. Some children have a high steroid expose due to multiple steroid treatments.

Bear in mind that doctors often use products off-license. Doctors are often lacking in knowledge about licensing and are frankly not very interested in it. They are more interested in whether a product is clinically appropriate and whether their peers would also consider it appropriate.

[bobbin]

on another note, say if you were still unhappy to dispense after the doc rang you can you refuse to dispense it and ask pt to go somewhere else

I don't see what that would achieve. It would inconvenience the patient and would not look professional.

If you were unhappy about dispensing, tell the patient why and discuss it with them. For example, in the case of the Beconase, the mother might decide not to use it if the child only had mild/tolerable symptoms.

[Nik]

Beconase is used in children under 6 in some cases. Antihistamines such as cetirizine are only partially effective for allergic rhinitis and some patients do not respond well at all. Steroids are generally much more effective, and for severe symptoms are unsurpassed. If the child has severe symptoms and has not responded to antihistamines, Beconase might be chosen. Look at the medication history and enquire with the mother about the severity of symptoms. Titrate to the lowest effective dose. Consider other steroids being used eg. inhalers and creams. Some children have a high steroid expose due to multiple steroid treatments.

Bear in mind that doctors often use products off-license. Doctors are often lacking in knowledge about licensing and are frankly not very interested in it. They are more interested in whether a product is clinically appropriate and whether their peers would also consider it appropriate.

Great advice Bobbin - just shows we need to think outside the box at times and not rely solely on the BNF for basing our clinical judgment.

[DavidS]

....i dont know maybe because im newly qualified i'm being too cautious...

No such thing as being too cautious, IMO. Because of your questions many of us have learned something useful on this thread.

[hibernia]

Bear in mind that doctors often use products off-license. Doctors are often lacking in knowledge about licensing and are frankly not very interested in it. They are more interested in whether a product is clinically appropriate and whether their peers would also consider it appropriate.

In contrast pharmcists are usually knowlegable about licensing (no harm in that) and use it instead of their clinical knowledge rather than using it in addition to all their other knowledge and experience. Clinical practice is always ahead of licensing and if doctors stuck rigidly to licences there would be very few advances.

Think of the patient first. Doses in the elderly are licensed for over 65s but there is a big difference between 65 and 90 and some 90 year olds are fitter than some 50 year olds. Anybody who hits 90 has beaten the odds many times in life and may well be able to tolerate a little off-licence medicine if it makes them feel better.