Interesting scripts

[Steve G]

The following interesting (=wrong) scripts came through the door today, mainly after 6pm:
- prednisolone 5mg 2 qds x7/7
- zyban 1 od x15/7
- levonelle one step x 1 tab
- metronidazole 400mg qds x5/7
- clotrimazole cream qds, x100g continue for two days after lessions clear

The metronidazole was from a dentist (surprise surprise), whose response when I queried the qds dose (reminding her that the standard doses are tds) was 'who says that? I want it qds so do it'. Lovely. So I labelled the script qds, but strongly advised the patient to take it tds, and sent the dentist a letter asking for some evidence to support her dosing for metronidazole.

Clotrimazole was from a nurse who I couldn't get hold of, so the parents got 'well the nurse has said four times a day, however I would use it three times a day and for a week after its cleared'. I'll have a chat with the nurse tommorrow if I get a chance.

[pharmatron]

Interesting scripts Steve - it highlights the importance of the Pharmacist in clinical checking. Not sure about the levonelle script though - I realise that the 'One Step' can be sold (and is more expensive) and that it's usually prescribed as Levonelle-1500...but, is it actually blacklisted as 'One Step'? I'm sure we've done similar ones..?

[Steve G]

some followup:

I spoke to the GP about the prednisolone (not one of my local ones). He said to keep it qds. Fine, great way to start the day. I did of course remind him about the possibility of adrenal suppression with the repeated evening doses.

The local surgery have a strange way of using Zyban: they give it once daily for two weeks, then increase it to two weeks if they think the patient needs it. Now if this is such a good idea, why isn't it mentioned in the SPC or BNF? I'll have to find out what their quit rate is.

For the levonelle I dispensed the POM product and sorted out a new script later.

Today I had another dental one, this time for amoxil 500mg qds. So again I speak to the dentist (not the same one as the metronidazole) reminding her that amoxil is tds, has a decent half life so no need to give qds. She said to keep it as qds, and when I asked if there was any particular reason for this her response was 'because thats what I want'. Right.

And then, just before closing at 6.30, a script for Baxan 500mg tds. Luckily the surgery were still open, so was able to check it and get the dose changed.

Another interestin day at work.

Now a question: does anyone know of any evidence supporting the use of either amoxicillin or metronidazole at a qds dose? (Especially in dental infections).

[Zoggite]

Why did you need to get the Levonelle-one step Rx changed? it's not blacklisted, it's actually listed in part XVI of the jan. 2007 drug tariff, in the list of contraceptives to be dispensed free of charge; as long as it was prescribed as the "one-step" version by the prescriber, and you've endorsed it as such, you should get paid the trade price for the OTC version(£12 roughly I think). If the p'ber has issued a script for the dearer OTC version, rather than prescribing the cheaper POM-pack, then that's his problem, and his budget...

[Steve G]

Why did you need to get the Levonelle-one step Rx changed? it's not blacklisted, it's actually listed in part XVI of the jan. 2007 drug tariff, in the list of contraceptives to be dispensed free of charge; as long as it was prescribed as the "one-step" version by the prescriber, and you've endorsed it as such, you should get paid the trade price for the OTC version(£12 roughly I think). If the p'ber has issued a script for the dearer OTC version, rather than prescribing the cheaper POM-pack, then that's his problem, and his budget...

Yes it's the prescribers budget and problem, but having just started managing this pharmacy I'm being extra nice to the doctors at the moment.

[Zoggite]

but having just started managing this pharmacy ...

PLEASE tell me you're not still working 43 hours/week for only £40k....

(and before anyone accuses me of indiscretions, Steve G published these figures himself on this very forum, on Nov. 25th 2006, otherwise I wouldn't have dreamt of revealing them...)

[Steve G]

PLEASE tell me you're not still working 43 hours/week for only £40k....

(and before anyone accuses me of indiscretions, Steve G published these figures himself on this very forum, on Nov. 25th 2006, otherwise I wouldn't have dreamt of revealing them...)

My pay review is due this month, and I'm expecting £45-47k for a 47 hour week (well nearer a 42 hour week, but as I stay on the premises at lunch and do urgent scripts I claim for my lunch hour).

[Zoggite]

That's a lot better, but make sure you that your new contract is for 42 hours/wk basic, leaving YOU to decide if and when you choose to make yourself available over lunch! Believe you me, you'll soon burn yourself out doing 47 hours/week every week! Make sure that lunchbreak-time is ring-fenced while you still can, it's on the "Endangered Species" list!!!

[admin]

Now a question: does anyone know of any evidence supporting the use of either amoxicillin or metronidazole at a qds dose? (Especially in dental infections).

I've never seen (as I recall) metronidazole prescribed QDS but in my neck of the woods every dentist prescribes amoxicillin QDS. It's not going to affect the patient, and isn't an overdose, so it doesn't concern me. My own dentist told me that was the dose he was told to use during his dentistry course.

I once worked for a week where one of the local GP's prescribed amoxicillin QDS and ampicillin TDS. I phoned up the surgery and tried to speak to him, but could not get through, so I left a message for him basically asking if he had got the two drug doses mixed up. He came into the pharmacy the next day for something else, and I had a conversation with him basically saying the same as I did in the message. I said I wasn't really concerned about the amoxicillin dose, but the ampicillin one was only 75% of the recommended dose, and that concerned me. The result - nothing changed, so I had to give up on that one.

[Linnear]

Today I had another dental one, this time for amoxil 500mg qds. So again I speak to the dentist (not the same one as the metronidazole) reminding her that amoxil is tds, has a decent half life so no need to give qds. She said to keep it as qds, and when I asked if there was any particular reason for this her response was 'because thats what I want'. Right.

Now a question: does anyone know of any evidence supporting the use of either amoxicillin or metronidazole at a qds dose? (Especially in dental infections).

I have always assumed that dentists are taught Amoxil is qds dosage.

I worked in Plymouth for two years and NEVER saw a dental script for tds Amoxil it was always qds!

[Jeff]

I once worked for a week where one of the local GP's prescribed amoxicillin QDS and ampicillin TDS.

The difference between ampicillin and amoxicillin is mainly one of licencing - as the patent on qds Penbritin (ampicillin) came too an end the new wonder antibiotic Amoxil was introduced with a tds dosage.

Amoxicillin half life 61.3 minutes
http://en.wikipedia.org/wiki/Amoxicillin

Ampicillin half life approx 1 hour
http://en.wikipedia.org/wiki/Ampicillin

Jeff

[Steve G]

The difference between ampicillin and amoxicillin is mainly one of licencing - as the patent on qds Penbritin (ampicillin) came too an end the new wonder antibiotic Amoxil was introduced with a tds dosage.

Amoxicillin half life 61.3 minutes
http://en.wikipedia.org/wiki/Amoxicillin

Ampicillin half life approx 1 hour
http://en.wikipedia.org/wiki/Ampicillin

Jeff

But half life is only part of the story, bioavailabilty is also important (95% for amoxicillin against 40% for ampicillin), as is volume of distribution and minimum inhibitory concentration.

Surely the licencing wouldn't be different unless there was a good reason for it, and given that amoxicillin is effective at a tds dose, why give it qds?

[Zoggite]

What about spectrum of activity? Salmonella is more sensitive to amoxicillin than to ampicillin, but it's the other way around for Schigella...

[Jeff]

Surely the licencing wouldn't be different unless there was a good reason for it,

The patent on Penbritin was soon to expire and its replacement Amoxil needed to offer an advantage in order to generate sales.

and given that amoxicillin is effective at a tds dose, why give it qds?

No reason at all, but neither expensive nor dangerous enough to worry about.

Jeff