Key to Prescriptions: Chapter 5
5.1
§ Is it prednisone 5 mg? Call the physician to make sure.
§ If it is 5 mg, make sure that 50-mg tablets are not dispensed.
§ Call doctor: How many tablets? Sig is one daily after breakfast.
§ Inflamase Forte 10 cc: Place one drop in right eye BID. The person should wash her hands before and after using the drops. They should be put into the conjunctival sac.
§ She is taking two anticholinergic drugs. That may explain the dry eyes and irritation.
§ It also may explain the constipation.
§ The dry eyes may be an adverse problem associated with RA. Some people have Sjögren’s syndrome. The treatment is to keep the eyes lubricated.
5.2
§ Flutamide is taken 2 of the 125 mg capsules (250 mg) TID.
§ Tylenol with Codeine. The Sig is 20 cc Q4H PRN. Take plenty of water with it.
§ The Rx should have the physician’s DEA number on it. Call the office to record it unless it’s in the store’s computer.
§ Remind the patient to see the physician for his Lupron injections. They should be used with the Eulexin.
§ If the patient is experiencing urinary obstruction, call the physician and request a change in his Claritin-D 24-hr Rx. It contains pseudoephedrine. This will probably constrict his bladder neck and sphincter, making the urinary obstruction worse. If he needs an antihistamine, plain Claritin 10 mg once a day should help.
§ Try to interest him in a smoking cessation product and counseling.
5.3
§ Tamoxifen is 10-mg tablets taken BID for 3 months. The Rx can be filled for 180 tablets. They should be taken with food to avoid GI upset.
§ Paxil is 20 mg tablets, #30. Sig: ½ tablet at HS for 4 days, then 1 at HS thereafter. The person should be told that this will take some time to start working.
§ Tell her that if she experiences constipation, soluble fiber may help. Metamucil Sugar Free would be appropriate for this patient.
§ Tell the patient about the importance of compliance and the importance of not smoking.
§ Does Dr. Zoeller know that the patient takes lorazepam? This should be communicated to her. This may have something to do with the depression.
§ Is the person doing blood glucose monitoring? Glyburide is not being taken correctly.
§ Chances are that her blood glucose is not controlled. Inform her about the importance of compliance. Demonstrate how to use a blood glucose monitoring test kit. Inform her that insurance may cover these important supplies.
5.4
§ Tamoxifen 10 mg # 100. 1 BID. 3 refills.
§ Serious interaction. Premarin (estrogen) and tamoxifen (anti-estrogen)
§ This probably will result in cancellation of both effects. Please inform her to stop the Premarin. Tamoxifen is the most important agent now.
§ Avapro 150 mg # 30. Sig: One daily.
§ Tell her that if a persistent cough occurs, she should contact her physician.
§ She should seriously consider stopping smoking for her health. Speak emphatically to her about the potentially harmful effects that smoking could cause at this point. Keep an open pack of Nicorette gum ready for her to sample. If she agrees to use it according to the manufacturer’s directions, she can then titrate her dose down over a period of weeks.
§ You can be her support “group.” Tell her that she is worth it for your concern.
5.5
§ Efudex is: Apply BID for 2 weeks and see me (the physician).
§ Explain the correct method of application. He can use a latex glove, a rubber finger cot, a Q-Tip, or a wood tongue depressor to apply the Efudex. If he uses his fingers, they should be washed immediately to avoid systemic absorption.
§ Inform him that he should use sunscreen with an SPF of over 30, but even that is not enough. He should use a hat when in the sun and should make an effort to avoid the sun. Actinic keratosis can occur in another area of the body, especially if there is exposure to the sun.
§ He should be warned about the burning and redness that will start in a few days. He should know that it is part of the therapy. Something resembling very bad sunburn will happen in about 6 days and get worse until day 14. If there is severe pain, he should contact his physician.
§ He should avoid all exposure to the sun while using this Rx. It may cause a very bad burn. He should be told to keep it away from his eyes.
§ Triamcinolone cream is used to decrease the inflammation from the Efudex cream.
5.6
§ Megace 200 mg/ 5 cc. 1 Pint. Sig: 20 mL BID
§ She should know that the Megace will not add more pounds unless she takes in more calories. The pharmacist’s advice about calories is very important. Recommend good food selection or Ensure Plus, Boost, or similar products.
§ The second Rx is HCTZ 25 mg. Sig: One daily.
§ She should be made aware of the serious hazard that results from smoking.
§ Remind her that Percocet should be taken with food or milk to protect her stomach.
§ Also, Soma has a metabolite: meprobamate (a CNS depressant).
§ This product should not be taken with alcohol.
§ Counsel the patient on products or foods containing potassium.
§ The patient should stand up slowly for the first few days.
5.7
§ Imuran 50 mg # 30. 1 BID
§ The second Rx is Indocin 25 mg #15. Sig: One TID for 5 days.
§ Auxiliary labels should be “take with food or milk” and “avoid OTC aspirin or NSAID products.”
§ There is an interaction between Zyloprim and Imuran. Zyloprim inhibits xanthine oxidase, the enzyme responsible for metabolizing Imuran. To avoid an increase of Imuran, its dose should be reduced to 1/3 or 1/4 of the original dose.
§ Call both physicians immediately because this is a critical interaction.
§ A suggestion would be to make a new Sig for Imuran: 1/2 tablet once a day. This would reduce the daily dose from 100 mg to 25 mg, a reduction of 25%.
§ Remind him not to drink alcohol while taking Xanax.
5.8
§ The Rxs are:
Verapamil 80 mg TID
Dyazide one QD
Digoxin 0.125 mg QD
Pepcid 40 mg HS
Prednisone 5 mg BID
§ Call the prescriber for the quantities.
§ There is a duplicate on Lanoxin (digoxin). Call the prescriber. Is this being reduced? If so, cancel the refills on the old Rx.
§ Does the physician want the Lanoxin brand or the generic? A call to the doctor will help.
§ Does the patient have CHF? This may be incorrect. Check with the doctor’s office to clear up the diagnosis. It may be just HTN or arrhythmia.
§ Inform the patient to take prednisone with food or milk to protect the stomach.
§ Ask him if the Antivert is necessary. It is a big dose and may give anticholinergic side effects. If he can use less or cut it out, it may be beneficial.
§ He will probably experience constipation because of the calcium blockade in the smooth muscles of the GI tract caused by verapamil. Recommend fiber foods (prunes, Raisin Bran) or Metamucil. It wouldn’t hurt to use these anyway; they will help with less straining at the stool.
§ Straining on the toilet using the Valsalva maneuver can be harmful to patients with heart issues.
§ This may sound like a lot of work for a seemingly simple order, but OBRA requires the pharmacist to be responsible for the patient’s therapy and therapeutic outcomes.
§ The second Rx is Cipro 750 mg #10, one BID. Auxiliary labels should include “stay out of sun,” “take full course,” and “avoid milk or antacids.”
5.9
§ Folic acid 1 mg # 100. 1 BID
§ Efudex cream is fluorouracil (5%). Sig: Apply to nose bid. (Usually for 14 days.)
§ This man will have to use hats, wear sunscreen (SPF >30), and adjust his lifestyle.
§ Exposure to the sun will result in more sunspots (actinic keratosis). These are precancerous skin lesions caused by exposure to the sun.
§ He should be reminded of these facts.
§ The folic acid prescription should be taken BID. He should see his doctor at the end of the Rx for a blood test.
§ Provide counseling on avoiding contact with the eyes and exposure to sun.
§ Give the same techniques as mentioned in patient #5.5
5.10
§ The new Rx appears to be folic acid 1 mg (generic). Make sure folinic acid is not dispensed.
§ The second Rx is Nystatin oral suspension, 6 mL PO QID S and S for 10 days.
§ Call the prescriber: Is it swish and swallow, or swish and spit?
§ The total Rx should be 240 mL (24 mL/day for 10 days).
§ Counseling: Place an equal amount in both sides of the mouth and retain for at least 5 minutes.
§ Is the QVAR used correctly? Ask her to show you how she uses it. As directed (u.d.) leaves a lot of opportunity for incorrect technique.
§ If the skin is infected with a fungus or yeast, it may indicate loss of glycemic control.
§ Make sure that she knows to do daily glucose blood test (fasting is the best time if she can only do it once). Ask her if she has done a test called hemoglobin A1C. If she remembers the number and if she is in the high range (7.5% to 9% or higher), it indicates loss of glycemic control over the past 3 months. If so, she should contact her physician for evaluation of the therapy.
§ Provide the usual diabetes counseling (compliance, blood testing daily, meal plans, exercise, and so on).
5.11
§ Methotrexate 2.5 mg # 16. As directed.
§ Zantac 300 mg # 30: 1 at bedtime.
§ The methotrexate 2.5 mg is probably being used to treat rheumatoid arthritis.
§ The tablets should be taken once a week at 12-hour intervals for three doses. The first dose can be given on Friday at noon. The second dose can be given at Friday night at bedtime, and the third dose on Saturday at noon. Determine the correct dose (three tablets, four tablets, and so on) and carefully instruct the patient about the exact regimen. Make sure that she does not take them every day. Mistaken daily use has led to toxicity that has resulted in death.
§ She should take them with plenty of water. Drugs to avoid are aspirin and other NSAIDs.
§ She should also avoid the sun while taking them.
§ Is she checking her blood pressure daily? She should be reminded.
§ She should be reminded about walking and other mild exercise for blood pressure control.
§ Her stomach problem (Zantac) may be caused by eating incorrect foods and eating late at night.
§ Recommend small, frequent meals and no food after 6 pm. She may be able to decrease the Zantac with her physician’s approval.
5.12
§ Methotrexate 2.5 mg # 12. Sig: Take 3 tablets once a week, every Tuesday.
§ The second Rx is folic acid 1 mg #100. Sig: Two a day
§ He should know that the methotrexate must be taken exactly as written (three tablets every week on Tuesday).
§ However, they should be taken 12 hours apart. To fit them into Tuesday, call the prescriber for exact instructions. Possibly two at noon and one at midnight.
§ It would be best to request a change in the Sig to one with 12-hour intervals.
§ Counsel the patient on taking it with plenty of water.
§ Offer regular diabetes counseling. Which insulin does he use? If he is buying it OTC, he should check it each time for accuracy. Recommend that he keep the top panel of the box in his wallet to check each time he buys it.
§ Does he need the 1-cc syringes? If he is using small amounts, such as 14 or 22 units, and if he has a hard time measuring the insulin, get his permission, call the prescriber, and create a new Rx for the smaller syringes (0.5 cc or 3/10 cc). The smaller measurements are easier to see on them than on the 1-cc size.
§ This should be taken on the days when methotrexate is not taken.
§ Caution: Motrin PM has diphenhydramine. If taken with Ambien, it could cause serious CNS depression and accidents.
5.13
§ The first Rx is prednisone 10 mg, #50. Sig: 3 daily for 3 days in the morning, then 2 daily in the morning for 3 days, and then one daily for 3 days.
§ Counsel the patient on taking it with food or milk to protect the stomach.
§ Mention mild exercise. Recommend diet education by a registered dietitian (R.D.) She is probably obese. A good suggestion is to mention that a few pounds of weight loss will result in fewer pills to take in the future. That may get her attention. It may also help to relieve the symptoms of arthritis.
§ The second Rx is Prilosec 20 mg #25. Sig: one daily in the morning before breakfast.
§ Counsel: It should be taken 30 minutes before breakfast for best results.
5.14
§ Prednisone 5 mg, #100. Sig: 3 tablets BID.
§ Zantac #60: 1 BID, with breakfast and at HS.
§ The dose of prednisone is high (30 mg/day).
§ There is duplication. Prednisone has also been prescribed by a different physician.
§ Both physicians should be called.
§ The patient should be cautioned about this duplication.
§ Call the physician to verify the dose of future refills.
§ Dr. Robbins will probably want to taper down and decrease the dose.
§ Recommend that the patient reduce salt intake, do daily blood pressure measurement, and report swollen ankles or unusual weight gain to the doctor.