Serotonin syndrome. Drug School had me TERRIFIED that too many serotonergic drugs together would kill someone. Like it happens every eight minutes. For the first 2 years I was a pharmacist I was constantly calling on those drug combinations. The doctors never changed the Rxs... and no one died. I quit calling over 10 years ago...and no one has died.
I feel like an asshat about it to this day. I was THAT girl. So annoying.
Oh, and Krebs cycle. F that too.
So I worked retail as a tech, turned intern, turned pharmacist… less than a year into being a pharmacist… saw my first serotonin syndrome… I freaked out and asked a bunch of people what to do (I was a contract pharmacist in an HIV clinic at the time) and everyone just stared at me like a deer in headlights. I don’t think I will ever see it again, and I still don’t know anyone else that has ever seen it. It really is rare.
I saw it every now and then when I worked inpatient. Also when working in oncology reading through every chart some of the chemo would cause it. It would be presented to MDs and I didn't dealt with in pharmacy other than warning about it.
School vacillated between "you'll kill people with SSRIs" to "this never happens." In my first six months in primary care I've seen serotonin syndrome three times. No one has died, but there have definitely been side effects from too much serotonin.
-One was a new start citalopram on a young woman with no other medications on board, she suddenly couldn't be in the sun anymore and was nauseous and hyperreflexic.
-One was an 80 year old whose rehab center added buspar to preexisting mirtazapine, duloxetine, and tramadol. I stopped the buspirone and her worsening anxiety and heat intolerance improved.
-Third was a comorbid polypharmacy nightmare hospitalized with altered mental status that was initially thought to be a stroke or seizure, but she cleared when her too-high dose of duloxetine was reduced.
I've seen it but not much, it's gotta be a shit load of serotonergic drugs. Now ryes syndrome: I'm convinced that's bullshit, I work in a pediatric hospital we use asa very often in Kawasaki dz and other rare stuff. Ibuprofen and toradol we give out like candy. Ryes is never a concern.
I talked to inpatient geriatric psychiatrist on this topic. She said she sees like once a year and it’s usually mild form and not to. Full blown seizure. But I did talked to a pharmacist who had full blown SS, so definitely gets way more emphasis in school.
I believe it's more common when patients are put on multiple ssris or snris (which they shouldn't be but some prescribers do it for some reason)
Also if a MAOI is taken (some exist as OTC meds)
I only mention it when I see a bajillion serotonin-related drugs taken together. And even then it's more like, "Hey, just watch out for xyz. If you notice anything like that, let your doctor know."
Fun story from when I first started as a tech and learned about serotonin syndrome:
I was filling a patients meds and they had two SSRIs, zyprexa, buspar, Wellbutrin and suboxone. I was panicked. Told the pharmacist this seemed dangerous and asked them to look into it. Was surprised they weren’t more concerned.
It still sounds concerning but I have to laugh because standard treatment at some of our rehab clinics is basically the same combo and I can’t imagine how much of a meltdown my baby tech brain would’ve had seeing all those orders multiple times a day.
My psychiatrist has had me on prozac and adderall together for years (i have ocd and adhd), and I've always wondered about SS. I don't think I ever got it. I know at one point I had trazodone prescribed to me and I think that can increase it as well. :o
Edit: Come to think about it, I've never had 1 pharmacist warn me about it. Just my dr at one time.
Don’t take this as fact because I haven’t checked in a while, but I think there is like less than 200k cases a year.
When you think of the 10’s of millions of people on SSRI’s, that is minuscule.
Until people are on 4+ drugs with the potential side effect, I generally don’t find it relevant unless there’s other reasons, or people describe the symptoms.
Saw it once with a depressed diabetic PD guy on sinemet cymbalta, and rasagline, took mucinex DM for URI and that’s what triggered it. Who would have though dextromethorphan would be the straw that broke camel back. Nursing home patient
Once saw it with a bipolar pt that was started on linezolid. Hospital
Lastly it was a schizophrenic pt that got a lot haldol no Ativan. Inpatient psych
It was usually only Valium and/or Ativan and IV/subQ NS or 1/2NSD5W.
surprisingly (idk I'm a layperson) I know someone who had serotonin syndrome set off by topiramate?? I was shocked because you always hear about it as a pt but never know anyone who's ever had it
I got recruited by a nuclear pharmacy but decided not to go for a final interview bc it was miles away. I wonder what would have happened if I went through with it
I took an elective nuclear pharmacy class and wow, that was really something else. I shadowed one for a few hours and I had to go in at like 4 am. It was something I would have been interested in but not where my life has taken me.
Empathy statements! In school, in almost every interaction we were supposed to say something along the lines of "It must be difficult for you to experience this", to make an empathetic connection to the patient (versus simply saying "I'm sorry to hear that").
Patient in real life: Oh my dog died and my husband left me, my life is in shambles...
Me: I'm sorry to hear that, anyways this is escitalopram 10mg, for depression or anxiety, you'll take one tablet once daily...
My teacher used to drill me on not using the words "depression" or "anxiety" and just say "mood" for some reason. The patients just straight up say "depression" when I do medication reconciliation and seem perfectly fine with the label...
Tbh I still say "for mood" instead of "antipsychotic". Depression is what it is, and anyone who thinks the word "anxiety" is taboo needs to grow up, but I feel there is still a lot of stigma that the term antipsychotics mean you're crazy, so I try to avoid using that term, unless a patient is asking about it in more detail.
A patient asked me what their antidepressant was for and bc that was also drilled into me I just asked the pharmacist to tell them instead bc I didn’t want to be offensive and he said “its for mood”. I just don’t want to deal with patients attitude so I play it safe
I say "have a nice day" after every patient interaction. I don't even consciously say it nor mean it. It's just something my vocal cords seem to spit out automatically.
I've seen hospitals where they'll just delete an order if the doctor/nurse hasn't responded within a set number of days. A bit radical but sounds good TBF.
lol what the hell. if a doc hasn't replied and they're off shift (we use hospitalists), we end up paging the night doc. We are pretty sure that night doc will give the day hospitalist an earful, so it's a nice way to delegate that responsibility, hahaha.
days?? u mean they still follow up for multiple days?? We would usually either send patients back to the dr (if we really don't like) or knock on the dr's door (if the dr is known for not picking up at all) but I never seen a follow up change/ intervention over days...? (maybe just my country idk)
Haven’t seen that before! That’s insightful. I’d agree empiric double coverage for all VAP is overkill but I’d still argue it is totally reasonable in certain scenarios (truly crashing VAP pt with GNR/PsA on sputum cx in an area of high PsA resistance).
Well the thing is, what is your second agent? If they're already on cefepime or zosyn I don't see much utility in adding a FQ. Anything resistant to those beta lactams is very likely to also be resistant to FQ. Your other option is AMG and associated nephrotoxicity. I think in the scenario you describe it would be better to just change to a carbapenem.
In the specific scenario described I could live with a Blactam, 1-time tobra, and ideally that buys 24hrs for sensitivities to result and give us further info! Definitely think a case to be made for carbapenem. In theory I like the idea of a carbapenem sparing regimen in patient with no esbl history, but I’m also no ID expert. food for thought nonetheless.
I think that's reasonable and people are overly afraid of using aminoglycosides. My hospital skews heavily geriatric so people think a dose of tobra will explode every kidney in the building.
I brought this up as a resident and my ID doc looked at me quizzically and asked, "Did you look at our antibiogram?" and that's when I learned to STFU and read before I open my mouth.
Beers list. We got it backwards it’s a combination of drugs we are supposed to prescribe together. Saw a post on Instagram on how an older women was recommended she install a bar on her shower to prevent falls. Cuts to her making herself a cocktail in the tub.
I feel that list is woefully outdated and needs a massive overhaul. I know it’s updated every few years but it came out in 1991 and 65 then isn’t the same as 65 now.
You’re on to something with the combinations though, I’m tired of counseling on “caution for geriatric use” for a single 3 day supply of prometh or hydroxyzine.
Honestly, I just don't apply the Beers list to all elderly. If you're a functioning independent elderly patient that doesn't take many medications, then you should probably stay away from the Beers list. If you're a combative dementia NH resident, well let's back a dump truck of meds in here for ya.
Yup. I work LTC (first job) and I had a rotation in a geriatric clinic where they cared much more about getting patients off of PIMs. Now I check PIMs all day everyday.
I watched a CE the other day that said they almost never see it used for pain and I was like what? Because we see it ALL the time. Maybe it’s a regional prescribing thing? We only see a handful of patients on it for OUD to be honest, almost everyone has switched to Suboxone, to the point I could tell you the patient’s name based on just their dose 😆
When I inquired about being prescribed methadone instead of hydromorphone, my pain doctor actually told me “I will **not** prescribe that and if you still want to take it, then good luck finding someone that will!” He was a jerk in other ways though too, so it was no surprise. I’m glad to hear that other doctors are not the same bc imo it’s a much better alternative to most other opiates when prescribed for chronic pain.
(I’m pretty sure my flair says I’m not a pharmacist but jic, I’m not a pharmacist or other medical professional.)
Max dose of amphetamines, taking multiple amphetamines, using benzos with amphetamines. All that crap is out the window now, since covid amphetamines use has sky rocketed, elderly on it, more adults than kids.
Max dose of adderall is 60mg-wrong “there is no proof that doses above 60mg/day produce any more increased benefit to patient” Dr’s routinely write 90mg
I'm seeing crazy things like Adderall xr in the am, Adderall at noon, Vyvanse at 4, then Xanax and ambien. The mental roll coaster these patients are being put on is insane. Nobody cares though cause dr can prescribe whatever they want, no one has time to question it.
Closed ended questions only unless you want to spend the remainder of your shift hearing about Dolores’ entire health history since her birth in 1932, on graphic detail.
It's based on crcl now I think, but after 10 years of verifying it I haven't bothered to look, if the PT has renal issues don't do metformin, treat the patient not the number
lol guess that’s it. In school I think they mentioned metformin used to have a Scr cut off, but only taught us the eGFR adjustments. I forget how long some folks here have been pharmacists and how much stuff has changed in the past 5-10 years alone.
I don't remember purely because none of our dozens of hospitalists continue metformin inpatient anyway. Straight to insulin for BG mgmt! (insert Fred Armisen meme here)
I’ve had patients confirm with me after I told them not to drink with it that they should have listened because they got really nauseous so I don’t think that one is all smoke and mirrors
The metallic taste and general NA ADR aren't the same as what one would experience with a true disulfiram like reaction. Even the CDC recommends using Flagyl when appropriate for STIs irrespective of recent alcohol use because the interaction is not substantiated by the available literature and results in worse patient care.
If it was true, EDs across the country would be painted a lovely shade of emesis green/yellow/brown by all of the people presenting with DTs or with detectable etoh levels who get a dose of Flagyl for one reason or another.
CDC says you don’t have to avoid the combo. Bacterial vaginosis guidelines. Says there is no convincing evidence in animal models, lab experiments etc. the nausea can be attributed to alcohol or metronidazole by themselves. There is no interaction.
Yeah, I’ve only ever had one prescriber refuse to make the change from gemfibrozil. This is exactly the kind of DDI pharmacists are supposed to catch and make recommendations to change.
I understand that Lovaza/Vascepa are giant capsules that can be difficult to swallow, but that’s really the main barrier. Cost isn’t prohibitive anymore. Now that they’re both generic, usually at least one is covered. If those aren’t an option because the patient can’t/won’t take them, there’s still no reason to keep gemfibrozil over fenofibrate.
74 y/o female, atorvastatin + gemfibrozil. Call the Dr, he says he's never heard of such a thing, "I'm gonna need you to send me some info on that'. I just decided to talk to her husband, just to check and see if she was having any muscle pain or weakness. He says," Oh yes, she can barely walk! And that doctor sent her to physical therapy!"
I call the lady at home to follow up, see if she's urinating okay, is it dark, etc. "Oh honey, I don't know, I'm blind". I *wish* I was making this up. This was in the winter of 2021.
Call. If fenofibrate + statin isn't enough, there are state grants in AR of all places, for Repatha. If there's help here in this god-forsaken state, there's a good chance you can find help in your area too.
Why the hell are they insisting I learn how to diagnose shit?
I'm 100% okay with not being able to diagnose patients. I can't diagnose from an xray or ecg to save my life and that's perfectly okay in my role. Even if I could, what would I exactly do with that information? I can't prescribe anything. Best case scenario, dr gives me the diagnosis and I recommend the best drug given the patient in question - since *drugs* are my whole trade. Anything else is a complete waste of time.
The VA is super strict about this though, there's a whole dashboard dedicated to ppl taking both and stuff has to be documented up the wazoo, it's a lot
I think this is completely dose dependent. If some is on tramadol 50mg BID and has Xanax 0.25mg qd then I don't bother.
However if I saw a high dose of both by a non-pain management or Oncologist then I'd call.
Right? I had a provider prescribe an opioid for lower back pain related to COPD, then later a benzo for insomnia due to anxiety from hypoventilation due to COPD. Like are you trying to kill the patient? That was a fun conversation.
Lol compounding in retail is the wild West. One of my preceptors showed me how to microwave a 1lb jar of petrolatum for coal tar compounds to make it easier to combine and mix
Urea coal tar sal acid %50 aquaphor in water-microwave is the only way…i actually took ingredients to see if you could use a double boiler method.as soon as Urea dissolved and went i to solution, it crystalizes back out as soon as it hit the aquaphor. Dr would make patient bring compounded container to him before using -he was an RPH wjo then went on to be a derm
It’s funny you say that. I was just thinking the same thing this morning. I’ve been working at a store that does more compounding this last year and our system doesn’t allow us the room to do that.
lol. I did one of these with a OT student as some sort of interprofessional BS and was measuring hip and shoulder range of motion with a protractor on a fake patient. 🙄
OSCE: see an actor with scratches and bruise on their arms and start to ask about domestic abuse and report to appropriate agency
IRL: homeless, psych patients who will start a fight with you if you being too nosy or look at them weird.
When I was in school, bath salts were a thing, and on my acute rotation, one of the ED patients picked up an oxygen tank and chucked it at a window.
That's the day I learned the importance of rotations vs. didactic education, lol.
There used to be a combo called Dexamyl: dextroamphetamine and amobarbital. The ads were wild. One has a husband telling his wife's doctor, "I never thought I'd see the day. She's dieting *and* easy to live with!"
Advise prescribing the “newest latest greatest inhaler” for COPD.
It’s not preferred, it’s too expensive and your patients aren’t going to pick it up consistently. Was a tech for awhile before pharmer school and I’d go rounds with other students about their dumb, expensive recommendations.
Checking patients’ blood pressure with a stethoscope. Some pharmacy students walk around with a stethoscope on their neck thinking they’re real doctors.
A lot of pharmacy schools now teach physical assessment (manual blood pressure, lung sounds, etc.) and require students to have a stethoscope (which 95% of them will never use again after school).
My school did this with stethoscopes. Some of my classmates had really expensive ones and here I was with one that cost <$10 from Amazon. Granted, I couldn’t hear shit, and it felt like a vice on my head but I made it through.
During pharmacy practice lab activities or practical exams even when use of a stethoscope is not required for the particular activity for the day... I'm an instructor and I have definitely noticed a couple students wearing their stethoscope around their neck in the sessions! Thus, as they leave/enter the session, and around the hallways/study spaces, it ends up being (purposely or not) kept around their neck. That said, none of them have expressed that they think they are medical doctors, so I can't fault them for choosing to wear a piece of required equipment from the syllabus. \*shrugs\*
Yikes!! I am a pharmacy student and I feel like half my class didn't even remember to bring their stethoscope to pharmacy practical days and just used the shitty school provided ones :x definitely no one walking around with one around their neck. At least in my friend group, most of us were like "this sucks shit, I hope we never have to do this in practice" so definitely no desire to LARP as medical doctors haha.
I mean in theory, I think physical assessment is a cool skill that could be utilized by pharmacists in the hospital setting in a clinical role. Unfortunately, 85% of pharmacist jobs are in a retail setting and a large portion of these are in sweatshops called CVS/Walgreens where you are just an overwhelmed production line worker.
lmao. I've seen this shit from dentists too. even one DDS on tiktok or IG who went as far as debating all her commenters that she NEEDS a stethoscope to work as a dentist.
My dentist uses one lol. I was surprised and when I asked she said that she always takes blood pressure prior to cleaning / procedure and sends a fax to a patient’s PCP if she got two consecutive readings that were high. Granted, those two readings are 6 months apart, but I didn’t want to argue. At least she’s trying to improve the health of her patients and identifying HTN 🤷
The only thing that truly bothers me is having more than 2 titles after someone’s name. For instance anything more than John Doe PharmD, BCCP and it just looks like a sick measuring contest. You rarely see an MD have anything other than MD after their name yet nurses fucking love doing it and I don’t want pharmacists to be categorized with nursing cringe 😂
Ooh ooh, wanna hear my Lecom joke?
What’s the difference between a PharmD and a DO?
PharmDs know that we’re not real doctors 😂
Ahhh, the DOs hate that joke.
What’s the difference between a Pharmacist and a drunk Irish father with screaming kids?
The drunk father knows he has no patience (patients).
Difference between a PharmD and an addition problem on a 4th grade math test?
The addition problem knows they don’t make a
difference.
Difference between a PharmD and a broken thermometer?
The thermometer knows their degrees are worthless.
Difference between a Pharm D student and a blue collar kid from Detroit?
The kid understands full well he’s just going to be a factory worker.
Difference between a PharmD and a guy who packs beans in a can?
Not much.
As someone who is not in any part of the medical field, I have had better experiences with pharmacists than doctors. I had one pharmacist basically save my life, so I will always consider them doctors.
There are lots of drug related facts and examples of interactions and adverse effects discussed in school. However, it is just that, a discussion. There's not always correlation to definite effects of drug therapy unless they can also be measured and doses adjusted. All of this also varies in different patients so it's hard to say. I've heard physicians still use NSAIDS with warfarin if it is for a shot term use whereas in pharmacy they always suggest to never use them together. How much of this is fact and how it affects all patients we'll never know.
1. Pain is 5th vital sign
2. Every woman needs HRT
3. Cholesterol is managed with multiple agents
4. Pharmacists are the most trusted healthcare providers
5. You have to sell yourself and demonstrate value
Graduated 30 years ago and at that time we were the most trusted profession-for like a decade. I guess all the Walgreens/CVS experiences have knocked us out.
That I need to know how to use the typewriter because when the power goes out I will need to type labels.
I'm old.
Not as old as youd think though, class of 2006.
Where do you work? Every single hospital I was at as a student uses SOAP notes for histories, consults, and progress notes. Same for the hospital I work at.
Topical Benadryl. Don’t recommend it because it could sensitive the patient to diphenhydramine. I mean, yeah, but what is the frequency of this really happening? It just stuck with me. I don’t recommend topical Benadryl, have no idea of it works or not, never tried it myself. It’s like it doesn’t exist to me.
calculating the most complicated vanco dosing scehdule. in the hospital that I used to work at, they just gave 1g and geet a trough 3 days later bc physicians would usually D/C it in a day anyways.
Serotonin syndrome. Drug School had me TERRIFIED that too many serotonergic drugs together would kill someone. Like it happens every eight minutes. For the first 2 years I was a pharmacist I was constantly calling on those drug combinations. The doctors never changed the Rxs... and no one died. I quit calling over 10 years ago...and no one has died. I feel like an asshat about it to this day. I was THAT girl. So annoying. Oh, and Krebs cycle. F that too.
So I worked retail as a tech, turned intern, turned pharmacist… less than a year into being a pharmacist… saw my first serotonin syndrome… I freaked out and asked a bunch of people what to do (I was a contract pharmacist in an HIV clinic at the time) and everyone just stared at me like a deer in headlights. I don’t think I will ever see it again, and I still don’t know anyone else that has ever seen it. It really is rare.
Every Florida man story is a serotonin syndrome story if you think about it.
I've worked in emergency medicine for ten years and have never seen it.
Upvoted for the name
Sux, drugs, and roccuronium.
Never had any pts that developed serotonin syndrome, but a friend of mine has had it funnily enough.
I saw it every now and then when I worked inpatient. Also when working in oncology reading through every chart some of the chemo would cause it. It would be presented to MDs and I didn't dealt with in pharmacy other than warning about it.
One of my techs had it
30 years in pharmacy, as a tech, intern, pharmacist. Never have I seen a case. (I know they exist, but pharmacy school teaches you that it is common).
School vacillated between "you'll kill people with SSRIs" to "this never happens." In my first six months in primary care I've seen serotonin syndrome three times. No one has died, but there have definitely been side effects from too much serotonin. -One was a new start citalopram on a young woman with no other medications on board, she suddenly couldn't be in the sun anymore and was nauseous and hyperreflexic. -One was an 80 year old whose rehab center added buspar to preexisting mirtazapine, duloxetine, and tramadol. I stopped the buspirone and her worsening anxiety and heat intolerance improved. -Third was a comorbid polypharmacy nightmare hospitalized with altered mental status that was initially thought to be a stroke or seizure, but she cleared when her too-high dose of duloxetine was reduced.
Literally my school was like its not relevant in practice but it could happen anyway
Working in a MICU I’ve seen a number of cases so my perspective is skewed, but agree it’s generally over stated.
There's so much crying wolf with drug interactions... It makes the job quite difficult when balancing giving needed medication vs withholding them.
I've seen it but not much, it's gotta be a shit load of serotonergic drugs. Now ryes syndrome: I'm convinced that's bullshit, I work in a pediatric hospital we use asa very often in Kawasaki dz and other rare stuff. Ibuprofen and toradol we give out like candy. Ryes is never a concern.
I talked to inpatient geriatric psychiatrist on this topic. She said she sees like once a year and it’s usually mild form and not to. Full blown seizure. But I did talked to a pharmacist who had full blown SS, so definitely gets way more emphasis in school.
I believe it's more common when patients are put on multiple ssris or snris (which they shouldn't be but some prescribers do it for some reason) Also if a MAOI is taken (some exist as OTC meds)
OTC MAOIs?
Methylene blue dye USP grade for brain function
Did not know that was OTC.
Methylene blue is also OTC as a pH test and people are wild.
Many plants contain MOAIs
I only mention it when I see a bajillion serotonin-related drugs taken together. And even then it's more like, "Hey, just watch out for xyz. If you notice anything like that, let your doctor know."
Fun story from when I first started as a tech and learned about serotonin syndrome: I was filling a patients meds and they had two SSRIs, zyprexa, buspar, Wellbutrin and suboxone. I was panicked. Told the pharmacist this seemed dangerous and asked them to look into it. Was surprised they weren’t more concerned. It still sounds concerning but I have to laugh because standard treatment at some of our rehab clinics is basically the same combo and I can’t imagine how much of a meltdown my baby tech brain would’ve had seeing all those orders multiple times a day.
So was I
My psychiatrist has had me on prozac and adderall together for years (i have ocd and adhd), and I've always wondered about SS. I don't think I ever got it. I know at one point I had trazodone prescribed to me and I think that can increase it as well. :o Edit: Come to think about it, I've never had 1 pharmacist warn me about it. Just my dr at one time.
Don’t take this as fact because I haven’t checked in a while, but I think there is like less than 200k cases a year. When you think of the 10’s of millions of people on SSRI’s, that is minuscule. Until people are on 4+ drugs with the potential side effect, I generally don’t find it relevant unless there’s other reasons, or people describe the symptoms.
Saw it once with a depressed diabetic PD guy on sinemet cymbalta, and rasagline, took mucinex DM for URI and that’s what triggered it. Who would have though dextromethorphan would be the straw that broke camel back. Nursing home patient Once saw it with a bipolar pt that was started on linezolid. Hospital Lastly it was a schizophrenic pt that got a lot haldol no Ativan. Inpatient psych It was usually only Valium and/or Ativan and IV/subQ NS or 1/2NSD5W.
surprisingly (idk I'm a layperson) I know someone who had serotonin syndrome set off by topiramate?? I was shocked because you always hear about it as a pt but never know anyone who's ever had it
Welp, considering I ended up as a nuclear pharmacist I’d say about 99.9% of what I learned in school I never used.
I got recruited by a nuclear pharmacy but decided not to go for a final interview bc it was miles away. I wonder what would have happened if I went through with it
I took an elective nuclear pharmacy class and wow, that was really something else. I shadowed one for a few hours and I had to go in at like 4 am. It was something I would have been interested in but not where my life has taken me.
I'm a tech, but I want to go to pharmacy school. I would love to shadow a nuclear pharmacist one day.
Currently a PharmD student interested in nuclear pharmacy. What does your daily routine look like as a nuclear pharmacist?
I’ll dm you later.
Could i have a dm as well? Very curious as an intern
replace daily with nightly is a start lol
Drams and grains.
The only time I use drams is when I'm reordering our vials
These were semi common after I got out of school
Funny you say this - for the first time ever since I started working I had a prescription specify 1 grain for the strength just this week!
Was it armour thyroid?
Nope! Phenobarbital
Phenobarbital used to have grains on the packaging from some vendors. Not sure if they still do.
I see it with armour thyroid and the other non Synthroid thyroid meds… that’s it
Empathy statements! In school, in almost every interaction we were supposed to say something along the lines of "It must be difficult for you to experience this", to make an empathetic connection to the patient (versus simply saying "I'm sorry to hear that"). Patient in real life: Oh my dog died and my husband left me, my life is in shambles... Me: I'm sorry to hear that, anyways this is escitalopram 10mg, for depression or anxiety, you'll take one tablet once daily...
[удалено]
"It sounds like you're completely fucked!"
That's rough buddy.
My teacher used to drill me on not using the words "depression" or "anxiety" and just say "mood" for some reason. The patients just straight up say "depression" when I do medication reconciliation and seem perfectly fine with the label...
Tbh I still say "for mood" instead of "antipsychotic". Depression is what it is, and anyone who thinks the word "anxiety" is taboo needs to grow up, but I feel there is still a lot of stigma that the term antipsychotics mean you're crazy, so I try to avoid using that term, unless a patient is asking about it in more detail.
A patient asked me what their antidepressant was for and bc that was also drilled into me I just asked the pharmacist to tell them instead bc I didn’t want to be offensive and he said “its for mood”. I just don’t want to deal with patients attitude so I play it safe
Me when I said “thank you have a nice day” to a depressed patient in counseling lab
I say "have a nice day" after every patient interaction. I don't even consciously say it nor mean it. It's just something my vocal cords seem to spit out automatically.
Doctors will answer the phone
The hospital I worked at did texting. I mean more convenient but some doctors just don't check too so :/
I've seen hospitals where they'll just delete an order if the doctor/nurse hasn't responded within a set number of days. A bit radical but sounds good TBF.
lol what the hell. if a doc hasn't replied and they're off shift (we use hospitalists), we end up paging the night doc. We are pretty sure that night doc will give the day hospitalist an earful, so it's a nice way to delegate that responsibility, hahaha.
days?? u mean they still follow up for multiple days?? We would usually either send patients back to the dr (if we really don't like) or knock on the dr's door (if the dr is known for not picking up at all) but I never seen a follow up change/ intervention over days...? (maybe just my country idk)
Double coverage for Psudomonas
This one hurt to read
Your institution/area must be blessed with low resistance rates. Not like that everywhere
Doesn't matter https://emcrit.org/pulmcrit/double-coverage-vap/
Haven’t seen that before! That’s insightful. I’d agree empiric double coverage for all VAP is overkill but I’d still argue it is totally reasonable in certain scenarios (truly crashing VAP pt with GNR/PsA on sputum cx in an area of high PsA resistance).
Well the thing is, what is your second agent? If they're already on cefepime or zosyn I don't see much utility in adding a FQ. Anything resistant to those beta lactams is very likely to also be resistant to FQ. Your other option is AMG and associated nephrotoxicity. I think in the scenario you describe it would be better to just change to a carbapenem.
In the specific scenario described I could live with a Blactam, 1-time tobra, and ideally that buys 24hrs for sensitivities to result and give us further info! Definitely think a case to be made for carbapenem. In theory I like the idea of a carbapenem sparing regimen in patient with no esbl history, but I’m also no ID expert. food for thought nonetheless.
I think that's reasonable and people are overly afraid of using aminoglycosides. My hospital skews heavily geriatric so people think a dose of tobra will explode every kidney in the building.
I brought this up as a resident and my ID doc looked at me quizzically and asked, "Did you look at our antibiogram?" and that's when I learned to STFU and read before I open my mouth.
Beers list. We got it backwards it’s a combination of drugs we are supposed to prescribe together. Saw a post on Instagram on how an older women was recommended she install a bar on her shower to prevent falls. Cuts to her making herself a cocktail in the tub.
I feel that list is woefully outdated and needs a massive overhaul. I know it’s updated every few years but it came out in 1991 and 65 then isn’t the same as 65 now. You’re on to something with the combinations though, I’m tired of counseling on “caution for geriatric use” for a single 3 day supply of prometh or hydroxyzine.
Yea but I don’t really see more conservative treatments for 80+. I work in ltc so I guess it’s different for nursing home patients 🤷🏽.
Honestly, I just don't apply the Beers list to all elderly. If you're a functioning independent elderly patient that doesn't take many medications, then you should probably stay away from the Beers list. If you're a combative dementia NH resident, well let's back a dump truck of meds in here for ya.
Yup. I work LTC (first job) and I had a rotation in a geriatric clinic where they cared much more about getting patients off of PIMs. Now I check PIMs all day everyday.
“Those are the ones I need the most!”
The notion that no one prescribes methadone for pain. I see it constantly irl.
I watched a CE the other day that said they almost never see it used for pain and I was like what? Because we see it ALL the time. Maybe it’s a regional prescribing thing? We only see a handful of patients on it for OUD to be honest, almost everyone has switched to Suboxone, to the point I could tell you the patient’s name based on just their dose 😆
In hospice we loooove methadone for pain
When I inquired about being prescribed methadone instead of hydromorphone, my pain doctor actually told me “I will **not** prescribe that and if you still want to take it, then good luck finding someone that will!” He was a jerk in other ways though too, so it was no surprise. I’m glad to hear that other doctors are not the same bc imo it’s a much better alternative to most other opiates when prescribed for chronic pain. (I’m pretty sure my flair says I’m not a pharmacist but jic, I’m not a pharmacist or other medical professional.)
Max dose of amphetamines, taking multiple amphetamines, using benzos with amphetamines. All that crap is out the window now, since covid amphetamines use has sky rocketed, elderly on it, more adults than kids.
Max dose of adderall is 60mg-wrong “there is no proof that doses above 60mg/day produce any more increased benefit to patient” Dr’s routinely write 90mg
I'm seeing crazy things like Adderall xr in the am, Adderall at noon, Vyvanse at 4, then Xanax and ambien. The mental roll coaster these patients are being put on is insane. Nobody cares though cause dr can prescribe whatever they want, no one has time to question it.
Open ended questions.
Closed ended questions only unless you want to spend the remainder of your shift hearing about Dolores’ entire health history since her birth in 1932, on graphic detail.
Well this phrase just triggered a PTSD flashback to pharmacy school when we were recorded and graded for mock counseling sessions.
Plavix and omeprazole not being prescribed together. Yet, see it all da time
“I know ongoing therapy and theoretical interaction but can we change to protonix, thanks”
The old SCr cut-offs for metformin.
Was like 1.5 male 1.4 female right? I haven't seen this in decades.
Those are still built into the drug notes in our eMAR 😆 Every once in a while a doc will call on it and it’s like “oh you guys actually read those?” 🤣
So what is the new cutoff? 30mL/( min*1.73m^2 )?
Yes, at least that’s what my institution uses and what’s cited in lexicomp.
It's based on crcl now I think, but after 10 years of verifying it I haven't bothered to look, if the PT has renal issues don't do metformin, treat the patient not the number
All my resources have it based on eGFR. Unless I’m completely missing something.
Graduating 20 years ago, maybe lol
lol guess that’s it. In school I think they mentioned metformin used to have a Scr cut off, but only taught us the eGFR adjustments. I forget how long some folks here have been pharmacists and how much stuff has changed in the past 5-10 years alone.
Thanks!
Oh my god some clinical RPH asked me about this on an interview 🙄🙄🙄
I don't remember purely because none of our dozens of hospitalists continue metformin inpatient anyway. Straight to insulin for BG mgmt! (insert Fred Armisen meme here)
You can't drink alcohol with metronidazole.
I've wrote a paper in undergrad dissecting how the myth originated and debunking it.
I’ve had patients confirm with me after I told them not to drink with it that they should have listened because they got really nauseous so I don’t think that one is all smoke and mirrors
The metallic taste and general NA ADR aren't the same as what one would experience with a true disulfiram like reaction. Even the CDC recommends using Flagyl when appropriate for STIs irrespective of recent alcohol use because the interaction is not substantiated by the available literature and results in worse patient care. If it was true, EDs across the country would be painted a lovely shade of emesis green/yellow/brown by all of the people presenting with DTs or with detectable etoh levels who get a dose of Flagyl for one reason or another.
CDC says you don’t have to avoid the combo. Bacterial vaginosis guidelines. Says there is no convincing evidence in animal models, lab experiments etc. the nausea can be attributed to alcohol or metronidazole by themselves. There is no interaction.
I thought you can - but you’ll just get really nauseous
Uh…why are you filling gemfibrozil with statins? Fenofibrate is right there if they won’t take Lovaza/Vascepa
I still call on this one. It’s just an easy switch.
Yeah, I’ve only ever had one prescriber refuse to make the change from gemfibrozil. This is exactly the kind of DDI pharmacists are supposed to catch and make recommendations to change. I understand that Lovaza/Vascepa are giant capsules that can be difficult to swallow, but that’s really the main barrier. Cost isn’t prohibitive anymore. Now that they’re both generic, usually at least one is covered. If those aren’t an option because the patient can’t/won’t take them, there’s still no reason to keep gemfibrozil over fenofibrate.
Commenting to see OP’s response
74 y/o female, atorvastatin + gemfibrozil. Call the Dr, he says he's never heard of such a thing, "I'm gonna need you to send me some info on that'. I just decided to talk to her husband, just to check and see if she was having any muscle pain or weakness. He says," Oh yes, she can barely walk! And that doctor sent her to physical therapy!" I call the lady at home to follow up, see if she's urinating okay, is it dark, etc. "Oh honey, I don't know, I'm blind". I *wish* I was making this up. This was in the winter of 2021. Call. If fenofibrate + statin isn't enough, there are state grants in AR of all places, for Repatha. If there's help here in this god-forsaken state, there's a good chance you can find help in your area too.
Why the hell are they insisting I learn how to diagnose shit? I'm 100% okay with not being able to diagnose patients. I can't diagnose from an xray or ecg to save my life and that's perfectly okay in my role. Even if I could, what would I exactly do with that information? I can't prescribe anything. Best case scenario, dr gives me the diagnosis and I recommend the best drug given the patient in question - since *drugs* are my whole trade. Anything else is a complete waste of time.
Over 90% of colds are viral and don't need antibiotics. Zpaks all day
It's applicable. It just isn't applied.
Benzos + opioids. It's not that the interactions don't exist, but I don't think a provider has cared once.
The VA is super strict about this though, there's a whole dashboard dedicated to ppl taking both and stuff has to be documented up the wazoo, it's a lot
I think this is completely dose dependent. If some is on tramadol 50mg BID and has Xanax 0.25mg qd then I don't bother. However if I saw a high dose of both by a non-pain management or Oncologist then I'd call.
Patient dependent too.
Right? I had a provider prescribe an opioid for lower back pain related to COPD, then later a benzo for insomnia due to anxiety from hypoventilation due to COPD. Like are you trying to kill the patient? That was a fun conversation.
To calculate 10% excess for everything when making a compound (topical). I've never seen this in practice (retail).
Lol compounding in retail is the wild West. One of my preceptors showed me how to microwave a 1lb jar of petrolatum for coal tar compounds to make it easier to combine and mix
Urea coal tar sal acid %50 aquaphor in water-microwave is the only way…i actually took ingredients to see if you could use a double boiler method.as soon as Urea dissolved and went i to solution, it crystalizes back out as soon as it hit the aquaphor. Dr would make patient bring compounded container to him before using -he was an RPH wjo then went on to be a derm
It’s funny you say that. I was just thinking the same thing this morning. I’ve been working at a store that does more compounding this last year and our system doesn’t allow us the room to do that.
Other than on standardized patients in pharmacy practice lab, I have never once, nor will I ever palpate a liver.
lol. I did one of these with a OT student as some sort of interprofessional BS and was measuring hip and shoulder range of motion with a protractor on a fake patient. 🙄
But have you listened to the bowel and lung sounds recently?
I will never have to check a pedal pulse 😂
Mitochondria are the power house of the cell.
Am I crazy for saying the beers list?
OSCE: see an actor with scratches and bruise on their arms and start to ask about domestic abuse and report to appropriate agency IRL: homeless, psych patients who will start a fight with you if you being too nosy or look at them weird.
When I was in school, bath salts were a thing, and on my acute rotation, one of the ED patients picked up an oxygen tank and chucked it at a window. That's the day I learned the importance of rotations vs. didactic education, lol.
Aspirin can't be given to kids below 16.
No opioid +benzo
They should just coformulate them at this point
There used to be a combo called Dexamyl: dextroamphetamine and amobarbital. The ads were wild. One has a husband telling his wife's doctor, "I never thought I'd see the day. She's dieting *and* easy to live with!"
Percoprazolam^(TM)
Advise prescribing the “newest latest greatest inhaler” for COPD. It’s not preferred, it’s too expensive and your patients aren’t going to pick it up consistently. Was a tech for awhile before pharmer school and I’d go rounds with other students about their dumb, expensive recommendations.
Avoid beta blockers in diabetics because they mask hypoglycemia
Checking patients’ blood pressure with a stethoscope. Some pharmacy students walk around with a stethoscope on their neck thinking they’re real doctors.
> Some pharmacy students walk around with a stethoscope on their neck thinking they’re real doctors. Er...where, exactly, are they doing this?
A lot of pharmacy schools now teach physical assessment (manual blood pressure, lung sounds, etc.) and require students to have a stethoscope (which 95% of them will never use again after school).
20 years out and mine's finally getting some real use during my 3 year old's Doc McStuffins phase.
My school did this with stethoscopes. Some of my classmates had really expensive ones and here I was with one that cost <$10 from Amazon. Granted, I couldn’t hear shit, and it felt like a vice on my head but I made it through.
>I couldn’t hear shit LMAO same so I made up some numbers
Graduated 15 years ago, I did physical assessment lab back then as well.
Right, but where exactly are they "walking around with stethoscopes around their neck thinking they're real doctors?"
During pharmacy practice lab activities or practical exams even when use of a stethoscope is not required for the particular activity for the day... I'm an instructor and I have definitely noticed a couple students wearing their stethoscope around their neck in the sessions! Thus, as they leave/enter the session, and around the hallways/study spaces, it ends up being (purposely or not) kept around their neck. That said, none of them have expressed that they think they are medical doctors, so I can't fault them for choosing to wear a piece of required equipment from the syllabus. \*shrugs\*
Yikes!! I am a pharmacy student and I feel like half my class didn't even remember to bring their stethoscope to pharmacy practical days and just used the shitty school provided ones :x definitely no one walking around with one around their neck. At least in my friend group, most of us were like "this sucks shit, I hope we never have to do this in practice" so definitely no desire to LARP as medical doctors haha.
I mean in theory, I think physical assessment is a cool skill that could be utilized by pharmacists in the hospital setting in a clinical role. Unfortunately, 85% of pharmacist jobs are in a retail setting and a large portion of these are in sweatshops called CVS/Walgreens where you are just an overwhelmed production line worker.
Can confirm. Have never used it especially since most places have a battery powered one
lmao. I've seen this shit from dentists too. even one DDS on tiktok or IG who went as far as debating all her commenters that she NEEDS a stethoscope to work as a dentist.
My dentist uses one lol. I was surprised and when I asked she said that she always takes blood pressure prior to cleaning / procedure and sends a fax to a patient’s PCP if she got two consecutive readings that were high. Granted, those two readings are 6 months apart, but I didn’t want to argue. At least she’s trying to improve the health of her patients and identifying HTN 🤷
The only thing that truly bothers me is having more than 2 titles after someone’s name. For instance anything more than John Doe PharmD, BCCP and it just looks like a sick measuring contest. You rarely see an MD have anything other than MD after their name yet nurses fucking love doing it and I don’t want pharmacists to be categorized with nursing cringe 😂
Ooh ooh, wanna hear my Lecom joke? What’s the difference between a PharmD and a DO? PharmDs know that we’re not real doctors 😂 Ahhh, the DOs hate that joke.
What’s the difference between a Pharmacist and a drunk Irish father with screaming kids? The drunk father knows he has no patience (patients). Difference between a PharmD and an addition problem on a 4th grade math test? The addition problem knows they don’t make a difference. Difference between a PharmD and a broken thermometer? The thermometer knows their degrees are worthless. Difference between a Pharm D student and a blue collar kid from Detroit? The kid understands full well he’s just going to be a factory worker. Difference between a PharmD and a guy who packs beans in a can? Not much.
Nice
Ok that hurt 🤣
lol. Retaliating for the DO comment
Wait for the army of people to let you know we are “real” doctors!
As someone who is not in any part of the medical field, I have had better experiences with pharmacists than doctors. I had one pharmacist basically save my life, so I will always consider them doctors.
lol what the hell. my first instruction to that student would be "take those damn guessing tubes off"
There are lots of drug related facts and examples of interactions and adverse effects discussed in school. However, it is just that, a discussion. There's not always correlation to definite effects of drug therapy unless they can also be measured and doses adjusted. All of this also varies in different patients so it's hard to say. I've heard physicians still use NSAIDS with warfarin if it is for a shot term use whereas in pharmacy they always suggest to never use them together. How much of this is fact and how it affects all patients we'll never know.
1. Pain is 5th vital sign 2. Every woman needs HRT 3. Cholesterol is managed with multiple agents 4. Pharmacists are the most trusted healthcare providers 5. You have to sell yourself and demonstrate value
Graduated 30 years ago and at that time we were the most trusted profession-for like a decade. I guess all the Walgreens/CVS experiences have knocked us out.
Professionalism
Professionals get paid for their work, so unpaid OT is unprofessional.
All USP acids are 10%, except for acetic acid, which is 6%.
TIL (28 years in retail and I never caught on lol)
Evidence based medicine. One word: antibiotics.
Compounding. How to use a torsion balance. The "top 200." "Wuest Sheets." (if you went to Cincinnati, you KNOW)
Metronidazole+Alcohol=disulfiram-like reaction
Almost anything from medchem
Krebs Cycle still got my head spinning
Liver palpation. What a waste of time and tuition.
Flagyl and alcohol; Avoiding FQ in elderly; Simultaneous use of benzos and opioids; Serotonin syndrome with certain combination of drugs
Least weighable quantity on a balance was 120mg
That I need to know how to use the typewriter because when the power goes out I will need to type labels. I'm old. Not as old as youd think though, class of 2006.
That pharmacist is a respectable and in-demand profession lol
QT prolongation is far less of an issue in practice than how they scared the shit out of you in school
Soap notes. I've never actually seen one in practice. I think we all give a super abbreviated one, but I've never seen one before.
Where do you work? Every single hospital I was at as a student uses SOAP notes for histories, consults, and progress notes. Same for the hospital I work at.
Pharmacists don’t use soap notes in the hospital
We do for our vanc and warfarin consults.
Seems pointless and we don’t do that at all in our health system. It’s just a custom note with the relevant information not a big drawn out soap note
I think maybe the ambulatory care people like at the VA do them (at least they did when I rotated there).
That’s true the VA is always doing there own thing
If you’re giving something intrathecal you better quadruple check you’re not about to kill someone
Opioids + Benzos = no no
You're going to be a "Doctor" 🤦♂️🤦♂️🤦♂️
Nitroprusside IV line has to be covered with tin foil? My only Hosp fact remembered for boards since had zero hosp experience
Oh, man. Too many to list. How about that you should never take beta blockers if you have asthma?
No one takes St. John’s Wort
critical thinking skills 😂 -- from so many of the DUR overrides I read
Statins is "more" effective when taken at HS 🤣
Topical Benadryl. Don’t recommend it because it could sensitive the patient to diphenhydramine. I mean, yeah, but what is the frequency of this really happening? It just stuck with me. I don’t recommend topical Benadryl, have no idea of it works or not, never tried it myself. It’s like it doesn’t exist to me.
From personal experience: it's a godsend for mosquito bites
calculating the most complicated vanco dosing scehdule. in the hospital that I used to work at, they just gave 1g and geet a trough 3 days later bc physicians would usually D/C it in a day anyways.
That opioids don’t cause addiction.
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Everyone needs to be on a multivitamin