Category: Pharmaceuticals

Medication Errors

Not infrequently Express Scripts, Medco, or other similar companies send a fax to alert me that my patient is taking two similar medications. Occasionally it’s intentional, but most of the time it means something went wrong.

Sometimes I change a patients’ medication to something similar to achieve better efficacy, to minimize side effects, or due to cost. Although I always put the changes in writing for the patient, telling them what to start and what to stop, this doesn’t always work. Patients may get an automatic refill of the original medication from the pharmacy or call it in when they notice a pill bottle is almost empty. Sometimes they go by a medication list they’ve generated, but not updated, rather than the printout I give them.

Sometimes patients end up on two similar medications after getting one from a specialist who doesn’t realize a patient is taking something, because the patient didn’t bring the list I gave them, and they don’t remember everything they take. For example I might have the patient on lisinopril for hypertension, and their cardiologist prescribes the similar benazepril.

A similar medication error happens when we tell patients to stop a medication and they don’t for similar reasons as above.

So the faxes are helpful when these things are caught, but it would be better if it occurred at the the time the prescription is sent to the pharmacy.  Ideally the pharmacy computer would automatically connect to the physician’s electronic medical record (EMR), particularly the primary care doctor, and compare medication lists. If they had medications to refill that didn’t match the EMR record, they would call to double check if the patient could not give them a good reason for the discrepancy. In addition, the pharmacy computer could keep track of all the chronic medications a patient has filled. If the patient doesn’t get the prescription refilled in a timely manner, their computer would query the physician computer to make sure it was still an active medication. If so they would call the patient (and maybe in the future talk to the patient’s medication list carried on their computer/mobile device) and remind them to refill their medication, assuming someone hadn’t stopped it, the patient was taking samples, or some other good reason.

If you use a program such as Quicken, you can download credit card and other transactions and reconcile them with entries you’ve entered. Comparing medications would be a similar process.

There are certainly barriers to such a solution. Electronic health records would need to have medication fields standardized, and there would need to be protocols to exchange the information. I’m not sure, but I think some of this already exists. Of course there are legal issues such as HIPAA.

As John Lennon said, “You may say I’m a dreamer, but I’m not the only one. I hope someday you’ll join us, and the world will be as one.”

Right for the Wrong Reason?

In 2007, Texas Governor Rick Perry signed an executive order mandating that teenage girls be vaccinated with Gardasil, a vaccine that helps prevent cervical cancer by providing protection against Human Pappillomavirus, or HPV. This was subsequently overturned by the Texas legislature. Now it’s a matter of discussion among Republican presidential candidates. Representative Michelle Bachmann has criticized not only that, ““To have innocent little 12-year-old girls be forced to have a government injection …is just flat out wrong,” but has also suggested that he was motivated by political donations from pharmaceutical company Merck.

We’ll have to see how things play out in regards to whether Governor Perry made his initial decision because of political donations, but it least has the appearance of impropriety.

From a medical point of view, I think he was right to mandate vaccination against HPV, even if he did so for the wrong reason. According to the CDC and the American Cancer Society, at least half of sexually active people will get infected with HPV in their life. Half of those people are infected between 15 and 24 year of age.

In the United States, about 12,000 women are diagnosed with cervical cancer, and 4,000 die from it, each year. HPV causes most of these, as well as many cases of anal and oropharyngeal (mouth and throat) cancer, and genital warts.

As a father of daughters, I get that when they’re 10 to 12-years-old, you don’t want to think of them being sexually active. But most people eventually are, and you can’t be certain that it will only be with one uninfected person the rest of their life. Once they’re infected, it’s too late.

The policy for vaccination against HPV should not be different than for other infectious disease, such as tetanus, polio, measles and chicken pox. If you love your children, you should seriously consider vaccinating them. Even if he had ulterior motives, I think Governor Perry had the right idea.

Glazed Donuts

A couple of pharmaceutical reps brought us lunch to discuss their new product, a testosterone gel that’s more concentrated, and thus lower volume, and applied to the inner thighs. Referring to their main competitor, that uses a larger volume applied to the shoulders and upper arms, one of the reps said that by using his product instead, one could avoid, “that whole glazed doughnut thing.”

Over-the-Counter Lipitor?

According to sources in the Wall Street Journal this week, Pfizer said they would apply to sell Lipitor over the counter. This is a bad, bad idea. Lipitor is in the class of medications commonly called statins. Although it’s an excellent drug, it can have serious side effects, including liver and muscle damage. Presumably an OTC dose would be low, and less likely to cause side effects, but it’s still likely patients would inadvertently take it in addition to statins prescribed by their doctor, or along with red yeast rice, a naturally occurring statin.

Even if there was zero risk of side effects, there is a high risk that patients would not use the medication properly. Lipid (cholesterol, triglycerides (fats), HDL (good cholesterol), LDL (bad cholesterol), etc.) management can be quite complex. One should know medical problems that might exacerbate the problem, such as diabetes and thyroid problems. There are many medications to choose besides statins, and different ones work better for some people than others. Then you have to know how aggressively to treat, which depends on the risk of cardiovascular disease, among other things.

Over-the-counter Lipitor would certainly be cheaper than the current prices, but it would likely be more than the generic price. Even if priced below generics, it could cost consumers more because their insurance would likely not cover it if it was available over-the-counter. This is what happened with the antihistamines Allegra and Zyrtec, though generic Claritin (loratadine) is quite cheap now.

So given all the down sides, why would Pfizer try to get OTC Lipitor approved? I wonder if it could have anything to do with their loss of patent protection when it goes generic 11/30/11?! Fortunately it’s unlikely the FDA will fall for this.