"Well, if I would have known that..."

Imagine going to the pharmacy and believing that the pharmacist had, without your permission or your physician's, switched your medicine to something lower quality, inferior clinically, different from your regular medicine, and all because it was "cheaper." Well, Mr. Jones called me for a price check, and that's the story I got. The more I listened, the more I realized that he didn't understand the "generic" they tried to give him was the exact same thing.

After I explained the situation, Mr. Jones said, well, no one ever told me that; I had no idea they were giving me the exact same thing. He told me that he was profoundly grateful to have this new information, since he had no idea how he was going to afford his medicine when insurance no longer covered it, because of the preference for the generic.

Just like that, a new believer in generic medicines was born. It was truly an epiphany. The things we take for granted--you can't even assume someone knows what a generic medicine is--wow! We must continue to spread the word, and not assume ANYTHING.

"The best I've felt in over 30 years!!!"

The situation: I recently learned from a patient, Betsy, that she has been constipated since age 16, now in her fifties. Because of a drug interaction, I had occasion to speak with her over the past few weeks regarding her condition. In a nutshell, she has been diagnosed with constipation-predominant irritable bowel syndrome (IBS-C). The spasms have been barely controlled with anti-spasmodics like dicyclomine and Hyomax, however they contribute to the constipation, which contributes to the spasms, especially when she eats, and results in numerous clinic, urgent care, and ER visits. Upon further investigation, another part of the problem was that she was taking her 'as needed' anti-spasmodic medicines all the time. This was causing serious difficulty swallowing her food and medicines, because even normal peristaltic spasms that move food along in the gut in her esophagus were inhibited--two hours for a capsule 'to go down' is not good.

The intervention: She has learned she only needs to take her anti-spasmodics as needed (as prescribed). She is also taking acetaminophen liquid instead of aspirin for pain relief. Plus, after research into therapeutic alternatives and her insurance formulary, and sending a request to her prescriber, her doctor added Amitiza (generic lubiprostone) to her regimen. Amitiza is a prostaglandin that basically adds lubrication to the gut and has very few side effects (nausea and headache are most common). When I told Betsy about it, she was eager to try it. The cost was under $10/month with her insurance, which was nothing compared to the costs of all the other things she has tried, both prescription and non-prescription.

The results: She reported two weeks later, that although she still has had some spasms, one recently sent her to the ER again, they seem to be lessening, she told me that it has been 30 years since she has "felt normal like this," in terms of her constipation. Now that's why I became a pharmacist :)

What could possibly be right about getting Ventolin EVERY week?!

Ventolin HFA, a rescue inhaler, aka albuterol inhaler, is often overused to improve breathing in people with various conditions, ranging from asthma to COPD (chronic obstructive pulmonary disease possibly due to smoking) to allergies to difficulty breathing while fighting off a cold.

Ms. Ventolin, and advanced stage COPD'r, had been telling us that she needed her inhaler refilled every week. Somehow her doctor must have agreed because she had a prescription for #4 inhalers with a year of refills. Well, according to the directions provided on the prescription, 200 puffs of Ventolin should have lasted 25 days--which is a lot longer than a week. However, the prescriber had been contacted by other pharmacists in the past and still approved the fill. Notably, there was a recent prescription for Advair, however, Ms. Ventolin had told us the Advair was "not helping, so she stopped it."

Since I have been working nights a lot, it was difficult for me to call and catch a doctor, so I started out by contacting the doctor-on-call the first night I decided to seriously tackle this issue, although I had sent a fax about a week earlier, which was ignored. The doctor-on-call was semi helpful, encouraged me to contact the patient's prescriber by fax with details on his filling history, and request another med. After a week of back-and-forth faxing and looking for alternatives her insurance would cover, we finally hit the jackpot last Friday and provided Ms. Ventolin with her new Symbicort inhaler twice a day.

Three days later I met Ms. Ventolin at the pharmacy counter. Apparently, the new inhaler has been working beautifully! Ms. Ventolin is feeling better and only using her Ventolin twice a day!!! (That's a reduction of about 30 puffs a day, but who's counting?) Plus she has been able to cut out the frequent albuterol nebulizations and save a boat-load of cash not by having to buy inhalers when the insurance said the claim was too early to fill (in spite of the way the prescription was written).

Now that's why I went to pharmacy school. To me, it is a reminder that if I'm ever too busy to help a patient in this kind of situation, I need to hang up my white coat and go be a cashier.

"I was hoping for a male pharmacist..."

I do not know this person, but he came in around 9:30pm one night, and that is how he started his conversation with me. Well, you might have guessed it. It was interesting to hear about more of the misconceptions people have surrounding pharmacology, specifically erectile/sexual dysfunction. This was actually a pretty academic discussion, although he was apparently inquiring for himself, after deciding I looked safe enough to ask. Here were some of the questions, which took awhile to actually define:
#1. What is the "natural equivalent" to Viagra?
My answer: there isn't one, although there are definitely medicinal natural compounds, there are no equivalent alternative/herbal medicines to Viagra. After I took out my PDA and looked into it for a second on Natural Medicines Comprehensive Database, I found out that yohimbine has some weak evidence. (It also has cardiac side effects that sound pretty scarey.)
#2. What does Viagra do anyway? I don't understand any of the physiology...
My answer: "Drugs like Viagra increase blood flow." I suppose I was somewhat inhibited, because he thought about it for a second, and looked at me, and I did not elaborate further, although he asked the question again after a few minutes, and I eventually did give him a little more..."...increased blood flow to certain relevant areas through dilation of blood vessels..."
#3. I tried Levitra and it didn't work for me. Do you think it could be because I drink about 5 cups of tea every day?
My answer: The caffeine in tea may have an effect on the nearby renal system by causing fluid loss (aka diuresis), but unlikely it's contributing. I would have to look into it more to say for sure. You may want to give Viagra a try, because it is a similar medicine with a slightly different chemical structure, which makes it a potential option, even though Levitra did not work for you.
#4. When I was with someone I really cared about, "I didn't have any trouble," so that makes me think it's partly emotional.
My answer: Sex originates in the brain for sure. And that could definitely be a factor.

Would you believe me if I told you he eventually confessed that he used to rob pharmacies--"not to make me nervous or anything..."? Since then he said he's tried to just find out where the natural source of the medicines we use is, so he can just buy it from the herbal section of the pharmacy [unsaid...and he won't have to resort to robbery anymore??!]

What would you have said? I have to admit that I was pretty happy when 10pm arrived and it was time to go; however, I felt pretty good about his taking the time to discuss such a personal issue with me at such length, although I clearly wasn't the male pharmacist he was hoping for. I was happy for the opportunity to dispel some myths. Too bad he didn't have any questions about avoiding STD's... maybe another day!

The "Drug Info Pharmacy"

What a weekend! With a job in community pharmacy, who needs a residency? Last weekend, I worked at a certain store, and the questions were amazing! Here is a sample:

"What about probiotics for a 6-month old with diarrhea?"

"What about colace solution in the ear to loosen ear wax?"

"I think I'm anemic because I had a bypass surgery on my heart 3 months ago, and I want to take some iron; what should I take?"

"I am looking for retinol cream to prevent skin cancer. My friend said you have it here, but I don't know what it's called..."

"I have an immune deficiency, and I'm wondering if this lotion will really do anything to lessen my dark, patchy, itchy spots all over my upper body that I've had for the last year, and nothing has worked so far."

"What is an equivalent dose of Dilaudid to Tylenol #3 for back pain?"

"I don't get my drugs here, but I got home with a prescription for Diflucan for my yeast infection, and I read it shouldn't be taken with omeprazole. What's the danger? Should I use these vaginal suppositories instead, because I have a serious stomach condition, which is why I take the omeprazole?"

"My doctor said I have a urinary tract infection, and then two days later, I got a message that I have a yeast infection! What is happening? Do I really need this medicine? Why didn't they tell me when I was there? Can my husband get this from me if we have sex?"

If these questions weren't enough, we had a very sad situation in the afternoon on Sunday when a seizure occurred in our store. Thank God the employee was in the back room when it happened. When they came running for help, the training just came right back to me... as we were calling 911... keep the area clear of obstacles, and the seizure should only last a minute or two, no objects in the mouth, and if possible, keep her turned so that she doesn't aspirate anything down her throat... she's in the hospital now, awaiting brain surgery for two large tumors on her brain this Friday! How sad! Lots of people are praying she has a full recovery!

Not bad for my second weekend working solo as a licensed community pharmacist?

Is this a good one?

CVS brands are routinely tested and proven high-quality according to the research I have done at consumerlabs.com and their own "satisfaction guarantee." So when the elderly lady in front of me asked if this multivitamin was a "good one," I felt confident indicating that all CVS brand supplements are tested and high-quality with a money-back satisfaction guarantee. However, was this supplement the right one for her?

Actually, since the lady was in a later stage of life, she didn't really need or stand to benefit from the iron in each tablet. Instead, I was able to direct her to a great supplement with even more vitamin D and no iron; since post-menopausal women are no longer losing blood during menstruation, iron replacement is not needed and can actually be harmful. We didn't stop there however, we also assessed the value of the 260 count bottle for $15.89 instead of the 100 count for $8.99 or the 150 count for $11.29. Which one would you have picked? $0.061/tablet (250) or $0.075/tablet (150) or $0.09/tablet (100). We decided on the 260 count and saved her about $7.28 [(0.089-0.061)*260]! Now that's real pharmaceutical care :)

The difference between supplements with glucosamine, chondroitin, MSM...?

This was the question. However, just because that's the product you're asking about, doesn't mean that's really what you need. "Achy legs" are not likely to benefit from any of these, unless there's actual pain in the joints from some degenerative process. Turns out the young lady was in need of support hose, not glucosamine. The average person really does need a good pharmacist to help them understand these things. Another life improved with pharmaceutical care!