Just what the doctor ordered?

Ensuring the safe supply of medicines can sometimes necessitate robust discussions with prescribers. Here’s how to tackle them. 

When reviewing and dispensing medicines, pharmacists have a professional obligation to ensure they are safe and therapeutically appropriate for the patient.

This responsibility also includes working to resolve medicine safety problems with prescribers when a medicine or dose is inappropriate or unsafe. However, traditional power imbalances can make this a tricky interaction to navigate.

Should pharmacists fail to effectively resolve the safety issue with prescribers, the worst-case scenario is the death of a patient – highlighted by the 2018 coronial inquest into the death of a 77-year-old Victorian man from methotrexate toxicity, prescribed to treat a psoriasis flare-up.²

While the pharmacist knew the dose was inappropriate – and contacted the prescriber, who insisted he was correct – the Coroner questioned why the pharmacist, a healthcare professional with 35 years’ experience, still chose to dispense the medicine.

‘In dismissing her concerns, it appears that the GP did not afford the pharmacist the respect she deserved,’ Coroner Rosemary Carlin found.

‘In dispensing methotrexate despite her concerns, it appears that the pharmacist afforded the doctor too much respect, or at least lost sight of her role as an independent safeguard against inappropriate prescribing,’ she noted.³

Four years earlier, in Western Australia, and in similar circumstances, a 66-year-old man died from multiple organ failure associated with methotrexate toxicity, vasculitis and cardiovascular disease. His medical care was described by the Coroner as ‘well below the standard reasonably expected’ after a pharmacist failed to query a doctor’s erroneous ‘daily’ 10 mg prescribed dose of methotrexate, which is usually taken weekly.⁴

Pharmacists are the final check before a patient receives a medicine and are expected to take responsibility and be accountable for their own actions and decisions. If there is a medicine safety problem identified, says Claire Antrobus MPS, PSA’s Manager – Practice Support, then the pharmacist has a responsibility to resolve it under Professional Practice Standard 2: Responsibility and Accountability

Building rapport

To ensure conversations with prescribers are mutually respectful, it’s crucial to build working relationships with regular GPs as equal peers. This extends to reception staff and practice managers who can facilitate urgent or important inquiries. The focus should always remain on the patient and their wellbeing, so a culture of open communication and willingness to collaborate is important.

Under Professional Practice Standard 3: Collaborative Practice – pharmacists should work collaboratively to present alternative solutions and further options to be worked through until a satisfactory resolution to any medicine safety issue is achieved.¹ ‘Don’t hesitate to ask the prescriber more questions, for example what references were used to prescribe the medication for the patient,’ suggests PSA New South Wales State Manager Amanda Fairjones MPS.

Ask those in the know

When dealing with a specialist doctor or situations outside your usual experience, contacting a drug information service for advice can be helpful, says Kay Dunkley MPS, Executive Officer of the Pharmacists’ Support Service (PSS).

‘You can contact the Medicines Line for information on prescription, over the counter and other medicines, including complementary medicines,’ she says.

‘For Schedule 8 medicines, there are state-based services for pharmacists to contact for clinical information and support, including drug and alcohol clinical advisory services,’ adds Ms Fairjones.

For medicines in pregnancy and breastfeeding, Ms Dunkley recommends checking with a specialist drug information service at a maternity hospital in a metropolitan area, as product information can be conservative to protect the company from litigation.

‘There are also local state-based information services, such as MotherSafe in NSW, along with the Pharmacist to Pharmacist Advice Line, available to all PSA members,’ says Ms Fairjones.

When the going gets tough

When these situations arise after hours, and doctors are unavailable, it is important to know what next steps to take.

‘Consider the health and wellbeing of your patient as your first priority,’ says Ms Antrobus.

‘Possible options if you can’t contact the prescriber may be withholding supply, or providing a reduced quantity of the medicine until you have a chance to discuss your concerns with the prescriber (depending on urgency for the medicine).

‘There may also be an opportunity to discuss your concerns with another doctor in the practice or at the hospital who can access the patient’s medical record.’

Ms Dunkley adds that in a situation where a patient may be at risk of harm, advise the prescriber that you’re not prepared to dispense the prescription at the dose prescribed.

‘This is a last resort if the doctor is not responding to your advice,’ she warns.

‘Always annotate the script with the words “declined to dispense”, the date and your initials, so that other pharmacists who may receive the script subsequently can see that you refused to supply it.’

Case 1 

Matthew Nicholas MPS Community Pharmacist Morpeth Pharmacy Hunter Region, NSW

Correct dosing is a fundamental tenet of antimicrobial stewardship.

A dose that’s too high or too low can have detrimental impacts on patient outcomes and the community through antimicrobial resistance. Paediatric dosing adds another layer of complexity.

A number of paediatric patients, mostly from the same GP practice near the small community pharmacy where colleagues and I work, presented with prescriptions for low doses of amoxicillin.

For example, a 2-year-old child weighing 13.2 kg presented with a prescription for amoxicillin 250 mg/5mL, 1.8 mL 8-hourly.

However, the Australian Medicines Handbook (AMH) advises a range of 15–25 mg/kg every 8 hours, placing the minimum dose closer to 4mL every 8 hours.

Due to antibiotic shortages, our initial assumption was of accidental miscalculations when converting between available formulations.

Upon contacting the prescribers, we were met with confidence that the prescribed dose was calculated correctly. Busy prescribers aren’t always open to discussion but, in each case, armed with our references from the AMH and Therapeutic Guidelines (TG), we were able to advocate for a higher, more appropriate dose.

But the low doses kept coming. As pharmacists, we made a concerted effort to fully recalculate every paediatric dose against our references and call the clinic when they were outside of the reference range.

A week of repeat phone calls later, one prescriber explained their reference for amoxicillin was 20 mg/kg/day and was straight from the Monthly Index of Medical Specialities (MIMS), which we found led to calculated doses up to two-thirds less than advised by the AMH.

While the clinic surgery was following good practice guidelines by weighing patients and prescribing in accordance with a renowned resource, the reference no longer aligned with other evidence-based sources.

Through a campaign of persistence – and no doubt patience both sides – paediatric patients now present with appropriate prescribed doses in line with those supported by the AMH and TG.

Case 2 

Atinuke Abraham MPS Consultant Pharmacist Victorian Aboriginal Health Service Melbourne, Victoria 

Aunty DJ is a 65-year-old elder with type 2 diabetes, chronic obstructive pulmonary disease, ischaemic heart disease, depression and gastro-oesophageal reflux disease.

She was referred for a Home Medicines Review (HMR) after a Victorian Aboriginal Health Service appointment, as the GP was concerned about her HbA1c results (8.5%). Aunty DJ takes metformin 2 g XR in her dose administration aid, and was recently started on semaglutide injection 0.25 mg weekly, which she began after the GP consultation.

During my HMR preparation, I noticed Aunty DJ’s creatinine clearance (CrCl) recently reduced to 37 millimoles per litre. When CrCl is between 30 and 60 mmol/L, it’s recommended metformin be reduced to 1 g XR daily due to increased risk of lactic acidosis.

During a quick phone call to confirm Aunty DJ’s upcoming HMR appointment, she mentioned there were no adverse effects from semaglutide so far, but that she was struggling to swallow the metformin tablets.

I sent a quick message to the GP to request a brief discussion regarding my findings during the HMR prep work.

Despite my concerns about Aunty DJ’s metformin dose and risk of lactic acidosis, the GP was reluctant to change the dose.

As Aunty DJ had an appointment with her endocrinologist in 6 weeks’ time, and her metformin dose was not reviewed when her CrCl was 51, the GP was keen to defer to the specialist’s advice.

I pointed out Aunty DJ’s difficulty swallowing the metformin tablets and the impact this could have on adherence, suggesting that since she started on semaglutide, we could reduce her metformin dose to 1 g XR and her HbA1c should still be under control.

I further suggested Aunty DJ would perhaps benefit from metformin 500 mg XR 2 tablets daily, which are a bit smaller than the 1 g XR tablet. Since it was almost 3 months since her last HbA1c measurement, I suggested Aunty DJ undergo a test before her specialist appointment.

Having knowledge of the patient’s medicine history allowed me to frame the conversation with Aunty DJ’s needs as a top priority while providing alternative treatment options.

Following our discussion, Aunty DJ’s metformin was reduced to 1 g XR (2 x 500 mg XR), and her dose of semaglutide was increased to 0.5 mg weekly.

Due to deteriorating renal function and an HbA1c of 7.5%, her metformin dose was further reduced to 500 mg XR daily after the specialist appointment, with semaglutide increased to 1 mg weekly. 

References

1. Pharmaceutical Society of Australia. Professional Practice Standards 2023: version 6. 2023. At: www.psa.org.au/practice-support-industry/pps/
2. Pharmacy Council of New South Wales. Having that difficult conversation. 2018. At:www.pharmacycouncil.nsw.gov.au/having-difficult-conversation
3. Victorian Civil and Administrative Tribunal. Pharmacy Board of Australia v Barca (Review and Regulation). 2020. At: www.austlii.edu.au/cgi-bin/viewdoc/au/cases/vic/VCAT/2020/1346.html?context=1;query=lim;mask_path=au/cases/vic/VCAT
4. Coroner’s Court of Western Australia. Inquest into the death of Daniel Lahengking. 2014. At: www.coronerscourt.wa.gov.au/I/inquest_into_the_death_of_daniel_lahengking.aspx?uid=0578-4407-4200-4647