On the back cover of the July/Aug acpnews, we posed a scenario about a man seeking a refill on a prescription to treat his eczema and asked what you would do. Here is one pharmacist’s take and our answer to his question.
Adapting: What would you do?
A 50-year-old male seeks a refill on a prescription for betamethasone ointment to treat his eczema. The patient is otherwise healthy and fit, with no complicating factors. He has a history of eczema that is reflected on the medication profile in the pharmacy, as he has been a long-term patient. The original prescription was written 22 months ago, but has two refills remaining. The man’s physician is not available for two weeks.
If this patient came to you, what would you do?
Warren from Calgary answered:
A couple of questions remain unanswered in the scenario: how extensive and severe is this flare-up? Was he in remission, or did he previously receive such a large quantity that he only recently ran out? Before adaptation, I would have recommended OTC hydrocortisone or clobetasone, which may still be appropriate. With adaptation, I have the option of renewing the prescription.
One of the recommendations of adaptation is to renew the same quantity previously prescribed; however, his previous fill lasted 22 months! I would not renew a 22-month supply; however, I refer back to my previous questions – was he in remission and how extensive/severe is this flare-up? I would require further discussion with this patient to determine whether the OTC options or renewal for two weeks is appropriate.
Warren’s proposed solution is sound. One thing to consider though: why only renew for two weeks?
There is no limit on how many doses or days of therapy pharmacists can provide. If your assessment reveals that the patient’s condition is otherwise unchanged and you feel you have the competencies and enough information to assess and treat the condition, adapting the prescription for a longer period may be more beneficial for the patient and the health system.
Warren’s question
METROCREAM is on backorder. Is substituting METROGEL an adaptation or a change of drug format?
The response to Warren’s question requires looking into both the Standards and the Code of Ethics.
According to Standard 12.6, changing the dose on a refill or repeat prescription is considered managing ongoing therapy which requires additional prescribing authorization. However, METROCREAM and METROGEL have the same potency and absorption rate[1], so it is considered a change in formulation, not dosage. This is definitely not the case for all cream/gel/ointment formulations of the same active ingredient (e.g., mometasone furoate ointment 0.1% is more potent than mometasone cream or lotion 0.1%).
Secondly, if the cream is on backorder (always check directly with the manufacturer and explore alternate supply options), substituting the gel formulation meets your ethical obligations to hold the well-being of each patient to be my primary consideration (Principle 1) and use health resources responsibly (Principle 7). The METROCREAM will not be any more available to the original prescriber, so sending the patient back to them will not help the patient or the health system.
The moral of this story? Always ask yourself if you have enough information with which to make a sound decision. Adaptation requires that you do a thorough patient assessment and have enough knowledge of the patient’s condition and the disease. As another check, ask yourself, “Could I defend my decision to my peers?”
Originally published in the July 10, 2012 issue of The Link
[1] Confirmed by checking indications, absorption rates, side effects, and application instructions for both products in the CPS and full product monograph.
