A lesson in prospective drug review: What is your job?
Laverne DiGiovanni’s physician, Dr. Shastri, had been prescribing lithium for her for almost 10 years. When Laverne needed to control her high blood pressure, Dr. Shastri prescribed Tenoretic. Mrs. DiGiovanni took her Tenoretic prescription to her pharmacist, Dr. Huyuh, who filled the prescription. While doing so, however, pharmacist Huyuh noted that Laverne was regularly refilling a prescription for lithium.
He also noted a possible interaction warning with Tenoretic, which can be found at Drugs.com: “Lithium generally should not be given with diuretics because they reduce its renal clearance and add a high risk of lithium toxicity. Read prescribing information for lithium preparations before use of such preparations with Tenoretic.”
This case provides a good learning moment for each pharmacist. Before we go on with Mrs. DiGiovanni’s story, ask yourself what the pharmacist should have done at this point. What is the pharmacist’s duty? What is our job?
Prospective review and the law
In 1990, the federal government passed what is generally referred to as OBRA 90, which mandated that states require pharmacists to perform certain services for patients on Medicaid. By 1993, most or all states had passed legislation or regulations implementing these federal requirements. Generally, today these rules apply to all patients.
Arizona law, as an example, requires pharmacists to perform a prospective drug review before dispensing a prescription and to verify the “legality and pharmaceutical feasibility of dispensing a drug based on,” among other items, “a patients’ allergies and incompatibilities with a patient’s currently-taken medications.” Arizona also says a pharmacist should “[I]nterpret the prescription order, which includes exercising professional judgment in determining whether to dispense a particular prescription.”
Unlike many states, Arizona requires a patient to be counseled about all new prescriptions. This includes the name and strength of the drug, indication for use, directions, route of administration, and special instructions — including side effects. Also, “through the exercise of professional judgment. . . . oral consultation “may include . . . common severe adverse effects, interactions, or therapeutic contraindications, and the action required if they occur,” along with other items. Note the rule does not say “shall” include interactions or therapeutic contraindications.