In my article, “What do pharmacists do?” I outlined the process that pharmacists go through to prescriptions for a given patient. In this blog post I’ll take you behind the counter and inside the mind of your community pharmacist. You’ll see all the questions we ask ourselves before clearing your medication to be prepared and dispensed. Hopefully by the end of this article you’ll have more confidence in your pharmacist and a little less frustration the next time you visit the pharmacy.
Here are the 18 key questions we ask ourselves when evaluating a new prescription for a patient. You’ll note that the answers are PATIENT SPECIFIC, which means your pharmacist may need to ask you some personal questions to do their job effectively and keep you safe. The questions fall under 5 headings, Necessary, Effective, Safe, Adherence, and Unmet Needs. So strap on your reading glasses and follow me.
Necessary:
1) What is the medical condition we are trying to treat?
There’s no point taking a medication with no medical condition to treat. Full stop. You may be confused when your pharmacist asks you what condition this prescription is for. Shouldn’t the pharmacist KNOW what the antibiotic is for!? Not necessarily: Many drugs are used in a variety of conditions, just at different doses, for different lengths of time. It’s important for us to know what condition we’re evaluating the drug for.
2) Does the patient have this medical condition?
Usually we don’t do much here. Your physician should have gone through this part and diagnosed you with a condition before selecting a drug. He/she will have looked at your signs/symptoms/lab values to come to this conclusion. However, technically it is our job to confirm that the diagnosis is appropriate.
3) Consider the patient’s other medical conditions as contributing factors to this one.
Just because you present with a certain set of symptoms doesn’t mean we need to treat with another drug. These symptoms could be your other conditions getting worse due to suboptimal treatment. Or it could be the result of a side effect from another medication you take. If this is the case, we should take a step back and consider your other conditions and medications first before adding another drug on top.
4) What are the goals of therapy for this condition?
Okay, now that we know there is a definite medical condition that we ought to treat, what is the end goal for treatment? Is it a condition that can be completely cleared up, like strep throat? Or is a progressive disease like multiple sclerosis. This questions helps to give some context to the treatment plan.
5) What options for treatment do we have at our disposal?
It’s important to know ALL the options available and the evidence for each of them. Without knowing this piece your pharmacist would be a fish out of water when assessing your new prescription. This is where the four years of pathophysiology, pharmacology and therapeutics comes in.
6) Is the patient already taking anything for their condition?
Perhaps they’re already taking a self selection product from the pharmacy, or they are on one of the options for treatment and now presenting with a prescription for an alternative. Knowing this helps us to determine if this medication is an add on therapy, or if it will replace what you already take.
7) Knowing the answers from 1-6, is there even a reason to take another drug?
The answers from 1-6 culminate in a stop or go question. Do we continue to evaluate this drug for our patient or do we contact the doctor and advise of another route that might be more appropriate.
Effectiveness:
Now that we know it is necessary to treat this condition of yours, is the drug in question going to be the best one for you?
8) Is this drug indicated for the condition we are trying to treat?
Sometimes this means it is an official Health Canada indication. Sometimes the medication is used commonly, but is not official per Health Canada. This is called an “off label use”. Sometimes it is abundantly clear that the medication the doctor meant to choose got replaced by something that sounds and looks a lot like it. We’ve unfortunately replaced poor doctor handwriting with drop down lists on computer software that have their own sources of error.
9) Is this the MOST EFFECTIVE drug for the condition?
Assuming the drug is indicated, is it the best one? Are there better options with higher efficacy?
10) Is the rest of the prescription (dose, frequency, duration of therapy etc) appropriate?
Even if it’s the most effective drug, the dose selected may not be appropriate. Ex: For antibiotics, the same drug can be used across a spectrum of different infections, but at different doses and durations. Sometimes the duration may seem really long for the infection, but then we talk to the patient and it’s their second infection of that kind in a month. Treating for longer may bring about the cure we desire.
11) Onset of action
Okay, so the drug will work, and work well at this dose, but how quickly is it going to work? Is the onset of action going to be appropriate for this condition? For example, there are antidepressants out there that work for anxiety, but they take about a month to have an effect. This would not be an appropriate choice for a person in a full blown panic attack. For that we need something that will act quickly to provide some relief to our patient.
12) Are there any interactions we need to look out for that would make this medication less effective.
Is the patient already on another drug that will cause this one to work less well. If yes, we may still be able to proceed, but with some changes.
Hang in there! We’ll get through this blog post together!
Safety:
Sweet! We’ve gotten this far. We know the medication is necessary and effective. But is it safe? This is by far the most important step to get right when considering a new medication. This step has four questions:
13) Contraindications!
Every drug comes with a list of them, and every patient ought to be screened to see if they have them. The classic case: pregnancy. This is why as a female you will very often be asked if there is any chance you could be pregnant.
14) What are the side effects?
Are any of them going to be unbearable for the patient? Or might those side effects contribute to a worsening of their other conditions? For example, some blood pressure lowering drugs work by dilating blood vessels. If a person already suffers from migraines, they could experience a worsening of that condition, so we might fax the doctor and ask for something with a different mechanism of action.
15) Is this a duplication of therapy?
If we’re already using this class of drugs, it can be dangerous to add another one on. However, in some cases, duplication can be okay and even necessary. Take pain management for example: the best control comes from using a long acting formulation in combination with a short acting one to be taken if there is any breakthrough pain.
16) Interactions
Are there any interactions with this drug that would make it unsafe to take? Interactions can be between the drug and a patient’s condition, other drugs or supplements. Some drugs even modify certain lab tests, which is important to know if that value is being monitored by your doctor for your other conditions.
Adherence:
17) After all of that, does our patient even WANT the drug?
This is another one that will stop you dead in your tracks. In fact, I often skip straight to this one before considering anything else. We consider whether the drug is available (Oh Canada, the land of drug shortages!), affordable, and whether the patient will have any other troubles taking the drug. We often see patients with trouble swallowing pills. In that case we’d need to switch them to a liquid formulation. Some drugs are highly effective, but need to be taken every 4 hours. That’s no good for someone who leads a busy life and is likely to forget half of the doses. To add insult to injury, often the most effective drugs are also the most costly. If a patient doesn’t have coverage, they will have to pay out of pocket for that expense. There is a lot to consider ON TOP of safety and efficacy, that we spend time considering behind that giant counter of ours.
Unmet Needs:
Often after evaluating a medication for a particular patient, it becomes clear that they have some other issue that need taking care of. Sometimes this means a referral to a specialist, education about non-drug measures they can take to reduce their symptoms or need for medication. Or perhaps a vaccination they are eligible for that will reduce the incidence of an infection in the future. Most often, we discover through our consult that the patient needs further evaluation of their other conditions to optimize treatment.
Still with me? You’re sleeping aren’t you? Well if you HAVE read this far, here’s a picture of my cat.
WAKE UP! The blog’s over!
So there you have it folks. The reason it SHOULD take your pharmacist at least 20 minutes to fill a new prescription. So the next time you get your medication within 5, perhaps you should ask a few questions of the white coat.
Now go get some fresh air. That was a lot.
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