Modern pharmacy management systems screen therapeutic duplication using third party databases, and these systems are not capable of exercising the necessary professional judgement to separate an actual duplication from a rational duplication. Duplication alerts, because they are so frequent, become almost a nuisance, and alert fatigue is a real concern.
Normally, therapeutic duplication alerts in our pharmacy are documented as:
Duplication Appropriate: Different mechanisms of action required to achieve therapeutic outcome(s)
The above is typically added to intervention notes in cases like the use of metoprolol (a beta blocker) with losartan (an ARB). When we create this note, we typically will flag the problem for re-evaluation in 6 months or 1 year.
Duplication Appropriate: Different courses of acute therapy.
This designation is often used for antibiotics or other acute therapies (prednisone, NSAIDs etc) that have been completed before the next course is started. These are typically flagged for re-evaluation with the next fill of the medication.
Case Study (An Exception)
Today’s Tales from the Counter story starts with a therapeutic duplication; sotalol 120 mg in the AM / 80 mg PM with metoprolol ER 25 mg QD in the AM. One prescription was ordered by the patient’s primary care provider and the other a cardiologist. Both of these drugs are in the same therapeutic class of beta blockers. In this case, the duplication alert is not necessarily a nuisance; it represents a potential problem.
In the case of this patient, the refill history made the problem more difficult to evaluate. Metoprolol was filled in April for 90 days, sotalol in June, and both filled in August. At first glance, it appeared that the medication was changed from sotalol to metoprolol and then back again. To be sure, the patient was approached and asked if they were taking both. The unexpected response was that they were taking both medications (they had just accumulated an excess of sotalol and did not need to refill it until that supply had been depleted).
At this point, we let the patient know that we were going to contact the prescriber to clarify the therapy. A SOAP note was created and faxed that day to the primary care provider. The note simply stated:
Subjective / Objective: KB came into the pharmacy today to pick-up her meds. Pharmacist noted patient is taking both metoprolol ER 25mg QD (Dr. One) and sotalol 80mg 1.5 tabs QAM and 1 tab QPM (Dr. Two).
Assessment / Plan:
Should KB be taking both metoprolol and sotalol? ___Yes ___No
If not, should metoprolol be D/C’d? ___Yes ___No ___N/A
Less than 24 hours later a reply was received. The response was unexpected by this pharmacist: KB should be on both medications — confirmed with cardiology.
Therapeutics Revisited
I was not expecting this response, and took some time to investigate the possible rationale for this decision. Sotalol is somewhat unique in the class of non-selective beta blockers as it also exhibits cardiac action potential duration prolongation (Vaughan Williams Class III) anti-arrhythmic properties. It is well documented that beta blockade can significantly decrease mortality and improve outcomes in several types of cardiac disease. In the case of a patient with an implantable cardioverter-defibrillator (ICD) and or a biventricular pacemaker, the combination of anti-arrhythmic and betalocking properties of sotalol can be beneficial, making it an excelent choice. Sotalol, being non-selective, may not offer enough beta blockade by itself, and the addition of a low dose selective beta blocker like Metoprolol Succinate 25 mg is therefore rational therapy. For a good review, see Chaki AL, Caines AE, Miller AB. Sotalol as adjunctive therapy to implantable cardioverter-defibrillators in heart failure patients. Congest Heart Fail. 2009 May-Jun;15(3):144-7.
This is a great time to re-emhasize the importance of documentation. This intervention was addressed as Duplication Appropriate – an exception to the normal “like mechanisms” duplication that would normally be a problem. The intervention and SOAP note, including the physician’s response, was documented and linked to the problem. The next time this problem is assessed in 3 months, the pharmacist will already know the story.
Monitoring
Just because the duplication problem has been addressed does not mean that the pharmacist’s responsibility is complete. In this case, the patient is at risk of the effects of too much beta blockade. This would manifest as a low resting pulse rate. The pharmacy should now regularly ensure that the patient’s pulse is being monitored and/or monitor the patient’s pulse periodically. Both activities should be documented in the patient’s record.
Every day I worry about the future of pharmacy as a profession. The current reimbursement climate continues to resemble a walk through Death Valley, California, without any water in sight. Despite some of the grim realities pharmacists face daily, finding problems (and even non-problems like the one above), and managing the care of patients still excites me. It makes my days enjoyable. And the added benefit of the patient’s gratitude for taking the time to look into the potential problem doesn’t hurt, either. It reenforces the fact that every encounter really does count.
