Friday, February 17, 2012

The value of a community pharmacist's intervention

Earlier this week, I was asked by a nurse practitioner from our electrophysiology group about alternative antibiotic therapy for a patient taking dofetilide (Tikosyn®), an antiarrhythmic used for the maintenance of normal sinus rhythm in patients with atrial fibrillation or atrial flutter.  While dofetilide is an effective option for this condition -- about three-fourths of patients will remain in normal sinus rhythm at 12 months -- it is also associated with a small risk of torsades de pointes (or, simply torsades), a type of arrhythmia that can be fatal if not treated immediately.  Because of this risk, patients are admitted to the hospital and closely observed for their first five doses of dofetilide. Prior to discharge, patients are educated on things that might increase their risk for torsades, including interactions between dofetilide and several commonly prescribed medications. However, rather than asking patients to memorize all of the prescription medications that may interact with dofetilide, I provide them with the list and recommend that they obtain all of their medications at the same community pharmacy so that their pharmacist can screen for potentially dangerous drug-drug interactions.

One of our recently discharged patients saw his primary care physician (PCP) out of concern for worsening upper respiratory symptoms that were consistent with community-acquired pneumonia (CAP). The PCP prescribed two common antibiotics for CAP -- both of which have been associated with an increased risk of torsades when used in combination with dofetilide.  The patient went to his local community pharmacy to have the prescriptions filled, but the interaction was quickly identified by the pharmacist.  She contacted the PCP to alert him of the interaction but was told to disregard it and dispense the prescription anyway.  Out of concern for the patient's safety, the pharmacist called our clinic to confirm.

While both of the antibiotics in question were not absolutely contraindicated with dofetilide, our patient had already required a reduced dose of dofetilide during his initial hospitalization due to ECG changes that were concerning for potential torsades.  Moreover, the antibiotics selected were prescribed at doses that were too high for the patient's renal function, only  further increasing his risk for the dangerous arrhythmia. Given the potential danger associated with these drug interactions, the nurse practitioner called me and we developed an antibiotic regimen that would be equally efficacious but avoid an increased risk of torsades.

After hearing how the pharmacist had been so persistent in the best interest of the patient -- despite the heated response she received from his PCP -- I made it a point to call and thank her for her going out of her way to ensure the safety of this patient.  Given all of the pressures that are placed on community pharmacists, many would have proceeded with the prescription -- and rightfully so, given the prescriber's demands.

However, this pharmacist went above and beyond the call of duty to put her patient first... and may have prevented a potentially dangerous drug interaction in the process.  So thank you, M, for being such an advocate for your patients.

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