Allergies and funny responses

1.  I have an allergy to Morphine.  It made my right arm swell. --Are you sure the line wasn't infiltrated which caused the arm to swell?

2.  Meperidine - "dies"

--Dies?  LOL!

3.  Meperidine - "makes mean"

--mean?

4.  Codeine - "sick to stomach"

--ok.  not an allergy really.

5.  Morphine - "gets sleepy"

--REALLY?! 

6.  Prednisone - allergic

--allergic to something given for allergies.  Makes a ton of sense.

7.  Codeine - "makes sick"

--very clear.  thanks.

8.  Codeine - "passes out"

--yep it'll do that!

9.  Effexor - "makes dizzy"

--yep it'll do that!

10.  Penicillin - "died"

--I'll hearken to that one!

Brain Shivers... Brain Zaps... Brain Shocks...

I do not know if many in the medical community are aware of this term that is thrown out there for such offenders as venlafaxine (Effexor), duloxetine (Cymbalta), paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro), but it is a very real phenomenon. Unfortunately, though many in the medical community have not had to rely on any of these meds in their own personal lives, I had a 2-3 year stint with venlafaxine from 2002-03. Basically, I presented with the inability to sleep due to anxiety of some personal issues (which we all have from time to time), and did not want a controlled substance. I tried paroxetine first and absolutely despised the drug. I quit cold turkey. Very smart for a pharmacist, right? (You can't just stop cold turkey and expect to not endure some uncomfortable sensory disturbances.) I found venlafaxine, at 75 mg extended release, to be a very good drug for its purpose of 9 to 12 months. However, what I didn't expect was that weaning from the drug would be so uncomfortable. 75 mg in itself is not even a moderate dose, falling more into the lower dose category. I've seen higher doses much more than the lower doses.

To explain what I felt, I will do my best to try to break down into words the feelings. Initially, there was a sinking feeling in my brain. If you've ever been to the Grand Canyon or a very tall building and looked down, there is a falling feeling that your brain sometimes throws at you though you are not falling at all. That feeling would happen for very short bursts, 2-3 seconds, enough to disrupt my thoughts, my work, and my being. I would just think, "What was that?" If I tapered over the recommended taper schedule (usually a week at a time step down, but keep in mind there's only one strength lower than the 75 mg XR - the 37.5 mg XR. Then where do I go? Literally it didn't matter. The big divide between the 75 mg and the 37.5 mg was enough to cause the "shivers" in my brain - a disorientation, falling, weird, and uncomfortable feeling.

"Brain zaps" are said to defy description for whomever has not experienced them, but the most common themes are of a sudden "jolt," likened to an electric shock, apparently occurring or originating within the brain itself, with associated disorientation for a few seconds. The phenomenon is most often reported as a brief, wave-like electrical pulse that quickly travels across the surface of (or through) the brain. Some people experience these "waves" through the rest of their body, but the sensation dissipates quickly. They are sometimes accompanied by brief tinnitus and vertigo like feelings. Immediately following this shock is a light-headedness that may last for up to ten seconds. The sensation has also be described by many as a flashbulb going off inside the head or brain. Moving one's eyes from side to side quickly while open has also been known to trigger these zaps and sometimes causing them to come in rapid succession. It is thought to be a form of neuro-epileptiform activity.

As withdrawal time increases, the frequency of the shocks decreases. At their peak, brain zaps have been associated with severe headaches. They may last for a period of several weeks after the last dose and usually resolve completely within a month or two. However, anecdotal reports of "zaps" during a protracted withdrawal are known to last a year or longer.

My remedy was to open the capsule and to count the tiny beads and literally make capsules with less and less tapering over a 6 week period rather than the usual 2 - 3 weeks at this dose. It did eliminate the feeling, but it definitely helped. One could go as far as asking the physician for a 37.5 mg immediate release tablet and maybe breaking it up into pieces and tapering at the very end that way. Any way you dice it, venlafaxine was a pain and taught me right away a bigger lesson in remembering the side effects than any package insert ever could.

10/31/12 - update and fitting it is Halloween! Guess what? Add Cymbalta (duloxetine) to the list. It has been given approval for pain, both arthritic lower back and cancer. Withdrawal when you miss a dose.

I did take Vitamin B Complex, and maybe it helped.  Others have mentioned other vitamins.  Would love to hear remedies that worked if you can email me at theblondepharmacist@gmail.com

Still training...

I don't know how many of you are interested in the work at home setup and how it works, but basically we use a program to Remote Desktop into several servers and work just as though we were sitting in the actual hospital verifying orders.  There's no mixing of IVs, chemo, or TPN...  you miss the hospital environment of wearing scrubs, walking to the cafeteria to buy food and saying hello to fellow nurses, social workers, physicians, etc...  but there's this peace to it. I am now verifying/entering hospital orders for three hospitals.  There are several more to learn, but so far so good.  I'm still realizing that every hospital has their own fingerprint or way they like to do things.  One likes you to enter patient's own meds one way, another not at all.  It's remembering those rules that makes it a little more challenging, I suppose... especially when it is entirely possible to flip from one hospital to the next minute to minute.

So far, I'm not regretting a moment of taking this particular job.  The other that I was interested in is in fact relocating and merging with another company down the road in long-term care, but I just didn't feel it when I worked there.  This would be the same place in the end where I interviewed awhile back with the manager who I knew through a mutual pharmacist friend.

She asked me, "What does your husband think of you looking for another job?"  I was working for a company down the road from this one that was and still is experiencing major hardship.  I told her that my husband was generally more conservative and personally would probably stay put but would probably support whatever it is that I decided to do.  That manager used that against me even telling someone who would have been my peer who later told me, "Yeah, uh the manager said that your husband didn't want you changing jobs right now."  That is not what I said at all.  But it did shed some light that somehow my name had been brought up and talked about from manager to peer (peer meaning we would have been equals and in fact good friends that we had worked together before in the same struggling company, go figure!).  I also believe in hindsight that I was NOT hired because I was competing with a male and there is some probability that I may have children one day.  My friend has this "thing" where he has no patience for a female pharmacist who calls out because her child is sick.  He just doesn't get life emergencies.  He's not married and never will have children.  We're not really sure if it's that he's a homosexual or not, and I don't care if he is, but it adds to the whole element of him not relating to another group of people and probably vice versa.

Well of to work...  sorry for the hiatus.  Had a vacation that went horribly and now back.

Hospice Care

When I'm entering/reviewing orders for someone with terminal cancer and the last "D/C to hospice" order.  A lump will come up in my throat and then I start thinking about life.  What will I die of?  Will someone enter my last orders someday?  Will I die of a terminal cancer or something else?  I know I shouldn't think about it, but the last few decades of life have passed rather briefly.  Will the rest of life be the same?  Quick and so fast you don't take the time to enjoy it? Anyway, that's what those orders do to me... and then I have to clear my thinking and my mind and get back to work.

I just wonder sometimes if others are affected by it in the same way.

One of the most profound rotations in my last year of pharmacy school was with a hospice nurse.  To this day I still remember each and every patient we visited at various stages of dying.  The man whose terminal wife was hours if not a day from death but yet he seemed so stoic and in denial.  That one was the worst.  They had this gorgeous custom home with all the fine details and obviously had planned retirement together in this space.

Life had other plans.

Drug Rep

Drug rep came to town today peddling his drug with the words, "This drug does not have ANY drug interactions."  "None?"  I said in disbelief processing the information.

He shook his head and smiled while getting my name to write down for the luncheon he was giving.

"NO drug interactions?"  I just can't hardly believe in a statement like that.

"No drug interactions and only about 50% protein bound."

Wow.  First thing I did was go research the drug.  Oh yeah.  It interacts with metoprolol for one.  Raises the AUC of metoprolol by 50%.  Maybe he got his 50% data memorized wrong.  Here's the list Mr. Drug Rep: 

Aspirin

Carbamazepine

Cimetidine

Desipramine

Drugs that act on the brain, including antidepressants, painkillers, sedatives, and tranquilizers

Ketoconazole

Linezolid

Lithium

Metoprolol

Narcotic painkillers

Nonsteroidal anti-inflammatory drugs such as ibuprofen

Sumatriptan

Warfarin

Never say "My drug has no drug interactions."  That's just not gonna fly.

The Wonder Drug

Study hails heart wonder drug They have been hailed as a wonder drug - the pill of life - a magic bullet in the fight against heart disease, one of the world's biggest killers.

Now new research supports claims by international drug manufacturers that statins, already the world's biggest-selling medication, dramatically reduce the risk of heart attack and death in high-risk middle-aged men. Statins may also provide health benefits up to 10 years after a patient stops using the drug, the research has found.

Statins are a cholesterol-lowering medication taken in pill form that prevents plaque buildup in arteries.

About 10,500 Kiwis die from cardiovascular disease each year.

It is one of the country's biggest killers, accounting for 40 per cent of all deaths.

Nearly 300,000 New Zealanders already consume one million prescriptions annually of the fully subsidised drug, marketed here as Lipex and Lipitor, at a cost to taxpayers of about $50 million.

But a leading Wellington cardiologist is urging calm following the latest findings, warning that statin use is no magic panacea against heart attacks for those most at risk - diabetes sufferers, smokers, Maori men, and people with high blood pressure or high cholesterol levels. Medical experts have just published the results of a 15-year trial in Scotland involving 6500 men aged between 45 and 64 who had not had heart attacks but showed elevated cholesterol levels.

Half were given the drug Pravastatin for five years and the rest given a placebo. Another study then tracked the men's progress for 10 years after the initial trial.

The results show a 25 per cent lower risk of heart attack or death from heart disease among those in the statin group - even though many stopped taking the drug a decade earlier.

Some health experts now suggest the drug - which has little or no side effects - should be prescribed preventively to those who are not high-risk.

Stewart Mann, Wellington School of Medicine Associate Professor of cardiovascular medicine, warned that statins are not a miracle panacea: "There are benefits and I strongly support their use, but particularly in those who are at enough level of risk that it will substantially reduce their risk. It does not guarantee freedom from heart attack."

Pharmac medical director Peter Moodie said people at high risk of heart disease could not substitute healthy living for a magic drug.

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The magic pill that most lazy people are looking for... statins. (after this is the disclaimer warning that the side effects of statins include and are not limited to: Percentages as reported with immediate release tablets; similar adverse reactions seen with extended release tablets.

>10%: Neuromuscular & skeletal: CPK increased (>2x normal) (11%)

1% to 10%:

Central nervous system: Headache (2% to 3%), dizziness (0.5% to 1%)

Dermatologic: Rash (0.8% to 1%)

Gastrointestinal: Abdominal pain (2% to 3%), constipation (2% to 4%), diarrhea (2% to 3%), dyspepsia (1% to 2%), flatulence (4% to 5%), nausea (2% to 3%)

Neuromuscular & skeletal: Myalgia (2% to 3%), weakness (1% to 2%), muscle cramps (0.6% to 1%)

Ocular: Blurred vision (0.8% to 1%)

10x normal), depression, dryness of skin/mucous membranes, dyspnea, eosinophilia, erectile dysfunction, erythema multiforme, ESR increased, facial paresis, fatty liver, fever, flushing, fulminant hepatic necrosis, GGT increased, gynecomastia, hemolytic anemia, hepatitis, hepatoma, hyperbilirubinemia, hypersensitivity reaction, impaired extraocular muscle movement, impotence, leukopenia, libido decreased, malaise, memory loss, myopathy, nail changes, nodules, ophthalmoplegia, pancreatitis, paresthesia, peripheral nerve palsy, peripheral neuropathy, photosensitivity, polymyalgia rheumatica, positive ANA, pruritus, psychic disturbance, purpura, rash, renal failure (secondary to rhabdomyolysis), rhabdomyolysis, skin discoloration, Stevens-Johnson syndrome, systemic lupus erythematosus-like syndrome, thrombocytopenia, thyroid dysfunction, toxic epidermal necrolysis, transaminases increased, tremor, urticaria, vasculitis, vertigo, and vomiting.

Wonder....FUL!

First day on the job...

I have a lot of hope for this one.  Blonde Pharmacist may have found her calling in the profession though I can remember several times in the past where I'm stoked up front, and then it all comes crashing down with SOMEthing.  Last job was the horrible boss with no personality and expectation of job being the number one priority in your life.  Job before that was such a negative atmosphere, I felt stifled.  The one before that was great.  They have continued to lay off more and more pharmacists where now there are only two full-time pharmacists.  Sad since I started there with over 20.  2007 has been a rough year for me professionally.  My resume looks like absolute hell.  You can't really hide the fact that you worked two jobs back-to-back - one for 4 months and the other 1 month.  That really bothers me.  It's all explainable in an interview, but it's not too much fun sweating through it.

I did find out that I won't be handling neonatal, TPN, or chemotherapy orders.  That's  a load off as far as liability. 

Pharmacist Joke

Peanuts Review

A pharmacist goes to a nursing home to review an elderly customer. As he is sitting there, he notices a bowl of peanuts beside her bed and takes one. As they talk, he can't help himself and eats one after another.

By the time they are through talking, the bowl is empty.

He says, "Ma'am, I'm sorry, but I seem to have eaten all of your peanuts."

"That's okay," she says. "They would have just sat there. Without my teeth, all I can do is suck the chocolate off and put them back.

To answer a question...

A comment was left on my blog asking me what did a work at home pharmacist do?  Good question!  I'm sure that most of the world has one image when thinking of a pharmacist.  The neighborhood retail pharmacist standing behind a counter with a phone propped on one shoulder (bad ergonomic posture) while typing in a prescription into a computer where the computer does all the brain work, etc...  There are many other pharmacist jobs out there... so many more that I want to take the time to address a few.  I am sure I will leave out some, so feel free to comment and leave more examples, if you wish. 1.  Hospital Pharmacist (staff) - the staff hospital pharmacist usually reviews orders that are entered from the chart.  In some settings the hospital pharmacist enters and reviews the orders from the charts, checks for drug interactions, appropriate doses, etc...  They also check carts that are filled with drugs for stock on each of the floors.  They also enter all chemotherapy orders (finding more mistakes, usually since dosage can be calculated by body surface area, etc...), mix chemotherapy and prepare, mix and prepare total parenteral nutrition (in layman's terms "IV food") that contains dextrose, lipids, amino acids, and a variety of electrolytes and salts, etc... that even within themselves have to be a specific concentration and even mixed in a certain order to prevent precipitation.  Precipitation in the vein is a bad thing.  They also mix and check IVs ranging from the easy vancomycin in sodium chloride to IVIG.  Some hospitals have staff pharmacists performing kinetics checks to make sure that the little 90 year old woman can renally (that's with the kidneys) clear certain drugs like vancomycin, tobramycin, and levaquin. 

2.  Specialty pharmacists in a hospital setting - Here we go, these are the pharmacists that did a residency - working for half of the pay for a year or more - learning a speciality.  Critical care pharmacists, infectious disease pharmacists, coumadin pharmacists, on and on and on...  These guys don't help much with the day-to-day stuff.  They usually do a lot of speeches, have pharmacist students under them during the year, have more of a 9-5 job, etc...  It's too narrow a spectrum for me, but it's definitely a brainer side of pharmacy.

3.  Work at home pharmacist - a lot of companies are centralizing their operations and in doing so the order entry/review front end work can be done from home.  Some companies that have many hospitals are condensing all of this into one job at home.  Depending on the company, you can be checking front end orders from charts that are scanned into a computer program like Pyxis all the way to handling one or two specialty drugs. 

4.  Retail pharmacist - makes a lot of money.  A lot of headaches.  A lot of stress.  And I never ever got to take a pee.  I remember most days holding my pee for 12 hours at a time all the while listening to the public bitch about their higher copay.  The real issue is that Eckerd, Walgreens, CVS, etc...  don't give you enough help hours so there's this frenzied pace of working that leads to the horrid mistakes you hear about on the news.  There's some good retail situations, but I found them few and far between.  Perhaps I am a wuss.

5.  Long term care pharmacist - front end and fulfillment responsibilities for servicing nursing homes.  Omnicare is your biggest player with Pharmerica/Kindred right behind.  Can be a good schedule. 

6.  Consultant pharmacist - the pharmacist that travels about nursing homes and residential places checking charts required by law and destroying expired controlled medications.  Making recommendations, etc... 

7.  Drug rep - Drug expert at one or two drugs - don't have to be a pharmacist.  Learns exactly what the drug company tells you.  Carries around charts and studies to look smart.  Gives away pens, free lunches, and sponsors speeches about the drug.  My personal opinion can be attacked here, but I feel this job is a conflict of interest for the public.  Some docs don't do their homework and what their drug rep tells them is what they believe.  Even if it is false.  Even if it is misled.  There are some good drugs out there, though.  I just bet the Avandia drug rep is a little nervous right now.

8.  Drug Information Center - mans an information center to answer questions from anyone, universities, and the public about drug questions, pill identification, etc...  The ability to know how to research and find what is needed.

9.  Pharmacy professor - self explanatory.

10.  Home Infusion pharmacist - takes call for new admits going home from the hospital on some sort of IV medication whether it be TPN, desferal pump, or an IV antibiotic... it's all IVs... no tablets, etc...  but a nice little clinical niche.

 I'm sure I'm leaving some out... but I wanted to at least let the world know pharmacists are more than the retail version.

Walgreens - the Superpower

Walgreens September Sales Increase 9.5 Percent;Opens 6,000^th Store

DEERFIELD, Ill.--(BUSINESS WIRE)--Walgreens (NYSE: WAG)(NASDAQ: WAG) had September sales of $4,413,000,000, an increase of 9.5 percent from $4,031,527,000 for the same month in 2006. Sales in comparable stores (those open at least a year) rose 4.7 percent.

September pharmacy sales increased 8.8 percent, while comparable pharmacy sales increased 3.9 percent. Comparable pharmacy sales were negatively impacted by 3.8 percentage points due to generic drug introductions in the last 12 months.Total prescriptions filled at comparable stores increased 1.6 percent. Pharmacy sales accounted for 66.4 percent of total sales for the month.

Comparable store front-end sales increased 6.3 percent during September.

Calendar day shifts accounted for a negative impact of 1.6 percentage points on comparable pharmacy sales. Patients fill more prescriptions on weekdays compared to weekends, and this year’s September had one additional Sunday and one fewer Friday compared to September 2006.

Calendar year-to-date sales were $40,357,306,000, an increase of 11.9 percent from $36,056,997,000 in 2006.

Walgreens fiscal year began Sept. 1, so fiscal year-to-date sales are the same as the month’s sales.

Walgreens opened 18 stores during September, including two relocations, and acquired one store. The company opened its 6,000th store in New Orleans and will celebrate the grand opening in October.

At Sept. 30, Walgreens operated 6,014 drugstores (including 101 home care division locations, eight specialty pharmacies and three mail service facilities) in 48 states and Puerto Rico, versus 5,475 a year ago. Franchisees of Option Care, Inc., a wholly owned subsidiary of Walgreens, are not included in Walgreens store count.

Please note: Monthly sales numbers are preliminary and unaudited. Comparable stores are defined as those locations open for at least 12 consecutive months without closure for seven or more consecutive days and without a major remodel or a natural disaster in the past 12 months. Relocated and acquired stores are not included as comparable stores for the first 12 months after the relocation or acquisition.