Having tried to understand each item that I dispense, looking at the prescription and hazarding a guess at the indication for each drug, I have identified certain prescriptions that appeared strange to me; obviously, I am not qualified enough to make a clinical judgement on these prescriptions, but in my view, they seemed clinically 'strange'.
A lady had a prescription for both glycerol suppositories and lactulose solution. I thought, okay, she could use the suppositories for a short period then once the lactulose had started to take effect, she could stop using the glycerol suppositories. I then found out that this was a regular prescription for the lady. This seemed very strange to me-surely long term use of lactulose would mean that suppositories would not need to be used. I thought that, clinically, constipation not responding to lactulose would need further investigation, rather than masking the problem using suppositories.
Even if this had been a new, acute prescription, surely just a prescription of 2-3 suppositories would suffice, to 'tide the patient over' until the lactulose started having effect. Instead, the prescription asked for a 28 suppository supply, to use when required. If suppositories were required, why was lactulose being used on a continual basis, if it clearly wasn't having the desired effect.
However, the pharmacist seemed quite happy to dispense this prescription and I carried on with my work, mystified.
Another prescription contained both co-codamol and loperamide. Clearly, co-codamol could cause constipation, and loperamide is used in the treatment of diarrhoea i.e. leading to constipation like effects. To me, this seemed to be double treating one problem. The pharmacist, when I questioned him, said that it was likely for long term diarrhoea, and that the co-codamol was likely just used as an analgesic. This rung alarm bells in my head: surely, if a patient was on long term loperamide and co-codamol, which can lead to you getting 'bunged up', and was still suffering from diarrhoea, was this really a problem that could be managed in the community? If two medicines having anti-motility effects did not treat the problem, was this prescription really clinically appropriate?
Again, the pharmacist saw no problem in this prescription, though did admit to seeing the logic in my reasoning.
These two scenarios make me ask the question : How often do pharmacists act on clinical issues in prescriptions, and how serious does a clinical issue need to be before we consult with the GP's? In my view, pharmacists should be questioning the issues I have raised above. Clearly, the pharmacist has a much better knowledge than me, but I feel pharmacists shouldn't just accept the logic of the doctors unconditionally. We should do the best for our patients, and this may involve questioning long term use of medicines, if their benefit is not at all clear.