Heed these 10 warnings to protect your patients from pharmacists' errors

Is this retail pharmacist going to change your veterinary prescription? GETTYIMAGES/REB ImagesEarlier this year, the Federal Trade Commission (FTC) released a report recommending ways to make pet medication costs more competitive.1 The report lent support to the Fairness to Pet Owners Act introduced in the U.S. Congress, which, if passed, would mandate that we provide pet owners with written prescriptions for medications that we as veterinarians would normally dispense. 

While this would possibly reduce costs to pet owners (in my opinion, it would have a minimal effect), it opens the door for serious medication and dispensing errors for the pet. 

As a pharmacist and veterinarian married to a retail pharmacist, I can assure you that in our pharmacy education we had no instruction on animal medications and how they differ from human medications, either by dosing or mechanism of action. Obviously the originators of these bills (S.B. 1200 and H.R. 3174) have no awareness of species differences with medications and how these differences can harm pets. 

The peril of prescription errors

When filling a pet's prescription, the pharmacist has no knowledge of the patient's diagnosis, current medications (to monitor for drug interactions) or the pet's age or health status. Many customers getting their human prescriptions filled at a pharmacy are unaware of what medications their pets are taking and for what disease, so it follows that pet owners need instructions about medications for their pets. Veterinary health professionals provide both drug instructions and counseling on how to administer the medication, knowing what current medications pets are taking relevant to their disease. 

As we all know, the life of a retail pharmacist is busy filling orders, so he or she has neither the time nor knowledge to provide owner counseling on pet medications. According to a 2012 Oregon Veterinary Medical Association survey, 35 percent of veterinary practices had their prescriptions changed by a pharmacy without authorization, resulting in 16.5 percent of patients suffering setbacks.2

The following are points to consider when having to provide a written prescription so that pharmacist-generated errors do not occur:

1. Thyroid doses for dogs are higher than those in people. I personally had a pharmacist change a golden retriever's Soloxine (Virbac) 0.5 mg b.i.d. dose to Synthroid (Abbott Laboratories) 0.05 mg, telling the pet owner that the dose was too high. Most pharmacists will check with the prescriber before changing a prescription, but we need to account for those who do not. 

2. Pharmacists and other human health professionals are not aware that ibuprofen can cause renal toxicosis in dogs. In one instance, a pharmacist recommended ibuprofen when he was not able to fill the carprofen prescription. Another example: My neighbor is an MD and was giving his arthritic Labrador retriever ibuprofen when I was called upon to examine the dog. 

3. Gabapentin liquid contains xylitol whereas the capsules do not, so the formulations are not interchangeable. Xylitol is toxic in dogs.

4. Acetaminophen should never be given to cats, and in dogs it can cause liver damage. A pharmacist once substituted hydrocodone with acetaminophen when the veterinarian had ordered a prescription Hycodan (hydrocodone and homatropine; Bristol-Myers Squibb).2

5. Phenobarbital doses are generally higher in dogs than in humans. In one case, a pharmacist told an owner that the dose was too high and, consequently, the dog suffered from additional seizures because it received too low of a dose.2

6. Some pharmacists do not realize that glargine insulin is not interchangeable with NPH insulin. NPH insulin should not be substituted without consulting the prescribing veterinarian. It is less expensive, and a well-meaning pharmacist trying to save the owner expense is likely not aware of the action of glargine versus NPH insulin in diabetic cats. 

7. Prednisolone and prednisone are not interchangeable, particularly in cats. 

8. The abbreviation “s.i.d.” should not be used since it is not known to mean “once daily” to most pharmacists. Instead write out “daily” or “once daily.”

9. Over-the-counter (OTC) mediations such as antihistamines should not be likened to antihistamines containing decongestants such as pseudoephedrine. This vasoconstrictor can cause hyperexcitability, elevated blood pressure and more in cats and dogs. 

10. Compounded medications should be used only if absolutely necessary. Even though a pharmacy may be making these products, its personnel have no idea of the stability, compatibility in the vehicle, or sterility of the product. The FDA regulates these factors for commercially available medications, whereas compounded medications are not subjected to this rigorous testing. If you allow your clients to use a compounded product and the compounding pharmacy does not carry product liability insurance, you may be liable as the prescriber. 

A few examples of medications that should not be compounded include:

• Itraconazole. It has poor solubility and is available in a commercially manufactured oral liquid (10 mg/ml).

• Cyclosporine. One study showed more than 10% of compounded cyclosporine liquids deviated from the label strength (not to mention the bioavailability or clinical efficacy).3

• Doxycycline. A study showed it was only viable for seven days when compounded.4

We must act against this act now!

As a pharmacist and veterinarian, I am strongly against the FTC's report that is trying to make pet medication costs “more competitive.” Most veterinarians I know work hard to keep patient costs down. The main problem as I see it is that even if there were minimal savings on medications for the owner with this act, the pet is subjected to medication errors, some of which could result in death. Please contact your congressperson (see dvm360.com/actout) and relay your thoughts on this act that, if passed, could bring harm to our veterinary patients. 

References

1. Burns K. FTC pushes for more competition in pet medications market. JAVMA News: July 1, 2015, Vol. 47. Avaialble at: https://www.avma.org/News/JAVMANews/Pages/150715c.aspx

2. Reimer K. Oregon veterinarians tally retail pharmacists' mistakes. dvm360 Magazine: Nov. 14, 2012.

3. Umstead ME, Boothe D, Cruz-Espindola C, et.al. Accuracy and precision of compounded cyclosporine capsules and solution. Vet Dermatol 2012;23(5):431.

4. Papich MG, Davidson GS, Fortier LA. Doxycycline concentration over time after storage in a compounded veterinary prescription. J Am Vet Med Assoc 2013;242(12):1674-1678.

Suggested reading 

Some compounding may be allowed, even if illegal. JAVMA News: July 1, 2015, Vol. 47.

Harlow B. 6 reasons why the proposed Fairness to Pet Owners Act fails patients, practices. Vet Econ 2015;55(6):32.

Risk Awareness Alert: Do you use a compounding pharmacy? AVMA PLIT News: August 14, 2015.

Dr. Alice Jeromin is a pharmacist and veterinary dermatologist in Cleveland, Ohio. She is a 1989 graduate of the Ohio State University College of Veterinary Medicine, 1977 graduate of the University of Toledo College of Pharmacy and an adjunct professor at Case Western Reserve University's College of Medicine.