Oral hormone therapy has shown itself to be an unhealthy route for women and topical application has proven itself to be the preferred choice longterm. Sudden discontinuation of clobazam can cause benzodiazepine withdrawal syndrome. Newer and more expensive medications that may have obvious benefit over older drugs may be left out in the cold for lengthy waits until a plan decides to cover them. This brings us back to the original issue of why are we dropping essential counselling and why are we too busy to catch interactions? Subscribe to receive email notifications whenever new articles are published. Thank you Marijuana for taking the bad press off of bioidentical hormone therapy.
Sudden discontinuation of clobazam can cause benzodiazepine withdrawal syndrome. Patients who require de novo treatment? In patients who require de novo treatment with an antiseizure medication during the clobazam shortage, physicians should consider whether an alternative medication could be used at least initially. Patients currently taking clobazam? If all supply avenues have been exhausted and there is no clobazam available, an alternate medication should be substituted until clobazam can be resupplied to the patient.
The following rationale for the selection of clonazepam as an alternative medication to clobazam during a drug shortage is from a document written by J. From the benzodiazepine group, only two other drugs have been found useful for the chronic management of seizure disorders: While there is no published evidence of efficacy under the circumstances, the most reasonable substitute for clobazam is clonazepam. It is not known if this will be efficacious in all patients or if the recommended equivalent will result in a decompensation of the seizure disorder, but it is reasonable to surmise that it may prevent the development of a withdrawal state resulting in status epilepticus.
Any given dosage will need to be carefully monitored by the prescribing physician and adjustments made where necessary. While making these recommendations, it is hoped that the health authorities and pharmaceutical companies will protect the public by urgently implementing a strategic plan that will prevent such shortages from occurring. It is imperative to be reminded of the potentially fatal consequences of breakthrough seizures.
Clonazepam brand name Rivotril is a 1,4-benzodiazepine. This medication is available as an oral tablet in 0. Clonazepam is more potent than clobazam. It is at least 10X more potent than clobazam if not? Following conversion to clonazepam, some dose titration may be required to achieve the desired therapeutic effect. Clinical judgement is necessary to determine the optimum dose for each patient.
Patients should be carefully monitored for changes in seizure frequency, as well as the emergence of any adverse effects excessive sedation, ataxia, increased difficulty handling secretions, worsening liver function following the switch. ClonazePAM causes more sedation than equipotent doses of cloBAZam and tolerance may be more likely to develop to its antiseizure activity.
The excipients and non-medicinal ingredients between formulations may be different so caution should be exercised in patients with known hypersensitivity to excipient. These, along with any differences in adverse event profiles, can be verified in the appropriate Product Monographs and labels. Dose titration, up or down, should be based on patient response.
Dose increases in pediatric patients, if required, are typically 0. When substituting clonazePAM for cloBAZam, a thorough drug interaction assessment should be done taking these metabolic paths into consideration. Should practitioners have reservations or concerns about the clinical management of their patients with epilepsy during this shortage, they should consult their nearest neurologist with epilepsy expertise or comprehensive epilepsy centre.
Drug therapy for disease is essential and cannot be interrupted for even one dose or one day. Canadian Pharmacists Association , Drug Shortages: A Guide for Assessment and Patient Management www. Ther Clin Risk Manag. Ed , Pediatric Epilepsy: Diagnosis and therapy, 3rd Edition. Demos Medical Publishing, New York, page ? Results from a UK database incident user cohort study. Epilepsy Research , ?
Seizures and Epilepsy, 2nd Edition. Oxford University Press, New York, page ? Therapeutic alternative to clobazam: Medical recommendation for adults with epilepsy. Retrieved from Epilepsy Ontario website: Who is it that really makes the final call on what your treatment is for any of your medical conditions?
Most would say their doctor. As a pharmacist however I see something different. It is common to see a patient come to the dispensary counter after their physician has already phoned to see if a first choice drug is covered. It is often frustrating for medical professionals to feel like their hands are tied and that they are being told what to write for. Newer and more expensive medications that may have obvious benefit over older drugs may be left out in the cold for lengthy waits until a plan decides to cover them.
As well, unrealistic hoops may be required to be jumped through before an effective one is covered. Meanwhile the patient suffers needlessly until the more effective one is paid for by the plan. Unbeknownst to the rest of the world is the strangle hold these plans have on pharmacies. While it is true that pharmacies fill more prescriptions when patients have third party plans, it becomes a profit based on volume that puts big chain pharmacies that avoid smaller communities at an advantage and smaller more community minded independents out.
Gone are the days when pharmacies had some say in their dispensing fee, now a four letter word to the public but the main way dispensaries make money. Pharmacies used to be and should be able to run based on their pharmacy sales but not so much any more. For the first time we are now seeing a decrease in dispensing fees. It has become a take it or leave it contract. Small communities that have relied on the donations of these strong businesses have seen this drop off or eliminate altogether, reducing spinoff benefits.
Keep in mind that small independent pharmacies have a more timely and positive response to the types of charity requests seen daily. Preferred provider contracts give lower prescription prices at specific chains, something that used to be illegal. The drop in pharmacy revenue causes front store prices to climb and customers find themselves paying for services that they assumed should be for free, like tax receipts, refill extensions, med reviews, calling the doctor and consultations — things that we are accustomed to getting gratis.
So, physicians are somewhat dictated to, pharmacies are told their price for what they are selling and who is it that controls your health? Of course there are benefits. It should not be a dictatorship that slowly undermines our entire healthcare model. I see bills for such things as faxing to a local number, photocopying, corking fee to open wine bottles at a function, cutting up a cake, supplying year end receipts, filling out health insurance forms, consultations, supplying information, It is also difficult to have a donation request responded to without a waiting period for most people.
So what does a pharmacy do differently? Well we give volumes of donations to local causes after weekly and sometimes daily requests. Quite often we give you your year end tax receipts free, call your doctor for free, fax your form to your drug plan after we have filled it out for you , talk to you on the phone for minutes at a time or sit down for even longer about your health concerns for free.
I do glucose and cholesterol tests for free, make deliveries daily to our nursing home and supply free INR tests to their residents as needed, and OTC counselling off and on all day long. Most people assume many of these things are done readily for free by their local pharmacy. Other services eek their way out as well, like a 45 minute grocery store tour to help people eat better http: While it is true that pharmacies charge a dispensing fee for filling a prescription, it is that one fee that fuels most of these other daily contributions and tasks.
Keep in mind that some pharmacies charge for some of these services and some do not. As well, lots of businesses do stuff for free. Should I be charging for all of these services? Some would say yes. In fact, virtually every study that has ever been done can be debated for some reason or other. As well, it is safe to say that not much has ever been proven of any value or consequence by just one study alone.
This can start out with a quick exchange of some handpicked positive and negative outcome studies that may be well designed or not or maybe had the power to determine the outcome or not. Maybe a study hid some of the data or the statistical analysis was done improperly. Maybe my colleague had 10 times as many studies compared to mine.
Is that what decides the outcome of all of these scientific studies? That one person can scrounge up more studies than someone else? Do they quietly pass off the study as a fluke or placebo effect or do they start to see what scientific study is for us — many studies that create a whole picture much like individual pieces of a puzzle make a picture. It is a puzzle of a field of green grass on a sunny day with blue sky and some white clouds. It turns out that this picture is a picture of a rabbit sitting in the field, only a very small part of the picture, less than one percent is taken up with the rabbit.
This translates into just 2 pieces of the piece puzzle. We separately lay out the pieces and get a vague idea about what the picture shows. It turns out I have both pieces that make up the rabbit, statistically not what we would expect but it happened. I call my colleague and tell him about the picture we are looking at and how it appears to be one with a rabbit in the field. So who is correct? Well based on what is in front of each of us, we are both correct.
When we both meet to put the puzzle together on one table, the entire picture becomes clear. The puzzle changes from a field on a sunny day to a rabbit on a sunny day. Each piece of the puzzle is a scientific study. This exercise shows us what the power of a study means, or an analysis of many studies can show. For an infrequent result, the amount of pieces that are required to find the rabbit are large.
My colleague arrived at what would be called a negative result and mine was a positive result. In a book called Statistics Done Wrong, Alex Reinhart it is described that in a review of studies between and in prestigious medical journals, almost a third of these studies yielded negative results. As always, I believe that scientific studies are the best thing we have to unlock what we do not know. One study however, can be deceiving when taken as a single data point on a graph.
Scientific studies are a group effort. Lately we have heard stories of Pharmacists not doing their job correctly. To be exact, in a survey of a sample of pharmacies, it was discovered that medications that are kept in the pharmacy but did not need a prescription, there was insufficient or completely absent counselling on behalf of the pharmacist. These medications are in a special class in that they can only be sold in a pharmacy, behind the counter of the dispensary, and the customer must ask for the medication in order to be screened for interactions with existing medications and medical conditions, as well as proper use of the medication so that it is safely used and gives the best results.
Although there were arguments that the sample size used in this observation was too small to make an overall conclusion, just 50 pharmacies, and that the study was not scientific, showing even one pharmacy not counselling this type of medication is not good. Undoubtedly spurred on by a few recent reports of dispensing errors across the country, this survey began in BC and spread across the country based on the results in that one province.
Trust me, when a pharmacist makes a mistake, it hits them like a ton of bricks, regardless of the outcome. This nationally broadcast report was fuelled by a week long buildup that caught the eyes of pharmacists and general public alike. Word began to spread in the New Year about the story and certainly when it finally came to air, there was a huge reaction from those who watched it. Many pharmacists chimed in.
Initially claiming unfair reporting in that it made pharmacists look completely inept. Others claimed that the story completely avoided the good that pharmacists do that is totally ignored for the most part. This was followed by examples of what we do as pharmacists every day. The reporter afterwards quickly claimed that the show was more about quotas imposed on pharmacists to increase script count than exposing pharmacists not doing their job correctly. It was certainly a perception of mine leading up to the program and certainly after watching the program that the latter was the case.
As someone that works for an independent in a small community, the concept of pressure imposed by quotas for increased prescription count is definitely foreign to me and one I must admit I had never heard of before. Pharmacists interviewed for the program claimed that this pressure to increase script count was responsible for other parts of their job slipping, including counselling these behind the counter medications and focussing properly on the filling and checking process.
Then obviously it is something eroding pharmacy that needs to be addressed. The profession of pharmacy is certainly not against change, but the change we have seen over the last 20 years has absolutely lead to great things, but in some cases has also lead to the erosion of the profession. Before I graduated from the College of Pharmacy in , things were strict. Gradually, we saw big box stores start to include incentives to their employees when they had their prescription filled at their banner, then drug plans that are affiliated with the pharmacy with restrictions that you are covered when you get your prescription filled only at that pharmacy chain and no other.
While on the subject of third party plans, in my opinion the most dramatic effect overall in the pharmacy business today, we have seen a very gradual undermining of the pharmacy business because dispensing fees and reimbursement to pharmacy from the third party plan has not grown with what is reality in dispensing. Dispensing has become a volume business in order to show a real profit. In fact we are starting to see decreases in dispensing fees from third party plans.
In a lot of ways I feel these plans are a part owner in my business. A move that seemingly made sense to the general population in that it aimed at lowering prescription prices by coming up with an imaginary dollar value for various popular generic medications, regardless of what the pharmacy paid for it. This move came about from the practice of generic companies giving rebates for purchases, a common practice in many types of business.
The government saw this as their money. These were the main dollars we used to run the programs of our pharmacy and the dollars we used for donations and community programs that came to us for help. Very quickly this money was gone. In effect, this attempt by the government to lower prescription drug prices was accomplished on the backs of the pharmacies in the provinces. Our communities are now realizing the effect of lack of income in their community pharmacies.
Before too long, we saw other third party plans jump on this bandwagon, and gone were more dollars we used to run health programs we conceived on our own for the health our community. Enter the expanded scope of practice. Use the pill finder to identify medications by visual appearance or medicine name. All fields are optional. Search for the imprint first, then refine by color and shape if you have too many results. Every effort has been made to ensure that the information provided by Multum, Truven Health Analytics, Inc.
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