Editorial: Basis for decisions: Documentation and/or judgment

It seems that too many practitioners (physicians and pharmacists), want everything "in writing" before they are willing to take action. This may be a result of a litigious society and the need for tort reform. However, this mentality tends to be rather narrow minded and stifling to new approaches to treating different disorders.

I often get requests for "documentation" of how a formula works or its use in different disease states, etc. This brings up some interesting thoughts.

1. If a "formula" doesn't work, who in their right mind would keep prescribing it? Granted, there are occasions where there is a "placebo effect," and some cases where there is a popularity associated with some formulations, but these seem to be rare.

If a physician is basing a professional reputation on diagnosis and prescribing activities, will they really prescribe something that patients have told them doesn't work? Or, will they tend to prescribe something that patient's explain "have" worked?

In other words, we got where we are now with many medications because of the physician-patient-pharmacist triad and open communication on what therapies do and do not work. This system works, especially if one doesn't have hundreds of thousands or even millions of dollars to conduct a "clinical study." It seems that some practitioners will not make a decision without a lot of published studies, etc.

2. If we only rely on what is published in the literature and reference books, are we practicing "good pharmacy"? Possibly not! How many times have you seen that many "clinical articles" are written by ghostwriters who are being paid by the major drug companies? How many times have you seen "scientific articles" shown to be inaccurate and even fraudulent? How many times have you seen similar studies report conflicting results? Some studies are reported to assist in getting new grant money for more research. All these "studies" can be incorporated into reference books which stay around and are depended upon for years. Which ones do you use as your "documentation" for your decision-making? Do you really know which ones are ghostwritten, fraudulent, inaccurate, etc.?

In summary, is it best to wait on "getting everything in writing" and allow patients to go without potentially lifesaving prescriptions and many different prescriptions that can make life more bearable? Or, is it reasonable to evaluate the experiences of physicians, pharmacists, etc. and, as appropriate, incorporate some of the new methods in your practice by recommending some of these to your physicians?

If we only do what is "documented," then there is really no "professional judgment" involved and computers can do that part of our job for us. There is nothing wrong with using professional judgment, experience, and other sources of information in making decisions.


Loyd V. Allen, Jr., PhD, RPh
Editor-in-Chief

Acetaminophen Combinations May be Changed
An FDA advisory panel has recommended acetaminophen dosage reductions, including steps to reduce the number of acetaminophen overdoses. The panel advised the FDA that they should lower the maximum daily dose of acetaminophen in OTC drugs from 4,000 mg to 2,600 mg and to also lower the maximum single dose from 1,000 mg to 650 mg.

Regarding prescription drugs, the panel also recommended removing products that combine acetaminophen with narcotics, such as Vicodin, from the market because of the risk for overdose and severe liver injury. Also recommended were stronger warnings about potential liver damage.
Source: DrugNews Monthly, August 2009

Editor's Note: This is a great opportunity for compounding to be utilized to provide narcotics without acetaminophen for patients; resulting in safer therapy.

Starting next week, we will feature a "Weekly Excipient" with a summary of uses and properties. This may provide additional excipients for consideration for use in your compounding activities.

Stockley's Herbal Medicines Interactions
Williamson E, Driver S, Baxter K, eds.
London, UK: Pharmaceutical Press
July 2009; Price $89.95; 400 pages

This latest edition contains data on over 150 different herbal medicines, dietary supplements, and nutraceuticals arranged in a highly structured, researched, and fully referenced monographs.

The information in the monographs contains the name, synonyms, constituents, use/indications, pharmacokinetics, interactions overview, abstract/summary, clinical evidence detailing the interaction, experimental evidence, mechanism as to why the interaction may occur, importance and management, and references. More than 550 interaction monographs are included in the book.

This edition is very easy to read and is a convenient size for easy reference. It is highly recommended as the number of patients taking these products along with prescription and nonprescription medications increases.

�we are seeing democracy in action with hundreds of thousands of citizens showing up at town hall meetings this month all over the nation. It's your opportunity to voice your opinions and get involved!

Be Involved!
As pharmacists, we MUST be involved. When one hears about the healthcare plan(s) and the providers, it seems we hear about the AMA (doctors), ANA (nurses), and big PHARMA (pharmaceuticals); as if big PHARMA represents pharmacists! Why do the news agencies not talk about the pharmacists and list the pharmaceutical associations? Could it be that not enough pharmacists are involved? EVERY pharmacist should be a member of the American Pharmacists Association (APhA) and then select others to support depending upon their practice site and professional preferences. Pharmacists' voices must be heard so we will see AMA, ANA, and APhA on the news together!