Capsule vs. Tablet & 'Salt Forms' Dispensing

[josh6718]

Just curious as to what everyone's thoughts were on this.

If a MD writes for an drug that doesn't specify the form, we usually dispense what is cheapest/covered. For example an RX written as 'doxycycline', will be dispensed as the monohydrate (as our Medicaid only covers this particular form).

However, in situations (that aren't 'AB rated') where a prescriber sends an e-prescription:

- Tizanidine 4 mg Capsule ($$$ > tablet or requires a PA)
- Diltiazem 240 mg ER Tablet (patient has always been getting ER capsules)
- Ventolin (insurance requires Proventil)

Do you spend time to call the MD or use professional judgement and dispense what the insurance prefers? If so, do you make any notation on the RX (assuming it has refills)?


Note: This excludes more obvious distinctions such as Metoprolol tartrate vs succinate

---

Members don't see this ad.

 

[BenJammin]

Tizanidine is a weird issue since the capsules and tablets aren't therapeutically equivalent. The residents here don't give a damn about ventolin vs proair vs proventil. Don't waste their time calling on that.

 

[farmadiazepine]

The quick answer for tizanidine: Tablets and capsules are bioequivalent when given under fasting conditions, and under fed conditions, they are not.

What I do in retail: Dispense whatever, and keep it consistent. Depends on how much customer copay, pharmacy reimbursement, and/or customer preference.

The long answer from LexiComp:

Dosing: Adult
Spasticity: Oral: Initial: 2 mg up to 3 times daily (at 6- to 8-hour intervals) as needed; may titrate to optimal effect in 2-4 mg increments per dose (with a minimum of 1-4 days between dose increases); maximum: 36 mg daily. Note: Single doses >16 mg have not been studied.

Food: Food alters absorption profile relative to administration under fasting conditions. In addition, bioequivalence between capsules and tablets is altered by food; capsules and tablets are bioequivalent under fasting conditions, but not under nonfasting conditions.

The tablet and capsule dosage forms are not bioequivalent when administered with food. Food increases both the time to peak concentration and the extent of absorption for both the tablet and capsule. However, maximal concentrations of tizanidine achieved when administered with food were increased by 30% for the tablet, but decreased by 20% for the capsule. Under fed conditions, the capsule is approximately 80% bioavailable relative to the tablet. Management: Administer with or without food, but keep consistent.

Absorption: Tablets and capsules are bioequivalent under fasting conditions, but not under nonfasting conditions.
-Tablets administered with food: Peak plasma concentration is increased by ~30%; time to peak increased by 25 minutes; extent of absorption increased by ~30%.
-Capsules administered with food: Peak plasma concentration decreased by 20%; time to peak increased by 2-3 hours; extent of absorption increased by ~10%.
-Capsules opened and sprinkled on applesauce are not bioequivalent to administration of intact capsules under fasting conditions. Peak plasma concentration and AUC are increased by 15% to 20%; time to peak decreased by 15 minutes.

 

[npage148]

Zanaflex pk is such a mess. It like the old Zithromax tab vs caps

 

[trailerpark]

Walmart wants us to call every time to change caps and tabs and what not. For example if the doctor writes for Amoxicillin 500 mg tablets we have to call and document to switch to capsules. In practice only one of our stores do this and I hate working there. I always will just switch to caps or tabs vice versa if that's what they had last time or depending on what we have in stock. We're also suppose to call if the rx just says Pyridium or Robitussin AC and crap like that. Same thing with inhalers.

 

[BenJammin]

Walmart wants us to call every time to change caps and tabs and what not. For example if the doctor writes for Amoxicillin 500 mg tablets we have to call and document to switch to capsules. In practice only one of our stores do this and I hate working there. I always will just switch to caps or tabs vice versa if that's what they had last time or depending on what we have in stock. We're also suppose to call if the rx just says Pyridium or Robitussin AC and crap like that. Same thing with inhalers.

I guarantee you that doctors offices have a dart board with your pharmacy as the backdrop. What a terrible waste of everyone's time.

 

[pezdispenser]

About 10 years ago, there was a pharmacist by the name of Bernard Lisitza who brought whistle blower lawsuits against Omnicare, Walgreens and CVS. The claim was that they were deliberately substituting the more expensive tabs/caps of ranitidine, fluoxetine and selegeline to defraud Medicaid. All three companies had to settle for $120 million altogether, and Bernard Lisitza personally received $31 million.

http://drugtopics.modernmedicine.co...nets-31-million-whistleblower-cases?page=full
http://www.huffingtonpost.com/2008/03/18/cvs-to-pay-375-million-to_n_92166.html
http://www.cbsnews.com/news/walgreens-settles-whistleblower-suit/

That's why you don't substitute tablets or capsules on anything, even amoxicillin. You're supposed to ask the prescriber and annotate the prescription.

If the dosage form is not specified, it's still at your discretion.

 

[trailerpark]

I guarantee you that doctors offices have a dart board with your pharmacy as the backdrop. What a terrible waste of everyone's time.

Not my pharmacy! It's one store in our district and that store is a disaster because they're so inefficient. They waste so much time doing stuff like this. I haven't worked there in months and I just got a staff position in my home store so I doubt I'll ever have to go back to that nightmare store.

 

[Ackj]

About 10 years ago, there was a pharmacist by the name of Bernard Lisitza who brought whistle blower lawsuits against Omnicare, Walgreens and CVS. The claim was that they were deliberately substituting the more expensive tabs/caps of ranitidine, fluoxetine and selegeline to defraud Medicaid. All three companies had to settle for $120 million altogether, and Bernard Lisitza personally received $31 million.

http://drugtopics.modernmedicine.co...nets-31-million-whistleblower-cases?page=full
http://www.huffingtonpost.com/2008/03/18/cvs-to-pay-375-million-to_n_92166.html
http://www.cbsnews.com/news/walgreens-settles-whistleblower-suit/

That's why you don't substitute tablets or capsules on anything, even amoxicillin. You're supposed to ask the prescriber and annotate the prescription.

If the dosage form is not specified, it's still at your discretion.

That was because they were substituting more expensive products. If you're going for the cheaper product that doesn't require a PA, you're probably good. You should "call" the prescriber and annotate that you did, but I wouldn't actually waste all that time calling unless I had a real doubt about the rx.

 

[wagrxm2000]

Awhile ago I asked all my main offices if they mind if I switch, I got the ok from all so I just annotate and switch

 

[pezdispenser]

That was because they were substituting more expensive products. If you're going for the cheaper product that doesn't require a PA, you're probably good. You should "call" the prescriber and annotate that you did, but I wouldn't actually waste all that time calling unless I had a real doubt about the rx.

That's not the point. I doubt anyone at Walgreens or CVS ever gave enough of a damn to look up the prices (if they even could) and start a scheme to switch everything to the more expensive form. But when it comes to Medicare and Medicaid and this whistle blower provision, if you don't do things perfectly by the book, there are lawyers and people like Bernard Lisitza waiting to pounce on you and file a whistle blower lawsuit. In fact, they could still accuse you of not actually calling the prescriber but annotating that you did, and your company will probably just settle because they can't risk being banned from Medicare/Medicaid.

 

[HelpfulPharmer1]

Key phrase: Deviating from doctor's instruction.

My friend got fined personal money 500 dollars for not giving enough pills ! (The chain got fined 500 dollars as well. When I finally convince my friend to allow the real letter, I will upload the letter). Until then, you just have to hear me out that the board fined my friend for not giving 90 pills when the label showed 90 pills of omeprazole ! The reason cited on the letter was: Deviating from doctor's instruction.

Take that and elaborate into changing capsule to tablet or auto-sub any Proventil to be ProAir or Ventolin. If you change without documenting and someone who hates you find out, my educated guess is that: we will get fined for deviating from doctor's instruction. Therefore, document the change to protect yourself. I like the move that was posted earlier and here I quote:

Awhile ago I asked all my main offices if they mind if I switch, I got the ok from all so I just annotate and switch

We will document on hard copy and store in a binder so all future scripts will be automatically interchanged to be the choice we can do (capsule or tablet, test strip..., albuterol.....) Our plan is that we will document each hard copy but we will not have to waste time calling each time. Is that allowed by law or banned by law? If anyone knows such law, please present source. Thank you very much in advance.

 

[HelpfulPharmer1]

......they could still accuse you of not actually calling the prescriber but annotating that you did, and your company will probably just settle because they can't risk being banned from Medicare/Medicaid.

Agree and to elaborate further, if a hateful coworker caught you committing that act of "Not actually calling but still annotating hard copy", you can expect harsh punishments:

Medicare or Medicaid can ban this individual pharmacist from filling future scripts for Medicare or Medicaid, which will destroy our ability to work.

Corporate representative will be forced to fire us for the reason of "Lying and Falsifying document." (I heard a lot of firings are done for technical reasons to prevent corporation from getting into trouble with the law even though they don't want to fire us.)

Knowing that....do the right thing at the right time, folks....if you know what I mean....so, pick up the phone....

 

[Deja]

lol if they are really going to fire pharmacist for switching amox tab vs cap, then majority of pharmacists would be out of a job

 

[Dred Pirate]

Easy answer - work in a hospital where you don't have to deal with these things and are covered by policy and procedure.

I agree technically and legally you should have to change these things. The problem is that it makes us look like a bunch of uneducated idiots if we call on things like this. In a small town where the majority of your scripts come from a couple of offices you can get the blanket authorizations and document them, but if you are in a big city where you see scripts from literally hundreds of MD's or near an academic medical center where you have residents coming and going, I just don't see how it is practical.

 

[ancienbon]

Really. I never call to change amox tab to capsule
Who has time to waste

 

[pillpharmer14]

In the great state of Texas, we can switch dosage form with patient consent. Obviously you have to use professional judgement and not go switching ointments to creams and such, but as far as abx, tab>cap>suspension is all up to the patient.

 

[BC_89]

moments like this really makes me ponder the thought of hospital vs retail...Who would of thought idoitic bigotry to the pharmacist in a retail setting will have you walking on egg shells on things like this...legally i see why, on the receiving end of it I def. can undersand the giving off of a vibe of an uneducated no-sense-of-judgment-call-pharmacist lol. Then again, different cities different approaches...same medication.

 

[Old Timer]

Depends on your neighborhood. I have decent Muslim population and almost all capsules are pork derived and tablets are not. So, I don't just switch Amoxicillin anymore. I just carry both. It's not that hard. Otherwise, in PA tablets and capsules are not interchangeable.

 

[PharmDDDD]

Just slap a label on it... Or wait what?

 

[BidingMyTime]

Depends on your neighborhood. I have decent Muslim population and almost all capsules are pork derived and tablets are not.

Interesting, I had no idea, I'm surprised this has never come up in my practice before (I'm guessing maybe a lot of people who don't eat pork for religious reasons, have no idea that capsules are pork derived?)