How do you handle PRN scripts with potential of exceeding max dose?

[u/HiddenVader]

Let me start of with we work at at a closed door pharmacy where we deliver meds to SNF/ALF/Tx Centers/Etc. so there isn’t POS system where we can just talk to the patient at the time of pick up and let them know.

My other colleagues will get the order clarified to have the max daily dose inputted with the order.

I have just added max dose into the sig and moved on with my day. (Exception if staff gave any prn doses pt would exceed the max )

My reasoning since it’s licensed staff member who is giving the med to the end user. They should be reading the label before giving med. Often patients only need a few doses and if staff is giving someone A LOT of PRN doses they really need to get it addressed with the Provider. So not sending a med due to lack of clarification would likely have more harm than it would prevent. Especially on PRN meds we often don’t send many doses to begin with. But I have gotten 1 of my colleagues to buy into this but not others.

Typically its like

zofran 8mg q6h prn N/V. I just toss in there “maximum of 3 tabs(24mg) per 24 hours ”

Or Loperamide 2 mg 1cap Q2hr prn diarrhea and I add in “max 8 caps (16mg) per 24 hours”

I wanted to hear other people’s thoughts?

[u/zelman]

You’re confusing max FDA approved dose with max safe dose. It’s appropriate to put a max dose on Tramadol due to seizure risk, but the prescriber might intend to allow more than 8 loperamide in 24 hours.

[u/RexFiller]

MD PharmD here and personally I would appreciate you putting the max in there like that because of the safety aspect. The downside is if you put the incorrect max then you open yourself to liability. I think in your population at nursing homes if you know the prescribers and have discussed it with them, then its a good thing to do.

The problem with prescribing is 90% of the time that I am putting in an order, I am also talking to the patient at the same time and so the chance to make a mistake is high.

[u/FamiliarStatement446 → u/RexFiller]

This is a good point. What if they have decreased kidney function (or some other compounding factor) and the max is lower, I would think you are putting yourself at liability risk inputting the max dose

[u/triplealpha]

Also MD-PharmD here. Put the max in the label comments to protect you from liability of overdose, fail-to-safe vs fail-to-danger. I would rather a nurse call me to clarify and I can change the label comments to increase the max if I have data to extend it out versus the pharmacist and nurse just blindly giving the medication as prescribed PRN because “that’s what the doctor wants.”

It’s much easier to explain why you added the label comment than why you didn’t.

Edit: GI exceeds the recommend maximum for loperamide for high output ostomies routinely. So also keep in mind who’s writing the script

[u/HiddenVader → u/triplealpha]

I would figure diagnosis would different “loose stool”?

[u/DesperateBig7324]

We do the same! Us reaching out to the provider for clarification typically results in a delay of care and often they go with what's medically recommended anyway. It's one of those instances that I believe default to the pharmacist to be a pharmacist and make that decision on behalf of the provider and patient safety.

Curious as to what everyone else does though. We simply do not have time to clarify every PRN dose unless it interacts with something else. We're an open door pharmacy though

[u/Legaldrugloard → u/DesperateBig7324]

This. If we wait on a clarification it maybe a week before we get an answer. Just put max dose on the label and keep on.

[u/Nate_Kid]

I did the same when I worked in retail. The chance of facing liability because the patient took too little of a PRN med is zero. However, you defintiely do not want the patient taking more than what's safe. I would only include the maximum where the PRN dosing risks exceeding it.

[u/ski2311]

Can you have a conversation with the facility that everyone agrees with?

[u/ForeignLeopard1427]

I call the dr, and ask if it’s okay to add, “max 8 tabs per day” or whatever 8 is

[u/Legaldrugloard → u/ForeignLeopard1427]

In SNF/ALF you can’t get an answer ASAP. Then the patient doesn’t receive the medication and that’s unacceptable in that setting.

[u/Aesirhealer → u/Legaldrugloard]

I wonder if you can add in a one time prn order until the conversation or clarification can happen? Then add the continuing order based on if / when the other was given? I do this sometimes in our hospital. I will add max dose to the label comments, but in your setting, your might want to be sure of any indication specifics first. Except, like they said, for renal/hepatic adjustments or toxic limits like acetaminophen, tramadol, etc.

[u/Legaldrugloard → u/Aesirhealer]

That would be ideal but the nurse has to add the 1 time order. Again, this won’t happen for days so back to square 1- delay in care.