When Pharmacists Go out of Bounds

I am sure that the overwhelming majority of pharmacists are good at what they do and that they limit their practice to the scope in which they were trained. But I have had several interactions with pharmacists that leave me somewhere between baffled, disappointed, and annoyed.

Most recently, I had a pharmacist call about a prescription for Tresiba U-200. The patient had been on a U-100 basal insulin, and the same number of units of Tresiba U-200 was prescribed. The pharmacist called and insisted that the patient would be getting too much insulin because “it’s much more concentrated.” He had difficulty grasping that the pen was designed to give the appropriate number of units, not a specific volume of insulin, thereby making the concentration irrelevant.

Several concentrated insulins are on the market now. Tresiba U-200, Toujeo, Humalog U-200, and the original one, Humulin R U-500. With the exception of U-500, they are all available in pens only (no vials), making the conversion from a U-100 insulin seamless. When U-500 was the only concentrated insulin we had and it was available in vials only (thankfully, it is available in pens now, too), we did have to compute unit equivalents; ie, if you wanted the patient to take 50 units, he had to draw up to 10 units in a syringe. The beauty of the pens is that computing equivalent doses is now unnecessary.

Now first of all, after the pharmacist was told that, yes, we are certain that is the dose the patient should be getting, he continued to argue his point. We explained that the patient would be receiving the same number of units, not the same volume, and therefore would not be getting “too much insulin.” I’m not sure he was convinced. And I can only hope that he let it drop, filled the prescription, and left the directions alone-in contrast to another pharmacist who told a colleague’s patient to cut the dose in half!

In other instances, pharmacists have told my patients to stop medications or change their doses without speaking to me. Or they have given the patients information (or misinformation) that leads them to stop being adherent to their treatment regimen: “My pharmacist told me that my ramipril can make my potassium high and I’m taking a potassium pill, so I stopped taking the ramipril.” This, without knowing what her potassium level is and not taking into consideration that she’s on a diuretic.

I understand that pharmacists are doing what they think is in the patient’s best interests, but I also believe they should be cautious of what can be interpreted as practicing medicine without a license.