prescriptions.

Re: prescriptions.

Braden Collins — Mon, 09 Dec 2013 02:36:38 GMT

In the past 3 months we have had 2 cases where clients have used the same prescription more times than was allowed. The pharmacies involved have had a phone call from us but couldn't give an adequate explanation. We have talked to the Vet Surgeons Board in WA and they have said we become liable for any misuse of the prescriptions.

We have made the decision that the clients currently receiving scripts from us can still have them, but we will fax them to a specific pharmacy then post the hard-copy across. No other patients will be given scripts from now on. We fortunately can do this in Western Australia. We know we will lose a couple of clients over this, but I can't think of one of them I will be sorry to see go.

Re: prescriptions.

Inge — Sun, 08 Dec 2013 21:30:58 GMT

I have phoned the Royal College about this and they did say to always follow the cascade where possible. They would not specifically answer the question but I think that says enough. Ronaxan it is (and stays). It got worse though..reception misunderstood the client request ; they actually wanted an open prescription for Doxycyline, so no animal name on it! I think not. Thanks for all your replies!!

Re: prescriptions.

Sammy82 — Sun, 08 Dec 2013 14:12:17 GMT

[quote user="Martin Atkinson"]

The legality and practicality of complying with the cascade apart: do you really want clients who only want a prescription to save money and then complain the drug is still too expensive but would probably be the first to complain when other fees have to go up to compensate for loss of income from sales of drugs Inge? I set my prescription fee (£15) at a level that is high enough to make it not worth their while, if they don't like it they can take a hike.

[/quote]

Unfortunately some drugs (even POM-Vs) are so cheap now at some online pharmacies that paying £15 for the prescription and getting it online still works out a lot cheaper for the client. I just googled Metacam, you can get 180ml for only £16.99, free P&P. I can not look up our wholesaler price right now as I am not at work, but it is definitely more than that!

Re: prescriptions.

Laurence Webb — Sat, 07 Dec 2013 21:12:01 GMT

You are bound by the law to prescribe a POM-V where one exists. Why should you lose business so that you can allow someone else to break the law?

If you dispensed a generic human product then you would be breaking the law. The pharmacist has similar legal obligations. If he dispenses a human generic he is breaking the law and his own professional code of conduct. Asking you to write a prescription for a generic is a way of muddying the waters - an audit of the pharmacy is unlikely to pick up that they dispensed a generic where a POM-V exists if the prescription is for a generic. A prescription for Ronaxan that has been filled when no Ronaxam has passed throug the pharmacy is more likely to be flagged up. The pharmacist can also claim that they dispensed a generic in innocence.

I have had instances where pharmacists have dispensed human generics instead of POM-Vs. I suspect this is because 1) they are cheaper (so 'help' the client out 2) The generic is sitting on the shelf and they do not have ready set up channels to order in POM-Vs 3) To order in a box of a POM-V and dispense a small proportion would be prohibitively expensive to the client or the pharmacist. These are all arguments of convenience.

When I have known this to have occurred I have sent a letter to the pharmacist pointing out their professional responsibilities and the section of the code of conduct that they are breaking. The request for prescriptions seem to dry up at that point.

One option may be to prescribe doxycycline with a sentence following that a POM-V product exists and must by law be dispensed. That may be a way of getting around Amoxy/Clav issues etc where lots of POM-V equivalents are available.

The law may be an ass where the cascade is concerned, but we are bound by it and so is a pharmacist

Re: prescriptions.

Bob Russell — Sat, 07 Dec 2013 10:38:30 GMT

[quote user="Andrew Kent"][quote user="David Mills"]

[quote user="Andrew Kent"]perhaps I am doing pharmacists a disservice but I do wonder if we don't stipulate a brand how often pharmacists would seek to find a vet licensed product.[/quote]

Maybe, maybe not. Slightly different, but on a number of occasions I've written prescriptions for levetiracetam tablets and written on the prescription 'generic' and they've given the client branded Keppra at a whacking great cost, which has annoyed me.

[/quote]

that would annoy me too. Perhaps suggests that pharmacists interpret our prescriptions fairly loosely. I guess in the majority of cases we never know when these things occur.

[/quote]

Some pharmacies/pharmacists stock more generics than others. I suspect they get paid the same by the NHS whichever they dispense.

Re: prescriptions.

Andrew Kent — Fri, 06 Dec 2013 19:33:02 GMT

[quote user="David Mills"]

[quote user="Andrew Kent"]perhaps I am doing pharmacists a disservice but I do wonder if we don't stipulate a brand how often pharmacists would seek to find a vet licensed product.[/quote]

[/quote]

that would annoy me too. Perhaps suggests that pharmacists interpret our prescriptions fairly loosely. I guess in the majority of cases we never know when these things occur.

Re: prescriptions.

David Mills — Fri, 06 Dec 2013 19:21:26 GMT

[quote user="Andrew Kent"]perhaps I am doing pharmacists a disservice but I do wonder if we don't stipulate a brand how often pharmacists would seek to find a vet licensed product.[/quote]

Re: prescriptions.

Andrew Kent — Fri, 06 Dec 2013 19:14:47 GMT

[quote user="David Mills"]

[quote user="Andrew Kent"]and in the case of a licensed product should be describing the trade name not just the ingredient. [/quote]

I've often wondered about this, and never been able to get a straight answer.

Prescriptions came in because of fair trade rules to prevent monopolisation of supply of goods to clients. By naming the trade name that must be supplied, this is still restricting the client's choice to that particular product (which may/not be the cheapest). As pharmacists must follow the cascade as well then there should be no real issue as they should not be supplying generics in place of licensed products. I just wonder, having filled out a prescription and ticked the relevant boxes, how liable vets are in that circumstance?

The GtPC or whatever it's called seems to be firmly pro-free trade and client choice.

[/quote] Good point, I was thinking more of ronaxan and similar where there is only one veterinary licensed product. And particularly in this case to stop the client/pharmacist trying to break the rules. Where there are lots of options (meloxicam) for example then I agree we shouldn't stipulate.

one thing that I have noticed is that lots of vets prescriptions seem to have a standard paragraph along the lines of 'prescribed under the cascade' even when prescribing a veterinary licensed product. In which case I suppose that suggest to the pharmacist that they can use a generic.

perhaps I am doing pharmacists a disservice but I do wonder if we don't stipulate a brand how often pharmacists would seek to find a vet licensed product.

Andy

Re: prescriptions.

David Mills — Fri, 06 Dec 2013 18:49:45 GMT

[quote user="Andrew Kent"]and in the case of a licensed product should be describing the trade name not just the ingredient. [/quote]

I've often wondered about this, and never been able to get a straight answer.

The GtPC or whatever it's called seems to be firmly pro-free trade and client choice.

Re: prescriptions.

Hannah Wynne Richards — Fri, 06 Dec 2013 17:58:33 GMT

My version is " Give me a cheque for £ 1million. After it's cleard, I'll consider your request.

Wynne

Funny no-one has yet said yes.

Re: prescriptions.

Dagmar Steele — Fri, 06 Dec 2013 16:41:11 GMT

Wynne, exactly what I wanted to say and what I blatantly tell clients if they ask me for anything like this. I ask: "are you prepared to pay my pension if I get struck off ?" None of them has said yes so far so I'll stick with the cascade. Having said that the cascade is the most ridiculous, annoying law we have and I am hugely disgusted by that nonsense. But I will not risk my license to save other people some money. I'm not completely insane. Plus I'm sure they wouldn't do the same for me.

Re: prescriptions.

Hannah Wynne Richards — Fri, 06 Dec 2013 15:28:08 GMT

Inge Don't even think of it. This client won't fund you until retirement afetr you've been struck off.

Wynne

Re: prescriptions.

Bob Russell — Fri, 06 Dec 2013 14:40:33 GMT

We have one client requesting prescriptions for meloxicam. I cover all my costs with the prescription charge so am not bothered really. We just ask which brand he wants and let them get on with it! They go through a lot of hassle to make a pretty small saving. Sadly they are not interested in allowing me to extract a number of teeth from their Labrador despite being able to smell his breath as he enters the waiting room! At 10 he is apparently too old for an anaesthetic! Tight ars*s! Not sure what the RSPCA would make of his mouth!

Our meloxicam is priced pretty competitively so nobody else bothers. It may be imagination but a few on-line suppliers seem to be bringing their prices up a bit presumably they have decided they need to make a profit!

Re: prescriptions.

Martin Atkinson — Fri, 06 Dec 2013 14:27:29 GMT

Re: prescriptions.

Andrew Kent — Fri, 06 Dec 2013 14:25:38 GMT

[quote user="mariette asselbergs"]I don't know if this is different for humans (must be) but on my prescription for diclofenac, my pharmacy gives me all different brands of diclofenac with different names. It seems idiotic to me that we must do prescriptions for a certain brand name instead of the drug itself. It is then the pharmacist's responsibility to see which one is appropriate (licensed) for your patient? [/quote]

Yes it is different to humans, very much so. And we should be putting on our prescriptions whether this is prescribed under the cascade or whether this is a licensed product, and in the case of a licensed product should be describing the trade name not just the ingredient. So it is a combined responsibility between us and the pharmacist. What this realistically means is that most veterinary prescriptions (that are NOT under the cascade) have to be filled online not at the high street chemist.

This has also slightly gone off topic from the original point - this is not a vet wishing to prescribe something on the cascade - presumably the vet in this case is very happy to be prescribing the veterinary licensed product. This is an owner wishing to avoid paying for the licensed product and there is no room for this eventuality under the cascade.

Andy

Re: prescriptions.

Bob Russell — Fri, 06 Dec 2013 14:16:47 GMT

Compliance problems allow cascade to be by passed but probably only once the owner has tried (and failed) with the licensed product. Sadly vets judgement officially does not count for much. Since Steve Dean left the VMD there has been at least a token softening of attitude!

Cascade is inflexible and pretty stupid in my opinion because of this element. It is sensible to be strict with food producing species and clinically flexible for non-food producing species. Nobody seems to have thought about this when the legislation was drafted.

No prosecutions but some DC issues so far but if you are daft enough to write a prescription for an unlicensed product where one is available then it is taking a silly risk.

Clearly from the tone of the post the reason for using generic doxy is to save money not on clinical grounds and is sticking your head over the parapet for no sound reason.

Re: prescriptions.

mariette asselbergs — Fri, 06 Dec 2013 13:36:32 GMT

I don't know if this is different for humans (must be) but on my prescription for diclofenac, my pharmacy gives me all different brands of diclofenac with different names. It seems idiotic to me that we must do prescriptions for a certain brand name instead of the drug itself. It is then the pharmacist's responsibility to see which one is appropriate (licensed) for your patient?

If it is much easier to give liquid doxyxycline to a cat than tablets then I think we would be allowed. under the cascase to say that in our vet judgement the liquid form is indicated e.g. for compliance reasons.

For food animals the cascade must be adhered to as much as possible, but for small animals our veterinary judgement should be allowed to override, and I have always understood that that is accepted. Is there any case of a small animal vet having been prosecuited for not sticking to the cascade? Is there actually any farm vet who has been harrassed or prosecuted for using meds off license?

Mariette

Re: prescriptions.

Mark Holmes — Fri, 06 Dec 2013 13:33:21 GMT

There is not a convenient tablet size for doxy in cats. 20 mg is too small for your average cat and 1/2 a 100mg too big. There is a rather convenient 50mg generic capsule. Research has shown the problem of compliance is rife, and convenience of dosing paramount. There is also a risk of oesophageal necrosis, increased I would suggest by overly large tablets and giving two - when one capsule would suffice. Justifications for the use of the generic off the top of my head

Re: prescriptions.

Bob Russell — Fri, 06 Dec 2013 13:30:09 GMT

It never fails to astound me what risks some pharmacists are willing to run for 'friends'. I gave a client marching orders because she refused to give licenced meloxicam, preferring to use human meloxicam from the pharmacy she worked at! Because she gave me grief, not because she was planning to break the law!

Yes its cheaper, yes its a bit of a con but it is the law! Presumably pharmacists have close monitoring of stocks of POM's so it should be quite a risk for them to take.

As above - Ronaxan is the licenced preparation that must be used under cascade. If the client does not like it tell her to talk to her MP.

Re: prescriptions.

Martin Atkinson — Fri, 06 Dec 2013 13:19:15 GMT

As above but tell her that if the pharmacist dispenses an alternative you will report them to their professional body.

Re: prescriptions.

David Mills — Fri, 06 Dec 2013 13:05:17 GMT

As above, you've no choice according the cascade.

Owner (one can sympathise) is trying to save money - generic doxy is about 5p/tablet for 100mg rather than whatever ronanxan retails at these days (?£1/100g).

The only way around it would be if the animal refused the oral tablet form then you may be able to prescribe the human oral solution.

Re: prescriptions.

Evelyn Barbour-Hill — Fri, 06 Dec 2013 12:57:50 GMT

Don't remove it. Your prescription is for Ronaxan.

Re: prescriptions.

Andrew Kent — Fri, 06 Dec 2013 12:55:43 GMT

Just because you are giving a written prescription doesn't mean you can ignore the cascade so you should stick with what you have done and the pharmacist should then follow this. If they don't have ronaxan she will have to source it from elsewhere

Stick to your guns.

Andy

Re: prescriptions.

KMurphy — Fri, 06 Dec 2013 12:55:13 GMT

Pharmacists are required to follow the cascade just as you and I. If that's what you've prescribed, that's what they'll need to dispense unless it can be otherwise clinically justified.