On-call scenario 4: Resolution
What an on-call pharmacist could advise...
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The guidelines that you find online from other NHS
Trusts vary in their quality: some lack references, others are missing authors
and publication dates. Those that do include references often cite a paper
published in the BMJ several years ago.
The Parkinson's UK website signposts you to two different calculators (OPTIMAL and PDMedCalc).
You decide
to dismiss the opinions you find in several discussion forums as you can’t
assess their accuracy.
The patient was taking co-beneldopa
dispersible 25/100 QDS and ropinirole 2mg TDS.
OPTIMAL: suggests rotigotine 16mg/24 hour using patches.
PDMedCalc: recommends rotigotine 6mg/24 hour using patches.
OPTIMAL: suggests rotigotine 16mg/24 hour using patches.
PDMedCalc: recommends rotigotine 6mg/24 hour using patches.
The Parkinson's UK site acknowledges the potential for different dose conversions and you read further that there is a dose correction in PDMedCalc to avoid large doses of rotigotine patches. The site also advises that the calculators should be used consistently between prescribing staff working with the same patients. As you do not know the preferred calculator at your base Trust, you explain your findings with the doctor. On balance, together, you decide to go with a 10mg/24 hour dose of rotigotine for this evening.
If at any stage you had felt out of your depth with this question you could have phoned a more senior pharmacist for advice: maybe a neurology, elderly care, or MI pharmacist. If not confident about your answer, you could also have asked Dr Kotecha if the answer could wait until the next working day for you to discuss with a colleague if clinically appropriate.
Follow up
The next morning you document your recommendation and speak to the pharmacist looking after the patient. She has already seen the patient on the ward round this morning and actually advised that the medical team switch to a 12mg/24 hour regime. Locally your Trust follows the OPTIMAL calculator which suggested a 16mg/24 hour dose, but this patient has dementia and so a lower dose is recommended. They will titrate the dose as necessary according to the patient’s response.Maybe this scenario makes you think you could do with a 'refresher' on solving these kind of problems. If so, then you might want to look at the Administration tutorial.