the potential for liver injury is already required on the label for OTC products containing acetaminophen. The FDA is continuing to evaluate ways to reduce the risk of acetaminophen‐related liver injury from OTC products.April 2009: onabotulinumtoxinA (marketed as Botox®/Botox Cosmetic®) and rimabotulinumtoxinB (marketed as Myobloc®) have the possibility of experiencing potentially life‐threatening distant spread of toxin effect from the injection site after local injection to produce symptoms consistent with botulism. Symptoms such as unexpected loss of strength or muscle weakness, hoarseness or trouble talking (dysphonia), trouble saying words clearly (dysarthria), loss of bladder control, trouble breathing, trouble swallowing, double vision, blurred vision, and drooping eyelids may occur. The other botulinum toxin product in this class, abobotulinumtoxinA (marketed as Dysport®), was approved on April 29, 2009 and included the Boxed Warning.July 2008: fluoroquinolone antibiotics (ciprofloxacin [Cipro®], levofloxacin [Levaquin®]) have an increased risk of tendonitis and tendon rupture that could cause permanent injury. This risk is further increased in patients over 60 years of age, in patients taking corticosteroid drugs, and in those with kidney, heart or lung transplants.November 2005: Clostridium difficile‐associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including clindamycin HCL, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile. C. difficile produces toxins A and B, which contribute to the development of CDAD. Hypertoxin‐producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotics or surgical intervention may be required.April 2005: the FDA concluded that the benefits of Celebrex® outweigh the potential risks in properly selected and informed patients. Accordingly, the FDA allowed Celebrex to remain on the market and asked the manufacturer Pfizer to take the actions listed below. According to the FDA requirements, the Celebrex label must:include a Boxed Warning containing the class NSAID warnings and contraindication (see below) about cardiovascular (CV) and gastrointestinal (GI) risk, plus specific information on the controlled clinical trial data that demonstrate an increased risk of adverse CV events for celecoxib (Messerli and Sichrovsky 2005)encourage prescribers to discuss with patients the potential benefits and risks of Celebrex and other treatment options before a decision is made to use Celebrexencourage practitioners to use the lowest effective dose for the shortest duration consistent with individual patient treatment goals.April 2005: the FDA asked manufacturers of all OTC products containing ibuprofen (Motrin, Advil®, Ibu‐Tab 200®, Medipren®, Cap‐Profen®, Tab‐Profen®, Profen®, Ibuprohm®), naproxen (Aleve®), and ketoprofen (Orudis®, Actron®) to revise their labeling to include more specific information about the potential CV and GI risks and instructions about which patients should seek the advice of a physician before using these drugs.July 2001: warning about the abuse potential of OxyContin, a Schedule II controlled substance.59 Q. How do I write for a prescription for doxycycline?
60 A. See Figure 2.1.Interpretation of prescription: the salt form of doxycycline is hyclate or monohydrate. Doxycycline monohydrate is used in the treatment of acne. Doxycycline hyclate is used for other bacterial infections. So it is necessary to identify the correct salt form. Also, in order to write a prescription, it must be known whether to write for capsules or tablets. Doxycycline is supplied as 50, 75, and 100 mg capsules or tablets. In this prescription, the prescriber prescribed capsules. Latin abbreviations were used but they were written legibly. It is probably safest not to use Latin abbreviations but rather write the prescription in English. The number of days the patient should take the medication for was indicated (× 10 days; the × refers to “for”). Also, it is important for the safety of the patient to write on the prescription “for dental infections” because the patient may be taking many different medications and may have a lot of pill containers in the medicine cabinet. Identifying this prescription bottle for use for a dental infection will make it easier for the patient to pick up that container. Directions for use (Sig:): Take one capsule orally every 12 hours on day 1, then one capsule every day for 10 days for dental infections.
2.5 How to Avoid Prescription Errors
1 Q. How can I prevent medication errors when writing a prescription?
2 A. If your handwriting is poor, consider faxing or e‐prescribing. Also, many drug names are very similar. To avoid misinterpretation, names should be written clearly and the use of abbreviations should be avoided. Also, before sending, review the prescription and make sure the drug, strength, and directions are correct.
3 Q. What else can I do to avoid prescribing errors?
4 A. Always interview your patient thoroughly about allergies. For example, a patient with asthma who is allergic to aspirin may experience an acute bronchospasm after taking an NSAID such as ibuprofen (Advil, Nuprin®) or naproxen sodium (Aleve). In adults, this reaction is called Samter's triad and it is a condition consisting of asthma, nonallergic aspirin sensitivity, and nasal polyps. Recently, a fourth symptom has been added, hyperplastic sinusitis, and instead of Samter's triad, it can also be called aspirin‐exacerbated respiratory disease. This occurs because NSAIDs block the production of prostaglandins and leukotrienes, which are chemical substances involved in the inflammatory response resulting in severe allergy‐like symptoms. It is best to avoid aspirin and NSAIDs in asthmatics.Figure 2.1 How a prescription for doxycycline is written.Another example: clindamycin is prescribed to a patient who is allergic to penicillin. A review of the patient's history confirms she has a history of ulcerative colitis. Clindamycin is contraindicated in an individual with a history of ulcerative colitis. An alternative would be azithromycin (Zithromax®). Refer to Chapter 4.
5 Q. Can there be errors when writing decimal points and zeros on a prescription?
6 A. Yes. To avoid prescription misinterpretations, avoid unnecessary decimal points. For example, when writing for 5 mL of a suspension or solution, it should be written as 5 mL not 5.0 mL because the 5.0 could be understood as 50. Also, always place a zero before quantities. For example, write 0.25 mg and not .25 mg because this could be misinterpreted as 25 mg.
7 Q. Should I review the prescription with the patient?
8 A. Definitely. The dentist should go over the medication and how to take it, including the number, frequency, and with meals or on an empty stomach. Also, make sure the patient is not allergic to the medication. Don't just review the medical history in the chart. You must ask the patient if he/she is allergic. If the patient confirms allergy, ask what happened when that drug was taken. Ask if there was a rash or difficulty breathing or just gastrointestinal upset (diarrhea). Document in the chart that you reviewed how to take the medication with the patient, whether history of allergies was denied, and if the patient had or did not have any questions and that they understood everything.
9 Q. Is it OK to use the Latin abbreviations on how to take the medicine?
10 A. Yes, but it is not advised because misinterpretation of abbreviations is a common source of error. Overdoses have occurred when “qd” used for every day was interpreted as “qid,” four times a day. It is recommended not to abbreviate and to write out all instructions in English and avoid Latin abbreviations.
11 Q. Is it acceptable to write abbreviations of drugs?
12 A. No. The full name should be written legibly. For instance,
