I worry. I worry too much. But when Chief Pharmacists come out with stuff like what I quote below, I realise that my worries are, unfortunately, well-founded.
(This is just an extract of the document - the full document is readily available from the link.)
West Suffolk NHS Foundation Trust
Trust Policy and Procedure
Substitution of Medicines Policy Document ref. no: PP(15)210
For use in: All clinical areas
For use by: Pharmacists and authorised Pharmacy Technicians
For use for: For use in ensuring that Trust prescribing meets the medicines management agenda of the Trust in an efficient manner
Document owner: Chief Pharmacist
Status: Approved
4. Rationalisation of Time of Administration of Other Medication
A change of timing of administration of the following products to achieve more rational drug therapy:-
Levothyroxine – Change of time of administration to before breakfast
They are telling all pharmacists and pharmacy technicians to change the timing of levothyroxine doses on the basis of achieving more rational drug therapy. Trouble is:
No recognition that "before breakfast" means any of a rainbow of possibilities from four hours before, to two minutes before.
Implicit assumption that the only other timing possibility is "after breakfast".
No recognition of the possibility that this change will conflict with other medicines.
(The document also suggests changing timing of iron to avoid quinolone.)
No recognition that changes of timing can result in change of biochemical impact and the possibility of a change of dose being required.
Frankly, no recognition that this sort of change needs to be explained - at least to the people who are charged with implementing it!
I'll stop there, but there are surely other points also to be made...
Written by
helvella
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I think - but I may be wrong - this is just about pharmacy staff being able to amend a in-patient drug chart rather than having to wait for a doctor to do it. So for example, in the circumstance where the doctor has put levothyroxine on the chart for 8am when breakfast is served at 8am - this allows the pharmacist to write on the chart that it's to be given at 6am, for example. Or, shock horror, so that it can be handed in one of those little cups to the patient at the time the patient tells the pharmacist they normally take it (which after all might be last thing at night).
Or, for example, where antibiotics have been written up to be given 6 hourly - but so that the patient gets a good night's sleep, the last dose of the evening can be given earlier (or the first dose of the next day a little later).
I agree this has been written up in a strangely simplistic way but the examples given are just suggestions rather than fixed recommendations. I think the slightly more troubling thing is that a document like this has to be written so that staff can legitimately use their common sense!
Sadly, anyone who's been in hospital recently will know that no matter what it says on your drug chart, the chances of you receiving said drugs at the timings on it are actually quite remote...
Here I think in my opinion is that thyroid patients who are dosing with Levothyroxine need to see which way works best for them in particular . Some might find that taking it away from food AM or PM might just works very well for them . And some patients who are more sensitive will find taking it with snake AM or PM works just great for them . As long as it's consistent there should not be any problems . Running labs will tell you if you dose with snake if you need an increase or not . It should be left up to the patients how they feel most comfortable to dose . Nutrients must still be four hours at least apart from thyroid meds .
In hospital, with all the other issues such as feeling unwell, different foods, other interventions, I suspect consistency with usual daily life is much more difficult to achieve.
Quite possibly it is backing chart changes in a hospital context.
I can't see it endorsing the "take it when you usually do" approach - it could so easily have said that. Or said nothing. It is an explicit instruction to shift time of dose - I cannot read it any other way, I'm afraid.
Completely agree it is troubling this needed to be written at all. I'd have zero confidence in something adjusting my levothyroxine taking who actually needed to be told! And, if they need to be told, my comments about the other issues would also be needed, I fear.
One French hospital I was in, my levo was served with my breakfast - breakfast was a large bowl of milky coffee! When I suggested to the nurse that it should be taken an hour before breakfast, she had fifty fits and a litter of kittens! Shouted at me that... well, I don't really know what. But, I think she disagreed. Thank god I was only in there for three nights!
Bahahaha, I love french nurses too. Having been given 1000mg of paracetamol 5 times /day, complaining about stomac ache, I was told that paracetamol had no side effects whatsoever!
She was barely 25 !
On another occation, having been on Tramadol for a week or two ,
in hospital recovery unite, without getting to see a doctor for 2 weeks, I did dare to downgrade, I was caught with Codolipran, (Paracetamol with some codein in it ).And treated like a criminal. For not having had the perscription changed.
I was accused with going behind their back, by being careful. (Codolipran beeing an over the counter here.)
What I would like to see is the day when the patient themselves are going to be trusted to administer their own meds according to their own schedule rather than that of a drugs trolley's... After all, nobody supervises us at home do they? We are BIG people, quite capable of administering our own treatment. 9.9 times out of 10 the hospitals get it totally wrong anyway!
Good points. It really is neglectful that there is no rationale for this information. Also wrong as those with a high cortisol spike in the morning and lower in the evening will do better and convert better if taken at night. Grrr
We need Diogenes to be put in charge of all pharmacists, GPs and endocrinologists, supported by a team of suitably informed people from this website. This silly situation could be sorted out over night!!!
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