Listen to your patients to learn how you can best answer their prescription needs.
"We've come a long way baby" and "Miles to go before I sleep" both seem appropriate in describing optometrists' drug prescribing privileges. I can still vividly remember how panic stricken I was when I first prescribed sulfacetamide drops for a patient.
What will I do if all of that hogwash our professional opponents said during our legislative battles was actually true? Am I going to kill my patient? What if he takes two drops instead of one? I better call him every night just to make sure he doesn't go into anaphylactic shock.
Fortunately, the patient survived and his eye got better. I got better too.
Live and learn
Over the past 20 years, I've become significantly more confident in my diagnostic, therapeutic and prescribing abilities. Sometimes I act a little too confident, which my patients may misinterpret as uncaring. The cases below helped me return to my optometric roots and not just treat a pair of eyes but treat my pntient as well and as appropriately as possible.
* CASE 1: Two is cheaper than one. J.H., a 32-year-old, hard-working male construction laborer presented with a moderate bilateral conjunctivitis that had both allergic and bacterial inflammatory signs. After examining his eyes, I determined that he needed an antibiotic/steroid combination drop, prescribed dexamethasone 0.1%/tobramycin 0.3% (Tobradex), and sent him on his way knowing I had just given him the solution to his problem.
About 30 minutes later, I received a call from J.H. asking me if there was something less expensive he could use. He had no health insurance, no prescription card and was fighting just to make ends meet financially. The 5 ml bottle brand name antibiotic/steroid combination drop cost more than $70. Initially, I was a little offended that my patient would question my treatment. After quickly considering the situation, I realized that substituting generic tobramycin ($11) and generic prednisolone sodium phosphate ($16) would work just as well in this case. At the one week follow-up exam, J.H.'s eyes had cleared up and he was appreciative of my attempt to save him money.
* CASE 2: Three equals one. I was treating L.P., a 70-year-old female, for chronic open angle glaucoma with latanoprost 0.005% (Xalatan), one drop OU every night at bedtime. Her pressures were well controlled. I received a call from L.P. one day asking if I could change my prescription from a single bottle of latanoprost to a three pack, because her insurance copay would be the same - even for the larger quantity. I agreed and promised myself to remember this when working with my other glaucoma patients.
Because brand name latanoprost is only available in a 2.5 ml bottle, prescribing a three-pack versus one bottle will also keep L.P. from running to the pharmacy quite as often.
* CASE 3: Three equals one, but I like the side effects of one better. I was treating C.Z., a 58-year-old female, for glaucoma with timolol 0.5% q.d. OU, and latanoprost q.d., h.s. OU.
After two years of controlled IOPs, she asked if she could switch to Lumigan (bimatoprost 0.03%). Somewhat startled, I asked why. She answered "My sister has glaucoma and is taking Lumigan, and her eyelashes became beautifully thick. I want thicker eyelashes." I initially declined her request and told her that latanoprost should have a similar effect.
She persisted and, after several months of quibbling, I decided to give it a try and switched her to bimatoprost. Fortunately, her pressures remain controlled, and she thanks me for her thicker lashes. We didn't notice any other differences or side effects.
* CASE 4: Symptoms say allergy, but dry eye relief does the trick. G.E, a 27-year-old female computer programmer who suffers from seasonal allergies, entered my office complaining of itching and teary eyes. Pollen counts in our area were sky high at the time and I knew her diagnosis before looking at her. During her exam, I placed a drop of olopatadine HCl (Patanol) in each eye, which met with wonderful success. Her eyes felt better almost immediately.
All other findings supported allergic conjunctivitis, so I wrote her a prescription for olopatadine OU, b.i.d. She used her drops every day, but before going for her third refill, she called and asked if there was something else she could take: the 5 mL bottle of brand name olopatadine cost more than $80.
I had her come in for a follow-up exam, only to find that her eyes were dry and without any apparent signs of an allergic reaction, just symptoms. I switched from olopatadine to artificial tears q.i.d. and occasional cold compresses to suppress the itching. After two weeks, G.F. called and reported everything was going well. People with dry eyes are more prone to allergic reactions so it's important to differentiate the primary cause of the symptoms.
Show some consideration
We should always choose the best therapeutic agent to treat our patients. It's equally important to remain current in the concentrations, dosage and packaging of all ophthalmic medications, as well as how much they'll cost our patients (see charts on this page). I keep a spreadsheet comparing prices of the more commonly prescribed medications available at local pharmacies so I can advise my patients better. (For a sample of the author's spreadsheet in the online version of this article, visit www.optometric.com.)
I've heard again and again that I shouldn't let price be an issue with my patients, but sometimes I break that rule for their benefit. I'm always amazed at how much I continue to learn from my patients.
by Thomas P. Finley, O.D.
Dr. Finley has a group opromctry practice in Herndon, Va. He is a fellow of the American Academy of Optometry You can reach him at email@example.com.
Dr. Christensen has a partnership practice in Midwest C.'ity, Okla. He's a diplomate in the Cornea and Contact Lens Section of the American Academy of Optometry. He's also a member of National Academies of Practice.
Copyright Boucher Communications, Inc. Jul 2004
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