Hyperemesis Gravidarum (HG) is the number one cause of hospital admissions in early pregnancy. Most people have experienced the process of going to see a doctor in an emergency room, which becomes far too familiar for HG patients, but few patients know what happens behind the scenes, specifically in the pharmacy. For that reason, I decided to share a recent day at work, as my hospital often has a pregnant woman in the ER for dehydration. Given what I know of HG women, the more information the better.
I have experience as both a retail and a hospital pharmacist. One thing I love about working in a hospital pharmacy is the access we have to patient information, opposed to retail pharmacy where we are flying blind as to how the patient’s body is functioning. We look at why the patient is in the hospital, lab values including liver function, kidney functions, blood cells counts, height, weights, other medications and over-the-counter (otc) products being taken and other disease states, and so much more. We use this information to determine if the medication the doctor prescribed is safe for the patient and in turn adjust the dose and duration as needed for best patient care. If we need more information or want to make a recommendation, we can contact the doctor right away. Once the medication order is verified, a pharmacy technician makes the medication, gets it checked by the pharmacist and then delivers it to the patient, where a nurse administers it.
When I have a question about why a medication is being ordered, I start by looking at the doctor’s notes. One day the notes I read on a patient said:
- “13 weeks pregnant, reports vomiting since three days ago
- Having pregnancy induced hyperemesis
- Exacerbating factors include eating and drinking
- Relieving factors: none
- Risk factors: pregnancy
- Associated symptoms: abdominal pain
- Plan: Diphenhydramine 50 mg one PO QHS, Zofran 8 mg IV Q8H PRN, Pantoprazole 40 mg, potassium, promethazine suppository, pyridoxine tabs 50 mg one PO BID, NS plus folic acid plus thiamin plus multivitamin, NS plus KCL 20 mEq, K+ in SWFI.”
I suddenly had flashbacks to when I was in the hospital with HG
I suddenly had flashbacks to when I was in the hospital with HG, long before I became a pharmacist, because I’m certain that’s what my chart said. My heart went out to this pregnant woman in our ER, getting her IV in place, and I wanted her to know she’s not alone, to stay positive, that she will get through this and there are support groups available to her. At that moment, however, I was verifying the doctor’s medication orders* in the inpatient pharmacy near where the IVs are made and the orders are filled, far from the emergency room. Since my queue was full of patients waiting on a pharmacist’s approval for their medications, going to visit her in the ER was not possible.
Shortly after verifying our pregnant woman’s medication orders, ensuring the five rights of medication safety** and checking they are safe for her to take based on her body’s functions, I answered the phone and was asked by the ER doctor if it is safer and more effective to give pantoprazole or famotidine. I was simultaneously stunned and grateful – surprised that a doctor wouldn’t know the answer, and grateful that there’s always a pharmacist available to answer these questions. It then occurred to me that ER doctors are experts and well trained in handling emergencies with tested medication strategies, yet when it comes to medications and pregnancy, few would be trained know what’s safe or more effective off the top of their head. Even with the fact that there is often a pregnant woman in the ER being treated for dehydration, confusion lies in treatment because, as far as I know, there are no consistent HG guidelines taught in medical school.
A pregnant woman who is dehydrated due to vomiting almost always enters the hospital by way of the emergency room, even though this is not considered an immediate life-threatening emergency. The ER doctor will then determine if the patient should be admitted into the hospital for additional treatment or be discharged home. Although the HER Foundation created a medication algorithm to follow and American College of Obstetricians and Gynecologists (ACOG) has HG recommendations, doctors specializing in emergency care are likely not trained in these guidelines. Additionally, there are other factors that determine which medications the doctor chooses to treat the patient including individualized training, insurance requirements or hospital formularies. Of these three variables, the hospital’s medication formulary has the strongest influence on medication choice.
Each pharmacy in a hospital has a formulary. The hospital formulary is what medications are available for use. While it is possible to get a rare or expensive medication that is not on the formulary for a patient, for the common ones we usually keep one medication for each drug class. For example, our formulary includes pantoprazole, so if a patient comes in who takes omeprazole at home, we have permission to change it to pantoprazole. We call this a therapeutic interchange or auto substitution. Another reason a doctor might not follow a standard protocol has to do with the patient’s allergies or the patient’s insurance plan. Once a patient is admitted into the hospital a case manager will coordinate with the patient’s insurance to use medications that their insurance will cover or get them to cover what is on our formulary. Insurances have their own formularies. These even differ by plan within the same insurance company. Since I have never worked for an insurance company, I only have an idea what determines which medications are accepted. Unlike the hospital where a medication is either on formulary or not, meaning we either carry it or we do not, insurances have three different levels called tiers. Tier 1 medications have the lowest copay, then tier 2 in the middle, with tier 3 having the highest patient costs. All other medications are considered non-formulary. These either have very high co-pays or are not covered at all. Since many doctors work at multiple hospitals and there are hundreds of insurance plans, it would be impossible for the physician to know which medications are preferred and available.
The probable reason this ER doctor did not know which medication is the better choice is because there is no right answer. While pantoprazole or famotidine are different classes of medications and work through a different pathway in the body, in the end they both result in less stomach acid therefore easing the patient’s pain and suffering. Additionally, both medications have the same pregnancy safety rating. The ultimate decision will then be based on our hospital’s formulary. We carry pantoprazole in IV form while famotidine is an oral tablet, so in this case pantoprazole was the better choice because the patient was not able to keep down any oral medications.
Going back to our HG patient in the ER, the doctor treated her with IV fluids with vitamins, diphenhydramine, zofran and pantoprazole, and she was discharged later that afternoon. While I didn’t get to speak to her, my hope for her is that she went home feeling better and her nausea and vomiting did not last much longer. Most importantly, I hope she was discharged with both outpatient anti-nausea medications and information about her disease state.
For pregnant women where nausea and vomiting continues throughout the pregnancy, that scene of being in an ER is all too familiar. If you’re not one of the lucky ones to be discharged home and are instead admitted to stay in the hospital, your selection of medications continue down the HER Foundation’s treatment algorithm. So know if you are admitted, there is at least one, if not many more, pharmacists working behind the scenes to ensure your safety and quick recovery.
Share your medication questions or hospital experiences with me at info@hgpharmacist.com.
Additional Notes:
*In the hospital we call the medication information orders, because the doctor literally orders the medication for the patient, unlike retail where prescriptions are brought into the store or sent electronically.
**right patient, right drug, right dose, right route, right time
My hospital now has specific shifts where a pharmacist works directly in the ER, and many larger hospitals always have a pharmacist in the ER, but this varies by hospital size and shift.
Ever wondered how the medication that the doctor ordered gets to you?
Each hospital may have a different system depending on size and specialty, but here is the process where I work:
- The doctor orders medication through a computer system
- The pharmacist approves, denies or adjusts the medication order as necessary. Once approved,
- A pharmacy technician fills the order by either compounding an IV in a sterile room or getting the medication from the shelf, safe or refrigerator
- The medications are then verified by the pharmacist to ensure it is the correct medication, for the correct patient, not expired along with many additional safety checks
- These are then delivered to the patient in the ER by a technician by either bringing it to the patient’s nurse, being sent through a tubing systemi or being pulled from a robot-style machine called a Pyxis by the nurse. *Pyxis machines are loaded with commonly used medications by the pharmacy technicians
Since the nurse is the practitioner who delivers the patient medications and who has direct communication to the patient, the pharmacist rarely gets to discuss the medications and disease states with the patient. Other than some rare situations, we have to hope that the medications and risks involved are explained clearly by the doctors, nurses and then possibly in an outpatient setting when the patient is picking up medications from a retail pharmacy to take at home.
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