Best Practice #2 FAQ
Best Practice #2:
a) Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered.
b) Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders.
c) Provide specific patient and/or family education for all oral methotrexate discharge orders.
1. Question: Does the Best Practice of a weekly frequency default for oral methotrexate apply to a specialty cancer hospital?
Answer: The intent of this Best Practice is to reduce errors when methotrexate is prescribed as a weekly regimen for non-oncologic or oncologic indications. Even when used for oncologic purposes, oral methotrexate is sometimes prescribed as a weekly regimen, not daily. Thus, this Best Practice applies to all patient care settings, including specialty cancer hospitals
2. Question: We want to put a safety mechanism in place to prevent "Daily" as a frequency for oral methotrexate. We have a weekly regimen default and an alert in place when the medication is ordered to remind the provider to not use "daily" but the Best Practice 2b requires a "hard stop" which prevents the provider from ordering it, unless an oncologic indication is chosen. We are not aware of any way to restrict a provider from ordering a medication with a specific frequency. Have you found a way to address this requirement?
Answer: One solution would be to remove the daily frequency as one of the available choices for the prescriber to select for all methotrexate oral products. This recommendation would require the prescriber to contact the pharmacy if the medication is needed at a frequency other than one of the available choices (e.g., daily for oncologic use).
3. Question: We have been unsuccessful in implementing this Best Practice in our hospital-based retail pharmacies because many of the prescriptions are generated by outside e-prescribing systems that we have no control over, so we cannot impact the dosage regimen default or implement a prescribing hard stop for these systems. What do you recommend?
Answer: This Best Practice was designed for hospital inpatient and outpatient systems with computerized prescriber order entry (CPOE). We realize that this can be a challenge for retail pharmacies, who accept prescriptions from outside their CPOE system. For printed and faxed prescriptions that must be entered by the pharmacy or are received electronically from an outside prescriber, we believe that the weekly regimen default and hard stop verification should be implemented in the pharmacy computer system. This would require the pharmacist to clarify all daily orders for methotrexate if the patient does not have a documented oncologic diagnosis. If your pharmacy system cannot accommodate a “hard stop”, then an alert to the pharmacist to clarify the order would be next best option. However, there are additional safeguards that you can implement.
In addition to alerting the pharmacist to clarify all daily orders for oral methotrexate if the patient does not have a documented oncologic diagnosis, the alert should also inform the pharmacist that patient counseling is mandatory for this drug.
Ensure that patient counseling includes clear written instructions AND clear verbal instructions that specifically reviews the dosing schedule, emphasize the danger with taking extra doses, and specify that the medication should not be taken “as needed” for symptom control.
Require the patient to repeat back the instructions to validate that the patient understands the dosing schedule and toxicities of the medication if taken more frequently than prescribed.
Provide all patients with a copy of the ISMP high-alert medication consumer leaflet on oral methotrexate (available at no charge here.)
Conduct a periodic audit of all daily orders for methotrexate dispensed to ensure that clarification was received or the patient has an oncologic diagnosis.