Nitro-Levitra cocktail, anyone?


One pharmacist wonders how it is possible that during 2 shifts in a row last week, she encounters complete ignorance of the potentially deadly and needless combination of popular ED pills and nitrates.

We are lucky to be free Americans. Our corporations are also free - to produce direct-to-consumer advertising. Now my close friends and adult family members who don’t have any medical background can recite the following: “Do not take [Cialis/Levitra/Viagra] if you use nitrates for chest pain as this can cause an unsafe drop in blood pressure. Side effects may include…” and then they giggle about the description of priapism as a medical emergency.

There rests my case that any American who watches television is aware of this drug interaction.

So then … how is it that during 2 shifts in a row last week, I encountered complete ignorance of this potentially deadly and needless combination? I’m sure you’ve run across similar.

Scenario #1

I verify the Cialis. It goes to DUR check and comes right back with a red flag. There’s a sublingual nitroglycerin prescription that had been filled last month. The nitro is new; the Cialis is not.

Not a minute later, this particular patient approaches to see whether his medication is ready. I wrinkle my nose, since his urologist’s receptionist has just directed me to leave a message on a refill line; I don’t have a response from the doc yet. I have seen that the nitro was from his primary doc. It’s likely that neither doc is aware of the other’s prescription. This makes me glad that this patient chose to have his prescriptions filled at only one pharmacy. I get to help prevent a medication misadventure!

I explain to Mr. Patient that we’ve spotted a problem with his prescription and that I haven’t been able to reach his doctor yet. Of course he wants me to elaborate, as a line of people hover closely behind him. I explain the situation. He waves his hand at me as if I’d told him his pills would just be a slightly different color of beige this time.

“Oh, I know about that. I haven’t had any problems, so it’s fine. You can just fill it.” His jaw set, he gives me a superior nod.

For a moment I’m speechless. “Uh, I’m sorry, sir, but this is a potentially life-threatening drug interaction. I will need to speak with your doctor. There’s no way I can fill this prescription for you right now. We can give you a call when we hear back from your doctor.” Mr. Patient appears to concede and moves to leave the counter. I head back to my computer.

But wait! He’s suddenly back and he’s shouting at me, “THIS IS BULL*%@#!”

Surprising even myself, I spit back, “You think a drug interaction that has the potential to kill you is bull?” He says, “Yeah!” and then “I’m never using this pharmacy again!”

I make a mental note not to allow the Cialis to be transferred before we hear back from Mr. Patient's urologist while I take a deep breath. With uncontrived sincerity I say, “Well I’m really sorry you feel that way, sir.”

His urologist was glad we called. He had no knowledge of the concomitant nitro need. Rx discontinued.

Scenario #2

Days later, I call on a nitro-spray script left by a patient who uses Levitra. I leave a message with a nurse, who tells me that doctor is out of town but that he’s already aware of these 2 scripts and that they are okay for us to fill.

Oh my. The better part of my brain refuses to believe her.

“Doctor gave him samples and he did fine.” I do my best to stifle my laughter (what does she even mean by that?) and ask her to please run it by doc again when he checks in. A bit later, the doctor’s physician assistant calls me back. She tells me doctor just discharged this patient from the hospital yesterday for ACS. She calls in a different PPI that will be covered without a prior authorization. Referring to the nitro, she lets me know that “Doctor is aware of the potential drug interaction but feels the patient can use these medications together safely.”

I know that PA’s have only 2 years of medical training before they start practicing medicine, so her statement doesn’t shock me. I explain that this particular interaction is quite serious and that fatalities have occurred. I say, “I guess I’m really calling to ask if I can discontinue the Levitra, so that we can safely fill the nitro.” She picks up on my tone. “Well let’s fill the nitro then, since that’s more important. I guess he’ll just have to get his Levitra filled at another pharmacy.”

DING! DING! DING! Yes- the nitro IS more important, but in the same breath… WHAT?

Of course I could always document my failed intervention and fill the prescription. I tried, right? I could counsel the patient and document that too, right? Some pharmacists have done it. However I might choose to justify it, though, I’d be wrong. We’re in the business of helping people, and that brand of medicine helps no one. Not in the bedroom, not while holding hands sitting in his-and-hers bathtubs, not in the ER, and definitely not in the courtroom when you’re being stared down by a grieving wife or adult child between sobs.

I could go on, but I’m sure your own mental commentary is more interesting.

Nicole L. Ebisch, PharmD, CGP, FASCP, works for a large retail chain in addition to her MTM consulting company in Erie, Pa.

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