Homa Woodrum, over at her blog ohmadeeness, recently posted that numerous people are receiving short dated Epipen® and Auvi-Q®. Short dating refers to an expiration date that will expire relatively soon. Getting a short dated medication is not always a negative experience since most medications will be consumed or otherwise used within 30 to 90 days. However, as needed, or PRN medications, should not be dispensed if short dated unless absolutely necessary such as in the event of a long-term manufacturer back order, emergency event, or if the patient absolutely needs the product immediately and cannot wait for an order to be placed. PRN medications include epinephrine, albuterol rescue inhalers, nitroglycerin, and others
Homa’s post addresses the issue of what to do if you have already purchased the short dated epinephrine. Her post also provides manufacturer numbers to obtain reimbursement. I have also provided contact numbers for each manufacturer in my Epinephrine Auto-Injector Comparison Chart. But better than dealing with the aftermath is avoiding purchasing a short dated epinephrine; I am going to outline strategies for you and the pharmacy on keeping short dated Epinephrine Auto-Injectors (EAIs) out of your hands at all.
How can a patient/parent handle a short dated EAI situation?
Try to remember to check the expiration date before leaving the pharmacy, preferably before you pay for the medication. Simply do not purchase the product unless absolutely necessary.
There are a few options in this instance:
1. Review at Drop-Off. One way to avoid short dated product is by having the pharmacy staff check the expiration date when the prescription is dropped off. This helps you avoid an unnecessary wait (if the expiration date is not acceptable) and it helps the pharmacy not fill medication that won’t be picked up. Win-Win. Plus, if the pharmacy is not crazy busy, the pharmacy staff may call other pharmacies to check on stock and expiration dates for you. Calling another pharmacy is not part of the pharmacy staff’s job, per se, but we do provide this service often, especially when asked nicely.
2. Call ahead. (I highly recommend this.) Call the pharmacy and ask them to review the expiration dates of the on-hand product. If the date is not satisfactory, do not take the prescription to that pharmacy. If your primary pharmacy does not have the product or a product with at least a year good dating, then call other local pharmacies to check their stock. Hopping from pharmacy to pharmacy in general is a bad idea, especially for people with food allergies or patients on multiple medications, but this would be one instance where it would be okay to use a pharmacy other than your home pharmacy.
3. Have the pharmacy order another box. Typically, retail pharmacies can order a product to be delivered overnight Sunday-Thursday (the orders are delivered Monday through Friday for most pharmacies). If the situation arises over a weekend or holiday, you may have to wait until the next business day for the pharmacy’s supplier. Pharmacy suppliers such as Cardinal Health and McKesson have different hours and holidays than the pharmacy; your pharmacy may be open but the supplier may not.
What if the pharmacist says she has no control over the expiration date of the medication delivered?
This statement is true. Pharmacists cannot request (or demand) specific expiration dates. However, the pharmacist can return a short dated product immediately upon delivery; I have had experience doing this with Cardinal Health. Another package can be ordered, but again, the pharmacist will not know the expiration date before it arrives.
Why would the pharmacist even fill a short dated EAI?
Pharmacies pull outdated medication frequently. Some pharmacies pull on a monthly basis, pulling all the medications that will expire the next month (i.e. anything that will expire in August is removed by the end of July), other pharmacies pull three months at a time. Additionally, technicians should be screening expiration dates at the filling/counting stage. Pharmacies have built-in redundancy, another layer of safety; this is one example. For that reason, the pharmacist may not look at the expiration date as the medication is being verified.
Overall, I believe this is a training issue. Pharmacists know that patients should be using EAIs infrequently (hopefully) and, based on that knowledge, pharmacists know that EAIs should have long expiration dates. What pharmacists may not know is that they can return a short dated product delivered by a supplier.
It’s my opinion that pharmacists should always check the expiration date on EAI at the verification stage. If the product has less than one year good dating the patient should be contacted to see how the staff should proceed.
In the pharmacy, several actions can take place to prevent short dated EAIs from being dispensed.
1. Patient profile note. The pharmacy staff can add a note into the patient’s profile stating that EAIs must have one year good dating. Most retail pharmacies have some mechanism for adding patient notes and patient requests into the system.
2. Signage. (Old school but potentially very effective.)The pharmacy staff could place a sign near the shelf location of the epinephrine reminding staff to review expiration dates and return any product that is received short dated. Short dated product that cannot be returned could be stickered, or otherwise tagged, in order to alert staff of the potential problem.
3. Training. The pharmacy can focus on training by reinforcing examination of EAI expiration dates at the various stages of the filling process: when pulled from shelf, when filled by the technician, and finally when verified by the pharmacist.
4. Technology. At this point, I would settle for a prompt at the verification stage reminding the pharmacist to review the expiration date, making sure it was at least one year from the dispensing date. A hard stop mechanism requiring the manual addition of the expiration date could be another solution.
There is pharmacy technology already utilized that scans and processes the UPC codes located on each manufacturer bottle/box. The scanning process verifies that the correct medication has been selected. Ultimately, I would love to see the expiration dates and lot numbers automatically logged via the UPC scan. The data collected would help screen expiration dates but also it would aid the pharmacist in the event of mass recalls (which happen quite frequently at varying levels of severity).
Of course, number four is the most difficult action in that it would require the IT department of a corporation to become involved.