Why?
Now don't get defensive, I'm sure you have your reasons, and I would honestly like to know what they are. I won't judge you. Think of this as like when a mistake happens in a hospital and the people investigating are more interested in finding out what went wrong than in assigning blame.
Because you made a stupid decision. And I mean that of course in a totally non-judgmental way.
It's diclofenac. I'm going to assume you know this, you're an educated professional and you fully understand diclofenac is one of maybe a dozen NSAIDS out there. Cambia is marketed to treat migraine headache, so the first thing you did when you wrote that prescription was decide that diclofenac was the most suitable option for treating your patient's migraines.
You'll see a bigger push to avoid ORAL diclofenac.
Think of it as a "three-strikes" NSAID.
Strike one...it increases the risk of cardiac events as much as rofecoxib (Vioxx) or high-dose celecoxib (Celebrex).
Strike two...it causes more liver toxicity than most NSAIDs.
Strike three...it causes more GI toxicity than celecoxib, etodolac, nabumetone, or meloxicam.
Recommend naproxen or ibuprofen if an oral NSAID is needed.
That came from the Pharmacists Letter. A totally non obscure newsletter mailed to pretty much everyone who knows anything about drugs in this country. There's references in the article if you're interested.
Remember what they said there about ibuprofen also. It'll come up again later.
But it's OK to go with the NSAID that competes for both the highest liver and GI toxicity in its class. There are exceptions to every rule, and there can and will be perfectly good reasons to prescribe diclofenac to certain patients.
Assuming you knew Cambia is simply a form of diclofenac. Nothing more, nothing less. And at 50 milligrams, it's a strength less than that of the strongest tablet.
Hit that migraine hard, doctor.
Here's the thing I really want to know though. The thing that separates Cambia from the diclofenac we all know and love is the dosage form. Cambia is a powder. It's powdered diclofenac. Like diclofenac tablets after you crush them with the back of a spoon. That's what the Cambia is. Pre-crushed diclofenac.
So pulling together what we know so far, when you prescribe Cambia, you have decided to use the NSAID with the highest toxicity profile and that it would be a clinical advantage to have the drug pre-crushed at the factory.
"Yes" I hear you saying, good doctor. "Because of a superior pharmacokinetic profile"
That's a fancy way of saying that a powder should get absorbed faster than a tablet, and while that is certainly intuitive, I'll point out that the makers of Cambia offer no actual proof of that when they would have every incentive to do exactly that should any proof exist.
I'll also point out the existence of liquid ibuprofen, a dosage form that should be the most rapidly absorbed of all, in a drug with fewer cardiac and hepatic side effects.
But you are nothing but a creature of science, right doctor? And your decision to use Cambia would have nothing to do with the fact that at $450 to $500 for nine doses, it just must be better 'cause it costs more than the diclofenac tablets you can find for less than $20. I won't insult you by suggesting that, or that a smokin' hot sales rep is playing you for a tool.
But it's just that, if I don't go with any of those ridiculous explanations, I'm not left with a whole lot, which is why I'm hoping you can help me.
Why did you write that prescription that made you look so stupid? Not that there's anything wrong with being stupid. Unless you're a doctor maybe. Doctors probably should be smart.
Which I guess means I really am judging you.
Dumbass.
