Originally posted on Reddit by u/grapejewz

Clinical pharmacist here. Was reviewing a patient’s chart this week and saw that the patient was recently diagnosed with AFib. Patient is on HD. Of fucking course a CRNP was “managing” the patient. I got an order for Eliquis 5 mg PO Q12.

So I message the “provider” asking if they wanted to decrease to 2.5 mg BID PO Q12 since patients getting Eliquis for stroke that are on HD and treated with 2.5 mg of Eliquis have similar drug levels compared to those with preserved renal function and are being treated with 5 mg. CRNP goes “but the Eliquis is for AFib” and I asked well aren’t you anti-coagulating the patient patient to prevent a stroke and the CRNP goes “no, it’s for rate control.”

Any time I get orders from mid-levels, I always look into them so carefully. CRNPs don’t understand that if a drug is renally cleared, and CrCl goes down, then drug level goes up. So annoying how much time I spend fixing their mistakes.

It doesn't take very long at all for medical students to become acquainted with the inner workings of anticoagulants, or as they're more colliqualiy known, blood thinners. From novel oral anticoagulants (NOACs) such as apixaban (Eliquis) and rivaroxaban (Xarelto), to heparin and warfarin, by the time the USMLE Step 1 rolls around, most successful medical students will have had the mechanisms of action for these agents nailed down in addition to the coagulation cascade and the alphabet soup of PT, PTT, and INR beaten into their skulls hard enough to cause an intracranial hemorrhage. And don't even get us started on the basic diagnosis and management of a medical condition as common as atrial fibrillation.

It's truly astounding, then, that a midlevel nurse practitioner such as the one described above, can't even clear the numbskull-level hurdle of recognizing what Eliquis does. It's certainly not for rate control, because it's a fucking blood thinner! Hell, a 70-year-old senior citizen in their lucid period after suffering an epidural hemorrhage could probably have told you that! How exactly does she think that a blood thinner would control the heart rate? Clearly, the heart doesn't have to work as hard if the blood isn't as thick and goopy /s. And of course this imbecilic midlevel isn't familiar with the renal dosing for the drug - why would she/he, when clearly, they don't have any fucking clue why they're even giving the drug?

As we've previously covered in our exposés on the curriculums of various NP degree programs, most NP students get little more than a class or two of "pharmacology". If this particular tale is any indication, certainly NPs aren't learning much else during their 500 or so hours of clinical "training" (other than learning how to prescribe a Z-Pak and steroids). By contrast, during their time in medical school, medical students will have been extensively taught pharmacology during block- or year-long pharmacology courses, and have this knowledge repeatedly tested and reinforced on board and shelf exams as well as structured clinical rotations in core fields such as internal medicine / family medicine / emergency medicine. Kudos to this pharmacist for watching midlevels' orders like a hawk - transgressions like these are exactly why it can be outright dangerous for midlevels to practice without tight, constant, physician supervision.