Need advice on issue with compounded med

[jcc813]

Has anyone dealt with a situation where a compounded medicine didn’t have the correct amount of doses?

I purchased misoprostol from my vet which was supposed to be 60 doses. The container was out after only 40. The barn worker was giving it to my horse but I had watched him do it several times and can attest that he was doing it correctly. (If some had spilled or he was giving more than needed, I wouldn’t have expected being exactly 20 doses short).

I got a new container from the vet and this time weighed the contents. This one only had 45 doses. When I notified the vet’s office and shared photos of the scale, their response was “Sorry you feel this way. We trust our pharmacy. We can price out ordering tablets instead” (the tablets btw would cost over $1300, 13x as much as the powder).

Am I wrong to be annoyed by this? These aren’t “feelings”–these are facts. The label says 60 doses–that’s not what I’ve been getting.

This is a vet that I only recently started working with but in the past month, I’ve spent nearly $4000 on vet bills between 3 horses (which I’ve paid promptly with every invoice I might add), so I’m a little miffed to say the least that they wouldn’t try to remedy this situation by either giving me a partial refund for the first batch or reduced price on a new one.

I checked with another client who’s also on miso from the same vet and her container appears to have more than 60 doses so there definitely seems to be some variance.

Anyone else been in this situation?

[If_husband_asks_horses_are_fre]

Are you paying by the dose or by volume? If paying by the ml/oz you should be getting billed and delivered the same volume. I’d check your invoice, and also confirm that the compounding company had the strength correct. A higher concentration could result in a smaller ‘dose’ with a lower volume for the same price as a lower concentration but bigger dose, if that makes sense. You can also ask for a written prescription and source the medication yourself. Your vet is allowed to charge a reasonable fee for writing the prescription (at least in my state they can) but it may pay off for you in the end if the compounding pharmacy is shorting you on a pricey medication.

[Simkie]

When you’ve weighed it, is the entire container short on weight, or is the entire container short on doses?

Like, the container says 500 grams but only weighs 450 grams?

Or the container says 60 doses but using the scoop it came with only contains 50?

If the latter, their scoop is probably slightly too large, or the powder has settled & compacted, so you’re able to fit more into the scoop. Which does suck, but you’re still getting the amount of drug you paid for.

[jcc813]

When you’ve weighed it, is the entire container short on weight, or is the entire container short on doses?

I did it all by weight. I weighed the full new container (131 g) then I subtracted the weight of the old container (41g) (they’re the same size/material–I just didn’t want to have to dump the powder out). Then I weighed 1 scoop (2g). Divided 90g by 2g = 45 scoops.

I made sure not to pack the powder–i just scooped and shook off the excess till it was close to level.

Directions are to give 1 scoop 2x/day for 30 days. Container says “60 doses.”

The only thing I recall noted on the container is 2.4mg/scoop, but I don’t think that could be referring to the weight b/c then it would be waay off.

I didn’t see a weight noted on the container, but I’ll double check again to make sure I didn’t miss something in the tiny print.

[Simkie]

“Close to level” isn’t level level.

Powder packs in shipping. The whole “contents settle in shipping, package is filled by weight” thing.

There’s no harm in calling the compounding pharmacy for their input, but I’d be very inclined to say you’re overdosing just a little because of settling. Go with a scant scoop instead of “close” to level.

[Bonnie2]

Compounding pharmacies vary widely in their reliability. I would have hoped the veterinarian would be more concerned about the issue. As the owner, I would also be concerned that the concentration of the medication in the carrier is correct - ie that there are 2.4mg of misoprostol in each scoop. Pills are always more accurate than powder although more trouble to feed. I don’t think you are being unreasonable!

[mmeqcenter]

@jcc813

The only thing I recall noted on the container is 2.4mg/scoop, but I don’t think that could be referring to the weight b/c then it would be waay off.

This is likely referring to amount of API per scoop, not entire product. API = Active Pharmaceutical Ingredient. Pharmaceuticals aren’t 100% of the substance you want, they’re mixed with excipients to create a dosage. You would need to know the % concentration by weight of the API to determine how much a “Scoop” is supposed to weigh. It sounds like the scoop is too big, but without knowing the concentration, can’t be sure.

@jcc813

I did it all by weight. I weighed the full new container (131 g) then I subtracted the weight of the old container (41g) (they’re the same size/material–I just didn’t want to have to dump the powder out).

Does the container provide a net weight on the label?

[jcc813]

Yeah the vet office said there’s only been one other time where a client thought their container looked less than normal but otherwise no issues have been reported.

But if everyone’s just going based off of a casual single scoop and the scoops are the same (and I guess apparently not necessarily accurate), wouldn’t they be hearing of more issues?

When I shared that the other client appears to have extra days’ worth of powder, the office said they reached out to the pharmacy and asked them to email what they do to ensure each jar has 60 scoops and will forward that to me.

[jcc813]

This is likely referring to amount of API per scoop, not entire product. API = Active Pharmaceutical Ingredient. Pharmaceuticals aren’t 100% of the substance you want, they’re mixed with excipients to create a dosage. You would need to know the % concentration by weight of the API to determine how much a “Scoop” is supposed to weigh. It sounds like the scoop is too big, but without knowing the concentration, can’t be sure.

Oh yes, that makes sense. Just got this note from the pharmacy:

"So, each container is weighed out to the correct measurement of each
ingredient before moving on to the next. We generally do these in
batches. So, let’s say we do a batch of 10 at 2.4mg/sc. We will weigh
out on the scale 2.4mg of miso powder and do that every time for all
10 jars. Then we move on to the flavoring for each jar. And then the
sugar.

I have a feeling the containers they are receiving are getting some
moisture in them (which is normal) and it is causing the powder to
pack down. I would suggest shaking it very well each time before use
in order to fluff it up. Then when they scoop it, make sure to scrape
the top (level it) before giving to the animal."

So that appears to align with what @Simkie said. But they didn’t clarify total weight to expect for each dose/the whole container.

[Simkie]

It would be interesting to see how full your scoop is at 1.5 g, both before and after “fluffing” the powder!

I do have compounded powder stuff that says to shake gently before scooping, just for this reason.

[Sarah616]

@jcc813

I got a new container from the vet and this time weighed the contents. This one only had 45 doses. When I notified the vet’s office and shared photos of the scale, their response was “Sorry you feel this way. We trust our pharmacy. We can price out ordering tablets instead” (the tablets btw would cost over $1300, 13x as much as the powder).

Where are you ordering from? When I order from Wedgewood, a bottle of 60 tabs is Misoprostol is $145. The tabs we have are 1400mcg/tab. Even if that dosage is lower than what you’re giving and you had to double the dose (two tabs twice a day, which some vets will recommend anyways for bad cases), you’re looking at $300 a month.

Also, when you shake the powder to loosen it up, be sure to let it settle before you open it! That dust will make you cough like crazy

[jcc813]

When I order from Wedgewood, a bottle of 60 tabs is Misoprostol is $145. The tabs we have are 1400mcg/tab. Even if that dosage is lower than what you’re giving and you had to double the dose (two tabs twice a day, which some vets will recommend anyways for bad cases), you’re looking at $300 a month.

Whaaa? My vet office said they normally give clients 9 bottles of 100 count tablets which would cost $1328! She didn’t mention the dosage or the pharmacy. I will ask…

[jcc813]

I asked if the pharmacy shared what the weight of the container or scoop should be given that they’re measuring out the active ingredient the adding the flavorings.

Her response was “They don’t go by that, if all the other weights are correct there is a chance every container is going to weigh a slightly different amount.”

I’m not sure I follow that. If they’re supposed to ensure the right concentration of active ingredient per scoop, doesn’t that mean

[Sarah616]

Well, ok, if they’re selling you 9 bottles at a time, you’re actually going to pay the same for the 100 count bottles than the 60 count. That’s about $147 a bottle for more tabs. How much are you paying for the powder? I can’t remember what we used to pay when we got the powder.

[mmeqcenter]

The label is required per FDA regulations to list the net weight. Have you looked at the label on the container

[jcc813]

The powder only cost $100 for 30 day supply.

Curious why the Rx would be so off though. So you’re only giving 2 1400mcg tabs/day? How bad were your horses ulcers?

[jcc813]

Is that the case even for compounded meds? I would have thought so, but I’m pretty sure I did not see any weight listed when I looked at the label before I weighed it.

I’m going to the barn today so will check again.

[Simkie]

@mmeqcenter

The label is required per FDA regulations to list the net weight. Have you looked at the label on the container

Is this true for meds dispensed from the vet, too?

I took a look at my powdered compounded stuff, and the misoprostil has a label from the vet rather than from the compounding pharmacy. There’s very little info, and no net weight. Really just drug name, dose per scoop, and # of scoops.

I have other stuff with the label from the compounding pharmacy, with everything you’d expect on a drug label.

Thought it was kinda curious tbh.

[mmeqcenter]

It’s been a few years since I was into pharma that deep, but a brief google search indicates that veterinary products maybe exempt.
That’s stupid.

[jcc813]

Yeah I double checked and there’s no weight. I also checked the compounded doxy powder I ordered from Chewy and there’s no weight on that either