KB is an 18 yo female coming to your local pharmacy today with a new prescription for an oral contraceptive. She is requesting more information about her medication and is wondering if you could tell her what to do if she misses a dose.

PMH: N/A

Medications: Claritin 10 mg PO daily prn seasonal allergies

New Prescription:  Yaz one tablet by mouth daily

Which of the following answer choices are counseling points to discuss with KB? Select all that apply.

A. If you miss one light pink pill of your pack, skip the missed dose and continue with your normal dosing schedule.

B. If you miss 2 light pink pills in a row during weeks 1 or 2, take two pills the day you remember and 2 pills the next day.  Use a backup contraceptive method for 7 days.

C. If you miss any of the 4 white pills in week 4, use a backup contraceptive method for 7 days. 

D. If you miss one light pink pill of your pack, take it as soon as you remember even if this means taking two doses in one day. 

E. If you miss ≥3 light pink pills in a row, use a backup contraceptive method for 7 days.

Brand/Generics Covered: Yaz (drospirenone/ethinyl estradiol), Claritin (Loratadine)

Answers with rationale:

Questions regarding contraceptive options including oral contraceptives are a common part of pharmacy practice. Approximately 20 states have authorized pharmacists to prescribe hormonal contraception and this is expected to grow. Missed doses can cause significant anxiety with patients and possibly lead to decreased effectiveness and ultimately pregnancy. Each product differs in its recommendations for management of missed doses. Here are the correct answers with rationale for our patient.

Answer Choice A is incorrect, because it is not recommended to skip a missed dose of Yaz. It is actually recommended to take the missed dose as soon as the patient remembers. 

Answer Choice B is correct, because if a dose is missed two days in a row, it is best to take the missed doses. It is also important to counsel the patient that they could become pregnant within 7 days after restarting the pills and should use back up contraceptive methods for those days. 

Choice C is incorrect, because white pills are inactive within Yaz. Thus the patient does not need to use a backup contraceptive method and should continue to take the remainder of the white pills. Some oral contraceptive products, such as Lo Loestrin Fe, have both white tablets and brown tablets that are inactive as the brown tablets contain iron.

Choice D is correct, because it is recommended by the Yaz package insert to take the missed dose when remembered, even if it means taking two doses at once. There is also no need to use a backup contraceptive method if a patient misses only one light pink pill. 

Choice E is correct, because it is recommended to use back up contraceptive methods if a patient misses 3 or more doses in a row according to the package insert. There are also more recommendations based on whether the patient is a day 1 starter versus a Sunday starter. If the patient is a day 1 starter, they should throw out the rest of the pack and start a new pack the same day. If the patient is a Sunday starter, they should keep taking one pill every day until Sunday. Starting on Sunday, they should throw out the remainder of the pack and start a new pack the same day. Once the pills are restarted a patient should continue to use a back up contraceptive for 7 days. 

Correct Answers: B, D, E

NAPLEX Core Competencies covered: 2.2(Brand/Generic, physical descriptions), 1.2(From patients: treatment adherence, or medication-taking behavior), 5.5 (Instructions or techniques for drug administration)

Source: Yaz Package Insert → page 27 “What to do if you miss pills”

We are almost into April! Continue to work hard to prepare for the exam which for most of you will be in just a couple of short months!

I begin my live speaking tour this week so excited to help students across the country prepare for the exam. Look forward to meeting many of you in person.

Dr. B