Refill Requests for Ambien (Zolpidem) and Voltaren Gel (Diclofenac)
What to Ask When Requesting Refills
Before authorizing refills for Ambien (zolpidem) or Voltaren gel (diclofenac), you must conduct a patient review rather than providing automatic repeat prescriptions, as both medications carry significant risks that require ongoing assessment. 1
Ambien (Zolpidem) Refill Assessment
Critical Safety Questions
Ask specifically about complex sleep behaviors, as these mandate immediate discontinuation:
- Has the patient experienced sleep-driving, sleep-walking, sleep-eating, making phone calls, or having sex while not fully awake? 2
- Any falls, injuries, or near-miss accidents since starting zolpidem? 1, 3
- Any suicidal thoughts or worsening depression? 3
- Any memory problems or next-day impairment affecting driving or work? 1, 2
Duration and Dependence Assessment
Evaluate treatment duration and effectiveness:
- How long has the patient been taking zolpidem? (FDA approval is for short-term use only) 2
- Is the patient requesting early refills or increasing doses on their own? (Suggests tolerance or dependence) 2
- Has the patient tried non-pharmacological approaches like cognitive behavioral therapy? 3
- Is the patient taking more than prescribed (>10mg/day for non-elderly, >5mg/day for elderly)? 4
Contraindications to Refill
Do NOT refill if:
- Patient reports any complex sleep behavior episodes 2
- Patient is combining with alcohol 2
- Patient is pregnant (especially third trimester due to neonatal respiratory depression risk) 2, 3
- Patient has respiratory conditions like sleep apnea, COPD, or asthma 4
Appropriate Refill Considerations
If refilling is appropriate:
- Limit refills to prevent automatic continuation 1
- Ensure dose is 5mg for women and elderly, 10mg for other adults 4
- Confirm patient takes it immediately before bed with 7-8 hours available for sleep 2
- Verify patient takes on empty stomach, not with or after meals 4
- Document that patient understands to avoid alcohol and other CNS depressants 4, 2
Voltaren Gel (Diclofenac) Refill Assessment
Cardiovascular Risk Evaluation
Diclofenac carries the highest cardiovascular risk among NSAIDs and requires careful assessment: 1
- Does the patient have cardiovascular disease or risk factors (hypertension, diabetes, hyperlipidemia, smoking)? 1
- Any history of myocardial infarction, stroke, or heart failure? 1
- Meta-analysis shows diclofenac increases vascular events (RR 1.63,95% CI 1.12-2.37) and recurrent MI (RR 1.54,95% CI 1.23-1.93) 1
- Registry data shows diclofenac increases mortality (RR 2.40,95% CI 2.09-2.80) 1
Gastrointestinal Risk Assessment
Ask about GI symptoms:
- Any abdominal pain, black stools, or signs of GI bleeding? 1
- History of peptic ulcer disease or GI bleeding? 1
- Is patient elderly? (Higher risk for serious GI events) 1
Application Site and Duration
Evaluate appropriateness of continued topical use:
- What body area is being treated? (Avoid poor healing sites like lower legs) 1
- How long has patient been using it? (Topical NSAIDs are for localized pain, not chronic systemic use) 1
- Is the pain improving or is this becoming chronic use without benefit? 1
- Typical application is 3 times daily for localized musculoskeletal pain 1
Contraindications to Refill
Do NOT refill if:
- Patient has active cardiovascular disease or recent MI 1
- Patient is scheduled for or recovering from CABG surgery 1
- Patient has active GI bleeding or ulcer disease 1
- Patient is applying to poor healing sites without supervision 1
Documentation Requirements
For both medications, document:
- Specific assessment of risks vs. benefits for continued use 1
- Patient's functional goals and whether they are being met 1
- Any adverse effects or concerning behaviors 1
- Plan for reassessment and potential discontinuation 1
- Discussion of non-pharmacological alternatives 1
A request for more medication should trigger a patient review, not an automated refill, especially when patients continue beyond expected healing periods or short-term use indications. 1