OSCE book 2010

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Qualifying Pharmacy Review

Pharmacy Prep OSCE Pharmacy Review

Contributors

Misbah Biabani, Ph.D Director, Tips Reviews Centres 5460 Yonge St. Suites 209 and 210 Toronto ON M2N 6K7, Canada

Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Qualifying Pharmacy Review Disclaimer

Your use and review of this information constitutes acceptance of the following terms and conditions: The information contained in the notes intended as an educational aid only. It is not intended as medical advice for individual conditions or treatment. It is not a substitute for a medical exam, nor does it replace the need for services provided by medical professionals. Talk to your doctor or pharmacist before taking any prescription or over the counter drugs (including any herbal medicines or supplements) or following any treatment or regimen. Only your doctor or pharmacist can provide you with advice on what is safe and effective for you. Pharmacy prep make no representation or warranty as to the accuracy, reliability, timeliness, usefulness or completeness of any of the information contained in the products. Additionally, Pharmacy prep do not assume any responsibility or risk for your use of the pharmacy preparation manuals or review classes. In our teaching strategies, we utilize lecture-discussion, small group discussion, demonstrations, audiovisuals, case studies, written projects, role play, gaming techniques, study guides, selected reading assignments, computer assisted instruction (CAI), and interactive video discs (IVD). Our preparation classes and books does not intended as substitute for the advise of NABPLEX®. Every effort has been made to ensure that the information provided herein is not directly or indirectly obtained from PEBC® previous exams or copyright material. These references are not intended to serve as content of exam nor should it be assumed that they are the source of previous examination questions. ©2000-2010 TIPS. All rights reserved. Foreword by Misbah Biabani, Ph.D Coordinator, Pharmacy Prep Toronto Institute of Pharmaceutical Sciences (TIPS) Inc 5460 Yonge St. Suites 209 and 210 Toronto ON M2N 6K7, Canada


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OSCE Pharmacy Review Content SECTION A: Communication Skills and Techniques                      

Chapter 1: Top 20 Rules of Communication in Exams Chapter 2: Counselling A New Prescription Chapter 3: Counselling on Refill Prescription Chapter 4: Counselling on Non Prescription Drugs Chapter 5: Counselling techniques: Questioning Chapter 6: Counselling techniques: Persuasion Chapter 7: Counselling techniques: Language Skills Chapter 8: Counselling techniques: Language for Instructions Dosage and Administration Chapter 9: Counselling techniques: Using written information effectively Chapter 10: Conducting Patient Interview: Symptom related questions Chapter 11: Counselling techniques: Counselling on lifestyles Chapter 12: Counselling techniques: Discussing alternative treatments Chapter 13: Assessing the potential for non compliance Chapter 14: Assessing the need for follow up Chapter 15: Counselling techniques: Assessing need for nutrition and supplements Chapter 16: Communication skills: Dealing with physician Chapter 17: Communication skills: Dealing with other Healthcare Professionals Chapter 18: Communication skills: Demonstrating devices Chapter 19: Communication Skills: Dealing Dispensing Errors Chapter 20: Communication Skills: Managing Med Check Program Chapter 21: Communication Skills: Discussing Payment Options Chapter 22: Communication Skills: Dealing with difficult questions

SECTION B: Problem solving: Identifying Drug Related Problems Problem Solving: Gastrointestinal Symptoms and DRPs  Chapter 23: Gastrointestinal Drugs  Chapter 24: Heartburn  Chapter 25: Diarrhea  Chapter 26: Constipation  Chapter 27: Hemorrhoids  Chapter 28: Nausea and vomiting  Chapter 29: Pinworm  Chapter 30: Infant Colic Problem Solving: Cardiovascular Symptoms and DRPs Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Chapter 47: Cardiovascular Drugs Chapter 48: Hypertension Chapter 49: Antihyperlipidemics Chapter 50: Ischemic Heart Diseases Chapter 51: Anticoagulants & Warfarin Management

Problem Solving: Psychotic and Neurological Symptoms and DRPs  Chapter 52: Psychological Disorders  Chapter 53: Neurological Disorders Problem Solving: Endocrine Symptoms and DRPs  Chapter 54: Contraception’s  Chapter 55: Diabetes  Chapter 56: Thyroid disorders Problem Solving: Respiratory Symptoms and DRPs  Chapter 57; Asthma and COPD  Chapter 58: Cold, Cough, Congestions and Fever  Chapter 59: Allergic Rhinitis Problem Solving: Mouth and Dental conditions  Chapter 60: Canker and cold sores Problem Solving: Eye Symptoms and DRPs  Chapter 61 Ophthalmic drugs  Chapter 62: Conjunctivitis Problem Solving: Ear Symptoms and DRPs  Chapter 63: Otitis media  Chapter 64: Otitis externa  Chapter 65: Vertigo and Dizziness Problem Solving: Foot Symptoms and DRPs  Chapter 66: Foot Symptom Assessment  Chapter 67: Athletes Foot Problem Solving: Dermatological Symptoms and DRPs  Chapter 68: Diaper rash  Chapter 69: Headlice  Chapter 70: Dermatitis  Chapter 71: Psoriasis  Chapter 72: Dermatological Drugs  Chapter 73 Acne


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Problem Solving: Musculoskeletal DRPs  Chapter 74: Arthritis  Chapter 75: Osteoporosis  Chapter 76: Pain Symptoms and Analgesics Problem Solving: Reproductive, Gynaecologic, and Genitourinary Symptoms and DRPs  Chapter 77: Dysmenorrhea  Chapter 78: Menopause  Chapter 79: Sexual dysfunction and DRPs  Chapter 80: Vaginitis  Chapter 81: Benign Prostate Hyperplasia Problem Solving: Cancer Chemotherapy DRPs  Chapter 82 Cancer Chemotherapy Problem Solving: Antimicrobials DRPs  Chapter 83 Antimicrobials  Chapter 84 Urinary Tract Infections Problem Solving: Lifestyle Management  Chapter 85: weight loss  Chapter 86: Smoking cessation  Chapter 87: Allergies and Hypersensitive reactions  Chapter 88: Photosensitivity  Chapter 89: Insomnia  Chapter 90: Immunizations and vaccines  Chapter 91: Medications use in pregnancy  Chapter 92: Traveling Tips  Chapter 93: Substance of Abuse PART 3: Non interactive stations Chapter 94: Non interactive stations Chapter 95 New Approved Drugs 2007 to 2010 Part 4: NAPRA Competencies  Chapter 96: Pharmaceutical Care  Chapter 97: Pharmacy Regulations and Ethics  Chapter 98: Pharmacy Practice Information Resources  Chapter 99: Communication Skills in Pharmacy  Chapter 100: Managing Drug Distribution  Chapter 101: Managing Pharmacy Operations


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Prep Notes

Part 1

Communication Skills

Number 1: Communication



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MISBAH’S TOP 20 RULES OF COMMUNICATION IN EXAMS Rule # 1: Always respond to the patient/actor  Make eye contact  Answer any question that is asked.  Respond to the emotional, as well as factual, content of question

Rule #2: Listen, reflect, encourage, and offer empathy  Introduce yourself (tell him/her who are you?/What are you doing)  Getting the patient to talk is generally better than having the pharmacist talk  Be sure who your patient/actor is? The child, mother, or her husband  Arrange seating for comfortable, close communication  If at all possible, both patient/actor and pharmacist should be both be seating

Rule # 3: Notice and response to information  Change the plans and goals as events change, new information should cause you to stop and reassess  Don’t carry away by inertia. How you reach your goal may shift with new information, even it the goal itself stay the same Rule # 4: Ask the prime questions  What did your Dr. tell you this medication was for?  How did your doctor tell you to take this medication?  What did your doctor tell you to expect?

Rule # 5: Be sure you understand what the patient medical conditions /Medications/ Allergies and alternate life style (MAMA) before recommending  Seek information before acting  When presented with a problem, get some details before offering a solution  Begin with open-ended questions then move to close ended questions Rule # 6: Assessment – critical thinking and analysis of the problem.  Are each of this patient’s medications appropriately prescribed?  Is each medication the best one for this patient to be taking? Safest, most effective?  Is this the right dose given the patient specific information (severity, size, gender, etc.)  Is the patient having any apparent drug related side effects?  Are any possible drug interactions present?  Is this patient able to follow this drug regimen?  Does the patient know how to use this medication correctly?  Is additional medication needed to resolve the patient’s complaint / symptom?

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 Are any of the patient’s complaints or abnormal objective/physical findings related to drug therapy?  What are some other possible causes of the patient’s complaints / symptoms? Rule # 7: Patient do not get to select inappropriate treatment  Patient select treatments, but only from presented, appropriate choices  If a patient asks for inappropriate medication that he/she heard advertised/ from friends/relatives, explain why it is NOT indicated and suggest an alternative Rule # 8: Never lie  Not to patient/actor, their families, or insurance companies  Do not deceive to protect coworkers Rule # 9: Work on developing a rapport on an ongoing basis, always seeks a good professional relationship with patient  Ask patient/actor if this prescription/refill/concern for you? Rule # 10: Patient is number one always placing the patient first  The goal is to serve patient/actor, not to worry about your exam results Rule # 11: Prepare Patient Counseling Plan before engaging in the counseling  What is the situation right now? (Special circumstances, medication itself, past history with the patient, etc.)  What does everyone who takes this medication need to know?  What does this patient need to know in addition to this? Rule # 12: Identify red flags that signal “physician referral”  Blood in stool/urine or vomiting of blood  Fever not responding to appropriate measures  Yellowing of skin or eyes  Severe pain (described as “the worst pain i’ve ever had”)  Fever, vomiting, headache, confusion, difficulty bending neck  Signs of infection or inflammation (fever, pus, swelling, redness, tenderness, heat)  Spontaneous bleeding or bruising  Chest pain  Pain on urination Rule # 13: When collaborating with the physician,  Always position the patient and his/ her health as the basis of interaction.  Do not make judgments on the physician’s capabilities to choose a therapy for his/her patient.  Establishing a good channel of communication and respectful relationship with the physician is essential in building a team approach to patient care.  Information the pharmacist passes to the doctor regarding drug interactions, contraindications or non-adherence, is highly valued by the physician. This

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information can dramatically alter the course of treatment or therapy that the physician prescribes. Rule # 14: Listen to what patient is saying and provide any  Information missed by patient. Rule # 15: Offer follows up and asks if the patient has any questions or concerns.  It sounds like you’ve got it. Please don’t hesitate to give me a call if you have any problems.  This is also a good place to remind about refills  Thank the patient Rule # 16: Final Verification  Assess whether verification or summary is needed  Has patient verbalized the information you wanted them to know?  yes – summarize & reinforce their knowledge  no – final verification (Just to make sure I haven’t left anything out, could you tell me how you are going to use the medication?)

Rule # 17: The key is not so much what you do, how you do it?

Rule # 18: There are three things that can destroy your exam: misinformation, poor communications, and poor judgement of question. Rule # 19: pharmacist should be able to discuss pros and cons of alternative treatment Rule # 20: Never assume patient knows every thing Good luck

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OSCE a step by step approach

2 Communication Skills: Counselling New Prescription The sample template describes how to approach a patient who comes to fill a new prescription. This template assist you to develop a communication model, however you have to adopt your communication model upon patient have some questions in between. COUNSELLING NEW PRESCRIPTION Opening discussion Introduction Offer privacy Empathy

↓ Discussion to gather information and identify problems MAMA TOPS

↓ Patient’s present knowledge about medication and condition.  Potential problems ↓ Identify problems and Educational needs Discussion to prevent or resolve problems and educate ↓ Discuss real or potential problems • Agree on alternatives • Implement plan • Discuss outcomes and monitoring • Provide information as necessary ↓ Recap ● Get feedback ● Encourage questions Follow up Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 2-1 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Practice Station Scenario # 1 A patient comes to fill prescription: Patient profile: (given by patient after pharmacist candidate request) Patient Name: Amy Age: 55 yrs Address: Pharmacy Prep Avenue Doctor: Tips Medical Condition: hyperlipidemia and high B.P Current Medications: Diovan HCT 80/12.5 mg po daily Rx: Lipitor Sig: 20 mg po daily x 3 months Mitte: 90 tablets R: 2 Solve problem and counsel

Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 2-2 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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3 Communication Skill: Counselling On Refill Prescription Opening discussion Introduction Offer privacy Empathy


↓

 Patient’s present knowledge about medication and condition.  Potential problems ↓ Compliance problems? • Evidence of side effects? • Effectiveness of treatment • Potential problems ↓ Discuss real or potential problems • Agree on alternatives • Implement plan • Discuss outcomes and monitoring • Provide information as necessary ↓

Recap ● Get feedback ● Encourage questions Follow up Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Scenario # 1 A patient comes to pick up his refill 2 weeks before his due date. Patient Profile: (on the table) Patient: Mathew Age: 18 years Gender: Male Dexedrine 10mg cap 1x3 90 tablets each 30 days Refills: (3) last refill 2 weeks ago

Scenario # 2 A patient is coming for her refill with a concern. Solve her concern as you are in your pharmacy. (She is pregnant) Rx Epival (Divalproex Na) 250mg tablet 1x1 Mitt: 30 tablet Refills (5) Last refill 30 days ago Patient Profile (on the table) Patient: Rosemary Khan Age: 33 Years Gender: Female Diagnosis: Grand Maleilepsy


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4 Communication Skills: Counselling OTC Drugs Opening discussion Introduction Offer privacy Empathy


↓ Has Physician been consulted before? • Description and duration of symptoms • What treatment has been used previously? ↓ Identify problems and Educational needs Discussion to prevent or resolve problems and educate ↓ Non Prescription Drugs Medication Recommended Medication Not recommended       

Name Purpose Directions Side effects Precautions Future treatment Self care recommendation

   

Advice patient to see physician Suggest non-drug treatment Give self care recommendation Reassurance

 Reassurance Recap ● Get feedback ● Encourage questions Follow up Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Practice Stations _______________________________________________________________ Scenario # 1 A young man approaches you requesting smokeless tobacco. He heard from his friend that smokeless tobacco reduces cancer and lung diseases. On the table:  Nicotine gum,  Nicotine patches  Nicotine inhaler  Nicotine gargle  Herbal products for smoking cessation. Patient profile: (given by patient after pharmacist candidate request) Age: 45 yo Allergies: none Current medications: None Current medical conditions: none

Scenario # 2 A woman come with a concern, and she wants an OTC product. She has white flakes on the shoulders of her black sweater after she brushes her hair. Her hair is clean, and the scalp is itchy. Available on the table:  Ketoconazole2% shampoo,  Selsun shampoo,  Zinc Pyrithione (Head and shoulders),  Salicylic  Sulphur bar and lotion  Coal tar shampoo Patient profile: (given by patient after pharmacist candidate request) Age: 22 yo Allergies: None Current medications: None Medical conditions: none


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5 Counselling Techniques: Questioning (Probing) The following questions may assist you to counsel efficiently and effectively to succeed solving problems.

Do’s Asking the right questions?  What did doctor tell you about your medication?  How the doctor told you to take this medication?  The doctor just wrote to take as directed. How did he/she tell you take them?  Medications can occasionally cause some unwanted side effects. What did the doctor tell you about possible side effects?  Is there anything further that you would like to do discuss or ask.

Don’ts  “ You do know how to take medication, don’t you? (leading questions)  “Did the doctor tell you about side effects” (close ended question)

[Type text] Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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6 Counselling Techniques: Persuasion During information giving phase of the counselling, it may be necessary for the pharmacist to provide information such a way that change the patient beliefs, attitude or behavior towards the medication use. This can be accomplished by persuading the patient that following his/her advice regarding medication is in the patient’s best interest. The pharmacist’s ability to persuade depends on his or her style of communication, effective methods of presenting information, organizing information, and confidence and credibility of information. Do’s  Use friendly tone, caring, use two sided communication, gently encourage the patient comply, and the same time making the patient aware of the risks of non-compliance.  Be neat and tidy  If you note on the prescription telling him that the patient prescription was one month late in being renewed, or earlier than refill time and prepare to discuss compliance.  I am concerned about your medication use, as it is very important to take medication regularly in order for it to work better.  You still need to take medications to continue feeling well  It is particularly important with this medication that you don’t stop suddenly. Although it is problem free, it could cause drug withdrawal symptoms. Don’ts  Preaching and threatening  Getting upset and loud when the patient does not accept pharmacist advice.  Boldly staring that this medication should be taken as directed, several reasons are given for the advice.  Fear arousing communication (lead to non compliance)


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7 Counselling techniques: Mastering Language skills It is important to have smooth flow of communication and organized approach before you start your counselling. Here are the few points master your language skills Empathy statements  It must be hard …  It must be difficult…  It seems your……….  It sounds like pain is real ordeal for your…  I am glad you told me that Paraphrasing  Paraphrasing allows the pharmacist to verify that he/she understood the patient. Paraphrasing is simply restating what he or she believes the patient has said and verifying the facts.  Paraphrasing also helps to reflect that your paying attention to patient concern or question.  Repeating the patient’s exact words is another techniques that encourage patient to talk more about a particular topic. Do’s   

Repeat the patient exact words.. Are you saying that…… Is your concern is…..

Don’t Repeating frequently patient’s exact words, it would be annoying Summarizing  Summarizing is useful techniques to end a series of asking questions or probing. [Type text] Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Before making a recommendation to problem, a pharmacist can summarize all that has been said in previous discussion.  After a pharmacist summary statements, the patient can correct the pharmacist if the summary is incorrect or provide additional information necessary. Do’s: You have told me that you have had diarrhea before starting medications..

Transition A transition is a specific, planned attempt to change to topic , in order to provide structure and continue during interview. This is especially useful when pharmacist needs to change to different topic like counselling on how to use medications to patient self care recommendations. This is also very useful especially when patient interrupt with comments on another topic. Do’s What if patient interrupts with other topic while your communications? After briefly discussing the patient’s comments, the pharmacist can return to


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8 Communication Skills: Giving Instructions Do’s Use future forms,” softens your language: for example: Be + going + infinitive “You’re going to take one pill in the morning and one at bedtime.” Be + going + to be + V-ing “You’re going to be taking this tablet once a day at bedtime.” Will + be + V-ing “You’ll be taking one tablet at breakfast one at lunch, and one at dinner.” Don’t’ (avoid using commands) “Take one pill in the morning” (sounds command) “Take this tablet with a full glass of water (sounds command) Use Passive Forms for Embarrassing Topics

Do’s      

Be + past participle “The suppository is going to be inserted into the rectum.” Will + be + part participle “The suppository will be inserted into the rectum.” Don’t (Avoid using you or your) “You are going to insert this suppository into your vagina,” you can use a passive construction to remove the emphasis from the “doer.”


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 Also, avoid using personal pronouns such as your when talking about potentially embarrassing topics with a patient. Instead, say “the vagina,” or the “the penis.” Use Sequencers Do’s  Try to use se short statements. Use simple (lay) language, as to talk to 6th or 7th graders  When giving instructions to patients, it’s very important to use sequencers such as “First,” “Next,” “Then,” etc. so the patient can easily follow the instructions. You can also use phrases such as,  “After washing your hands, you are going to remove the cap and place it on a tissue.” Don’t  Avoid using long complications sentences  Avoid using textbook type of statements Use Signifiers of Importance Use language that tells your patient that the instruction is important, such as:  It’s important to wash your hands first.  It’s important that you take this tablet with a full glass of water.  You must avoid alcohol while taking this medication. My reference shows that patient must avoid taking alcohol with medication: Avoid using “must” in lifestyle recommendation Confirm the Patient’s Understanding Confirm that the patient has understood your instructions by using the following language:  Just to make sure I’ve explained myself completely, would you mind telling me how you’re going to use this medication?  Do you have any questions about how to use this medication? Giving Instructions on a Dosage Form Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Do’s  Maintain professional attitude, and eye contact.  Speak clearly  Use logical sequence  Use sequencer in phrases such as “ first, next, then, after etc.  Use future forms instead of commands  Give enough information, rather over information (do not over kill)  Use appropriate body language while presentation  Use simple language (avoid text book type of professional language)  Use signifiers, such as it is important, or must avoid etc. Lay language Describing how a class of drugs works and o explain Mechanism of actions: Antihistamines – These medications help to reduce your allergy by reducing certain substances in your blood. Nitrates – These medications help prevent you from having chest pains and shortness of breath by delivering more oxygen supply to your heart and lungs. Beta-Blockers – These medications slow down your heartbeat and slow down your blood pressure by blocking certain chemicals to avoid any heart complications. Bisphosphonates – These medications help strengthen your bones by adding calcium to them, thus helping to prevent fractures. Anti-Anxiety Agents – These medications help reduce your anxiety (calm down) and make you feel more relaxed by reducing certain messengers in your brain. Diuretics – These are water pills that help to remove fluids from your body and lower blood pressure and prevent a heart attack. Anticoagulant – These medications help to make your blood thinner and prevent clot formation, thereby preventing you from having a stroke or heart attack. Statins – These medications help elevate levels of good cholesterol and reduce bad cholesterol by inhibiting certain enzymes in your blood, thus helping prevent you from having a stroke. Birth Control Pills – These medications help prevent pregnancy by inhibiting ovulation. Anti-Depressants – These medications help to control your mood and make you feel well by inhibiting certain messengers in your brain. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Cough Suppressants – These medications help to reduce your cough by blocking the cough centres in your brain. NSAIDs – These medications help to reduce pain by clocking certain substances in the body. They also work as pain killers. Sulfonylureas (for Type 2 Diabetes) – These medications help to reduce your blood sugar by stimulating the production of insulin in your body. Carbonic Anhydrase Inhibitors (for Glaucoma) – These medications help to reduce the pressure in your eye by draining the accumulated fluid, thus improving your eyesight and reduce pain. Bronchodilators – These medications help open your body airways and make your breathing easier. Proton Pump Inhibitors – These medications help treat your stomach ulcers by reducing the acidity in your abdomen. Anti-Psychotics – These medications help improve your emotions and behavior by controlling certain substances in your brain.


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9 Counselling techniques: Using written patient information effectively Along with verbal counselling, pharmacist needs to select the right information sheet for each patient, and know how to present that information. Commonly used written information:  Computer generated patient information sheet  Package inserts  Photocopies of articles  Scientific journal articles  Health Canada food guide  Drug recall from health Canada and manufacturers Do’s  It is very important to review highlights of written information, relevant to patient questions. Make sure the information provided is accurate and well presented.  Pharmacist may need to modify the written information by highlighting certain areas that is most relevant patient.  Written information can be useful in addition to verbal counselling to provide detail information  Written information also helps patient family and caregiver to understand the therapy  In all cases, pharmacist should review information with patient and offer it to discuss it further after patient have had reading and understanding information it in detail at home. Don’t Written information should never be used just as bag stuffer. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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10 Conducting Patient Interview: Symptom related questions Pharmacist is a primary healthcare provider, and has responsibility to identify symptoms that need medical attention.

Do’s  Memorize all disease and drugs overdose and withdrawal symptoms  Identify symptoms that need medical attention and determine urgency of referral  Identify symptoms to make recommendations on drug therapy to treat identified symptoms  Be alert for undiagnosed conditions, pharmacist have some time an excellent opportunity to help identify a serious condition.  Appropriate questioning during a symptom related patient interview might help to determine urgency of further medical assessment and intervention. Don’t  Don’t be judgemental


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Scenario # 1 Mr XP a regular patient at my best pharmacy, patient approaches you for recommendation. Sounding a little discomfort in stomach and have hard time with bowel movements. On the table:  Anusol Plus suppositories  Anusol Plus ointment  Tuck’s wipes  Senokot  Metamucil  Soflax (Sodium Docusate) Patient information (gives this information after asking questions)    

Age: 45 year old Allergies: Not known Current Medications: None Medical conditions: None

Life style:  Non-smoker  Alcohol: moderate 3 to 4 drinks/wk  Works as courier delivery, and always on wheels and eats on the run

Scenario # 2 A 55 year old man comes into the pharmacy and complains of chest pains. He asks if you could recommend something for heartburn. Counsel the patient. Patient information (gives this information after asking questions)  Allergies: Not known  Current Medications: atorvastatin 20 mg daily, enalapril 10 mg  Medical conditions: high cholesterol and high blood pressure


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11 Counselling techniques: Counselling on Healthy lifestyles The pharmacist the most important concern is counselling on appropriate use of prescription and non-prescription drugs. The pharmacist should also consider the overall health of their patients. Health and lifestyle issues that pharmacist may emphasize include:  Smoking  Alcohol  Exercise  Safe sex  Unwanted pregnancy  Illegal drug use  Wife and child abuse How to approach problem Do’s    

Offer help, rather than preach Communicated non judgemental way Help patient to set achievable, individualized goals Delivering lifestyle information should be done by tact and empathy since lifestyle is personal issue and as well as difficult thing to change  Be empathetic in challenges to lifestyle changes that faced by patient  Make your patient aware of facts concerning the risk of any unhealthy behavior Don’t  Don’t be taskmaster  Don’t counsel in an authoritative and aggressive manner  Don’t be judgemental Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Don’t create more dilemmas


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12 Counselling techniques: Discussing alternative treatment It is important for a pharmacist to become knowledgeable about herbal remedies, homeopathic medicines, naturopathic treatments, and acupuncture. How to approach a problem Do’s Pharmacist should be able to discuss pros and cons of alternative treatment  Provide information about available products and recommend reputable practitioners of reputable alternative treatment, if required  Discourage unproven or products that have insufficient information about clinical studies.  Prevent harm by becoming knowledgeable about serious drug interactions of alternative treatment with medications  Prevent harm Don’t  Do not recommend alternative product that may result into serious risk to patient. What is often asked? Pharmacist are often asked about alternative treatment, and requested supply various products?

Herbal Remedies Ginseng  Commonly used to help the body combat stress, to enhance mental & physical capacities (ò weakness, exhaustion, tiredness, loss of concentration) [Type text] Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 American Ginseng (Panax quinquefolium) has shown to lower post-prandial glucose & improves glucose metabolism  Prevention & treatment of cardiovascular disease (induce nitric oxide, block Ca channel in the heart, prevent platelet adhesion)  Obesity and hyperlipidemia  Cold & Flu treatment Ginseng & Digoxin  Ginsenosides (Asian & American ginseng) & Eleutherosides (siberian ginseng) partly resemble the structure of digoxin  Patients taking ginseng may have falsely ñ or ò digoxin levels due to laboratory interference  Case report: patient asymptomatic for digoxin toxicity exhibited supratherapeutic digoxin levels (5.2 nmol/L) [Therapeutic range 2.2 nmol/L] Ginseng & Warfarin  In vitro Ginsenosides inhibit platelet aggregation & prolong the activated partial thromboplastin time (aPTT)  Two case reports show a ò in warfarin effect (drop in INR) in pts taking ginseng & warfarin  Patients should avoid ginseng due to possible reduction in INR. St. John’s Wort (SJW)  Has been used in a variety of psychiatric disorder, including depression  MOA: alters serotonin (inhibits its reuptake), dopamine & norepinephrine activity.  Typical antidepressant dose: 300 gm TID  Inducers of CYP 3A4 & intestinal P-glycoprotein St. John’s Wort (SJW) & Immunosuppressants  Cyclosporine & SJW reduced plasma levels of cyclosporine & even graft rejection  Tacrolimus & SJW reduced plasma levels of tacrolimus  Cyclosporine & Tacrolimus both are eliminated by CYP 3A4 & are substrates of Pglycoprotein  Mycophenolate (CellCept®) & SJW, no effect St. John’s Wort (SJW) & Oral Contraceptives  Both Ethynyl estradiol & progestin in OC are metabolized by CYP3A4  Studies show a low probability of significant interaction between SJW & OC  However, St. John’s Wort (SJW) & Oral Contraceptives ] breakthrough bleeding & theoretical risk of contraceptive failure, & also reported cases of pregnancy  Warn patients about possibility of breakthrough bleeding and reduced effectiveness of OC St. John’s Wort (SJW) & Antidepressants [Type text] Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Pharmacodynamic Interaction (SJW & SSSRIs, Effexor, etc.) ] Serotonin Syndrome Serotonin Syndrome symptoms: Altered mental status (agitation, delirium) Autonomic hyperactivity (tachycardia, hypertension, chills, sweating, hyperthermia) Neuromuscular (tremor, myoclonus (involuntary twitching of a muscle)

St. John’s Wort (SJW) & Antidepressants  Pharmacokinetic interaction with amitriptyline  Amitriptyline is metabolized by CYP2D6, CYP3A4, CYP2C19 & is a substrate of Pglycoprotein  Efficacy of amitriptyline may be ò when taken with SJW  Digoxin & SJW ] reduced digoxin levels ] loss of disease control  (P-glycoprotein is involved in intestinal absorption, distribution & renal elimination of digoxin)  Antiretrovirals & SJW reduced systemic exposure to PIs & NNRTIs viral load ñ & drug resistance ñ(PIs & NNRTIs: both metabolized by CYP3A4  PIs: substrates of P-glycoprotein) Garlic & its uses

    

Anti-infective properties Immune-enhancing properties Prevention & treatment of cardiovascular disease Allicin (active compound in garlic) induce CYP3A4 Garlic my also inhibit CYP2C9, CYP2C19 & CYP3A4, as well as P-glycoprotein

Garlic & Warfarin  Antiplatelet activity of Garlic may enhance the anticoagulant activity of warfarin  Case reports (Garlic & Warfarin):  bleeding  increase in INR (in two cases, the INR increased approximately twofold) Ginkgo Biloba  Has been used to treat Alzheimer’s disease & dementia  Ginko Biloba & reported interactions  Ginko may increase risk of bleeding with ASA, ibuprofen, and warfarin Echinacea  Stimulates immune system  Directly opposes the effect of immunosuppressants


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 Contraindicated in systemic & autoimmune diseases such as rheumatoid arthritis, lupus, inflammatory GI disease, tuberculosis, multiple sclerosis, leukemia, diabetes, connective tissue disorders  Use by AIDS & HIV patients is contraindicated  Should not be given to children younger than 2 years old Other important herbal products that recommended to read are : Saw Palmetto Indicated for BPH, Cranberry-Indicated for UTI and Velarian - To treat insomnia. Kava - To treat insomnia.


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Practice Stations Scenario # 1 A young man comes to your Pharmacy asking for your assistance. He has got a concern regarding his condition and wants to purchase something that he feels would help him. On the table:  Echinecea Tablets  Pseudoephedrine 30mg tablets  Saline nasal drops

 Dextromethorphan cough syrup Scenario # 2 A 25 year old women is inquiring about the use of Echinacea  Profile: Materna and Multivitamins  On the table:  Echinacea lozenges Scenario # 3 A lady is inquiring about the use of St. John’s Wort.  Currently using: Carbamazepine 200mg po TID and Folic acid 5 mg po od  On the table  St. John Wort


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Scenario # 4 A female in her 50’s Patient Profile: (given on table) Age: 51 yo Current medications  Eltroxin 100 mcg daily  Crestor 10 mg daily  HCTZ 25 mg daily  Atenolol 50 mg dailyWarfarin 2 mg ud  Warfarin 1 mg ud Medical History:  Dyslipidemia  Hypothyroidism  Hypertension  DVT 3 month ago COLD-fX® is a highly purified extract derived from North American ginseng (Panax quinquefolius)


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13 Assessing the potential for non compliance In pharmaceutical care it is an important to make sure, to the best of pharmacist ability, that the patient received the necessary necessary medication at the required time in order to get desired effect. Do’s It is essential consider the individual patients personal and environmental characteristics, these include:    

The patient attitude to medication use Their knowledge of their condition and medication treatment Their previous experience with medication use, including family and friends. Their lifestyle and time schedule

Although you short time with patient, however look for factor that can contribute to noncompliance, such as:  Number and types of medication currently patient using  Drugs that require that have special instructions, such as taking empty stomach, with full glass water, should not combine with other drugs, and do not chew etc. How to figure out non-compliance in patients;  A careful and direct discussion with patient at the time of medication provision Motivate patient by explaining of taking medication regularly gives desired effect Strategies To Enhance Adherence To Medication Regimens  Integrate new behaviours in patient lifestyle.  Provide or suggest compliance or reminder aids.  Suggest patient self-monitoring. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Monitor use on an ongoing basis.  Refer patients when necessary.


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14 Assessing the need for follow up counselling In pharmaceutical care practice it is important for pharmacist to ensure that appropriate outcome achieved from medication use Do’s Pharmacist need to schedule follow up counselling with patient, when they are conducting initial prescription counselling. It is challenging to assess the risk level of each situation The nature of follow up arrangement will depend on: Pharmacist assessment of the risk of drug related problems such as side effects and non-compliance.  High risk drug situations follow up:  Pharmacist should discuss with the patient an appropriate time for follow up schedule either by phone or in person.  Low risk situation follow up:  Follow up schedule may involve a suggestion that the patient call if he or she has any questions. If certain drug side effects occur or if after a given period of time the desired effect has not been achieved



15 Counselling techniques: Assessing patient need for supplements It is important for a pharmacist to become knowledgeable about calcium supplements, iron supplements, and multivitamins. How to approach a problem Do’s  It is important to assess necessity of supplements  Pharmacist should ensure that the client uses the product appropriately and identify and resolve any drug related problems  It is important to know dosages and how to take them What is often asked?  Pharmacist is often asked about calcium, iron supplement and multivitamins, supplement drops for children Iron supplements Know available iron salts  Ferrous Gluconate 300 mg tablet – 35 mg of elemental Iron  Ferrous Sulfate 300 mg tablet – 60 mg of elemental Iron  Ferrous Fumarate 300 mg tablet – 100 mg of elemental Iron  Triferexx - Polysaccharide-Iron Complex – 150 mg of elemental Iron  Proferrin is a heme iron polypeptide. It is the same form of iron found in red meat 11 mg of elemental iron. Iron supplements in Pregnancy  Ask more questions about pregnancy?  Recently, have you seen your Dr?


 But for better assessment please see your Dr. Iron Supplement counselling tips  Take between meals to increase absorption  May take with food if GI upset occurs  Do not take with dairy products  May cause dark colored stool  During the first 3 months of pregnancy a proper diet provides enough iron. However, during the last 6 months an iron supplement recommended in order to meet the increased needs of the developing baby.  Antacids May make the iron supplement, less effective do not take at the same time. It is best to space dose 2hours

Calcium supplements Know Calcium formulations  Chewable Tablets (Caltrate, Tums)  Soft chews (Caltrate)  Liquid Calcium  Effervescent Calcium (Calcium Sandoz) Know available calcium salts  Calcium Carbonate – the most concentrated (40% elemental calcium), least expensive, has slowest absorption (pH dependent)  (Caltrate, O-Calcium “Natural Source”, Tums, Calcia)  Calcium Citrate – more soluble; OK for patients with hypochlorhydrea (on PPI, H2 antagonists); does not cause gas, bloating or constipation; can be taken with or without meals  Citracal, Calcium Citrate Tablets Each tablet provides 200 mg of elemental calcium as Ca citrate,  Citracal, Caplets + D One caplet provides 315 mg of elemental calcium as calcium citrate, 200 IU of Vitamin D  Citracal Plus with Magnesium Counselling tips  Bisphosphonates, tetracycline, ciprofloxacin, iron supplements – absorption of these drugs is negatively affected by calcium  Food with high levels of sodium & caffeine accelerate Ca loss through urination (Recommend: one glass of milk for every cup of coffee consumed)


Practice Stations Scenario # 1 A lady comes to you in the Pharmacy and wants advice on a certain products for her 4month-old infant. Assist her and solve her concern as you would in the Pharmacy. On the Table:  Multivitamin Drops for infants  Vitamin D Drops  Iron supplemental drops  Enfalac formula with iron Scenario # 2 Patient comes to fill the Rx Rx Actonel 75mg Take 2 tablets every month M: 1 mo supply

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16 Communication skills: Dealing with Physician Pharmacist responses to physician questions are handled a little different than those to patients. Most of these questions are not difficult to answer, but it is important require building a good relationship with the physician How to approach a problem: Do’s  When collaborating with the physician, always position the patient and his/ her health as the basis of interaction.  Be forthright & assertive and state the nature of your call right up front. If the patient asked you to make this call, make the physician aware of this.  Establishing a good channel of communication with the physician is essential in building a team approach to patient care.  Establish a respectful relationship where all the parties are aware of how each professional can contribute to optimize the overall care of the patient. Don’t  Do not make judgments on the physician’s capabilities to choose a therapy for his/her patient. What is often asked?  Pharmacist are often asked about regarding  Alternate antibiotics therapy options,  Drug interactions,  Contraindications or non-adherence, is highly valued by the physician. This information can dramatically alter the course of treatment or therapy that the physician prescribes. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 16-1 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Practice Stations Scenario # 1 You are supposed to have a dialogue with the Doctor, who will be inside the room waiting for you. Go through the patient’s therapy. You may ask the Doctor anything you feel is relevant to the case. Recommend any changes that you believe are necessary for the benefit of the patient and document your response. Patient Profile: (on the table) Patient Name: John carlos Age: 45 years Address: Prep Ave Allergies: Septra Medications: Ferrous Sulphate (started 6 months ago) Comments: Ulcerative Colitis Dr: Tips New Rx: Sulfaslazine 1.5gms TID x 1 / 12 On the Table: CPS and TC Scenario # 2 You are supposed to have a dialogue with the Doctor, who will be inside the room waiting for you. Go through the patient’s therapy. You may ask the Doctor anything you feel is relevant to the case. Recommend any changes that you believe are necessary for the benefit of the patient and document your response. Patient Profile: (on the table) Patient Name: Mrs Joshua Age: 52 years Address: XYZ Dr: Gaucher

Comments: Breast Cancer Parkinson’s disease Medications: Pergolide 1mg TID (Started 3yrs ago) Sinemet CR 200/50 QID (Started 10 yrs ago) Tamoxifen 20mg BIB (Started 2 wks ago) New Rx: Metochlorpromide 10mg po PRN (30 Tablets) References on the desk: CPS and TC Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 16-2 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Scenario # 3 You are supposed to have a dialogue with the Doctor, who will be inside the room waiting for you. Go through the patient’s therapy. You may ask the Doctor anything you feel is relevant to the case. Recommend any changes that you believe are necessary for the benefit of the patient and document your response. Patient Profile: (on the table) Patient Name: Miss Jane Age: 28 months Address: Prep Ave Dr: Tips

Comments: Otitis Media Medications: Amoxicillin Suspension (Stopped today) Allergies: None known

New Rx: Cefuroxime Suspension 250mg, 1tsf BID x 5 / 7

Scenario # 4 You are a Hospital Pharmacist and you are supposed to have a dialogue with the Doctor, who will be inside the room waiting for you. Go through the patient’s therapy. You may ask the Doctor anything you feel is relevant to the case. Recommend any changes that you believe are necessary for the benefit of the patient and document your response. Patient Name: Ms Casie Age: 29 years Address: Prep Ave Dr: Tips

Comments: Community Acquired Pneumonia Medications: Materna Multivitamins (Started 4 months ago)

New Rx: IV Levofloxacin 500mg Q24HRS x 10 / 7

Scenario # 5 You are supposed to have a dialogue with the Doctor, who will be inside the room waiting for you. Go through the patient’s therapy. You may ask the Doctor anything you feel is relevant to the case. Recommend any changes that you believe are necessary for the benefit of the patient and document your response. Patient Profile: (on the table) Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 16-3 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Patient Name: Mrs Jacky Age: 55 years Address: Prep ave Dr: Tips


Comments: Osteo-Arthritis Medications: Tylenol 1000mg QID (Started 2 months ago) Codeine SR 60mg QID x 2/52 (Started 2 days ago)

New Rx: Carbamezapine 100mg TID x 5/7 then, 200mg TID x 1/12 (For Trigeminal Neuralgia)

Scenario # 6 Patient Profile: (on the table) Patient Name: Billy Age: 9 years Address: Prep Ave Dr: Tips

Comments: Asthma & phenylketonuria Medications: Salbutamol Inhaler PRN Fluticasone Inhaler 1puff BID (Started 2 years ago)

New Rx: Zafirlukast 20mg tablets BID x 1 / 12, then to review.

Scenario # 7 Patient Profile: (on the table) Patient Name: Catherine Age: 82 years Address: Prep Ave Dr: Tips

Comments: hypothyroidism and Hypertension Medications: Levothyroxin tablets Chewable Aspirin 81mg QD Metoprolol SR 100mg QD

On the desk: CPS


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17 Communication Skills: Collaborating with healthcare professional Pharmacist and Pharmacy Technician Relation If the pharmacist observes the pharmacy technician making mistakes, the pharmacist has to deal with the errant technician in a proper way. Politely ask the technician to excuse himself from his work and talk to him/her in a private area. Talk in a calm and firm manner and discuss about his/her error. Appreciate his/her hard work, her/ his contribution to the pharmacy (like doing his/her job properly), etc., but discuss the problem clearly. For e.g. if the technician has counseled a patient for an OTC formulation, he/she has to be told that there are 2 reasons why a technician cannot counsel: It is not legal for a pharmacy technician to counsel on any OTC medication. Only the pharmacist is allowed to counsel patients. One may risk the health of patients probably due to an allergy triggered by the OTC formulation or if the patients have medical conditions in which the product is contraindicated. Pharmacist has the knowledge needed to explain the potential dangers of natural health products to customers and he can advise them about herb-drug or herb-disease interactions. Pharmacist always uses his professional judgment to make a decision. Alternative therapies are not always safe and without side effects contrary to general opinion. There is a lack of scientific data on their effectiveness ad safety profile and their interactions with Rx drugs. That is why it is important to refer patients to the pharmacist if they have any queries about natural / alternative products as the pharmacist can determine if the benefits of using alternative product is worth the risk/side effects. Take this opportunity to go over the duties of a pharmacy technician. Give a copy of the regulations and ask the technician to go over it and discuss it, if he/she needs any further explanation. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Take his/her signature over the copy. Always use positive words (USE POSITIVE CRITICISM) and expect the technician to learn from the mistake and not repeat it. Encourage the technician to keep up with his/her good work. A situation where the technician has taken a new Rx over the phone from a doctor. Firstly, technicians are not allowed to take new Rx from a doctor over the phone, the call must be transferred to the pharmacist as the pharmacist can discuss any drug related problems or any other question related to the therapy, with the doctor. Even if the pharmacist is busy, the technician should take the doctor’s phone number and let the pharmacist call the doctor and take the new prescription personally. Take this opportunity to go over the duties of the technician. Call the doctor and verify the prescription.


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Practice Stations Scenario # 1 The pharmacy technician comes to you, the pharmacist, in your office with a Prescription for a patient who is already on Hydrochlorthiazide Tablets 25mg and asks for your opinion. Have a dialogue with him and guide him accordingly. Rx: Enalapril 20mg QD. On the desk: Photocopies of regulation and CPS

Scenario # 2 You are a Hospital Pharmacist and you overheard one of the junior Pharmacists having a conversation with a Doctor over the phone and advising him that Vancomycin IV can be replaced with oral vancomycin. Have a dialogue with the Pharmacist and advice him accordingly.

Scenario # 3 You just dispensed Paroxetine 20 mg tablets to a male patient. While paying for his medication you overheard the patient asking the cashier at the Dispensary that he read in the leaflet of the medication, it causes sexual dysfunction in males. The cashier’s response to the patient was that many men take it and not so many complain of it. Talk to the cashier and take the right action to solve the situation.

Scenario # 4 You are the Pharmacy Manager and you overhear one of the staff Pharmacists in the Pharmacy recommending a mother of an 18 month-old Lopramide capsules for her child. If you believe that it is a problem, talk to him accordingly and assist in solving it. On the table:  Maalox suspension  Oral rehydration sachets Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Scenario # 5 A patient comes in to collect a prescription for Amoxicillin. Prescribed by a dentist to be taken just before dental treatment. The patient profile shows that the patient is allergic to penicillin. Discuss an alternative with the dentist.


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18 Communication Skills: Devices Demonstrations Aerochamber    

Remove cap. Shake inhaler and insert in back of aerochamber Place mouthpiece in mouth (or mask over mouth and nose) Encourage person to breathe in and out slowly and gently. (If you hear a whistling sound the person is breathing in too quickly*)  Once breathing pattern is well established, depress canister with free hand and leave canister in same position as person continues to breathe in and out slowly (tidal breathing) five more times  Remove the aerochamber from person’s mouth  For a second dose wait a few seconds and repeat steps 2-6 The child Aerochamber

The child aerochamber device with mask and infant aerochamber device with mask do not whistle

Metered dose inhalers Metered dose inhaler

 Remove cap and shake inhaler  Breathe out gently  Put mouthpiece in mouth and at start of inspiration, which should be slow and deep, press canister down and continue to inhale deeply  Hold breath for 10 seconds, or as long as possible then breathe out slowly  Wait for a few seconds before repeating steps 2-4


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Diskus Diskus

 Hold the outer casing of the Diskus in one hand whilst pushing the thumb grip away until a click is heard (OPEN)  Hold diskus with mouthpiece towards you, slide lever away until it clicks. This makes the dose available for inhalation and moves the dose counter on  Breathe out gently away from the device, put mouthpiece in mouth and breathe in.  Remove Diskus from mouth and hold breath for about 10 seconds  To close, slide thumb grip back towards you as far as it will go until it clicks  For a second dose repeat sections 1to 5

Turbohaler Turbohaler

 Unscrew and lift off white cover. Hold turbohaler upright and twist grip forwards and backwards as far as it will go. You should hear a click  Breathe out gently, put mouthpiece between lips and breathe in as deeply as possible. Even when a full dose is taken there may be no taste  Remove the turbohaler from mouth and hold breath for about 10 seconds. Replace the white cover

Patient Counseling Information on Nasal Decongestants: Drops  Blow your nose.  Squeeze rubber bulb on dropper & withdraw medication from bottle  Recline on a bed & hang head over the side (preferred) OR tilt head back while standing or sitting.  Place drops into each nostril & gently tilt the head from side to side to distribute the drug.  Keep head tilted for a few minutes after instilling the drops.  Rinse the dropper with hot water. Spray (atomizer)  Blow your nose.  Remove cap from spray container.  For best results, don’t shake the squeeze bottle.  Administer one spray with head in upright position. Sniff deeply while squeezing the bottle.  Wait 3-5 minutes & blow nose.  Administer another spray if necessary.  Rinse the spray tip with hot water taking care not to allow water to enter the bottle.  Replace cap. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Inhalers  Blow your nose.  Warm inhaler in your hand to increase volatility of the medication.  Remove the protective cap.  Inhale medicated vapor in one nostril while closing off the other nostril, repeat in other nostril. Wipe the inhaler clean after each use.  Replace cap immediately.  Note: Inhaler loses its potency after 2 to 3 months even though the aroma may linger. Metered Dose Pump (Spray)  Blow your nose.  Remove the protective cap.  Prime the metered pump by depressing several times (for first use), pointing away from the face.  Hold the bottle with the thumb at the base & nozzle between first & second fingers.  Insert pump gently into the nose with the head upright.  Depress pump completely & sniff deeply.  Wait 3-5 minutes & then blow nose. Administer another spray if necessary.  Rinse the spray tip with hot water taking care not to allow water to enter the bottle.  Replace cap. Transdermal patches  Evra patch (Hormonal Contraceptive) – The patch should be applied to a clean, dry intact healthy skin on the buttock, abdomen, upper outer arm or upper torso, in a place where it won’t be rubbed by tight clothing. Not on a breast. Half of the clear protective liner is peeled away. The patient should avoid touching the sticky surface of the patch. The patch is positioned on the skin and the other half of the liner is removed. The patient should pres down firmly on the patch with the palm of her hand for 10 seconds, making sure that the edges stick well. The patch is worn for 7 days. On the “Patch Change Day”; Day 8, the used patch is removed and a new one is applied immediately.  Estalis and Estalis Sequi Patch (HRT) – Immediately after removal of a patch from the pouch, and removal ½ of the protective liner, the adhesive side of the Estalis or Vivelle patch should be placed on a clear, dry area of intact skin and peel off the remaining onehalf of the protective liner. The site selected should also be one at which little wrinkling of the skin occurs during movement of the body (buttocks and lower abdomen). The waist should be avoided, since tight clothing may dislodge the patch. Patches should not be applied to the same skin site for at least 1 week. Not on breast.


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 Nitro – Dur patch – Apply it on arm or chest. Application site should be rotated. A suitable area may be shaved if necessary. Don’t put it on the distal part of extremities. Hands should be washed thoroughly after application.  Duragesic Patch – Apply on chest, back, flank, or upper arm every 3 days.


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Practice Station Scenario # 1 A patient comes to pick up his prescription Patient profile (given on the table) Patient: John Hirtz Age: 40 years Allergies: Unknown Gender: Male

Patient Profile Pulmicort turbohaler 200μg 1x2 Serevent Diskus 50μg 1x2 Ventolin inh 1-2 puff prn

Rx Advair Diskus 250μg 1x2 60 blisters

Scenario # 2 A patient comes to pick up a prescription Rx Ventolin MDI i-ii puffs q 4 to 6 hours prn Flovent 250 MDI 2 puffs BID Patient profile: (given by patient after pharmacist candidate request)  Allergies: none  Current medications: benadryl for cough  Medical conditions: just diagnosed with asthma


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OSCE step by step approach

19 Communication Skills: Handling Dispensing Error It is important to handle situation appropriately to minimize the harm to patient health and the pharmacist and patient relationship. Communication is the key of handling dispensing error. If an error does occur, the cause of error must be assessed and correct action should be taken to prevent future error. Client Presentations     

May not be error? Error but medication not used? Error and medication used but no risk? Error and medication used and risk? Error and medication used and risk to patient?

Pharmacy Accident Flow Chart Immediately take control pharmacist on duty – advise pharmacist/owner

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Isolate - take customer to private area-do not discuss in front of other customers if personal visit or telephone call, pharmacist must give patient individual attention

Get the facts -inquire and show concern for the patient’s well being -determine if any medication was ingested or used - do not deny

Action to be taken Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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determine if indeed error has been made; if so apologize “I am sorry, it appears an error has been made” If not used immediately replace the incorrect item with the proper one – personally deliver/taxi as needed

If used - immediately return medication for professional evaluation

assure patient that this is an isolated - immediately replace the incorrect incident, you will review Rx filling and item with proper one- personally Rx checking process deliver/ taxi. be genuine, spend as much time with patient as required to alleviate all concerns Counsel New medication Follow up

Evaluate - notify Dr., state facts only - use reference text before talking to patient or Dr.  tell patient no risk and assure no danger  notify Dr. and explain giving professional analysis  if necessary, have Dr reinforce with patient      

show empathy, concern notify Dr notify Dr. in all cases based on Dr recommendations direct patient to hospital for tests Call regional pharmacy operations   

complete Rx incidence report Follow- up calls, visit to patient to show concern and to ask physical status


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Practice Station Scenario # 1 A regular customer of your pharmacy comes to you with a concern and she is very worried. Assist her accordingly. Patient profile: (Provided on desk) Patient Name: Ms Harry Age: 47 Years Address: Xyz Dr: Tips Comments: Deep Vein Thrombosis Current medication: Warfarin 2.5mg QD

Scenario #2 A pharmacist has expired stock of CIPROFLOXACIN and a patient comes to fill prescription for CIPRO. Your pharmacy has only expired medication. Solve problems?


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OSCE a step by step guide

20 Communication Skills: Managing Med Check Program ______________________________ Med check programs are designed to manage medication use more effectively, and improving the patient outcomes of medication use and some cases reducing the need for medications. It is important to have good communication skills, and pharmacist should have empathy with dealing with patient objection or concern. Pharmacist should have assertiveness in communication to explain benefit and harmful effects. How to approach problem? Do’s    

Emphasize the benefits of medication, by discussing about medications. Make sure medications are working properly Identify unwanted effects as soon as possible Identify any problems with taking the medicine so that adjustment can be made as possible example: timing for convenience, dosage form that palatable and appropriate.  Avoid wastage if for any reason the medication is discontinued, dispose in environmentally safe manner



OSCE a step by step guide

Practice Stations Scenario # 1 Age 70-year-old patient does not remember how to take his pills; Patient profile: (given by patient after pharmacist candidate request) Allergies: None Medical conditions: high blood pressure, hyperthyroidism Current medications: given in table

Current medications Captopril 25 mg tid Aspirin 81 mg QD Propylthiouracil 50mg Bid Hydrochlorothiazide QD K-Dur QD

Scenario # 2 A female patient is confused, and concern about taking her daily pills. Patient profile: (given by patient after pharmacist candidate request) Medical conditions: high blood pressure, diabetes and depression Current medications Hydrochlorothiazide 25 mg QD Zoloft QD

Break fast

Lunch

Dinner Bedtime

Orlistat TID Glyburide BID Metfromin TID




21 Communication Skills: Discussing Payment Options It is important to have prepared your response ahead of time dealing with third party plan payments, co-payment, and deductibles. Know policies and procedures of your pharmacy, some pharmacies may decide to waive some of these co-payment, or additional drug cost charges. How to approach a problem? Do’s  Prepared for the discussion about competitor advertisements  Give enough time to patient about his/her concerns about extra charges or fee  Provide the best service and explain patient the benefit of staying with your pharmacy




22 Communications Skills: Dealing with Difficult Questions Patients may have some concerns and questions regarding quality of a patient’s doctor, medication prescribed is appropriate, and what outcome the patients can expect from these medications, etc. It is important to ask more details about their concerns, and their medical conditions, some are these best referred to doctor. Sometimes require re assurance. In all cases these types of questions require skill and tact to avoid upsetting patient or doctor. Do’s  Take initiative, do not hesitate to listen their concerns, ask more details about their concerns.  Address their concerns and questions  Speak in calm and empathetic tone, example: It must be confusing to you, to have your medications changed several times like this.  Help the patient find the answer. Assist patient to make own assessment of his doctor and make informed decision.


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Problem Solving Skills


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GI Symptoms and DRPs GERD Patient Presentation GERD chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus Symptom complex rather than a specific disease entity and commonly refers to pain or discomfort cantered in the upper abdomen. Patients often use terms as heartburn, indigestion, gas, bloating and nausea to describe dyspepsia.  Antacids and alginic acid are appropriate for the management of mild symptoms of GERD (phase I therapy)  Symptoms persisting longer than 2 weeks require further evaluation and treatment with prescription medications  Refrigeration of liquid antacids may aid in palatability. Chewable tablets may be more effective than liquids due to increased adherence of antacid and saliva to the distal esophagus. Antacids must be taken at least 2 hours apart from tetracycline’s, iron, and digoxin. Antacids and quinolones should be taken 4-6 hours apart  Alginic acid is effective for the relief of GERD symptoms, but there are no data to indicate esophageal healing on endoscopy. Alginic acid is ineffective if the patient is in the supine position, and must not be taken at bedtime

Peptic Ulcer Disease Nonpharmacological Choices  Bland diets are no longer prescribed – use moderation if food or beverage makes dyspepsia worse i.e. o Coffee o Orange juice o Spicy foods o Fatty foods o Large meals Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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o Eating on the run  Smoking – patients were advised to stop smoking prior to H. pylori being recognized as the causative agent. Patients should be advised to stop smoking for general health reasons.  Stress and Type A personality are still considered to predispose to PUD – with the identification of H. pylori, the roll of stress in PUD has lessened. Stress management may benefit overall health. Regimens:  Amoxicillin 1000 mg BID  Clarithromycin 500 mg BID  Lansoprazole 30 mg BID HP Pack  Omeprazole 20 mg BID Losec 1-2-3 A  Esomeprazole 20 mg BID Nexium 1-2-3 A Patient instructions and Counseling  PPIs are best taken before meal  H2RA may be taken with or without meal  Inform the patient about the importance of completing the entire drug therapy to ensure the eradication of H pylori and to avoid bacterial resistance  For patients who have trouble of swallowing Lansonaprole granules may be sprinkled onto applesauce.  Omeprazole capsules should be swallowed whole  If antacid are being used to control breakthrough symptoms, dose should be less than 12hours or after taking an H2RA  Amoxicillin, clarithromycin, and metronidazole may be taken without regard to meals; however taking clarithromycin and metronidazole with food often reduces the incidence of stomach upset.  Tetracycline is best taken on an empty stomach  Antacids, dairy products, iron containing products should be taken 2 hours before or after taking tetracycline  Sucralfate should be taken 1 hour before meals and at bedtime

Irritable Bowel Syndrome (IBS) Abdominal discomfort associated with altered bowel habits. It is characterized by symptoms of abdominal pain or discomfort  Antispasmodics and anticholinergic agents are best used on an as-needed basis up to three times per day during acute attacks or before meals when postprandial symptoms are present  Patients taking a TCA should avoid prolonged exposure to sunlight and avoid concurrent use of CNS depressants  Tegaserod should be taken before meals and should not be initiated during an acute exacerbation of IBS Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Osmotic laxatives should be used on an as-needed basis. Lactulose may be mixed with water or juice to increase palatability. Patients should drink plenty of water Patients must be enrolled in the manufacturer prescribing program in order to receive alosetron. Patients should not initiate therapy with alosetron if they are currently constipated. Alosetron should be discontinued if no improvement in symptoms is seen after 4 weeks of therapy

Inflammatory Bowel Disease (IBD) Ulcerative colitis (UC) and Chron’s Disease  Sulfasalazine Should is taken after meals. Patients should avoid sun exposure while taking sulfasalazine. Folic acid supplementation should be given during sulfasalazine treatment to avoid anemia. Sulfasalazine may cause orange discoloration of urine and skin. Mesalamine tablets should be swallowed whole. Suppositories should not be handled excessive and foil wrappers should be removed before insertion. Suspension enemas should be shaken well before use  Antacids and ciprofloxacin should be taken 4 to 6 hours apart. Iron or Zinc-containing products should be taken 4 hours before or 2 hours after taking ciprofloxacin. Patients should avoid excessive exposure to sunlight  Patients taking methotrexate should avoid alcohol, salicylates, and prolonged exposure to sunlight. Female patient of child bearing age should be counselled on appropriate contraceptive measures during methotrexate therapy  Patients receiving therapy with infliximab should be counselled on the possibility of infusion reactions. Live vaccines should not be administered to patients taking infliximab


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Practice Stations Scenario # 1 Patient information (Provided on your desk) Patient Name: John Age: 45 years Address: Tips Comments: Duodenal ulcers Medications: Ferrous Sulphate (started 6 months ago) Allergies: Penicillin Dr: Gaucher New Rx: Losec 1-2-3 A x 7 d On the Table: CPS and TC Dispense the new prescription; address their concerns and their need for information. Help them to prevent illness and promote healthy life style

Scenario # 2 A patient comes to fill a prescription Patient information (Provided on your desk) Patient Name: Anna Age: 40 yrs Address: Tips Doctor: GM Medical condition: peptic ulcer Current medications: Nexium (esmoprazole) 40 mg po od x 28 (filled 10 days ago) Rx: Losec 1-2-3 A for 7 days Solve Problems and Counsel

Scenario # 3 Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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A man comes with following Rx: Losec 1-2-3 A Patient profile: (provided on desk) Current medication: Prevacid (lansoprazole) 30 mg po od x 30 (filled 14 days ago) Trying to dispense this prescription you find out that you have no more Losec (omeprazole) in stock. No other pharmacy is working; wholesale delivery is in 2 days because of long weekend. Solve Problems and Counsel

Scenario # 4 A patient is asking for your recommendation Profile: (patient gives after asking questions)  Diclofenac suppositories 100mg BID  Cyclobenzaprine 10mg TID PRN On the table:  Tums  Rolaids  Zantac (Ranitidine) 75 mg  Maalox  Gaviscon  Pepto-Bismol Solve Problems and Counsel

Scenario # 5 A patient approaches you for recommendation On the table:  Anusol Plus suppositories  Anusol Plus ointment  Tuck’s wipes  Senokot  Metamucil Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Soflax (Sodium Docusate) Solve Problems and Counsel

Scenario # 6 Patient is asking for your recommendation to treat upset stomach. He wants to try Peptobismol and is asking if that would be OK. Medication History: AC & C (222) 375 mg of ASA, 15 mg of caffeine, and 8 mg of codeine phosphate. prn for back pain

Solve Problems and Counsel

Scenario# 7 A young lady is asking for your recommendation to treat constipation.

Medication history:  Alesse 21’s (6 mo)  Palafer 300 mg 1 cap TID (1 week) On the table:  Sennokot  Metamucil  Soflax Solve Problems and Counsel

Scenario# 7 Patient Name: Mr John Age: 45 years

Comments: Ulcerative Colitis


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Address: XYZ Dr: Gaucher

OSCE a step by step approach Medications: Ferrous Sulphate (started 6 months ago) Allergies: Septra

New Rx: Sulfaslazine 1.5gms TID x 1 / 12 On the Table: CPS and TC Solve Problems and Counsel


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24

Heartburn Presentation Symptoms      

Acid regurgitation, pain and heart burn Heart burn worse when bending over, lying down or after a fatty meal Pain/difficulty swallowing Excess burping/ belching/ abdominal bloating Feeling full after a small meal if pregnant  reassure that it usually resolves after delivery

Questions to ask:  Medical conditions? (hypertension, CHF, pregnancy – any restrictions in taking Na antacids, renal dysfxn – restricts Mg)  Current meds? ASA/NSAIDS ↓ PGs which protect stomach from acid  What makes it better/worse? Lying down/bending over usu. worsens or after a lg, fatty meal  Where is the pain? Drug Related Problems  Patient taking drugs/eating foods that contribute to GERD  Patient taking drugs that are contraindicated for their medical conditions (ex. Na+ antacid for pregnancy/HTN) Refer  Age: <12 or >50  frequency of pain >2x/week  Symptom incompletely relieved by antacids/ H2RAs; no improvement after 2 weeks  Vomiting, bleeding, unexplained wt. loss, dysphasia, radiating chest pain  Upper airway manifestations (chronic cough >3x/wk, moaning hoarseness Pharmacotherapy Non-Prescription Drug Prescription Drugs


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Non-Pharmacological recommendations  Avoid lying down after meals, eating 3hrs before sleeping  Avoid heavy meals or fatty meals  Exercising on full stomach  Wearing tight fitting clothing  Avoid excessive alcohol, caffeine, nicotine consumption  Elevate torso (not just the head) ~10cm to prevent reflux  Weight loss (if obese)  Encourage to stop smoking

Practice Station Scenario # 1 A 55-year-old man comes into the pharmacy and complains of chest pains. He asks if you could recommend something for heartburn. Patient information (gives after questioning) Allergies: None

Address his concern

Scenario # 2 A Patient is asking you: “What would you recommend for heartburn?” On the table:  Tums  Rolaids  Zantac (Ranitidine) 75 mg  Maalox  Gaviscon  Pepto-Bismol


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Diarrhea Symptoms  Running to washroom several times a day, Nausea / Vomiting, Abdominal pain, Bloating  Urgency, Malaise, Fever  Bloody or mucoid stool o Dehydration symptoms:  Sunken eyes  Absence of tears  Decreased urine output  Greater than 5% loss of body wt Questions to ask:      

What is your Age? How long has the patient had these symptoms? (onset, duration) Has the patient had similar symptoms before? Has the patient tried anything to solve the problem? Outcome? Are there any aggravating factors that cause the constipation? Reassure that travelers’ diarrhea is common and self-limiting

Refer to Physician  Refer to physician if diarrhea does not improve in 48 hours with high fever, blood in feces, severe pain in belly, children less than 6 months old, with vomiting for more than 4-6 hours with sign of rehydration; more than 6BM in one day Non pharmacological Choices  Discontinue drugs that cause diarrhea (laxatives, antacids containing magnesium, antibiotics, diuretics, theophylline, cholinergic drugs, promotility agents, prostaglandins, acarbose, orilstat)  Stop ingestion of carbohydrate that are poorly absorbed by the small intestine (dietetic candies, jams containing sorbitol, lactose containing dairy products)  Lactose intolerance – two-week therapeutic trial of a lactose-restricted diet can avoid costly diagnostic work-ups  Reduce oral food intake for 12 to 24 hours will improve symptoms of acute diarrhea  Important to maintain adequate fluid and electrolyte intake Copyright © 2000-2010TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Bland diet (low fat/ low carbohydrate), can be reintroduced once bowel motions have subsided Pharmacotherapy Traveller’s diarrhea  Educate on prevention/non-pharms  Avoid foods/beverages aggravate ie. dairy, prune juice, orange juice, caffeine  Frequent hand washing (soap and water or hand sanitizers)  “Boil it, cook it, peel it, or forget it”

Practice Scenarios Scenario # 1 A 48-year-old male patient is traveling to Mexico on business. He asks for something for diarrhea, as he always seems to get it when traveling to this location. Counsel the patient.

Scenario # 2 Mr G is a healthy 33-year-old male, he presents with prescription for ciprofloxacin 500 mg twice daily for three days. Your determine that he is traveling to Mexico the following week for business meeting, and the doctor told him that he may need this drug to treat diarrhea, if it develops. The doctor also instructed him to buy some Lopramide. Rx: Cipro 500 mg bid for 3 days

Copyright © 2000-2010TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Constipation Presentation Symptoms          

Feeling full quickly / feeling bloated Small and hard dry stools Infrequent defecation Straining to defecate Incomplete defecation Abdominal distension Nausea and vomiting Anorexia Uncomfortable and sluggish Fecal impaction

Questions to ask  How long has the patient had these symptoms? (Onset, duration)  Has the patient had similar symptoms before?  Has the patient tried anything to solve the problem? Outcome?  Are there any aggravating factors that cause the constipation (i.e. certain foods)?  Do you/Have you use(d) laxatives? (rebound) Drug Related Problems  Drugs that the patient is taking is causing constipation: opioids, verapamil, anticholinergics and TCAs  Patient is not using any product, or is using the wrong laxative to relieve constipation  Patient requires preventive measures (non-pharmacological options)  Patient is overusing laxatives Refer  Rectal pain / bleeding  Blood in stool  Fever / abdominal pain / nausea and vomiting  Narrow stool  No stool for 7d  Severe discomfort Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Nonpharmacological Choices  When possible discontinue drugs with constipating effect  Dietary fibre (20 to 30 g/day) – increase gradually to minimize side effects (Flaxseed, unprocessed bran, whole grains, fruits and vegetables).  Lactase deficient patients – can use lactose-containing dairy products (milk, young cheese) – cost effective natural cathartic  Increase fluid intake (8 glass of water per day) – avoid alcohol and caffeinated beverages  Try Prunes, stewed fruit, and figs  Encourage regular schedule tome for toilet use e.g. after breakfast – develop a conditioned gastrocolic reflex  Avoid prolonged straining  Encourage physical exercise  Relaxation exercises for pelvic floor and external anal sphincter muscles in conjunction with biofeedback  Should not ignore defecatory reflex  Digital manipulation of the anal sphincter – motility problems e.g. spina bifida  Constipation is a symptom not a disease – establish the cause if any – correcting it is the primary objective of treatment. Treatment Non-Prescription drugs Bulk-forming/Fiber Laxatives (Psyllium (Metamucil), bran)  Increase in stool bulk and consistency  Each dose (4.5-20g, 1-3x/day) with adequate fluid (6-8 glasses water/day)  Onset 2-4 days -- Don’t use more than 7 days  SE: bloating, flatulence, and. discomfort Emollient/Lubricant Laxatives (Mineral Oil)  Softens fecal matter Stimulant Laxatives (Cascara, Senna, Bisacodyl, Castor oil)  Enhances propulsive peristaltic activity Osmotic Laxatives  Act by drawing fluid into the lumen of the colon (softens stool) 1. Hyperosmotic – lactulose (15-60ml), glycerine (2.6g), sorbitol  Lactulose has action in 24-48 hours  Saline Laxatives –Magnesium hydroxide (milk of magnesium), Magnesium Citrate and Sodium Phosphate  Onset = few hours  Side effect of saline laxatives is excessive diuresis Stool softeners (Docusate Calcium/Docusate Sodium (Colace)


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Practice Station Scenario #1 Patient comes to you in the Pharmacy with a concern. Handle the situation and take the right course of action. Patient is asking for your recommendation Profile information: (gives information after questioning) Materna Multivitamins On the table:  Sennokot  Soflax  Glycerin supp  Lactulose  Ducolax (Bisacodyl)  CitroMag (Mg Citrate)  Metamucil Fiber  Fleet enema

Scenario # 2 A young lady is asking for your recommendation to treat constipation. Medication History:  Alesse 21’s (6 mo)  Palafer 300 mg 1 cap TID (1 week) On the table:  Sennokot  Metamucil  Soflax


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27 Hemorrhoids (Piles) Abnormally swollen veins in the rectum and anus, caused by too much pressure in the rectum forcing the blood to stretch and bulge the walls of the veins, and sometimes rupturing them. Presentation Symptoms  Painful mass at the anus usually lasting several days to weeks, sometimes accompanied by the sudden relief of pain following rupture of the skin overlying the thrombus and bleeding  Itching, swelling and burning  Prolapse and increased anal discharge  Fecal soiling of underwear  Internal hemorrhoids are painless, with bright red rectal bleeding, pruritus, and pain when prolapsed  External hemorrhoids are painful, itchy, and there is a mass felt upon defecation.  Pain peaks 48-72 hours after hemorrhoids develop and improves by the 4th day and heals by the 10th day Questions to ask:  Determine urgency (see reasons to refer). determine if we can treat in pharmacy  Is there any mucous or blood in the stool? If there is blood, is it bright red or dark?  Any prolapse? Is it painful? Is there a bump that is bluish in colour? Is there a burning sensation?  Medical conditions? thyroid disorder, HT, diabetes C/I for vasoconstrictors  Medications? meds that cause constipation  Does the patient have any allergies to medication? some pts allergic or sensitive to local anesthetics  Have you previously experienced similar signs and symptoms?  Are you currently taking any medications for the signs and symptoms?  What is your diet like? Do you eat a lot of fast food, spicy food, and fibre? How much liquid do you consume daily? (also alcohol and coffee) Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 What is your occupation? Does it require you to be sitting for prolonged periods of time or lift heavy things?  Any constipation? Any diarrhea? Do you resist the urge to defecate? Refer        

Problem lasts for longer than 7 days Patient is under the age of 12 Stool or mucous leaks from rectum between bowel movements Hemorrhoid does not go back in place after a bowel movement Rectal bleeding is present and is present in large amounts, is recurrent, is dark in colour Patients at high risk of colorectal cancer Patients who experience acute weight loss Change in bowel habit (chronic constipation, sudden diarrhea)

Non pharmacological  Decrease risk factors  Treat constipation/diarrhea  Sitz bath (warm water) 3-4 times a day for 15 minutes to relieve irritation and pruritis by relaxing the anal sphincter  Replace prolapsed hemorrhoids with a moist toilet tissue  Anurex ® for 6 minutes, twice daily to relieve pain and pruritis  Surgical options & other medical treatments Treatment Plan         

Anti-inflammatory agents = Hydrocortisone 0.5% (should not be used  7 days) Astringent = ZnO (relieves irritation and burning sensation), calamine (5-25%) Local anesthetic = Benzocaine (5-20%) Antiseptics = Domiphen (0.05% cream/ointment) Protectants = Glycerine, white Petrolatum, ZnO Vasoconstrictor = Ephedrine, Naphazoline, Phenylephrine Wound healing = Shark liver oil, yeast Pregnancy = correct constipation and taking sitz bath Analgesic = menthol, camphor

Education      

Educate patient on product chosen, how to apply Wash hands and anal area Suppositories should not be inserted into the rectum; need contact with anus Medications may help control symptoms but do not fix problem Non-drug important for prevention if symptoms persist >10 days, see physician


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Practice Station Scenario # 1 A patient comes to you in the Pharmacy with a concern. Handle the situation and take the right course of action.

Patient Name: Mr Andrew Age: 44 years Address: XYZ Dr: Gaucher

Comments: Hypertension Medications: Verapamil SR 180mg QD Tylenol #3 (Stopped 3mnths ago)

On the table:  Xylocaine rectal gel  Hydrocortisone gel  Psyllium powder  Senna tablets  Lactulose suspension

Scenario # 2 A patient approaches you for recommendation On the table:  Anusol Plus suppositories  Anusol Plus ointment  Tuck’s wipes  Senokot  Metamucil  Soflax (Sodium Docusate)


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Nausea & Vomiting, Motion Sickness Presentation Symptoms        

Nausea and vomiting Epigastic distress Upper abdominal pain Hypersalivation Body warmth Belching Sweating Drowsiness, headache, confusion, hyperventilation

Motion Sickness Sensation of nausea or vomiting due to conflicting signals between the body’s balance system, and the visual cues. In other words, the eyes see motion, but the body thinks it’s staying still. Questions to ask:    

Any other symptoms? (ear pain - OM, diarrhea - GI, abdominal pain – food poisoning) Has the patient had similar symptoms before? Has the patient tried anything to solve the problem? Outcome? Are there any aggravating factors that cause the motion sickness?

Non Pharmacological       

Minimize motion sensation on transport Fresh air, good ventilation Get well rested before travel, sleep well during travel Do not read during motion Fix vision on horizon that isn’t moving Do not smoke, or drink alcohol Eat light low fat not spicy meals


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Non salted soda crackers to absorb saliva and excess acid in gut Follow BRAT (banana, rice, apple sauce, toast) Drink carbonated beverages Avoid caffeine Slow deep breaths

Treatment Non prescription drugs


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Practice Station Scenario # 1 A young lady comes to you in the Pharmacy for your advice on a product she feels would be helpful for her condition. Gather the necessary information from her and advice her accordingly.

On the Table: Dimenhydrinate 25mg tablets and Pyridoxine Tablets)

Scenario # 2 A young lady comes with prescription:

Rx: Diclectin tab. PRN 2 hrs before symptoms Continue till Nausea and vomiting reduce M: 90 Profile: Patient Name: Billy Age: 26 years Address: Tips Dr: Gaucher Comments: Pregnancy induced nausea and vomiting Medications: Multivitamins/Folic acid Allergies: None


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OSCE a step by approach

29 Pinworm Presentation symptoms  Many people are asymptomatic  Most common: nocturnal perianal or paerineal itching  Due to Scratching: Insomnia (due to itching), skin irritation, eczematous dermatitis, bleeding or 2o bacterial infection  Migration to female genital area: vulvovaginitis, vaginal discharge  Heavy infestation: anorexia, irritability, abdominal pain Questions to ask:         

Any medical conditions? (epilepsy is important) allergies? Who else is living in the same household? –Because all need to be treated Have they tried any treatments and did they work at all before? Have you had this problem before? Ask questions to find out if body lice or pinworms… ie. ask where it is itchy (just anal area, or elsewhere?) Does itching get worse at night? (May be contributing to insomnia) – basically ask about signs and symptoms. Any secondary infection from the scratching? Do any of the children have a fever? Are you pregnant? –how far along into pregnancy?

Drug Related Problems  Failure to retreat in 2 weeks  Failure to treat infected family members or contacts  Failure to carry out concomitant nonpharmacological hygiene measures


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Nonpharmacological:           

Take shower each morning Regular cleaning or bedding, nightclothes, under wear and hand towels. Hand wash, nail cleaning mainly before meals. During week following treatment all family members should wear cotton underpants. (washed in soap water). Worn day and night change twice daily. Cleaning of floors of sleeping place. Clean bedroom articles, curtains where high concentration of eggs. Avoid shaking linens, curtains before wash. Avoid thumb sucking in children. Not effective: Cleaning or vacuuming entire house or washing sheets every day is probably not effective for reinfection. No problem: sharing dishes Avoid sharing undergarments

Prevention: 1. Proper hygiene Treatment Non prescription drugs Pyrantel pamoate (Combantrin)  Comes as suspension or tablet (mix with juice)  Take as single dose, repeat in 2 weeks!  >1yr  11mg/kg x 1 dose, rpt in 2 weeks  max 1gm (also in 125mg tablet)  SE: anorexia, N/V/D,  Avoid with liver disease or pregnancy Combantrin treatment plan:  Give– 11mg/kg 1 dose, and make sure to repeat in 2 weeks! – shake well before use.  Secondarily, if doesn’t work, refer to doctor  Treat others in household who are asymptomatic.  For itch, can give calamine oil, cold compress, and anti-histamines. Avoid local anesthetics.  non pharms are important Prescription drugs Mebendazole (Vermox)  Single dose 100mg (repeated after 1 to 2 weeks)  > 2yrs old, minimal SE  Efficacy: 95% effective: Mebendazole > OTC drugs  CI in pregnancy  DI with ANTI SEIZURE drugs Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Key counseling Tips  Retreat, in 2 weeks.  Make sure everyone in household is treated  Get the patients’ weights, and make sure they know how to accurately measure the dose of the meds they need to be taking  Letting school, playmates, etc. know to try to reduce spread in the community  When we say ‘hygiene’ - we have to be careful of that… cause pinworms is something that can be very easily picked up… not necessarily due to being in a dirty environment or anything like that. Even if they are very clean, they could pick it up from somewhere!  So make sure patients are aware that this is very common, so they don’t feel bad about it and they don’t worry that people will think they’re dirty and not tell you about their hygiene

Practice Stations Scenario # 1 A mother comes into your pharmacy requesting something to treat a child’s pinworms. She said her oldest son had been treated last year but she cannot remember what had been used and how her youngest son has ‘caught’ them. Patient’s profile:  Three-year-old son  Weight about 45lbs (20kg)  After visit to a physician, doctor diagnosed son as having pinworms and recommended a treatment that could be bought from a pharmacy  Symptoms: Scratching his bottom a lot  No pain or increased frequency in urination  Recently travel to Disneyland in Anaheim, California  Allergic to erythromycin  Medical history: Down’s syndrome  Current Medications: None Scenario # 2 A Father comes to take advice for his 3-year-old son who seems not to be himself. Assist him as you would usually in the Pharmacy. On the table:  Combatrin Tablets  Combantrin Oral Suspension, 5ml single dose  Benadryl syrup  Metamucil powder Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Infant colic Symptoms  Pattern of crying with no apparent cause (diagnosis of exclusion)  Wessel’s Rule of 3: Rhythmic, convulsive crying that lasts for >3 hrs/day, 3days/wk for >3wks  Starts when baby is 2wks, most common at 4-6wks, then improves (uncommon at 3-4mts)  Baby is otherwise healthy and thriving  Inconsolable, clenched fist, arching of back, drawing up of baby’s legs to chest, flatus, reddened face, abdominal distension Questions to ask:       

Age of child? Signs and symptoms? What time of day does the crying occur most often? How long and how frequently has the baby had these symptoms? Has the parent tried anything to solve the problem? Outcome? Is the parent breastfeeding? Reassure parent that infant colic is common, peaks at 4 to 8 wks and then subsides around 3-4mts, self-limiting  Cause is unknown Refer    

Fever Vomiting Infection or illness is suspected Blood or mucus in stool

Treatment Plan


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 Drug measures are generally NOT recommended and should not be used unless recommended by a physician  If had to recommend one:  Flatulex/Simethicone 40mg/ml (anti-flatulent)  unlabeled use for colic (Prof’s choice)  12% sucrose solution (possible analgesic effect <30min)  Herbal teas: chamomile, mint  some antispasmotic activity, used in some cultures to soothe infants (don’t add sugar or honey)  Generally NOT recommended:  Gripe water (no evidence of benefit)  Dicyclomine (antispasmotic; not for <6mts)  Hypnotics, sedatives, muscle relaxants,alcohol, diphenhydramine, antispasmotic + antichol combo Non pharmacological            

Try different Strategies Soft rhythmic motions, whole body or belly massages Car rides, walk, rock baby in arms Create white noise – playing music, vacuum cleaner, washer, fan Skin-to-skin contact Continue breastfeeding Try removing cow milk from mom and baby’s diet for one week to see if symptoms lessen Mother should avoid foods that aggravate colic (garlic, caffeine) Substitute formula for soy or hypoallergenic formula- d/c if no benefit after 1 wk Change frequency and technique of feeding the baby Burp more frequently Sleeping positions (Refer to Edu/Counselling)

Education  Sleeping positions: Baby should be placed face up on their backs for sleeping; can lay on stomach for short time (supervise)  Foods that aggravate colic: Cruciferous vegetables (broccoli, cabbage, cauliflower), soy, onions, peanuts, artificial sweeteners, eggs, chocolate  Feeding: Only feed baby when it’s hungry instead of every time it cries  Hold baby in vertical position to minimize swallowing air, burp after 30-60mL or every 510 min  Use collapsible bag to decrease amt of air swallowed  If bottlefed- choose a nipple with the appropriate hole size to reduce amt of air swallowed  For gastric distress: do bicycle motions with baby’s legs  Discourage switching to formula in an effort to reduce colic  can make situation worse


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Practice Stations Scenario # 1 A mother comes in complaining that her baby has severe colic. She is now quite desperate, as nothing seems to work. Counsel the patient on how best to handle the infant. Patient profile: (gives after pharmacist candidate requests)  Age; 3 months  Allergies: Not known  Current medications: None  Medical conditions: none


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Cardiovascular DRPs Diuretics  Patients who are allergic to sulfa-containing drugs may be allergic to these medications.  It can cause frequent urination.  Patients should weigh themselves daily if possible every morning after urinating. If the patient gains more than one pound a day or 3-5 pounds in a week should contact his/her health care provider.  Muscle cramps, dizziness, excessive thirst, weakness, or confusion should be reported as these are signs of overdiuresis.  Photosensitivity: Patient should avoid sun exposure or put sunscreen if cannot be avoided. Angiotensin-Converting Enzyme Inhibitors (ACE Inh)  Breast feeding and pregnant mothers should not take ACE inhibitor. If they become pregnant while on medication, they should contact their physician immediately.  Captopril should be taken in an empty stomach, 1 hour before or 2 hours after meal.  Use salt substitutes that contain potassium cautiously  Call doctor ASAP if you experience swelling of the face, eyes, lips, tongue, arms, or legs, or if you have difficulty breathing or swallowing  These may cause cough Beta-Blockers  May cause fluid retention or worsening of heart failure with initiation of therapy or an increase in dose  Patients should weigh themselves daily if possible every morning after urinating. If the patient gains more than one pound a day or 3 to 5 pounds in a week should contact his/her health care provider.  Body or leg swelling or increased shortness of breath should be reported  Fatigue or weakness may occur in the first few weeks of treatment, but often may resolve spontaneously.  Report any cases of dizziness, light-headedness, or blurred vision. These may be caused of too low blood pressure or from bradycardia or heart attack.  Carvedilol should be taken with food  It is important not to miss doses or abruptly stop taking these medications.  Beta blockers may cause blood sugar to rise and mask the signs of hypoglycemia except for sweating with diabetic patients. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Warfarin  Hemorrhagic complications due to changes in INR (acute increase in bruises and nosebleeds)  Skin necrosis – uncommon but serious, occurs in first week of therapy (prevented by initiation of heparin with warfarin)  Purple toe syndrome  Teratogenic  Skin rashes and alopecia occasionally occur Nitrates  Nitrate tolerance develops with continuous use in most patients  Nitrate tolerance ] Loss of hemodynamic and antianginal effects during sustained therapy  Provision of nitrate-free period of 12 hours with all long-acting preparations is required to limit or prevent tolerance from developing  ISDN schedule: “TID on a QID schedule” (7 a.m., 1 p.m., and 7 p.m.) Amiodarone      

Ocular – corneal microdeposits (“feels like sand in the eyes”), reversible on discontinue Thyroid – hyperthyroidism, hypothoroidism Respiratory – pulmonary inflammation or pulmonary fibrosis (new respiratory symptoms) Neurologic – Dizziness, tremor, fatigue, headache Dermatologic – photosensitivity GI – nausea, vomiting, constipation

Digoxin  Patient should report to the health care provider if any of the following may occur:  Dizziness, lightheadedness, fatigue  Changes in vision like blurred or yellow vision  Irregular heartbeat  Loss of appetite Nausea, vomiting, or diarrhea


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Practice Station Scenario # 1 A patient comes to fill prescription: Patient profile: (given by patient after pharmacist candidate request) Patient Name: Amy Age: 55 yrs Address: Tips Doctor: OZ Medical Condition: hyperlipidemia and high B.P Current Medications: Diovan HCT 80/12.5 mg po daily Rx: Lipitor Sig: 20 mg po daily x 3 months Mitte: 90 tablets R: 2 Solve problem and counsel

Scenario # 2 A patient comes to fill prescription: Patient Name: MK Age: 62 years Address: Pharmacy Prep Doctor: MD Medical Condition: DVT Current Medications: Fragmin 15,000 IU s/c od x 7 days (filled 2 days ago) Rx Warfarin 5 mg po od or ud x 30 tabs Mitte: 30 Solve problem and counsel Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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___________________________________________________________________ Scenario # 3 Patient provides following Rx Rx Isosorbide dinitrate 30mg TID on QID (6 hourly) schedule Current Medications:  Hydralazine 25 mg tid  Ramipril 5 mg po od  Bisoprolol 5 mg po od  ASA 352 mg po od Solve problem and counsel Scenario #4 A patient approaches you for recommendation about cough syrup Patient Profile:  Ramipril 10 mg po od (1 month)  Simvastatin 10 mg po od (1 year)  On the table: DM syrup, DM-E syrup Solve problem and counsel

Scenario # 5 A doctor is calling with new prescription Patient’s Profile: Patient’s medical history:  Atrial Fibrilation, Dyslipidemia Current medications  Diltiazem CD 180 mg po od  Simvastatin 20 mg po od  Warfarin 5 mg po od Solve problem and counsel


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Scenario # 6 A patient presents following prescription Rx Amiodarone 200 mg po od Patient’s Profile: (gives after pharmacist candidate requests)  Diltiazem CD 180 mg po od  Simvastatin 20 mg po od  Warfarin 5 mg po od Solve problem and counsel Scenario # 7 A doctor is calling with new prescription Patient profile (present on the table) Patient Name: OZ Age: 60 yrs Medical condition: Congestive Heart Failure, and Renal Insufficiency Patient’s Body Weight: 50 kg Current Medication: Enalapril 5 mg po BID Solve problem and counsel Scenario # 8 A patient has approached you for recommendations on anti-nausea medication Patient’s profile: Current medications: Enalapril 5 mg po BID, digoxin 125 mcg po daily Patient’s medical condition: Congestive Heart Failure, Renal Insufficiency Solve problem and counsel


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Scenario # 9 A patient presents with the following Rx Rx: Adalat XL 30 mg po od M: 30 tabs

Solve problem and counsel

Scenario # 10 A 48 year old man complains that he has been wheezing lately and a but short of breath. He has just recently moved up from Vancouver and is now living in Toronto. Within the last week he has been put on a medication for mild hypertension. Counsel the patient.


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32 Hypertension Counselling Tips Nonpharmacological Choices  Weight loss if overweight  Healthy diet – high in fresh fruits, vegetables, and low-fat dairy products, low in saturated fats and salt  Regular moderate intensity cardio respiratory physical activity  Low risk alcohol consumption 0 to 2 drinks/day less than 9 per week for women and less than 14 per week for men  Smoke free environment

Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep.

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Practice Station Scenario # 1 Patient is inquiring if he can you Zostrix HP (Capsaicin cream) for his burning feet. Patient is holding an old tube (used) of Zostrix HP cream. On the table:  Tylenol ES RUB A535 heat



Myoflex 15%

Scenario # 2 A patient comes to you in pharmacy for your advice, educate and counsel patient.    

Patient Name: John Age: 52 Years Doctor: Tips Address: xyz

 Medical condition: Hypertension  Medications: HCT 25 mgQD (started 3 years ago) New Rx: Felodipine 5mg QD x 1/12 (4 refills)

Scenario # 3 The lady comes to you in the pharmacy. Solve her concern and take the steps necessary. Patient Name: Mrs Kathy Age: 52 years Address: XYZ Dr: Tips  Comments: Hypertension  Medications: HCT 25mg QD (5 yrs ago)  Enalapril 20mg (Started 2wks ago) Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep.

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 OTC Medications: Benylin DM (Since 1wk)  On the table: Throat lozenges Codeine cough syrup

Scenario # 4 A very disturbed old lady comes to you in the pharmacy and asks for your assistance. Respond the way you would in the pharmacy in daily life. Promote compliance. Patient record: Presented on desk Patient Name: Mrs. Harry Age: 75 Years Address: xyz Doctor: Tips Comments: Hypertension and Hyperthyroidism Medications Captopril 25mg TID Asprin 81 mg QD Propylthiouracil 50 mg BID HCT 12.5 mg QD K-DUR QD

Doctor Name Tips Tips Tips Tips Tips

Repeats 0 0 0 0 0

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33 Antihyperlipedemic Drugs Statins  Usually administered in the evening because most hepatic cholesterol production occurs during night  Lovastatin conventional tablets should be given with the evening meal since absorption is better with food. For the extended-release lovastatin products should be taken at bedtime.  Lovastatin + Niaspan combination product should be taken at bedtime with low-fat snack  Non-extended release statins can be dosed once daily  Other regular dosage forms should be divided as the doses are raised above 40mg/d  Atorvastatin may be given any time of the day because of its longer half-life  Rosuvastatin dosage adjustment is required in patients with severe renal impairment. Plasma concentrations of rosuvastatin increased to a clinically significant extent (about 3fold) in patients with severe renal impairment (CLCR 30mL/min/1.73m2) compared with healthy subjects (CLCR 80mL/min/1.73m2). Dosage adjustment is also required in patients with liver disease  Monitor LFTs and muscle toxicity. Bile acid sequestrants (resins): Cholestyramine and colestipol:  Start with 1 dose daily with the largest meal. May be increased (after the patient adjust to the resin) to two doses daily with the largest meals or divided between breakfast and dinner  Titrate doses slowly to avoid gastrointestinal side effects  Powdered doses can be mixed with food such as soup, oatmeal, nonfat yoghurt, apple sauce among others. The mixture can also be chilled overnight to improve palatability  Do not use carbonated beverages to mix, as this promotes increased air swallowing  Drinking through straw may also help  Patients who suffer constipation with the resins may mix them with psyllium; however, this mixture should be ingested immediately after mixing in order to prevent gel from forming  Counsel patient to rinse the glass to ensure ingestion of all resin  Colesevelam is a tablet formulation, which may be easier for some patients to selfadminister. However, the tablets are large, and some patients may not be able to swallow them Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is 33-1 illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Monitor for adherence and gastrointestinal side effects for all resins. Nicotinic Acid (Niacin)  Immediate-release (IR) niacin should be started at a low dose and slowly titrated upward  Start with 100mg tid and adjust upward the second week to 200mg tid; the next will increase to 350mg tid. When 1500mg/d is reached and maintained for 4 weeks, assess effectiveness before increasing the dose  If further titration is needed, go to 750 mg tid and assess effectiveness after 4 weeks before increasing. Maximum dose is 1000mg tid  Aspirin 325mg or ibuprofen 200mg must be given 30 minutes before the morning dose to minimize flushing and itching  Caution patients to avoid hot beverages and hot showers so as not to exacerbate the flushing effect  Extended-release formulation (ER) should be taken at bedtime (500mg) and titrated weekly to a maximum of 1500mg/d. Aspirin should be taken 30 minutes before the dose.  Sustained-release formulations are started at 250mg bid and increased at weekly intervals to a maximum of 2000 mg/d. Aspirin should be given 30 minutes before the dose  Monitor for adherence and side-effects. The titration schedule for some patients may have to be gradual due to flushing and itching. Fibric Acids (Fibrates): Gemfibrozil  Gemfibrozil should be taken twice daily 30 minutes before meals  Tricor can be taken wit or without food once daily  Reduce dose in renal insufficiency and monitor for muscle toxicity, especially when used in combination with statins and niacin Cholesterol Inhibitors  Dosed once daily without regard to food  Can be taken simultaneously in combination with statins.


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Practice Station Scenario # 1 The patient comes to you with a concern. Respond the way you would in the Pharmacy. Patient record: (presented on desk) Patient Name: Mr Harry Age: 48 years Address: XYZ Dr: Tips

Comments: Hyperlipidemia Type 2 Diabetes

Medications Atorvastatin 20 mg QD Metformin 500 mg TID

Qty

(On the table: Tylenol 500mg tablets Advil 200mg tablets Centrum Multivitamins)

Scenario # 2 A 52-year-old male brings a prescription Rx: Questran powder Take one 4g scoop in the morning M: 1 can Patient’s profile: (presented by patient after request)  Medical conditions: Hypertension, and high cholesterol  No known drug allergies  Medication: 3 prescriptions for Furosemide 40mg 1 tab qam, on for the last 1 year


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Ischemic Heart Diseases Counselling Tips  Nitrate tolerance develops with continuous use in most patients  Nitrate tolerance, Loss of hemodynamic and antianginal effects during sustained therapy  Provision of nitrate-free period of 12 hours with all long-acting preparations is required to limit or prevent tolerance from developing  ISDN schedule: “TID on a QID schedule” (7 a.m., 1 p.m., and 7 p.m.)

Nitrates  Avoid alcohol consumption  May cause dizziness. Avoid driving, operating machineries, doing hazardous activities until drug effect is known  To avoid abrupt drop of blood pressure when standing from sitting position, rise slowly.  Report to the physician if you feel dizziness, acute headache, or blurred vision Nitroglycerin Sublingual tablets:  Keep tablets in their original container  Dissolve tablet under the tongue. Lack of tingling does not indicate a lack of potency  *Take one tablet at first sign of chest pain. If chest pain is unrelieved, seek emergency medical attention Nitroglycerin Translingual spray:  Spray under the tongue or onto tongue  Hold spray nozzle as close to the mouth or under the tongue  Do not inhale the spray or use near heat, open flame, or while smoking  Close mouth immediately after spraying  Avoid eating, drinking, or smoking for 5-10 minutes  If the pain does not go away after 1 spray, seek emergency medical attention Nitroglycerin Transmucosal tablets:  Place between cheek and gum. Do not chew tablet; allow to dissolve over 3- to 5-hour period  Touching the tablet with the tongue or hot liquids may increase release of the medication Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Nitroglycerin Ointment:  Measure the correct amount using the papers provided with the product  Use papers for the application, not fingers  Apply to the chest or back Nitroglycerin Transdermal patches:  Tear the wrapper open carefully. Never cut the wrapper or patch with scissors.  Do not use any patch that has been cut by accident  Apply to a hairless area and rotate sites to avoid irritation. Be sure to remove the old patch before applying a new one  Do not put the patch over burns, cuts, irritated skin  Remove the patch approximately 12-14 hours after placing it on every day. This prevents tolerance to the beneficial effects of NTG  Used patches may still contain residual medication; use caution when disposing around children and pets  Store the patches at room temperature in a closed container, away from heat, moisture, and direct light. Do not refrigerate Nitroglycerin Sustained-release tablets  Take at the same time each day as directed  Do not chew or crush tablets/capsules Antiplatelet Drug Therapy: Aspirin  Avoid additional OTC products containing ASA, NSAIDs, or salicylates ingredients without the direction of a physician  Patient who have received a stent will need the combination of clopidogrel and aspirin  Notify physician of dark, tarry stools, persistent stomach pain, difficulty breathing, unusual bruising or bleeding, or skin rash  Do not crush an enteric-coated product Thienopyridines:  Combination with ASA is necessary in patients receiving stents  Avoid additional ASA, salicylates, and NSAID products unless under the direction of a physician  Notify physician for unusual bleeding or bruising, blood in the urine, stool, or emesis; skin rash or yellowing of the skin or eyes  Do not stop taking without discussing with physician Statins  Usually administered in the evening because most hepatic cholesterol production occurs during night  Lovastatin conventional tablets should be given with the evening meal since absorption is better with food. For the extended-release lovastatin products should be taken at bedtime. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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    

Lovastatin + Niaspan combination product should be taken at bedtime with low-fat snack Non-extended release statins can be dosed once daily Other regular dosage forms should be divided as the doses are raised above 40mg/d Atorvastatin may be given any time of the day because of its longer half-life Rosuvastatin dosage adjustment is required in patients with severe renal impairment. Plasma concentrations of rosuvastatin increased to a clinically significant extent (about 3fold) in patients with severe renal impairment (CLCR 30mL/min/1.73m2) compared with healthy subjects (CLCR 80mL/min/1.73m2). Dosage adjustment is also required in patients with liver disease  Monitor LFTs and muscle toxicity.

Practice Stations Scenario # 1 A patient comes to pick up his new prescription he left at the pharmacy with you earlier today. He also has a concern regarding his medications, solve as you would in the Pharmacy. Patient Name: Mr Garry Age: 62 Years Address: Xyz Dr: Tips Comments: Rheumatoid Arthritis Angina Pectoris

Diclofenac Sr 75mg Qd Nitro Spray Lisinopril 20mg Qd Simvastatin Qd Asprin 81mg Qd Metoprolol Sr 100mg Qd

Started 1 Wk Ago

New Rx: Nitroglycerin SL tablets 0.5mg PRN (dispense 1 bottle) On the DESK: Nitroglycerin SL and Nitroglycerin Spray CPS

Scenario # 2 A lady comes to you, the pharmacist, for your advice. Counsel her as you would in the Pharmacy. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Patient profile: (Presented by patient after request) Patient Name: Ms. Jane Age: 67 Years Address: xyz Doctor: Tips Comments: Type 1 Diabetes Angina Medications Human Insulin 10 iu BID Nitro Spray

Since 10 years Since 2 months

On the Desk: Nitro lingual spray On the desk: CPS

Scenario # 3 A 50 year old male comes into the pharmacy to collect his prescription for Nitrolingual spray. He is a first time user. Counsel the patient.


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Anticoagulants and Warfarin Management Counselling Tips Therapy to prevent Venous Thromboembolism: Heparin, LMWH, Warfarin, Fondaparinux, Direct thrombin inhibitor    

Heparin, Fondaparinux, thrombin inhibitors, thrombolytic are not applicable LMWHs, Fondoparinux: patient should be taught to self-inject after hospital discharge monitor for the signs and symptoms of bleeding or VTE recurrence Avoid NSAIDs

Warfarin  Hemorrhagic complications due to changes in INR (acute increase in bruises and nosebleeds)  Skin necrosis – uncommon but serious, occurs in first week of therapy (prevented by initiation of heparin with warfarin)  Purple toe syndrome  Teratogenic  Skin rashes and alopecia occasionally occur


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Practice Station Scenario # 1 Patient comes into the pharmacy wishing to purchase Bengay (methyl salicylate ointment) for a pain that he has in his ankle. Name: Rick Age: 45 years Address: Tips Doctor: MD Comments: Ankle Pain Current Medications: Warfarin 5mg 1 QD (Started 1 month ago) Counsel the patient.

Scenario # 2 A patient comes to you in the Pharmacy and has questions regarding a certain product. Counsel and advice the patient accordingly, and take the right course of action. Patient Name: Mr John Age: 45 years Address: XYZ Dr: Gaucher

Comments: Deep Vein Thrombosis Medications: Warfarin 2.5mg QD

On the table:  Ginkgo Biloba capsules  Ginseng capsules


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Psychological Disorders Patient Concerns  Because many are embarrassed and demoralized by having a mental disorder, the patient, his family, and his employer (when appropriate and after obtaining informed consent from the patient) should be told that most often, depression is a self-limiting medical disorder, with a good prognosis. SSRI The Serotonin Syndrome (SS)  Results of excessive stimulation of the brain & spinal cord at the 5-HT receptors  Symptoms: confusion, agitation, diaphoresis, shivering, myoclonus, tremor, diarrhea, in coordination.  Also, seizures, parasthesias, hypertension or hypotension.  Patients should be informed of the potential symptoms of SS & be referred to doctor should these symptoms occur. Serotonin Discontinuation Syndrome  Occurs if an SSRI is stopped abruptly  Occurs in 2 or 3 days or up to 1 week after discontinuation of treatment  Can last 1 to 2 weeks  Symptoms: dizziness, impaired coordination, gastrointestinal disturbances, flu-like sensations, insomnia, nightmares, anxiety, agitation and mania  Symptoms are self limiting  To avoid – taper SSRI gradually To promote compliance pharmacists must emphasize:  Depression is a legitimate illness that is quite common.  Depression needs to be treated. Treatment can be successful, but success depends on compliance.  Treatment will take a minimum of 6 months.  Antidepressants are non-addicting.  Most antidepressants need to be discontinued slowly.  Antidepressants have side effects. However, most side effects can be managed. Assure patient that most side effects will not occur.  Encourage patient to call or see you if side effects occur or become bothersome. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 A response to the medication may take 2 to 4 weeks. The dose may have to be adjusted before treatment is successful.’  Encourage patients to keep a record/diary of how they are feeling: they can rate mood, irritability, appetite, fatigue, etc.  Obtain the patient’s permission for follow up consultations. Use of antidepressants in pregnancy  Discontinuing or modifying effective treatment is associated with an increased risk of relapse, a greater severity of illness and in suicidality.  Uncontrolled depression during pregnancy – many adverse outcomes for mother and baby (unfavorable maternal/infant biochemical profile)  Maternal anxiety/depression ] reduced blood flow to the fetus (low birth weight, delayed growth, and premature birth)  Virtually no medication can be described as completely safe during pregnancy  None of the antidepressants currently available in Canada are considered contraindicated in pregnancy.  When making a decision regarding the use of antidepressants during pregnancy always consider risks vs benefits of using these drugs.  Avoid abrupt discontinuation whenever possible Use of antidepressants in pregnancy Risks  Paroxetine – cardiovascular malformations – rare and the absolute risks are relatively small  Sertraline – no particular concern  Fluoxetine – preferred drug  Citalopram – no adverse association in 1st trimester  Venlafaxine, Mirtazapine – no elevation of risk beyond the baseline rate of 1 to 3% for any major malformation. Use of antidepressants in pregnancy Benefits  Minimal/lack of symptoms  Suicide prevention  Reduction of depressive relapse  Improved quality of life  Better care during pregnancy and after  Prevention of post partum depression  Avoid potential problems with delivery


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Practice Station Scenario # 1 A elderly lady approaches you to inquire about the side effects of the new drug that she recently picked up from your pharmacy. Pt’s profile: Presented on your desk  Citalopram 20 mg po od  Lorazepam 1 mg po hs prn  Ramipril 5 mg po od Address her concerns.

Scenario # 2 A patient approaches you for recommendation Profile:  Lithium Carbonate 300mg TID  Lorazepam 1 mg po hs PRN On the table:  Pepto-bismol  Gravol  Immodium  Maalox

Scenario # 3 Patient comes with the following Rx: Zyprexa Zydis 5 mg po daily Provide counseling and address all patients concerns


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Scenario # 4 A patient is asking for your recommendation Profile: Tylenol #3 1-2 tabs q4-6hrs prn x 35 tabs On the table:  Metamucil  Glycerin supp  Fleet enema  Soflax (Sodium Docusate)  Sennokot tabs  Bisacodyl tabs  Citro-Mag

Scenario # 5 A very disturbed and confused patient comes to you in the Pharmacy and asks for the Pharmacist for assistance. Counsel him as you would in the practice.    

Patient Name: Andrew Age: 32 Years Address: Xyz Dr: Tips

Comments: Major Depressive Disorder Medications: Citalopram20mg QD On the Desk:  Diphenhydramine 25mg Reference: PSC and CPS

Scenario # 6 Patient comes to pick his new prescription and has some queries. Solve his concern and counsel him. Patient Name: Jack, Age: 33 years Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Comments: Major Depressive Disorder Medications: Phenelzine Tablets 15mg tid started 2 months ago Address: XYZ Dr: Tips New Rx: Paroxetine 20mg 1/12 (1 repeat) On the DESK:  Paroxetine tablets  Phenelzine tablets Reference: CPS

Scenario # 7 A patient comes to fill prescriptions

Patient Name: Jackson Age: 36 Years Address: Toronto Doctor: Tips

Medications: CBZ 400 mg TID (since 3 months)

New Rx: Bupropion 150mg QD x 3/7 then, 150mg BID x 8/52

Scenario # 8 A 90-year old, 40 kg patient wishes to purchase: Patient profile: presented after request Allergies:

No known allergies

Current medications: warfarin (Coumadin) 2.5mg daily x 2 years donepezil (Aricept) 5 mg daily x 2 months

Patient wants to buy Ginkgo biloba to improve his memory


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37 Neurological Disorders Antiseizure drugs  

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Do not drink alcohol, CNS depressants or illegal drugs with this medication The full effect of this medication may not be seen for several weeks, but still continue to take the medication unless directed otherwise by your doctor Make a diary of your seizure/s and keep regular appointments with the doctor to determine whether the medication is working properly or not and if you are experiencing unwanted side effects If it (except Gabapentin) causes drowsiness, and blurred vision, do not drive nor operate heavy machinery unless you have become accustomed to its effects. Consult your doctor if you are pregnant, plan to get pregnant, or plan to breast feed while taking this medication It’s important if you are a woman capable of having children that you must take 1 mg of folic acid. Do not stop taking this medication without your doctor’s advice. Some drugs have to be stopped slowly. Let your doctor or pharmacist know if you stop taking this medication Ask your doctor or pharmacist before any or starting any new medication (prescription, OTC, or even herbal products)

Missed doses:  Missed a dose: take it as soon as you remember unless it is almost time for the next dose  If it is almost time for the next dose, skip the missed dose and resume to regular schedule.  Do not take extra or double doses  If you missed two or more doses ask your doctor for further instructions  If skin rashes occurs contact your physician immediately


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Parkinson’s Disease Techniques to improve patient understanding  1-Examine your own attitude toward patient counselling in specific situations.  2-Emphasize key points. Telling patients beforehand,” now this is very important” may help them to remember what follows.  3-Give reasons for key advice. Tell why it is necessary to continue taking the medication, such as using an antibiotic even though symptoms disappeared.  4-Give definite, concrete, and explicit instructions. Any information the patient can mentally picture is more easily remembered.  Use visual aids, photographs, or demonstrations.  5- Present key information at the beginning or end of the interaction. Experience has shown that patients concentrate on the initial information given and remember best the last items discussed.  6-Supplement the spoken words with instructions.  7-Finally, end the encounter by giving patients the opportunity to provide feedback about what they learned. Ask patients to restate critical points of information to check for accuracy. Nonpharmacological Choices    

Coping with impact on patient’s and caregivers lives Assisting with depression Physical therapy for ambulation and balance Speech language assessments for speech and swallowing assisting

Strategies To Enhance Adherence To Medication Regimens  Integrate new behaviours in patient lifestyle.  Provide or suggest compliance or reminder aids.  Suggest patient self-monitoring.  Monitor use on an ongoing basis.  Refer patients when necessary.


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Practice Station Scenarios # 1 A patient wants to fill a prescription Patient Profile: (given on the table) Current medications:  Lorazepam 1 mg po hs x 30 tabs  Temazepam 30 mg hs PRN x 30 tabs  Note that all Rxs from different Doctors Allergies: none

Rx: Clonazepam 0.5mg BID PRN x 20 tab

Scenarios # 2 A patient wants to fill a prescription Profile: Relpax (eletriptan) 40 mg po qd PRN x 6 tab Rx: Topiramate 25mg daily x 7 days then 50mg daily x 30 tabs

Scenario # 3 A 28 year old female patient suffering from seizures and is on maintenance treatment with Phenytoin has just found out that she is pregnant. She asks you whether she should continue with the medication. Counsel the patient


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Contraception Choosing a right oral contraceptive options  Estrogen + progestin (combined oral contraceptives or COC)  Progestin only (Minipill)  Long-term injectibles or implantation products (Progestin only). Efficacy is high but dependent on proper scheduled use  Oral contraceptives do not prevent the transmission of sexually transmitted diseases  Expect changes in characteristics of menstrual cycle  Use of a back-up contraceptive method is advised if more than one dose is missed per cycle  Warning signs of important complications:  Severe abdominal pain  Severe chest pain, shortness of breath, coughing up blood  Severe headache  Eye problem such as flashing light, blurred vision or blindness Drug Interactions with OC  Anticonvulsants (barbiturates, carbamazepine, phenobarbital, phenytoin) – enzyme P450 inducers ↓ level of hormones Recommendations       

Don’t recommend OCs < 35μg alone Use first-day start method to ↓ interval between packs of pills May suggest back-up method for the first 3 months If no spotting during initial period – can use 35μg OC alone If spotting – prescribe 50μg OC such as Ovral Patch or Vaginal Ring – Not recommended IUD & Mirena or Depo-Provera – can be used

Recommendations  All low-dose OCs have a beneficial effect on acne  Two OCs approved in Canada for the treatment of acne: Tri-Cyclen & Alesse


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 Diane - 35: is indicated in cases of severe acne that do not respond to oral antibiotics or other types of treatment. Diane-35 may not be used in Canada for contraceptive purposes alone.  Handbook of Hormonal Contraception & Office Gynecology 2nd edition, by Rodolphe Maheux Emergency contraception (Plan B)  Plan B is an emergency contraception, indicated for use for unprotected sex (also in case of sexual assault)  The first tablet should be used within 72 hours of unprotected sex. The second tablet 12 hours later.  It is not recommended as routine use as contraception. (Explain why ECP contains a higher dose of hormones and Increase risk of side effects, nausea, vomiting, irregular bleeding, fatigue)  Effects of menses  Experience of delay in menses for +/- 7 days  Lower abdominal pain  Contact physician  Plan B does not protect against infections or STD.  Woman should abstain from sexual intercourse or use an alternate contraception method until the onset of next normal menstrual period.  If necessary pregnancy suspected do pregnancy test and discuss with your doctor.  Most common side effects  If vomit within 1 hour taking medication, then take another medication. (PSC page 669)  You may reduce n/v by taking this pill with food or at bedtime and by taking Gravol an hour before each dose.  Use plan B in emergency situation. Taking ECP won’t have any effect on your future ability to get pregnant or have child.  Prevent unwanted pregnancy. Evra Patch  A study of extended wear of an Evra patch has shown that norelgestromin and ethinyl estradiol concentrations are maintained for 10 days  Patch adhesion is not affected by heat, humidity, swimming, bathing, and exercise or skin moisture.  Most common S/E reported by patch users are breast tenderness & headache.


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Practice Stations Scenario # 1 A female, comes to fill prescription: Rx: Evra patch 3 months Patient profile (presented after pharmacist request) Name: Faith Hart Age: 23 years old Allergies: Not known Current medication; None Medical conditions: None

Scenario # 2 A doctor has a question for his patient? Patient: 28 years old woman Profile: Tegretol CR (Carbamazepine CR) 400mg BID

Scenario # 3 Father of one of your patients comes into the pharmacy very upset and angry Patient: 16 years old Profile: Alesse 28 x 3 pks

Scenario # 4 Doctor is calling for your recommendation for a 20 years old female, “Which contraceptive would you suggest for lady who has acne problem?” Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is 38-3 illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Scenario # 5 A 20 years old female comes to your pharmacy with prescription Rx: Diane®-35 for 3 months

Scenario # 6 An extremely worried young 25 years old lady comes to you, the pharmacist, for your assistance. Ask her what her concern is and help her with any product you feel would be necessary for her condition. On the table: Plan B Patient profile: (presented after pharmacist request) Allergies: not known Current medication; none Medical conditions: none Age: 25 yo


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39 Diabetes Presentation Symptoms Hypoglycemia: Hunger, Nausea, Weakness, Headache, Sweating, Shaking (tremors), Skin becomes pale (pallor), Numbness of lips or tongue, Irritability, Change in mood or behavior Fast heartbeat (palpitations), Faster breathing, Confusion, Vision changes, Seizures, and Coma Hyperglycemia: Increased thirst (polydipsia), excessive urination (polyuria), Nausea/vomiting Weakness, fatigue, Headache, Visual disturbances (blurred vision), Positive urine test for glucose, and elevated blood glucose readings NORMAL = FPG = 5-6 MMOL/L, PPPG = 14 mmol/L, HbA1C = 6% (for 3 months), BMI = 25-27 and HBP + diabetes= > 130/80 Education program to teach the patient:  Basic understanding of diabetes  Role of diet, exercise and medication  How and when to self-monitor blood glucose and why it is necessary  Management of sick days  Recognition and treatment of hypoglycemia  Knowledge of major side effects of medications and how to adjust drugs in response to changes in diet and activity  Care of feet Nutritional Management  Counseling by a registered dietician  Instruct on nutrients from all basic food groups  In Type II diabetics – reduce total caloric consumption so as to reduce weight and improve metabolic control  For patients on insulin, tailor food intake into meals and snacks according to preference, lifestyle and medication


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 In Type I diabetics the amount and type of carbohydrate have the most immediate impact on the level of blood glucose. Advise patient to fix carbohydrate consumption or count the amount of carbohydrate ingested and adjust insulin accordingly Self-monitoring of blood glucose levels  Results in improved diabetic control  Allows for recognition of low blood glucose levels and provides immediate feedback on the effect of therapy  Patients on intensive therapy – monitor before each meal and at bedtime, this is an absolute minimum  Self-monitoring is an integral part of the treatment of Type I and Type II diabetics on insulin and oral hypoglycemic  Also useful in diabetics treated with diet only Physical activity and exercise  An integral part of the management of Type II diabetes  It improves cardiovascular function  Enhances insulin sensitivity  Lowers BP  Lowers lipid levels  Improves glycemic control  Adjust insulin dosage with exercise  Time meals and/or regulate food consumption to ensure safety of exercise regimen Weight loss of 4 Kg or more if overweight  Histories and physical examination to detect comorbidities and complications and should include:  BP measurement  Long-term control – HbA1c every 3 to 4 months for patients on insulin and every six months for those on nutritional therapy or on oral hypoglycemic  Assure accuracy of blood glucose measurements made by the patient  Reinforce skills learned in education and dietary counseling  Urinary albumin excretion rate – using albumin-creatinin ratio – annually  Fasting lipid profile – at time of diagnosis and every one to three years if normal  Eye examination – at time of diagnosis in Type II and five years following diagnosis. In type I at the time of puberty and repeat at least every two years if initially normal Diabetic foot care  Shoes (comfortable), large, no open toe  Socks – no tight, cotton  Don’t walk bare feet  Change shoes and socks daily  Keep feet dry and warm, moisturize (Uremol)  Inspect feet daily  Nail care (avoid ingrown nails) Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 No self care for problems – always go to podiatrist

Practice Station Scenario # 1 A male is overweight and has just been diagnosed with type II diabetes. The doctor has not put him on any medication and he asks you what he can do to improve his condition. Counsel the patient. Patient profile: (given after pharmacist candidate interview)  Age: 55 years old  Current medications: None  Medical conditions: none

Scenario # 2 A 60 year old male comes into the pharmacy and complains of going to the washroom frequently and seems to be thirsty most of the time. In discussion he also complains of slightly blurred vision. Asks you what he can take. Counsel the patient. Patient profile: (given after pharmacist candidate interview)  Age: 60 years old  Current medications: None  Medical conditions: none

Scenario # 3 A patient is asking for your recommendation Profile:  Glyburide 10 mg BID  Metformin 500 mg 1&½ tab BID On the table:  B-D Glucose tablets,  lifesavers candy,  DEX-4 tablets Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Scenario # 4 A patient comes for your recommendation Profile:  Metformin 500mg BID  Glyburide 5 mg BID  Acarbose 100mg TID On the table:  Pepto-Bismol  Zantac (Ranitidine) 75mg  Tums  Maalox  Gaviscon

Scenario # 5 A patient comes for your recommendation On the table:  Dr. Scholl's® one step corn remover  Dr. Scholl's® Liquid Corn/Callus Remover

Scenario # 6 A prescription brings a new prescription    

Patient Name: Billy Age: 46 years Address: XYZ Dr: Tips

Comments: High cholesterol, Type II Diabetes and neuropathic pains Medications:  Metformin 500 mg bid  Glicalizide 40 mg daily  Atorvastatin 40mg/Fenofibrate 100mg Allergies: Penicillin Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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New Rx: Lyrica 75 mg caps I po BID x 90 d R: 3 Scenario # 7 A patient comes for your recommendation Profile: Metformin 500 mg, 2 tabs BID On the table:  Pepto-Bismol  Zantac (Ranitidine) 75mg  Tums  Maalox  Gaviscon

Scenario # 8 A 40 years old male patient presents prescription: Profile: Metformin 500mg BID Rx: Gluconorm (repaglinide) 2 mg TID M: 1 month


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40 Thyroid Disorders Hyperthyroidism Pharmacotherapy Thionamides  It prevents excessive thyroid hormone production  It must be taken regularly in order to be effective.  Do not discontinue used without first consulting your physician  When there is fever, sore throat, unusual bleeding, rash, abdominal pain, or yellowing of the skin patient should notify the physician Iodides  Dilute with water or fruit juice to improve taste



Notify physicians if ever, skin rash, metallic taste, swelling of the throat, or burning of the mouth occurs

Non pharmacologic Choices  Surgery in patients (medical therapy is often initiated prior to surgery to make patient euthyroid if possible):  With thyroid nodules  With large goiter  Occasionally in Graves disease

 For management of thyroid cancer (malignancy), control ectopic production of thyroid hormone.


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Practice Stations Patient Profile: Presented on desk Patient Name: Jenny Age: 32 years Address: xyz Dr: Tips

Comments: Hyperthyroidism Medication: Methimazole 10 mg BID (3 weeks ago)

A patient comes to you in the pharmacy with a concern. Respond as you would in the pharmacy. On the table:  Tylenol Extra Strength tablets  Advil tablets


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Asthma Asthma Management  Assess: asthma control, triggers, compliance, inhaler technique & co-morbidities  Assessmentregular assessments of asthma technique, assess adherence to therapeutic regimen, assess asthma control.  Education teach correct inhaler technique, demonstrate to confirm patient understands, and explain the basic principles of the disease highlight inflammation and muscle constriction. Ensure patients understand the role of the medications. Using inhaled corticosteroids on a regular basis in order to achieve good asthma control is a key message for pharmacists to focus on.

Questions to ask  Have you used these puffers before? (Review techniques)  Do you know what makes your asthma worse? (Avoid triggers-dust mite, mould, some food, pet allergies, pollen) Keep diary.  Do you take any other Rx medications, such as beta-blockers, aspirin (they could exacerbate asthma)  Have you had any changes recently-ask about non-allergic triggers cold and flu virus, weather changes, thunderstorms; ask about exercise- often asthma symptoms triggered by exercise; perfume and hairspray can irritate the airways. It is best not to use them. Some women find that their asthma worse during pregnancy, periods or menopause. Defining asthma control  Daytime symptoms < 4 days per week  Night-time symptoms < 1 night per week  Normal physical activity  Mild, infrequent exacerbations  No absenteeism due to asthma  < 4 doses/week of a fast-acting β2-agonist (apart from 1 dose/day before exercise)  Peak expiratory flow (PEF) ≥ 90% of personal best  Diurnal variability in PEF < 10-15% Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Treatment plan  Very Mild: short-acting β2-agonist PRN  Mild: ICS at low doses (if ICS is not an option, then LTRA, although less effective)  Moderate: if not adequately controlled by ICS, add LABA (alternatives: add LTRS or #ICS to moderate dose, but less effective)  Severe: #ICS to high dose, if very severe add Prednisone PO. Complementary Activity of ICS & LABA  ICS improve the effectiveness of LABA by up-regulation of β2 receptors  LABA improve the effectiveness of ICS, possibly by priming the glucocorticoid receptor for activation Budesonide/Formoterol – single inhaler as maintenance & reliever     

Prolongs time to first severe exacerbation Reduces frequency of severe exacerbations Improves asthma symptoms PRN doses allow early intervention (increasing ICS dose) thus preventing exacerbation before it occurs.

Formoterol for asthma relief  Has onset of action as fast as salbutamol, 1-3 minutes after inhalation  In combination with budesonide has been shown to be as effective & well tolerated as salbutamol in relieving acute asthma  Formoterol: full β2-agonist  Salmeterol: partial β2-agonist with slower onset of action (not to be used as reliever) Counseling on Symbicort  Maintenance of BID dosing is necessary  As effective in short term as short acting β2-agonists (i.e. salbutamol), and beneficial in the long-term.  Maximum dosing: 8 inhalations per day  Symbicort SMART approach approved by Health Canada  SMART – single maintenance and reliever therapy


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Practice Station Scenario # 1 A very concerned lady comes to you, the pharmacist, asking for your help. Respond as you would in the Pharmacy. Patient Profile: Presented after pharmacist request Patient Name: Mrs Jane Age: 28 years Address: XYZ Dr: Tips Comments: Asthma Medications Salbutamol Inhaler PRN Advair Diskus 1puff BID

Since 3 years ago

Dr Tips Tips

Scenario # 2 A doctor’s station, wants to talk to you! Patient Profile: (presented on desk)  Advair MDI 250 mcg I puff BID 250/25mcg  Bricanyl as reliever  Advair Diskus 250/50 I BID Allergies: None Medical conditions: Asthma for the past 2 years

Scenario # 3 A very concerned lady comes to you, the pharmacist, asking for your help. Respond as you would in the pharmacy. Patient profile (presented after pharmacist request)  Candesartan 8 mg po od  HCTZ 25 mg po od Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Fatigue, Nasal Congestion, Sore Throat No fever On the table:  Tylenol, Sudafed,  NeoCitran total,  Otrivin,  Salinex NS,  Tylenol Cold,  Cepacol Lozenges,  Strepsil Lozenges  Salinex NS, Lozenges

Scenario # 4 A doctor’s has question for his asthma COPD patient. Patient profile: (presented by patient after pharmacist request) Combivent (ipratropium bromide/salbutamol) ii puffs QID

Scenario # 5 Address their concerns and their need for information. On the table:  Tylenol  Sudafed  NeoCitran  Otrivin  Dristan  Salinex NS  Tylenol Cold  Cepacol Lozenges  Strepsil Lozenges  Ricolla Lozenges


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Scenario # 6 A mother comes into the pharmacy and complains that her 15 year old son who is using a Sodium Cromoglycate bid inhaler seems to be getting more frequent asthma attacks and his asthma seems worse at night. He also takes Salbutamol, which he has not been taking that regularly. She asks whether she should increase the use of the Cromoglycate inhaler. Counsel the patient.


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Cold, Cough, Congestion and Fever Signs and symptoms  First sign is usually sore throat, described often as dry or scratchy sensation  Rhinorrhea and nasal congestion follow the sore throat. Nasal discharge is initially clear and watery, but becomes thicker as the infection progresses  Congestion may lead to sinusitis and headache or to otic symptoms (especially in children)  Postnasal drip is common and can cause coughing or laryngitis  A dry cough often follows the nasal congestion  Fever is common in children, but not in adults Nonpharmacologic Choices  Bed rest  Drinking plenty of fluids  Humidifying the air Pharmacotherapy        

Salt water gargles and throat lozenges – soothing to a sore throat First generation antihistamines – relieves rhinorrhea and watery eyes Topical and oral nasal decongestants – relieves stuffy nose and sinuses Oral decongestants more effective than topical but produces more adverse systemic effects Expectorant, guaifenesin – treats dry cough with chest congestion Dextromethorphan – to suppress dry, unproductive cough Analgesic/antipyretic – for body aches and fever in adults Zinc – controversial but zinc gluconate lozenges may reduce some symptoms of common cold but may cause nausea and impart bad taste


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Practice Station Scenario # 1 A young man comes to your Pharmacy asking for your assistance. He has got a concern regarding his condition and wants to purchase something that he feels would help him. On the table:  Echinecea Tablets  Pseudoephedrine 30mg tablets  Saline nasal drops  Dextromethorphan cough syrup

Scenario # 2 A male patient comes to you in the Pharmacy to purchase a certain product, which he believes will benefit his condition. Advice him accordingly and give the necessary recommendations regarding his condition. On the table:  Echinecea Tablets  Garlic capsules  Vitamin E capsules  Ginseng capsules

Scenario # 3 A patient approaches you for recommendation about cough syrup Patient Profile: (patient provides after pharmacist request)  Ramipril 10 mg po od (1 month)  Simvastatin 10 mg po od (1 year)  On the table: DM syrup, DM-E syrup Solve problem and counsel Scheme # 4 A young mother with a baby comes into the pharmacy and asks you for something to give her baby as the baby have a fever. Counsel the patient. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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43 Allergic Rhinitis Patient presentation symptoms  Runny nose, watery eyes, itchy tongue, eye, Questions to ask:  Is your nasal drainage clear, white, yellow, green (to rule out infection)? Is it thick or watery?  Do you have a cough, fever, or sore throat?  How often do these symptoms occur?  Do you notice a change in different environments? Is it better indoors or outside?  Are your symptoms associated with specific activities (eg. gardening)? Risk factors: age (usually before 20 years), family history of atopy (asthma, eczema) Nonpharmacological Choices       

Avoid allergens – reduces medication use Use air conditioning – reduces pollen exposure Remove pets – reduces perennial symptoms caused by animal dander Avoid dust – reduces symptoms by 60% Saline nose spray – symptomatic; washes out mucus and inhaled allergens Lubricant eye drops – relieves conjunctival symptoms Desensitization/ allergy shots (immunotherapy) – indicated in difficult to control IgE mediated sensitivity caused by pollen or dust mites  Antihistamine counseling? Patient advised to not drive. Non-sedating antihistamine rarely effect skilled tasks, require caution. Pregnancy consider use: Chlorpheniramine, hydroxazine, and cetrizine. Suggested reference  Patient Self care pp135, 2002  Therapeutic choice 4th ed. Page 404 Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Practice Stations Scenario # 1

A doctor has recommended that a pregnant patient who is a regular customer at your pharmacy takes Chlorpheniramine maleate for about a bad hay fever. She asks for your opinion and seeks reassurance. Counsel the patient. Patient profile: (given by patient after pharmacist candidate request) Name: Julia Bown Age: 29 yo Allergies: none Current medications: OTC materna Medical conditions: None During discussion, she mentioned that she is 4 months pregnant.


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44 Canker and Cold Sores Presentation symptoms Canker sores  Painful, recurrent ulcers in the oral mucosa  3-10mm shallow lesions  Round with white centre and red halo  Persist for 7-14 days Cold sores  Begins with prodromal symptoms of mild burning or itching on the lips  Small vesicles filled with clear fluid, which eventually ruptures and crust over  Last for 3 to 10 days Differential diagnosis  Canker sores tend to arise inside the mouth on the inner lining of the lips or the cheeks or on the tongue.  Cold sores tend to arise on the outside of the lips. Counsel patients with canker sores to:  Rinse their mouth as often as possible with warm  Water, a saline solution or a mouthwash  Avoid any known precipitating factors and irritating foods and remove any cause of trauma such as ill-fitting dentures  Ice applied within 24 hours of the prodrome can abort a cold sore. Ice should be applied continuously in the area for 45 to 60 minutes as soon as possible after the prodromal symptoms are felt. Pharmacological Treatment Goal – alleviate pain and protect the lesion  Topical anesthetics – contain up to 20% benzocaine  Applied to only small areas of the mouth to prevent a “cotton-mouth” feeling and loss of oral sensation Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is 60-1 illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Protectants – emollient mixtures or denture adhesives can alleviate pain  Chlorhexidine gluconate mouthwashes – help resolve cankers  Burrow’s solution or cold compresses with tap water – applied 3-4 times daily is helpful for cold sores  Sunscreeen with SPF 15 – recommended to prevent cold sores in those with recurrence after exposure to sun Useful Tips In Treating Cankers And Cold Sores  Try to avoid any of the known triggers of cankers and cold sores  Avoid touching a cold sore. Herpes virus can be spread by physical contact with other parts of your body or with other people  Wash hands frequently, especially after applying medication to cold sores. Avoid sharing washcloths, towels and linens  A cold sore can sometimes be prevented by applying ice for 45 to 60 minutes to the affected area during the tingling or burning sensation that sometimes happens just before a cold sore forms.  Apply pain-relieving medications to only small areas of the mouth. Applying too much pain-relieving medicine or anaesthetizing too large an area of the mouth can result in a “cotton-mouth” feeling, or can result in serious burns from hot foods and liquids  If sunlight seems to trigger cold sores, try using a lip balm containing a sunscreen

Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is 60-2 illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Practice Station Scenario # 1 A 20-year-old man comes to you to the dispensary counter to pay for a can of Vaseline that he took from the self-selection area of the Pharmacy and asks if he can use it for his problem. Assist and counsel him as would in the Pharmacy. On the DESK: Ora-base (Benzocaine gel) Reference: PSC and CPS

Scenario # 2 An 18-year-old male asks about a blister that has reoccurred on the same spot on his lip. He had the same thing happen earlier this year. Counsel the patient.

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Ophthalmic Drugs Presentation symptoms      

Red, ITCHY (mod to severe), watery eyes Mild eyelid swelling- may cause pain Clear discharge Foreign body sensation Affects both eyes +/- Clear nasal discharge, sneezing

Questions to ask:    

How long has the patient had these symptoms? (Onset, duration) Has the patient had similar symptoms before? Has the patient tried anything to solve the problem? Outcome? Are there any aggravating factors that cause the red, itchy, watery eyes? (i.e. Allergies, certain times of the day or year, environment)?

For Differential Diagnosis (if allergy is less obvious), ask if…  Purulent, sticky discharge (+/- fever, may be one eye)= Bacterial  Watery, inflamed conjunctiva, (+/- fever, usually one eye)= Viral  Burning, no discharge= Chemical  Itchy/ irritated, minimal discharge, both eyes= Dry eye Refer  Moderate to severe SAC or those who don’t respond to non-Rx tx w/in 48-72hrs  Acute bacterial conjunct in children, contact lens wearers, and those who don’t respond to non-Rx Polysporin eye drops w/in 48hrs—Need empiric broad spectrum antibiotic eye drops like TMP/polymyxin B or erythromycin (FQ reserved for serious infections). Normally it’s self-limiting, resolve w/in 2 wks, tx shortens course to 1-3 days (caused by S. auerus, S. pneumo, H. influenza). Soak eyelids stuck together w/ warm compress, stop contact lens wear, irrigate eyes w/ sterile saline, Polysporin (polymixin B/gramicidin) 24x/day x 7-10d; continue for 2 days after symptoms resolve. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Hyperacute bac conjunct (if suspect N. gonorrhea or N. meningitides)—Need antibiotic (ceftriaxone IM or cipro)  Chronic bac conjunct (>4 wks, assoc w/ blepharitis and makeup)—Need oral antibiotic (tetracycline or metronidazole)  Viral conjunct (if herpes simplex or zoster instead of adenovirus)—HSV or zoster need topical trifluridine or antiviral (ACV, FCV, VCV); Adenovirus treat supportively only: warm or cold compress, avoid contact w/ other ppl (out of school, etc) for 7d  Dry eyes if symptoms don’t resolve w/in a few days (if preservative free OTC artificial tears not enough). Non-pharmacological  Avoid allergens like grassy fields, trees, and flowers, keep pets outside, stay indoor in AM. Keep windows shut, hardwood floors, avoid curtains so you don’t collect dust or animal dander  Don’t wear contacts until symptoms resolve b/c they trap allergens, dirt, debris  Apply cool, moist compress  Irrigation w/ sterile saline to dilute allergen and decrease contact time to eye  Avoid rubbing/scratching eyes  Good hygiene, proper hand washing. Treatment Plan Non-prescription drugs  Oral antihistamine: Good if patient also has nasal symptoms and sneezing—1st gen Benadryl slightly faster onset, can cause drowsiness + QID, 2nd gen Claritan/Aerius OD.  Mast cell stabilizer eyedrops (Cromolyn, Opticrom): prevent release of histamine and most inflammation mediators. Good for prophylaxis for entire allergy season: loading time 2 wks= little effect if histamine has already been released, not for acute attacks. BID-QID  Antihistamine/Decongestant (vasoconstricting) eyedrops (Naphcon A, Opcon A, Visine Advance Allergy): best for immediate relief of red, itchy eyes, but SHORT term use only b/c risk of rebound redness. Decongestant eye drops NOT for pts w/ glaucoma, HTN, MAOI. BID-QID  Artificial Tears (Genteal, Tears Naturale II, Refresh Tears): lubricate + soothe eyes, dilute allergen; freq dosing Prescription drugs  Mast cell stabilizer/Antihistamine (Zaditor, Patanol): relief within minutes + long duration. Best for long term prevention. BID  Ophthalmic antihistamine (Livostin= levocabastine, Emadine= emedastine): better than antihistamine/decongestant combos for relieving itchy, watery eyes. TID-QID  Ophthalmic corticosteroids (FML, PredForte= prednisolone): save for more serious conditions or as last resort. Can mask infection, lead to glaucoma, increase IOP  Ophthalmic NSAIDs (Acular= ketoralac): reduce inflammation, redness, but takes 2-3wks for onset of action. Interact w/ ACEI, B-blockers QID—not a good choice. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Education:  How to instil eye drops (press corner of eye to decrease systemic SE; most have few SE, some sting), cold compress  Don’t use decongestant eye drops >3days, non-pharms to avoid allergen exposure  Wait 5-10 mins between instilling different eye drops so they don’t dilute one another, order doesn’t matter  Once you open eye drops, discard w/in 1 month usually, some okay up to 2mo

Practice Station Scenario # 1 An elderly man comes into your pharmacy claiming to need something for his eyes. They are sore but not appear red. Patient’s profile: (patient provides after pharmacist request)  Optometrist diagnosed his condition as dry eye  Eyes are not itchy, but irritation has lasted for month or so. They seem to be the most sore when he is lying in bed to sleep  Tried eye drops but found it difficult to administer them, so he quit using them  Medical history: High cholesterol  No known drug allergies  Current medicines: a multivitamin and mevacor

Scenario # 2 A patient is asking for your recommendation. On the table:  Tears Naturelle II  GenTeal Artificial tears  Polysporin eye/ear drops  Visine original

Scenario # 3 A patient comes for your recommendation On the table: Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Visine Allergy Cromolyn eye drops Optichrom Tears Naturelle II

Scenario # 4 A patient comes to fill prescription Rx: Fucithalmic eye drops Sig: 1 gtt ou bid x 7 days Patient profile: Name: Faith Hill Age: 60 yo Allergies: Not known Current Medications: Atorvastatin 10mg Medical conditions: High cholesterol


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Conjunctivitis Allergic conjunctivitis Presentation symptoms  Red, ITCHY (mod to severe), watery eyes  Mild eyelid swelling- may cause pain  Clear discharge  Foreign body sensation  Affects both eyes +/- Clear nasal discharge, sneezing Non Pharmacological therapy:  Allergen avoidance  Cold compress over the eyes offer considerable relief of symptoms Viral conjunctivitis (Keratoconjunctivitis)  Non-Pharmacological: Give warm or cold compress to increase comfort.  Non Rx therapy: Ocular decongestants and/or lubricants may be useful.


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Practice Station A young male patient comes to you in the Pharmacy. He is very worried and concerned about his condition. Solve his concern and provide all relevant information that you feel would be necessary. On the table:  Polysporin Eye Drops  Phenylephrine Eye Drops  Sodium Chromoglycate Eye Drops

Patient profile: Age: 30 yo Allergies: None Current medications: None Medical conditions: none


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48

Otitis Externa Presentation symptoms     

Pain with tragus movement Pruritis Discharge Difficulty hearing Fever

Questions to ask: What is the description of the problem?  Is ear itchy?  When did pain begin and how severe?  Discharge?  Difficulty hearing?  Fever? Has the patient seen a physician? What measures have been taken? Refer  If blood in ear-this means tympanic membrane has been perforated  Significant edema or debris in the ear Non pharmacological  Keep ears dry with low heat hair drier after shower  Use ear wick- not ear wig, promotes movement of drug into canal especially when there is lots of inflammation-use for 12-36 hours  Use hot compress to alleviate pain Pharmacotherapy  Antibiotics for bacterial infection  Fluoroquinolones: Ofloxacin 0.3% solution Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 97% efficacy, no ototoxicity, only prescription antibiotic that can be used with a ruptured tympanic membrane  Instil one to two drops twice daily  Analgesics for pain  Ibuprofen- (Advil)  Has anti-inflammatory effects which acetaminophen does not have, aspirin can be ototoxic at high doses  Take one to two tablets every 4-6 hours as needed  Fast relief- a couple of hours Prevention Keep the ear canal as dry as possible  Use bathing caps when swimming Do not clean wax out of ears  Ears are usually self-cleaning and the wax protects against infection –do not use q-tips Administering drops  Wash your hands  Hold the bottle between hands for 1 to 2 minutes to bring it to body temperature to avoid dizziness  Lie on side with affected ear facing upward. Shake bottle well and instil drops.  The bottle tip should not touch ear, fingers, or other surfaces.  Gently pull the outer ear lobe upward and backward allowing drops to flow down ear canal.  Remain on side for 60 seconds. Repeat, if necessary, for the opposite ear.  Discard any unused medicine.


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Practice Station Scenario # 1 A mother comes to you in the pharmacy complaining that her daughter is not doing that well. Advice her and take the right action to help her. On the table:  Tylenol syrup  Auralgan eardrops  Advil syrup  Gastrolyte sachets Patient profile: (provided after pharmacist candidate request)  Daughter age: 3 yo female  Current Medication: None  Medical conditions: Not feeling well, complaining pain

Scenario # 2 A patient comes to fill a prescription Rx: Ciprodex ear drops ii gtts into affected ear BID x 7 days Patient profile: (provided by patient after pharmacist request)    

Age: 18 yo Allergies: Not known Current medications: none (use contact lens) Medical conditions: none, just ear pain


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49

Vertigo and Dizziness Vertigo is defined as sensation of motion where there is none or an exaggerated sense of motion in response to given bodily movement. It is cardinal symptoms of Vestibular disease as a result of lesions or disturbances in the inner ear. Dizziness is defines as variety of sensations such as light-headedness, fainting, spinning and giddiness. Non pharmacological  All patients with vertigo should see a doctor to find out what is causing it.  Vestibular rehabilitation is a physical therapy program to improve balance, eye hand coordination and habituate the patient to feelings of dizziness.  Salt restriction for Meniere’s disease  Bedrest for acute viral neurolabyrinthitis  If you suffer from attack for vertigo, avoid potentially hazardous activities.  Medication may be used to treat vertigo and any upset stomach it may cause.


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Practice Station Scenario # 1 A man comes to your pharmacy, complaining variety of sensations such as light-headedness, fainting, spinning and giddiness. Patient profile: (patient presents after pharmacist candidate request)  Current medication: none  Medical conditions: none  Allergies: none  Age 40 yo


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50 Foot Symptom Assessment Plantar warts  Medication should go down to root. May take months to completely resolve, however you may see improvement in 2 weeks. Self care measures:  Keep feet dry  Avoid sharing personal items.  Do not go bear feet on swimming pools.  Patient 27 year old Toenail infection    

Itraconazole capsules (for toenail with or without finger nails) fungal infections. 1 cap bid for 7 days (3 weeks drug free period) Take with food and after food Avoid grapefruit juice

Ref: CPS page 1976, 2005


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Practice Station Scenario # 1 A women comes with have painful lump on sole. Wants to buy Duofilm forte 27 gel compound with liquid Patient profile: Name: Red Rose Age: 45 yo Current Medications: Metformin 500 mg bid, glicalizide CR 60 mg once daily and ASA 81 mg Medical conditions: diabetes from past 5 yrs On the desk: Reference: Patient Self Care

Scenario # 2 A 33-year-old female got a new prescription for toenail fungal infection Rx Sporanox 200 mg 1bid for 3 months Patient profile: (provided after pharmacist candidate request)  Daughter age: 33 yo female  Current Medication: None  Medical conditions: not comfortable, nail bothers

Scenario # 3 A patient comes to fill a prescription Patient Name: Michael Age: 26 years Address: XYZ Dr: Gaucher

Comments: Onchomycosis Medications: None Allergies: Sulphur

New Rx: Lamisil Cream, apply BID x 3/12


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Athlete’s Foot

51 Athlete’s Foot Patient presentation  Most commonly presents as chronic infection between lateral toes, often spreading to instep/sole  May also present as blisters, pruritus lesions, burning sensations, redness and inflammation; skin may appear macerated, odour may be present  Differential diagnoses include disturbances of sweat mechanism, contact dermatitis, eczema, erythrasma, psoriasis, bacterial infections Patient concern  Patient may be upset/embarrassed about condition – stress that it is common & curable  Patient should be monitored for possible allergic reaction to product - if one develops, advise to discontinue use & refer to M.D.; also monitor for efficacy of treatment, if symptoms show no improvement w/in 2 wks or if have not disappeared w/in 6 wks, refer to M.D., chiropodist or podiatrist  Emphasize importance of finishing course of treatment to prevent recurrence, even if symptoms improve  Emphasize that condition is contagious and provide suggestions to prevent transmission to others  Tell patient to complete the full course of therapy for improvement (for 1 wk)

Pharmacotherapy Treatment plan

Effective antifungals include imidazoles (fungistatic, 70% effective, bid, also have some anti-inflammatory and gram +ve antibiotic effects), butenafine (fungicidal, 90% effective, od), terbinafine (Rx, fungicidal, 90% effective, od for 1wk) products containing chlorphenesin, tolnaftate, or undecylenic acid have unknown or poor efficacy, and should not be recommended If secondary bacterial infection is also present (diagnosed by M.D.), Polysporin cream can also be used, bid-tid for 1wk


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Tolnaftate Clotrimazole 1% Miconazole nitrate 2% Oxiconazole 1% Tioconazole 1%

Athlete’s Foot Prescription oral antifungals (terbinafine, ketoconazole, itraconazole, griseofulvin) are indicated for infections of the nail or infections resistant to topical treatment Cream, Gel, Liquid, Powder, Spray Powder, not used under 2 year age not under 2 years of age, oral lozenges, topical cream 1%, topical lotion, vaginal tablet, vaginal cream. cream, spray powder, not under 2 years cream and lotion not under 12 years age Cream, not under 2 years Butenafine 1%, Chlorphenesin 1%, Undecylenic acid

Nonpharmacologic Choices  The most important consideration is to keep feet clean and dry - advise pt to change socks daily, allow shoes to dry completely before wearing again, dry feet thoroughly (esp. between toes), use a clean towel every day, don’t share towels, don’t go barefoot in public places (wear flip-flops), wear socks of natural material (eg. cotton, wool), wear shoes with good ventilation (eg. leather, canvas)  Antiperspirant can be applied to feet to decrease sweating  Patients with hyperhidrosis of athlete’s foot can dust an antifungal power on feet (but don’t place in shoes – may coagulate with moisture)  Separate toes with cotton ball to absorb moisture and decrease moisture build-up Refer to physician  Patient with diabetes, Cancer or PVD, and immune compromised,  Elderly, Malnourished, Child <12yrs; if lesion is weeping, Severely inflamed, Oozing purulent material, Eczematous, Painful; if toenails are thickened or discoloured.

Practice Station Scenario # 1

Rx: Sig: M:

Lamisil 250mg tabs 1 tab OD x 7days for athlete’s foot 7 tabs

Patient’s Profile:  21 year old male  Codeine allergy  Past medical history: Amoxicillin 2 years ago, nothing more Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Diaper Rash Patient presentation  Infant patient – caregiver worried, afraid, frustrated; baby crying but not able to tell how he/she feels.  Adult patient – embarrassment, frustration, fear, language barrier, patient values How to approach a problem? Questions to ask  Medication history: Antibiotics or anticonvulsants. The risk of drug induced diaper dermatitis in infants is higher than other patients because of the high surface-to-volume ratio and the difference in drug metabolism and detoxification.  Frequency of diaper change  Specific location of the rash  What does the rash look like & how severe it is?  Did the rash change in severity from mild redness to tomato red plaques? (may indicate Candida diaper dermatitis)  Have they tried using anything to get rid of the rash? Drug Related Problems  Patient is not administering therapy properly.  Patient requires drug and non-drug therapy but is not using it.  Patient is experiencing adverse reaction secondary to use of products with lanolin, fragrance, or other irritants.  Patient is using therapy, which is not required (eg. Topical antibiotic, anesthetic).  Patient is being administered inappropriate dose (eg. Zinc oxide). Refer to physician


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 Rash has been identified correctly but has failed to improve over a week of recommended treatment  Increased pain, inflammation or itching, fever  Oozing blisters or pus present  Dermatitis has not healed in 7 to 10 days, or is chronic or recurs frequently  Complicated secondary infection UTI or infection of penis or vulva  Signs of immunodeficiency, deep ulceration, or abuse or neglect. Treatment plan:  Prevention of diaper rash  Non-pharmacological + Zinc Oxide 15%  Complicated diaper rash  Non pharmacological + zinc oxide 40%+clotrimazole 1% cream  Order of application: Hydrocortisone, then antifungal, then barrier Nonpharmacological Choices        

The ABCDE’s Air drying: as long as is practical during and in between diaper changes Barriers: avoid any type of powder Cleansing use water with mild soap to clean the soiled area. Do not use the clean part of the diaper or baby wipes with fragrance or alcohol Diapers should be changed as frequently as practical to reduce occlusion & decrease contact time of urine and feces with skin. If using cloth diapers wash with mild detergent only and use a cup of vinegar in the final rinse cycle which lowers the pH. Educate patients & caregivers on prevention & treatment of diaper dermatitis. Compressing with tap water until blistering and wetness has stopped (1 minute on, 1 minute off for 2 minutes a few times per day) if blisters are present. Diet: avoid foods that increase urinary output and urinary & fecal pH (eg. high protein diets, caffeine, citrus juices)

Pharmacotherapy Barriers  Desitin Zinc oxide cream (37% zinc oxide) for treatment of diaper dermatitis (Note: Zincofax Extra strength 40% contains lanolin so it may not a good recommendation). Zincofax fragrance free 15% can be used for prevention. Apply at each diaper change. To remove the cream, use mineral oil or water.  Vasoline (petrolatum) may be irritating to inflamed skin and can lead to maceration of over-hydrated skin  Silicone Based: Dimethicone, dimethlypolysiloxane (No Sting Barrier) is a soothing cream, but it may be irritating since it contains lanolin. Antifungal  Clotrimazole (Canesten) 1% topical cream or miconazole (Monostat ) 2% applied q12h for 7 to 14 days. Anti-inflammatory Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Hydrocortisone: 0.5% OTC.  Apply TID for no more than 1 week  Consult physician if under 2 yrs of age

Practice Station Scenario # 1 A mother of a child comes to you in the Pharmacy with a concern about her 9-month-old baby. She is really worried and needs your assistance. Advice her accordingly and solve her concern. Patient profile: (present on the table) Patient Name: Jim Age: 9 months Address: XYZ Dr: Tips

Comments: None Medications: Zinc Oxide 15% (6 months ago) Zinc Oxide 25% (2 months ago)

On the table:  Hydrocortisone Cream 0.5%  Miconazole Cream  Zinc Oxide 40%

Scenario # 2 A mother comes into the pharmacy with her baby and complains that the baby has a very red bottom and she has also noticed that the skin is a little broken. She asks how she could prevent this from happening. Counsel the mother


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Head lice and Scabies Patient presentation  Itching in respective areas (refer if due to drugs and other disease)  due to lice squirming/moving (Head lice  back and sides of scalp & behind ears)  Scratching can cause inflammation, excoriations, crusts and secondary bacterial infection (pustules)  Hypersensitivity reaction to bites  itchy papules  Hatched nits are light/translucent, while unhatched live nits are darker colour  Extreme case: fever, fatigue, irritation  Body lice  nocturnal pruritus, erythematous papules with central puncture point (bite sites)

 Pubic lice  lice are small, yellow-brown to gray dots.

Itching, burning, eye

irritation Questions to ask:       

Any allergies to chrysanthemum or ragweed? If so, describe symptoms Other close contacts (family, friends, etc.) that could be infected? Has the patient used a particular medication for lice before? Is patient currently using a lice treatment? If so, how is it being used? Is patient pregnant? History of seizures/epilepsy? Does the itch get worse at night? If pubic lice, have you been tested for STD’s?

Drug Related Problem  Re-infestations due to lack of treatment of close contacts and fomites  Lack of nit removal  Not using medication properly (ie. not leaving on scalp for appropriate length of time, etc.)  Not using enough of the medication/shampoo each time  Medication not working due to resistance Refer Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 53-1 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep



Recurrent/unresponsive head lice Patient contraindicated or resistant to use of pediculicides Evidence of bacterial infection (redness, pus)  may require antibiotics Excessive itch still after treatment (it is normal to be itchy for several weeks after treatment)  may require a steroid (hydrocortisone) cream or antihistamine for relief

Pharmacotherapy Treatment Plan  All available products are similarly effective when used correctly.  Generally: permithrin (most efficacious) > pyrethrins > lindane  Oral anti-histamines or topical corticosteroid (hydrocortisone 0.5% cream)  itch relief (caused by lice or pediculicide treatment)  Resistance: Try switching to another class of pediculicide. If that fails, try permethrin 5% cream left on hair overnight covered with shower cap, ivermectin 200 ug/kg po (avail thru special access program in Canada), or combo of oral co-trimoxosole 10 mg/kg/day (BID x 10 days) plus permethrin 1% used daily for 10 min on days 1-7. Permethrin 1% (Nix, Kwellada)  MOA: Good ovicidal activity and immobilizes lice  Caution in kids less than 2 months old  CI: Allergies to ragweed and chrysanthemum (but if it is just an inhaled ragweed allergy, topical permethrins can still be used)  SE: Mild, transient itching, redness, swelling (less common: burning, stinging, rash, tingling, numbness)  Alcohol base is more effective than aqueous, but aqueous is preferred in asthmatics and pregnancies  Applying method: Apply to towel-dried hair, leave for 8-10 hours (off-label recommendation  better efficacy), then rinse. Apply second treatment 7-10 days later. (Product monograph says leave on 10 min, but that is not as efficacious) Pyrethins with piperonyl butoxide (R&C Shampoo/conditioner):  Low ovicidal activity  CI: Avoid in people with allergies to ragweed, chrysanthemum, or petroleum products  SE: contact dermatitis  Sprays  uncertain efficacy for inanimate objects  Applying method: Apply to dry hair for 10 min, and then add a little bit of water to lather. Rinse thoroughly with water. Repeat treatment in 7 to 10 days. Lindane 1% (Hexit shampoo, PMS-Lindane (generic))  Caution in children < 10 y.o., elderly, pregnancy/lactation, seizure disorders, inflamed skin  Low ovicidal activity Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 53-2 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 CI: People with extensively excoriated/open skin, elderly and children may have enhanced percutaneous absorption and increased risk of toxicity  SE: slight local irritation, neurotoxic (dizziness, N&V, hallucinations, abnormal movements, seizures)  Applying method: apply to dry hair for 4 min, and then add small amt of water to lather. Rinse thoroughly with water. Repeat in 7 to10 days. Non-pharmacological choices  Avoid sharing personal items such as clothing, combs, hats, hair accessories and bedding  After each treatment, dead nits will still be attached to hair. Use nit combing/Bug Busting. May apply formic acid 8% rinse to loosen nit  Clothes, linens, scarves, hats and other fomites should be dry-cleaned, washed in hot water and dried in the hot cycle, or stored in plastic bags for at least 10 days.  Comb wet hair over white paper (to catch lice) using a fine-tooth nit comb. Comb from scalp to the end of the hair. Then rinse and repeat.  Repeat every 3-4 days for 2 weeks.  Combs and brushes should be soaked in hot water for 5-10 min. or washed with a pediculicide shampoo.  Clean comb with soap and hot water after use. (Can also use fingertips/nails or tweezers to remove nits from hair)  If meds are CI, can use only Bug Busting (with conditioner to loosen nit). But this only kills 50% of lice/not ovicidal.  Vinegar to loosen nits is not proven.  Furniture and rugs should be vacuumed for scabies


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Practice Station Scenario # 1 A mother comes to you in the pharmacy complaining that her daughter is itchy and irritatingll. Advice her and take the right action to help her. Patient profile: (patient presents after pharmacist candidate request)  Age: 9 yo, goes to elementary school, grade 3  Current medication: none  Medical conditions: none  Allergies: none On the table

Scenario # 2 A mother comes into the pharmacy and explains that there is a lice epidemic at her 8 year old daughter’s school. She has used the lice shampoo, but still believes there are lice in the hair. She has difficulty in seeing the lice and asks what she should do. Counsel the mother


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Dermatitis Patient Presentation Symptoms  Acute: itching & inflammation (redness, swelling, pain, warmth)  Chronic: scratching, scaling, inflammation, dryness  Acute lesions – erosions with serous exudate or intensely itchy papules and vesicles on an erythematous base  Subacute lesions – characterized by scaling, excoriated papules, or plaques over erythematous skin.  Chronic phase – less red; skin shows lichenification and pigmentary changes (increased or decreased) with excoriated papules and nodules.  Pattern of disease varies based on the age of the patient  Areas: face (esp. infants), neck, upper trunk, wrists, and hands (esp. adults) and, folds (esp. children) Questions to ask:  Do you have (or do you have a family history of) asthma, hay fever, or allergy, atopic dermatitis?  Is it itchy? Does it disrupt sleep / daily activities?  How long have you had it? Previous history?  Are others affected? Occupation? Contact?  Age/distribution (may vary w/ age)  Area of involvement, blisters?  What makes it better/worse?  What have you tried already? Drug Related Problems  Using unnecessary drug (e.g. topical anti-histamine)  Experiencing adverse effects (e.g. allergic reactions to topical)  Inappropriate use of topical corticosteroids (continuous, excessive use over long periods)  Requires prevention measures (non-drug and hydrating agents)

Treatment Plan  Avoid trigger factors and pruritus  Suppress inflammation, Lubricate skin, use moisturisers and  Acute: itching & inflammation (redness, swelling, pain, warmth) should ↓50% w/in 7-10 d; no progression/extension to other sites.  Chronic: scratching, scaling, inflammation, dryness - control by 4-8 weeks. No progression. Lengthen symptom-free periods. Pharmacotherapy  For itch and inflammation that have appeared:  Topical corticosteroids: consider age, location, extent, vehicle, frequency, and concentration  Hydrocortisone 0.5% (OTC) – face, scalp, skin folds  Stronger steroids: not for use on face of skin folds  Low potency – twice weekly with emollients for chronic, dry AD  Mid-to-high potency – for acute exacerbation  Apply a thin layer to affected area BID-QID  Avoid using for >2 weeks (tachyphylaxis)  Taper when scaling, itching is subsiding: from BID to daily to alternate-day dosing while using emollients  AE: atrophy, hypopigmentation, striae, telangiectasia, thinning of the skin  Target root cause: topical calcineurin inhibitors (2nd line)  Tacrolimus 0.1%, 0.03% (Protopic) and Pimecrolimus 1% (Elidel) – non-steroid creams  Reduce itching and redness of eczema; use in >2 y.o  No skin atrophy and no systemic effects. Local burning.  Other: 1st generations Oral Antihistamines – antipruitic by helping patient sleep through the night Non-pharmacological  Moisturize skin often and liberally  Bathing (once daily): use warm (not hot) water; mild soaps (Dove, Aveeno, Cetaphil, Spectrogel)  Moisturize with emollient w/in 3 min after shower  Emollients control dryness (creams better than lotions): Aquaphor, Eucerin, Glaxal base, Lipikar, Moisturel, Vaseline  Lubrication:  Chronic – bath oils (Alpha, Keri) at end of bath to damp skin  Acute – colloidal oatmeal (Aveeno) dispersed in water for dry, itchy skin  Hydrating Agents attract H2O hydrate/soften skin (better than emollient for dry skin): Uremol (10%, 20% - also antipruritic)  Wear cotton gloves or mittens to prevent scratching

Acute AD (weepy): wet compress for 20 min (4-6xdaily); avoid ointments and occlusions



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Psoriasis Presentation symptoms  Chronic plaque psoriasis (most common): on sites: scalp, arms, legs, palms, soles, nails  Thickened red plaque, or adherent silvery scales or well demarcated  Punctate bleeding spots when scales scraped off  Other types include: flexural (in body folds/flexures w/o scales), scalp (w/ silvery scales)  Acute/Subacute forms: guttate (after viral/strep infection), pustular (on palms and soles), erythrodermic (generalized erythematic w/o lesions) Questions to ask:  Allergies, current drugs, other medical conditions? (Drugs that cause BB, ACEI, ASA, steroids, antimalarials, lithium, alcohol)  Family history? (Genetic risk factor)  How long has the patient had these symptoms? (Onset, duration)  Has the patient had similar symptoms before?  Has the patient seen a doctor about it and was it diagnosed?  Has the patient tried anything to solve the problem? Outcome?  Is the patient using any other topical products on it?  Are there any aggravating factors? (stress, obesity, UV light, excessive alcohol, What makes it better? Drug Related Problems  Not on a medication and requires drug therapy (ex. Needs to start on steroid +/steroid sparer)  Experiencing side effects of the medication (ex. Staining from anthralin)  Experiencing tachyphylaxis with medication (ex. Using HC for long periods of time)  Using too low of a dose (ex. Using 0.5% HC on thicker skin while 0.5% HC is only good for scalp and flexures)




Treatment plan  1st line treatment for Mild to moderate = topical steroids  1st line treatment severe extensive psoriasis = systemic treatment warranted  Strategies for steroid sparing: 5d steroid + 2 d sparer OR 4d steroid + 1d sparer. As psoriasis improves, gradually  number of sparer applications until it almost completely replaces steroid.  Topical steroids (limit to 2-3wks treatment w/ steroid sparing agents)  0.5% HC (OTC): Cortate, Cortef – only for face/folds; ung most effective, lotions on scalp. Appl BID-TID  Stronger steroids (Rx) – for trunk/extremities Topical Steroid + steroid sparing agents:  Petrolatum – can appl ring of petrolatum around steroid to avoid irritation of surrounding skin  Salicylic acid  Coal Tar: Targel, Denorex – for scalp and extremities; OD; 0.5%-10%; SE: odor, staining, inflam of hair follicles, apply in direction of hair growth (don’t rub in circular motion)  Anthralin: Micanol 1%, 3% – best for scalp; OD; scat – short contact anthralin therapy using 2-4% for 20min-2hrs; SE: staining of skin and clothes, burning, discolor blonde hair  Calcipitriol (Rx) – can use on face and flexures, better vs tazarotene  Tazarotene (Rx) – cannot use in face/folds, pregnancy; SE: skin irritation, burning, photosensitivity Biologicals – for unresponsive psoriasis; Anti-TNF, Anti-Tcell agents Light therapy – PUVA (psoralen po/cr/bath + UVA) 2-3x/wk; SE: acute burns, skin cancer, pigmentation, photoaging SYSTEMIC THERAPY – Oral retinoids (Acitretin, isotretinoin) CI in pregnancy; Sulfasalazine; Methotrexate; Cyclosporin Non-pharmaceutical       

Avoid triggers and skin irritants (soap) Bathing (use tepid water) Cool air humidifier Aqueous creams (can be used as cleanser and emollient) Most important to keep skin moist! Handle stress Don’t remove scale




 Saran wrap (used to occlude area and enhance penetration of topical agent) Prevention:  Avoid triggers 3P’s: Prevent injury, Persistence in avoiding over treatment, pauses or rest periods in treatment


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Dermatological DRPs Practice Station Patient wants your recommendation On the table:  Rubbing Alcohol  Hydrogen Peroxide  Polysporin cream  Polysporin ointment


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57 Acne Patient presentation Patient concern  Patient may be upset/embarrassed about condition – stress that it is common & curable Question to ask  Duration, onset and severity; Location and distribution of ache  Seasonal variation; present and past treatments;  Family history. For females (menstrual period; pregnancy status; scalp hair thinning; contraceptive method).  Other skin disorders or medical problems: allergies; use of cosmetics; moisturizer; pomade; areas of skin irritation or friction. Drug related problem        

Drug side effects, causing acne like symptoms Interaction with exipient of emollients, hydrators, or cleansers Taking retinoids in pregnancy and continuing with acne medications Taking an excessive amount of benzoyl peroxides at day time Not avoiding excessive sun exposure Too little drug Unnecessary drug Putting antibiotic on unbroken skin

Non-pharmacologicals:  Treat as soon as it appears to avoid complications such as scarring.  Discontinue use of greasy cosmetics, hair pomades/sprays.  Avoid environmental irritants: coal tar, mineral oil, petroleum oil, humidity, heat  Use make-up infrequently if possible, oil-free products and remove at bedtime. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Wash twice daily with a mild, non-alkaline soap or soapless cleanser (Cetaphil), don't rub or scrub skin.  Shampoo hair regularly if it is oily, keep hair off face (occluding factors)  Men: shave in the direction of hair growth (try electric and manual razor for best comfort)  Do not manipulate lesions: avoid picking, scratching, popping or squeezing.  Eliminate mechanical friction: headbands, violins, chinstraps, orthopaedic braces etc  Use an oil-free sunscreen and avoid benzophenone type (apply after cleansing and before acne meds) Pharmacotherapy Treatment plan  1st line try OTC benzoyl peroxide  Apply acne meds to the entire affected area; allow 6-8 weeks of treatment before assessing improvement.  Some meds cause initial reddening or worsening that subsides with treatment  Lesions on back/ extensive distribution cannot use topical, require systemic treatment  Inflammatory acne requires antibacterial therapy (topical or systemic depending on distribution) Benzoyl Peroxide (up to 5% OTC, >5% require prescription):  Most effective OTC 1st line therapy  Bactericidal effects, anti-sebum effects, anti-inflammatory effects, and is also weak peeling agent  eg. Solugel 4 OTC- hydrophase base, which is well absorbed and does not leave a film  Start with once daily application, wash face with soapless cleanser, pat dry with towel, apply to the affected area (not just lesions), leave on for 15 mins for the first night, then wash off (this is to let the skin get used to the meds and reduce potential drying and irritation). Repeat each night leaving the benzoyl on for twice as long each time, until it is left on for about 4h. Thereafter, it can be left on over night.  Twice daily application may be started after about 1-2 weeks of usage and can be applied once in the morning and once at night.  SE: redness, skin irritation initially (usually resolves w/ continued tx), stains clothes, linens; breakdown product gives off odour Prescription drugs Topical Antibiotics (clindamycin, erythromycin and combos w/benzoyl peroxide): • Antibacterial action against intrafollicular P.acnes • Use for inflammatory acne that does not adequately respond to benzoyl peroxide Topical Retinoids (tretinoin, adapalene, tazarotene) : • Effective peeling agents Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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• Use for non-inflammatory acne that doesn't respond to benzoyl peroxide and topical antibiotics Oral Antibiotics (tetracycline, minocycline): • Systemic antibacterial action against intrafollicular P.acnes • Use for inflammatory acne that does not adequately respond to topical antibiotics OR has extensive involvement (ie. Back) Oral Isotretinoin (Accutane): • Extremely strong, stops comedogenesis through peeling action and antisebum properties • Reserved for patients with severe nodulo-cystic acne that does not respond to a variety of treatments • Extensive list of serious adverse effects including teratogenic effects and association with suicide (pts who are depressed can exacerbate depression when put on accutane) Nonpharmacological Choices  Balanced diet – no specific food causes acne (acne is not influence by diet)  Do not squeeze pimples – increases risk of scarring  Cosmetic use: o Avoid excessive use o Cosmetics should be “oil-free” rather than “water base” or ”non-camedogenic”  Comedo extraction – avoid unnecessary manipulation  Sunshine – not recommended due to UV radiation’s carcinogenic potential and increased risk of photosensitivity (patient’s taking antibiotic and isotretinoin).  Washing the face should be at least 2x/day with mild soap.  Shave with sharp blades, slightly and frequently.  Sunshine helps acne but is carcinogenic and may cause photosensitivity hence not advice.  Patients should use sunscreen of SPF≥15 with alcohol or oil free bases.  Avoid benzophenone (oxybenzone and dioxybenzone) as they are acnegenic.  Sunscreen should be applied first and then the medication  Heat, humidity, pressure, friction, excess scrubbing, or washing can exacerbate existing acne.  Emotion (excess anger/stress) can increase acne.  Corticosteroids can also increase acne but not hydrocortisone (doesn’t inhibit protein synthesis) Refer to physician  Drug induced acne  Experiencing scarring  No response to non prescriptions products or presents with infection or systemic symptoms References  Therapeutic Choices, 4th ed. page 660. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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58 Arthritis Osteoarthritis Nonpharmacologic Choices  Team approach to treatment – occupational therapists, physiotherapists, social workers, pharmacists  Patient education sessions as per Arthritis Society  Physical therapies may be beneficial – TENS; laser therapy  Aids – canes, walkers, for hip and knees OA  Bracing of affected joints  Exercise with or without physiotherapy  Patient Education. Note: No benefit from – Ultrasound in knee OA or Acupuncture (Note that acupuncture therapy did not show any benefit in treatment of OA)  Weight loss (if overweight), aerobic exercise, physical therapy  Assistive devices. Joint protection (by avoiding trauma on joint, e.g. over standing), Thermal therapy (though there’s lack of evidence)  Risk Factor: Age, obesity and hereditary (genetic susceptibility). Can also occur in younger patients due to trauma.

Rheumatoid Arthritis Nonpharmacologic Choices  Multidisciplinary team approach focusing in patient education and rehabilitation  Patient education e.g.:  Balancing rest, activity and exercise  Heat and cold application  Adjustment to activities of daily living  Maintenance of joint range of motion and muscle strength  Dynamic exercise  Increases aerobic capacity and muscle strength  Evaluation for spirits, orthotics, proper footwear, and surgery Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Gout and Hyperuricemia Nonpharmacological Choices  Dietary factors can precipitate an attack o Fasting o Overindulgence in purine rich foods (kidney, liver, anchovies, sardines) o Beer and wine  Weight reduction – however aggressive caloric restriction may increase uric acid and precipitate a gouty attack.


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Practice Station Scenario # 1 Patient profile: (Present on the table)\ Patient Name: MB Age: 52 yrs Address: Tips Doctor: MD Medical condition: RA Current Medications: diclofenac sodium 50 mg tid Rx: Methotrexate 2.5mg tablets Sig.7.5 mg weekly D/C Diclofenac Mitte 1 month

Scenario # 2 A patient with osteoarthritis in the right elbow has approached you for recommendation Patient Name: Medical History:  Osteoarthritis  Medication Profile:  Actonel 35 mg po weekly  Aspirin 81 mg po daily


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Scenario # 3 Doctor asking for recommendation to switch from C.E.S for osteoporosis patient does not want to take estrogen anymore. Patient profile: (Present on the table)\ Patient Name: Oz Age: 55 yrs Address: Tips Doctor: MD Medical condition: Menopause Medications: OTC: Calcium carbonate, vitamin D Allergies: Not known On the desk: Therapeutic Choice

Scenario # 4 A patient comes in with a concern and to pick his new medication. Respond as you would in the Pharmacy. Patient Name: Andrew Age: 58 years Address: xyz Dr: Tips

Comments: Rheumatoid Arthritis Medication: Prednisone 40mg QD (Started 2wks ago)

Rx: Methotrexate 7.5mg Q week

Scenario # 5 A patient presents with a prescription fill. Rx: Arthrotec tabs Sig: 1 tab BID M: 60 tabs Patient’s profile: (presented after pharmacist candidate request)  31 year old female  No known drug allergies  Medical conditions: Arthritis, pregnant (due date, in next 2 months) Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Previously she used Indomethacin 25mg TID


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59 Osteoporosis Nonpharmacologic Choices  Regular exercise (especially impact type or weight bearing, e.g. walking & jogging. Swimming is not weight bearing exercise); Reduce risk of falling; improve strength and balance;  Adequate protein, Calcium and vitamin intake;  Stop smoking, avoid excessive and alcohol intake.  Inactivity or prolonged periods of bed rest; sedentary life style smoking history; excessive alcohol or caffeine intake.  Prevention: Calcium; Vitamin D (best source is diet); exercise. Pharmacotherapy Treatment plan Calcium supplements  Separate doses to achieve a dose of 1000-1500 mg/day (approximately only 500mg of calcium can be absorbed from GI at a time)  Calcium carbonate contains the highest level of elemental calcium  Calcium citrate may be administered without regard to meals Vitamin D Therapy:  It is used in the conjunction with calcium supplement dietary phosphorus restriction and phosphate binding agents  Therapy may need to be temporarily discontinued if calcium and phosphorus are elevated  If there is weakness, headache, decreased appetite, lethargy, health care provider should be notified Bisphosphonates: Alendronate, Risedronate  Bisphosphonates must be taken with full glass of water (8 oz) 30 minutes prior to the first meal of the day  Remain in an upright position for at least 30 minutes following ingestion Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Take medication on a regular basis  Compliance may be increased by once-weekly dosing Estrogen replacement Therapy:  Patient must discuss and weigh benefits and risk of estrogen or combined hormone replacement therapy with her physician Selective estrogen receptor modulator: raloxifene (Levista)  This medication may be taken without regard to food  Concomitant use with estrogen therapy is not recommended  It will not treat symptoms of menopause such as hot flashes  In instance of prolonged immobilization, discontinue raloxifene 3 days prior to and during the immobile period when possible Calcitonin (Miacalcin)  If it is administered as an injection, it should be given in the upper arm, thigh, or buttocks.  Proper education regarding administration of the injection and the nasal spray preparation is necessary  When miss a shot, administer it as soon as possible. Do not administer the shot if it is almost time for your next dose.  Store the nasal spray in the refrigerator until time for use.  Warm the spray to room temperature

Practice Station Scenario # 1 One of your patients comes to you in the Pharmacy with a concern and asks you for your advice on a product. Assist her as you would in the Pharmacy. Patient profile: (Present on the table)\ Patient Name: Mrs Stacey Age: 58 years Address: XYZ Dr: Tips

Comments: Osteoporosis Medication: Alendronate Sodium -Fosamax. 70 mg Q week (Started 3 weeks ago)

On the table:  Maalox suspension  Gaviscon suspension  Calcium tums  Ranitidine 75mg tablets


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60 Pain Management and Analgesics Counseling on Triptans  Onset and duration of action of specific triptan (when can pt repeat the dose)  Adverse effects (chest discomfort, dizziness, drowsiness, nausea, fatigue)  Check for drug interactions

 Do not use a triptan within 24 hours after using another triptan Low Back Pain

Nonpharmacological Choices  Avoid unnecessary bed rest for uncomplicated back pain. As well as premature physical therapy  Symptomatic relief for acute recurrent back pain of less than 3 weeks:  Encourage patient to resume activity and work as soon as tolerated  Educate patient to expect early recovery


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Practice Station A lady comes to you with a new prescription and has a few concerns about the medication that she has been prescribed. Assist her accordingly. Patient profile: (Present on the table)\ Patient Name: Mrs Fiona Age: 32 years Address: XYX Dr: Gaucher

Comments: Migraine HA Medications: None

New Rx: Sumatriptan 50mg PRN (4 tablets) On the table: Tylenol 500mg caplets and Advil 200mg Tablets

A patient is asking for your recommendation to treat Sprain – injury to a ligament caused by over-stretching or twisting Patient profile: (Presented by patient after pharmacist candidate request) Patient Name: TD Age: 49 yrs Address: Tips Doctor: M. Patel Medical condition: Sprain – injury to a ligament caused by over-stretching or twisting Current Medications: None Allergies: ASA

On the desk:


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Practice Station Patient profile: (Present on the table)\ Patient Name: Ms. Lee Comments: Trigeminal Neuralgia Age: 18 Years Address: xyz Doctor: Gaucher Medication: Morphine SR 30mg BID (stopped 6 months ago)

New Rx: Gabapentin 100 mg OD x 7/7 then, 100 mg BID x 7/7 then, 200 mg BID x 1/12


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61 Dysmenorrhea Nonpharmacologic Choices  Explain to Patient: o A common, exaggerated but natural phenomenon  Reassure Patient: o That pain does not indicate an organic process or abnormality  Local Heat  Regular exercise: o Provide some relief by decreasing stress o Regular aerobic exercise, reducing stress, cessation of tobacco, decrease fat and increase omega 3 polyunsaturated fatty acids intake, warm bath, and applying heat pads. Therapy is based on the specific symptoms and previous therapy.

Practice Station Scenario # 1 A 25 year old female comes to the pharmacy complaining of what she considers is premenstrual tension. She wants you to recommend something natural. Counsel the patient and recommend a natural remedy if appropriate.


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62 Menopause Menopause is cessation of menstrual periods. Postmenopausal Hormone replacement Therapy Estrogen and Progestin  Side effects due to estrogen may be diminished by starting with a low dose and may be alleviated by changing products. Fewer side effects are associated with the transdermal preparation  Side effects due to progestin may be alleviated or diminished by changing products or changing from a continuous to a cycle regimen  Report immediately any vaginal bleeding  Contact physician immediately if there is:  Abdominal tenderness, pain, or swelling  Coughing up blood  Disturbances of vision or speech  Dizziness or fainting  Lumps in the breast  Numbness or weakness in an arm or leg  Severe vomiting or headache  Sharp chest pain or shortness of breath  Sharp pain on the calves Nonpharmacological Choices  Exercise: Do the pelvic floor exercises  In women experiencing vaginal dryness, increasing sexual activity tends to be more beneficial than avoiding it (this increases blood flow to the pelvic region resulting to decrease dryness and dyspareunia).  Diet = decrease alcohol, caffeine and spicy food intake.  Dress in layers so that clothes can be removed as temperature increases (heat exacerbates symptoms). Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is 1 illegal to reproduce without permission. This manual is being used during review sessions conducted by 78-1 PharmacyPrep

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 As menopause lead to decrease estrogen environment, one of the outcome could be osteoporosis. It is essential to take calcium (1g/day) and Vitamin D (400-800iu/day)

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Sexual Dysfunction and DRPs Drugs that cause sexual dysfunction  Trazadone  Priapism  SSRI  alternate bupropione, mirtazepine, and meclobemide  Sildenafil, verdanafil and taldanafil  priapism  contact doctor  (priapism= continous erection longer than 4 hours)  Finesteride and dutesteride  male genitalia defect in fetus, pregnant women should not touch

Practice Station Scenario # Doctor wants to write prescription for 50-year-old male patient with renal disease and diabetic condition. Patient profile: (Present on the table) Allergies: none Current medications: insulin long acting Medical history: Renal disease Creatinin clear 30ml/min Medical conditions: diabetes, renal disease, and low sexual libido Rx Sildenafil (Viagra) 50mg


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64 Vaginitis Presentation Symptoms    

Burning & itching in vaginal area Abnormal vaginal discharge  grey/white, thick, pasty, curdy, clumpy, odorless “Cottage cheese – like discharge” pH of discharge  4.5

Questions to ask:  Have you had similar symptoms before? If so, how long ago? How long did it last? Did you see a physician about it? Did the physician diagnose s/s as a yeast infection?  If had before & symptoms are same  How often have you had a yeast infection in the past year?  Recurrence = 4 episodes/year [may need to refer for prophylaxis or treatment for 14days]  Do you have a fever, pain upon urination, sores, and profuse discharge? (refer for STDs)  Delicate topic  assess if pt has high-risk sexual behavior (ie. Unprotected intercourse, multiple partners, casual encounters, etc)  Tell me about the discharge (Fishy? Color? Thick or thin? Amount/Purulence?  Is the area burning or itchy?  Are you taking any meds? Are you taking antibiotics or have you taken them recently? [antibiotics may  risk of vaginitis]  Other medical conditions? Pregnant? (Pregnancy is risk factor) Refer:       

Pre-pubertal (under age 12 yo) 1st episode Recurrence of VVC within 2 months of last episode (complicated cases may need RX) Symptoms not improving w/in 3d of TX, or persisting >7d of TX Underlying disease (diabetes, HIV, immunosuppressed) or pregnant At risk for STDs (Hx of unprotected intercourse, multiple partners) Uncharacteristic s/s (fever, pelvic pain, malodorous, colored disch)


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 ** Women who have symptoms of vaginitis & have had previous drug are eligible for self treatment Treatment Plan  Non prescription azoles if patient is eligible for self treatment  All durations/products have equal efficacy (~85%)  Symptomatic relief within 3d & resolve in 7d  1 day treatments may be more irritating because higher dose  S/E minimal – may warn about irritation, burning, redness – if pt’s symptoms get worse, advise to stop treatment and see doctor. Non prescription drugs Clotrimazole (Canesten)  1 day: Tablet (500mg), Cream (10%)  3 day: Tablet (3x200mg), Cream (2%)  6 day: Cream (1%) Miconazole (Monistat)  1 day: Ovule (1200mg)  3 day: Ovule (3x400mg), Cream (4%)  7 day: Ovule (7x100mg), Cream (2%)  Combi-paks available which incl. small tube of external cream Prescription For persistent or recurrent (>4/yr) cases or for those with greater tendency to develop vaginitis (ie. Immunosupp) Fluconazole (Diflucan)  Single 150mg oral dose  patient may prefer this choice for convenience (high acceptability& compliance)  well tolerated [SE: rare: GI upset, headache, and pain]  DI: warfarin, phenytoin, theophylline, rifampin; CI: pregnancy Terconazole (Terazol)  3 day: Ovule (3x80mg), Cream (0.8%)  7 day: Cream (0.4%)  Recurrenceusually due to diff strain of candida (C. glabrata) Can recommend boric acid 600mg gelatin caps (1 capsule p.v. BID x 14-28days), compounded, or refer for prophylaxis (ie. Fluconazole 150mg once wkly x6mo)

Non pharmacological Choices Copyright © 2000-2010TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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   

Good genital hygiene, keep vaginal area clean & dry Shower > Bath, Wipe front  back Avoid vaginal deodorants, douching, soaps & perfumed products Avoid tight clothing &synthetic, plastic underwear  instead wear cotton underwear & loose fitting clothes  Avoid wearing wet clothes for extended periods of time  Diet  can try to avoid high sugar foods &  consumption of yogurt with lactobacilli, but evidence is lacking  Probiotics (L acidophilus) – effectiveness questionable


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Practice Station Scenario # 1 A young lady patient comes to you in the Pharmacy asking you for assistance regarding her condition. Solve her concern and give her all the necessary information regarding her condition. On the table:  Canesten 3 Cream 3%  Miconazole Ovule 400mg x 3 Patient profile: (presented by patient after pharmacist candidate request)  Allergies: None  Current medications: None  Medical conditions: None

Scenario # 2 A 38 year old female comes into the pharmacy with severe prutiritis of the vaginal area and complains of a cottage cheese discharge. Patient profile: (presented by patient after pharmacist candidate request)  Allergies: None  Current medications: metformin 500 mg bid, glicalizide 30 mg daily  Medical conditions: Diabetes for past 1 years  She does not have other symptoms like fever, burning at the time of urination etc.


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Benign Prostatic Hyperplasia Practice Station Patient profile: (Present on the table)\ Patient Name: Mr Jim Age: 38 years Address: XYZ Dr: Gaucher

Comments: Benign Prostratic Hyperplasia

New Rx: Finasteride 5mg QD x 1 / 12 (8 Repeats) Wife comes to pick up prescription.


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66

Anticancer drugs and Chemotherapy Chemotherapy  All drugs are carcinogenic, teratogenic, and mutagenic.  Medications may cause sterility  Tell your dentist that you are on chemotherapy, due to an increase risk of bleeding and infections  Hydration and mesna therapy are recommended for C and I  Notify your doctor if you have burning upon urination Antimetabolites: S-phase-specific  Avoid crowded place and sick people  You may be asked to chew ice if receiving fluorouracil (5-FU) to reduce damage to mucosal lining in your mouth  Contact your physician if you have uncontrolled nausea or vomiting, excessive diarrhea, or pain, swelling, or tingling in palms and soles of feet (hand-foot syndrome)  Call the doctor if you feel dizzy, lightheadedness, or have trouble urinating (clofarabine). You should be receiving folic acid and vitamin B12 injection if you are receiving pemetrexed.  Nelerabine may cause sleepiness and dizziness Antitumor antibiotics Anthracyclines; Mitomycin; Dactomycin; Bleomycin  Contact doctor for fast, slow, or irregular heartbeats and/or breathing difficulties  Anthracyclines may cause a change of urine color or whites of eyes to a bluish-green or orange-red  Bleomycin may cause a change in skin color or nail growth


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Hormones and antagonists  Avoid to use in pregnant  Some agents may cause weight gain and menstrual irregularities among women  Be aware of leg swelling or tenderness (it may be a sign of DVT), breathing problems, and sweating  Transient muscle or bone pain, problems urinating, and spinal cord compression may occur initially in patients receiving LHRH agonist a) Take exemestane after meal Plant Alkaloids  Call doctor for uncontrolled diarrhea (irinotecan), nausea or vomiting, signs and symptoms of an infection  Patient should receive prophylaxis for emesis, pretreatment for anaphylaxis or peripheral edema (taxanes)  Patient should receive a prescription for loperamide and atropine with irinotecan therapy Biologic Response Modifier  Let your doctor know if you have severe fatigue, trouble breathing, or irregular heart rhythm.  Chills, fever, depression, and flu-like symptoms are just common  There is taste and smell alterations with levamisole  Monoclonal antibodies can cause infusion-related reactions such as fever and chills.  Blood pressure, protein test in your urine should be checked regularly if patient receive Bevacizumab  For patient receiving Cetuximab, you should avoid excessive exposure and should wear sunscreen  You should take medication for thyroid if you are receiving Tositumomab.  Do not try to conceive until 12 months after finishing therapy for both men and women  Women who are taking Thalidomide and lenalidomide should not be pregnant  Two forms of birth control must be used, including men on the drug that have sexual contact with women of childbearing age Cyclophosphamide SE: Myelosuppression, Nausea and vomiting, Hemorrhagic cystitis (toxic metabolites)  Alopecia, Cardiomyopathy (rare), Interstitial pneumonitis, Hemorrhagic cystitis:  Urotoxicity occurs because bladder contains very low concentration of thiol compounds, which neutralize reactive chemicals  Symptoms: painful urination, frequency & hematuria  Prevention: adequate hydration to flush toxic metabolites out of the bladder Pulmonary Toxicity:  Not schedule or dose related and may occur after discontinuation Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Symptoms: dyspnea, fever, dry cough, etc

Practice Station Scheme # 1 A 52 years old male, patient is to fill prescription Medical History: cancer Rx: Cytoxan (Cyclophosphamide) 50 mg 500 mg po od x 5 days Provide counseling Patient profile: Allergies: none Current medications: tylenol for headache and multivitamins


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Antimicrobials DRPs Practice Station A patient is asking for your recommendation Profile:  Tylenol #3 i-ii tabs q 4 to 6 hours prn x 50  Cephalexin 500mg qid x 40 On the table:  Senokot tabs  Soflax (Docusate Na)  Metamucil pwder  Glycerin suppositories  Fleet enema  Milk of Magnesia  Dulcolax (Bisacodyl) tabs

Scenario # 2 A male patient, 50 years old comes to fill a prescription Rx: Biaxin 500 mg BID x 10 days Flagyl 500 mg BID x 10 days

On the table: Information sheet about herbal product


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Scenario # 3 A patient presents with the following Rx Rx: Ciprofloxacin 500mg po bid x 7 days Provide counseling and address all the concerns.

Scenario # 4 A healthy 33-year-old male, he presents with prescription for ciprofloxacin 500 mg twice daily for three days. Your determine that he is traveling to Mexico the following week for business meeting, and the doctor told him that he may need this drug to treat diarrhea, if it develops. The doctor also instructed him to buy some Lopramide. Rx: Cipro 500 mg bid f 3d Loperamide Scenario # 5 Patient profile: (Present on the table) Patient Name: Casie Age: 29 years Address: XYZ Dr: Gaucher


New Rx: IV Levofloxacin 500mg Q24HRS x 10 / 7

Scenario # 6 A patient comes to fill a prescription Rx Rifampin 300mg Sig: 2 tabs od x 14 days for prophylaxis treatment of H. influenza type B M: 28 tabs Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Patient profile: (given by patient after pharmacy candidate requests)  Allergies: None  Current medications: none  Medical conditions: None

Scenario # 7 A doctor prescribes Zithromax for one of your patients. Patient has been diagnosed with community-acquired pneumonia. Patient profile: (provided on the table)  Allergies: clarithromycin  Medical conditions: Pneumonia and Renal disease  Current medications: Enalapril 5 mg Discuss this prescription with the doctor.

Scenario # 8 A patient comes in to collect a prescription for Amoxicillin. Prescribed by a dentist to be taken just before dental treatment. The patient profile shows that the patient is allergic to penicillin. Discuss an alternative with the dentist.


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68 Urinary tract infections Symptoms    

Frequency and urgency of urination. Burning with urination Fever and chillsimmediately refer to the physician Itching and irritation

Question to ask  Have you experienced a urinary tract infection?  How recently?  Do you have currently any hemorrhoid or menstrual bleeding? Patient counseling:  Consumption of cranberry juice has been shown beneficial in postmenopausal woman.  In prevention:  Drink adequate daily water (8 glasses)  Empty bladder at regular intervals.  Consider other birth control methods than diaphragm, tampons, and spermicidal.  Discourage use of phenazopyridine (non prescription medication)


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Weight Loss How to approach the problem    

Communicate in non judgmental way Express concerns about the health risks associated with the condition Help patient to set achievable, individualized goals Educate “One thing that seems to be very important for most patients is physical activity. What are your thoughts about increasing your activity level?”  Consider social and environmental cues that lead to undesired eating (eating while watching television)

Counsel on benefits of weight loss (Health advantages gained by a 10 kg weight loss)  30-40% reduction in diabetes-related deaths  20-25% decrease in total mortality  Reduction of 10/20 mmHg Blood Pressure  Reduction of LDL cholesterol by 15%  Reduction of 10% total cholesterol  Reduction of 30-50% in fasting blood glucose  Even loss of 5% fo body weight can improve insulin action & ò fasting blood glucose levels & ò the need for medications


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Practice Stations Scenario # 1 Patient profile: (present on the table) Patient Name: K. S Age: 25 years Address: Tips Dr: Tips Comments: Obese Allergies: None Medication: Cipralex 20 mg po od New Rx: Meridia 10 mg po od M: 30 Capsules Rep x 2

Scenario # 2 A patient is here to fill a prescription: Patient profile: (present on the table) Patient Name: Long ly Age: 38 years old woman Address: pharmacy prep ave Dr: Tips Comments: obesity Allergies: None New Rx: Xenical 120 mg po tid with meals M: 1 box (84 tabs/1 month)


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Smoking Cessation Presentation symptoms  Irritability, insomnia, weight gain, headaches, anxiety poor concentration (Withdrawal symptoms)  GI upset (improper gum use)  Nicotine overdose: smoking with gum use, exercise with patch  Heart racing (overdose symptoms)

Questions to ask:  Determine what stage in smoking cessation. (Pre-contemplation, contemplation, preparation, action, maintenance)  What is your motivation to quit?  How long have you been smoking?  How many cigarettes do you smoke per day?  Have you tried to quit smoking before? How? What failed?  Where and when most often do you find yourself smoking? Refer  Heart disease  <18 yo  Pregnancy  Nicotine replacement therapy  Gum: onset 30 min; 4mg = 1cig/h, 20 pieces / day; 2mg = ½ cig/h, 30 pieces / day; gradually decrease 3-6 months  indigestion, salivation, bloating, jaw ache, throat sore  Patch: onset 6 hours; 24 hour patch, 7, 14, 21 mg; gradually decrease 3-4 months  Irritation, headache, insomnia, dizziness, indigestion, NV, bowel change  Inhaler: oral absorption, 2mg / cartridge, lasts 20 min, 6-12 cartridges for 1-3 months, then decrease over 2-3 months  First week: cough, irritation, nasal congestion, dizziness, NV  CI in: pregnant, <18 yo, CV disease  Buproprion (Zyban) Rx product Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Antidepressant that reduces withdrawal symptoms  Dry mouth, insomnia, dizziness, tremor, taste perversion  CI in: depression with other antidepressants, seizures, heavy alcohol, diabetics, asthma  Varenicline (Champix)  Nicotinic acetylcholine receptor partial antagonist, reduce withdrawal and decrease pleasure from smoking  NV, insomnia, abnormal dreams, constipation, gas, Nonpharmacological Choices  Nicotine withdrawal: Symptoms to be monitored in case of nicotine withdrawal are: Severe craving, Anxiety or irritability, Restless, nervousness, difficulty with concentration sleep disturbance, and headaches.  Overdose symptoms” Increase appetite or eating behavior, palpitation (heart racing), difficulty in breathing, Nausea, vomiting, and diarrhea Education  Reassure quitting smoking is very hard, and often takes multiple attempts  Convince patients to keep trying despite failing  Applaud their decision to quit smoking, and reassure them of their frustration, anxiety  Educate patient on the positives from quitting (lifestyle and health)  Educate patients on importance of nonpharmacolical aids with pharmacological therapy  Set up quit date

 Follow up is very important to maintain


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Practice Stations Scenario # 1 A male patient who picked up his Nicorette gum 1 week ago from your Pharmacy has got a concern regarding his medication. Solve his concern and counsel him as you would in the Pharmacy. Patient profile: (given by patient after pharmacist candidate request) Patient Name: J.K. Age: 29 years Address: Tips Dr: Tips

Comments: Smoking cessation Medications: Nicorette gum 4 mg

Scenario # 2 A very concerned patient comes to you, the Pharmacist, asking for your assistance. Solve his concern and take the right course of action. Patient profile: (given by patient after pharmacist candidate request) Patient Name: J.K. Age: 29 years Address: Tips Dr: Gaucher

Comments: None Medications: None

On the table:  Nicoderm Patches 14mg  Nicorrette gum 2mg

Scenario # 3 A very concerned patient comes to you in the Pharmacy and asks for your assistance. Solve his concern as you would in the Pharmacy. Patient profile: (given by patient after pharmacist candidate request) Patient Name: Jack Jill Age: 33 years

Comments: None Medications: Nicotine Polacrilex Gum


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OSCE a step by step approach (Started 3 weeks ago)

Scenario # 4 A patient comes to fill a prescription Patient profile: (given by patient after pharmacist candidate request) Patient Name: Pink Rose Age: 43 years Address: XYZ Dr: Tips

Comments: None Medications: Bupropion Tablets 150mg BID (started 2 weeks ago) OTC Medications: Nicoderm Patches 14gms (Started yesterday)

New Rx: Carbamezapine 100mg TID x 5/7 then, 200mg TID x 1/12


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Allergies and Hypersensitive Reactions Anaphylactic Reaction  Symptoms: Difficulty breathing, Wheezing, Abnormal breathing sound, Confusion, Slurred speech, Rapid or weak pulse, Blueness of the skin (cyonosis), including lips, or nail. Fainting, light headedness, dizziness, Hives, and generalized itching. Palpitation (heartbeat), nausea and vomiting, diarrhea, abdominal pain or cramping. Skin redness, Nasal congestion and cough.  Swelling of throat, lips, and tongue or around the eye.  Note: Symptoms develop rapidly often with seconds or minutes of allergen or factors causing anaphylactic shock.  Commonly caused by: Insect bite, and Peanut


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Practice Station Scenario # 1 A lady patient comes to pick up her medication. Counsel her and provide all necessary supporting measures. You may also advice her any non-prescription product you believe would help her. Patient profile: (presented on table Patient Name: Miss Kelly Age: 15 years Address: Tips Dr: Gaucher

Comments: Hypersensitivity to pea nuts Medication: None

New Rx: Epipen auto injector, Inject 0.3ml SC as needed


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Photosensitivity Presentation Symptoms  Exaggerated sunburn on sun-exposed areas (forehead, cheeks, chin, rim of ears, chest, neck, hands)  Three types of responses:  A strong delayed erythema & edema (begins 8 to 24 hrs after sun esposure & lasts 2 to 4 days). May involve hyper pigmentation & appear darker red than sunburn  Rapid, transient erythema with immediate onset (30 min), lasting 1 to 2 days, without edema  Rapid transient wheals and flares, with a burning sensation Photoallergy Clinical Presentation  Eczematous eruptions, usually pruritus, appear on exposed areas within 24-48 hours of reexposure to the photo allergen  Solar urticaria (multiple pruritus, raised areas on the skin that occur following exposure to sunlight)  Photo allergic contact dermatitis: occurs after topical application of a photo allergen. Lesions are well demarcated and mostly symmetrical. Drugs associated with photosensitivity      

Tetracyclines: may also induce persistent pigmentation on sun exposed areas Floroquinolones: photo toxic reactions with redness, blistering and peeling Sulfonamide derivatives (sulfonamides, oral hypoglycemic, diuretics) Amiodarone NSAIDs (Indomethacin with lowest photochemical activity) Topical agents: sunscreens (PABA), retinoids, coal tar (intense burning & stinging within minutes)

Photosensitivity reactions  Photosensitivity – adverse drug reaction that can be caused by topical or systemic administration of medication  Two types of photosensitivity reactions: phototoxicity and photoallergy. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Phototoxicity  Results from direct cellular damage produced by the photo-product  No immunologic mechanisms are involved  Manifest during an initial exposure Photoallergy  Less common than phototoxicity, however it is usually more severe  Occur as a result of cell-mediated (delayed) or humoral-mediated (immediate) hypersensitivity to an allergen activated or produced by the effect of light (UVA) on a drug. Management      

Stop the offending agent Avoid exposure to UV light Treat similarly to that of sunburn Symptom relief (cool wet dressings, soothing gels and oatmeal baths) Oral antihistamines may help to reduce itching Topical antibacterial creams to prevent infection of broken skin blisters


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Practice Stations Scenario # 1 Patient is asking for your recommendation about what appears to be sunburn. On the table:  Ombrelle SPF 30  Tylenol ES  Advil  Aveeno lotion  Aloe Vera gel  Benadryl tablets  Benadryl Cream  Calamine Lotion Patient profile: (given by patient after pharmacist candidate request)  Allergies: None  Current medications: none  Medical conditions: none


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Insomnia Good Sleep Hygiene Measures  Maintain a regular schedule  Go to bed only when sleepy  Avoid daytime naps  Avoid caffeine & nicotine especially within 4-6hrs of bedtime  Do not drink alcohol (especially within 4hrs of bedtime), since it causes fragmented sleep  Avoid heavy meals before going to bed, but a light carbohydrate snack before bedtime is acceptable  Do not eat chocolate or large amounts of sugar before bedtime  Avoid drinking excessive amounts of fluid in the evening  Minimize noise, light & extreme temperature in the bedroom  Exercise regularly during the day, but avoid vigorous exercise within 3 hrs of retiring  Develop relaxing rituals (e.g. reading, listening to music) before bedtime  Get out of bed & go to another room if unable to sleep within 20 minutes. Return when sleepy


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Practice Station One of your patients comes to you in the Pharmacy, looks confused and asks for your assistance. Take the right course of action based on your professional judgement. Advice the patient accordingly. Patient profile: (present on the table) Patient Name: Andy Mutt Age: 37 years Address: XYZ Dr: Tips

Comments: Insomnia Medications: Lorazepam 0.5mg QD (3 refills) last refill: 15 days ago


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Vaccines Flu vaccine (flu shot)  Generally people over 65 years old and people with another serious condition should take flu shot to prevent any attack. You are in a high-risk group, therefore I strongly recommend you to do flu shot. If you have flu, it might develop to much worse condition. Influenza may aggravate your COPD, and even you may need to be hospitalized.  I understand your concern. But not all people taking flu vaccine experience s/e, they are very mild and could be prevented by taking Tylenol you should not be scarred.  It’s advisable (health Canada recommends you have to do flu shot every year, because the virus is changing every year, that’s why it’s so important to keep composition of vaccine updated annually. Each year new vaccine is produced that provides protection against the most common strains.  Flu shot is the most effective way to protect you from flu. Regular hand washing is another way to help minimize your risk become sick. Keep on alcohol based sanitizer handy at work, home and in the car.  Wash hands at least 5 times a day. Cover your mouth and nose with tissue when you cough.  The benefits of flu shot far outweigh the risks. The flu vaccine can’t cause influenza because it doesn’t contain any live virus.  The most common S.E are soreness at the site of injection, fever, and fatigue, muscle aches within 6-12 hours after your shot. These effects may last a day or two in most cares these effects are mild and will disappear within 48 hours.  Many people confuse the flu with a cold. The flu vaccine will not protect against cold.  If you didn’t get a flu shot last year and didn’t get sick, it doesn’t mean that you will not get sick this year.


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 Every year different strains of the flu virus circulate. By not getting the flu shot, you are increasing your chances of becoming ill.  Protection from the vaccine develops by 2 weeks after the flu shot, and may last up to one year (4-6 months).  After you get a flu shot, your immune system produces antibodies against the strains of virus in the vaccine, when you are exposed to the influenza virus, the Ab will help to prevent infection or reduce severity of ill Who should get the shot?  Everyone, everyone aged 6 months or older can benefit from getting flu shot. Also, it’s very important for some group of people because they have greater risk of developing complications from the flu. Or they may spread it to others at high risk because they are in close contact.  A few people are severely allergic to eggs they shouldn’t get flu shot.  Is the flu just a bad cold?  *The flu is much worse than a cold. Cold symptoms and complications are much milder than that of the flu.  Is the flu shot highly effective?  A flu shot is about 70-90 percent effective in preventing flu in healthy adults, when the vaccine is a good match with the strains. The vaccine can help prevent pneumonia and hospitalization in about six out of ten people, and is up to 85% effective in preventing death. However, vaccine effectiveness varies from one person to another.  Why your kids should get the flu shot.  Healthy young children aged 6 to 23 months are at increased risk of being admitted to the hospital because of flu symptoms compared with healthy older children and young adults. And once the children enter daycare, school, or begin playing with groups of children, their close contact enables the flu virus to spread quickly and easily among them.  This helps make children one of the main spreader of the virus both in the school and in household.  Facts about children, the flu and vaccination:  Only children 6 months of age and older can be vaccinated.  Children under 9 years old getting vaccinated for the first time need tow doses of vaccine-the second dose at least one month after the first.  Children and teenagers (6 months-18 years) who have been treated with aspirin for long periods may have an increased risk of developing Reye’s syndrome if they get the flu.  Indications for vaccine


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 Age 65 years and older Nursing Home and Chronic care residents Chronic cardiopulmonary disease (e.g. Asthma): all ages Chronic disease requiring frequent hospitalization Long term Aspirin use under age 18 years Prevents Reye's Syndrome  Vectors , Health care workers , Nursing home personnel Family members of high risk patients  Essential service providers Students in Institutional settings Second or third trimester of pregnancy Human Immunodeficiency VirusTravel to tropics any time of year Travel to Southern Hemisphere April to September Pregnancy (second and third trimester) Breast Feeding.  Schedule: Annually  Flu season in Canada: Oct to April  Immunization season: Oct to Mid Nov  Vaccine Efficacy Prevents illness in 70% healthy people age <65 yearsPrevents 3070% Pneumonia hospitalizations in elderlyContraindications to Vaccination:  Anaphylaxis to eggs or other vaccine components Reaction to thimerosal (in contact lens solution) Adults with acute febrile illness History of Guillain Barre Syndrome  Children from 6 month age to 2 years is high risk  Children up to 8 years taking first time should receive  two shots 1 month apart


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Hepatitis vaccines Product

Age recommendation

Engerix B pediatric dose

Neonates, infants, children, and adolescents up to 19 years, inclusive

Engerix B adult dose

Adults 20 years and over

Twinrix junior (Hepatitis A&B)

Children and adolescents from 1 year to 18 years

Twinrix adult (Hepatitis A&B)

Adults 19 years and over*

Havrix 720 Junior (Hepatitis A)

Children and adolescents from 1 year up to and including 18 years of age

Havrix 1440 (Hepatitis A)

Adult 19 years and over

Hepatitis A Vaccine  Indications Travelers to endemic Hepatitis A areas, Children living in endemic states  Preparation Hepatitis A Vaccine (Havrix, Avaxim, Epexal, Vaqta) · Twinrix (Combined Hepatitis A and Hepatitis B Vaccine) Adults: 720 EU/20 ug (1.0 ml) Not approved for use in Children under one year?· Requires 3 doses as in Hepatitis B Vaccine schedule  Contraindications Not indicated for under age 1 years Use Hepatitis A Immunoglobulin instead Efficacy Protective antibodies by 4 weeks in 98-100% of patients Protection lasts at least 10 years after series. Hepatitis B Vaccine Indications  All Newborns (at birth, age 2 months, and age 6 months) All health care personnel  Hemodialysis patients Patients requiring frequent blood transfusion Staff and residents at developmentally disabled home Male homosexuals and their sexual contacts Intravenous Drug Abuse Sexual contacts of chronic HBsAg carriers  Contraindications Anaphylactic reaction to baker's yeast  Available Preparations Recombivax HB Infants, Children and Adolescents: 5 ug/dose  Adults: 10 ug/dose Immunosuppressed Adult: 20 ug/dose Energix-B (SKB) Infants and Children: 10 ug/dose Twinrix (Combined Hepatitis A and Hepatitis B Vaccine)  Adults: 720 EU/20 ug (1.0 ml)  Not approved for use in Children

 Requires 3 doses as in Hepatitis B Vaccine schedule


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Varicella zoster infection (chickenpox)  Dose: healthy children 12 months to 12 year age à One dose adults and adolescent > 13 à Two dose of vaccine is given 4 to 8 wks apart.  Vaccinate all susceptible adults  Contraindication: Pregnancy  Complications of herpes zoster include post-herpetic neuralgia, bacterial infections and paralysis.  Inform patient of the importance of hygiene, especially thoroughly.  washing their hands before and after touching their lesions to prevent secondary infections.  Provide patient with information on treating their lesion and easing their discomfort.  Compresses of cool tap water to lesions for 20 minutes several times a day.  Application of a sterile non-occlusive, non-adherent dressing over the involved  dermatome will help protect the lesions from contact with clothing.  Application of capsaicin cream to affected area 3-4 x/day, once healed  (warn patient about potential burning sensation).  Inform the patient to avoid contact with young children (especially neonates),  pregnant women and immunosuppressed persons since the active lesions are potentially infectious.  (Patient with HZ can only infect someone who is seronegative for VZV).  Discuss with the patients the possible side effects for each medication used in the management of PHN.

Gardasil: Human papilloma quadrivalent 9 to 26 yrs administered 0, 2, 6 months im Prevents: External genital warts caused by HPV 6, 11, 16 and 18 strains. Cervical carcinoma, cervical dysplasia, vulvar dysplastic lesions.  Counseling: Immunization will not eliminate the need for cervical cancer screening in the foreseeable future as not all strains will be covered by a vaccine. Also, it is unclear if the vaccines will offer therapeutic action against established infections.  Annual pap smear is required as the vaccine does not protect against all HPV strains  Not recommended in pregnancy  Can be used in nursing mothers  Side effects: Pain, swelling, erythema and pruritus at injection site, headache, fatigue.

Dukoral vaccine Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 74-5 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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   

Inactivated cholera vaccine –BS-WC Indications: Travelers diarrhea (E.coli) and cholera 2 doses at least 1 week but <6 weeks apart If > 6 weeks elapse between doses, restart the primary immunization.  Children aged 2 to 6 years: one-half the amount of buffer solution is discarded, and the remaining part is mixed with the entire contents of the vaccine vial.

Typhoid vaccine        

Inactive typhoid vaccine (shot): Should NOT be given to children UNDER 2 A booster is needed every 2 YEARS for individuals who remain at risk Live typhoid vaccine (oral): Should NOT be given to children UNDER 6 4 doses, given 2 days apart, are required for protection A booster is needed every 5 YEARS for people who remain at risk C/l in immunocompromised and cancer patients


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Practice Stations Scenario #1 A male concerned about flu, his medical history includes COPD. Patient profile: (patient presents after pharmacist candidate request) Patient Name: David Age: 32 years Address: XYZ Dr: Tips


Scenario # 2 A doctor wants to know that his patient is schedule to receive his annual influenza vaccination. What is your concern at this time? Patient profile: (presented on table) Allergies: None Medical conditions: Deep vein thrombosis Current medication: Warfarin 6.0 mg Lab test: INR 2.0-3.0

Scenario # 3 A women bring a varivax vaccine to your pharmacy and wants to know more information on varivax vaccine. Patient profile: (patient presents after pharmacist candidate request) Age: 30 yo Allergies: None Current medication: none Medical conditions: none

Scenario # 4 Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 74-7 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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A patient presents with a prescription to fill: Patient Name: David Age: 32 years Address: XYZ Dr: Gaucher


On the desk Rx: Dukoral oral vaccine M: 2 doses

Oral antidiarrheal vaccine (for travelers diarrhea) and also prevents Cholera.  Dukoral  Taken 2 oral dose (1 week apart)  2nd dose should be within 6 wks of first dose.  If you exceed 6 weeks, should start from 1st dose  Dissolve and take with water.


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Pregnancy & Lactation Immunization in pregnancy Factors to address when considering immunization during pregnancy  Likelihood of infection exposure  Risk of infection to mother and/or fetus  Maternal Immune status for disease in question  Risk of adverse effects from immunization Summary of potential risks associated with selected diseases in pregnancy Disease Cholera Hepatitis A Hepatitis B Influenza Measles Rabies Rubella

Tetanus

Maternal Risk Dehydration; potential increased severity in 3rd trimester Potential increased disease severity in 3rd trimester, miscarriage Potential increased disease severity in 3rd trimester Increased risk of maternal morbidity, serious complications, hospitalization Increased risk of encephalitis, pneumonia Close to 100% fatality (regardless of pregnancy status) Increased risk of miscarriage; susceptibility is 8% to 15% among adult women Tetanic muscle contractions, death (regardless of pregnancy status)

Typhoid

Increased risk of miscarriage

Varicella booster

Increased risk of pneumonia, death

Fetal Risk Premature labor Potential increase in prematurely Chronic infant infection Stillbirth Premature delivery, stillbirth Depends on severity of maternal illness Congenital rubella syndrome (serious malformations), stillbirth Infant born to a non-immune mother is at risk of neonatal tetanus, which can be fatal Depends on severity of maternal illness Congenital varicella syndrome (serious malformations)


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Fatality can be >50%

Depends on severity of maternal illness

Practice Station A pregnant woman came to your pharmacy and she is concern about her daughter who has chicken pox. What will you advice this patient?

A young lady comes to you in the Pharmacy for your advice on a product she feels would be helpful for her condition. Gather the necessary information from her and advice her accordingly. (On the Table: Dimenhydrinate 25mg tablets and Pyridoxine Tablets)

Patient Name: Ms Casie Age: 29 years Address: XYZ Dr: Gaucher


New Rx: IV Levofloxacin 500mg Q24HRS x 10 / 7 Patient pregnant and admitted to ward hence suggest appropriate alternative i.e 2nd/3rd gen cephalosporin + macrolide


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Travel Tips Travelers Diarrhea Non Pharmacological  Boil it, cook it, and peel it  Bottled water only  No ice  Hygiene (brushing teeth)  Don’t eat from street vendors  Avoid cold cuts and uncooked food (sea food)  Avoid buffets where food has been sitting there for a while

Malaria Prophylaxis DEET (N, N-Diethyl-m-toluamide) should be applied on the skin before outdoor activities during the main hours of malarial transmission.

Diabetes Management While Traveling  Planning Ahead  Diabetes should not stop you from doing the things you want to do. If you have diabetes, you must plan ahead carefully as traveling can be stressful sometimes and can raise blood glucose levels. Being well prepared can help you avoid undue stress. It is very good idea to meet your doctor for a checkup several weeks before you leave. Take your travel itinerary to your health care team and work out plans for your meals and medication, especially if you are traveling through different time zones. Ask for a list of your medications (including the generic names and their dosages), if you are taking insulin- what type of insulin and whether the insulin is sort, intermediate or long acting. Photocopy the list and carry one copy with you at all times. Carry identification with you at all times stating that you are diabetic.  Packing Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and 76-1 it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Divide your medications and diabetes supplies and pack them in more than one bag, in case you lose one of your bags. It s important to keep some supplies on your carry on luggage. Take extra supplies in case of accidental destruction. Also consider taking some of the other supplies you may need for treatment for hypoglycemia, food supplies, nausea, diarrhea, etc.  While Flying  Tell your travel agent that you are diabetic and most airlines offer special meals for diabetic passengers. Be aware of time zone changes ad schedule your meals accordingly. Carry all our insulin with you as manufacturers indicate that insulin should not be exposed to X-rays as it may lose potency. Inspect your insulin before every injection.  Do some activity during your journey to improve blood circulation  Storage Conditions  Insulin retains its potency at room temperature for 30 days. It must be stored properly. If you are traveling in hot temperatures, insulin must be kept in a cooled thermos / insulated bags. If you are skiing, camping or working in a cold climate, keep insulin from freezing.  Keeping Blood Glucose Levels Under Control  While on a vacation, test your blood glucose levels frequently using a meter. It is a good idea to keep the instruction manual for the glucose meter and keep spare batteries and test strips. Packing List For Diabetic Travelers  Extra supply of insulin or oral agent for diabetes  Extra supply of syringes, needles and an extra insulin pen if used  Blood glucose testing kit and record book  Fast acting insulin for high blood glucose and ketones  Fast acting sugar to treat low blood glucose  Extra food to cover delayed meals such as a box of cookies or crackers  Urine ketone testing strips  Anti nausea and anti diarrhea pills  Pain medication  Sun block  Insect repellant  Large amount of bottled water if necessary  Comfortable walking shoes  Glucagon (used if person is severely hypoglycemic and unconscious)  Telephone numbers of your doctor


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Practice Station Scenario # 1 A patient comes in the Pharmacy to pick up his medication and also has a few questions about certain other products on the outside shelf. Counsel him and advice him accordingly about the product. Also give him the necessary tips. Patient profile: (present on the table) Patient Name: David cox Age: 32 years Address: XYZ Dr: Tips


New Rx: Ciprofloxacin 500mg tablets QD (15 tablets) (On the Table: Bismuth subsalicylate suspension Immodium Capsules 2mg Oral Rehydrate sachets)

A lady patient comes to pick up her medication. Counsel her and provide all necessary supporting measures. You may also advice her any non-prescription product you believe would help her. Patient profile: (present on the table) Patient Name: Miss Kelly Age: 38 years Address: ZYZ Dr: Tips

Comments: None Medication: None

New Rx: Mefloquine 250mg tablets Q Week (8 tablets) (On the table: DEET spray 31%)


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77 Substance of Abuse


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Why OTC drugs get abused:  Cheap  Readily accessible  Carry no stigma of abuse (like cocaine or heroine)  Carry minimal risk of detection

Antihistamines  Dimenhydrinate (Gravol)  adolescents become “high” when they consume anywhere between 750-1,250 mg (15-25 tabs)  chronic abusers have been reported to take up to 5 gm (100 tabs) daily  Diphenhydramine (Benadryl)  usually taken by patients with schizophrenia and chronic insomnia  reported cases of chronic abuse include daily consumption of 1,250-2,500 mg (50-100 tabs)  Gravol  At high doses: feelings of well-being, euphoria, hallucinations  At large doses: sluggishness, paranoia, agitation, memory loss, increased blood pressure and heart rate, and difficulty swallowing and speaking.  Overdose: confusion, irrational behaviour, muscle uncoordination, high fever, convulsions, heart & breathing problems.

Dextromethophan (DM)  Teenagers and adolescents abuse DM to get “high”  “high” - state of separation from the environment or “out of body” experience  Euphoria; increased perceptual awareness; altered time perception; feelings of floating; tactile, visual & auditory hallucinations; visual disturbances; paranoia and disorientation.  At high doses: nausea, vomiting, psychosis, mania, seizures and respiratory depression.


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Dose-dependent "plateaus“ of DM (Dose in cough syrups ranges from 10 mg to 15 mg per 5 ml )

Plateau

Dose (mg)

Behavioral Effects

1st

100 – 200

Mild stimulation

2nd

200 – 400

Euphoria and hallucinations

3rd

300 – 600

Distorted visual perceptions Loss of motor coordination

4th

500 -1500

Dissociative sedation

Laxatives  Stimulant laxatives (bisacodyl, castor oil, senna) have been abused in the attempt to control weight  Act on the colon, not on the stomach  By the time food reaches the colon, all of the calories from the food have already been absorbed by the body  May feel like you have lost weight, but the only thing you lost is water  Within 48 hours of using a laxative the body retains water to make up for all that it has lost Laxative abuse may cause:  Chronic Diarrhea (after repeated use of laxatives you eventually lose control of your rectum)  Bloating  Dehydration  Nausea & Vomiting  Electrolyte Disturbances (may lead to heart arrhythmias and heart attacks)  Chronic Constipation  Dependency (larger & larger doses needed to produce bowel movement)  Permanent damage of your bowels

Pseudoephedrine regulations As established by federal government Precursors A – ephedra, ephedrine, pseudoephedrine Precursors B – solvents/reagents (i.e. acetone) used to produce CM. Pseudoephedrine & its salts as a single entity - Schedule II (as of April 10 2006) Pseudoephedrine & its salts in combination products – Schedule III


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 Government of Canada invests $10 million to prevent illicit drug use in youth On January 30th, 2008 The Government of Canada announced an additional $10 million investment into its new National Anti-Drug Strategy.  The goal of the CCSA's project is to reduce illicit drug use among Canadian youth between the ages of 10 and 24, including high-risk youth, focusing on risk and protective factors before drug use begins.  Health Canada, News Release, January 30 2008

Street drugs Drugs taken for nonmedical reasons Examples: Marijuana, Gamma hydroxybutyric acid (GHB), heroin, MDMA or ecstasy, Crystal Methamphetamine, Cocaine, Lysergic acid deithylamide (LSD), etc. Reasons for use:  Curiosity  Pleasure  Peer pressure  Medical purposes (pain relief)

Pseudoephedrine Crystal Methamphetamine (CM)    

Pseudoephedrine is extracted in underground labs to produce CM CM use is approaching an epidemic proportions in Canada $10 worth of CM can get person “high” from 5 to 48 hours One line of cocaine produces “high” that lasts 20-30 minutes and costs $60-80

Crystal Methamphetamine (CM) –powerful and addictive CNS stimulant MOA: neuronal release of large amounts of dopamine & smaller amounts of norepinephrine. Effect:  Heightened sense of well-being, euphoria, & alertness that can last for hours  mimics the fight-or-flight response (ñ in heart rate, BP & blood sugar), also ñalertness, awareness & motivation, and ò appetite, hunger & fatigue Crystal Methamphetamine (CM) –powerful and addictive CNS stimulant •Onset:  Injected: seconds  Smoked: seconds  Inhaled: 5 minutes  oral ingestion: 20 minutes • Distribution: readily crosses BBB • Metabolism: CYP 450 2D6 • t½: ~12 hours (max 48 hours) • Elimination: renal (4-5 hours with Nr Renal Fnx) Copyright © 2000-2010TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Crystal Methamphetamine (CM)  Chronic use leads to tolerance  Withdrawal: begins 24 hours & peaks at 72 hours after last dose (excessive sleepiness, GI symptoms, huge appetite) anxiety, agitation & depression ] may last for several month  Adverse effects: tachycardia, hypertension, anorexia, insomnia, diaphoresis, psychosis, aggression, paranoia, hyperthermia, seizures, etc. Crystal Methamphetamine (CM) (chronic use)  Striking feature: “jitteriness” & Parkinson’s disease-like symptoms (CM depletes dopamine, damage cells)  Compromised immune system  Hallucinations and paranoid psychosis  Movement disorder (continuous shaking)  Memory impairment, verbal skill deficiencies  Anhedonia (lack of enjoyment) & suicidal tendencies

Cocaine        

Cocaine hydrochloride: snorted or injected Chemically changed cocaine can be smoked ("crack") At low doses: energetic, talkative, alert and euphoric; more aware of their senses: heightened sound, touch, sight and sexuality; hunger and the need for sleep are reduced At high doses: panic attacks; psychotic symptoms: paranoia (feeling overly suspicious, jealous, or persecuted), hallucinations (seeing, hearing, smelling things that aren't real) & delusions (false beliefs)  erratic, bizarre and sometimes violent behavior  Dangerous Effects:  hypertension, stroke, heart attack, seizures and heart failure, sinus infections and loss of smell, lung damage (can be fatal), violent behaviors, psychiatric symptoms

Ecstasy      

3,4-methylenedioxymethamphetamine (MDMA) causes release of high level of serotonin in the brain At low doses: feelings of pleasure and well-being, increased sociability and closeness stimulant effects: can make users feel full of energy and confidence At high doses:


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 jaw pain, sweating, ñblood pressure and heart rate, anxiety or panic attacks, blurred vision, nausea, vomiting and convulsions  after-effects: confusion, irritability, anxiety, paranoia, depression, memory impairment or sleep problems  Dangerous Effects:  body temperature, blood pressure and heart rate, which can lead to kidney or heart failure, strokes and seizures  Ecstasy may cause jaundice and liver damage  A lot of ecstasy-related deaths are due to the dehydration and overheating

Dangers of Illicit Drugs  Harmful effects on the body  Risk of addiction  Compromised purity (there are no controls over the strength and purity of the drugs produced, contaminants may be present)  May contain combination of two or more illicit substances  Interact with Rx medicines and alcohol  Illegal

Herbals as drugs of abuse  Ginseng – at high doses → immediate effect of stimulation  Long term use of ginseng may lead to CNS excitation (hypertension, nervousness, sleeplessness, skin eruptions and diarrhea), blood glucose level disturbances


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Practice Stations Scenario # 1 Patient: female, 36 years old Rx: Effexor (Venlafaxine) XR 37.5mg po daily x 7 days, then 75 mg po daily x 30 days Provide counseling

Scenario # 2 A Male asking you to refill his Rx for Ativan SL tablets only. Patient Profile: Current medication - Sertraline 25 mg po od x 30 capsules (30 days ago) - Ativan SL 1 mg po hs prn x 15 tablets (30 days ago) No allergies Medical Conditions: depression Meds history: Tylenol for Headache. Age: 33 Lifestyle: works at Rogers Cable (technical support), Moderate exercise, and drinks socially, doesn’t smoke.

Scenario # 3 A lady comes to you with the following question: “Can you please tell me the side effects of Citalopram (Celexa)” Patient profile: (provides after pharmacist candidate requests) Current medications:  Citalopram 20 mg po qd (filled 5 days ago) Copyright © 2000-2010TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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 Lorazepam 1 mg po qhs  HCTZ 25 mg po qam  Atenolol 50 mg po daily Allergies: None Medical conditions: depression

Scenario # 4 A young man approaches your pharmacy asking for sleep aid. Patient profile: (gives after pharmacist candidate requests)    

Current medications: None Medical conditions: none Allergies: none Age: 22

On the table:  Nytol (diphenhydramine)  Sleep-ezz,


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Part 3

Non-Interactive Stations


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78

Non-Interactive Stations  There are two types of non interactions stations, 1-Prescription errors and 2-Dispensing errors       

Prescriptions Errors Verifies their authenticity and appropriateness Prescriber information on prescription Prescribers name and Title Prescribers office address Prescribers license No. (5 digits) Methadone license number

   

Patient information on prescriptions: patient’s name patient’s age (DOB) Not mandatory date on which Rx was written

      

Dispensing errors Drug information on prescription 1-Drug name, strength 2- Quantity to be dispensed Sign directions to patient refill instructions Prescribers signature

 TIPS:  Fill the Rx without guesswork  Benzodiazepines: Should not be filled or refilled (if any refills are indicated) more than 1 year after the script is issued to the patient  A carefully screened Rx order can avoid many potential unnecessary problems and confusion.


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Scenario # 1 Mr. J a 5-year-old boy Rx Captopril 5mg tid Mitte 90 Dispensed: 20 tablets of 25mg strength Scenario # 2 Rx Mr O, weight 44 lbs Ondansetron HCl cherry syrup

0.15mg/kg/tsp qs 60 ml

dispensed: 10 tablets of 4mg Scenario # 3 Rx #1 Mr JS New Rx for chicken pox Acyclovir 200mg 1-tab 5 x days F 7 day Scenario # 4 Rx # 2 Mr D. New Rx for depression Celexa 60 mg Qd 1month

Scenario # 5 Rx #3 Mr PF Rx for stable angina Nitrodur 0.4 mg/hr Apply 1 patch qd and remove before bed 3 months


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Scenario # 6 Rx #4 Mr. BW, weight 20 kg Rx for otitis media Amoxil 125mg/5mL 1tsp tid F7d

Scenario # 7 Rx#5 Ms TB New Rx Lipitor 10 mg Sig: 1 tid 1month Mitte: Repeat 6 Dr. TIPS

Scenario # 8 Rx # 6 Mr. LM Allergy to Penicillin (shortness of breath and hives) Losec 1-2-3A F 7 days Dr. TIPS

Scenario # 9 Rx #7 Mr. MK For malaria Prophylaxis Lariam 250mg 1qd 3months Dr. TIPS


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Scenario # 10 Rx#8 Ms. SL Estracomb patches Apply 3 times a week 3 months Dr. TIPS Scenario # 11 Rx#9 Ms SH For Onychomycosis Lamisil cream 30 g Apply AA bid R x4 Dr. TIPS Scenario # 12 Rx#10 Ms JS For osteoporosis Fosamax 70mg 1qw pc for 3 months Dr. Misbah Dr. TIPS Scenario # 13 Rx # 11 Mr. MF Atenolol 1qd 60 tablets Dr. TIPS Scenario # 14 Rx#12 Ms LB For toe nail fungal infections (Onchomycosis) Sporanox 200 mg


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Dr. TIPS Scenario # 15 Rx#13 Mr. RK Age 8-year-old weight 20kg New Rx for sinusitis Cipro 250 mg 1 bid F7d Dr. TIPS

Scenario # 16 Rx#14 Mr PF For migraine Imitrex 100mg 1qd 3 months Dr. TIPS Scenario # 17 Rx#15 Ms SF Monocor 1qd 3months Dr. TIPS

Scenario # 18 Rx # 16 Ms LS Rx for osteoporosis Actonel 35mg 1qd for 3 months Dr. TIPS Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Scenario # 19 Rx# 17 Mr. WP Rx for scabies Nix 1% cream  1 bottle Rinse Dr. TIPS

Scenario # 20

Rx#18 Mr. SF Salmeterol 25mcg Inhaler 1puff q4h prn Refills 3 Dr. TIPS

Scenario # 21 Rx 19: Ms LG Tylenol # 3 1tab qid prn 120 tabs Rx4 Dr. TIPS


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79

New Approved Drugs Finasteride 5mg and 1mg    

Selective 5alpha reductase inhibitors type 1 isoenzyme? 5mg Treatment of BPH, Major SE: Sexual dysfunction (Men only drugs) 1mg treatment of alopecia

Dutasteride 0.5 capsule QD capsule QD x 1/12    

5alpha and beta reductive inhibitors, type 1 and type 2 isoenzyme? Take one capsule every day Contraindicated in women It is important use condoms

Clarus:         

Take 2 capsules once a day Take with food Helps to dry up your fluid in acne Swallow it with water Completely contraindicated in pregnancy Initially acne can get worst, this may take few weeks to take effect Store in original container Even stopping your medication, you should continue using contraception for 1 month No blood donation up to 6 months after stopping medications.

Escitalopram 10mg QD:    

It helps to elevate mood Onset of effect 3- 4 wks Optimal effect 6 wks Escitalopram is safe with Tylenol that codeine because, however SSRIs (CYP 2D6) drugs are require caution with Tylenol # 2, 3 and 4 require caution. (escitalopram have least drug interactions)


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Pregabalin  Indicated for diabetic peripheral neuropathy and post herpetic neuralgias.  It can cause addiction and dependence. Abrupt discontinuation can cause d/c symptoms Concerta 36mg capsule QD  Advantage of this medication of over Ritalin (TID) is once a day  You notice capsule shell in stools.  Combine with Ritalin can lead to overdose  Encourage social activities (Martial arts- Karate) Solifenacin succinate  Take with lots of fluids  Recommended dose is 5mg once daily, should be taken with liquid, with or without food.  Maximum effect takes 4 weeks.  Anticholinergic side effects  For dry mouth, take small sip of water  Before start a new anticholinergic drugs, wait for one week  NP: pelvic exercise.  Note: film coated tablets can be crushed Fosavance 1 tablet Qwk x 1/12 (6 repeats)  Combination of alendronate and vitamin D3  Indicated for osteoporosis  If your taking alendronate, stop, and start new drug.  No need of vitamin D supplement  Continue taking calcium supplements Memantine HCL 10 mg tablets  Indicated for dementia  Take with or without food Sativex Spray PRN (dispense 1 unit)  Spray in mouth Niaspan 500mg BID  It is niacin the niacin products are niacinamide, it is not substitutable with niacin (niaspan)  Increase uric acid levels in blood.


Prep Notes

Part 4

NAPRA Competencies

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81 Regulations These drugs must have a ‘N’ symbol in the upper left portion of the label. The list of narcotic drugs also appears under Schedule N, The Food and Drugs Act (FDA). Narcotics

Straight Narcotics 1 or 1+1

Narcotic preparations Or Verbal narcotics 1+2

OTC or exempted Narcotics

Straight Narcotics Requirements for prescribing, dispensing and record-keeping

Prescription Refills or repeat Part Fill Transfers Record Keeping Sales Report Loss & Thief Reports

Written Verbal Written Verbal Written Verbal

Narcotic drugs  Permitted Not Permitted Not Permitted Not Permitted Permitted  Not Permitted Not Permitted 2 years Required 

Narcotic Drugs Preparations  Permitted Permitted Not Permitted Not Permitted Permitted  Permitted  Not Permitted 2 years Not Required

Yes 

Yes 

Tylenol # 4 1 or 1+1

Tylenol # 2 and 3 1+2


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Benzodiazepine regulations Requirements for prescribing, dispensing and record-keeping Benzodiazepines & Targeted Substances  Written Permitted Prescription Verbal Permitted Written Permitted Refills Verbal Permitted Written Permitted  Part Fill Verbal Permitted  Transfers Permitted once only Record Keeping 2 years Sales Report Not required Loss & Thief Yes  Reports. Control substances Requirements for prescribing, dispensing and record-keeping Controlled Drugs Part I  Part II  Part III  Written Permitted Permitted Permitted Prescription Verbal Permitted Permitted Permitted Written Permitted Permitted Permitted Refills Verbal Not Permitted Permitted Permitted Written Permitted  Permitted  Permitted  Part Fill Verbal Permitted  Permitted  Permitted  Transfers Not Permitted Not Permitted Not Permitted Record Keeping 2 years 2 years 2 years Not Required Sales Report Required  Not required



Loss & Thief Reports

Yes 

Yes 

Yes 


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Destroying Narcotics    

Step 1- Count all the medication and note them on this book Step 2- To destroy this drugs we have to follow certain regulations We should contact to Office of control substances and send our request. Step-3: You will then receive letter-acknowledging receipt of your request from the office of controlled substances.  You may destroy the products once this confirmation has been received.  The destruction must be witnessed by another health professional such as pharmacist, pharmacy intern or field representative from college of pharmacy.  The inventory of destroyed material is to be signed and dated by both parties.  For narcotics: Wait for response from office of control drug and substances permission Outdated Narcotics and Controlled Drugs  Unopened bottles of narcotics and controlled drugs may be returned to a distributor or manufacturer depending on their return policy for credit after obtaining written or faxed permission to do so.  For part bottles, permission to destroy must be obtained form Health Canada.  A request including a list of expired drugs and quantities can be faxed and destroyed after authorization has been given.  The destruction of these drugs must be witnessed by another health professional such as another pharmacist, pharmacy intern or a field representative form college.  The inventory of destroyed or stapled to the Pharmacy’s Narcotic and Controlled Drug Register.


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Practice Station A pharmacy intern wants to know how destroy return benzodiazepines. Advise him accordingly.


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82 Information Resources The familiarity with the following pharmacy practice references is essentials to effectively offer patient centred care.     

Compendium of Pharmaceutical Specialties (CPS) Patient Self Care Therapeutic Choices Drugs in Pregnancy by Briggs and Briggs Food & Drug guide, Health Canada


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A Step-By-Step Approach How to use the CPS The contents of the CPS are well known from its first page “CPS at a Glance”. These are:  Discontinued products (white pages at the beginning of CPS)  Brand and Generic name index (blue pages)  Therapeutic guide (Pink pages)  Product identification (Pages containing photographs of the medicines)  Directory (yellow pages)  Clini-info (lilac pages)  Monographs (white pages)  Appendices (white pages at the end of the CPS) There are additional pages, which are of benefit to the student in the exam, and these are:  Glossary of abbreviated Latin prescription, which are of benefit for the student in the exam or in the real practice.  Glossary of abbreviated terms of many classes of medications and laboratory tests that the student is not familiar with.  Microorganism abbreviations, which more often the student can’t differentiate if which type bacteria (e.g. pneumonia) whether it is chlamydia or clostridium or cryptosporidium or campylobacter. Discontinued Products: many times a student is confronted with a certain medication where he can not find it in the brand and generic name index (blue pages) and forgets to go to the “discontinued Products” pages, and he loses a lot of time searching for nothing. He simply can go alphabetically to the “discontinued Products” pages and find out whether the product is discontinued or not. Brand and Generic name index: These blue pages have the brand and generic name alphabetically whereby the students can pick the brand name and go to the monograph (White pages) directly. However the difficulty here is not everything mentioned in the blue pages, so that one can find full complete monographs. Sometimes only short paragraphs which the students can’t benefit a lot. So how can we differentiate those that have monograph in detail from ones that have short monographs? This is simple, by looking at the medications that are underlined. Those that are underlined have long monographs while those are not underlined have very short monographs. E.g. Acetaminophen/ Brompheniramine Maleate/Phenylephrine HCl. Dimetapp oral Infant Cold & Fever Drops has long monographs because it is underlined. Accolate, Prandase, Accupril, Accuretic have long monographs while, ZeaSorb, Amphojel, Amcort cream, Alcaine have short monographs.


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PharmacyPrep.Com In these pages we see CphA monographs. They direct youOSCE to CPhA a step monographs by step approach shaded in gray. They are comprehensive medications monographs or comprehensive monograph of a class of medication. E.g. ACE inhibitors (CPhA Monograph), which contain the information needed for all ACE inhibitors, like Benazepril HCl, Captopril, Clizapril, Enalpril Maleate, Enalprilat, Fosinopril, Lisinopril, Perindopril Erbumine, Quinapril HCl, Ramipril, Trandolapril. Such monographs prevents different tables to compare with different medications within the same class regarding pharmacokinetics, labeled indications dosages for comparison which you don’t find it in specific monographs of individual medications. It is also easier to study such monographs and to grasp the information than going specifically to each individual medication within the same class. Other examples: Bisphosphonates, Calcium channel blockers, carbonic anhydrase inhibitors, systemic cephalexin, Benzodiazepine, and SSRIs. The only thing, these monographs lack is the “supplied information” where you have to go to the individual monographs if you want some information about the strength of the medication, its delivery system and storage temperature. Product identification: These pages are helpful when you want to know directly how many dosage forms for medication and how much strength, by following the trade name alphabetically without going into the monograph. The individual monograph will tell you the different strength but you should go to other pages to look for other dosage forms whether the medication is in liquid form, injection or sustained released form which takes more time to search for, in contrast when you use the page of the product identification and this is very useful in nonintercative stations to save time. Also these pages are helpful to look at the product (device) and see its shape, color, size, and how you can identify the different pills of the same medication with different strengths which is also of benefit in non-interactive stations or in stations when there is an overdose due to dispensing error. Directory: The important here is section II that contain “Health Organizations” which are supporting group to different disease conditions. These are important to provide their phone numbers and their websites to patients suffering from certain disease in certain stations of “OSCE”. You can follow these health organization alphabetically and it id prudent for each candidate to be familiar with these health organizations. Clin-Info: It is important how to measure body surface area for children and adult. To be familiar with this, it is important for measuring antineoplastic doses. A straight edge is placed from the patient’s height in the left column to his weight in the right column and where the line intersects the body surface area column indicates the body surface area. How to covert “SI” & “traditional units” is important for different laboratory data. To convert from “traditional” to “SI units”, multiply the traditional value by the conversion factor found in the table for that of the laboratory tests. To convert from “SI” to “ traditional unit”, divide the SI value by conversion factor. This thing also applies for conversion factors for serum drug concentration. Recommendations for serum drug concentration monitoring are very important especially in determining the time to reach the steady state and when to adjust the dose. These informations are somewhat difficult to get them from the monographs. It takes time to look under the Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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ACE inhibitors, hypoglycemics, NSAIDs can be stopped abruptly CNS medications, PharmacyPrep.Com OSCE a while step byallstep approach cardiac drugs (with the exception of ACE inhibitors, corticosteroids, HRT and Opioids should be tapered). pharmacokinetics of the individual monograph, whereby here we can get it easily with some informations of the required drug concentration, and when to do the sampling. Drugs use in pregnancy. Here the informations are not for all medications and it is preferable to go to the individual monograph, and go to “use of drug in pregnancy” which mostly come after the “precaution” in the monograph. Drugs during lactation. It doesn’t mention all medications and it is preferable if needed to go to the monograph of the medication. Drugs in Dentistry. It is prudent for the student to look at this page before the exam to know the scope of practice of dentists regarding medications, which are mostly analgesics, antibiotics, and some antihypertersensitivity medications. Tables of endocarditis after certain procedures are well mentioned here and the student should be well familiar in knowing the information mentioned. It is the only place within the wellknown references that we find a summary of the management of endocarditis (we can not find that in therapeutic choices, psc, or cps) Medical Emergencies. One has to be familiar with these like oxygen, epinephrine, ASA (indicated in suspected MI or unstable angina), diphenhydramine or chlorpheniramine, nitroglycerine, and salbutamol. Perioperative management of medications. It is important to know which medications are continued perioperatively and which are withheld. E.g. withholding Sinemet will result in withdrawal of Levodopa-carbidopa, which has been associated with neuroleptic malignant-like syndrome. Another example is SSRI and NE reuptake inhibitors should be discontinued 2 weeks preoperatively because of possible interaction with Opioids such as fentanyl and meperidine. So the table gives a lot of informations in carrying out patients’ pre and post operatively using different kind of medications. Looking at these tables enrich the students with a lot of clinical interactions, in addition to giving periods of washout before doing the operation, and it is important to know them because they could be presented in Doctors stations or in non-interactive stations Routine Immunization Schedules. This is a very important schedule for infants and children and also for adults. Only “MUR” and varicella vaccine are contraindicated in pregnancy, all the other vaccines should be susceptible during pregnancy to rubella (German measles) should be given rubella vaccine postpartum) The page of routine immunization mentions the priority of those vaccines especially the influenza, pneumococcal and tetanus for many diseased conditions. Drugs in older Individuals. This page mentions the necessity of reducing the doses for most medication when administered to elderly due to hepatic and renal impairment. Thus all medications should be reduced in dosages and adjusted on renal function and rate of metabolism. Therefore lower starting doses and slower upward titration is recommended. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Drugs which have minimal pharmacokenitic changes with aging are; Valproic acid, CBZ, Clopidogrel, and amiodarone. Adverse drug reactions in elderly are mostly in:  CNS (mental confusion)  Cardiovascular system (CHF, hypertension, orthostatic hypotension), and stroke  GIT (ulcer, bleeding, perforation, esophagitis, strictures, bowel erosive disease, constipation  Renal and urinary retention (acute renal failure, fluid and electrolyte disturbance, involuntary loss of urine and urinary retention) Withdrawal of selected medications in older individuals. It is an important page in CPS where the student should know which medications could be stopped abruptly and which medications should be tapered. Malaria prevention: This page is the best page to get the information about malaria medication because the CPS lacks the detailed monographs for Chloroquine phosphate. So the student is referred to this page when he wants to get information about antimalarial and not to waste time in monographs. The student can find the table sufficient informations regarding the doses in adult and children, adverse effects, and some comments to different antimalarial medications. According to CPS (2005), the monographs available to antimalarial medications are malarone (atovaquone 250mg/proguanil HCl 100mg), and Doxycycline (vibra-tabs) only. Cytochrome P450 Drug interactions: This page is good to get general informations about certain medications whether they are enzyme inducers, inhibitors or substrates. However it is prudent to go to the individual monographs to see whether these interactions (pharmacokinetic or pharmacodynamic interactions) are contraindicated because of certain clinical impacts or could be monitored and are classified under “precautions” and “warning” or there is no clinical impact from these interactions. Drug Administration and Food: In “OSCE” stations, it is better to search whether the medication is administered with or without food by looking at the dosage in the monograph of that medication prior to going to lilac ages and looking at the drug and Food. It is mentioned whether the drug is to be taken with or without food or on empty stomach. Actually this is used to save time. In case if nothing is mentioned about the drug administration, then one can go quickly to the table of “drug administration and food”. The medications in that table are mentioned alphabetically under the scientific name; so that’s why it is better to go to the monograph first where we can have the brand name and generic name, and if there is no indication to the administration, one can go to the table of “drug and Food” directly afterwards. Drug Administration and Grape Juice: In general, grape juice is an inhibitory of CYP3A4 (intestinal). There appears to be a prolonged inhibitory effect of grapefruit juice on intestinal CYP3A4-medicated metabolism. Sweet orange juice does not appear to cause the same interaction, however sour (Seville) orange juice and limejuice have similar enzyme inhibitory effects. The quantity of grapefruit juice consumed is important to be considered, since as little as 250 ml can cause significant inhibition of Cytochrome 3A4. Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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Nutrient requirements: The tables provided in that page are important if you don’t have a patient self care book, as a reference in the station or other specific references dealing with nutrient requirements. The information includes dietary supplementation to infants, pregnant and lactating mothers, strict vegetarians and older individuals. Also smokers who have to take ascorbic acid (Vitamin C) and individuals with little or no exposure to sunlight, a Vitamin D may be required. Ethanol-containing Pharmaceuticals: Ethanol is often used as preservative and solvent in pharmaceutical preparations. Certain medications and conditions influence the need for awareness of the ethanol content of pharmaceuticals. “Disulfiram-like reactions” characterized by flushing, headache, nausea, sweating and/or tacchycardia may occur when ethanol is taken with metronidazole, Chlorpropamide, and some cephalosporins (e.g. cefotetan). Ethanol is a CNS depressant, when taken with drugs such as sedatives, hypnotics, antihistamines, and antidepressants, the CNS effects of ethanol may be enhanced. Ethanol content of oral products should be assessed in individuals with diabetes. Avoidance or use of low-ethanol content products is preferred for children. In general, elixirs, syrups, liquid, solutions, lotions, vials, gels, and aerosol contain alcohol in different percentages. The table listed in CPS worth to be considered in certain diseased conditions and when medication have high or moderate percentage of alcohol.

Gluten-containing pharmaceuticals: The students can use this page or in the supplied section of the CPS product monograph, he statement “containing gluten” refers to the gluten derived from wheat, barley, oats, and rye. Celiac disease is intolerance to the gliadin fraction of ingested gluten, resulting in immunologically mediated inflammatory damage to the lining of the small intestine. The inflammation may lead to malabsorption by reducing the amount of surface area available for absorption of the nutrients, fluids, and electrolytes. Lactose-containing Pharmaceuticals: Many medications that use as filler may cause symptoms of lactose intolerance in those who take multiple lactose-containing medications. Lactose intolerance occurs in individuals with deficiency of the intestinal enzyme lactase and leads to symptoms including abdominal cramps, diarrhea, distention, and flatulence. Administration of the enzyme lactase can increase lactose tolerance of lactose-intolerant individuals. Lactose is also contraindicated in individuals with the fructose-galactose malabsorption syndrome called galactosemia. It is preferable to go to the supplied where quicker information about the availability of the lactose or not. Sulfite-containing Pharmaceuticals: Sulfiting agents are used as antioxidants in the preservation of foods and drugs. Here the condition is not like lactose intolerance. Hypersensitivity reactions such as urticaria, nausea, diarrhea, wheezing, and dyspnea have been reported most frequently after the ingestion of restaurant foods treated with sulfites, but they also occur after exposure to the drug products containing sulfites. The concentration of sulfites in pharmaceuticals is usually low but adverse reactions to sulfites are not always related.


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Tartrazine-containing Pharmaceuticals: Most common reactions to tartrazine are asthma or urticaria. Although the overall sensitivity to tartrazine is low, it may occur more frequently in ASA-sensitive and NSAID-sensitive individuals as a cross-sensitivity. Peanut oil, Soybean oil, or Soya lecithin: Soya and peanuts both belong to the legume family and there may be potential for cross-reactivity. Peanut allergic individuals may develop a soya allergy in 5%-15% of cases. Soya lecithin and soybean oil ingredients found in some pharmaceuticals may contain small amounts of soya protein. Medications that contain soya lecithin and soybean oil should be avoided in individuals with severe soya allergy unless otherwise advised by their doctor. However peanut allergy is not contraindicated to use of soya products unless there is a c0-existing soya allergy. Monographs: It is very important for the student to have a certain strategy in dealing with different monographs of medications. We all know that there are short and long monographs but in either one the student should not spend more than 2 ½ minutes to be safe in finishing his station and in presenting the most useful aspects of that medication. So the strategy depends on the task of the station. If the task is just simple counseling, it is better to look first at the indication and pick up the indication that most relevant to the information that gathered from the patient. The student can pick the indication as the doctor told that to the patient in case if the patient said that the doctor told him that this medication is used for this purpose. Many of the indications of certain medication may fit certain hidden conditions in the patient where you have to prove and gather informations that are relevant to that medication. For example ACE inhibitors; they are indicated for:  Management of hypertension  Slow progression of nephropathy in D.M., which is independent of blood pressure reduction.  Considered standard therapy in post-MI patients  First line treatment of systolic heart failure So we can see here, there are different indications so if after asking the patient (what did the doctor tell you about this medication is for?) and he informed the pharmacist about it; so you can simply then confirm what the doctor has told the patient. In a different case where the patient doesn’t inform the pharmacist, then our job is to probe more and get relevant information to the indication. After that the student should go directly to the dosage and read carefully the dosage that is related to that medication, for example: You see a monograph of Betaloc and Betaloc durules. They share a common monograph, but when you go to the dosage, you should be careful to go to the dosage of the one that is requested like Betaloc only or Betaloc durules, since each one has different dosage. Betaloc is immediate release, and Betaloc durules is sustained release, and the dosage will duffer accordingly. The other thing is to focus while you are looking for the dosage, on the way of administration (swallow whole, crush, chew, or not crush or chew) with water or is it dispersible, or inhaled, Copyright © 2000-2010 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep

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or any route of administration and look whether before or after meal, because this could be mentioned under the dosage paragraph if not go quickly to the lilac pages to confirm that. So don’t go to the lilac pages before you check that in the dosage mentioned in the monograph, and then check the dosage that is on label or in the prescription with that in the monograph that is relevant to that condition. Doing these things you picked a lot of information to inform patients like the indication, the dosage, the administration, the route of administration, and the frequency. Just underneath the dosage you can have a glance to the “supplied” to know the storage and sometimes they mention about the delivery system of certain medications when they are sustained release. Then you go to the side effects, which could be gathered promptly, from any table about side effects if present or go and read quickly most common side effects and at least one rare side effect. Then take a glance to the bold letters under warnings and precautions, afterward start to convey those information to the patient, in addition to self care measures that you should already know them to tell the patient about them. In other stations when there is a visible drug interaction, it is better to go directly to the contraindication, in an attempt not to waste more time since some interactions are contraindicated and you can finish the station by calling the doctor directly without going and searching for the drug-drug interaction under “drug interactions” or “warnings”. However if it is not mentioned anything about the drug interaction in the “contraindication” then definitely in that case, you go and look under precautions warnings. It is advisable for every student to go over all charts that are mentioned in the CPS to be familiar with them and go over all bold letters in the monographs to gain more information. Actually this I will not take more than 7 days. It is advisable to understand these tables especially those, which require dosage adjustment due to renal failure and dose adjustments for neutropenia and Thrombocytopenia.

Therapeutics Guide Drugs are listed under alphabetically arranged therapeutic indications (e.g. acne, diarrhea). Drugs may be further classified under pharmacologic or chemical subheadings within a therapeutic indication. Therapeutic Guide is very essential when you don’t have any other reference book like therapeutic choices or Patient’s self care or any other clinical book. If information about medication used in hypothyroidism like thyroid desiccated and you want to change this medication into another one which is also used for this purpose, you can’t find directly in CPS unless you go to therapeutic guide under “hypothyroidism” and you see three medications listed which are Levothyroxine, liothyronine, and thyroid desiccated; whereby you can choose anyone and go to its individual monograph to use, it is an alternative for any purpose the physician wants.


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PharmacyPrep.Com OSCE a step by step approach This appendix could be used when you have some suspicion or lack of certain legal information that you forgot. So it is very simple just to go to Appendix 1 where all the legal requirements for narcotic drugs, narcotic preparations, and controlled drug part I and II, controlled drugs, benzodiazepines, and other targeted substances. Something with nausea and vomiting medications if you want any medication to act as antinauseant and act as an alternative to certain antinauseant medication, let say dopamine antagonists (like metoclopromide) you go simply to “nausea & vomiting” in the therapeutic guide and pick the suitable medications to be used as an alternative after going their individual monographs. That’s how you can use a reference book that deals with medications not with disease like CPS book, use its therapeutic guide for different conditions by which we can’t opt different medications for the same targeted disease. In the last example as antinauseant and vomiting we have: Anticholinergics like scopolamine Antihistamines like dimenhydrinate, hydroxyzine, and promethazine Cannabinoids like dronabinol, nabilone Dopamine antagonist like chlorpromazine, metoclopromide, perphenazine, prochloroperazine, and trifluperazine. Serotonin CS-HT3 antagonist like dolasetron mesylate, granisetron HCl, ondansetron hydrochloride dihydrate. Otherwise we can’t depend on our memory in this regard. So this is a way to go from one medication to another within the same class or within different classes as an alternative when the doctor asks you for that or when you want to present certain alternatives to the doctor due to any reason requested. Appendices: The most important one is appendix 1: narcotic, controlled drugs, Benzodiazepines and other targeted substances.


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