CLINICAL PHARMACY Prepared by: Francis R. Capule, RPh PHARMACEUTICAL CARE The provision of drug therapy & other patient care services intended.to achieve outcomes related to the: Cure or prevention of a disease, elimination or reduction of a patient's symptoms, or arresting or siowing of a disease process, CLINICAL PHARMACY A patient-focused pharmacy practice ESSENTIAL KNOWLEDGE & SKILLS FOR A CP: Drug therapy ‘Communication Non-drug therapy Patient monitoring Disease Physical assessment Laboratory & diagnostic test. Therapeutic planning Drug information PHARMACEUTICAL CARE PLAN 4.Assessment- a review of the medical conditions and symptoms to determine the need for drug therapy 2.Plan- a decision of an appropriate drug therapy based ‘on the assessment of the patient 3.Monitoring- a review of the outcomes of drug therapy (goals and endpoints) to determine if the patient is obtaining the desired outcomes DISEASE STATE MANAGEMENT Hypertension (HTN) most common cardiovascular disorder - sustained BP = 140/90 (systolic/ diastolic) = usually asymptomatic intially lead to myocardial infarction (Ml), heart faiture, stroke, or kidney disease Types: 1. Primary (Essential) HTN = most common (>80%) = no specific cause can be identified = major risk factors: * family history of cardiovascular disease * smoking * diabetes melitus * dyslipidemia * age (>55 for men; >65 for women) 2. Secondary HTN -25% - identifiable cause causes: * chronic kidney disease (most common) + renovascular disease (most common) = Cushing's syndrome = pheochromocytoma * primary aldosteronism * drug-induced: steroid or estrogen, NSAIDs, nasel decongestants, TCAs, appetite suppressants, cyclosporine, erythropoietin, MAOIs 7th Report of the Joint National Committee on Detection, Evaluation, & Treatment of High BP (JNC-7): ‘Category Systolic | Diastolic (mmHg) | _(mmHg) _| Normal, < 120 &< 80 Pre-hypertension | 120-139 (0r-80-85 ‘Stage 1HPN_ ‘Or 90-99 ‘Stage 2 HPN Or= 100 Cardiac Output (CO) = determines your systolic pressure - amount of blood pumped from heart/min - influenced by HR, contractility and blood volume SVxHR Stroke Volume (SV) ~ amount of blood ejected from each ventricle/beat Total Peripheral Resistance (TPR) = determines your diastolic pressure = determined by vasoconstriction Strategy: | CO or | TPR Treatment: Target: <140/90; 130/80 (with diabetes or renal disease) Non-Pharmacologic 4. weight reduction 2. dietary sodium reduction 3. increased physical activity 4, moderation of alcohol consumption 5, smoking cessation Pharmacologic Stage 1 HTN: * thiazide-type diuretics *"may consider ACEI, ARB, B-blocker, CCB, or combination Stage 2 HTN: = two-drug combination * thiazide-type diuretic & ACEI or ARB or B-blocker, or cca, ‘A. SYMPATHOLYTICS 1. Centrally-Acting / a2 Agonist = Methyldopa, Clonidine, Guanabenz, Guanfacine - presynaptic a, agonist > | NE release ((-) feedback) - activity of methyldopa: due to stimulation of central alpha adrenoceptors by methyldopamine & methyiNE SIE = sedation, dry mouth, depression = methyldopa: false (+) Coomb's test for hemolytic anemia clonidine: rebound hypertension on withdrawal c-METHYLDOPA arunatieLaming H aod decartenrase H —G—nie oe METHYLDOPAMINE by { dopamine Ppaxdase He Hy wo: ¢ - METHYLNOREPINEPHRINE 2. Blockers = Prazosin, Terazosin, Doxazosin = block a; > | vasoconstriction > | PR SIE: orthostatic hypotension especially after the 1 dose 3. B Blockers =| HR, contractility > | CO - block stimulation of renin secretion Page 1 of 12~ selectivity Selective Non-Seiective Betaxolol Propranolol Bisoprolol Penbutolol Esmolol Carieolol ‘Aienolol CarvediLOL (@& 8) ‘Acebutolol LabetALOL (a & 8) Metoprolol Timolol Celiprolol Nadolol - intrinsic sympathomimetic activity * Pindolol, Penbutolol, Acebutolol, Carteolol * release catecholamines * maintain satisfactory HR * may also prevent bronchoconstriction SIE = hypotension, bradycardia, CHF, bronchospasm (asthma, COPD patients) 4. Ganglionic Blockers ~ Trimethaphan, Hexamethonium + rarely used due to side effects: Parasympathetic blockade > urinary retention, blurring of vision ‘Sympathetic blockade -> orthostatic hypotension, sexual dysfunction 5. Postganglionic Adrenergic Neuron Blockers = Reserpine, Guanethidine = deplete catecholamine stores in the brain & in the Peripheral adrenergic system rarely used due to low efficacy & side effects B. DIURETICS = | Na, H20 retention > | BV> | CO = thiazide-type diuretic (thiazide, Chlorthalidone, Indapamide, Metolazone, Quinethazone) ~ ingrease urinary excretion of Na & H,0 by inhibiting Na‘-Cr symporter in the DCT SIE - hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia, hypertipidemia C. VASODILATORS 1. Hydralazine - directly relaxes arterioles > | PR ~ hypertensive crisis (IV or iM) SIE: ~ reflex tachycardia, systemic lupus erythematosus. 2. Minoxidil = directly relaxes arteriolar smooth muscle > | PR - decreases renal vascular resistance ‘SIE: hypertrichosis 3. Sodium Nitroprusside has potent effects on both the arterial & venous systems - acute hypertensive crisis (IV) SE ~ hypotension, cyanide toxicity 4, Diazoxide ~ exerts a direct action on the arterioles = acute hypertensive crisis (IV) = hypoglycemia due to hyperinsulinism (prevents insulin release) SIE hypotension, hyperolvcemia 6. Calcium Channel Blockers (CCB) Dihydropyridines: ~ Amlodipine, Felodipine, Isradipine, Nicardipine, Nifedipine, Nisoldipine vascular smooth muscles = vasodilation - | PR Non-dihydropyridines: = Verapamil & Diltiazem - vascular smooth muscles & cardiac muscles = vasodilation - | PR + (-) inotropic / chronotropic effect - | CO Sie = flushing, headache, peripheral edema (Nifedipine) ~ constipation (Verapamil) Renin-Angiotensin-Aldosterone System (RAAS) - long term regulation of BP - | BP > | renal blood flow > kidney releases renin @. renin - converts angiotensinogen (produced by the liver) to angiotensin | b. angiotensin converting enzyme (ACE) (lungs) - converts angiotensin | to angiotensin I . angiotensin II 4. vasoconstrictor > 7 PR 2.aldosterone release in adrenal cortex > Na, H;O retention > 7 blood volume > t CO D.ACE INHIBITORS - Captopril, Enalapril, Lisinopril, Benazepril, Fosinopril, Moexipril, Perindopril, Quinapril, Ramipril, Trandolapril - | angiotensin ll > | vasoconstriction > | PR + angiotensin II-> | aldosterone > | Na, H,0 retention | blood volume > 1 CO SIE = dry cough, hypotension, hyperkalemia, teratogenic, neutropenia, proteinuria, angioedema E_ANGIOTENSIN Il RECEPTOR BLOCKERS (ARB) ~ Candesartan cilexetil, Eprosartan, Irbesartan, Losartan, Olmesartan, Telmisartan, Valsartan - block the binding of angiotensin I! to the angiotensin I receptors SIE =no dry cough, hypotension, hyperkalemia, teratogenic Competing Indications: 1, Heart failure - diuretics, B-blockers, ACE inhibitors, ARB, aldosterone antagonist 2. Post-MI - B-blockers, ACE inhibitors, aldosterone antagonist 3. High coronary disease risk - diuretic, 6-blocker, ACE inhibitors, CCB 4, Diabetes - diuretic, B-blockers, ACE inhibitors, ARB, coe 5, Chronic kidney disease - ACE inhibitors, ARB. 6. Recurrent stroke prevention - diuretic, ACE inhibitors Heart Failure (HF! ‘complex clinical syndrome that can result from any cardiac disorder that impairs the abilty of the ventricle to deliver adequate quantities of blood to the metabolizing tissues during normal activity or at rest = 1cO Classification: Page 2 of 124. Left Heart Failure 2, Right Heart Failure Normal Circulation: ‘Systemic circulation —> Right atrium — Right ventricle — Lungs — Left atrium — Left ventricle + Systemic 1 Na-> Na-Ca exchanger > 1 Ca low therapeutic index SIE: Digitalis toxicity (especially if hypokalemic) Signs! = anorexia * fatigue, headache & malaise + mental confusion & disorientation * alterations in visual perception = armhythmia Treatment: * Lidocaine or Phenytoin Cholestyramine * Digoxin-specific Fab fragment antibodies 2, Inamrinone, Milrinone 's phosphodiesterase > { cAMP > 1 Ca + inodilators ~ SIE: hypotension, arrhythmia, thrombocytopenia 8, Dopamine 2-5 mogikg/min: renal D; receptor + 5-10 mog/kgimin: By receptor =>410 megikg/min: a; receptor 4, Dobutamine ~ Br & Beagonist with some a, agonist effect - produces less tachycardia B, VASODILATORS = {PR 4. Nitroprusside 2. Hydralazine 3. Prazosin 4. Nitrates: 5. Nesiritide = recombinant form of human B-type natriuretic peptide - binds to natriuretic peptide receptors in blood vessels > 1 cGMP in target tissues = reduces pulmonary capillary wedge pressure & systemic vascular resistance ©. DIURETICS = |. Na, H,0 retention 1. Thiazide Diuretics 2. Loop Diuretics - Furosemide, Torsemide, Ethacrynic acid, Bumetanide - decrease Na reabsorption by inhibiting the Na‘/K"/2Cr transporter in the loop of Henle acute pulmonary edema, acute hypercalcemia SE = ototoxicty, hypovolemia, hypomagnesemia, hypokalemia, hyperuricemia, allergy 3, Potassium-Sparing Diuretics - Spironolactone, Amiloride, Triamterene, Eplerenone Spironolactone, Eplerenone ~ aldosterone antagonist - inhibit Na reabsorption, K secretion at the collecting tubule = combined with loop, thiazide diuretics to prevent K loss - hyperaldosteronism (Conn’s syndrome), CHF SIE hyperkalemia, gynecomastia, impotence (due to structural simiiarity with progesterone) D.B BLOCKERS - Bisoprolol, Metoproto!, Carved!LOL = Carvedilol: management of chronic HF = initiate with low doses, titrate upward slowly E. ACE INHIBITORS Ischemic Heart Disease (IHD) = form of heart disease with primary manifestations that result from myocardial ischemia due to atherosclerotic: CAD = Coronary Artery Disease (CAD): refers to a number of diseases other than atherosclerosis causing a narrowing of the major epicardial coronary artery = may present as acute MI, unstable angina, chronic stable angina or variant angina Angina Pectoris = most common form of IHD = applied to varying forms of transient chest discomfort that are attributable to insufficient myocardial oxygen Types: 1, Stable or Classic Angina = most common form - exertion, emotional stress, or a heavy meal usually precipitates chest discomfort = usually relieved by rest, nitroglycerin, or both Page 3 of 122. Unstable or Crescendo Angina ~ the patient experiences: * rest angina + severe new-onset angina (CCSC (Class IIl)) * increasing angina * decreased response to rest or nitroglycerin 3. Prinzmetal's or Vasospastic or Variant Angina = usually occurs at rest rather than with exertion or ‘emotional stress = due to coronary artery spasm Strategy: 4. | Op delivery: vasodilators (Nitrates, CCBs) 2. | Op demand: 8 Blockers, CCBs A NITRATES = Nitroglycerin: SL, spray, transdermal patch, oral, IV infusion - Isosorbide dinitrate; mononitrate: SL, oral - Pentaerythritoltetranitrate: SL - Erythrtoltetranitrate: SL, oral ~ converted to nitric oxide (NO) > inc. GMP > smooth muscle relaxation > vasodilation = venodilation & arterial dilation > | O; demand SIE: headache, flushing, postural hypotension, reflex tachycardia, tolerance (prevention: nitrate-free Periods) B. CALCIUM CHANNEL BLOCKERS - Nifedipine, Amlodipine, Felodipine, Isradipine, Nicardipine, Nisoldipine, Nitrendipine, Bepridi, Diltiazem, Verapamil = DOC for Prinzmetal's angina C.B BLOCKERS = Propranolol, Metoprolol, Atenolol, Nadolol, Timotol, Acebutolol, Betaxolol, Bisoprolol, Esmolol, Pindolol, LabetALOL =| HR, contraction> | O2 demand ‘Thyrold Disease Thyroid gland = synthesizes, stores, & secretes hormones that are important to growth, development; & the metabolic rate Thyroid hormones: thyroxine (T.) & triiodothyronine (Ts) Thyroid-stimulating hormone (TSH): released by the anterior pitultary gland, which is triggered by thyrotropin- releasing hormone | (TRH), secreted from the hypothelamus Hyperthyroidism = thyrotoxicosis -1T3&Ts, | TSH Grave's Disease = most common form of hyperthyroidism = autoimmune disorder (long-acting thyroid stimulators (LATS) bind to & activate TSH receptors) Signs & Symptoms: * diffusely enlarged nontender goiter = nervousness, iritabilty, anxiety, & insomnia * heat intolerance & profuse sweating * weight loss despite increased appetite * tremor & muscle weakness. * palpitations & tachycardia = exophthalmos, stare, & lid lag (slow upper lid closing) * diarrhea * thril or bruit over the thyroid * periorbital edema ‘Steps in Thyroid Hormone Synthesis: Step Inhibitors, [Todide uptake / trapping | Anion Inhibitor Peroxidation of iodide to lp = oF periodate ‘Organification of fe Thioamides: lodides. Coupling reaction “Thioamiges Proteolysis Todinated contrast media lodides Peripheral conversion of | Propytthiouraci TatoTs B-Blockers | | Corticosteroids | Todinated contrast media ANTITHYROID AGENTS 1. B-Blookers. Propranolol (DOC) = reduces some of the peripheral manifestations (¢.g tachycardia, sweating, severe tremor, nervousness) of hyperthyroidism 2. Thioamides = Propylthiourecil, Methimazole, Carbimazole = SIE: dermatologic reactions (rash, urticaria, pruritus, hair loss, skin pigmentation) 3, Radioactive lodine (1"") = destroys some of the cells that would otherwise concentrate iodine & produce Ts, thus decreasing thyroid hormone production 4, lodides - Potassium iodide, Lugo's solution = for thyroid storm (thyrotoxic crisis) 5. Corticosteroids 6. Anion inhibitors = perchlorate, pertechnetate, thiocyanate Potassium perchlorate - patients with iodide-induced hyperthyroidism rarely used (aplastic anemia) 7. lodinated contrast media - Diatrizoate, lohexol = useful adjunctive therapy in the treatment of thyroid storm = valuable alternatives when iodides or thioamides are + contraindicated Hypothyroidism = 11387. t TSH Cretinism = hypothyroidism that begins at birth & results in developmental abnormalities & severe mental retardation signs & symptoms: constipation * has feeding problems = somnolence = mentally retarded hoarse cry - physical abnormalities: * short stature * coarse features * widely set eyes = protuberant abdomen = umbilical hernia Page 4 of 12Myxedema = severe hypothyroidism with accumulation of hydrophilic mucopolysaccharides in the dermis Causes: = Hashimoto's thyroiditis (autoimmune destruction of the thyroid gland) + treatment of hyperthyroidism * surgical excision * goiter (enlargement of the thyroid gland) Signs & Symptoms: - early clinical features: * lethargy * sensitivity to cold * fatigue = unexplained weight gain * forgetfulness * constipation - characteristic features of myxedema: * dry, flaky, inelastic skin * coarse hair + slowed speech & thought hoarseness puffy face, hands, & feet eyelic droop heating loss menorthagia decreased libido slow return of deep tendon reflexes coma (poor prognostic sign) Therapeutic Agents: 1. Levothyroxine (T«) = agent of choice 2. Liothyronine (Ts) = 3-4x more active than Levothyroxine - useful for myxedema crisis Diabetes Mellitus disorder of glucose metabolism that results from an absolute or relative fack of insulin Pancreatic Hormones Islet of Lengerhans: * alpha (a) cell - glucagon (increase level of circulating blood of glucose) * beta (8) cell - insulin (decrease level of circulating blood of glucose) + delta (6) cell - somatostatin * PP or F cell- pancreatic polypeptide Pathophysiology Normal glucose regulation involves both insulin & counterregulatory hormones. Insulin: * slimulates glucose transport across cell membranes & promotes the storage of glucose as glycogen in muscle & liver cells enhances fat storage (lipogenesis) & prevents the mobilization of fat for eneray (lipolysis & ketogenesis) * inhibits production of glucose from liver or muscle glycogen (glycogenolysis) promotes incorporation of amino acids into proteins inhibits the formation of glucose from amino acids (gluconeogenesis) = decreases the breakdown of fatty acids to ketone bodies Counterregulatory hormones * Giucagon * Epinephrine + Norepinephrine * Growth hormone * Cortisol Classification: 1. Type 1 + insulin-dependent diabetes melitus (IDDM) - juvenile-onset diabetes = ketosis-prone diabetes: = most common in children & in adults < 30 years old + insulin production & secretion is destroyed 2. Type2 non-insulin-dependent diabetes melitus (NIDDM) - adult-onset diabetes ~ adults > 30 years old = insulin production & secretion may be altered or reduced but is not totally lacking Signs & Symptoms: ~ classic: = polydipsia (excessive thirst) * polyuria (excessive urination) * polyphagia (excessive hunger) other common findings: * dry skin * frequent skin & vaginal * fatigue infections = weakness * weight alterations * visual disturbances - additional for type 1 DM * unintentional weight loss. = with or without signs & symptoms of ketoacidosis (accumulation of ketone bodies in body tissues & fluids) Treatments: Nonpharmacologicat: 4. Attain &/or maintain BMI <27 2. Cessation of alcohol intake, or limit to nme toziday 3. Nicotineltobacco cessation 4, Sodium restriction: nmt 2g/day 5, Routine, aerobic exercise nit 3x\week, 20-30 mins per session Pharmacologic: INSULIN * 1 glucose uptake & utilization by peripheral tissues = tT glycogenesis * | glycogenolysis * | gluconeogenesis * | lipolysis & ketogenesis * 7 formation of protein from amino acids * + formation of adipose tissue from triglycerides & fatty acids Types of Insulin { Ultra rapig-acting Lispro insulin analogue E Aspart insulin analogue Rapid-acting Reguiar insulin infermediate-acting | NPH insulin Lente insulin [Tong-acting: Ufiralente insulin Ultra long-acting ‘Glargine insulin analogue ORAL HYPOGLYCEMIC AGENTS A Insulin Secretagogues Page 5 of 12Chemical Classes: 4. Sulfonyureas ist Generation ‘2nd Generation | Tolbutamide Giyburide ‘Acetohexamide Glipizide Chiorpropamide Glimepiride 2, Megltinides - Repagiinide & Nateglinide - stimulate pancreatic secretion of insulin B. Insulin Sensitizers Chemical Classes: 1. Biguanides - Metformin 2. Thiazolidinediones - Pioglitazone, Rosiglitazone Metformin. = T hepatic sensitivity to insulin Pioglitazone & Rosiglitazone * | postraceptor defect in muscle & adipose tissue * [number &/or sensitivity of insulin receptors in muscle & adipose tissue cn: = lactic acidosis (Metformin) ~ hepatic disease (Pioglitazone & Rosiglitazone) C. Alpha-Glucosidase Inhibitors - Acarbose, Vogibose, Migiitol - inhibit the intestinal enzyme a-glucosidese Asthma =a chronic inflammatory disorder of the airways Characteristics .inflammation obstruction c.increased airway responsiveness dLepisodic asthma symptoms Classification of Asthma Severity Severe persistent = continual symptoms = nighttime occurrence: frequent Moderate persistent daily symptoms = nighttime occurrence: > 1 night a week Mild persistent ~ symptoms > 2x a week but not every day nighttime occurrence: > 2 nights a month Mild intermittent ~ symptoms < 2x a week + nighttime occurrence: = 2x a month Pathophysiology Main Events: 1. Triggering Precipitating Factors: * Allergens = Occupational exposures * Viral respiratory tract infections = Exercise = Emotions. * Ievitants = Environmental exposures * Drugs: 2. Signaling 3. Migration Inflammatory Cells = Mast cells ' Alveolar macrophages ' Eosinophils * Other cells (neutrophils, lymphocytes) 4. Cell activation Inflammatory Cells Mediators Mast cells Histamine Leukotrienes Prostaglandins | Avveoler macrophages | Prostaglandins Thromboxanes eae Platelet-activating factor | Eosinophils Major basic protein 5. Tissue stimulation & damage Activities: ‘= Mucus secretion = Smooth muscle constriction = Mucosal edema = Hyperactivity * Epithelial damage Clinical Evaluation Physical Findings: ‘A Acute exacerbations ~ Shortness of breath = Wheezing = Chest tightness = Cough ~ Tachypnea & tachycardia - Severe exacerbations B, Chronic, poorly controlled, severe asthma = Chronic hyperinflation ‘(barrel chest, decreased diaphragmatic excursion) Diagnostic Test Results Pulmonary Function Test = Decreased forced expiratory volume in 1 second (FEV1) & forced vital capacity * Increased residual volume & total lung capacity = Provocation testing with histamine or methacholine challenge Blood Analysis * slightly increased WBC *= (+) eosinophilia * (+) leukocytosis: ‘Sputum analysis * Eosinophils * Curschmann’s spiral (mucous casts of the small airways) * Charcot-Leyden crystals (products of eosinophil breakdown) * Creola bodies (clumps of epithelial cel's) Bacteria Pulse Oximetry * Oximeter - measures O, saturation in arterial blood & pulse = Normal: 95%-98% oxygen Others ® Arterial blood gas measurements = ECG = Chest radiograph * Allergy skin test Page 6 of 12Nonpharmacologic Treatments: 1. Humidified 0, - severe, acute asthma 2. Heliox - He & O; 3. IV fluids & electrolytes 4, Environmental control & allergen avoidance 5. Vaccines (influenza virus, polyvalent pneumococcals) Pharmacological Treatments: ‘A. BRONCHODILATORS: 1. BeAgonists - stimulate Brteceptors, activating adenyl cyclase, which increases intracellular production of cAMP — bronchodilation, improved mucociliary clearance & reduced inflammatory cell mediator release Classification: 4. Rapid acting, short acting: Terbutaline, Albuterol 2 Rapid acting, long acting: Formotero! 3. Slow acting, long acting: Salmeterol, Bambuterol Indications: ‘Short-acting! = acute exacerbations & prophylaxis of EIB Long-acting - moderate-severe persistent asthma = prophylaxis of EIB -COPD ‘SIE: tremor, palpitation, tachycardia, nervousness, headache 2. Methyixanthines = inhibit phosphodiesterase, which increases cAMP. levels = Theophylline, Aminophyltine, Doxofylline Indications: = acute. asthma exacerbation (if Bragonists & corticosteroids fail to contro!) - persistent. asthma (alternative to long-acting B- agonists) ~ patients wi nocturnal symptoms (adjuvant to inhaled corticosteroids) SIE: diarrhea, anorexia, palpitations, dizziness, restlessness, insomnia, nervousness, seizures, reduced lower esophageal sphincter tone & control of GERD 3. Anticholinergics block postganglionic muscarinic receptors in the alway - Ipratropium Br, Oxytropium Br, Tiotropium Br Indications: = severe, acute asthma execerbation (+ B,-agonists) - older patients & patients with coexisting COPD = patients who cannot tolerate B-agonists - patients with bronchospasm induced by a 6-blocker B. ANTLINFLAMMATORY 1. Mast Cell Stabilizers - inhibit mast cell degranulation = Cromolyn Na, Nedocromil Na (inhalation) - Ketotifen (oral) Indications: = maintenance therapy of persistent asthma or for prevention of EIB 2. Leuketrione Modifiers 2.1 Leukotriene Receptor Antagonists - selectively antagonize cysteiny! leukotriene 1 (CysLT1) receptor = bronchodilator - Montelukast, Zafirlukast - SIE: Churg-Strauss syndrome- eosinophilic vasculitis. 2.2 Lipooxygenase Inhibitor = blocks 5-lipooxygenase - bronchodilator Zileuton 3. Corticosteroids = bind to glucocorticoid receptors: - decrease airway hyperresponsiveness Classification: 4. Locally acting inhaled steroids: Budesonide Fluticasone Beclomethasone Flunisolide Triamcinolone 2. Systemic parenteral steroids: Hydrocortisone Methylprednisolone 3, Systemic oral steroids: Prednisone Prednisolone Others: 1. Antihistamines - with coexisting allergic rhinitis 2. MgSO, - bronchodilator 3. Immunotherapy - improves asthma control Stepwise Approach for Managing Asthma (adults & children older than 5 years of age): Step 4 (Severe Persistent Preferred Treatment: High-dose inhaled corticosteroids & long-acting inhaled Beagonists Step 3 (Moderate Persistent) Preferred Treatment: Low-to-medium dose inhaled corticosteroids & fong- acting inhaled B,-agonists, Alternative Treatment: Increase inhaled corticosteroids within medium-dose range or low-to-medium dose inhaled corticosteroids & either leukotriene modifier or theophylline Step 2 (Mild Persistent) Preferred Treatment Low-dose inhaled corticosteroids Alternative Treatment: Cromolyn, leukotriene modifier, nedocromil, or SR theophylline Step 4 (Mild intermittent No daily medication needed PATIENT MEDICATION COUNSELING = provision of oral or written information about drugs & other health-related information to a patient or his / her representative during the dispensing process or stay in hospital ‘Communication Skills: 41. Attending & active listening skills 2. Empathic responding skills, 3. Interviewing skills 4, Influencing skills Page 7 of 12Tips on Active Listening: * Stop talking * Get rid of distractions * React to the ideas, not to the person = Read non-verbal messages * Listen to how something is said * Provide feedback to clarify any message Empathic Responding Skis: Reflecting - concentrating on the emotional meaning Paraphrasing - conveying the essence of what was seid Focusing - getting back to the topic of conversation Interviewing Skils: * Ask open questions * Ask closed questions = Check if the patient has understood or requires more information Tips on Effective Interviewing: * Avoid suggesting during data-gathering phase *= Do not jump into conclusion * Avoid shifting from one topic to another until one is finished * Provide a balance of questions * Keep goals of the conversation in mind = Maintain objectivity Influencing Skills: = Give relevant advice ** Share correct information = Make good suggestions = Summarize main points of information given Tips on Giving Advice: + Emphasize key points with "This is important, = Give reasons for key advice * Give definite, concrete, explicit instruction = Supplement spoken word with written instruction = Check for accuracy of patient's understanding ‘Scope of Counseling * Generic name, trade name * Use, action & onset * Route, dosage form & storage * Directions for use * Action in case of missed dose * Precautions * Side & adverse effects * Techniques for self-monitoring + Potential drug interaction = Contraindications * Relationship with lab or X-ray procedure * Disposal of drugs & devices * Any other relevant health information unique to an individual patient MEDICATION ERROR = any preventable event that may cause or lead to inappropriate: medication use or patient harm while the medication is in control of the health care professional or patient Types: 4. Prescribing Error 2. Monitoring Error 3, Dispensing Error 4, Administration Error 4.1 Omission Error (Skipped Dose) Exclusions: patient's refusal, recognized ils, patients for procedure 4.2. Wrong Time Error 4.3 Unauthorized Drug Error = wrong drug - a dose given to the wrong patient - unordered drugs = doses given outside a stated set of clinical - guidelines or protocols 4.4 Administration of Discontinued Medicine 4.5 Improper Dose Error - overdosage -underdosage 4.6 Wrong Dosage Form Error 4.7 Wrong Drug Preparation Error - incorrect dilution or reconstitution mixing drugs that are physically or chemically incompatible 4.8 Wrong Administration Technique Error wrong route - correct route but at the wrong site - wrong rate of administration 4.9 Deteriorated Drug Error = administration of expired drugs & improperly stored/unstable drugs 4.10 Uncharted Dose 5. Compliance Error CLINICAL LABORATORY TESTS COMMON SERUM ENZYME TESTS: 1. Creatine kinase (Ck): CK-MIM: skeletal muscles CK-MB: heart CK-BB: brain 2, Lactic dehydrogenase: aid in diagnosing MI, hepatic LDH, & LDH, (hear!) LDH (lungs) LDH, & LDHs (liver & skeletal muscles) ease, & lung disease 3. Alkaline phosphatase (ALP) =f: biliary obstruction, Paget's disease, osteomalacia, hyperparathyroidism 4. Alanine aminotransferase (ALT) - serum glutamic-pyruvic transaminase (SGPT) = relatively specific for liver cell damage 6, Aspartate aminotransferase (AST) = serum glutamic-oxaloacetic transaminase (SGOT) 6. Cardiac Troponins - diagnosis of acute Ml Troponin T: cardiac & skeletal muscle Troponin |: cardiac muscle Troponin G: skeletal & cardiac muscle COMMON RENAL FUNCTION TESTS: 1. Blood urea nitrogen (BUN) - f: renal disease - | liver disease 2. Creatinine =}: renal failure - | creatinine clearance - renal failure Cockcroft & Gault Equation [140-Age(yrs)] x BW(Ka) serum (mg/dL) x 72 creatinine xF Creatinine Clearance Page 8 of 12Factor: if male: 1 if female: 0.85 ELECTROLYTES: 1, Sodium. =: HPN, 2, Potassium = t: fenal dysfunction, cellular breakdown, with the administration of Spironolactone = |: diuretic use, vomiting & severe diarthea, with the administration of steroids, Amphotericin, & Li carbonate 3. Chloride = 7: acute renal failure, renal tubular acidosis, 1 hyperparathyroidism, dehyoration = |: chronic renal fallure, adrenal insufficiency, fst prolonged diarhea, severe vomiting, diuretic (thiazide & oop) MINERALS: 1. Calcium = T: hyperparathyroidism, Paget's disease, diuretic (Thiazides) = |: parathyroid hormone (PTH) or vitamin D deficiency, diuretic use (Loop) 2. Magnesium = 1: Addison’s disease ~ |: severe diarrhea, hyperaldosteronism, diuretic use 3. Phosphate =f: renal dysfunction, increased vitamin D intake, hhypoparathyroidism, hyperthyroidism = |: hyperparathyroidism, insufficient vitamin D intake OTHER TESTS: 1. Acid phosphatase = t: prostate carcinoma 2. Gamma glutamy! transpeptidase (GGT) : hepatocellular & hepatobiliary disease, alcoholic liver disease 3. Albumin iver disease 4, Glucose (Fasting) =: diabetes, adrenal corticosteroid use 5. Cholesterol = fr atherosclerosis (LOL) = |: atherosclerosis (HDL) 6. Bilirubin =}: hemolysis, biliary obstruction, liver cell necrosis 7. Uric acid = t: gout, rapid cellular destruction (chemotherapy or malignancies) - |: Wilson's disease, malabsorption syndromes HEMATOLOGICAL TESTS: 1. RBC (Erythrocytes) = |: anemias 2. Hematocrit, =o, of RBCs in 100mL of blood reported as a % 3, Hemoglobin = Or-carrying protein in RBCs 4. Mean cell hemoglobin (MCH) - average RBC Hgb content ~ cell color: - chromic ‘normochromic (normal) hhypochromic anemia hhyperchromic anemia ‘5. Mean cell hemoglobin concentration (MCHC) - amount of Hab per volume of RBCs 6. Mean cell volume (MCV) average volume of the individual RBCs cell size: -cytic normooytic rooytic acrocytic anisoeytic Types of Anemia: 1) Macrocytic-Normochromic Anemia a Pernicious anemia , Megalobiastic anemia 2. Microeytio-Hypochromic Anemia a.1DA 3. Normocytic-Normochromic Anemia 1, Aplastic anemia - bone marrow is not producing enough RBCS b. Hemolytic anemia - early destruction of RBCs in the blood c. Sickle Cell anemia - genetic disease causing anemia from improperly formed RBCs 7. Activated partial thromboplastin time (aPTT) = used to monitor Heparin therapy 8, Prothrombin time (PT) = used to monitor Warfarin therapy 9. international normalized ratio (INR). = (PTpatient / PT control) "==™ Senet nts 10. Platelets (Thrombocytes) ~ smallest formed elements in the blood 11. WBC (Leukocytes) - bacterial infection 3 Kinds of Granulocytes: ‘Neutrophil - bacterial infection Eosinophil - parasitic infection Basophil Leukocytes w/o granules in their cytoplasm: Lymphocytes - viral infection Monocytes DRUG UTILIZATION REVIEW (DUR) = process of quantitatively & systematically reviewing prescription claims data to evaluate the appropriateness of crug therapy Types 1, Prospective DUR - normally done before or at the time of dispensing the drug 2. Retrospective DUR - normally done after dispensing the drug Advantages: “helps to identify the physician's prescribing & the patient's drug utlization pattern = improves the drug therapy process by eliminating previously occurring medication regimen problems. Page 9 of 12CLINICAL DRUG LITERATURE Types: 1. Primary literature ~ articles appearing in pharmaceutical & medical journals that have the most current & accurate health-related information 2, Secondary literature = represents 2 types of resources: * indexing (bibliographic) * abstracting 3. Tertiary literature = Teference books & text books DRUG INFORMATION SOURC! ‘Adverse Textbook of Al 1 Effects Side Effects of Drug Dispensing | USPINF a Oriented Merck Index: | References _| Remington Drug Index Nominum Manufacture | Martindale: The Extra Pharmacopoeia Outside of | USAN Dictionary of Drugs Names | USA USP Dictionary of DrugNames ‘Drug Oriented | AHFS Drug Information References _| USP Dispensing Information | | ‘AMA Drug Evaluation Martindale: The Extra Pharmacopoeia Pharmacological Basis of Therapeutics investigational | The NDA Pipeline Drugs Drug Facts & Comparisons Martindale: The Extra Pharmacopoeia Parenteral | Handbook of Injectable Drugs Guide to Parenteral Admixture Poison Dreisbach’s Handbook of Poisoning Information | Clinical Toxicology of |Commercial Resources _| Products ff Product ‘American Drug Index Oriented PDR | References | Facts & Comparisons | Handbook of Non-Prescription Drugs Blue book Red book Therapeutic | Merck Manual | Oriented Applied Therapeutics References | Clinical Pharmacy & Therapeutics Cancer Chemotherapy Handbook PRE-CLINICAL STUDIES Pharmacologic Studies = determine the action of new drug in animals to estimate the magnitude of its intended therapeutic effect Pharmacokinetic Studies = determine the new drug's absorptive, distributive, metabolic & excretory pathways Pharmacodynamic Studies = determine the mechanism of actions & pharmacologic effects of drugs Toxicologic Studies = determine the relative safety in humans & monitor parameters that will be used in clinical trials CLINICAL TRIALS Phases: Phase | to detect the adverse effects of the new drug «involves a small no. of subjects for study of the drug's toxicity, bioavailability, metabolism, elimination & pharmacological action of the drug Phase I = to determine the efficacy of the drug & dosage at wie efficacy may occur ‘ested on @ limited no. of patients who actually suffer irom the disease for wic the new drug is claimed for Phase il involves hundreds or thousands of patients - double-blind study is normally conducted in this phase = if the phase Ill studies are favorable, the drug sponsor's may submit a New Drug Application (NDA) to the FDA Phaso IV - aka post marketing surveillance = once the NDA has been approved, the innovator company may legally distribute the drug in interstate commerce ‘STUDY DESIGNS Case-Control / Retrospective Study = observational study ~ samples chosen based on presence (cases) or absence (controls) of disease - information collected about risk factors - advantage: inexpensive - disadvantage: recall bias e.g. people with lung cancer and people without lung cancer & see who smoke more Cohort / Prospective Study - observational study - samples chosen based on presence or absence of risk factors = subjects followed over time for development of disease - advantage: less recall bias - disadvantages: time-consuming, expensive e.g. smokers & nonsmokers then see who develops lung cancer Cross-Sectional Study / Prevalence Studies - survey of the population at a single point in ime = looks at disease prevalence & prevalence of factors. e.g, more colon cancer & high fat diet in US versus less colon cancer & low fat in Japan Randomized controlled clinical trial - gold standard; experimental study = compares 2 or more treatments or treatment & placebo - randomization decreases bias & confounding - blinded (patient) - double blinded (patient & researcher) - disadvantages: costiy, time-intensive, ethical considerations (cannot compare new treatment to placebo if there is @ standard of care) Page 10 of 12USE-IN-PREGNANCY CATEGORIES, A = adequate studies in pregnant women have failed to show a risk to the fetus in the 1st trimester of pregnancy, & there is no evidence of risk in later trimesters Category B = animal studies have not shown an adverse effect on the fetus, but there are no adequate clinical studies in pregnant women Category C = animal studies have shown an adverse effect on the fetus, but there are no adequate studies in humans Category D ~ there is evidence of risk to the human f Category x = studies in animals & humans show fetal abnormaites, of adverse reaction reports indicate evidence of fetal risk PHARMACY ETHICS. ‘Autonomy ~ obligation to respect patients as individuals & to honor, their preferences in medical care Nonmaleficence + Do no harm. However, if benefits of an intervention ‘outweigh the risks, a patient may make an informed decision to proceed. Beneficence ethical responsibility to act in the patient's best interest - Patient autonomy may conflict with beneficence. If the patient makes an informed decision, ultimately the Patient has the right to decide. Confidentiality respects patient privacy & autonomy = Disclosing information to family & friends should be guided by what the patient would want. PHARMACOECONOMIC METHODOLOGIES Costof-liness Evaluation = measuring direct & indirect costs attributable to a specific disease = @.g. Cost of migraine in U.S. Cost-Benefit Analysis = allows for the identification, measurement, & ‘comparison of the benefits & costs of a program or treatment alternative = benefit-o-cost ratio = benefit ($)/costs($) Table 1135. Cost Benefit Analysis Example Pagulsrion Cox 300 «00 ‘dministion 0 ° Monier Es 5 Bowers 193 a ‘Subtotal 500 = benefits BE Wore) 1000 1000 era hos of fe 8) 2000 3am ene 3 CR 3000/508 sooottog Cost-Minimization Analysis - involves the determination of the least costly alternative ‘when comparing 2 or more treatment alternatives = the outcomes are assumed or determined to be equivalent Table 113.8. Cost Minimization Analysis Example cairo nares pee rg oats ‘eausion Cost, 250 350 s ° 3 8 00 aie 300 we 0% 0% SEP gies eA meat Ral oaaeTE Te Sats ning ha gb S100 wert ND ty Analysis = measures the consequences in terms of the quality adjusted life year (QALY) gained Quaiity-Adjusted Life Year (QALY) = combines mortality & quality of Ife gains (outcome of a treatment measured as the number of years of Ife saved, adjusted for quality) = integrates the patient preferences & health-related quality of tife Quaiity of Life (QOL) - physical, social, & emotional aspects of a patient's well being that are relevant & important to the individual Table 113-7. Cost-utility Analysis Example com ora paus ous coats Aezqition Cort 300 ‘00 ‘ainieaton| 0 0 Mentoring 50 ° averse fleas 190 5 Subtotal $00 vies Extra Years of Lite 18 Quslty of ite 25 ‘oatys" ao ost ta Utility Ratio 404 ‘31000 aly ASRS Cost-Etfectiveness Analysis = compare treatment alternatives with cost measured & treatment outcomes expressed in terms of therapeutic objective - cost-to-eftectiveness ratio: cost ($) / therapeutic effect (in measurable units) = summarizing the health benefits & resources used by competing health care programs so that policy makers ‘can choose among them Table 112-6, CostEtfectiveness Analysis Example ao DAUGA oy Seats Begulstion Cost 300 400 ‘aministration 30 9 Monitoring 50 0 averse Efecte 100 te Subtotal 300 00 uaauts Entra Years of Life 1s 16 ConecHociveress ato. sous $250" Fer arayearaT Te, PRICING METHODS Page 11 of 12Dispensing Fee Method = the price is calculated by adding a fixed fee to the acquisition cost of the unit of product dispensed Percentage Mark-Up Method = the patient receiving a more costly drug pays for a proportionately larger part of overall pharmacy service costs regardless of the amount of service received Per Diem Method = the average drug cost per patient day, the average pharmacy service cost per patient day, & the desires Profit. margin are computed to arrive at a single pharmacy charge for each day the patient stayed in the hospital COMPLEMENTARY AND ALTERNATIVE MEDICAL HEALTH CARE Terms: Nutraceutical = may be considered a food or part of a food & provides medical or health benefits, including the prevention & treatment of Phytochemical = found in edibie fruits & vegetable that may be ingested by humans daily in gram quantities & that exhibit 2 potential for modulating human metabolism in @ manner favorable for cancer prevention Chemopreventive Agent = nutritive or non-nutritive food component being scientifically investigated as a potential inhibitor of carcinogenesis for 1° & 2° cancer prevention Designer Food = processed food that are supplemented wi food Ingredients naturally rich in disease-preventing substances Acupuncture = ancient Chinese healing art that employs fine needles inserted at various locations in the body to restore the smooth flow of energy Homeopathy - therapeutic method that clinically applies the Law of, Similar & uses medically active, potentized substances at weak or infinitesimal doses. Hypnosis, = state of altered consciousness, sieep, or trance induced artificially in a subject by means of verbal suggestion or by the subject concentrating upon some subject Iridology = diagnostic tool that purports to correlate changes in the color & texture of the iris with mental & physical disorders CONTAINERS: A RECALL Wide-mouth bottios = for bulk powders, large quantities of tablets or capsules, & viscous liquids that can not be poured easily Applicator botties = for applying liquid medication to a wound or skin surface Prescription bottles for dispensing liquids of low viscosity Dropper bottles = for dispensing ophthaimic, nasal, otic, or oral liquids to be administered by drop Round vials - for solid dosage forms such as capsules & tablets ‘Aerosol containers - for powders to be applied by sprinkling Slide boxes = for dispensing suppositories & powders prepared in packets Ointment jars, Collapsible tubes - for dispensing semi-solid dosage forms (e.g. creams & ointments) PARTS OF THE PRESCRIPTION 4, Prescriber’s office information 2. Patient information 3. Date 4, Superscription = generally understood to be a contraction of the Latin verb recipe, meaning take thou or you take 5. Inscription - body or principal part of the prescription order that contains the names & the quantities of the prescribed ingredients 6. Subscription - consists of directions to the pharmacist for preparing the prescription 7. Signatura = where the prescriber indicates the directions for the patient's use of the medication 8. Refill, special labeling, and/or other instructions 9 Prescriber’s signature and license Leste he afaat See eat z omits Page 12 of 12INTERPRETATION OF CLINICAL LABORATORY TESTS [__ LABORATORY TESTS NORMAL UNITS NOTES Common Serum Enzyme Tests _ SE ie Creatine kinase (CK) =f: myocardial necrosis (CK-MB) Female 40-150 U/L -CK-MM: skeletal muscles Male 60-400 U/L - CK-MB: heart e - CK-BB: brat y Lactic dehydrogenase 110-210 UL aid in diagnosing MI, hepatic disease, & lung disease LDH; 17-27% - LDH; & LDH, (heart) LDH. 28-38% ~ LDH (lungs) LDH; 18-28% - LDH, & LDHs (liver & skeletal muscles) LDH, 5-15% SUD Hee ee 5-15% = aa fee si Alkaline phosphatase (ALP) ~ 7: biliary obstruction, Paget's disease, hyperparathyroidism, osteomalacia Female 30-100 U/L Male ae pp beak Tonge ae sel De) Bs i Alanine aminotransferase ~ serum glutamic-pyruvic transaminase (SGPT) (ALT) - telatively specific for liver cell damage Female 7-30 U/L - fi liver disease Malas cs pinata te 10-55 U/L, os i Aspartate aminotransferase = serum glutamic-oxaloacetic transaminase (SGOT) (AST) - 1: myocardial infarction, liver di Female 9-25 U/L. Male 10-40 U/L a! a ete Cardiac Troponins = diagnosis of acute MI Troponin T < 0.1 ngimL - Troponin T (cardiac & skeletal muscle) Troponin | < 1.5 ng/mL - Troponin | (cardiac muscle) Troponin C x 4 ‘Common Renal Function Tests ew Blood urea nitrogen (BUN) 8-18 mg/dl - |: liver disease: cust Creatinine 06-1.2 mg/dl ={:tenalfailure Seam Creatinine clearance 80-120 mL/min = [renal failure eW/E 2°0-0 AIG ‘SISOJ0@U [199 JAAI ‘UOHONSGo AueNIq ‘sisAjoWeY :1 - 1p/6w O'L-1'0 101. uignayig i Ip/6w OSL-OF (Gunse3) sapyeoh|Buy rs 1p/BW OS <7GH (1GH) siscueposoueyje :f - Ip/6w og) > 107 (1G) sisorajosoueype :| - ip/6w 00z > 1e}01 4 Joraysa}04D 3 ‘SN plolajSoooo jeuaipe ‘Seyeqeip :1 - Ip/BW OLL -OL __(Guyse 3) esoonig, a Ip/ 8-9 TeIOL “V6 se-ez suIINGOI, aseasip Joni :t - Ip o-v wngiy uiejog pee ae z (is) asepadedsven, aseasip J8ni| ajoyooje ‘aseasip Areriqoyeday g sejnjjeoojeday :| - Tun 09-1 iAweinj6 eued | Tes Bulouloseo ayeysoid :| = NSS -0 __ asejeydsoud poy a im Bea ___ 81881 JOUI0 | OE ‘SyeqU C ULUEYA WE!SNSU “WUsIploIAMexediedAy ‘UoRIANU|EU T~ z @ye1U! UIWUEWA posee.oUl ‘Wusiplosyeddy ‘wsiprosAyjeredodAy ‘uonounysAp jeuel :| ~ p/w ¢-5°z ie ayeydsoyg @sn ohaunip ‘wsiuoseysopjeiedfy ‘snjearoued ‘wsijoyooje ‘eayuielp a1enes ‘uondiosqejeu :t - aseasip suosippyy ‘snneday : - aya y°2-9'1 e winisoubeyy {doo} Ssn oyainip “AouaBYSp q UILIEYAIO (Hid) SUoUNOY plouAyyesed =f - (sopizeity) asn ajaunip ‘aseesip sje6eq ‘wisiploukujenediodAy :) - cyosweol-s3s __wnieo Suet z zs ra ‘S|BJOUIY, = Sea te ~~ doo] 9 SpizeiMy) sn ORaINIp se ‘Bunlwion eines ‘eoyeip peBuojoid ‘Buysey ‘foue!oysnsul jeuedpe ‘eunjiey feues O1UOAYO :t - uonespAyap ‘wisiplosAyjesediedAy of ‘sIsopioe Jejngny jeued ‘eunjtey jeued aynoe 2} - “yea sor -s6 epuoiyo a ayeuoqieD T) ® ‘uloUaoyduIy ‘sploisys Jo uopensiulwipe eyy m ‘eeyielp e1enes ¥ Buyiwion ‘sisojexe ‘esn oneunip ‘1 - auio}oejoUuoLidg Jo UoHeNsIUlWIpe ayy ms \(SuONDEIUI ‘SUING ‘sishiowey ‘eBewep ens) umopyeeig Jejnjj99 ‘UoReIpAYEp ‘sisopioe ‘uonOUNysAp Jeuad :| - aybauig-s'¢ ___unissejog ___NdH t= “ybaw Zpi-sel uunipos: ‘seyfjouoa/3,a Indirect: 04-1, img/di Sr Uric acid =7: gout, rapid cellular destruction (chemotherapy or malignancies) Female 2.3-6.6 mg/dl - |: Wilson's disease, malabsorption syndromes Male _ 3.6-8.5 mgidl = ig Ge, ie, Hematological Tests ee a RBC (Erythrocytes) =n. of RBCs found in a cubic | Female 3.5- 5 million/mm? - |: anemias Male iw 4.3- 5.9 millionimm? _ ar Bi: Hematocrit =no. of RBCs in 100mL of blood reported as a % Female 37-47% ~t polycythemia vera, dehydration, vitamin By & By2 deficiencies Male E 42-52% ____| - |: iron deficiency anemia (IDA), overhydration, blood loss Hemogiobin ~ O;-carrying protein in RBCs Female 12-16 g/dl - |: blood loss, iron deficiency anemia (IDA) Male Cena s 13-18 g/dl 2 a fi Mean cell hemoglobin (MCH) 26-34 ~ average RBC Hgb content <26 - hypochromic anemia >34 - hyperchromic anemia | - t: vitamin Bg & B:2 deficiencies, hemolytic anemias Rahs s = |: ton deficiency anemia (IDA) an Mean cell hemoglobin 31-37 = amount of Hgb per volume of RBCs concentration (MCHC) <3 - hypochromic anemia >37 ~ hyperchromic anemia is te = |: hypochromia (iron deficiency anemia (IDA)) Mean cell volume (MCV) 80-100 = average volume of the individual RBCs <80 - microcytic: iron deficiency anemia Bors? Sate 100 ‘vitamin Bs & Biz deficiencies Reticulocytes 0.4-2.4% immature RBCs that contain residual RNA & protoporphyrin but no nucleus > 24% - blood loss, hemolytic anemia ley < 0.1% = polychromasia ia Erythrocyte sedimentation = measures the rate of RBC settling of whole, uncoagulated blood over time rate (ESR) - f: inflammation, infection, tissue necrosis or infarction, malignancy, rheumatoid collagen Female % 4-30 mm/hr diseasesNdH 0} Bugngajuos siojoey eZTUTUIUN K $89] 10 Aep sod Bg 0} uojoU}seu Jes * ‘es1016Xe ‘uoNONpA JYBIEM fenpeIS “peziUMUILY aq PINoYs xeIU! jJes eNISsoxo °3 Ayseqo se yons si0joe) BugngujUoo ‘uonIppe U} ‘S899 8 SoNeunip epnjoul NdH Jo wWeUNeaN jenIUI euy 10} Se01049 ueld| ne Beas NaH qwauissessy|__v en SHUI GOL/SPL da ‘enelqo | O aa ~__ einsseid poolq yBly jo Aio\siH anyoalang |S S1dNVxXa AVINNOS dvOs ESR eam eas ake, 8 = arene eit Tacley 2 SASaUBD pe po. a ah paweup se a 41 je pou ee ___paiseup se E jeader jou op UN] dei vou jeoidoy (sn) 7 qu Tae ean e Sauy easy) Sjun jeuoneusayui i Aiep sown eeu ‘aun padie | Zac eel jereIPSUNLUL ———epeu eq ial ‘Syeur iw Teqe} uo Sum = Spinip NP = aey-auo : asuedsip asip re yoy Ps. WoHeoIpau enuRUOOSIP 9a 1e}09) etic WeAiB @q S@Sop YONS 39} ese anioy Alene @aniip ip (Giedeid) 0} AUER jusioWns & 7 um a qwa!eWns S Se Yon se . rep amy) SSG | ~_Kep Taino iene KS YES 40 SiS UIOq ne SO} Sty punore OW Te3 5) "se4-43 mmihr_ 24-37 sec = assesses the intrinsic clotting pathway " thromboplastin time (aPTT) - used to monitor Heparin therap} Prothrombin time (PT) 88-116 sec ~ assesses the extrinsic clotting pathway - used to monitor Warfarin therap) International normalized ratio INR) = more standardized expression of PT == (PToationt / PT contr)!™*"™* WBC (Leukocytes) 4000-11,000 WBC/mm* =no, of WBCs found - f: bacterial infection (leukocytosis) - |: bone marrow depression (leukopenia) Neutrophils =f: infections, tissue necrosis, inflammatory diseases, metabolic disorders, myelogenous Polymorphonuclear 50-70% leukemia, rickettsial diseases (neutrophilic leukocytosis) leukocytes (PMN) ~ |: overwhelming infection of any type (neutropenia) Bands 3-5% [es as. ai te Eds, Basophils 0-1% - f: chronic myelogenous leukemia (CML), chronic hypersensitivity states, systemic mast cel ___|_ disease (basophilia) Eosinophils. 05% [=7: acute allergic reactions, parasitic infections (eosinophilia) ce? Lymphocytes 20-40% =f: viral infection (lymphocytosis) ey - |: severe debilitating illness, immunodeficiency, AIDS (lymphopenia) ane} [Monocytes 07% =: TB, subacute bacterial endocarditis (monocytosis) MTT Ee Platelets (Thrombocytes) 150,000-300,000/mm' = smallest formed elements in the blood - involved in blood clotting & responsible for initiating hemostasis < 100,000 - moderate thrombocytopenia < 50,000 __| - severe thrombocytopenia _ABBREVIATIONS a [ences aa ofeach ou ~__ [both eye or each eye en ac before meals pc _|aftermeals oe ad to,upto 5 ps este evening ad. right ear Namipo Sp.cn by mouth __ad fib at pleasure, freely eT | (Piscatins cape es per rectum aa AM morning pm. ‘whennecessary ms aq water q everyTubjam WubIey ‘suoVEAUSUOD Poojd UUeds Indino ® nduI “Kep Jad sj00}S 6500) jo “Ou "NIB feuTUUOpGe Indjno eulI SHOSUeNSOSI | Boubse9/9 oulunjeeso “euoUUoY Bi nus-PiowAyy ‘eUxXOIAY, ‘@UIUOIAWJopOIN) ‘uoRdeY) UORdefe ‘AyjpedeD [EWA pao10} ‘aUNjOn Alojeuidxa peoi9) ‘a}e1 Moy Aloyesldxe Yeeq | _sise} waysks UeBLO dyloadg ‘anssh winynds ‘euuin ‘pooig| __—SSNIANISUES ® Seunng, a ae 5 UiBjoId "]WaHUCD 1ejn[90 “A|AeIB oy!eds. SISKEUI sn Tenuereyip @ WN DaM “Whos Daw “OHOW AW Wooewiey "GBH. ABO|OELAH SuNgo|bouNTiLay ‘sjuawa|dwoo "IUNgIe "UiE|OId [eIOL Sujeioud pooig | & ~~ ajeuoqieaiq “Od 200d ‘Hd soseB pOo|g | pioe nee. ‘@soon|6 jueUCO 209 ‘NN ‘LIV ‘1SV'HOT'dIv ‘SW ‘20 10H 'eN| _———_—Anisiuayo pooja ate sae Ue UH ‘dg eunyesodures SUBIS [eA SUSLAWVUYVd SALLOarAO NOWWOD = ied souainyel ee eae Z Toe SSeUqUINN anByes Se oa Buzeeu SSSUuSTOAION = eunskq a ~____ SSOU 23M easnen, : ups hig = obmen| Bu TeseN 2 BugeRuedUCS AINOWIG is eons UoRSEBLOS [eSEN BeULeiC 5 ‘SSOUYEOM S/S uoisseidaq eS ‘Sayoe S/SNA ‘ajedde paseaieq ie cau RRS Opidiy Jo S807) sduieig a aujedde jo S807 UoHeTHSUO | Wout B10S, ge jed quior OIsHIUOD Burzsoug Suu BOUBIO|OWU POD uoaeds pains | _ ejuwosuj | SiO) “Wesigyo sseuoys | H uonsabipuj | ‘Sseulepuay seaig | seinzieg ‘eousjoduiy uOIsIA pounig usey Soueisjojul 19H uinjnds pabuy-poorg | ‘asind Bulpunog z uInqueeH Buneoig ____Suonelidied SuDepeoH Ronuy ‘SUALEINVUYd SALLOSENS NOWNODPATIENT CASE ABBREVIATIONS eCuemiee: ____ | Chief complaint i 5 ROSHaite Review of systems HPI History of present : Med Hx ‘Medication history _ PMH Past medical history PE —_| Physical examination FH Family history Labs __ [Laboratory & diagnostic test results [SH ________ [Social history Chief complaint reasons the patient is seeking medical care ws History of present illness = narrative that describes the current medical problem Past medical history = brief description of current & previous patient problems unrelated to the present ilness Social history = contains information about the patient's use of tobacco, alcohol, & illicit drugs I cart information about the patient's occupation, marital status, sexual history, & living conditions __ Family history = brief summary of the medical histories of the patient's 1" degree relatives. Medication history \clude demographic information, dietary information, social habits, current & past prescription & non-prescription pias | medications, allergies, ADRs & compliance. Review ofsystems—=—=—_~*| - summarizes all patient complaints not included in the HPI Physical examination = short description of the patient Fas a isi Laboratory & diagnostic test results _| - results of laboratory & diagnostic test done to the patient4. possible delay in obtaining required medication 2. increase in costto the patient Il Combination of | & II- use the individual drug order system as the primary means of dispensing but also utiize a limited floor stock; most commonly used, Incorporates unit-dose dispensing as well IV. Unit Dose Dispensing- the pharmacist prepares ‘every dose of medication ready for administration Advantages: 1. improved pharmaceutical service 24 hours a day and patients are charged only those doses which are administered to them 2. all doses are prepared in the pharmacy giving ‘nufses more time for direct patient care 3. allows checking or interpreting of the doctor's ‘original order thus reducing medication error liminates excessive duplication of orders and Paper works at the nursing station and pharmacy eliminates credit IV preparation and reconstitution done at the pharmacy 7. more efficient utilization of professional and non- professional personnel 8. reduced revenue loss 8. conserves space in nursing units by eliminating bulky floor stocks 10. eliminates pitferage and drug waste 11. extend pharmacy control and coverage throughout the hospital 42. improved communication of medication orders and delivery systems 13. ward work as drug consultants and help provide the team effort needed for better patient care Major Forms of Unit Dose System: 4. Centralized = the most common and probably the most cost- efficient - orders are interpreted and almost all drug doses are picked and placed in the patient drawers of the ‘medication carts in a central pharmacy Decentralized ~ have one or more satellite pharmacies scattered throughout the hospital from which most of the single unit doses are distributed - routine packaging of medication is usually carried out ‘Systems Combining 1 & 2 = some distribution activities are performed in the pationt- care areas while the rest are performed centrally 4, Partial = some unit dose systems are only partially complete due to special circumstances of certain hospitals Drugs for the Emergency Box ‘Aminophyline | Mannitol injection ‘Amphetamine Nalorphine HCI ‘Amy! nitrite inhalation Neostigmine methyisulfate ‘Atropine sulfate Norepinephrine | injection Caffeine sodium benzoate | Pentobarbital Calcium gluconate Pentylenetetrazol injection __ ‘Chioroprophenpyrmadine | Phenobarbital maleate = [Dino eevee eee ess hPhenyephrinel ee ee, iphenylhydantoin sodium | Phytonadione injection Epinephrine HCI Piorotoxin injection Heparin Procaine amide Hydrocortisone Protamine sulfate isoproterenol ‘Saline for injection Magnesium sulfate injection | Sodium molar lactate solution Metaraminol bitarrate ‘Water for injection COMPOUNDING IV Fluids- functions as a means for fluid replacement, electrolyte balance restoration and supplementary Nutrition, and as vehicles for administration of other drug substances and in TPN. Large volume parenterals- 100-1000mL ‘Small volume parenterals- 25-50mL IV Admixture = when one or more sterile products are added to an. IV fluid for administration - itis prepared with aseptic technique or environment provided by laminar flowhood, in which the air is filtered through HEPA (high efficiency particulate ait) filter HEPA filters remove 99.97% of all particles larger than 0.3 um the fiow of air may be in either a horizontal or vertical pattern - the best way to determine the proper functioning of a HEPA filter is to use the dioctylphthalate (DOP) test using the vapor at room temperature Total Parenteral Nutrition IV administration of calories, nitrogen, and other nutrients in sufficient quantities to achieve tissue synthesis and anabolism originally, the term hyperalimentation was used to describe the procedure Dudrick developed the technique for administering fluids for PN by way of the subclavian vein into the superior vena cava where the solution is diluted rapidly by the large volume of blood available, thus minimizing the hypertonicity of the solution - PN is indicated for patients who are unable to ingest food due to carcinoma or extensive burns and patients who refuse to eat, as in the case of depressed geriatrics or young patients suffering from anorexia nervosa and surgical patients who should not be fed orally Normal Caloric Requirement: 2500 cal/ day for adults Formulation of TPN: Protein- source of amino acid Carbohydrates- provide eneray \id- source of essential fatty acids Electrolytes- for proper enzymatic and energy conserving or expending reactions within the body (e.g. sodium, potassium, magnesium, calcium, chloride, phosphate) 6. Trace elements ~e.g. zinc, copper, selenium, chromium, iron, manganese, cobalt, motyodenum 6. Vitamins- for fong- term therapy 7. Fluids Container: silicone based bags, superseded by PVC and ethyivinyl acetate Storage and Packaging: stored at 2- 6°C, not allowed to be stored at room temperature for periods in excess of 12- 24 hours required for administration. It is packaged in polystyrene containers,