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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.
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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Prep Notes
Part 1
Communication
Skills
Number 1: Communication
Number 2: Communication
Number 3: Communication
2
MISBAH’S
TOP 20 RULES OF COMMUNICATION IN EXAMS
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
3
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 # 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?
4
information can dramatically alter the course of treatment or therapy that the
physician prescribes.
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 # 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
Good luck
5
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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
↓
Practice Station
Scenario # 1
Rx:
Lipitor
Sig: 20 mg po daily x 3 months
Mitte: 90 tablets
R: 2
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3
Communication Skill:
Counselling On Refill 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
↓
Compliance problems?
• Evidence of side effects?
• Effectiveness of treatment
• Potential problems
Scenario # 1
A patient comes to pick up his refill 2 weeks before his due date.
Patient: Mathew
Age: 18 years
Gender: Male
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
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4
Communication Skills: Counselling
OTC Drugs
Opening discussion
Introduction
Offer privacy
Empathy
↓
Discussion to gather information and identify problems
MAMA
TOPS
↓
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 Advice patient to see physician
Side effects Suggest non-drug treatment
Precautions Give self care recommendation
Future treatment Reassurance
Self care recommendation
Reassurance
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Practice Stations
_______________________________________________________________
Scenario # 1
On the table:
Nicotine gum,
Nicotine patches
Nicotine inhaler
Nicotine gargle
Herbal products for smoking cessation.
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.
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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]
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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.
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]
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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
[Type text]
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8
Communication Skills:
Giving Instructions
Do’s
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
Use language that tells your patient that the instruction is important, such as:
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?
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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:
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.
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.
Anti-Depressants – These medications help to control your mood and make you feel
well by inhibiting certain messengers in your brain.
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Cough Suppressants – These medications help to reduce your cough by blocking the
cough centres in your brain.
Sulfonylureas (for Type 2 Diabetes) – These medications help to reduce your blood
sugar by stimulating the production of insulin in your body.
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.
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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.
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.
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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
On the table:
Anusol Plus suppositories
Anusol Plus ointment
Tuck’s wipes
Senokot
Metamucil
Soflax (Sodium Docusate)
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.
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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.
Don’t
Don’t be taskmaster
Don’t counsel in an authoritative and aggressive manner
Don’t be judgemental
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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.
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.
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]
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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
[Type text]
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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.
[Type text]
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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
On the table:
Echinacea lozenges
Scenario # 3
On the table
St. John Wort
[Type text]
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Scenario # 4
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)
[Type text]
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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:
Although you short time with patient, however look for factor that can contribute to non-
compliance, 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.
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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.
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15
Counselling techniques: Assessing
patient need for supplements
It is important for a pharmacist to become knowledgeable about calcium supplements,
iron supplements, and multivitamins.
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
Iron supplements
Calcium supplements
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)
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Practice Stations
Scenario # 1
A lady comes to you in the Pharmacy and wants advice on a certain products for her 4-
month-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
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
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.
This information can dramatically alter the course of treatment or therapy that the
physician prescribes.
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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.
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.
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.
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.
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.
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Scenario # 6
Scenario # 7
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17
Communication Skills: Collaborating
with healthcare professional
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.
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.
On the desk:
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
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Scenario # 5
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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 The child aerochamber device with mask and infant aerochamber device
Aerochamber with mask do not whistle
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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
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.
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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.
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 one-
half 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
Rx
Advair Diskus 250μg
1x2
60 blisters
Scenario # 2
Rx
Ventolin MDI i-ii puffs q 4 to 6 hours prn
Flovent 250 MDI 2 puffs BID
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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
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
Action to be taken
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- determine if indeed error has been made; if so apologize “I am sorry, it appears an error
has been made”
Evaluate
- notify Dr., state facts only
- use reference text before talking to
patient or Dr.
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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.
Scenario #2
A pharmacist has expired stock of CIPROFLOXACIN and a patient comes to fill prescription
for CIPRO.
Solve problems?
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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.
Do’s
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Practice Stations
Scenario # 1
Age 70-year-old patient does not remember how to take his pills;
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.
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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.
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
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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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Part 2
Problem
Solving
Skills
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23
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
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
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
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
Dr: Gaucher
Dispense the new prescription; address their concerns and their need for information.
Help them to prevent illness and promote healthy life style
Scenario # 2
Rx:
Losec 1-2-3 A for 7 days
Scenario # 3
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Rx:
Losec 1-2-3 A
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.
Scenario # 4
On the table:
Tums
Rolaids
Zantac (Ranitidine) 75 mg
Maalox
Gaviscon
Pepto-Bismol
Scenario # 5
On the table:
Anusol Plus suppositories
Anusol Plus ointment
Tuck’s wipes
Senokot
Metamucil
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Scenario # 6
Patient is asking for your recommendation to treat upset stomach. He wants to try Pepto-
bismol 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
Scenario# 7
Medication history:
Alesse 21’s (6 mo)
Palafer 300 mg 1 cap TID (1 week)
On the table:
Sennokot
Metamucil
Soflax
Scenario# 7
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24
Heartburn
Presentation Symptoms
Questions to ask:
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.
Scenario # 2
On the table:
Tums
Rolaids
Zantac (Ranitidine) 75 mg
Maalox
Gaviscon
Pepto-Bismol
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25
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:
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
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.
Scenario # 2
Rx:
Cipro 500 mg bid for 3 days
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26
Constipation
Presentation Symptoms
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)
Refer
Rectal pain / bleeding
Blood in stool
Fever / abdominal pain / nausea and vomiting
Narrow stool
No stool for 7d
Severe discomfort
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Nonpharmacological Choices
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
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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.
On the table:
Sennokot
Soflax
Glycerin supp
Lactulose
Ducolax (Bisacodyl)
CitroMag (Mg Citrate)
Metamucil Fiber
Fleet enema
Scenario # 2
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:
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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
Non pharmacological
Treatment Plan
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.
On the table:
Xylocaine rectal gel
Hydrocortisone gel
Psyllium powder
Senna tablets
Lactulose suspension
Scenario # 2
On the table:
Anusol Plus suppositories
Anusol Plus ointment
Tuck’s wipes
Senokot
Metamucil
Soflax (Sodium Docusate)
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28
Nausea & Vomiting, Motion
Sickness
Presentation Symptoms
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
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
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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.
Scenario # 2
Rx:
M: 90
Profile:
Patient Name: Billy
Age: 26 years
Address: Tips
Dr: Gaucher
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29
Pinworm
Presentation symptoms
Questions to ask:
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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
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
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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
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30
Infant colic
Symptoms
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
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 5-
10 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.
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31
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.
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.
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Warfarin
Nitrates
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
Rx:
Lipitor
Sig: 20 mg po daily x 3 months
Mitte: 90 tablets
R: 2
Scenario # 2
Patient Name: MK
Age: 62 years
Address: Pharmacy Prep
Doctor: MD
Rx
Warfarin 5 mg po od or ud x 30 tabs
Mitte: 30
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___________________________________________________________________
Scenario # 3
Current Medications:
Hydralazine 25 mg tid
Ramipril 5 mg po od
Bisoprolol 5 mg po od
ASA 352 mg po od
Scenario #4
Patient Profile:
Ramipril 10 mg po od (1 month)
Simvastatin 10 mg po od (1 year)
On the table: DM syrup, DM-E syrup
Scenario # 5
Patient’s Profile:
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Scenario # 6
Rx
Amiodarone 200 mg po od
Scenario # 7
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
Scenario # 8
Patient’s profile:
Current medications: Enalapril 5 mg po BID, digoxin 125 mcg po daily
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Scenario # 9
Rx:
Adalat XL 30 mg po od
M: 30 tabs
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.
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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
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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.
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.
Comments: Hypertension
Medications: HCT 25mg QD (5 yrs ago)
Enalapril 20mg (Started 2wks ago)
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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.
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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 3-
fold) 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.
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 self-
administer. However, the tablets are large, and some patients may not be able to swallow
them
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Monitor for adherence and gastrointestinal side effects for all resins.
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.
Cholesterol Inhibitors
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Practice Station
Scenario # 1
The patient comes to you with a concern. Respond the way you would in the Pharmacy.
Medications Qty
Atorvastatin 20 mg QD
Metformin 500 mg TID
Scenario # 2
Rx:
Questran powder
Take one 4g scoop in the morning
M: 1 can
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34
Ischemic Heart Diseases
Counselling Tips
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 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
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.
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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 3-
fold) 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.
New Rx:
Nitroglycerin SL tablets 0.5mg PRN (dispense 1 bottle)
Scenario # 2
A lady comes to you, the pharmacist, for your advice. Counsel her as you would in the
Pharmacy.
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Scenario # 3
A 50 year old male comes into the pharmacy to collect his prescription for Nitrolingual spray.
He is a first time user.
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35
Anticoagulants and Warfarin
Management
Counselling Tips
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
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.
On the table:
Ginkgo Biloba capsules
Ginseng capsules
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36
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
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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.
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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.
Scenario # 2
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
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Scenario # 4
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.
On the Desk:
Diphenhydramine 25mg
Scenario # 6
Patient comes to pick his new prescription and has some queries. Solve his concern and counsel
him.
On the DESK:
Paroxetine tablets
Phenelzine tablets
Reference: CPS
Scenario # 7
Scenario # 8
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37
Neurological Disorders
Antiseizure drugs
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
Nonpharmacological Choices
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Practice Station
Scenarios # 1
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
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.
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38
Contraception
Choosing a right oral contraceptive options
Recommendations
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
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
Scenario # 2
Scenario # 3
Father of one of your patients comes into the pharmacy very upset and angry
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?”
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Scenario # 5
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.
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39
Diabetes
Presentation Symptoms
NORMAL = FPG = 5-6 MMOL/L, PPPG = 14 mmol/L, HbA1C = 6% (for 3 months), BMI =
25-27 and HBP + diabetes= > 130/80
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
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.
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.
Scenario # 3
On the table:
B-D Glucose tablets,
lifesavers candy,
DEX-4 tablets
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Scenario # 4
Profile:
Metformin 500mg BID
Glyburide 5 mg BID
Acarbose 100mg TID
On the table:
Pepto-Bismol
Zantac (Ranitidine) 75mg
Tums
Maalox
Gaviscon
Scenario # 5
On the table:
Dr. Scholl's® one step corn remover
Dr. Scholl's® Liquid Corn/Callus Remover
Scenario # 6
Medications:
Metformin 500 mg bid
Glicalizide 40 mg daily
Atorvastatin 40mg/Fenofibrate 100mg
Allergies: Penicillin
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R: 3
Scenario # 7
A patient comes for your recommendation
On the table:
Pepto-Bismol
Zantac (Ranitidine) 75mg
Tums
Maalox
Gaviscon
Scenario # 8
A 40 years old male patient presents prescription:
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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
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
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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41
Asthma
Asthma Management
Questions to ask
Treatment plan
Counseling on Symbicort
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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.
Comments: Asthma
Medications Dr
Salbutamol Inhaler PRN Tips
Advair Diskus 1puff BID Since 3 years ago Tips
Scenario # 2
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.
On the table:
Tylenol, Sudafed,
NeoCitran total,
Otrivin,
Salinex NS,
Tylenol Cold,
Cepacol Lozenges,
Strepsil Lozenges
Salinex NS, Lozenges
Scenario # 4
Scenario # 5
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.
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42
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
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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
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.
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
Suggested reference
Patient Self care pp135, 2002
Therapeutic choice 4th ed. Page 404
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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.
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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.
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
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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
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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.
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.
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45
Ophthalmic Drugs
Presentation symptoms
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)?
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) 2-
4x/day x 7-10d; continue for 2 days after symptoms resolve.
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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.
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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.
Scenario # 2
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:
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Visine Allergy
Cromolyn eye drops
Optichrom
Tears Naturelle II
Scenario # 4
Patient profile:
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46
Conjunctivitis
Allergic conjunctivitis
Presentation symptoms
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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
Questions to ask:
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
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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
Scenario # 2
Rx:
Ciprodex ear drops
ii gtts into affected ear BID x 7 days
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
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
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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.
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
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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
Scenario # 2
Rx
Sporanox 200 mg
1bid for 3 months
Scenario # 3
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Prep Notes
Pharmacyprep.com 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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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:
Lamisil 250mg tabs
Sig: 1 tab OD x 7days for athlete’s foot
M: 7 tabs
Patient’s Profile:
21 year old male
Codeine allergy
Past medical history: Amoxicillin 2 years ago, nothing more
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52
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
Questions to ask
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
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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.
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.
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53
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:
Refer
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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.
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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.
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.
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54
Dermatitis
Patient Presentation Symptoms
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?
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
55
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?
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)
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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
Light therapy – PUVA (psoralen po/cr/bath + UVA) 2-3x/wk; SE: acute burns, skin
cancer, pigmentation, photoaging
Non-pharmaceutical
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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56
Dermatological DRPs
Practice Station
On the table:
Rubbing Alcohol
Hydrogen Peroxide
Polysporin cream
Polysporin ointment
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Acne
Patient presentation
Patient concern
Patient may be upset/embarrassed about condition – stress that it is common & curable
Question to ask
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.
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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)
Prescription drugs
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• Use for non-inflammatory acne that doesn't respond to benzoyl peroxide and topical
antibiotics
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
References
Therapeutic Choices, 4th ed. page 660.
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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
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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 Name: MB
Age: 52 yrs
Address: Tips
Doctor: MD
Medical condition: RA
Current Medications: diclofenac sodium 50 mg tid
Rx:
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 Name: Oz
Age: 55 yrs
Address: Tips
Doctor: MD
Scenario # 4
A patient comes in with a concern and to pick his new medication. Respond as you would in
the Pharmacy.
Rx:
Methotrexate 7.5mg Q week
Scenario # 5
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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
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.
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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.
A patient is asking for your recommendation to treat Sprain – injury to a ligament caused by
over-stretching or twisting
Patient Name: TD
Age: 49 yrs
Address: Tips
Doctor: M. Patel
On the desk:
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Practice Station
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.
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Menopause
Menopause is cessation of menstrual periods.
Nonpharmacological Choices
Copyright
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63
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.
Rx
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Vaginitis
Presentation Symptoms
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:
** 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.
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%)
Recurrenceusually 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)
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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
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.
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Benign Prostatic Hyperplasia
Practice Station
Patient profile: (Present on the table)\
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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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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
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
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Practice Station
Scheme # 1
Provide counseling
Patient profile:
Allergies: none
Current medications: tylenol for headache and multivitamins
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67
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
Rx:
Biaxin 500 mg BID x 10 days
Flagyl 500 mg BID x 10 days
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Scenario # 3
Rx:
Ciprofloxacin 500mg po bid x 7 days
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
Scenario # 6
Rx
Rifampin 300mg
Sig: 2 tabs od x 14 days for prophylaxis treatment of H. influenza type B
M: 28 tabs
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Scenario # 7
A doctor prescribes Zithromax for one of your patients. Patient has been diagnosed with
community-acquired pneumonia.
Allergies: clarithromycin
Medical conditions: Pneumonia and Renal disease
Current medications: Enalapril 5 mg
Scenario # 8
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Urinary tract infections
Symptoms
Question to ask
Patient counseling:
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69
Weight Loss
How to approach the problem
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Practice Stations
Scenario # 1
Patient Name: K. S
Age: 25 years
Address: Tips
Dr: Tips
Comments: Obese
Allergies: None
Medication: Cipralex 20 mg po od
Scenario # 2
Comments: obesity
Allergies: None
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70
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:
Refer
Heart disease
<18 yo
Pregnancy
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.
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.
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.
Scenario # 4
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71
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.
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72
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 re-
exposure 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.
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.
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Phototoxicity
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
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Practice Stations
Scenario # 1
On the table:
Ombrelle SPF 30
Tylenol ES
Advil
Aveeno lotion
Aloe Vera gel
Benadryl tablets
Benadryl Cream
Calamine Lotion
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73
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.
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74
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
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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
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Hepatitis vaccines
Twinrix junior (Hepatitis A&B) Children and adolescents from 1 year to 18 years
Havrix 720 Junior (Hepatitis A) Children and adolescents from 1 year up to and
including 18 years of age
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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Dukoral vaccine
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Practice Stations
Scenario #1
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?
Scenario # 3
A women bring a varivax vaccine to your pharmacy and wants to know more information
on varivax vaccine.
Scenario # 4
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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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75
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
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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.
Patient pregnant and admitted to ward hence suggest appropriate alternative i.e 2nd/3rd gen
cephalosporin + macrolide
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76
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
Packing
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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.
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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.
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.
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77
Substance of Abuse
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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)
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Dose-dependent "plateaus“ of DM
(Dose in cough syrups ranges from 10 mg to 15 mg per 5 ml )
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
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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)
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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
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Practice Stations
Scenario # 1
Rx:
Effexor (Venlafaxine) XR
37.5mg po daily x 7 days, then
75 mg po daily x 30 days
Provide counseling
Scenario # 2
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
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)”
Current medications:
Citalopram 20 mg po qd (filled 5 days ago)
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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
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
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
Mitte 90
Scenario # 2
Rx
Mr O, weight 44 lbs
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
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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
Clarus:
Pregabalin
Indicated for diabetic peripheral neuropathy and post herpetic neuralgias.
It can cause addiction and dependence. Abrupt discontinuation can cause d/c
symptoms
Solifenacin succinate
It is niacin the niacin products are niacinamide, it is not substitutable with niacin
(niaspan)
Increase uric acid levels in blood.
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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
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Benzodiazepine regulations
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
Yes Yes Yes
Reports
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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.
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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.
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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.
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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
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ACE inhibitors, hypoglycemics, NSAIDs can be stopped abruptly
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step byallstep
CNS medications,
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 well-
known 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.
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.
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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.
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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.
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.
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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,
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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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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.
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.
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