Mrs Kearns (78 y.o) asks for an

antihistamine. She tells you that she

used to use Teldane® when she last had

this problem.

Tutorial Scenario.• Mrs Kearns, a healthy 78 year old female is visiting

Sydney to attend her grandson’s wedding.

• She is 5 days in to a 14-day course of erythromycin therapy.

• Yesterday she had an upset stomach and diarrhoea, so she is also taking diphenoxylate (Lomotil), which contains a sub-therapeutic amount of atropine sulfate to discourage abuse.

• She is feeling a little tired and she also as a dry mouth and slightly blurred vision.

Tutorial Scenario.• She has woken up with red itchy, watery eyes and is

sneezing frequently.

• She used to suffer from hayfever when she lived in Sydney and her doctor had treated her with Teldane (10 years ago).

• The antihistamines you have available are Claratyne (loratadine), Phenergan (promethazine), Telfast (fexofenadine) and Polaramine (dexchlorpheniramine).

Tutorial Scenario.• She also asks you for a Ventolin inhaler and presents an

asthma card

• She woke up coughing last night and needed her Ventolin

Lectures to support this case

• Histamine and Antihistamines A/Prof J Hanrahan• Clinical Interventions Dr T Chen• Adrenergic Receptors (relevant to Cardiovascular and

Respiratory) Prof B Roufogalis• Allergic Rhinitis Dr L Smith • Asthma Therapy Dr B Saini• Asthma Devices Dr B Saini• Inhaler Technique Dr S Bosnic-Anticevich

References to support this case

• Second year lectures on antibiotics• Foye's Principles of Medicinal Chemistry; Thomas

L Lemke, David A Williams, Victoria F Roche & S. William Zito, 6th Edition, 2007.

• NAC Asthma management handbook• NAC health professional guide Allergic rhinitis and

the patient with Asthma• Respiratory Guidelines• AMH

General learning objectives for PHAR3812

By the end of this tutorial students should be able to: Predict the activity of a drug based on its structure and

physicochemical properties Demonstrate an understanding of how the physical and

chemical properties of a drug determine its pharmacology, toxicology, bioavailability and behaviour in formulations

Identify typical examples of drugs which are used to restore physiological functions in the respiratory system

Describe the mechanism of therapeutic action of a selected drug at the molecular, cellular, organ system and whole body levels

General learning objectives for PHAR3812

By the end of this tutorial students should be able to:• Describe the common adverse effects of a selected drug

and their mechanism of production • Demonstrate an understanding of basic metabolism in

relation to drugs and efficacy and safety in relation to the treatment of disease and/or maintenance of health

• Apply an understanding of the basic and applied sciences to pharmaceutical care in order to optimise health outcomes

• Respond to direct product and symptom based requests (in relevant therapeutic areas)

Learning outcomes specific for Case 1

By the end of this tutorial students should be able to:• Have an understanding of the link between

Asthma and Allergic Rhinitis• Identify the different structure of antihistamines • Understand the structural features likely to cause

adverse effects with antihistamines• Demonstrate an ability to develop appropriate

allergic rhinitis and asthma management plans.

Information Gathering Prior to Tutorial 1

• WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED?

• Before your tutorial you should have a list of questions that you would like to ask Mrs. Kearns

Information Gathering Prior to Tutorial 1

• WHAT ARE THE POSSIBLE CAUSES OF COUGH?

• Before your tutorial you should have a list of possible causes of cough and differentiating features.

Information Gathering Prior to Tutorial 1.

• WHAT IS THE LINK BETWEEN ASTHMA AND ALLERGIC RHINITIS?

• Before your tutorial you should have read the NAC health professionals guide on WebCT

Information Gathering Prior to Tutorial 1

• WHAT DO THE STRUCTURES OF THE AVAILABLE ANTIHISTAMINES TELL YOU ABOUT THEIR ACTIVITY AND SIDE EFFECTS

• Before your tutorial you should review the structures, think about solubility of functional groups, size, drug interactions and adverse effects

Information Gathering Prior to Tutorial 1

• HOW IS ERYTHROMYCIN METABOLISED BY THE LIVER?

• Before your tutorial you should review the metabolism pathways of erythromycin and her other medicines.

Information Processing Prior to Tutorial 1.

During tutorial 1.

• You may be asked to present interesting insights from your placement

• The tutor will ask for answers to the pre-work questions

• A role play with the patient will occur

• Discussion and debate will occur in order to choose appropriate management for Mrs Kearns

Information Gathering In Tutorial 1

• WHO IS THE PATIENT?

• In your tutorial students should role-play with the patient

• (20mins)

Information ProcessingIn Tutorial 1

• WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED?

• Identify key issues that need to be addressed and discuss in your table groups

Information ProcessingIn Tutorial 1

• WHAT COULD BE CAUSING HER COUGH?

• After questioning make a differential diagnosis

Information Processing in Tutorial 1

• WHAT DO THE STRUCTURES OF THE AVAILABLE ANTIHISTAMINES TELL YOU ABOUT THEIR ACTIVITY AND SIDE EFFECTS

• Discuss the pros and cons of each medicine and choose an appropriate agent

Information Processing in Tutorial 1

• WHAT ISSUES MAY LOMOTIL AND ERYTHROMYCIN POSE?

• Discuss the pros and cons of each medicine and choose an appropriate agent

Information Processing in Tutorial 1.

• WHAT IS THE BEST WAY TO MANAGE MRS KEARNS’ SYMPTOMS

• During the tutorial devise an appropriate allergy and asthma action plan

Information Processing in Tutorial 1

• WHAT ASTHMA THERAPY WOULD YOU RECOMMEND IF SHE WAS:– A. BACK AT HOME– B. PLANNING ON STAYING IN SYDNEY FOR A

WHILE?

• During the tutorial devise an appropriate allergy and asthma action plan

• END OF TUTORIAL 1.

Information Processing before Tutorial 2

• WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED TO ACHIEVE THE DESIRED THERAPEUTIC OUTCOME?

• Before tutorial 2. identify and prioritise the issues on hand

Information Delivery before Tutorial 2

• WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED TO ACHIEVE THE DESIRED THERAPEUTIC OUTCOME?

• Before tutorial 2. document your findings and recommendations for this case. (Be ready to discuss these with the doctor and patient)

During tutorial 2.

• You may be asked to present interesting insights from your placement

• The tutor will ask for answers to the pre-work questions

• role play with the doctor will occur

• role play with the patient will occur

Information Delivery duringTutorial 2

• WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED TO ACHIEVE THE DESIRED THERAPEUTIC OUTCOME?

• During tutorial 2. present your findings and recommendations in powerpoint

Information Delivery duringTutorial 2

• DISCUSS ANY ISSUES YOU HAVE WITH THE DOCTOR

• During tutorial 2. articulate your clinical intervention(s) to the patient’s doctor

Information Delivery duringTutorial 2

• COUNSEL THE PATIENT ON THE CORRECT USE OF THE APPROPRIATE ANTIHISTAMINE

• During tutorial 2. explain to the patient why you have chosen the particular agent and counsel her on its use

Information Delivery duringTutorial 2

• COUNSEL THE PATIENT ON HER OVERALL PLAN

• During tutorial 2. tell Mrs Kearns about her asthma and allergy management