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NON-INTERACTIVE 7 MINUTE STATIONS Calculations: REVIEW MATH MODULES 1-5 for practice questions Roman Numerals: ss = 0.5 i = 1 v = 5 x = 10 l = 50 c = 100 d = 500 m = 1000

• If first value ≥ second value, the two are added ex// vi 5 > 1 5 + 1 = 6

• If first value < second value, it is subtracted ex// cm 100 < 1000 1000 – 100 = 900 Apothecary System:

• Estimates: ʒ = 5 mL ℥ = 6 drams/ounce = 30 mL ℥ = 25 g (sometimes 30 g)

• Exact conversions: ʒ = 3.55 mL ℥ = 8 drams/ounce = 28.44 mL

• Liquid medications where either the mitte or sig are in apothecary symbol: use estimates

• Oral liquid med where both mitte & sig are apothecary symbols: use estimates for sig, use exact conversion for mitte

• Semi-solid medications (creams & ointments), where mitte is given in ounces (by weight): use estimate (℥ = 25 g) Concentrations:

Concentration by percent • % w/w = grams of x in 100 g total mixture

• % w/v = grams of x in 100 mL total mixture

• % v/v = millilitres of x in 100 mL total mixture

• mg % = milligram of x in 100 mL (or 100 g) of total mixture

Concentration by parts • ppm = parts of x (g or mL) in 1,000,000 parts total mixture (g or mL)

• 1 x:y = parts of x (g or mL) in y parts total mixture (g or mL)

Concentration by moles • M (molarity) = moles of x in 1000 mL (1 L) of solution

• m (molality) = moles of x in 1000 g of solvent

• mol fraction = moles of x in the sum of the # of moles of each substance, as a fraction o ex// moles of x / mole of x + mole of y

• mol percent = mol fraction multiplied by 100% Conversions and miscellaneous: 1 kg = 2.2 lb 1 lb = 454 g 1 cm = 0.39 in 1 in = 2.54 cm

oC = 5/9 (xoF – 32o) oF = (9/5 xoC) + 32o

𝑚𝐸𝑞 = 𝑚𝑔∗𝑣𝑎𝑙𝑒𝑛𝑐𝑒

𝑎𝑡𝑜𝑚𝑖𝑐,𝑚𝑜𝑙𝑒𝑐𝑢𝑙𝑎𝑟 𝑜𝑟 𝑓𝑜𝑟𝑚𝑢𝑙𝑎 𝑤𝑒𝑖𝑔ℎ𝑡 valence = total # of +ve or -ve charges (not the charges added together)

Percent error = 𝑑𝑖𝑓𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 𝑎𝑐𝑡𝑢𝑎𝑙 & 𝑒𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑣𝑎𝑙𝑢𝑒𝑠

𝑒𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑣𝑎𝑙𝑢𝑒𝑠 𝑥 100%

Nebules: Strength of nebule = mg/mL vs. amount of drug in mL (volume of each nebule affects amount of drug) Dose = mg Example: Budesonide dose is 0.25 mg BID and comes in Pulmicort 2 mL nebules 0.25 mg / 2 mL per nebule = 0.125 mg/mL Therefore, use pulmicort 0.125 mg/mL strength to get a dose of 0.25 mg

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PharmaCare: NOTE: % covered in Zone Y if one spouse is born in 1939 or earlier is 75% instead of 70% LCA Calculations: 1. Actual Rx cost = AAC + professional fee (NOTE: if pt reached maximum, pharmacy can only charge max $10.00 fee)

Example: Rx for 7 fentanyl 50 µg patches (pt wants Duragesic brand) + $12.00 pharmacy fee

Duragesic is $150.28 for 5 patches = $30.06/patch AAC = $30.06/patch x 7 patches = $210.42 Actual Rx cost = $210.42 + $12.00 = $222.42

2. Amount PharmaCare will pay pharmacy (NOTE: PharmaCare will only pay max $10.00 fee)

a. Zone X = $0 b. Zone Y = 0.70 [(amount needed x LCA price) + $10.00]

Example: Rx for 7 Duragesic patches with LCA price = $7.4345/patch = 0.70 [(7 patches x $7.4345/patch) + $10.00] = $43.43

c. Zone Z = (amount needed x LCA price) + $10.00

3. Amount credited to patient’s maximum

a. Zone X = (amount needed x LCA price) + $10.00 b. Zone Y = 0.30 [(amount needed x LCA price) + $10.00]

Example: Rx for 7 Duragesic patches with LCA price = $7.4345/patch

= 0.30 [(7 patches x $7.4345/patch) + $10.00] = $18.61

c. Zone Z = $0 4. Amount patient pays pharmacy = Actual Rx cost – amount paid by PharmaCare NOTE: fully covered drugs that only have a MAX PRICE listed = LCA price NOTE: fully covered drugs that have MAX PRICE & LCA price, PharmaCare covers lower cost NOTE: P* can become fully covered with special authority

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RDP Calculations: RDP program applies to medications in 5 drug categories: H2RA; NSAIDs; oral nitrates; ACEIs; CCBs with each class having “reference drugs” from which the RDP pricing is set 1. Actual Rx cost = AAC + professional fee (NOTE: if pt reached maximum, pharmacy can only charge max $10.00 fee)

Example: Rx for 120 Pepcid 20 mg tabs, i BID with professional fee = $12.00 and pt wants brand name Pepcid is $34.23/28 tabs = $1.223/tab Actual Rx cost = (120 tabs x $1.223/tab) + $12.00 = $158.76

2. Amount PharmaCare will pay pharmacy (NOTE: PharmaCare will only pay max $10.00 fee)

a. Zone X = $0 b. Zone Y = 0.70 [(days supplied x RDP price) + $10.00]

Example: Rx for 120 Pepcid 20 mg tabs BID with RDP price $22.062/30 days = 0.70 [(60 days x $22.062/30 days) + $10.00] = $37.88

c. Zone Z = (days supply x RDP price) + $10.00

3. Amount credited to patient’s maximum

a. Zone X = (days supply x RDP price) + $10.00 b. Zone Y = 0.30 [(days supply x RDP price) + $10.00]

Example: Rx for 120 Pepcid 20 mg tabs BID with RDP price $22.062/30 days = 0.30 [(60 days x $22.062/30 days) + $10.00] = $16.24

c. Zone Z = $0 4. Amount patient pays pharmacy = Actual Rx cost – amount paid by PharmaCare NOTE: reference drugs are LCA program drugs, and you can adapt a Rx of a non-reference drug to the reference drug NOTE: if RDP Special Authority is given (P* drugs in the RDP program), then it becomes an LCA drug Modernized RDP program: in effect (Dec. 1, 2016)

• Adding 3 new drug categories: ARBs, PPIs, and statins (HMG-coA reductase inhibitors)

• Changes to reference drugs of: H2RA, ACEI, and CCB categories

• No changes: NSAIDs and oral nitrates PharmaCare plans: more info in PharmaCare summary table on Connect

• Fair PharmaCare: residents of BC who have valid MSP coverage

• Plan B: permanent residents of licensed residential care facilities

• Plan C: assistance from Ministry of Housing and Social Development

• Plan D: registered with a Cystic Fibrosis clinic

• Plan F: severely handicapped BC children in the “at home” program

• Plan G: registered with a mental health service center

• Palliative Care Benefits Program: palliative care at home certified by a physician

• BC Centre for Excellence in HIV/AIDs: enrolled in the Centre by a physician

• Methadone Maintenance Program: for opioid dependence

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Drug Information / Therapeutics Resources:

Category Resource Brief Intro

General Resources

CPS Drug monographs arranged in alphabetical info by brand name (or generic if no brands)

• Green pages: brand & generic names

• Pink pages: classifying drugs by therapeutic indication

• White pages: identification (pictures)

• Symbols: Prescription (Pr), Controlled Drug (C), Narcotic (N), Targeted Substance (Tc)

DIH Brief information on drugs (PK, ADR, storage), alphabetical by generic name

• Dosing information and forms are American

Martindale Information of drugs used throughout the world

• Volume A: drugs grouped by similar uses and actions

• Volume B: general index & preparations used in different countries

Rx Files Drug comparison resource; reference at back for symbols

Natural Medicines Provides evidence for safety & efficacy of NHPs, including potential interactions

Merck Manual Discussions of medical conditions (pathophysiology, etiology, diagnosis & treatment)

Merck Index Drug monographs providing info on chemical property (molecular weight, chemical structure, physical data)

• 2 indexes: chemical formula or by brand/generic name

Drug Interactions

Stockley’s Drug Interactions

Start with Index to find the medication, and look under it for the interacting product to find the page number Drug Interactions

Binder

Special Populations

Pregnancy and Lactation

Briggs’ Drugs in Pregnancy & Lactation

Go to guide with evidence summaries

Medications & Mother’s Milk Drug monographs with infant monitoring points

Pediatric

Pediatric & Neonatal Handbook Similar to DIH (also American)

BC Children’s Hospital Pediatric Dosage Guidelines

Appropriate dosing for neonates (pink pages) and infants (yellow pages)

Geriatric

Geri-Rx Files For appropriateness of drugs used in older adults

Geriatric Dosage Handbook Similar to DIH (also American)

Anti-microbials

Bugs & Drugs Infectious diseases and Antimicrobial agents

• Yellow: antibiotic information (spectrum of activity, dosing)

• Blue: treatment recommendations

• Purple: dental

• Red: pregnancy/lactation

• Green: antimicrobial information

Sanford Guide to Antimicrobial Information

• Spectrum of activity chart

• Common indications chart

• Special populations (pediatrics, patients with decreased kidney function)

• Resistance patterns, dosing, abx availabilities = American

Institutional or Hospital

Handbook on Injectable Drugs

• Monographs organized by generic names (storage info, reconstitution info, routes)

• Compatibility information: in various solutions, with other drugs at Y site, with other drugs in IV solutions or syringes

Drug Prescribing in Renal Failure

• Drugs grouped into adult and pediatric tables based on drug class

• Comprehensive index at back

• Abbreviation definitions on pg. 16

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Pharmacy Regulations: Drug Scheduling:

• Schedules and regulations: o Schedule 1 = Prescription o Schedule 1A = Controlled Prescription Program o Schedule 2 = Professional Services Area (no public access or opportunity for pt self-selection) o Schedule 3 = Professional Products Area (OTC must be visible and within 25 ft of the dispensary) o Schedule 4 = Emergency contraception (pharmacists can prescribe) o Unscheduled = non-pharmacy sale

• If asked about drug scheduling, go to the Drug Schedule Regulations in Tab 4 (Drug Distribution) of College Binder o Generic names: if given brand name, need to use CPS o Combination products: follow the most restrictive drug schedule

▪ Ex// ratio-Emtec-30 = APAP (unscheduled) + codeine 30 mg (schedule 1) = overall schedule 1 o Exempted product: codeine ≤ 8 mg or ≤ 20mg/30 mL + 2-3 medicinal (non-narcotic) ingredients = schedule 2 o New updates: check the pages following Drug Schedule Regulations for updates or changes to scheduling o Drug not on list: it is unscheduled, but be careful because some categories may be broad

▪ Ex// testosterone is not listed but falls under the category of sex hormones (schedule 1) Prescription Regulations:

• If asked about prescription requirements, refills, sales record and other files and records, go to the “Prescription Regulations” table in Tab 4 (Drug Distribution) of College Binder

Scope of practice and prescribing:

• Prescribing limitations: o MD, vets (species-specific), DDS: narcotics, controlled drugs, prescription drugs o Podiatrists: benzodiazepine and prescription drugs o Pharmacists: schedule 4 drugs o Optometrists: topical ophthalmics o Midwives, NDs, NPs: prescription drugs (see CPBC for scope)

• If asked about scope of prescribing for other HCPs, check for “Prescribing Schedules” or “Scope of Practice” documents in Tab 4 (Drug Distribution) of College Binder

Prescription Adaptations: “PPP-58 Orientation Guide” in Tab 3 (Legislation) of College Binder (Amendment to “Professional Practice Policies” NOTE: does not apply to narcotics, controlled drugs or targeted substances

• Change: changing dose, formulation, or regimen of a prescription to enhance patient outcomes ($10) o Can’t change dose or regimen for Rx for: cancer, CV disease, asthma, seizures or psychiatric conditions o Can complete missing information (even for above diseases) on a Rx if there is historical evidence

• Regimen: renewing a prescription for continuity of care ($10) o For stable, chronic conditions (same medication with no change for minimum of 6 months) o No psychiatric meds unless on a multi-disciplinary team o Renewals can’t exceed expiry of the prescription

• Substitution: making a therapeutic drug substitution within the same therapeutic class for a prescription ($17.10) o Limited to 8 therapeutic classes of medications: H2RAs, NSAIDs, nitrates, ACEI/ARBs, DHP CCBs, PPIs, statins

Drug Interchangeability: examples: brand generics; capsules suspensions (NOT creams and ointments) Emergency Refills (PPP-31): “Professional Practice Policies” in Tab 3 (Legislation) of College Binder

• To ensure continuity of care (try to renew under PPP-58 before deferring to PPP-31)

• Emergency refills can be provided without access to prescription (evidence such as an empty rx vial, a label, or a copy of the rx receipt is sufficient)

• Pharmacist providing the emergency refill is named as the prescriber on the prescription label & patient’s medication profile (not required to notify original prescriber)

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Medication Reviews: under “PharmaCare Policy Manual: Medication Review Services, Section 8.9” MR-S: $60 MR-PC: $70 MR-F: $15 Eligibility criteria:

• BC resident, have a BC PHN, not covered under PharmaCare Plan B

• At least 5 different qualifying meds (Schedule 1 Rx medication or insulin) entered onto PharmaNet within the last 6 months and before the med review is provided

• Clinical need for service: o Prescriber requested medication review o Patient has multiple diseases, one or more chronic diseases o Patient’s medication regimen includes one or more NHP o Patient has a DTP o Patient recently discharged from hospital o Patient has multiple prescribers o Patient is receiving med(s) that require lab monitoring

• Not exceed max allowable (max 1 MR-S or MR-P per 6 months and max 4 MR-F per 12 months)

• Sign acknowledgement on Best Possible Medication History Form Resolution of DTPs:

Necessary • Unnecessary drug therapy

• Needs additional therapy

Effective • Ineffective drug

• Dosage too low (dose, dosing interval, drug interactions)

Safety • Adverse drug reaction

• Dosage too high (dose, dosing interval, drug interactions)

Adherence • Identify reason (cost, route, timing, etc) Changing Rx: reason, v/o, dr’s name, date, your initials Other tidbits :

• CrCl (mL/min) = [ 140−𝑎𝑔𝑒

𝑆𝐶𝑟 x 90 ] (x 0.85 if female)

• Recommendations and OTC selections Dose Max

Acetaminophen < 12 years old 10 – 15 mg/kg/dose po q4-6h prn 65 mg/kg/24 h

≥ 12 years old 325 – 650 mg po q4-6h prn 4000 mg/24 h

Ibuprofen < 2 years old 5 mg/kg/dose po q6-8 h prn 40 mg/kg/day

2 – 12 years old 5-10 mg/kg/dose po q6-8 h prn 40 mg/kg/day

> 12 years old 200 mg po q4h prn OR 400 mg po q6-8 h prn 1200 mg/24 h

Osteoporosis Calcium 1200 mg Vitamin D 800 IU

Tech Check: PQRSD3E

• Label (check for spelling errors/typos as well): o Patient o Doctor o Drug o DIN o Auxiliary labels

o Quantity (mitte) – includes calculations o Sig o Refills o Dosage form

• Product: drug, DIN, expiry, dosage forms REVIEW METHADONE AND SUBOXONE TECH CHECKS

• Expiry of formulations: o Non-aqueous: earliest expiry date of any API or 6 months, whichever is earlier o Water-containing oral: 14 days at room temperature o Water-containing topical/dermal; mucosal liquid; semi-solid: 30 days

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Opioid Management

Clinical scenario Tolerance Dependence Addiction

Short-term Low risk MANGEABLE

Low risk PROBLEMATIC

Low risk PROBLEMATIC

Long-term High risk PROBLEMATIC (need dosage increase)

High risk PROBLEMATIC

High risk PROBLEMATIC

Palliative High risk EXPECTED

High risk MANAGEABLE

Addiction PROBLEMATIC

• Do not adjust daily dose when switching dosage forms of same drug o EXCEPT: reduce codeine phosphate by 25% when switching to codeine contin (240 mg PO4 180 mg contin)

• Reduce dose of new opioid by 25-50% when switching, depending on: clinical scenario, frailty of patient, supervision level of patient’s environment, relative potency of new opioid, original dose, available dosage forms

• Mix of long-acting and short-acting in regimen design o Chronic pain: 75 – 80% of total daily dose as long-acting, with remainder as short-acting o Cancer/palliative pain: breakthrough doses to be in addition to long-acting product

▪ Size of breakthrough dose is typically 10-15% of daily dose at each dose ▪ Regular use of > 3 BT doses per day indicates regimen should be adjusted (although occasional use of

more is fine if reasoning clear) Opioid Rotation

• Same as any other opioid conversion – reduce dose by 25 – 50% Opioid Taper

• Doses can be reduced by 5-20% (or more) depending on scenario: o Community environment: 10% per week (or even month) or slower o Highly supervised environment: 10-30% per week or more o Institutionalized detox facility: highly variable (50% or more)

• Taper usually needs to be slowed as taper progresses – slow rate by 50% once patient reaches 30% of original dose Opioid Monitoring: Pasero Opioid-induced sedation scale

• S = sleep, easy to arouse

• 1 = awake and alert

• 2 = slightly drowsy, easily aroused

• 3 = frequently drowsy, arousable, drifts off to sleep during conversation

• 4 = somnolent, minimal or no response to stimuli Opioid Constipation

• If no BM for > 3 days (after expected BM): soften AND stimulate

• Prevention on opioids: stimulate +/- soften

• Regular, but hard: PEG/lactulose + increased fluid intake

• Irregular, but soft and without pain: no treatment required Transdermal Fentanyl Dosing: not for opioid naïve (only use for pts already receiving ≥ 60 mg/day morphine equivalents) 1. Duragesic Monograph Approach

a. Estimate daily ORAL morphine equivalence. DO NOT account for incomplete cross-tolerance. b. Select Duragesic dose based on provided table. (Morphine ranges are very broad = likely too low for 50% of pts) c. Titrate dosage up every 3-6 days until analgesic efficacy is reached.

2. Nomogram (ex// Fraser Health)

• Don’t use 12 patch by itself (it’s for titrating only)

• Nomograms are unidirectional!

• Provides information on recommended dose and schedule for the switch, also breakthrough pain doses

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Opioid Summary

OG OpioidReasons to change: Dosage form changes (example oral to SC), opioid rotations, etc

Same opioidSame total dose, except codeine

phosphate --> codeine contin = reduce by 25%

New opioid Reduce total dose by 25-50% for

cross-tolerance

Fentanyl (Duragesic) Patch

Method 1: covert to oral morphine (WITHOUT reducing for cross-tolerance), then use Duragesic monograph to find patch dose

Method 2: Fraser Health nomogram (also provides BT dosing)

Opioid Regimen

Chronic

Long-acting = 75-80% of total dose

Remainder of dose is short-acting (breakthrough doses)

Cancer/palliative Long acting = 100% of total dose

Breakthrough doses is 10-15% of TOTAL DAILY dose at EACH dose (q1h), should be

using only 3 BT/day

Opioid Tapering

Reduce by 5-20% per time, depending on setting

Detox50% or more

Hospital/In-patient

10-20% per week (or more)

Community10% per week (or even month)

or slower

Slow rate by 50% once at 30% of original dose

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Benzodiazepine Tapers

• General rates are 5-20% every 2 weeks in a community setting (or slower!!!)

• Longer acting BZDs easier to taper, switch from original BZD to: diazepam (young & healthy) or lorazepam (hepatic impairment or geriatric)

o Direct switching from BZD to BZD is poorly tolerated – can transition or cross-over from one BZD to the other Tools (click for link):

• MSE (summary): Mental Status Exam o 5 components: appearance and behavior; speech & language; mood; thoughts & perception; cognition

• PHQ-9 : Patient Health Questionnaire (self-reported) o Diagnostic tool for depression:

▪ Q1+Q2 = one or both should be rated as 2-3 ; Q1 – Q9 = ≥ 5 boxes within shaded section

• Scoring: minimal = 1-4; mild = 5-9; moderate = 10-14; moderately severe = 15-19; severe = 20-27 ▪ Q10 = “somewhat, very or extremely difficult”

• GAD-7 : Generalized Anxiety Disorder Questionnaire (self-reported) o Screening tool for anxiety (NOT diagnostic)

▪ Question 1-7 scoring: minimal = 0-4; mild = 5-9; moderate = 10-14; severe = 15-21 ▪ Question 8 assess impairment “somewhat, very, or extremely difficult”

• BPRS : Brief Psychiatric Rating Scale o Tests positive, negative, and affective sx; useful for monitoring (most useful in mod-severe psychoses) o Some items are self-reported, some observed (# 3, 4, 6, 7, 13, 14, 16, 18)

• AIMS: Abnormal Involuntary Movement Scale (clinician reported) o Conduct entire exam prior to scoring patient; rate highest amplitude or frequency observed o Positive score for tardive dyskinesia= score of 2 in ≥ 2 movements or score of 3-4 in a single movement

▪ Don’t total scores (score of 1 in 4 movements ≠ positive score of 4)

• CIWA : Clinical Institute Withdrawal Assessment (clinician reported) o Incorporate vital signs into assessment o CIWA-Ar score: mild = 0-9; moderate = 10-19; severe = ≥ 20

• Diabetic Foot o Use the highest (L vs. R) for total score and follow-up accordingly

▪ 0-6 = annual; 7-12 = every 6 m; 13-19 = every 3 m; 20-25 = every 1-3 m

• Brief Pain Inventory o Pain score: average the scores from questions 3-6 o Functional Score: average the scores from question 9 (A-G)