Pharmacy Pharmacy

REVIEW OF PRIMARY REVIEW OF PRIMARY PHARMACOLOGY FOR PHARMACOLOGY FOR PHYSICIAN ASST. PHYSICIAN ASST.

Typical day in officeTypical day in office

8am-6pm8am-6pm Appointment every 15 Appointment every 15

minutesminutes 30-32 patients per day 30-32 patients per day

with ½ hour for lunchwith ½ hour for lunch

Problems of patientProblems of patient 1. colds, flu, infections1. colds, flu, infections 2. heart disease, htn, 2. heart disease, htn,

cadcad 3. warfarin lab checks3. warfarin lab checks 4. diabetes4. diabetes 5. assorted misc. 5. assorted misc.

complaints like cuts, complaints like cuts, ticks, musculoskeletal ticks, musculoskeletal pain and headachespain and headaches

ANTIBIOTICSANTIBIOTICS

1. How to determine if an antibiotic is 1. How to determine if an antibiotic is needed or if an infection is viral.needed or if an infection is viral.

2. what antibiotic is appropriate and why 2. what antibiotic is appropriate and why choose one over anotherchoose one over another

3. decisions – who makes them? You or 3. decisions – who makes them? You or the insurance company??the insurance company??

4. Time management – call backs cost 4. Time management – call backs cost money, pick the right drug the first time.money, pick the right drug the first time.

Case #1Case #1

53 y/o wf,-no insurance-153 y/o wf,-no insurance-1stst visit to office visit to office cc: here for yearly pap (last pap 6 yr ago) and also has cc: here for yearly pap (last pap 6 yr ago) and also has

cough productive of green mucous cough productive of green mucous PMH: + viral/stress induced asthma, COPD, Gerd, PMH: + viral/stress induced asthma, COPD, Gerd,

obesityobesity Allergies: pcn- IodineAllergies: pcn- Iodine Meds: omeprazole otc, primateneMeds: omeprazole otc, primatene Vitals- t 98.8, bp 128/78, wt 210lb, ht 64”, bmi 36.1Vitals- t 98.8, bp 128/78, wt 210lb, ht 64”, bmi 36.1 Pertinent findings on exam- scattered rhonchi b/l do not Pertinent findings on exam- scattered rhonchi b/l do not

clear with cough and forced expiratory wheeze. Vaginal clear with cough and forced expiratory wheeze. Vaginal exam + atrophic vaginits. exam + atrophic vaginits.

What does she need?What does she need?

Pt thinks she has bronchitis and needs Pt thinks she has bronchitis and needs antibiotics- antibiotics-

What do you say and why?What do you say and why?

Treatment planTreatment plan

1. pt needs routine inhaler for asthma- she does not have 1. pt needs routine inhaler for asthma- she does not have insurance so how do we do this?insurance so how do we do this?

2. pt does not need antibiotics-but she does need education on 2. pt does not need antibiotics-but she does need education on causes of bronchitis- normally viral and antibiotics do not really causes of bronchitis- normally viral and antibiotics do not really work for this.work for this.

3. pt needs fluvax-due to asthma3. pt needs fluvax-due to asthma 4.pt does admit to vaginal dryness and also vulvo/vaginal irritation 4.pt does admit to vaginal dryness and also vulvo/vaginal irritation

at times.at times. 5.pt was discharged from visit with samples of premarin cream 5.pt was discharged from visit with samples of premarin cream

0.5mg vaginally hs x 3 wk and skip a week before resuming, 0.5mg vaginally hs x 3 wk and skip a week before resuming, advised to use ventolin inhaler q 4-6 hr for cough and wheezing advised to use ventolin inhaler q 4-6 hr for cough and wheezing reassured and given paperwork for indigent medication program. reassured and given paperwork for indigent medication program. Advised to return if sx worse or if running a fever. She agreed to Advised to return if sx worse or if running a fever. She agreed to the fluvax and left the office happy without an antibiotic. the fluvax and left the office happy without an antibiotic.

Option 2Option 2

If the patient had a fever and chills along If the patient had a fever and chills along with the rhonchi and a chest x-ray with the rhonchi and a chest x-ray showed possible consolidation in right showed possible consolidation in right lower lobe of lungs –what antibiotic would lower lobe of lungs –what antibiotic would we choose and why?we choose and why?

Community acquired Community acquired pneumoniapneumonia

1. azithromycin-use on antibiotic naïve pt1. azithromycin-use on antibiotic naïve pt 2. cost- least expensive since it is generic now 2. cost- least expensive since it is generic now 3. quinolone?- avelox, levaquin, cipro???3. quinolone?- avelox, levaquin, cipro??? 4. the choice of quinolone is often driven by 4. the choice of quinolone is often driven by

insurance companies most insurance will cover insurance companies most insurance will cover cipro but is this the best choice for cap? Why cipro but is this the best choice for cap? Why not augmentin/rocephin in this pt??not augmentin/rocephin in this pt??

Case #2Case #2

85 y/o wm 85 y/o wm Cc: fever chills nausea vomiting and right upper quad pain – Cc: fever chills nausea vomiting and right upper quad pain –

sudden onset, although has had a cold x 2 week before sx startedsudden onset, although has had a cold x 2 week before sx started Pmh: +DM, dyslipidemia, gerd, hx prostate ca with prostatectomy, Pmh: +DM, dyslipidemia, gerd, hx prostate ca with prostatectomy,

(pt speaks broken english daughter is translating during visit)(pt speaks broken english daughter is translating during visit) NKDANKDA Meds: levemir, novolog, pravastatin, prevacid 15mg, Meds: levemir, novolog, pravastatin, prevacid 15mg, Labs: hga1c 7.5, cholest. 185, hdl 70, ldl 104, trig 127 Labs: hga1c 7.5, cholest. 185, hdl 70, ldl 104, trig 127 Vitals: bp 100/58, t 101.5, p 85 r, wt 161Vitals: bp 100/58, t 101.5, p 85 r, wt 161 Note: had flu vax 10/08, Note: had flu vax 10/08, Pertinent findings: + rales right lower lobe, expiratory wheezes b/l Pertinent findings: + rales right lower lobe, expiratory wheezes b/l

do not clear with cough, mucous membranes moist, ruq palpation do not clear with cough, mucous membranes moist, ruq palpation no hepatomegaly and mild tenderness lowe rib area, cxr + rll no hepatomegaly and mild tenderness lowe rib area, cxr + rll consolidation and enlarged heartconsolidation and enlarged heart

What do we use to trt What do we use to trt this CAP?this CAP?

1. azithromycin- inexpensive and 1. azithromycin- inexpensive and insurance covers this medinsurance covers this med

2. promethazine 25mg tab/suppos ½-1 2. promethazine 25mg tab/suppos ½-1 tab po q 4-6 hr prn n/v.tab po q 4-6 hr prn n/v.

Recheck-2 days max- have them bring in Recheck-2 days max- have them bring in blood sugar records and instruction on blood sugar records and instruction on watching blood sugar closely due to watching blood sugar closely due to decrease in food intake.decrease in food intake.

Case #3Case #3

46 y/o wf46 y/o wf Cc: toothache-started last night and pt cannot get to Cc: toothache-started last night and pt cannot get to

dentist for 3-4 days he is not in the office.dentist for 3-4 days he is not in the office. PMH: tobacco abuse, Dysfunctional uterine bleeding, PMH: tobacco abuse, Dysfunctional uterine bleeding,

hyperlipidemiahyperlipidemia NKDANKDA Meds: lopid 600mg bid, fish oil 1000mg caps bid, Meds: lopid 600mg bid, fish oil 1000mg caps bid,

provera 10 mg one tab 10 days/mo.provera 10 mg one tab 10 days/mo. Pertinent exam findings: right side facial swelling, pain Pertinent exam findings: right side facial swelling, pain

with percussion on 2with percussion on 2ndnd molar with tongue depressor, molar with tongue depressor, noxious breath, gum swelling and erythema right lower noxious breath, gum swelling and erythema right lower jaw and tender enlarged submandibular lymph nodes.jaw and tender enlarged submandibular lymph nodes.

Oral infectionsOral infections

1. most oral infections are caused by gram 1. most oral infections are caused by gram positive organisms- so best treatment would be positive organisms- so best treatment would be penicillin vk qid x 10 days.penicillin vk qid x 10 days.

2. why would we choose amoxicillin instead?2. why would we choose amoxicillin instead? 4. why not cephalosporin?4. why not cephalosporin?

5. what part does cost play in this decision?5. what part does cost play in this decision?

6. what if pt is allergic to pcn- would you use 6. what if pt is allergic to pcn- would you use azithromycin ? Why or why not?azithromycin ? Why or why not?

Case #4Case #4

22 y/o w/m 22 y/o w/m Cc: sore throat x 4 days- with headache and Cc: sore throat x 4 days- with headache and

fatigue swollen glands and no cough cold or fatigue swollen glands and no cough cold or congestion sx.congestion sx.

Pmh: depression, low back pain chronicPmh: depression, low back pain chronic Allergies: NKDAAllergies: NKDA Current meds: fluoxitine 40mg dailyCurrent meds: fluoxitine 40mg daily * pt started amoxicillin 3x day x 24 hours.* pt started amoxicillin 3x day x 24 hours. Vitals: t 101.5, bp 120/80Vitals: t 101.5, bp 120/80

Strep pharyngitisStrep pharyngitis

1. pt meets 85% criteria- do we do a 1. pt meets 85% criteria- do we do a rapid strep to verify dx- why or why not?rapid strep to verify dx- why or why not?

Antibiotic overviewAntibiotic overview

Penicillin- covers gram positive bacteria, problems with Penicillin- covers gram positive bacteria, problems with resistance due to over use in the past so developed resistance due to over use in the past so developed forms with more beta lactmase resistance- ampicillin, forms with more beta lactmase resistance- ampicillin, amoxicillin, and then added clauv. Acid to increase the amoxicillin, and then added clauv. Acid to increase the resistance –ie: augmentinresistance –ie: augmentin

High allerginicity reported- rashes-anaphylaxisHigh allerginicity reported- rashes-anaphylaxis A lot of allergy reports are invalid-parents have told pt A lot of allergy reports are invalid-parents have told pt

they are allergic and pt never really had allergic they are allergic and pt never really had allergic reaction-many allergies are also gi intolerance and pt reaction-many allergies are also gi intolerance and pt gets yeast infections so assumes this is allergy.gets yeast infections so assumes this is allergy.

Getting a good history is most important tool to Getting a good history is most important tool to determine if pt is really allergic to medication.determine if pt is really allergic to medication.

cephalosporinscephalosporins

1. 3 generations of cephalosporins1. 3 generations of cephalosporins 2. 12. 1stst generation most coverage of gram generation most coverage of gram

positive organisms and slight gm negative positive organisms and slight gm negative coverage. Ie: cephalexincoverage. Ie: cephalexin

3. 23. 2ndnd generation: less gram positive coverage generation: less gram positive coverage and more gram negative- ie: ceclor and more gram negative- ie: ceclor

4. 34. 3rdrd generation : gram negative coverage- generation : gram negative coverage- rocephinrocephin

5. cross allerginicity- 10-15% cross allergy with 5. cross allerginicity- 10-15% cross allergy with penicillin- penicillin-

erythromycinerythromycin

1.1. Different salt forms- erythromycin base, Different salt forms- erythromycin base, erythromycin succinate, stearate,lactobionateerythromycin succinate, stearate,lactobionate

2.2. Gram positive and atypical bacterial infection Gram positive and atypical bacterial infection coverage- good if suspected mycoplasma coverage- good if suspected mycoplasma infection or if pt allergic to penicillininfection or if pt allergic to penicillin

3.3. Newest erythromycins-clarithromycin and Newest erythromycins-clarithromycin and azithromycin- less gram positive activity azithromycin- less gram positive activity much resistance by strep pneumo organisms- much resistance by strep pneumo organisms- must check resitance info in area where you must check resitance info in area where you are working.If using for strep a infection use 1 are working.If using for strep a infection use 1 gm/kg dose not 500mg/kggm/kg dose not 500mg/kg

quinolonesquinolones

3 quinolones used at present time3 quinolones used at present time 1. avelox-used for upper respiratory infections 1. avelox-used for upper respiratory infections

no indication for uti.no indication for uti. 2. levaquin- coverage for upper respiratory 2. levaquin- coverage for upper respiratory

infections and also urinary track infectionsinfections and also urinary track infections 3. cipro- used mainly for urinary tract 3. cipro- used mainly for urinary tract

infections- has much resistance in upper infections- has much resistance in upper respiratory infectionsrespiratory infections

(floxin) also available but much resistance so (floxin) also available but much resistance so use is limiteduse is limited

Misc antibioticsMisc antibiotics

1. sulfa drugs- mostly used in uti- much resistance in 1. sulfa drugs- mostly used in uti- much resistance in uri so not used much for sinus infection anymore. uri so not used much for sinus infection anymore. Newest use is mrsa infection at twice the normal bid Newest use is mrsa infection at twice the normal bid dose.dose.

2. macrodantin- used in lower urinary tract infections-2. macrodantin- used in lower urinary tract infections-never for pyelo does not cover organisms of pyelonever for pyelo does not cover organisms of pyelo

Aminoglycosides: not used much due to ototoxicity- Aminoglycosides: not used much due to ototoxicity- used mainly in hospital- except for vancomycin oral-used mainly in hospital- except for vancomycin oral-which is used for c-dif infections.which is used for c-dif infections.

Metronidazole- used for bacterial vaginitis and gi Metronidazole- used for bacterial vaginitis and gi infectionsinfections

Tetracycline- broad spectrum abx- good skin Tetracycline- broad spectrum abx- good skin penetration used for acne much resistance with uripenetration used for acne much resistance with uri

Warfarin Warfarin

This group of case studies includes This group of case studies includes patients from other doctors and also patients from other doctors and also other practices. other practices.

The purpose of this group of cases is to The purpose of this group of cases is to show the thought process behind a short show the thought process behind a short (10 minute) visit for evaluation of pt/inr (10 minute) visit for evaluation of pt/inr which is done on site with adjustment of which is done on site with adjustment of dose of warfarin.dose of warfarin.

Case #1Case #1

46 y/o wm on warfarin for a-fib46 y/o wm on warfarin for a-fib Pmh- DM, Polyneuropathy, Insomnia, Anxiety, CHF, Pmh- DM, Polyneuropathy, Insomnia, Anxiety, CHF,

Gout, DyslipidemiaGout, Dyslipidemia Meds: sotalol 120mg bid, Glipizide ER 10mg bid, Meds: sotalol 120mg bid, Glipizide ER 10mg bid,

Enalapril 20mg bid, Metformin 500mg po bid, fish oil Enalapril 20mg bid, Metformin 500mg po bid, fish oil 1000 mg bid, mvi, allopurinol 300mg q day, furosemide 1000 mg bid, mvi, allopurinol 300mg q day, furosemide 40mg po bid and 1 dose extra for 2lb wt gain, digitek 40mg po bid and 1 dose extra for 2lb wt gain, digitek 0.25mg q day, metoprolol 100mg bid, spironolactone 0.25mg q day, metoprolol 100mg bid, spironolactone 25mg q day, novolog 70/30 as directed, Warfarin 5 mg 25mg q day, novolog 70/30 as directed, Warfarin 5 mg alt with 7.5 mg every other day.alt with 7.5 mg every other day.

Labs: pt/inr 16.9/ 1.9Labs: pt/inr 16.9/ 1.9

Questions Questions

1. if inr > 3 what medication changes would 1. if inr > 3 what medication changes would you expect to cause this change?you expect to cause this change?

2. If inr <1.8 what would you expect to be the 2. If inr <1.8 what would you expect to be the cause?cause?

3. Where do you want this pt’s pt/inr?3. Where do you want this pt’s pt/inr? 4. What is the effect of decreased or increased 4. What is the effect of decreased or increased

edema on warfarin levels?edema on warfarin levels? 5.What is the effect of diet and otc meds on 5.What is the effect of diet and otc meds on

warfarin levels-Why?warfarin levels-Why?

Case #2Case #2

80 y/o wf- warfarin therapy for a-fib80 y/o wf- warfarin therapy for a-fib Pmh- chf, polycystic kidney disease, Pmh- chf, polycystic kidney disease,

osteoarthritis, gerd, htn, hx-cva, cad, osteoarthritis, gerd, htn, hx-cva, cad, depressiondepression

Meds: pacerone 200mg q day, simvastatin Meds: pacerone 200mg q day, simvastatin 40mg, furosemide 40mg q day, paroxetine 10 40mg, furosemide 40mg q day, paroxetine 10 mg po q day, celebrex 200mg po q day, toprol mg po q day, celebrex 200mg po q day, toprol xl 50mg po q day, warfarin 1 mg alt with ½ mg xl 50mg po q day, warfarin 1 mg alt with ½ mg daily.daily.

Pt/inr 17.2/2.0Pt/inr 17.2/2.0

questionsquestions

1. what medical condition can cause 1. what medical condition can cause sharp increase in inr and why?sharp increase in inr and why?

2. Does celebrex use change inr ?2. Does celebrex use change inr ? 3. Why would change of statin change 3. Why would change of statin change

inr?inr? 4. would adding ppi change inr?4. would adding ppi change inr? 5. What otc med would you question if pt 5. What otc med would you question if pt

has sharp drop in inr?has sharp drop in inr?

Case #3Case #3

56 y/o wf-warfarin therapy due to clotting 56 y/o wf-warfarin therapy due to clotting disorder w/hx dvt.disorder w/hx dvt.

Pmh-fx ankle with fusion, osteoarthritis, Pmh-fx ankle with fusion, osteoarthritis, obesity, allergic rhinitis, depression, obesity, allergic rhinitis, depression, hypothyroidhypothyroid

Meds: flonase, lyrica 75mg, synthroid 75mcg, Meds: flonase, lyrica 75mg, synthroid 75mcg, coumadin 10mg daily, effexor 75mg daily, coumadin 10mg daily, effexor 75mg daily, tramadol 50mg q 6 h prn, ambien cr 12.5mg tramadol 50mg q 6 h prn, ambien cr 12.5mg daily hs, hydrocodone 5/500mg q 4 h prndaily hs, hydrocodone 5/500mg q 4 h prn

Pt/inr 17.2/2.0Pt/inr 17.2/2.0

questionsquestions

1. what would be likely cause of 1. what would be likely cause of fluctuation of this pt pt/inr?fluctuation of this pt pt/inr?

2. what is the range of pt/inr for this pt’s 2. what is the range of pt/inr for this pt’s condition.condition.

Case #4Case #4

85 y/o wf- warfarin for a-fib85 y/o wf- warfarin for a-fib Pmh- htn,dyslipidemia, chfPmh- htn,dyslipidemia, chf Meds- lipitor 10mg po daily, amitriptylline 25mg Meds- lipitor 10mg po daily, amitriptylline 25mg

po hs daily, kcl 20eq po q day, lasix 20mg po q po hs daily, kcl 20eq po q day, lasix 20mg po q day, lisinopril 20mg po daily, asa 81mg po day, lisinopril 20mg po daily, asa 81mg po daily, warfarin 5 mg po daily, centrum silver po daily, warfarin 5 mg po daily, centrum silver po daily, metoprolol er 200mg po daily.daily, metoprolol er 200mg po daily.

Int/pt 2.7/18.6Int/pt 2.7/18.6

questionsquestions

1.is it appropriate to take both coumadin 1.is it appropriate to take both coumadin and asa daily?and asa daily?

2. is there another med in the profile 2. is there another med in the profile which is not appropriate for an 85 y/o? If which is not appropriate for an 85 y/o? If so why?so why?

Complex Patients-just for Complex Patients-just for funfun

1. 65 y/o wm here for f/u diabetes1. 65 y/o wm here for f/u diabetes 2. dx- afib, dm, cad, htn, dyslipidemia, anxiety, bph, gerd2. dx- afib, dm, cad, htn, dyslipidemia, anxiety, bph, gerd 3. meds: simvastatin 40mg po daily, novolin 70/30 bid, zoloft 100 3. meds: simvastatin 40mg po daily, novolin 70/30 bid, zoloft 100

po daily, ativan 1 mg po tid prn, lisinopril 10mg po daily, metformin po daily, ativan 1 mg po tid prn, lisinopril 10mg po daily, metformin 1000mg q day, celebrex 200mg po daily, isosorbide mono er 1000mg q day, celebrex 200mg po daily, isosorbide mono er 60mg, ranexa 500mg po q day, niaspan 1000mg daily, hctz 25mg 60mg, ranexa 500mg po q day, niaspan 1000mg daily, hctz 25mg po daily, warfarin 5 mg po daily, co q10 po daily, saw palmetto po po daily, warfarin 5 mg po daily, co q10 po daily, saw palmetto po daily.daily.

Vitals: 130/64, p 60 reg, resp 16, wt 231Vitals: 130/64, p 60 reg, resp 16, wt 231 Labs: ldl-66, creat 1.1, ast/alt normal, a1c-7.7, pt/inr 17.8/2.2Labs: ldl-66, creat 1.1, ast/alt normal, a1c-7.7, pt/inr 17.8/2.2 Exam: obese, chest-cta, cardiac-rrr/+2/6 sfm,extremities-no Exam: obese, chest-cta, cardiac-rrr/+2/6 sfm,extremities-no

cyanosis or edema feet no lesions or callousescyanosis or edema feet no lesions or callouses

questionsquestions

1. what is of primary importance?1. what is of primary importance? 2. Where should we set his a1c goal ?2. Where should we set his a1c goal ? 3. Where should we set lipid goal?3. Where should we set lipid goal? 4. What changes would you suggest for 4. What changes would you suggest for

pt at this visit?pt at this visit?

Last case-and this is a Last case-and this is a blingerblinger

1.55 y/o wf- f/u in nursing home for chronic 1.55 y/o wf- f/u in nursing home for chronic problemsproblems

2. pmh-dm, afib,copd, s/p amputation of 22. pmh-dm, afib,copd, s/p amputation of 2ndnd toe toe right foot due to mrsa, phx-mrsa pneumonitis right foot due to mrsa, phx-mrsa pneumonitis with respiratory failure, chronic renal failure with respiratory failure, chronic renal failure stage 4 secondary to diabetic stage 4 secondary to diabetic glomerulosclerosis, anemia of chronic disease, glomerulosclerosis, anemia of chronic disease, allergic rhinitis, blindness of left eye and allergic rhinitis, blindness of left eye and glaucoma right eye with decreased vision and glaucoma right eye with decreased vision and morbid obesity- recent thrombocytopenia morbid obesity- recent thrombocytopenia (platelets were zero)(platelets were zero)

1. vitals: bp 140/80, wt 356(down from 450 lb. t—97.8, 1. vitals: bp 140/80, wt 356(down from 450 lb. t—97.8, r-20r-20

Labs- na 137, k+ 4.3, Cl 111, CO2-21.2, Bun 101, Labs- na 137, k+ 4.3, Cl 111, CO2-21.2, Bun 101, Creat 2.8(pt baseline), ast/alt normal, hg/hct 8.8/26.2 Creat 2.8(pt baseline), ast/alt normal, hg/hct 8.8/26.2 platelets 95000.platelets 95000.

Meds: lantus 40 u sq hs daily, novolog coverage, phos-Meds: lantus 40 u sq hs daily, novolog coverage, phos-lo 667 mg tid, metoprolol 100mg bid, lisinopril 30 mg lo 667 mg tid, metoprolol 100mg bid, lisinopril 30 mg poq am, prednisone 40 mg with slow taper per poq am, prednisone 40 mg with slow taper per heme/onc, coumadin 5 mg daily, cymbalta 60 mg po heme/onc, coumadin 5 mg daily, cymbalta 60 mg po daily, pulmicort 2 puff bid, atrovent 2 puff qid, daily, pulmicort 2 puff bid, atrovent 2 puff qid, xalatan .005% hs ou.xalatan .005% hs ou.

New complaintNew complaint

Cellulitis- left lower legCellulitis- left lower leg Culture 4+ mrsa and 4+ enterococcusCulture 4+ mrsa and 4+ enterococcus Sentitivity- sulfa/clindimycin/vancomycinSentitivity- sulfa/clindimycin/vancomycin Allergies- sulfa/cephalosporin/poss Allergies- sulfa/cephalosporin/poss

thrombocytopenia to vancomycin in past.thrombocytopenia to vancomycin in past. Pt/inr- very labile- has been hospitalized with Pt/inr- very labile- has been hospitalized with

inr > 25 received blood tranfusions x 2 in last yr inr > 25 received blood tranfusions x 2 in last yr due to complications of coagulopathy.due to complications of coagulopathy.

What is our plan?What is our plan?