The Jury is STILL Deliberating

The title of this post comes from one of the education sessions I attended at Midyear this year. So, the JNC-8 was supposed to come out last year or the year before, and is now set to be released next year in 2012 (hopefully!). The session was presented by two pharmacists - the first one was discussing all the major articles published about hypertension in that last few years - papers that the JNC committee cannot ignore when releasing the latest guidelines. The second speaker went over cases. I thought this talk was very interesting, and jotted down the following notes.

*The guidelines used today for hypertension come from the JNC-7 (published in 2003) and the AHA Scientific Statement (published in 2007). 

*BP goals:

• JNC7 states: <140/90, and <130/80 for patients with DM or CKD. 
• AHA states: <140/90, and <130/80 for patients with DM, CKD, and/or an increased CAD risk. 
• The diabetes goal being lower is interesting - because according to the speaker, this isn't really evidence-based medicine. The ACCORD trial (done in DM patients) for example, compared a SBP goal of either <140 or <120. The primary endpoints were stroke and MI. Results - more meds were needed to reach SBP <120 and no difference between primary outcomes (p = 0.20). I believe there was a study that showed that patients with proteinuria of 300-1000mg (probably signifies diabetics) had better outcomes when their blood pressure goals were lower. In the HOT trial, blood pressure goals were also studied. In the diabetic population, there were better outcomes with a DBP <80 rather than <90. However, the latter was a subgroup analysis. This is important to consider in my opinion, because diabetic patients are likely already on a couple medications. Is adding more blood pressure medication to reach a lower goal blood pressure worth it if it's not truly evidence-based?

*Treatment schemes:

• In 2003
• If a patient had compelling indications other than hypertension, then specific BP meds would be prescribed (ex. comorbid disease DM, then ACEI/ARB, or post MI, BB, etc.).
• Non-compelling indication stage 1 HTN: HCTZ first line usually, or ACEI/ARB/CCB/BB
• Non-compelling indication stage 2 HTN: 2-drug combo of any of the above with HCTZ as one of the choices. 
• In 2007 (AHA Scientific Statement) 
• If a patient had compelling indications, then no change to above.
• Changes to non-compelling indications: BB were taken off the list and no preference to HCTZ. 
• The ACCOMPLISH trial was a study that looked at combination HTN medications - CCB/ACEI vs. HCTZ/ACEI. The trial was stopped early because the CCB/ACEI combination was significantly better than the other combination. This may have been one of the reasons to take away the preference for HCTZ. 

*ACEI/ARBS

• How are these two different?
• ACEI: dry cough, more data, less expensive. 
• ARB: no dry cough, less data, more expensive; however, 2 generics are supposed to be coming out in 2012, so the use of ARBs may increase. 
• the ONTARGET trial studied the effects of ACEI alone, ARB alone, and combination ACEI/ARB. The results showed increased renal dysfunction, increased incidences of hyperkalemia, with no added benefit. This is why we don't see the combination used very often (except in severe CHF or proteinuria). 

*Chlorthalidone and HCTZ

• If a patient is on HCTZ, and has resistant HTN (on 3 or more meds not at goal OR on 4 or more meds at goal), then consider switching to chlorthalidone. 
• Also, something that the speaker said about HCTZ caught my attention - I've always thought that 25mg/day of HCTZ was maximum that should be recommended - and that anything above causes increased hypokalemia with no benefit. The speaker, however, encouraged going up to 50mg/day HCTZ or adding another agent if BP wasn't at goal with just HCTZ. I haven't completely made up my mind about this, but it's something to look into. 

*What We MAY See in JNC8

• BB as second line therapy or just for compelling indications. 
• Goal SBP <140 for ALL patients, with specific individual goals between patient and PCP. 
• The HCTZ vs. chlorthalidone issue
• ACEI or ARB with CCB as first line combination therapy
• Tailored recommendations for the elderly with HTN.

Long Time No Talk

So…it’s been a while! But, to be fair, my last rotation ended on October 31, and I haven’t been on rotations since. I get back to it on January 2 at a psychiatric ambulatory care site, which I’m looking forward to. So what exactly have I been doing since then…?

1. I started a job with Fry’s pharmacy! I did the bulk of my training in November, which included a week of computer work, and then 80 hours of in-pharmacy training. Now, I’m working 12 hours a week until rotations begin again, and then most likely 8 hours/week after that. This is my first real experience with community pharmacy as an employee, which is crazy since I’m a fourth year student.  But, it’s better late than never. My favorite part of the job is counseling patients. It’s amazing how much I remember (and don’t remember) about certain medications. This also gives me a reason to go back into lexicomp and pull up specific counseling points for different drugs, especially the ones that keep coming up. For example…

Antibiotics in General (most of them)…

• Each dose should be taken with food to increase absorption and decrease GI upset (which is the main side effect)
• Take entire prescription (even if you feel better)
• Talk to your doctor if your condition worsens or dose not improve upon completing the prescription
• Can decrease the effectiveness of birth control (Use back up form of contraception to be safe)
• The pharmacist at my training store also emphasized having yogurt included in the patient’s diet while on antibiotics (but not within 2 hours of the medication). This is to help with digestion.
• For tetracyclines specifically – no dairy, vitamins, antacids 1 hour before and 2 hours after the medication.

Steroids in General…

o        Take with food

o        Can increase blood glucose (so careful in patients with diabetes)

o        Can cause water retention, but this goes away after the course of treatment

o        Can make people moody

o        Can cause early morning insomnia

o        If patient becomes puffy, then PCP needs to be called

Beta Blockers…

o        Can cause dizziness

o        Can cause coldness of the hands and feet

o        Can cause water retention

Ace Inhibitors…

o        Can cause dizziness

o        Take with food

o        Can cause the dry cough

o        Need to get potassium checks

Pain Medications in General…

o        Can cause dizziness and drowsiness

o        NO alcohol due to additive effects

o        Can cause constipation (so offer ideas on some OTC products to help with this, encourage increased fiber in diet)

o        For combination products, watch the Tylenol intake

I also had to do ProAir a few times…

o        Go over how to use an inhaler (prime it – 4 test sprays into the air before the first time of use or if it hasn’t been used in over 2 weeks). When using the inhaler, exhale first, and then inhale deeply while pushing down the inhaler and hold your breath for 10 seconds. Wait 60 seconds between puffs.

o        If also using this with another inhaler, use your proair (albuterol) first, so it opens up your lungs. This will make the other inhaler more effective. 

I’m sure I’ll be asked to counsel on a lot of other meds, but that will come with time. I also sent in my immunization certification from APhA to the state board of pharmacy. I think this will make it official for me to start giving immunizations at Fry’s! My least favorite part of community pharmacy has to be all the insurance claims – this is the part that makes me shy away from the community setting. It becomes more about who owes who money rather than patient care at times. Other than that, it’s the perfect part-time job for now J.

2. I’ve been busy preparing for residency applications. Everyone now a days is encouraging students to apply to about 12 programs, since it’s become so competitive, so that’s exactly how many I’m applying to! At this point, I’ve got my letter of recommendation writers lined up, my CV updated, and a table with specifics for each program/when things are due. Now, all I have to do is actually apply! I was hoping to get everything done by the 17^th, but we’ll see how that goes. I made my finalized list after attending Midyear – which really pushed me towards some programs, and made me eliminate others. I would highly recommend anyone fourth year student who wants to do a residency to go. It’s worth it! And it was in New Orleans this year, which was a blast.
   
   
3. In addition to absolutely loving pharmacy, I love to dance! My sister, myself, and four of our friends founded UofA Om Shanti, which is University of Arizona’s Bollywood Dance Team in 2008. Since then, we’ve competed in competitions in LA, Berkeley, and New York…plus do tons of local performances. Just last month we won first place in New York, which qualifies us for the BIG competition called “Bollywood America,” which is coming up in a few months. I’ve also been busy with this since my break began on October 31^st.

I should have more rotations-related posts about what I’m learning once I start again in January. Until then, I’ll have summaries on what I read in all the pharmacy journals I need to catch up on!

"Suga, Suga" (...how you get so fly)

...My diabetes medications review! I made this list during my last rotation, since I felt like I was all over the place with my diabetes medications knowledge. Enjoy!

Types of Insulin – insulin is safe in pregnancy

Rapid-acting – for meals eaten at same time as injection

• Humalog (Lispro): 15-20mins/3-5 hours
• Novolog (Aspart): 10-20mins/3-5 hours

Short-acting – for meals eaten within 30-60mins

• Humulin or Novolin (Regular): 20-60mins/5-8 hours
• Velosulin: 30-60mins/2-3 hours

Intermediate-acting – half day or overnight (combo with rapid/short)

• NPH: 1-2 hours/18-24 hours
• Lente: 1-2 hours/18-24 hours

Long-acting – about a full day (combo, if needed, with rapid/short)

• Lantus (glargine): 1-1.5 hours/20-24 hours
• No peak time, delivered at a steady level
• Levemir/Detemir: 1-2 hours/up to 24 hours
• Peak time 6-8 hours

Pre-mixed – twice with meals

Oral Medications

Actos (pioglitazone) – thiazolidinediones (^insulin sensitivity and secretion)

• Maximum 45mg/day, Start 15-30mg/day
• ADR: liver problems (2.5x ULN)
• Contraindications: CHF III-IV (BBW)
• Well tolerated in older adults, don’t cause hypoglycemia, okay for renal dysfunction

Janumet (sitagliptin/metformin) – sitagliptin increases levels of incretin, decreases sugar from liver, metformin restores body’s response to insulin, decreases sugar from liver

• Maximum 100/2000mg/day

Metformin – restores body’s response to insulin, decreases sugar from liver

• Contraindications: renal dysfunction (CHF?)
• Perks: has also been shown to decrease LDL and TC, weight loss, less hypoglycemia  
• ADRs: GI, lactic acidosis (d/t OD or renal dysfunction)

Sulfonylureas (chlorpropamide, glyburide, glimepiride, glipizide) – increase insulin release

• 1^st and 2^nd generations
• ADR: hypoglycemia, weight gain

Meglitinides (repaglinide and nateglinide) – similar to sulfonylureas

• If patient can’t use sulfonylureas, same weight gain as sulfonylureas, possibly less risk of hypoglycemia.

Alpha-glucosidase inhibitors (acarbose and miglitol) – block complex carbs to monosaccharides (slows glucose absorption)

• ADR: GI very common

DDP-IV inhibitors (gliptins) – regulates enzymes involved with glycemic control

• No risk of hypoglycemia and weight-neutral (from UpToDate); however, safety of these drugs has not been established for long-term use. Also expensive, and need to be adjusted in renal insufficiency.

Subcutaneous Medications

Byetta (Exenatide) - ^incretin to ^insulin

• BID with breakfast and dinner, Abx/BC with lunch
• ADR: N/V/D/GI/decreased weight
• Contraindications: T1DM, Renal, Pancreatitis, pregnancy

Victoza (liraglutide) – increases insulin, decreases gastric emptying, decreases glucagon, GLP-1 analog

• BBW for thyroid tumor
• Another one in this class is exenatide, but it is BID injections (should not use with CrCl < 30ml/min)

"So will you be getting your master's next?"

I'll get to how my current rotation is going, and all the wonderful things I'm learning. But first, I wanted to take a second to explain the title of this post! Last week, we had a huge dinner party at my parent's house - aunties and uncles I hadn't seen in a long time were there, and we were all catching up. They were asking questions about my life..."Soo, when are you getting married?!" (umm, not quite even engaged yet)..."Are you working now?" (nope, still a student)..."So, will you bet getting your master's next?" (....WHAAT?!). This last question was what really got to me. But only for a second. I realized that the older generation (actually, the majority of people) know a pharmacist as an RPh (which I believe is a bachelor's degree). They don't know that a Pharm.D. degree is what current pharmacy students are getting...a doctor of pharmacy degree, and includes more clinically oriented courses. Anyway, instead of actually blurting out the initial "WHAAT?!" I explained that there would be no more schooling after this (yay!), because it is a doctorate degree, and that I'll be doing a residency because I'm passionate about a clinical career. The transition to pharmacists being seen as clinicians will take time, which is why it's so important to educate anyone and everyone around you about what it means to be a pharmacist.

Anyway, enough preaching. So my current rotation site is great! The clinic rotation was relaxing, since I wasn't busy all the time. Now that I'm back in the hospital, and the rotation site is custom to having pharmacy students, it's been nonstop. My preceptor is SO smart, and she's literally a super star on rounds. She just graduated from pharmacy school 2 years ago, and is already the trauma pharmacist at the hospital I'm at. Very impressive. I have a few tasks to do everyday:

1. Dialysis patients - I print out the list of patients on dialysis at the hospital, and make sure their medications are all renally dosed - the major ones I look for are the antibiotics. I've taken it upon myself to make sure there aren't any drug-drug interactions too - and I catch them fairly often. The major ones I keep finding are simvastatin with amlodipine and diltiazem. Since the guidelines changed, the max dose of simvastatin with amlodipine is 20mg, and with diltiazem is 10mg. There are others, but these are the most common ones that keep coming up.
2. Epidemiology reports - This is a print out of completed culture and sensitivitie reports for patients in the hospital. My job is to look at the clinical picture of the patient, and make sure they're on antibiotics/antifungals if needed, and if they're already on something, then to make sure they cover the bugs that grew out. I've made many interventions doing this so far. For example, we had a patient who was on day 18 of cefepime and day 12 of vancomycin. The patient had not had a fever in days, and did not have a white count. So I went to the chart, and looked at progress notes - and the plan was to discontinue the antibiotics on a certain day, but it was never done. So, finally...10 days later, they were discontinued. It bothers me when patients are getting medications when they're not getting any benefit from them - then it just becomes unnecessary chemicals in the body. Another intervention was when I identified a patient with MDR Enterobacter and a Staph haemolyticus wound infection who was on the wrong abx. I was able to talk to the physician and change the patient to the correct antibiotics. Today, one of my patients' C.dif result came back negative. She was on prophylactic Flagyl, but was never discontinued - so I made sure it was gone before the end of my work day!
3. Coumadin teachings - we get a print out of all the patients on coumadin in the hospital. The students are responsible for doing these coumadin teachings, since it is such a serious medication. They're very redundant, but it's been fun talking to patients. 
4. Vent rounds - Every Wednesday, the pulmonary doctor volunteers to come in and go through her patients on vents with the respiratory therapist and the pharmacist. I tag along too, since my preceptor is this pharmacist. So far, I've presented patients at two vent rounds - I make sure there's DVT and stress ulcer prophylaxis, PRN sedation and pain medications, make sure they're on the correct abx, etc. 
5. Go on rounds - I around on trauma rounds every Monday and Thursday. It's a sad hour in my opinion, since a lot of these patients are young. However, it's a great learning experience - I listen to see what kinds of issues my preceptor brings up, and 9/10 times, her suggestions are followed through. Everyone on the team, including the head trauma surgeon, is always interested to hear my preceptor's opinion, which makes me happy :D. 


By the time I've gotten through all my patients, dealt with the issues that I found while going through the charts, and finish my teachings...it's time to go home!

And...It's a Wrap!

I haven't updated in forever! Wrapping up my last rotation, moving back to AZ, settling back into Chandler, and starting my new rotation has  all been a little crazy :). The following is what I had typed up on my last week of rotations at the clinic in North Carolina...

Day XVIII.

• Patient #1 – 65 y/o woman on HCTZ 12.5mg/day, Evista 60mg/day, and Lotrel (amlodipine/benazepril) – not sure about the dose. This was what was listed on her profile. Her blood pressure was 140/90. I asked her what her BP readings were prior to starting her medications and she said about 160/100. So, it was helping her. However, she hadn’t had her labs done since 2009, when her cholesterol was high (she refused statins at the time). She actually had a few misconceptions about statins – that they decrease good cholesterol and make people put on weight like crazy and require weekly blood draws (the latter 2 were her friend’s experiences). She said instead, she has been taking niacin everyday. She also takes vitamin D and calcium randomly, and ASA whenever she “doesn’t feel so good.” I told her that her friend may have experienced those things (maybe or maybe not from the statin), but that thousands of people do benefit from the drug. But, I also said that I won’t be making any recommendations to the doctor until her blood work was updated. I also mentioned that she should be taking a baby aspirin everyday for overall heart health.
• Patient #2 – 60 y/o woman with history of depression. She’s on alprazolam, citalopram, carvedilol, HCTZ, fish oil, multivitamin, and pravastatin. Her blood pressure was under control – 108/76, as well as her cholesterol. I also asked about over the counter medications. Now, I’ve noticed something interesting when I ask this question. Usually, when I ask, “So, what kind of OTC medications to do you take,” they’ll say none. Then, I’ll say, “So, if you ever have a headache or something, what do you take?” That’s when they’ll say either ibuprofen or Tylenol. If I ask how often, the patient will usually say once in a while, which I’m not concerned about. However, this patient, after saying “no over the counter medications” initially, ended up telling me that she does take Tylenol everyday – about 1-2g/day. Statins…liver….Tylenol…liver…I recommended getting her LFT’s checked.
• Doctor’s question – if a patient has diabetes, and renal dysfunction, and refuses insulin, what are my options? First, I asked what exactly the creatinine clearance was (42ml/min). My first response to this was – Januvia 50mg/day, need to decrease down to 25mg/day if CrCl falls below 30ml/min. Another option is Amaryl (glimepiride) – can start at 1mg/day and increase up while monitoring glucose. Also, the glitazones are an option. The patient was prescribed Januvia.

Day XIX.

• Patient #1 – talked to a patient on lisinopril/HCTZ, simvastatin 40mg/day, actonel once a month, baby aspirin, Allegra, pantoprazole, and flonase. We basically just went over all of her medications. My contribution to her health was to get a magnesium level, since I found out she had been on the pantoprazole for about a year.
• Patient #2 – 50 y/o male on amlodipine 5mg, Lipitor 20mg, flomax 0.4mg, and HCTZ 12.5mg. I recommended starting this patient on a baby aspirin, since he does have high blood pressure and cholesterol. He said he would buy some when picking up his prescriptions J.

Day XX.

• We had a patient come in to be seen – she said her job is to teach nurses and doctors about medications, etc. However, when I started talking to her, I was surprised that she did work in the health care field. Her AIC 3 month ago was 12%, her blood pressure was 190/112, and she had gained weight since the last time she was seen. She said she was taking all of her medications. When I asked her when she was taking them, she said she takes her first dose at 12pm and her second dose at 5pm (most of her medications were BID dosing). I recommended that she take her 12pm dose in the morning when she wakes up/with breakfast. Taking her medications 12 hours apart may help her. I still have my doubts about compliance, but she claims she is. Anyway, she’s coming back next week after she gets her labs done, and said she would ask for me. She may be hardcore dieting and exercising this week to get her labs to look a little better, but her AIC will tell the truth about what she’s been doing the last few months.  

Day XXI.

• Didn’t have a lot of patients come in today, but was asked about the interaction between PPIs and clopidogrel (theory is PPIs decrease effectiveness of clopidogrel, so more adverse CV events are possible). So, I looked into the COGENT trial (Clopidogrel and the Optimization of Gastrointestinal Events Trial). In this study, 3700 patients were randomly assigned to clopidogrel, ASA, omeprazole OR clopidogrel, ASA, placebo. Results – fewer patients had GI events with omeprazole (significant), and the CV events were similar with both (no significant differences). Apparently, the only real interaction is between clopidogrel and omeprazole, and the other PPIs are okay. If this comes up again in the future, I’d recommend switching to a different PPI – but if this isn’t possible, I’d bring up the results of the COGENT trial. With the results of this trial, my opinion is that omeprazole is also safe.

I’m sitting here on my last week of rotations, and just wanted to take a second to reflect on my experience here. First off, I think I had an extremely unique rotation – as I’ve said before, this clinic has never had a pharmacy personnel of any kind working here. I didn’t have a pharmacist preceptor to “second” my recommendations, so I went to the literature to double check many times. Many of the nurses hadn’t even heard of a Pharm.D. I came here with the goal of educating not only patients about their medications, but also my coworkers about the awesome-ness of pharmacy. Something that I’ve been interested in lately is collaborative practice agreements. It’s when a clinical pharmacist (nowadays, I’m sure a residency is required) and a physician sign a contract – and pharmacists can prescribe medications for certain disease states. For example, I emailed a few clinical pharmacists in North Carolina, and one in particular said she even has her DEA number and can prescribe controls and antidepressants. Anyway, basically when a patient comes into a clinic to see a physician, and that patient is diagnosed with a disease state covered by the contract (usually diabetes, hypertension, hyperlipidemia, GERD), then that patient’s care is transferred to the clinical pharmacist. From this point on, with respect to this disease state, the clinical pharmacist is in charge of prescribing that patient’s medications, writing labs, and seeing them at follow up appointments. Honestly, even if I could just do this for DM, HTN, and HLD, I’d be content. These three disease states are major risk factors for further health complications, and I would be fulfilled if I could be a part of preventing any of these complications. I’m talking to one of the pharmacists I emailed over the phone in the next few weeks to ask her questions, get her input on a few things. So, I’ll update on that as soon as that conversation is over.

As far as leaving NC and this clinic – it’s been an amazing experience. My preceptor told me she considers me as one of her daughters, the nurses said they would miss me, and the doctors said they appreciated my “pharmacy consults.” Having my Phoenix rotation canceled to make room for this one was a real blessing. With that said, I’m ready to be in a hospital again, and see how the next hospital is different from my previous hospital rotation :).

1st (non-orange) Vaccination!

I read up on collaborative practice agreements this week, and was inspired by one article in particular: http://www.ncpharmacists.org/displaycommon.cfm?an=13. I'm still on the fence about what kind of residency I want to do - acute care or ambulatory. It's weird because I was so set on acute care before rotations started. I enjoyed it and all, but I'm just not so sure anymore. I know a lot of residencies include both over the year, but it would be nice to be able to focus on just one. We'll see! Anyway, on to my week...

Day XIII.

• Older female patient on Nexium for over 2 years.
• Recs: Change medication to an H2-blocker if possible. If not possible, then patient should be taking some calcium and vitamin D supplements, and getting her magnesium level checked.
• Female with vaginal candidiasis – fluconazole best option, but currently trying to get pregnant.
• Recs: Fluconazole category C or D depending on dose and duration. If it’s a one-time 150mg dose, then category C, but still not good enough. Wait til next month to get pregnant!

Day XIV.

• Upper respiratory infection in a pregnant woman.
• Usually no treatment needed, but there are options to control symptoms for pregnant women. APAP (category B) for aches, diphenhydramine (category B) or chlorpheniramine (category B) if antihistamines are needed.
• Acute sinusitis – usual culprits are H. influenza, M. catarrhalis, and S. pneumo. Safe in pregnancy are: amoxicillin, augmentin, cefpodoxime, cefuroxime, cefdinir. AVOID: quinolones, tetracyclines, clarithromycin. If the patient has a penicillin allergy, then bactrim can be used in the 2^nd trimester or azithromycin can be used anytime during pregnancy.
• H1N1 flu – oseltamivir is safe.
• Community-acquired PNA – azithromycin + ceftriaxone (the latter if severe enough)
• Drug-drug interaction between ciprofloxacin and calcium carbonate
• Recs: Can take both, but space it out. Take cipro 2 hours before and 4 hours after the calcium carbonate.

Day XV.

• Patient came in with CC: “Side effects of medications.” And, of course I wanted to see her. She was taking Rocephin, doxycycline, and metronidazole for PID. I looked up some of the major ADRs before seeing her. Rocephin – anaphylaxis, anemia (if she was feeling tired all the time), C. dif (if she was having major diarrhea), pancreatitis (if she said she was having abdominal pain), increased liver enzymes. Doxycycline – photosensitivity, C. dif, URI symptoms, discoloration of skin, dysmenorrhea, vaginal candidiasis. Metronidazole – encephalopathy, meningitis (if she complained of neck pain), metallic taste, rash, furry tongue. When I went in, her major complaint was itchiness around the vaginal area. Maybe some candidiasis? From the doxycycline? Possibly! Anyway, she was given fluconazole 150mg once for that.

Day XVI.  I wasn’t feeling too hot today, so looked into details for ASHP midyear. The Best Western is 1.2 miles from the convention center, and 0.8 miles from Bourbon street! It’s also fairly priced – about $140 a night including taxes and fees. Plane tickets are still expensive, but I’m hoping they’ll go down soon.

Day XVII.- Vaccine day!!

• Patient came in for “med check.” She’s on Klonopin prn, vitamin D 50,000 U weekly, synthroid 50mcg qday, and levocetirizine prn. Thyroid level was fine. If it was low – would’ve asked about when she is taking it during the day. If it’s not the first thing in the morning, then I’d recommend her trying that before increasing the dose.
• Another patient, he’s actually a physician, is on 5 medications for his blood pressure, diabetes (on metformin), and CrCl of 41ml/min. He should know better!!
• Recs: D/C metformin…got asked about glyburide, but contraindicated with CrCl <50ml/min. Januvia 50mg/day is a possibility, decrease to 25mg/day if CrCl < 30ml/min. 
• When I was getting my evaluation from my preceptor, my boyfriend texted me wanting to know if the clinic had Tdap vaccines. I asked my preceptor and she said, "Of course! Tell him to come on in. Do you want to give it to him?" My first response was no (yes, I'm trained, and we had to practice with saline solutions on our classmates/oranges, but I was still nervous). Then I thought about it for a couple seconds, and figured my first real one might as well be for someone I know. I wanted the nurse to be in there with me though. So, I got a quick run-down of what I'm supposed to do and say to the patient. It's an IM injection, so in at 180 degrees. I put my gloves on, swabbed the area (upper arm), prepared the injection, pinched the skin, and went right in like a dart! Then, to make sure I didn't get an artery, I pulled out some fluid to see if there was blood in it. There wasn't, so I went ahead and injected the vaccine. The feedback I got was that it didn't hurt at all! 

Time for the 3-day weekend.
(or continue it)     :) 

Birthday Week...earthquakes, hurricanes, and cake

I'll jump right into it. 

Day VIII. I saw a few patients with one of the doctors during the first half of the day. Most of them were on antidepressants and antipsychotics, and psych medications are something I need to work on. Needless to say, I didn’t have too much input. However, one of the patients was on Paxil and was having trouble sleeping, so she was recommended from someone to take it at night. I brought this up again a few minutes later, and explained to her that it’s recommended to take the Paxil in the morning in order to get the effect during the day. The doctor seconded this as well, and added that she may not be sleeping well d/t not having the medication for the last week. So, I mostly listened to the doc’s recommendations regarding the prescription medications, and jumped in to ask about OTC products. Other than that, I’ve noticed a lot of patients here talk about having fibromyalgia, which I don’t know a lot about, so I read the Up To Date page for it.

• Fibromyalgia – unexplained chronic pain. In 2009, duloxetine (start with 20mg in AM, up to 60mg qday), milnacipran (start with 12.5mg x1, then BID x2 days, then 25mg BID x4days, then 50mg BID maintenance), and pregabalin (75mg BID) were the three medications approved for treatment of this disease. Some other TCA’s, SSRI’s, and SNRI’s have also been used. For patients with sleep issues on top of fibromyalgia, pregabalin or gabapentin is preferred, and for patients with exhaustion issues, duloxetine or milnacipran at breakfast is recommended. If going with a TCA, then amitriptyline 5-10mg starting is appropriate. TCAs, in general, may not be okay for the elderly d/t anticholinergic side effects (dry mouth, constipation, fluid retention, etc.). If contraindicated for a specific patient, then desipramine could be considered – it’s still a TCA, but with fewer anticholinergic effects. Some people believe fibromyalgia is a “bs” diagnosis…just putting together any unexplained chronic pain under an umbrella term.

Some things I learned (or relearned) today…

• The ACEI cough is not dose-dependent, and the onset can be from after the first dose all the way til months after therapy started (from CHEST)
• Birth control and antibiotics – makes birth control less effective, so always educate the patient about being extra careful, or using an extra form of protection while on the antibiotics.
• 5ml = 1 teaspoon – I know, I know…I should know this…
• Took some blood pressure readings – never quite got the hang of it, but practice makes perfect. I know pharmacists don’t generally take BP readings, but what’s the harm in having an extra skill?

Day IX. My Birthday!! The big 2-3 today, and also my golden birthday :). I got to work earlier, and brought a chocolate cheesecake! And then I went back to the kitchen where I found this amazing looking cake, made by my preceptor (pictured!). 

Amazingness!

And of course after I stopped taking pictures of the cake, I got to work ;). I took a look at the charts this morning, and noticed two patients were coming in for impacted cerumen and also iron deficiency, so I thought I’d look into the treatments for these.

• Impacted cerumen (ear wax) – this may be useful for community pharmacists especially. The causes are usually some kind of obstruction, narrowing of the ear canal, or cerumen overproduction. Treatments usually include cerumenolytics like mineral oil or hydrogen peroxide (the latter not generally for dry, irritated ears). If the cerumen has hardened, then carbamide peroxide (Debrox) is a good choice. Sig is 5-10 drops BID in the affected ear (tilt head for 3-5 minutes with a cotton ball in ear). This should be limited to 4 days, since a longer duration has shown to cause infection, irritation, or rash. Also, don’t recommend ear candling – AKA holding a narrow tube close to the opening of your ear with a flame at the other end. Ear wax = candle wax? Maybe, but let’s not get too carried away now.
• PO iron supplements – absorption of iron may be affected by anatacids (take 2 hours before or 4 hours after), quinolones, tetracycline, and general breakfast foods. It’s best absorbed as the ferrous salt in an acidic environment – maybe some ascorbic acid…OJ please!
• Ferrous fumarate – 106mg elemental iron in a 325mg tablet
• Ferrous sulfate – 65mg elemental iron in a 325mg tablet – cheapest
• Ferrous gluconate – 38mg elemental iron in a 325mg tablet
• So, iron content-wise: F>S>G…Forrest Shrimp Gump, or if you’re a fan of Pixar, then Fiona Shrek Gingerbread man. Take your pick! 

For iron deficiency anemia, 150-200mg elemental iron is recommended daily. For older adults, 10ml of ferrous sulfate elixir in a class of OJ should do the trick everyday. Results regarding improved feeling/energy should be seen in a week or so. Half of the Hgb deficit should be replenished in about a month, and then normal Hgb by 6-8 weeks. The duration of therapy varies between practitioners – some stopping therapy after Hgb is normal, others continuing it for 6 months. Also, iron can be used to treat pica – those who eat non-food items. Sometimes, this is due to iron deficiency, so they tend to eat things that contain iron. The following is a picture of what they found in a person’s body with pica. If a patient has pica d/t iron deficiency, then iron therapy should work quickly to treat this disease. 

Contents of someone's stomach with pica

 

 Day X. Day after my birthday…not as exciting, but there was still cheesecake and cake left over ;). We had a patient come in today wanting more Ambien for sleep. She started off with just 1 pill a week, and now is up to 3 pills a week. It’s not recommended to take this long-term, so we discussed some alternatives with her. We ended up putting her on trazodone – since it’s shown to be okay long-term, it’s not too expensive, and there’s low abuse potential. She was a little bit resistant at first, but left willing to try it out. As for sleep medications in general…

• Benzos – triazolam is short acting, and flurazepam and quazepam are long acting (others are intermediate).
• The “Z’s” – Zaleplon is good for sleep initiation since it’s short acting, zolpidem is also good for sleep initiation, and zolpidem ER & eszopiclone are for sleep maintenance. The latter two are brand only.
• Ramelteon – is a melatonin agonist (brand only) and is good for sleep initiation. It’s the only sedative-hypnotic that isn’t controlled. 8mg PO QHS.
• Antidepressants – amitriptyline 5-10mg at night, trazodone 50mg at night, and doxepin 3-6 mg at night (longer acting).

Day XI. We got a call today from one of our patients about whether or not she can use the Miacalcin (calcitonin-salmon) Nasal Spray that she got in the mail. It’s supposed to be refrigerated prior to opening, and then after opening, it can be in room temperature for 35 days. She had been receiving the Miacalcin via mail order, but it’s always been sent with an ice pack or something. This time, however, it wasn’t chilled. The question is…can she still use it? She emailed the company, and the response she received was something along the following, “The product must be refrigerated prior to opening. There was a study done by Rutgers in 2002 that showed that Miacalcin Nasal Spray retained its potency even in 40’C (about 104’F) for 3 days, so that her product should be fine.” Doesn’t the latter sentence kinda contraindicate the first one? Anyway, so I pulled up the study, and sure enough…the researchers studied 55 vials of Miacalcin Nasal Spray in 20’C, 40’C, and 60’C for 3 days. The vials in the first two temperatures retained about 97-99% of the potency (60’C was too hot, however). The patient also asked her pharmacist and he said that the manufacturers send the product without ice packs, so it should be okay. I actually called the manufacturer myself and asked them about it. She said she’d have to call me back after discussing it with the shipping department. So what she found out was that they do send it to pharmacies without ice packs, but it’s overnight shipping, and they expect the pharmacies to refrigerate the product right away. She said she can’t say anything about the mail order company, since it’s not as controlled – we don’t know if it was an overnight shipment, how long it was sitting outside of the patient’s house, whether or not she put it in the refrigerator right after, etc. My opinion on this issue was that if she found it on her door step in the morning, and put it in the fridge right after…then it’s fine to take.

Day XII. Spent most of the day looking into residency programs…I’m thinking North Carolina and some of the surrounding states, California possibly, and Florida. Maybe Chicago and Michigan, but I don’t know about the weather. One of the doctors is off today, and the other one I usually work with has a half day, so today will be fairly slow! Anyway, a lot of weird things have been happening lately, like an unexpected earthquake in Virginia (aftershocks felt in NC), and also a huge hurricane warning…Hurricane Irene. I don’t know if it’s just me, but it seems like more people have been coming in this week about their anxiety. So the point is I was asked a lot of unexpected questions about anxiety today that I didn’t know the answers to. So, of course, I read about it in hopes that I’ll be more prepared next time.

• First line: SSRI’s (paroxetine, sertraline, citalopram, and escitalopram studied…but others used too) and SNRI’s. Studies have shown that these medications work for 6 months, but clinical experience has shown much longer. So, I’ve listed a few interesting characteristics about some of these antidepressants used for anxiety. Now THIS is the stuff we need to memorize. You know that drugs like paroxetine, sertraline, and citalopram are SSRIs? Good for you. You know that SSRIs increase serotonin levels in the synaptic cleft? Good for you. Being able to recall the following information when making recommendations is where the money is at…this is how pharmacists can be seen as knowledge workers.
• Fluoxetine – long half life, no tapering off necessary, but also takes a while to see effects.
• Paroxetine – some week anticholinergic effects (from my previous post, this is also the SSRI associated with weight gain), and most notorious for sexual dysfunction of the SSRIs.
• Sertraline – GI symptoms have been seen.
• Venlafaxine – some GI symptoms, may increase BP at 100-300mg/day doses
• Duloxetine – good for when patient also has diabetic neuropathy.
• Mirtazapine (different class of antidepressant) – less sexual dysfunction, increased weight associated.

It’s these little differences that are good to know – then you are able to help guide individualized therapy.  With respect to duloxetine and venlafaxine (SNRIs), the common side effects include nausea, dizziness, insomnia, sedation, constipation, and sweating.

• Second line – TCAs. Imipramine is a TCA that has been shown to be efficacious for anxiety. However, TCAs are generally chosen as second line due to the cardiotoxic and anticholinergic effects seen with TCAs.
• Second line – Benzos. Short term benzo use is fine, but long-term is not recommended d/t dependence issues. If a patient is not responding to antidepressants, and benzos are working – then long term use can be considered IF they can maintain a low dose over time. However, if they are increasing their dose, then that could be a sign of tolerance (and long term use is contraindicated). Generally, benzos have a faster onset than antidepressants.
• Second line – buspirone. A few things about this medication – time to onset is about 4 weeks, much like the antidepressants, and has a weaker anxiolytic effect than the benzos. I would recommend trying this if the above classes don’t work.
• Second line – pregabalin. It’s approved for anxiety in Europe, but not in the US (yet?). Dependence is possible with this medication, but to a lesser extent than the benzos.
• Others to try if absolutely nothing seems to help: quetiapine, tiagabine, hydroxyzine.

Overall this week was interesting! I mean, with an earthquake on your birthday and a hurricane on its way, that's kind of an understatement.

Fake it 'til ya make it

I’m happy to say that I had a fulfilling week.

Day V (Wednesday):

• Pt. #1 was a newly diagnosed diabetic, and I was asked to be at the counseling session not only for his diabetic medications, but also his others. His medications included: losartan/HCTZ, ASA 81, Vitamind D, MVI, Simvastatin 40mg/ amlodipine 5mg, Jalyn (dunasteride and tamsulosin), fish oil, starting metformin (500mg once a day). The question I was asked was when to take metformin. My answer was that the important thing is to take it with food, so it can be taken whenever you’re used to taking your other medications, as long as it’s with food. He also asked about some stomach upset he was experiencing after taking his metformin, but also after eating some nice fried chicken. I wanted to find out if he experienced the GI symptoms any other time he had taken the metformin (since it is a common ADR), and he said no. So, my thoughts were that it may not have been the metformin, and to continue taking it. I was asked, from his wife, about changes in the ability to taste with warfarin. I had NO idea, but my reply was, “I haven’t heard of that side effect specifically, but it may be a rare one that researchers found in their studies.”
• So this is what inspired the title of this post. As upcoming new, young Pharm.D’s (or any field for that matter), it may be a challenge to gain respect from patients d/t lack of experience. The second you show a slight bit of uncertainty in your response, you’ve lost their confidence in you. And I don’t mean you always have to have an answer, or make up anything (definitely not the latter). Either respond confidently if you DO know the answer or confidently say, “I learned that in pharmacy school, but would like to brush up on the details before giving you an answer.” The problem that I have is if I actually do know an answer to a question, I feel like I need to know exactly which study showed that conclusion (which I don’t usually know), so that prevents me from sounding confident. Just say what you learned with confidence, even if you don’t feel 100% confident – it comes with practice, and you KNOW this stuff. I’ve used some from of the word “confident” about 6 times in this paragraph – just trying to drive home a point.
• Patient #2 wanted to go over her medications – Lipitor, PPI, DM medications, metroprolol, temazepam PRN, losartan. Her chief complain was being tired all the time and muscle pain. Her Lipitor was going to be D/C’d, so I explained that this will help with the muscle pain. I also told the doctor later that losartan has been shown to be associated with myopathy…and that may be something to consider if she shows up with her next appointment with the same complaint. This patient was 90 y/o, so I wanted to know if she knew her S/S of hypoglycemia to prevent a devastating fall. She also told me about some arthritic pain in her joints and that she takes Tylenol for that. I explained the difference between NSAIDs and Tylenol as far as anti-inflammatory properties are concerned, so hopefully this will help her pain a little bit.
• Some of the patients have specialists who change their medications around for one reason or another, and the family doctor here was just wondering the reason behind some of the changes. For the first one – the specialist had changed a patient’s sertraline to another antidepressant d/t risk of bleeding. I hadn’t heard of this before, and didn’t have much information about the patient, but apparently SSRIs have an anti-platelet effect. So, I thought this might be the cause of this change. The other one – a patient was on Multaq, Wellbutrin, and metroprolol. I did a drug-interactions check on these three before, and didn’t see anything major, except for the possibility of increased metoprolol levels in the body d/t hepatic enzyme inhibition. Well, turns out that he eventually got switched to atenolol, and it’s likely because atenolol is not hepatically metabolized!

Day VI.

• Patient #1. She had triglycerides > 1200. She was on Tricor (fenofibrate) last year, and decided to stop taking her medication. I did some research on fibrates for cholesterol, and here’s what I learned:
• Fenofibrate and gemfibrozil can decrease TGs by 20-50%. Gemfibrozil increases muscle toxicity if given concomitantly with a statin, but fenofibrate does not. (As a side note, pravastatin, fluvastatin, and rosuvastatin are not metabolized by CYP3A4). Dose for Tricor is 54-160mg once a day, and gemfibrozil is 600mg BID. Both must be taken 30 minutes before meals to have the maximum effect.

              Anyway, I was consistent with the open-ended questions, and finally got out of her that she takes all of her medications every other day (Thanks Drs. Apgar and Herrier). So we discussed her concerns, and how high doses and overdoses of medications are the things usually associated with kidney and liver dysfunction, and not the doses she was on.

• Pt. #2 – only issue with him was lots of hypoglycemic events with his diabetes. My first question to the doctor was whether the patient was whether the patient was on a sulfonylurea, which he wasn’t sure about. So we go in to see the patient, and he’s on glimepiride BID (which is odd). We switch him over to once a day dosing, and all eyes are on me when asked what time he should take it during the day. I say (with confidence, continuing with this post’s theme) “I would like you to take it in the morning with your first meal…” which is actually something I had looked up a couple days ago.

I also looked into a few things for the doctors today, which was beneficial for both of us…

• She wanted a refresher on the potency of the different IM steroid injections. Low potency: cortisone and hydrocortisone. Intermediate potency: methylprednisone, prednisolone, prednisone, triamcinolone. High potency: betamethasone and dexamethasone. The more soluble a drug is, the shorter acting it is. The more insoluble, the longer acting – but also associated with more irritation. Sometimes, a clinician will want to have a mixture of long and short acting to get the benefit of the longer acting steroid but with less irritation.
• I also looked into twice a week statin dosing for patients who need the drug but can’t tolerate it everyday. There was a study published in the American Journal of Cardiology in 2008 that looked at Crestor twice weekly. There was improvement over 8 weeks with twice a week dosing, regardless of whether or not the patients were taking baseline anticholesterol medications from different classes. Crestor and Lipitor have been looked into for less frequent dosing d/t their long half lives (19 hours and 14 hours, respectively). However, my question is why not pravastatin? Its half life is 77 hours.
• Weight gain associated with SSRIs. According to UpToDate, fluoxetine is the most notorious for this, and paroxetine is the least associated with weight gain.
• Going back to the beta blocker discussion from the previous post, some BBs have ISA (intrinsic sympathomimetic activity) – both agonist and antagonist at the beta adrenergic receptors. This allows these beta blockers to be indicated for excessive bradycardia – pindolol, penbutolol, and acebutolol.

Day VII.

• Pt. #1. 59 y/o male comes in with hypertension and elevated triglycerides (400), history of drinking, and gout. Medications include: lisinopril, ASA 81mg BID, OTC niacin, simvastatin 80mg, colchicine QOD. He was in for his elevated triglycerides and muscle pain. Now let me warn you – I wasn’t too happy with all the recommendations I gave or didn’t give for this patient after he had already left. First of all, of course his simvastatin dose had to be decreased to 40mg d/t FDA regulations, so that’s fine. He was taking his colchicine every other day d/t muscle pain – this helped with the muscle pain and still controlled the gout flare ups. With respect to this, the muscle pain could have been just the statin or a combination of both of these drugs, it’s hard to tell. So we’re just going to see how he does on the QOD colchicine and lowered statin dose. ALSO, speaking of colchicine, the patient mentioned that Colcrys was fairly expensive, so the doctor said it came as a generic and seconded that with me. So right on the spot, I wanted to check the price difference between the two…and they both came out to the same $$. Consequently, I googled it (I love my iPhone!), and turns out the generic colchicine oral tablets were stopped in 2009 so the company could have exclusive marketing with Colcrys for 3 years! While the doctor did his examination, I asked if he took any OTC pain medications – just Aleve (I wanted to make sure he wasn’t taking APAP d/t his drinking issues). When asked what I thought of Niaspan vs. Tricor for his elevated TGs, I said both are good drugs for elevated TGs, but Tricor has been associated with a great drop in TG levels. The doctor still wanted to go with Niaspan, however. In retrospect, I would’ve stated the actual %decrease in TGs with both these drugs (15-25% with Niaspan and 20-50% with Tricor). At least I know this now though! Then we got to his ASA 81mg BID regimen. He had no history of an MI or stents, so we recommended going back down to 81mg a day. In retrospect, I wish I had recommended 325mg ASA before the niacin – to kill two birds with one stone. I didn’t though, but will pay more attention to this next time.
• I was also asked to counsel a patient with a PhD in pharmacology – haha. It actually went well though, and I could answer his questions. He was wondering when to take Synthroid, and why he had to take it at a certain time. I explained that the absorption of Synthroid is fairly erratic (40-80%), and that taking it with food may decrease the absorption even more. So, I recommended taking it right when he woke up, 30 minutes before breakfast. Also, if a patient were also taking calcium and iron, then I’d recommend separating these two from the Synthroid by about 2 hours.
• Another thing I was asked to look up was sexual dysfunction with lisinopril/HCTZ combo. A few of the doctor’s patients actually complained about this side effect when put on this medication. This ADR, I believe, is attributed to the HCTZ.

Here’s me, ready for another week!

First, and Second, Impressions

I got spoiled with CPRS and Vista – the two computer programs used in the VA hospital system. I didn’t realize it then, but they are amazing! Anyone with access to patient information can get a patient’s lab values, current medications, outpatient medications…and can go back years and years. It’s a great system for excellent communication between nurses, doctors, pharmacists, and specialists. Okay I’m getting to my point…so I walk into my current rotation site for the first time last week (I’m at an outpatient clinic). I get my login username and password and sit down at my computer, ready review charts. I log in, and the only thing my log in is good for is to get the schedule of patients for the day. Where do I find all the labs? What about the medications and past medical history and chief complaint??

…Ten minutes later, you would’ve found me sitting about ten feet away from my computer, physically flipping through papers to find all this information. I know paper charts are the norm in most outpatient clinics, but after being at the VA for three months (and as my first clinical experience), it just seemed so archaic to me. I guess this was my first experience with “culture shock.” So in a nutshell, I’m really liking this place…I’m learning a lot in general – not just about pharmacy, but about adjusting to different perceptions and settings in the health care world. I’m also learning about myself – things I like and dislike (and am working on changing!). To organize this a little bit, I’ll discuss my first 4 days (which includes today) at my new rotation site.

Day 1. I walked into the clinic at 8:00. I was introduced to everyone else (who already knew a pharmacy student from AZ was coming!), and took a tour of the clinic – which is a beautiful facility, complete with a decked out kitchen/gym/dance room (!)/patient rooms/offices. Then I sit down in one of the offices, and talk to the nurses for a little bit. Some of the first questions I was asked, which caught me off guard – “So, what exactly are they going to have you do here? You know, we take the medication histories as nurses, and don’t really need a pharmacist.” And after I talked about how I was certified to give immunizations, they turn to each other and say, “I can’t believe they’re having pharmacists stick people.” At this point, I’m feeling a little uneasy since they have no clue what I’ll be doing for the next 6 weeks, and some slight negativity toward pharmacy. 12:00pm rolls around, and I still haven’t met my preceptor. She is THE nicest lady in the world, and just didn’t realize I was there already. Anyway, my first task for the day was to go to the airport with the doctor and give a combined talk about women’s health to a group of women. Uhhh, our women’s health lecture was a year ago, and all I remembered was that progestin requires an intact uterus, oh and estrogen = breast cancer? Needless to say, I researched as much as I could for the hour I had. I looked up a few things I thought I’d be asked about…

• The HCG diet – HCG is a hormone that is released during pregnancy that allows fat stores be available for energy use. So, with a couple drops of this per day (with the restricted 500 calorie/day diet), you’re using up those calories quickly and then getting into your fat stores even more quickly with the help of the HCG. With this diet, they claim you lose 1-2 lbs a day (comes in 26 or 40 day kits).
• Osteoporosis – nonpharmacologic therapy includes diet with calcium and vitamin D, exercise, stop smoking, **long term glucocorticoid and PPI use**. Basic drug therapy would be bisphosphonates – risedronate 5mg/day, 35mg/weekly, or 150mg/month. Another option is alendronate 10mg/day or 70mg/weekly. Another class of drugs is raloxifene, which has a decreased risk of breast CA compared to estrogen, but an increased thrombus risk. Important counseling point with bisphosphonates is to stand up for 30 minutes after taking the oral form.
• Post menopause – Estrogen is an option, but with the risk of breast CA down the road, coronary heart disease, previous thrombotic events, stroke. The Women’s Health Initiative study is what is often cited with respect to this topic. If hormone therapy is started, the lowest possible and effective dose should be used. After 2-3 years, see if the patient can D/C it (40-50% stop therapy in one year, 65-75% stop in within 2 years).
• And that’s about all I got to J. Not a lot, but when I got to the conference, I found myself able to answer a lot of the questions the women asked. Some asked about diabetes control (I discussed goal levels, different types of insulin and oral medications), best OTC medication for pain (NSAIDs having the anti-inflammatory effect unlike APAP, maximum doses, underlying kidney/liver dysfunction, history of gastric ulcers, etc.), and other questions. I had a great time!

When I got back to the clinic, I was back to sitting at my desk. I was given a couple of patients to look over, but didn’t get to talk to any patients about their medications. As I was going through the patient med lists, I realized there were a lot of brand names that I didn’t know, especially considering I didn’t work through pharmacy school. Some I learned include (and I’m including this, since the NAPLEX doesn’t differentiate between brand and generic names now):

• Nuvigil (armodafinil) – for narcolepsy
• Savella (milnacipran) – fibromyalgia
• Mirapex (pramipexole) – RLS
• Lyrica (pregabalin) – fibromyalgia
• Paxil (paroxetine) – depression
• Cymbalta (duloxetine) – depression, fibromyalgia, anxiety

The rest of the day was spent looking things up, and just waiting til 5:00pm, honestly.

Day II. If I thought the day before was slow, boy was I in for a treat on Day II. Let’s just say my phone was charged 100% at 9:00am, and by 2:00pm I was at 0%. After the first couple hours though, I told myself I would make the best use of my time, and to be thankful for any down time at all. I also reminded myself that my experience will be what I make it, and that they had never had a pharmacy student before, so I had to be proactive about things. I told myself I would make the best of the day, and tell them exactly what I wanted to do the next week. What does making the ‘best of the day’ mean to me?

• Looking up all the residency programs that I’d be interested in North Carolina. My preceptor said she knows a lot of the hospital pharmacists here, and would take me to see them personally, so I decided to make a list of the pharmacists who do take students in for residencies.
• Matched AIC levels to average glucose levels – for example, if a patient’s AIC is 6%, then his/her average glucose was 120 for the last 3 months. As the AIC level goes up in increments of 1%, the glucose goes up by 30’s…7% ~ 150, 8% ~ 180, etc.
• Read the news!

I’m the type of person who likes to feel useful and have a purpose. To be honest, this isn’t exactly what I was feeling at this point, so I felt a little bit defeated at the end of the day. However, I also went into Day II with a negative mindset. So, I talked to the doctors about how I would like to see the patients with them, and have their medication list before-hand so I can make any relevant drug therapy recommendations. I also discussed how in pharmacy school, we’re trained to read and evaluate the literature, and make evidence-based recommendations, so to use that for the 5-6 weeks that I’m here. In response, one of the doctors said, “okay, let’s plan then,” and pulled up his patient list for Monday. If you’re proactive, others around you will notice and reciprocate.

Day III. I went into work on Monday with a good feeling. I got to my desk, put on my white coat, set up my laptop, and went up to the front desk to ask for specific patient charts. I wasn’t told to do this, or really given formal permission, but I started setting up my own morning routine.

• Patient #1. 65 y/o male with PMH of hyperlipidemia, CKDIII, uncontrolled diabetes, hypertension, 8 stents, possible CHF (he hadn’t been to use cardiologist in about 4 years). His CC was his DM, and the need for more test strips. Medications included: simvastatin 80mg (just increased in May), Novolin 70/30, lisinopril/HCTZ 20/12/5 BID, amlodipine 10mg, ASA 325BID, plavix 75mg, coreg 25mg BID, lasix 80mg qday, vitamin C. He is extremely noncompliant, always making excuses for not eating well and exercising, money is very tight (only takes plavix when he can afford it).
• My recommendations: Decrease his simvastatin to 20mg/day…which is consistent with the new FDA guidelines from June that state max dose of simvastatin is 20mg/day if also on amlodipine. I suggested this only after checking his lipid panel and seeing that it was fairly well controlled: TC – 168, TG – 165, LDL – 93, HDL – 43. Also, his ASA dose was weird, but I wanted to see if there was a valid reason for this dose. I asked him if he takes ASA, and he said he took 325 BID. After that, I asked him if any of his doctors recommended this specific dose, and his response was that he wasn’t sure but he’s been doing it for years. I mentioned this to his doctor, and we both decided that he may be compensating for not taking his Plavix regularly. Considering this patient’s situation, compliance history, and unwillingness to cooperate (myself and the manager of the clinic/CDE tried talking to him for 2 hours today), we decided not to change anything except for his insulin and simvastatin dose.
• Patient #2, I don’t have her medications written down, but it was a 1 on 1 session. The doctor was changing a few of her medications, and wanted some clarification as to why. She was a diabetic patient taking HCTZ for her HTN. She noticed that every time she took HCTZ, her blood sugars would go up, and if she stopped the diuretic then she’d experience edema. So, I explained that a side effect of HCTZ in some patients is the elevated blood glucose, and that she would be switched to another HTN drug. We also went over her inhaler technique (with spacer) and any other questions she had.

I looked up a few things today…a patient came in saying that his blood sugars are always high in the morning. I was asked to explain the Somogyi and Dawn effects to the patient, but I had to admit I had no clue what these were. But, if asked again, I could totally do it J

• Dawn Phenomenon: elevated growth hormone, catecholamines, cortisol released in the early morning for everyone in response to lower glucose levels in the body than usual. This is okay for non-diabetics, but for diabetic patients who don’t have enough insulin, this could lead to hyperglycemia…enough to block the effects of the last dose of insulin. Some recommendations could be to decrease carbs at night time or eat in the morning to turn off the hormone cycle.
• Somogyi Effect: This usually happens post long-acting insulin – when it’s working too strongly at the wrong time. So, the hormones in the body could detect low sugars and kick in to signal the liver to release glucose. A way to differentiate between the two is to check sugars at 2-3am. If blood sugar is high, then it’s a Dawn Phenomenon, if it’s low, then it’s due to the Somogyi effect.

I also got asked for my starting dose of gabapentin for DM neuropathy. I said 300mg a day and titrate up to TID if renal function is okay, and that the max dose is 3600mg/day. And that’s how I ended my Monday!

Day IV: Came in, looked up the patients!

• Patient #1: 80y/o male with GERD, HTN, HLD, BPH, Depression. His medications: ranitidine 150mg qday, fenofibrate 160mg qday, pantoprazole 40mg qday, citalopram 20mg qday, flomax 0.4mg qday, metoprolol ER 50mg qday.
• My recommendations: If his GERD symptoms aren’t severe, then stop the pantoprazole and continue the ranitidine. Add back the PPI if absolutely necessary. If his BPH sx aren’t better, then consider changing the flomax to terazosin or prazosin…this actually ended up being the case. That was all for him – his BP was great (128/84), cholesterol was fine.
• Patient #2: 60 y/o female with HTN, HLD, and renal issues. Medications include Toprol XL 100mg, simvastatin 40mg, and amlodipine 2.5mg.
• My recommendations included decreasing the simvastatin dose to 20mg d/t the amlodipine. Also, she mentioned that she would sometimes feel her ankles swelling up, but it would go away and wasn’t painful – and I attributed this to the CCB which acts by peripheral vasodilation.

I also looked up things I’ve been meaning to look into again…

• Selective beta blockers: metoprolol, esmolol, bisoprolol, atenolol. Nonselective beta blockers: propranolol, timolol, nadolol. Beta and alpha blockers: carvedilol, labetolol
• If using simvastatin with verapamil, diltiazem, and amiodarone, the maximum simva dose is 10mg. If using simvastatin with amlodipine and ranolazine, the max simva dose is 20mg.
• Simvastatin 80 mg = rosuvastatin 10mg, atorvastatin 40mg

All in all, I do feel like I’m getting something from this rotation site and am happy I’m here. I’m also glad that I waited a few days to write about this site. This post would have been completely different if I had based it on my first impressions.