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!