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.