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.