"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 :).