Rules of 7

I realise than there is a lot of things about medicine involves the number 7.

The "SEVEN" rules
1. Combined oral contraceptive pills : Take 7 active pills to get covered
2. Head lice treatment : Repeat after 7 days ( 1 week)
3. Scabies : Repeat after 7 days
4. Most antifungal products : Continue using for 1 or 2 weeks ( 7 to 14 days) after the symptoms have ceased.
5. Lamisil® AT Spray direction: once a day for 7 days

I think there are more, but I can't remember at this stage.

fungal infection

Fungal infection is one of the very common infection that you will find in community.

Different fungal infection on different part of the body is given a different name.

The medicine Box

I have not been updating the blog for a LOOOOONG LOOONG time. I have been lazy..

Anyway, when i was an intern, I found a very useful website. It has sample questions for intern exam, a lot of case studies and study notes as well.


THE MEDICINE BOX

Registration is free!!!

Statin drugs : update

Changes for statin drugs ( cholesterol lowering drug)

In late February 2012, the U.S.Food and Drug Administration (FDA) approved safety label changes for statin drugs. In summary,  the FDA changes are as follows:

1. Monitoring Liver Enzymes

Removal of the need for periodic monitoring of liver enzymes. Liver enzyme tests should now be performed before commencing statins and as clinically indicated thereafter, due to the rare and unpredictable nature of serious liver injury with statins.

 

2 Adverse Event Information

Addition of information about the potential for :

 

A)Cognitive adverse events

The FDA report suggests that rare post-marketing reports of cognitive impairment have been made, including reports of memory loss, forgetfulness, amnesia and confusion, associated with statin use. These are generally non-serious and reversible

 

**I have heard of the memory loss experience from a customer .**

 

B) Increases in glycosylated haemoglobin (HbA1c) and fasting plasma glucose

 

 

 

 

 

The Australian Therapeutics Goods Administration (TGA) is currently reviewing the evidence for these safety-related changes and will update the Product Information for these medicines where necessary.

 

 

Reference: RGH Pharmacy E-Bulletin Volume 45 (12): April 16, 2012

Label

Some people claim that pharmacists are label stickers..

Well, it is true. Labels sticking is part of our job. I never understand how the label that I printed out from UniSA works until I started my placement..

So, I am going to explain a little bit about different "sections" of a label and where should they go.

Please note that different dispensing software produce different labels. The one that I am showing is the Amfac Healthlink label. I will talk about Minfos label next time.

In some pharmacies, they place the barcodes to the customer slip. They are scanned when the customers bring their items to the cashier.

Safety net stickers are given to the customer to be placed onto their safety net record card to keep track how much they have spent in a year. Once they have reached the threshold, they get their medication at a lower price.

More detail about safety net, please check the medicare website. Be rewarded! Join RewardsCentral today!

An Overview on OTC topics

This is a very brief overview on the common OTC topics for counselling.

This is the little human I drew in preparation for my intern final exam.

Detailed information on each topic will be posted soon...

Oh no, I missed out a few things : fever, ear wax, otitis media, otitis externa, nausea, travel sickness, morning after pill

Random stories - counselling 2

Continued from random stories- counselling 1


1. Suppositories
    Someone has used it without unwrapping the foil.

2. Spiriva
    The common story : People swallow the capsule.

3. Suppositories ( use of slang)
" Stuck this to your back door every night"
Case: a pharmacist used the phrase" back door" (which refer to rectum ) while
counselling on a patient on the use of suppositories
Result : The patient did exactly what he/she was told. The suppository was placed at
the back door every night. ( I mean the real DOOR)


These examples clearly illustrate the importance of GOOD counselling to ensure that patient understand how to use their medication properly.

Random Stories - counselling 1

Many students might wonder why their tutors/lecturers get so fussy when it comes to counselling or instruction written on the labels. Read the stories below and you will understand why.

1. Antibiotic syrup ( for child)
  "Give 5ml (by metric measure) twice a day until finished "
   This antibiotic was indicated for treat ear infection.
   Result : The parent placed the syrup into the child's ear twice a day.
   Lesson : Always remind them to give it by mouth.

2. Inhaler
    Due to poor understanding on the device, some patients :
    - spray onto their armpits like using deodorant
    - spray to the air, and inhale/sniff the medication with their nose

3. GTN spray
   - indication: for angina, when experience chest pain
  - result: someone spray the medication onto the chest to relieve the pain.

4. Bisphosphonate
   " Remain upright for at least 30 minutes after swallowing the tablet"
   Result : Patient's comment, " I hate taking this. I need to stand up for at least half an
   hour in the morning after taking the tablet."
    Upright was misinterpreted as "standing".


More examples, see random stories- counselling 2

Spacer

Why should I use a spacer?

More medication gets into your lungs than if you use a puffer on its own.

Reduce the local side effects of inhaled steroids in preventer medications (because less of the medication sticks in your mouth and throat)

Don't need to coordinate pressing your puffer and breathing in at the same time

Reliever medication via a spacer is at least as effective as via a nebuliser in an asthma attack

Type of spacer

There are a range of spacers available, in different shapes, sizes and colours. There are two main differences: large volume and small volume.

Large volume spacers are an oval shape, and are bigger. One of the most common ones is the Volumatic spacer. These should be used only for adults or children over five years old, as younger children aren’t able to take deep enough breaths to empty the spacer out.

Small volume spacers are usually shaped more like a tube, or a cone. They are more convenient because they are smaller and so fit into handbags and schoolbags more easily. Children under five should use a small volume spacer. Many older children and adults also use small volume spacers because they are more portable.

How to use spacer

How to help your child to use a spacer device

Extra tips for use of spacer

When educating a patient who is new to spacer or puffer, I would say "fire" a few puff of your medication into your new spacer before use ( to coat a layer around it before use).

In cases where the puffer is new as well, instead of priming ( wasting a few puffs to ensure that the medication is loaded properly) in the air, I encourage the patient to prime it into the spacer.

When to clean my spacer?

- Wash it the first time before you use a new spacer and every MONTH thereafter.

How to clean my spacer?

- Take the spacer apart and soak it in clean warm water with dishwashing detergent. DO NOT PUT YOUR HAND INSIDE TO WASH IT .
 - Let it air dry or dip dry.  Don’t rinse the bubbles off it or wipe it, .
   (The residue of the bubbles from the detergent puts a coating on the inside of the spacer/ acting as a surfactant. This stops the creation of static electricity inside, which can make the medication stick to the sides of the spacer instead of travelling through it when breathed in.)
 - Some spacers have a removable valve (a piece of rubber that you can take out and wash separately).

Tips for Tilade or Intal users

If you are using Tilade or Intal ( types of preventer medication) you should wash your spacer more frequently. These medications are quite sticky, and build up faster than other medications.

When should I replace my spacer?

Replace your spacer about every 12 months if you use it every day. If it breaks or cracks, get a new one straight away.


Other related devices:
turbuhaler, accuhaler, MDI inhaler/puffer, Handihaler, nebuliser

Reference:
www.asthmafoundation.org.au

accuhaler

ACCUHALER

Other devices

Handihaler, Turbuhaler, MDI inhaler/puffer, nebuliser, spacer

Handihaler

There are many inhalation devices available in the market for asthma control. This type of administration method aims to deposit most of the drug molecules in the lung. However, it is not uncommon to see patients with poor technique, causing most of the medication to deposit behind the throat instead of reaching the lungs.

Therefore, it is important to understand how to use each device in order to achieve the best result.

Handihaler

When counselling, remember to tell the patients ; DO NOT SWALLOW THE CAPSULE, I have heard story where patient swallowed the capsule. ( Funny, but this also tells us the patient has not been educated properly on the correct method to use the devices.)

Other important counselling point
1. Always throw away the empty capsule after use.
2. Press the button to create a hole on the capsule before you inhale the content.

Other devices : Accuhaler, puffer/MDI inhaler, nebuliser, turbuhaler, spacer

Byetta

Byetta is increasingly popular among the prescribers ever since it is listed under PBS.

It is important to know how to use the Byetta pen.

The differences between byetta and normal insulin

1. Byetta must be kept in the fridge after each use. Insulin pen can be kept at room temperature for 28 days.

2. Byetta pen comes with a fixed dose/instruction. It is available in 5mcg or 10 mcg, to be injected twice daily within 1 hour before breakfast and dinner. Insulin dose varies according to individual's need.

3. Byetta MUST NOT be injected after a meal.

4. Byetta can be injected around abdominal area, arm and thigh. In the case of insulin, arm and thigh are less commonly used as site of injection.

SLOWS GASTRIC EMPTYING!!

Byetta slows gastric emptying and therefore potential interact with oral administrated drug.

1.  oral medications that require rapid gastrointestinal absorption or medications associated with local gastrointestinal irritation, e.g. bisphosphonates or tetracyclines.

2. Gastroresistant formulations containing substances sensitive to degradation in the stomach, e.g. proton pump inhibitors, should be taken at least one hour before or more than four hours after exenatide injection.

3. For oral medications that are particularly dependent on threshold concentrations for efficacy, e.g. contraceptives and antibiotics, patients should be advised to take those medicines at least one hour before exenatide injection.

See diabetes study note

If you have any other query, do not hesitate to email me or leave a comment below

Reference

eMIMS 2011

Major depression study note

One with colour, one without , which might be better for printing purposes.

Diabetes study note

Diabetes

Types of diabetes Type 1 Type 2 Gestational

Symptoms of diabetes ·         Being excessively thirsty ·         Passing more urine ·         Feeling tired and lethargic ·         Always feeling hungry ·         Having cuts that heal slowly ·         Itching, skin infections ·         Blurred vision ·         Gradually putting on weight ·         Mood swings ·         Headaches ·         Feeling dizzy ·         Leg cramps.

Symptoms of Hypoglycaemia Hypoglycaemia occurs when sugar level falls below 4 mmol/L, although this can occur in some people at sugar level above 4mmol/L ·         Weakness, trembling or shaking ·         Sweating ·         Light headedness ·         Headache ·         Dizziness ·         Lack of concentration/behaviour change. ·         Tearful/crying ·         Irritability ·         Hunger ·         Numbness around the lips and fingers

Symptoms of Ketoacidosis Most cases of ketoacidosis occur in people with type 1, it very rarely occurs in people with type High blood glucose levels and moderate to heavy ketones in the urine with: ·         Rapid breathing ·         Flushed cheeks ·         Abdominal pain ·         Sweet acetone (similar to paint thinner or nail polish remover) smell on the breath ·         Vomiting ·         Dehydration.

Treatment targets

BGL Ideal 4.0–6.0 mmol/L (fasting) ;  NHMRC 6.1–8.0 mmol/L (fasting) ; HbA1c ≤7%

Drugs for diabetes

Drugs	Dosage/ Mode of Ac	Counselling points	Contraindication/ precaution	Other comment
Metformin	Conventional tablet: Initial low, Maximum 3g daily CR tablet: Maximum 2g once daily Max for Renal impairment 60-90ml/min: 2g 30-60ml/min: 1g	-Take with food to reduce stomach upset. -Lactic acidosis ( Early symptoms: nvd, anorexia, abdo pain, cramps, weight loss, malaise -nausea,vomiting, diarrhoea (nvd)	Type 1 diabetes Ketoacidosis *Respiratory failure *Dehydration *Alcohol misuse *Heart failure	No hypoglycaemis, no weight gain Should try on all patient Surgery: Stop 2 days before, during and 2 days after surgery. Replace with insulin as required Can be used in polycystic ovarian syndrome
Sulfonylureas Gliclazide Glipizide Glimepiride Glibenclamide	-Increase pancreatic insulin secretion	Hypoglycaemia -          Take with food or immediately before food to reduce risk of hypoglycaemia -          Alcohol reduces sugar level and mask symptom of hypo. Avoid binge drinking and have something to eat when drink alcohol -       Educate friends and family on hypo	Type 1 diabetes Ketoacidosis	-Can cause weight gain ( because promote insulin secretion) -The longer the name of the drug, the higher the risk of hypoglycaemia
Acarbose	Initial 50mg. Maximum 600mg daily.	-Flatulence, diarrhoea, abdominal pain and distension -Take with first mouthful of food -GI adverse effect unlikely to be alleviated by taking an antacid		Should be safe in breastfeeding
Insulin	Varies	-Common side effect Hypoglycaemia, weight gain, lipoatrophy -refrigerate NOT FREEZE. Keep in the vegetable compartment of the fridge. Used insulin vial/pen can be kept at room temperature for 28 days http://www.youtube.com/watch?v=4ZYc6bjh9uA		Drug of choice for pregnant women See AMH 2011 page 400 for comparative information
Repaglinide	Increase pancreatic secretion Maximum 16mg daily	Hypoglycaemia as above -nausea, abdo pain,constipation,diarrhoea	-Type 1 diabetes -Ketoacidosis -Gemfibrozil
Thiazolidinediones Pio & Rosi	-Involve in lipid and glucose metabolism -decrease hepatic glucose output -increase sensitivity of peripheral tissue to insulin	Side effects Peripheral oedema ( swollen ankles eg), weight gain, headache, anaemia	-Type 1 diabetes -Ketoacidosis -Insulin – Rosi is contraindicated -Osteoporosis -Diabetic macular oedema -**Heart failure**	Rosi is associated with cardiovascular event, increase HDL and LDL cholesterol
Exenatide	Synthetic analogue of glucagon-like peptide, delay gastric emptying, reduce rate of glucose absorption and decrease appetite Initial, 5mcg bd Increase to 10mcg bd	-Nausea & vomiting ( in 50% of pts) BYETTA -Inject within 1 hour BEFORE morning and evening meals. Do not inject after meal. -Antibiotics to be taken 1 hour before or 4 hours after injection -To see how to use Byetta pen -can inject on arm, thigh and abdominal area http://www.youtube.com/watch?v=7g7fxMnUrOw - Must be kept in fridge at all time, discard after 28 days OR 30 days according to eMims	-severe GI disease -History of pancreatitis with exenatide -Comb with sulphonylurea-, may need to reduce dose of sulphonyurea
Di-peptidyl peptidase-4 inhibitor (-gliptin) Sita & Vilda	Increase concentration of incretin hormone and glucose-dependent-insulin secretion Sita : 100mg daily, reduce dose in renal impairment	SIta : Nausea and Stevens-Johnson Syndrome (SJS) Vilda: dizziness, peripheral oedema and arthralgia Take in the morning for once daily doseing Liver enzymes monitoring	-ACE inhibitor, vilda increase risk of angioedema	Less effective than metformin, sulphonylureas and thiazodinedione

Reference
AMH 2011, eMIMS 2011, Diabetes SA wesbite viewed on 2nd April 2012

How to flag your AMH

In preparation for my intern final exam, I was having a discussion with my folks on "how to flag your AMH effectively". I have seen several flagged AMH, mine was slight under-flagged.most people over-flagged, some were just right.

So let's talk about the book.

There are 3 sides of a book that you can flag.

Some people have 2 layers of flagging on each sides, which I personally discourage.

The idea of flagging is to flag important pages, not every few pages.








TIPS:
1. Flag your index
- from A to Z, I find it very useful. For myself, I use green flags for index. For other things I use different colour.

2. Flag important tables ( according to AMH 2011)
The following is my list of important tables. Just for reference, it is up to your own judgement which are the important ones.

- Opioid comparative information pg 48
-guide to drug choice for selected infection pg 96
-comparative information for sympathomimetics pg 235
- coexisting conditions and antihypertensive choice pg 246
- drugs that may prolong QT interval pg 276
-drugs affecting blood glucose concentration pg 399
- insulins : comparative information og 400
-antineoplastic pg 527
-comparison of tyrosine kinase inhibitor pg 570
-comparison of oral/parental corticosteroid pg 603
- comparison of NSAIDS pg 619
- antidepressant changeover guide pg 736
- drugs that contribute to serotonin toxicity, symptoms pg 738
-comparative characteristic of antipsychotic drug pg 755
- inhaled corticosteroid doses in adults pg 800

3. Know your flags
- What is the use of flag if you don't know which table you have flagged?

In short, just make sure your flagged AMH is user friendly

Share with me if you have other ideas on flagging the pharmacist bible.

HMR report ( Pre-exam tips)

A junior recently mentioned to me that she will be taking a test on home medication review soon. Back in my time, they called it medication management ( i think)..Oh well, similar thing i guess. So, the usual format would be :

" A doctor refer a patient to you to review his/her medication. You have a list of medication in front of you, with or without presenting problem, and maybe some laboratory test result"

Okay, I did badly when I was a student  ( a borderline pass, I wasn't a particularly academic-bright student anyway). I vaguely remember about half of the class passed the test. We were given 45 minutes to produce a letter/report to the doctor.

45 minutes flies like a rocket when you are taking exam. So, I have some several tips to share, which might be a little help for students who will be taking it soon or in the near future.

TIPS:
PRE-EXAM

1. MEMORISE the format of the letter, introduction and conclusion BY HEART...!!
 - Under stressed condition with restricted time, the last thing you want to do is to waste extra 5 or 10 minutes on these standard stuffs. This is especially important for students whose English is not proficient ( like me).

2. Flag/label your AMH
- It will save you so much time when you do bit of flagging on your AMH. I did not do it till during my intern exam. I regretted not doing it during uni.
- Of course, do not over do it. I have seen AMH that is so over flagged that I wonder how the person use the book ( seems like every third page is flagged).
- For detail, see how to flag your AMH

3. Go through your lecture notes
- Duh...., isn't it obvious?
-Examiners will normally set question based on what he/she has taught. Don't spend one night studying cytotoxic drugs when your lecturer only taught you antibiotics and cardiovascular.

4. Sleep well ( if you can)