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Pharmacy Prep
OSCE Pharmacy Review





Contributors

Misbah Biabani, Ph.D
Director, Tips Reviews Centres
5460 Yonge St. Suites 209 and 210
Toronto ON M2N 6K7, Canada



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Disclaimer

Your use and review of this information constitutes acceptance of the following terms and
conditions:
The information contained in the notes intended as an educational aid only. It is not intended
as medical advice for individual conditions or treatment. It is not a substitute for a medical
exam, nor does it replace the need for services provided by medical professionals. Talk to your
doctor or pharmacist before taking any prescription or over the counter drugs (including any
herbal medicines or supplements) or following any treatment or regimen. Only your doctor or
pharmacist can provide you with advice on what is safe and effective for you. Pharmacy prep
make no representation or warranty as to the accuracy, reliability, timeliness, usefulness or
completeness of any of the information contained in the products. Additionally, Pharmacy prep
do not assume any responsibility or risk for your use of the pharmacy preparation manuals or
review classes.
In our teaching strategies, we utilize lecture-discussion, small group discussion,
demonstrations, audiovisuals, case studies, written projects, role play, gaming techniques, study
guides, selected reading assignments, computer assisted instruction (CAI), and interactive
video discs (IVD).
Our preparation classes and books does not intended as substitute for the advise of
NABPLEX

. Every effort has been made to ensure that the information provided herein is not
directly or indirectly obtained from PEBC

previous exams or copyright material. These


references are not intended to serve as content of exam nor should it be assumed that they are
the source of previous examination questions.
2000-2010 TIPS. All rights reserved.

Foreword by
Misbah Biabani, Ph.D
Coordinator, Pharmacy Prep
Toronto Institute of Pharmaceutical Sciences (TIPS) Inc
5460 Yonge St. Suites 209 and 210
Toronto ON M2N 6K7, Canada


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OSCE Pharmacy Review
Content
SECTION A: Communication Skills and Techniques

Chapter 1: Top 20 Rules of Communication in Exams
Chapter 2: Counselling A New Prescription
Chapter 3: Counselling on Refill Prescription
Chapter 4: Counselling on Non Prescription Drugs
Chapter 5: Counselling techniques: Questioning
Chapter 6: Counselling techniques: Persuasion
Chapter 7: Counselling techniques: Language Skills
Chapter 8: Counselling techniques: Language for Instructions Dosage and Administration
Chapter 9: Counselling techniques: Using written information effectively
Chapter 10: Conducting Patient Interview: Symptom related questions
Chapter 11: Counselling techniques: Counselling on lifestyles
Chapter 12: Counselling techniques: Discussing alternative treatments
Chapter 13: Assessing the potential for non compliance
Chapter 14: Assessing the need for follow up
Chapter 15: Counselling techniques: Assessing need for nutrition and supplements
Chapter 16: Communication skills: Dealing with physician
Chapter 17: Communication skills: Dealing with other Healthcare Professionals
Chapter 18: Communication skills: Demonstrating devices
Chapter 19: Communication Skills: Dealing Dispensing Errors
Chapter 20: Communication Skills: Managing Med Check Program
Chapter 21: Communication Skills: Discussing Payment Options
Chapter 22: Communication Skills: Dealing with difficult questions

SECTION B: Problem solving: Identifying Drug Related Problems

Problem Solving: Gastrointestinal Symptoms and DRPs
Chapter 23: Gastrointestinal Drugs
Chapter 24: Heartburn
Chapter 25: Diarrhea
Chapter 26: Constipation
Chapter 27: Hemorrhoids
Chapter 28: Nausea and vomiting
Chapter 29: Pinworm
Chapter 30: Infant Colic

Problem Solving: Cardiovascular Symptoms and DRPs
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Chapter 47: Cardiovascular Drugs
Chapter 48: Hypertension
Chapter 49: Antihyperlipidemics
Chapter 50: Ischemic Heart Diseases
Chapter 51: Anticoagulants & Warfarin Management

Problem Solving: Psychotic and Neurological Symptoms and DRPs
Chapter 52: Psychological Disorders
Chapter 53: Neurological Disorders

Problem Solving: Endocrine Symptoms and DRPs
Chapter 54: Contraceptions
Chapter 55: Diabetes
Chapter 56: Thyroid disorders

Problem Solving: Respiratory Symptoms and DRPs
Chapter 57; Asthma and COPD
Chapter 58: Cold, Cough, Congestions and Fever
Chapter 59: Allergic Rhinitis

Problem Solving: Mouth and Dental conditions
Chapter 60: Canker and cold sores

Problem Solving: Eye Symptoms and DRPs
Chapter 61 Ophthalmic drugs
Chapter 62: Conjunctivitis

Problem Solving: Ear Symptoms and DRPs
Chapter 63: Otitis media
Chapter 64: Otitis externa
Chapter 65: Vertigo and Dizziness

Problem Solving: Foot Symptoms and DRPs
Chapter 66: Foot Symptom Assessment
Chapter 67: Athletes Foot

Problem Solving: Dermatological Symptoms and DRPs
Chapter 68: Diaper rash
Chapter 69: Headlice
Chapter 70: Dermatitis
Chapter 71: Psoriasis
Chapter 72: Dermatological Drugs
Chapter 73 Acne

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Problem Solving: Musculoskeletal DRPs
Chapter 74: Arthritis
Chapter 75: Osteoporosis
Chapter 76: Pain Symptoms and Analgesics

Problem Solving: Reproductive, Gynaecologic, and Genitourinary Symptoms and DRPs
Chapter 77: Dysmenorrhea
Chapter 78: Menopause
Chapter 79: Sexual dysfunction and DRPs
Chapter 80: Vaginitis
Chapter 81: Benign Prostate Hyperplasia

Problem Solving: Cancer Chemotherapy DRPs
Chapter 82 Cancer Chemotherapy

Problem Solving: Antimicrobials DRPs
Chapter 83 Antimicrobials
Chapter 84 Urinary Tract Infections

Problem Solving: Lifestyle Management
Chapter 85: weight loss
Chapter 86: Smoking cessation
Chapter 87: Allergies and Hypersensitive reactions
Chapter 88: Photosensitivity
Chapter 89: Insomnia
Chapter 90: Immunizations and vaccines
Chapter 91: Medications use in pregnancy
Chapter 92: Traveling Tips
Chapter 93: Substance of Abuse

PART 3: Non interactive stations
Chapter 94: Non interactive stations

Chapter 95 New Approved Drugs 2007 to 2010

Part 4: NAPRA Competencies
Chapter 96: Pharmaceutical Care
Chapter 97: Pharmacy Regulations and Ethics
Chapter 98: Pharmacy Practice Information Resources
Chapter 99: Communication Skills in Pharmacy
Chapter 100: Managing Drug Distribution
Chapter 101: Managing Pharmacy Operations

Prep Notes

Par t 1


Communi c at i on
Sk i l l s
2













Number 1: Communi c at i on

Number 2: Communi c at i on


Number 3: Communi c at i on
3
MISBAHS
TOP 20 RULES OF COMMUNICATION IN EXAMS

Rule # 1: Always respond to the patient/actor
Make eye contact
Answer any question that is asked.
Respond to the emotional, as well as factual, content of question


Rule #2: Listen, reflect, encourage, and offer empathy
Introduce yourself (tell him/her who are you?/What are you doing)
Getting the patient to talk is generally better than having the pharmacist talk
Be sure who your patient/actor is? The child, mother, or her husband
Arrange seating for comfortable, close communication
If at all possible, both patient/actor and pharmacist should be both be seating


Rule # 3: Notice and response to information
Change the plans and goals as events change, new information should cause you to
stop and reassess
Dont carry away by inertia. How you reach your goal may shift with new
information, even it the goal itself stay the same

Rule # 4: Ask the prime questions
What did your Dr. tell you this medication was for?
How did your doctor tell you to take this medication?
What did your doctor tell you to expect?


Rule # 5: Be sure you understand what the patient medical conditions /Medications/
Allergies and alternate life style (MAMA) before recommending
Seek information before acting
When presented with a problem, get some details before offering a solution
Begin with open-ended questions then move to close ended questions

Rule # 6: Assessment critical thinking and analysis of the problem.
Are each of this patients medications appropriately prescribed?
Is each medication the best one for this patient to be taking? Safest, most effective?
Is this the right dose given the patient specific information (severity, size, gender,
etc.)
Is the patient having any apparent drug related side effects?
Are any possible drug interactions present?
Is this patient able to follow this drug regimen?
Does the patient know how to use this medication correctly?
Is additional medication needed to resolve the patients complaint / symptom?
4
Are any of the patients complaints or abnormal objective/physical findings related to
drug therapy?
What are some other possible causes of the patients complaints / symptoms?

Rule # 7: Patient do not get to select inappropriate treatment
Patient select treatments, but only from presented, appropriate choices
If a patient asks for inappropriate medication that he/she heard advertised/ from
friends/relatives, explain why it is NOT indicated and suggest an alternative

Rule # 8: Never lie
Not to patient/actor, their families, or insurance companies
Do not deceive to protect coworkers

Rule # 9: Work on developing a rapport on an ongoing basis, always seeks a good
professional relationship with patient
Ask patient/actor if this prescription/refill/concern for you?

Rule # 10: Patient is number one always placing the patient first
The goal is to serve patient/actor, not to worry about your exam results

Rule # 11: Prepare Patient Counseling Plan before engaging in the counseling
What is the situation right now? (Special circumstances, medication itself, past
history with the patient, etc.)
What does everyone who takes this medication need to know?
What does this patient need to know in addition to this?

Rule # 12: Identify red flags that signal physician referral
Blood in stool/urine or vomiting of blood
Fever not responding to appropriate measures
Yellowing of skin or eyes
Severe pain (described as the worst pain ive ever had)
Fever, vomiting, headache, confusion, difficulty bending neck
Signs of infection or inflammation (fever, pus, swelling, redness, tenderness, heat)
Spontaneous bleeding or bruising
Chest pain
Pain on urination

Rule # 13: When collaborating with the physician,
Always position the patient and his/ her health as the basis of interaction.
Do not make judgments on the physicians capabilities to choose a therapy for his/her
patient.
Establishing a good channel of communication and respectful relationship with the
physician is essential in building a team approach to patient care.
Information the pharmacist passes to the doctor regarding drug interactions,
contraindications or non-adherence, is highly valued by the physician. This
5
information can dramatically alter the course of treatment or therapy that the
physician prescribes.

Rule # 14: Listen to what patient is saying and provide any
Information missed by patient.

Rule # 15: Offer follows up and asks if the patient has any questions or concerns.
It sounds like youve got it. Please dont hesitate to give me a call if you have any
problems.
This is also a good place to remind about refills
Thank the patient

Rule # 16: Final Verification
Assess whether verification or summary is needed
Has patient verbalized the information you wanted them to know?
yes summarize & reinforce their knowledge
no final verification (Just to make sure I havent left anything out, could you tell
me how you are going to use the medication?)


Rule # 17: The key is not so much what you do, how you do it?


Rule # 18: There are three things that can destroy your exam: misinformation, poor
communications, and poor judgement of question.

Rule # 19: pharmacist should be able to discuss pros and cons of alternative treatment

Rule # 20: Never assume patient knows every thing

Good luck

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2-1
2
Communication Skills: Counselling
New Prescription

The sample template describes how to approach a patient who comes to fill a new
prescription. This template assist you to develop a communication model, however you
have to adopt your communication model upon patient have some questions in between.
COUNSELLING NEW PRESCRIPTION
Opening discussion
Introduction
Offer privacy
Empathy

Discussion to gather information and identify problems
MAMA
TOPS

Patients present knowledge about medication and condition.
Potential problems


Identify problems and Educational needs
Discussion to prevent or resolve problems and educate

Discuss real or potential problems
Agree on alternatives
Implement plan
Discuss outcomes and monitoring
Provide information as necessary



Recap Get feedback Encourage questions
Follow up
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2-2
Practice Station

Scenario # 1

A patient comes to fill prescription:

Patient profile: (given by patient after pharmacist candidate request)

Patient Name: Amy
Age: 55 yrs
Address: Pharmacy Prep Avenue
Doctor: Tips

Medical Condition: hyperlipidemia and high B.P
Current Medications: Diovan HCT 80/12.5 mg po daily

Rx:
Lipitor
Sig: 20 mg po daily x 3 months
Mitte: 90 tablets
R: 2

Solve problem and counsel
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3
Communication Skill:
Counselling On Refill Prescription

Opening discussion
Introduction
Offer privacy
Empathy

Discussion to gather information and identify problems
MAMA
TOPS

Patients present knowledge about medication and condition.
Potential problems


Compliance problems?
Evidence of side effects?
Effectiveness of treatment
Potential problems



Discuss real or potential problems
Agree on alternatives
Implement plan
Discuss outcomes and monitoring
Provide information as necessary



Recap Get feedback Encourage questions
Follow up
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Scenario # 1

A patient comes to pick up his refill 2 weeks before his due date.

Patient Profile: (on the table)

Patient: Mathew
Age: 18 years
Gender: Male

Dexedrine 10mg cap 1x3 90 tablets each 30 days
Refills: (3) last refill 2 weeks ago


Scenario # 2

A patient is coming for her refill with a concern. Solve her concern as you are in your
pharmacy. (She is pregnant)

Rx

Epival (Divalproex Na) 250mg tablet 1x1
Mitt: 30 tablet
Refills (5)
Last refill 30 days ago

Patient Profile (on the table)

Patient: Rosemary Khan
Age: 33 Years
Gender: Female
Diagnosis: Grand Maleilepsy
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4
Communication Skills: Counselling
OTC Drugs
Opening discussion
Introduction
Offer privacy
Empathy

Discussion to gather information and identify problems
MAMA
TOPS

Has Physician been consulted before?
Description and duration of symptoms
What treatment has been used previously?

Identify problems and Educational needs
Discussion to prevent or resolve problems and educate

Non Prescription Drugs
Medication Recommended Medication Not recommended
Name
Purpose
Directions
Side effects
Precautions
Future treatment
Self care recommendation
Reassurance



Advice patient to see physician
Suggest non-drug treatment
Give self care recommendation
Reassurance




Recap Get feedback Encourage questions
Follow up
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Practice Stations
_______________________________________________________________

Scenario # 1

A young man approaches you requesting smokeless tobacco. He heard from
his friend that smokeless tobacco reduces cancer and lung diseases.

On the table:
Nicotine gum,
Nicotine patches
Nicotine inhaler
Nicotine gargle
Herbal products for smoking cessation.

Patient profile: (given by patient after pharmacist candidate request)
Age: 45 yo
Allergies: none
Current medications: None
Current medical conditions: none


Scenario # 2

A woman come with a concern, and she wants an OTC product. She has white flakes on
the shoulders of her black sweater after she brushes her hair. Her hair is clean, and the
scalp is itchy.

Available on the table:
Ketoconazole2% shampoo,
Selsun shampoo,
Zinc Pyrithione (Head and shoulders),
Salicylic
Sulphur bar and lotion
Coal tar shampoo

Patient profile: (given by patient after pharmacist candidate request)
Age: 22 yo
Allergies: None
Current medications: None
Medical conditions: none
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5
Counselling Techniques:
Questioning (Probing)



The following questions may assist you to counsel efficiently and effectively to succeed
solving problems.


Dos
Asking the right questions?
What did doctor tell you about your medication?
How the doctor told you to take this medication?
The doctor just wrote to take as directed. How did he/she tell you take them?
Medications can occasionally cause some unwanted side effects. What did the doctor
tell you about possible side effects?
Is there anything further that you would like to do discuss or ask.


Donts
You do know how to take medication, dont you? (leading questions)
Did the doctor tell you about side effects (close ended question)



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6
Counselling Techniques:
Persuasion

During information giving phase of the counselling, it may be necessary for the
pharmacist to provide information such a way that change the patient beliefs, attitude or
behavior towards the medication use. This can be accomplished by persuading the patient
that following his/her advice regarding medication is in the patients best interest.

The pharmacists ability to persuade depends on his or her style of communication,
effective methods of presenting information, organizing information, and confidence and
credibility of information.

Dos
Use friendly tone, caring, use two sided communication, gently encourage the patient
comply, and the same time making the patient aware of the risks of non-compliance.
Be neat and tidy
If you note on the prescription telling him that the patient prescription was one month
late in being renewed, or earlier than refill time and prepare to discuss compliance.
I am concerned about your medication use, as it is very important to take medication
regularly in order for it to work better.
You still need to take medications to continue feeling well
It is particularly important with this medication that you dont stop suddenly.
Although it is problem free, it could cause drug withdrawal symptoms.

Donts
Preaching and threatening
Getting upset and loud when the patient does not accept pharmacist advice.
Boldly staring that this medication should be taken as directed, several reasons are
given for the advice.
Fear arousing communication (lead to non compliance)


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7
Counselling techniques: Mastering
Language skills
It is important to have smooth flow of communication and organized approach before
you start your counselling. Here are the few points master your language skills

Empathy statements
It must be hard
It must be difficult
It seems your.
It sounds like pain is real ordeal for your
I am glad you told me that

Paraphrasing
Paraphrasing allows the pharmacist to verify that he/she understood the patient.
Paraphrasing is simply restating what he or she believes the patient has said and
verifying the facts.
Paraphrasing also helps to reflect that your paying attention to patient concern or
question.
Repeating the patients exact words is another techniques that encourage patient to
talk more about a particular topic.

Dos
Repeat the patient exact words..
Are you saying that
Is your concern is..

Dont
Repeating frequently patients exact words, it would be annoying

Summarizing
Summarizing is useful techniques to end a series of asking questions or probing.
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Before making a recommendation to problem, a pharmacist can summarize all that
has been said in previous discussion.
After a pharmacist summary statements, the patient can correct the pharmacist if the
summary is incorrect or provide additional information necessary.

Dos:
You have told me that you have had diarrhea before starting medications..




Transition
A transition is a specific, planned attempt to change to topic , in order to provide structure
and continue during interview.
This is especially useful when pharmacist needs to change to different topic like
counselling on how to use medications to patient self care recommendations.
This is also very useful especially when patient interrupt with comments on another topic.
Dos
What if patient interrupts with other topic while your communications? After briefly
discussing the patients comments, the pharmacist can return to

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8
Communication Skills:
Giving Instructions


Dos

Use future forms, softens your language: for example:
Be + going + infinitive
Youre going to take one pill in the morning and one at bedtime.
Be + going + to be + V-ing

Youre going to be taking this tablet once a day at bedtime.
Will + be + V-ing
Youll be taking one tablet at breakfast one at lunch, and one at dinner.

Dont (avoid using commands)

Take one pill in the morning (sounds command)
Take this tablet with a full glass of water (sounds command)

Use Passive Forms for Embarrassing Topics


Dos

Be + past participle
The suppository is going to be inserted into the rectum.
Will + be + part participle
The suppository will be inserted into the rectum.
Dont (Avoid using you or your)
You are going to insert this suppository into your vagina, you can use a passive
construction to remove the emphasis from the doer.
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Also, avoid using personal pronouns such as your when talking about potentially
embarrassing topics with a patient. Instead, say the vagina, or the the penis.

Use Sequencers

Dos

Try to use se short statements. Use simple (lay) language, as to talk to 6
th
or 7
th

graders
When giving instructions to patients, its very important to use sequencers such as
First, Next, Then, etc. so the patient can easily follow the instructions. You
can also use phrases such as,
After washing your hands, you are going to remove the cap and place it on a tissue.

Dont

Avoid using long complications sentences
Avoid using textbook type of statements

Use Signifiers of Importance

Use language that tells your patient that the instruction is important, such as:

Its important to wash your hands first.
Its important that you take this tablet with a full glass of water.
You must avoid alcohol while taking this medication.
My reference shows that patient must avoid taking alcohol with medication:

Avoid using must in lifestyle recommendation

Confirm the Patients Understanding

Confirm that the patient has understood your instructions by using the following
language:

Just to make sure Ive explained myself completely, would you mind telling me
how youre going to use this medication?

Do you have any questions about how to use this medication?

Giving Instructions on a Dosage Form

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Dos
Maintain professional attitude, and eye contact.
Speak clearly
Use logical sequence
Use sequencer in phrases such as first, next, then, after etc.
Use future forms instead of commands
Give enough information, rather over information (do not over kill)
Use appropriate body language while presentation
Use simple language (avoid text book type of professional language)
Use signifiers, such as it is important, or must avoid etc.

Lay language
Describing how a class of drugs works and o explain Mechanism of actions:

Antihistamines These medications help to reduce your allergy by reducing certain
substances in your blood.

Nitrates These medications help prevent you from having chest pains and shortness
of breath by delivering more oxygen supply to your heart and lungs.

Beta-Blockers These medications slow down your heartbeat and slow down your
blood pressure by blocking certain chemicals to avoid any heart complications.

Bisphosphonates These medications help strengthen your bones by adding calcium
to them, thus helping to prevent fractures.

Anti-Anxiety Agents These medications help reduce your anxiety (calm down) and
make you feel more relaxed by reducing certain messengers in your brain.

Diuretics These are water pills that help to remove fluids from your body and lower
blood pressure and prevent a heart attack.

Anticoagulant These medications help to make your blood thinner and prevent clot
formation, thereby preventing you from having a stroke or heart attack.

Statins These medications help elevate levels of good cholesterol and reduce bad
cholesterol by inhibiting certain enzymes in your blood, thus helping prevent you
from having a stroke.

Birth Control Pills These medications help prevent pregnancy by inhibiting
ovulation.

Anti-Depressants These medications help to control your mood and make you feel
well by inhibiting certain messengers in your brain.
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Cough Suppressants These medications help to reduce your cough by blocking the
cough centres in your brain.

NSAIDs These medications help to reduce pain by clocking certain substances in
the body. They also work as pain killers.

Sulfonylureas (for Type 2 Diabetes) These medications help to reduce your blood
sugar by stimulating the production of insulin in your body.

Carbonic Anhydrase Inhibitors (for Glaucoma) These medications help to reduce
the pressure in your eye by draining the accumulated fluid, thus improving your
eyesight and reduce pain.

Bronchodilators These medications help open your body airways and make your
breathing easier.

Proton Pump Inhibitors These medications help treat your stomach ulcers by
reducing the acidity in your abdomen.

Anti-Psychotics These medications help improve your emotions and behavior by
controlling certain substances in your brain.
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9
Counselling techniques:
Using written patient information
effectively

Along with verbal counselling, pharmacist needs to select the right information sheet for
each patient, and know how to present that information.

Commonly used written information:
Computer generated patient information sheet
Package inserts
Photocopies of articles
Scientific journal articles
Health Canada food guide
Drug recall from health Canada and manufacturers

Dos
It is very important to review highlights of written information, relevant to patient
questions. Make sure the information provided is accurate and well presented.
Pharmacist may need to modify the written information by highlighting certain areas
that is most relevant patient.
Written information can be useful in addition to verbal counselling to provide detail
information
Written information also helps patient family and caregiver to understand the therapy
In all cases, pharmacist should review information with patient and offer it to discuss
it further after patient have had reading and understanding information it in detail at
home.

Dont
Written information should never be used just as bag stuffer.

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10
Conducting Patient Interview:
Symptom related questions

Pharmacist is a primary healthcare provider, and has responsibility to identify symptoms
that need medical attention.


Dos
Memorize all disease and drugs overdose and withdrawal symptoms
Identify symptoms that need medical attention and determine urgency of referral
Identify symptoms to make recommendations on drug therapy to treat identified
symptoms
Be alert for undiagnosed conditions, pharmacist have some time an excellent
opportunity to help identify a serious condition.
Appropriate questioning during a symptom related patient interview might help to
determine urgency of further medical assessment and intervention.

Dont
Dont be judgemental
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Scenario # 1

Mr XP a regular patient at my best pharmacy, patient approaches you for
recommendation. Sounding a little discomfort in stomach and have hard time with bowel
movements.

On the table:
Anusol Plus suppositories
Anusol Plus ointment
Tucks wipes
Senokot
Metamucil
Soflax (Sodium Docusate)

Patient information (gives this information after asking questions)

Age: 45 year old
Allergies: Not known
Current Medications: None
Medical conditions: None

Life style:
Non-smoker
Alcohol: moderate 3 to 4 drinks/wk
Works as courier delivery, and always on wheels and eats on the run


Scenario # 2

A 55 year old man comes into the pharmacy and complains of chest pains. He asks if
you could recommend something for heartburn.

Counsel the patient.

Patient information (gives this information after asking questions)

Allergies: Not known
Current Medications: atorvastatin 20 mg daily, enalapril 10 mg
Medical conditions: high cholesterol and high blood pressure


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11
Counselling techniques:
Counselling on Healthy lifestyles

The pharmacist the most important concern is counselling on appropriate use of
prescription and non-prescription drugs. The pharmacist should also consider the overall
health of their patients.

Health and lifestyle issues that pharmacist may emphasize include:
Smoking
Alcohol
Exercise
Safe sex
Unwanted pregnancy
Illegal drug use
Wife and child abuse

How to approach problem
Dos

Offer help, rather than preach
Communicated non judgemental way
Help patient to set achievable, individualized goals
Delivering lifestyle information should be done by tact and empathy since lifestyle is
personal issue and as well as difficult thing to change
Be empathetic in challenges to lifestyle changes that faced by patient
Make your patient aware of facts concerning the risk of any unhealthy behavior

Dont
Dont be taskmaster
Dont counsel in an authoritative and aggressive manner
Dont be judgemental
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Dont create more dilemmas


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12
Counselling techniques: Discussing
alternative treatment

It is important for a pharmacist to become knowledgeable about herbal remedies,
homeopathic medicines, naturopathic treatments, and acupuncture.

How to approach a problem

Dos
Pharmacist should be able to discuss pros and cons of alternative treatment
Provide information about available products and recommend reputable practitioners
of reputable alternative treatment, if required
Discourage unproven or products that have insufficient information about clinical
studies.
Prevent harm by becoming knowledgeable about serious drug interactions of
alternative treatment with medications
Prevent harm

Dont
Do not recommend alternative product that may result into serious risk to patient.

What is often asked?
Pharmacist are often asked about alternative treatment, and requested supply various
products?


Herbal Remedies

Ginseng

Commonly used to help the body combat stress, to enhance mental & physical
capacities ( weakness, exhaustion, tiredness, loss of concentration)
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American Ginseng (Panax quinquefolium) has shown to lower post-prandial glucose
& improves glucose metabolism
Prevention & treatment of cardiovascular disease (induce nitric oxide, block Ca
channel in the heart, prevent platelet adhesion)
Obesity and hyperlipidemia
Cold & Flu treatment
Ginseng & Digoxin
Ginsenosides (Asian & American ginseng) & Eleutherosides (siberian ginseng) partly
resemble the structure of digoxin
Patients taking ginseng may have falsely or digoxin levels due to laboratory
interference
Case report: patient asymptomatic for digoxin toxicity exhibited supratherapeutic
digoxin levels (5.2 nmol/L) [Therapeutic range 2.2 nmol/L]

Ginseng & Warfarin
In vitro Ginsenosides inhibit platelet aggregation & prolong the activated partial
thromboplastin time (aPTT)
Two case reports show a in warfarin effect (drop in INR) in pts taking ginseng &
warfarin
Patients should avoid ginseng due to possible reduction in INR.

St. Johns Wort (SJW)
Has been used in a variety of psychiatric disorder, including depression
MOA: alters serotonin (inhibits its reuptake), dopamine & norepinephrine activity.
Typical antidepressant dose: 300 gm TID
Inducers of CYP 3A4 & intestinal P-glycoprotein

St. Johns Wort (SJW) & Immunosuppressants
Cyclosporine & SJW reduced plasma levels of cyclosporine & even graft rejection
Tacrolimus & SJW reduced plasma levels of tacrolimus
Cyclosporine & Tacrolimus both are eliminated by CYP 3A4 & are substrates of P-
glycoprotein
Mycophenolate (CellCept) & SJW, no effect

St. Johns Wort (SJW) & Oral Contraceptives
Both Ethynyl estradiol & progestin in OC are metabolized by CYP3A4
Studies show a low probability of significant interaction between SJW & OC
However, St. Johns Wort (SJW) & Oral Contraceptives ] breakthrough bleeding &
theoretical risk of contraceptive failure, & also reported cases of pregnancy
Warn patients about possibility of breakthrough bleeding and reduced effectiveness of
OC

St. Johns Wort (SJW) & Antidepressants
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Pharmacodynamic Interaction (SJW & SSSRIs, Effexor, etc.) ] Serotonin Syndrome
Serotonin Syndrome symptoms:
Altered mental status (agitation, delirium)
Autonomic hyperactivity (tachycardia, hypertension, chills, sweating, hyperthermia)
Neuromuscular (tremor, myoclonus (involuntary twitching of a muscle)

St. Johns Wort (SJW) & Antidepressants
Pharmacokinetic interaction with amitriptyline
Amitriptyline is metabolized by CYP2D6, CYP3A4, CYP2C19 & is a substrate of P-
glycoprotein
Efficacy of amitriptyline may be when taken with SJW
Digoxin & SJW ] reduced digoxin levels ] loss of disease control
(P-glycoprotein is involved in intestinal absorption, distribution & renal elimination
of digoxin)
Antiretrovirals & SJW reduced systemic exposure to PIs & NNRTIs viral load &
drug resistance (PIs & NNRTIs: both metabolized by CYP3A4
PIs: substrates of P-glycoprotein)

Garlic & its uses
Anti-infective properties
Immune-enhancing properties
Prevention & treatment of cardiovascular disease
Allicin (active compound in garlic) induce CYP3A4
Garlic my also inhibit CYP2C9, CYP2C19 & CYP3A4, as well as P-glycoprotein

Garlic & Warfarin
Antiplatelet activity of Garlic may enhance the anticoagulant activity of warfarin
Case reports (Garlic & Warfarin):
bleeding
increase in INR (in two cases, the INR increased approximately twofold)

Ginkgo Biloba
Has been used to treat Alzheimers disease & dementia
Ginko Biloba & reported interactions
Ginko may increase risk of bleeding with ASA, ibuprofen, and warfarin

Echinacea

Stimulates immune system
Directly opposes the effect of immunosuppressants
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Contraindicated in systemic & autoimmune diseases such as rheumatoid arthritis,
lupus, inflammatory GI disease, tuberculosis, multiple sclerosis, leukemia, diabetes,
connective tissue disorders
Use by AIDS & HIV patients is contraindicated
Should not be given to children younger than 2 years old

Other important herbal products that recommended to read are : Saw Palmetto
Indicated for BPH, Cranberry-Indicated for UTI and Velarian - To treat insomnia.
Kava - To treat insomnia.
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Practice Stations
Scenario # 1

A young man comes to your Pharmacy asking for your assistance. He has got a concern
regarding his condition and wants to purchase something that he feels would help him.

On the table:
Echinecea Tablets
Pseudoephedrine 30mg tablets
Saline nasal drops
Dextromethorphan cough syrup

Scenario # 2

A 25 year old women is inquiring about the use of Echinacea

Profile: Materna and Multivitamins

On the table:
Echinacea lozenges

Scenario # 3

A lady is inquiring about the use of St. Johns Wort.

Currently using: Carbamazepine 200mg po TID and Folic acid 5 mg po od

On the table
St. John Wort

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Scenario # 4

A female in her 50s

Patient Profile: (given on table)

Age: 51 yo
Current medications
Eltroxin 100 mcg daily
Crestor 10 mg daily
HCTZ 25 mg daily
Atenolol 50 mg dailyWarfarin 2 mg ud
Warfarin 1 mg ud

Medical History:
Dyslipidemia
Hypothyroidism
Hypertension
DVT 3 month ago

COLD-fX is a highly purified extract derived from North American ginseng (Panax
quinquefolius)



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13
Assessing the potential for non
compliance

In pharmaceutical care it is an important to make sure, to the best of pharmacist ability,
that the patient received the necessary necessary medication at the required time in order
to get desired effect.

Dos
It is essential consider the individual patients personal and environmental characteristics,
these include:

The patient attitude to medication use
Their knowledge of their condition and medication treatment
Their previous experience with medication use, including family and friends.
Their lifestyle and time schedule

Although you short time with patient, however look for factor that can contribute to non-
compliance, such as:
Number and types of medication currently patient using
Drugs that require that have special instructions, such as taking empty
stomach, with full glass water, should not combine with other drugs, and do
not chew etc.

How to figure out non-compliance in patients;
A careful and direct discussion with patient at the time of medication
provision
Motivate patient by explaining of taking medication regularly gives desired effect

Strategies To Enhance Adherence To Medication Regimens
Integrate new behaviours in patient lifestyle.
Provide or suggest compliance or reminder aids.
Suggest patient self-monitoring.
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Monitor use on an ongoing basis.
Refer patients when necessary.

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14
Assessing the need for follow up
counselling

In pharmaceutical care practice it is important for pharmacist to ensure that appropriate
outcome achieved from medication use

Dos
Pharmacist need to schedule follow up counselling with patient, when they are
conducting initial prescription counselling. It is challenging to assess the risk level of
each situation

The nature of follow up arrangement will depend on: Pharmacist assessment of the risk of
drug related problems such as side effects and non-compliance.

High risk drug situations follow up:
Pharmacist should discuss with the patient an appropriate time for follow up
schedule either by phone or in person.
Low risk situation follow up:
Follow up schedule may involve a suggestion that the patient call if he or she has
any questions. If certain drug side effects occur or if after a given period of time
the desired effect has not been achieved
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15
Counselling techniques: Assessing
patient need for supplements

It is important for a pharmacist to become knowledgeable about calcium supplements,
iron supplements, and multivitamins.

How to approach a problem

Dos
It is important to assess necessity of supplements
Pharmacist should ensure that the client uses the product appropriately and identify
and resolve any drug related problems
It is important to know dosages and how to take them

What is often asked?
Pharmacist is often asked about calcium, iron supplement and multivitamins,
supplement drops for children

Iron supplements

Know available iron salts
Ferrous Gluconate 300 mg tablet 35 mg of elemental Iron
Ferrous Sulfate 300 mg tablet 60 mg of elemental Iron
Ferrous Fumarate 300 mg tablet 100 mg of elemental Iron
Triferexx - Polysaccharide-Iron Complex 150 mg of elemental Iron
Proferrin is a heme iron polypeptide. It is the same form of iron found in red meat 11
mg of elemental iron.
Iron supplements in Pregnancy

Ask more questions about pregnancy?
Recently, have you seen your Dr?
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But for better assessment please see your Dr.

Iron Supplement counselling tips
Take between meals to increase absorption
May take with food if GI upset occurs
Do not take with dairy products
May cause dark colored stool
During the first 3 months of pregnancy a proper diet provides enough iron. However,
during the last 6 months an iron supplement recommended in order to meet the
increased needs of the developing baby.
Antacids May make the iron supplement, less effective do not take at the same
time. It is best to space dose 2hours



Calcium supplements

Know Calcium formulations
Chewable Tablets (Caltrate, Tums)
Soft chews (Caltrate)
Liquid Calcium
Effervescent Calcium (Calcium Sandoz)

Know available calcium salts
Calcium Carbonate the most concentrated (40% elemental calcium), least
expensive, has slowest absorption (pH dependent)
(Caltrate, O-Calcium Natural Source, Tums, Calcia)
Calcium Citrate more soluble; OK for patients with hypochlorhydrea (on PPI, H
2

antagonists); does not cause gas, bloating or constipation; can be taken with or
without meals
Citracal, Calcium Citrate Tablets Each tablet provides 200 mg of elemental calcium
as Ca citrate,
Citracal, Caplets + D One caplet provides 315 mg of elemental calcium as calcium
citrate, 200 IU of Vitamin D
Citracal Plus with Magnesium

Counselling tips
Bisphosphonates, tetracycline, ciprofloxacin, iron supplements absorption of these
drugs is negatively affected by calcium
Food with high levels of sodium & caffeine accelerate Ca loss through urination
(Recommend: one glass of milk for every cup of coffee consumed)
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Practice Stations
Scenario # 1

A lady comes to you in the Pharmacy and wants advice on a certain products for her 4-
month-old infant. Assist her and solve her concern as you would in the Pharmacy.

On the Table:
Multivitamin Drops for infants
Vitamin D Drops
Iron supplemental drops
Enfalac formula with iron

Scenario # 2

Patient comes to fill the Rx

Rx
Actonel 75mg
Take 2 tablets every month
M: 1 mo supply

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16-1
16

Communication skills:
Dealing with Physician

Pharmacist responses to physician questions are handled a little different than those to
patients. Most of these questions are not difficult to answer, but it is important require
building a good relationship with the physician

How to approach a problem:

Dos
When collaborating with the physician, always position the patient and his/ her
health as the basis of interaction.
Be forthright & assertive and state the nature of your call right up front. If the
patient asked you to make this call, make the physician aware of this.
Establishing a good channel of communication with the physician is essential in
building a team approach to patient care.
Establish a respectful relationship where all the parties are aware of how each
professional can contribute to optimize the overall care of the patient.

Dont
Do not make judgments on the physicians capabilities to choose a therapy for his/her
patient.

What is often asked?
Pharmacist are often asked about regarding
Alternate antibiotics therapy options,
Drug interactions,
Contraindications or non-adherence, is highly valued by the physician.

This information can dramatically alter the course of treatment or therapy that the
physician prescribes.
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16-2
Practice Stations
Scenario # 1

You are supposed to have a dialogue with the Doctor, who will be inside the room
waiting for you. Go through the patients therapy. You may ask the Doctor anything you
feel is relevant to the case. Recommend any changes that you believe are necessary for
the benefit of the patient and document your response.

Patient Profile: (on the table)

Patient Name: John carlos
Age: 45 years
Address: Prep Ave
Allergies: Septra
Medications: Ferrous Sulphate (started 6 months ago)
Comments: Ulcerative Colitis
Dr: Tips

New Rx: Sulfaslazine 1.5gms TID x 1 / 12

On the Table: CPS and TC

Scenario # 2

You are supposed to have a dialogue with the Doctor, who will be inside the room
waiting for you. Go through the patients therapy. You may ask the Doctor anything you
feel is relevant to the case. Recommend any changes that you believe are necessary for
the benefit of the patient and document your response.

Patient Profile: (on the table)

Patient Name: Mrs Joshua Comments: Breast Cancer
Age: 52 years Parkinsons disease
Address: XYZ Medications: Pergolide 1mg TID
Dr: Gaucher (Started 3yrs ago)
Sinemet CR 200/50 QID
(Started 10 yrs ago)
Tamoxifen 20mg BIB
(Started 2 wks ago)
New Rx: Metochlorpromide 10mg po PRN (30 Tablets)

References on the desk: CPS and TC
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16-3
Scenario # 3

You are supposed to have a dialogue with the Doctor, who will be inside the room
waiting for you. Go through the patients therapy. You may ask the Doctor anything you
feel is relevant to the case. Recommend any changes that you believe are necessary for
the benefit of the patient and document your response.

Patient Profile: (on the table)

Patient Name: Miss Jane Comments: Otitis Media
Age: 28 months Medications: Amoxicillin Suspension
Address: Prep Ave (Stopped today)
Dr: Tips Allergies: None known


New Rx: Cefuroxime Suspension 250mg, 1tsf BID x 5 / 7

Scenario # 4

You are a Hospital Pharmacist and you are supposed to have a dialogue with the Doctor,
who will be inside the room waiting for you. Go through the patients therapy. You may
ask the Doctor anything you feel is relevant to the case. Recommend any changes that
you believe are necessary for the benefit of the patient and document your response.

Patient Name: Ms Casie Comments: Community Acquired
Age: 29 years Pneumonia
Address: Prep Ave Medications: Materna Multivitamins
Dr: Tips (Started 4 months ago)


New Rx: IV Levofloxacin 500mg Q24HRS x 10 / 7


Scenario # 5

You are supposed to have a dialogue with the Doctor, who will be inside the room
waiting for you. Go through the patients therapy. You may ask the Doctor anything you
feel is relevant to the case. Recommend any changes that you believe are necessary for
the benefit of the patient and document your response.

Patient Profile: (on the table)

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16-4
Patient Name: Mrs Jacky Comments: Osteo-Arthritis
Age: 55 years Medications: Tylenol 1000mg QID
Address: Prep ave (Started 2 months ago)
Dr: Tips Codeine SR 60mg QID x 2/52
(Started 2 days ago)

New Rx: Carbamezapine 100mg TID x 5/7 then,
200mg TID x 1/12
(For Trigeminal Neuralgia)

Scenario # 6

Patient Profile: (on the table)

Patient Name: Billy Comments: Asthma & phenylketonuria
Age: 9 years Medications: Salbutamol Inhaler PRN
Address: Prep Ave Fluticasone Inhaler 1puff BID
Dr: Tips (Started 2 years ago)


New Rx: Zafirlukast 20mg tablets BID x 1 / 12, then to review.


Scenario # 7

Patient Profile: (on the table)

Patient Name: Catherine Comments: hypothyroidism and Hypertension
Age: 82 years
Address: Prep Ave Medications: Levothyroxin tablets
Dr: Tips Chewable Aspirin 81mg QD
Metoprolol SR 100mg QD


On the desk: CPS





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3-1
17

Communication Skills: Collaborating
with healthcare professional

Pharmacist and Pharmacy Technician Relation

If the pharmacist observes the pharmacy technician making mistakes, the pharmacist has to
deal with the errant technician in a proper way.
Politely ask the technician to excuse himself from his work and talk to him/her in a private
area.
Talk in a calm and firm manner and discuss about his/her error.
Appreciate his/her hard work, her/ his contribution to the pharmacy (like doing his/her job
properly), etc., but discuss the problem clearly. For e.g. if the technician has counseled a patient
for an OTC formulation, he/she has to be told that there are 2 reasons why a technician cannot
counsel:

It is not legal for a pharmacy technician to counsel on any OTC medication. Only the
pharmacist is allowed to counsel patients.
One may risk the health of patients probably due to an allergy triggered by the OTC
formulation or if the patients have medical conditions in which the product is contraindicated.
Pharmacist has the knowledge needed to explain the potential dangers of natural health
products to customers and he can advise them about herb-drug or herb-disease interactions.
Pharmacist always uses his professional judgment to make a decision.

Alternative therapies are not always safe and without side effects contrary to general opinion.
There is a lack of scientific data on their effectiveness ad safety profile and their interactions
with Rx drugs. That is why it is important to refer patients to the pharmacist if they have any
queries about natural / alternative products as the pharmacist can determine if the benefits of
using alternative product is worth the risk/side effects.

Take this opportunity to go over the duties of a pharmacy technician.
Give a copy of the regulations and ask the technician to go over it and discuss it, if he/she
needs any further explanation.
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3-2
Take his/her signature over the copy.
Always use positive words (USE POSITIVE CRITICISM) and expect the technician to learn
from the mistake and not repeat it.
Encourage the technician to keep up with his/her good work.

A situation where the technician has taken a new Rx over the phone from a doctor.
Firstly, technicians are not allowed to take new Rx from a doctor over the phone, the call must
be transferred to the pharmacist as the pharmacist can discuss any drug related problems or any
other question related to the therapy, with the doctor. Even if the pharmacist is busy, the
technician should take the doctors phone number and let the pharmacist call the doctor and
take the new prescription personally.
Take this opportunity to go over the duties of the technician. Call the doctor and verify the
prescription.




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3-3
Practice Stations
Scenario # 1

The pharmacy technician comes to you, the pharmacist, in your office with a Prescription for a
patient who is already on Hydrochlorthiazide Tablets 25mg and asks for your opinion. Have a
dialogue with him and guide him accordingly.

Rx: Enalapril 20mg QD.

On the desk:

Photocopies of regulation and CPS



Scenario # 2

You are a Hospital Pharmacist and you overheard one of the junior Pharmacists having a
conversation with a Doctor over the phone and advising him that Vancomycin IV can be
replaced with oral vancomycin. Have a dialogue with the Pharmacist and advice him
accordingly.


Scenario # 3

You just dispensed Paroxetine 20 mg tablets to a male patient. While paying for his medication
you overheard the patient asking the cashier at the Dispensary that he read in the leaflet of the
medication, it causes sexual dysfunction in males. The cashiers response to the patient was
that many men take it and not so many complain of it. Talk to the cashier and take the right
action to solve the situation.


Scenario # 4

You are the Pharmacy Manager and you overhear one of the staff Pharmacists in the Pharmacy
recommending a mother of an 18 month-old Lopramide capsules for her child. If you believe
that it is a problem, talk to him accordingly and assist in solving it.

On the table:
Maalox suspension
Oral rehydration sachets
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3-4
Scenario # 5

A patient comes in to collect a prescription for Amoxicillin. Prescribed by a dentist to be taken
just before dental treatment. The patient profile shows that the patient is allergic to penicillin.

Discuss an alternative with the dentist.
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61
18
Communication Skills:
Devices Demonstrations
Aerochamber



Remove cap.
Shake inhaler and insert in back of aerochamber
Place mouthpiece in mouth (or mask over mouth and nose)
Encourage person to breathe in and out slowly and gently. (If you hear a
whistling sound the person is breathing in too quickly*)
Once breathing pattern is well established, depress canister with free
hand and leave canister in same position as person continues to breathe
in and out slowly (tidal breathing) five more times
Remove the aerochamber from persons mouth
For a second dose wait a few seconds and repeat steps 2-6

The child
Aerochamber
The child aerochamber device with mask and infant aerochamber device
with mask do not whistle

Metered dose inhalers
Metered dose
inhaler

Remove cap and shake inhaler
Breathe out gently
Put mouthpiece in mouth and at start of inspiration, which should be
slow and deep, press canister down and continue to inhale deeply
Hold breath for 10 seconds, or as long as possible then breathe out
slowly
Wait for a few seconds before repeating steps 2-4


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62
Diskus
Diskus

Hold the outer casing of the Diskus in one hand whilst pushing the
thumb grip away until a click is heard (OPEN)
Hold diskus with mouthpiece towards you, slide lever away until it
clicks. This makes the dose available for inhalation and moves the
dose counter on
Breathe out gently away from the device, put mouthpiece in mouth
and breathe in.
Remove Diskus from mouth and hold breath for about 10 seconds
To close, slide thumb grip back towards you as far as it will go
until it clicks
For a second dose repeat sections 1to 5
Turbohaler
Turbohaler

Unscrew and lift off white cover. Hold turbohaler upright and twist grip
forwards and backwards as far as it will go. You should hear a click
Breathe out gently, put mouthpiece between lips and breathe in as deeply
as possible. Even when a full dose is taken there may be no taste
Remove the turbohaler from mouth and hold breath for about 10 seconds.
Replace the white cover

Patient Counseling Information on Nasal Decongestants:
Drops
Blow your nose.
Squeeze rubber bulb on dropper & withdraw medication from bottle
Recline on a bed & hang head over the side (preferred) OR tilt head back while standing or
sitting.
Place drops into each nostril & gently tilt the head from side to side to distribute the drug.
Keep head tilted for a few minutes after instilling the drops.
Rinse the dropper with hot water.

Spray (atomizer)
Blow your nose.
Remove cap from spray container.
For best results, dont shake the squeeze bottle.
Administer one spray with head in upright position. Sniff deeply while squeezing the bottle.
Wait 3-5 minutes & blow nose.
Administer another spray if necessary.
Rinse the spray tip with hot water taking care not to allow water to enter the bottle.
Replace cap.
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Inhalers
Blow your nose.
Warm inhaler in your hand to increase volatility of the medication.
Remove the protective cap.
Inhale medicated vapor in one nostril while closing off the other nostril, repeat in other
nostril. Wipe the inhaler clean after each use.
Replace cap immediately.
Note: Inhaler loses its potency after 2 to 3 months even though the aroma may linger.

Metered Dose Pump (Spray)

Blow your nose.
Remove the protective cap.
Prime the metered pump by depressing several times (for first use), pointing away from the
face.
Hold the bottle with the thumb at the base & nozzle between first & second fingers.
Insert pump gently into the nose with the head upright.
Depress pump completely & sniff deeply.
Wait 3-5 minutes & then blow nose. Administer another spray if necessary.
Rinse the spray tip with hot water taking care not to allow water to enter the bottle.
Replace cap.

Transdermal patches

Evra patch (Hormonal Contraceptive) The patch should be applied to a clean, dry intact
healthy skin on the buttock, abdomen, upper outer arm or upper torso, in a place where it
wont be rubbed by tight clothing. Not on a breast. Half of the clear protective liner is
peeled away. The patient should avoid touching the sticky surface of the patch. The patch
is positioned on the skin and the other half of the liner is removed. The patient should pres
down firmly on the patch with the palm of her hand for 10 seconds, making sure that the
edges stick well. The patch is worn for 7 days. On the Patch Change Day; Day 8, the
used patch is removed and a new one is applied immediately.


Estalis and Estalis Sequi Patch (HRT) Immediately after removal of a patch from the
pouch, and removal of the protective liner, the adhesive side of the Estalis or Vivelle
patch should be placed on a clear, dry area of intact skin and peel off the remaining one-
half of the protective liner. The site selected should also be one at which little wrinkling of
the skin occurs during movement of the body (buttocks and lower abdomen). The waist
should be avoided, since tight clothing may dislodge the patch. Patches should not be
applied to the same skin site for at least 1 week. Not on breast.

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Nitro Dur patch Apply it on arm or chest. Application site should be rotated. A
suitable area may be shaved if necessary. Dont put it on the distal part of extremities.
Hands should be washed thoroughly after application.

Duragesic Patch Apply on chest, back, flank, or upper arm every 3 days.

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Practice Station

Scenario # 1

A patient comes to pick up his prescription

Patient profile (given on the table)

Patient: John Hirtz Patient Profile
Age: 40 years Pulmicort turbohaler 200g 1x2
Allergies: Unknown Serevent Diskus 50g 1x2
Gender: Male Ventolin inh 1-2 puff prn

Rx
Advair Diskus 250g
1x2
60 blisters


Scenario # 2

A patient comes to pick up a prescription

Rx
Ventolin MDI i-ii puffs q 4 to 6 hours prn
Flovent 250 MDI 2 puffs BID

Patient profile: (given by patient after pharmacist candidate request)
Allergies: none
Current medications: benadryl for cough
Medical conditions: just diagnosed with asthma

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19
Communication Skills:
Handling Dispensing Error


It is important to handle situation appropriately to minimize the harm to patient health and the
pharmacist and patient relationship. Communication is the key of handling dispensing error. If
an error does occur, the cause of error must be assessed and correct action should be taken to
prevent future error.

Client Presentations

May not be error?
Error but medication not used?
Error and medication used but no risk?
Error and medication used and risk?
Error and medication used and risk to patient?

Pharmacy Accident Flow Chart

Immediately take control pharmacist on duty advise pharmacist/owner




Isolate
- take customer to private area-do not discuss in front of other customers
- if personal visit or telephone call, pharmacist must give patient individual attention


Get the facts
-inquire and show concern for the patients well being
-determine if any medication was ingested or used
- do not deny


Action to be taken
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- determine if indeed error has been made; if so apologize I am sorry, it appears an error
has been made

If not used If used
- immediately replace the incorrect - immediately return medication for
item with the proper one personally professional evaluation
deliver/taxi as needed

- assure patient that this is an isolated - immediately replace the incorrect
incident, you will review Rx filling and item with proper one- personally
Rx checking process deliver/ taxi.
- be genuine, spend as much time with
patient as required to alleviate all concerns
Counsel New medication
Follow up




Evaluate
- notify Dr., state facts only
- use reference text before talking to
patient or Dr.

tell patient no risk and assure no danger
notify Dr. and explain giving professional analysis
if necessary, have Dr reinforce with patient


show empathy, concern
notify Dr
notify Dr. in all cases
based on Dr recommendations
direct patient to hospital for tests
Call regional pharmacy operations

complete Rx incidence report
Follow- up
calls, visit to patient to show concern and to ask physical status
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Practice Station

Scenario # 1

A regular customer of your pharmacy comes to you with a concern and she is very worried.
Assist her accordingly.

Patient profile: (Provided on desk)

Patient Name: Ms Harry
Age: 47 Years
Address: Xyz
Dr: Tips

Comments: Deep Vein Thrombosis

Current medication: Warfarin 2.5mg QD


Scenario #2

A pharmacist has expired stock of CIPROFLOXACIN and a patient comes to fill prescription
for CIPRO.

Your pharmacy has only expired medication.

Solve problems?


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20
Communication Skills: Managing
Med Check Program
______________________________

Med check programs are designed to manage medication use more effectively, and
improving the patient outcomes of medication use and some cases reducing the need for
medications. It is important to have good communication skills, and pharmacist should
have empathy with dealing with patient objection or concern. Pharmacist should have
assertiveness in communication to explain benefit and harmful effects.

How to approach problem?

Dos

Emphasize the benefits of medication, by discussing about medications.
Make sure medications are working properly
Identify unwanted effects as soon as possible
Identify any problems with taking the medicine so that adjustment can be made as
possible example: timing for convenience, dosage form that palatable and
appropriate.
Avoid wastage if for any reason the medication is discontinued, dispose in
environmentally safe manner
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Practice Stations

Scenario # 1

Age 70-year-old patient does not remember how to take his pills;

Patient profile: (given by patient after pharmacist candidate request)
Allergies: None
Medical conditions: high blood pressure, hyperthyroidism

Current medications: given in table




Scenario # 2

A female patient is confused, and concern about taking her daily pills.

Patient profile: (given by patient after pharmacist candidate request)
Medical conditions: high blood pressure, diabetes and depression


Current medications
Captopril 25 mg tid
Aspirin 81 mg QD
Propylthiouracil 50mg Bid
Hydrochlorothiazide QD
K-Dur QD
Current medications Break fast Lunch Dinner Bedtime
Hydrochlorothiazide 25 mg QD
Zoloft QD
Orlistat TID
Glyburide BID
Metfromin TID
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21
Communication Skills: Discussing
Payment Options

It is important to have prepared your response ahead of time dealing with third party plan
payments, co-payment, and deductibles. Know policies and procedures of your
pharmacy, some pharmacies may decide to waive some of these co-payment, or
additional drug cost charges.

How to approach a problem?

Dos
Prepared for the discussion about competitor advertisements
Give enough time to patient about his/her concerns about extra charges or fee
Provide the best service and explain patient the benefit of staying with your pharmacy

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22
Communications Skills: Dealing with
Difficult Questions

Patients may have some concerns and questions regarding quality of a patients doctor,
medication prescribed is appropriate, and what outcome the patients can expect from
these medications, etc.
It is important to ask more details about their concerns, and their medical conditions,
some are these best referred to doctor. Sometimes require re assurance. In all cases these
types of questions require skill and tact to avoid upsetting patient or doctor.

Dos
Take initiative, do not hesitate to listen their concerns, ask more details about their
concerns.
Address their concerns and questions
Speak in calm and empathetic tone, example: It must be confusing to you, to have
your medications changed several times like this.
Help the patient find the answer. Assist patient to make own assessment of his doctor
and make informed decision.




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Par t 2
Pr obl em
Sol vi ng
Sk i l l s
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23
GI Sympt oms and DRPs

GERD

Patient Presentation

GERD chronic symptoms or mucosal damage produced by the abnormal reflux of gastric
contents into the esophagus
Symptom complex rather than a specific disease entity and commonly refers to pain or
discomfort cantered in the upper abdomen.

Patients often use terms as heartburn, indigestion, gas, bloating and nausea to describe
dyspepsia.

Antacids and alginic acid are appropriate for the management of mild symptoms of GERD
(phase I therapy)
Symptoms persisting longer than 2 weeks require further evaluation and treatment with
prescription medications
Refrigeration of liquid antacids may aid in palatability. Chewable tablets may be more
effective than liquids due to increased adherence of antacid and saliva to the distal
esophagus. Antacids must be taken at least 2 hours apart from tetracyclines, iron, and
digoxin. Antacids and quinolones should be taken 4-6 hours apart
Alginic acid is effective for the relief of GERD symptoms, but there are no data to indicate
esophageal healing on endoscopy. Alginic acid is ineffective if the patient is in the supine
position, and must not be taken at bedtime

Peptic Ulcer Disease

Nonpharmacological Choices
Bland diets are no longer prescribed use moderation if food or beverage makes dyspepsia
worse i.e.
o Coffee
o Orange juice
o Spicy foods
o Fatty foods
o Large meals
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o Eating on the run
Smoking patients were advised to stop smoking prior to H. pylori being recognized as the
causative agent. Patients should be advised to stop smoking for general health reasons.
Stress and Type A personality are still considered to predispose to PUD with the
identification of H. pylori, the roll of stress in PUD has lessened. Stress management may
benefit overall health.

Regimens:
Amoxicillin 1000 mg BID
Clarithromycin 500 mg BID
Lansoprazole 30 mg BID HP Pack
Omeprazole 20 mg BID Losec 1-2-3 A
Esomeprazole 20 mg BID Nexium 1-2-3 A

Patient instructions and Counseling

PPIs are best taken before meal
H2RA may be taken with or without meal
Inform the patient about the importance of completing the entire drug therapy to ensure the
eradication of H pylori and to avoid bacterial resistance
For patients who have trouble of swallowing Lansonaprole granules may be sprinkled onto
applesauce.
Omeprazole capsules should be swallowed whole
If antacid are being used to control breakthrough symptoms, dose should be less than 1-
2hours or after taking an H
2
RA
Amoxicillin, clarithromycin, and metronidazole may be taken without regard to meals;
however taking clarithromycin and metronidazole with food often reduces the incidence of
stomach upset.
Tetracycline is best taken on an empty stomach
Antacids, dairy products, iron containing products should be taken 2 hours before or after
taking tetracycline
Sucralfate should be taken 1 hour before meals and at bedtime


Irritable Bowel Syndrome (IBS)

Abdominal discomfort associated with altered bowel habits. It is characterized by symptoms of
abdominal pain or discomfort
Antispasmodics and anticholinergic agents are best used on an as-needed basis up to three
times per day during acute attacks or before meals when postprandial symptoms are present
Patients taking a TCA should avoid prolonged exposure to sunlight and avoid concurrent
use of CNS depressants
Tegaserod should be taken before meals and should not be initiated during an acute
exacerbation of IBS
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Osmotic laxatives should be used on an as-needed basis. Lactulose may be mixed with
water or juice to increase palatability. Patients should drink plenty of water
Patients must be enrolled in the manufacturer prescribing program in order to receive alosetron.
Patients should not initiate therapy with alosetron if they are currently constipated. Alosetron
should be discontinued if no improvement in symptoms is seen after 4 weeks of therapy

Inflammatory Bowel Disease (IBD)

Ulcerative colitis (UC) and Chrons Disease

Sulfasalazine Should is taken after meals. Patients should avoid sun exposure while taking
sulfasalazine. Folic acid supplementation should be given during sulfasalazine treatment to
avoid anemia. Sulfasalazine may cause orange discoloration of urine and skin. Mesalamine
tablets should be swallowed whole. Suppositories should not be handled excessive and foil
wrappers should be removed before insertion. Suspension enemas should be shaken well
before use
Antacids and ciprofloxacin should be taken 4 to 6 hours apart. Iron or Zinc-containing
products should be taken 4 hours before or 2 hours after taking ciprofloxacin. Patients
should avoid excessive exposure to sunlight
Patients taking methotrexate should avoid alcohol, salicylates, and prolonged exposure to
sunlight. Female patient of child bearing age should be counselled on appropriate
contraceptive measures during methotrexate therapy
Patients receiving therapy with infliximab should be counselled on the possibility of
infusion reactions. Live vaccines should not be administered to patients taking infliximab

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Practice Stations

Scenario # 1

Patient information (Provided on your desk)

Patient Name: John
Age: 45 years
Address: Tips
Comments: Duodenal ulcers
Medications: Ferrous Sulphate (started 6 months ago)
Allergies: Penicillin

Dr: Gaucher

New Rx: Losec 1-2-3 A x 7 d

On the Table: CPS and TC

Dispense the new prescription; address their concerns and their need for information.
Help them to prevent illness and promote healthy life style


Scenario # 2

A patient comes to fill a prescription

Patient information (Provided on your desk)

Patient Name: Anna
Age: 40 yrs
Address: Tips
Doctor: GM

Medical condition: peptic ulcer
Current medications: Nexium (esmoprazole) 40 mg po od x 28 (filled 10 days ago)

Rx:
Losec 1-2-3 A for 7 days

Solve Problems and Counsel


Scenario # 3
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A man comes with following

Rx:
Losec 1-2-3 A

Patient profile: (provided on desk)
Current medication: Prevacid (lansoprazole) 30 mg po od x 30 (filled 14 days ago)

Trying to dispense this prescription you find out that you have no more Losec (omeprazole) in
stock. No other pharmacy is working; wholesale delivery is in 2 days because of long
weekend.

Solve Problems and Counsel


Scenario # 4

A patient is asking for your recommendation

Profile: (patient gives after asking questions)
Diclofenac suppositories 100mg BID
Cyclobenzaprine 10mg TID PRN

On the table:
Tums
Rolaids
Zantac (Ranitidine) 75 mg
Maalox
Gaviscon
Pepto-Bismol

Solve Problems and Counsel


Scenario # 5

A patient approaches you for recommendation

On the table:
Anusol Plus suppositories
Anusol Plus ointment
Tucks wipes
Senokot
Metamucil
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Soflax (Sodium Docusate)

Solve Problems and Counsel


Scenario # 6

Patient is asking for your recommendation to treat upset stomach. He wants to try Pepto-
bismol and is asking if that would be OK.

Medication History:
AC & C (222) 375 mg of ASA, 15 mg of caffeine, and 8 mg of codeine phosphate.
prn for back pain







Solve Problems and Counsel



Scenario# 7

A young lady is asking for your recommendation to treat constipation.


Medication history:
Alesse 21s (6 mo)
Palafer 300 mg 1 cap TID (1 week)

On the table:
Sennokot
Metamucil
Soflax

Solve Problems and Counsel


Scenario# 7

Patient Name: Mr John Comments: Ulcerative Colitis
Age: 45 years
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Medications: Ferrous Sulphate (started 6 months ago)
Address: XYZ Allergies: Septra
Dr: Gaucher

New Rx: Sulfaslazine 1.5gms TID x 1 / 12

On the Table: CPS and TC

Solve Problems and Counsel

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24
Hear t bur n

Presentation Symptoms

Acid regurgitation, pain and heart burn
Heart burn worse when bending over, lying down or after a fatty meal
Pain/difficulty swallowing
Excess burping/ belching/ abdominal bloating
Feeling full after a small meal
if pregnant reassure that it usually resolves after delivery

Questions to ask:

Medical conditions? (hypertension, CHF, pregnancy any restrictions in taking Na
antacids, renal dysfxn restricts Mg)
Current meds? ASA/NSAIDS PGs which protect stomach from acid
What makes it better/worse? Lying down/bending over usu. worsens or after a lg, fatty meal
Where is the pain?

Drug Related Problems
Patient taking drugs/eating foods that contribute to GERD
Patient taking drugs that are contraindicated for their medical conditions (ex. Na+ antacid
for pregnancy/HTN)

Refer
Age: <12 or >50
frequency of pain >2x/week
Symptom incompletely relieved by antacids/ H2RAs; no improvement after 2 weeks
Vomiting, bleeding, unexplained wt. loss, dysphasia, radiating chest pain
Upper airway manifestations (chronic cough >3x/wk, moaning hoarseness

Pharmacotherapy
Non-Prescription Drug
Prescription Drugs
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Non-Pharmacological recommendations
Avoid lying down after meals, eating 3hrs before sleeping
Avoid heavy meals or fatty meals
Exercising on full stomach
Wearing tight fitting clothing
Avoid excessive alcohol, caffeine, nicotine consumption
Elevate torso (not just the head) ~10cm to prevent reflux
Weight loss (if obese)
Encourage to stop smoking

Practice Station

Scenario # 1

A 55-year-old man comes into the pharmacy and complains of chest pains. He asks if you
could recommend something for heartburn.

Patient information (gives after questioning)
Allergies: None


Address his concern


Scenario # 2

A Patient is asking you: What would you recommend for heartburn?

On the table:
Tums
Rolaids
Zantac (Ranitidine) 75 mg
Maalox
Gaviscon
Pepto-Bismol


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25
Di ar r hea
Symptoms
Running to washroom several times a day, Nausea / Vomiting, Abdominal pain, Bloating
Urgency, Malaise, Fever
Bloody or mucoid stool
o Dehydration symptoms:
Sunken eyes
Absence of tears
Decreased urine output
Greater than 5% loss of body wt

Questions to ask:

What is your Age?
How long has the patient had these symptoms? (onset, duration)
Has the patient had similar symptoms before?
Has the patient tried anything to solve the problem? Outcome?
Are there any aggravating factors that cause the constipation?
Reassure that travelers diarrhea is common and self-limiting

Refer to Physician

Refer to physician if diarrhea does not improve in 48 hours with high fever, blood in feces,
severe pain in belly, children less than 6 months old, with vomiting for more than 4-6 hours
with sign of rehydration; more than 6BM in one day

Non pharmacological Choices
Discontinue drugs that cause diarrhea (laxatives, antacids containing magnesium,
antibiotics, diuretics, theophylline, cholinergic drugs, promotility agents, prostaglandins,
acarbose, orilstat)
Stop ingestion of carbohydrate that are poorly absorbed by the small intestine (dietetic
candies, jams containing sorbitol, lactose containing dairy products)
Lactose intolerance two-week therapeutic trial of a lactose-restricted diet can avoid costly
diagnostic work-ups
Reduce oral food intake for 12 to 24 hours will improve symptoms of acute diarrhea
Important to maintain adequate fluid and electrolyte intake
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Bland diet (low fat/ low carbohydrate), can be reintroduced once bowel motions have
subsided

Pharmacotherapy

Travellers diarrhea
Educate on prevention/non-pharms
Avoid foods/beverages aggravate ie. dairy, prune juice, orange juice, caffeine
Frequent hand washing (soap and water or hand sanitizers)
Boil it, cook it, peel it, or forget it


Practice Scenarios

Scenario # 1

A 48-year-old male patient is traveling to Mexico on business. He asks for something for
diarrhea, as he always seems to get it when traveling to this location.

Counsel the patient.



Scenario # 2

Mr G is a healthy 33-year-old male, he presents with prescription for ciprofloxacin 500 mg
twice daily for three days. Your determine that he is traveling to Mexico the following week for
business meeting, and the doctor told him that he may need this drug to treat diarrhea, if it
develops. The doctor also instructed him to buy some Lopramide.

Rx:
Cipro 500 mg bid for 3 days
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26
Const i pat i on

Presentation Symptoms

Feeling full quickly / feeling bloated
Small and hard dry stools
Infrequent defecation
Straining to defecate
Incomplete defecation
Abdominal distension
Nausea and vomiting
Anorexia
Uncomfortable and sluggish
Fecal impaction

Questions to ask
How long has the patient had these symptoms? (Onset, duration)
Has the patient had similar symptoms before?
Has the patient tried anything to solve the problem? Outcome?
Are there any aggravating factors that cause the constipation (i.e. certain foods)?
Do you/Have you use(d) laxatives? (rebound)

Drug Related Problems
Drugs that the patient is taking is causing constipation: opioids, verapamil, anticholinergics
and TCAs
Patient is not using any product, or is using the wrong laxative to relieve constipation
Patient requires preventive measures (non-pharmacological options)
Patient is overusing laxatives

Refer
Rectal pain / bleeding
Blood in stool
Fever / abdominal pain / nausea and vomiting
Narrow stool
No stool for 7d
Severe discomfort
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Nonpharmacological Choices

When possible discontinue drugs with constipating effect
Dietary fibre (20 to 30 g/day) increase gradually to minimize side effects (Flaxseed,
unprocessed bran, whole grains, fruits and vegetables).
Lactase deficient patients can use lactose-containing dairy products (milk, young cheese)
cost effective natural cathartic
Increase fluid intake (8 glass of water per day) avoid alcohol and caffeinated beverages
Try Prunes, stewed fruit, and figs
Encourage regular schedule tome for toilet use e.g. after breakfast develop a conditioned
gastrocolic reflex
Avoid prolonged straining
Encourage physical exercise
Relaxation exercises for pelvic floor and external anal sphincter muscles in conjunction
with biofeedback
Should not ignore defecatory reflex
Digital manipulation of the anal sphincter motility problems e.g. spina bifida
Constipation is a symptom not a disease establish the cause if any correcting it is the
primary objective of treatment.

Treatment

Non-Prescription drugs
Bulk-forming/Fiber Laxatives (Psyllium (Metamucil), bran)
Increase in stool bulk and consistency
Each dose (4.5-20g, 1-3x/day) with adequate fluid (6-8 glasses water/day)
Onset 2-4 days -- Dont use more than 7 days
SE: bloating, flatulence, and. discomfort
Emollient/Lubricant Laxatives (Mineral Oil)
Softens fecal matter
Stimulant Laxatives (Cascara, Senna, Bisacodyl, Castor oil)
Enhances propulsive peristaltic activity
Osmotic Laxatives
Act by drawing fluid into the lumen of the colon (softens stool)
1. Hyperosmotic lactulose (15-60ml), glycerine (2.6g), sorbitol
Lactulose has action in 24-48 hours
Saline Laxatives Magnesium hydroxide (milk of magnesium), Magnesium Citrate and
Sodium Phosphate
Onset = few hours
Side effect of saline laxatives is excessive diuresis

Stool softeners (Docusate Calcium/Docusate Sodium (Colace)
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Practice Station

Scenario #1

Patient comes to you in the Pharmacy with a concern. Handle the situation and take the right
course of action.

Patient is asking for your recommendation

Profile information: (gives information after questioning)
Materna Multivitamins

On the table:
Sennokot
Soflax
Glycerin supp
Lactulose
Ducolax (Bisacodyl)
CitroMag (Mg Citrate)
Metamucil Fiber
Fleet enema


Scenario # 2

A young lady is asking for your recommendation to treat constipation.

Medication History:
Alesse 21s (6 mo)
Palafer 300 mg 1 cap TID (1 week)

On the table:
Sennokot
Metamucil
Soflax

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Hemor r hoi ds (Pi l es)
Abnormally swollen veins in the rectum and anus, caused by too much pressure in the rectum
forcing the blood to stretch and bulge the walls of the veins, and sometimes rupturing them.

Presentation Symptoms
Painful mass at the anus usually lasting several days to weeks, sometimes accompanied by
the sudden relief of pain following rupture of the skin overlying the thrombus and bleeding
Itching, swelling and burning
Prolapse and increased anal discharge
Fecal soiling of underwear
Internal hemorrhoids are painless, with bright red rectal bleeding, pruritus, and pain when
prolapsed
External hemorrhoids are painful, itchy, and there is a mass felt upon defecation.
Pain peaks 48-72 hours after hemorrhoids develop and improves by the 4th day and heals
by the 10th day

Questions to ask:

Determine urgency (see reasons to refer). determine if we can treat in pharmacy
Is there any mucous or blood in the stool? If there is blood, is it bright red or dark?
Any prolapse? Is it painful? Is there a bump that is bluish in colour? Is there a burning
sensation?
Medical conditions? thyroid disorder, HT, diabetes C/I for vasoconstrictors
Medications? meds that cause constipation
Does the patient have any allergies to medication? some pts allergic or sensitive to local
anesthetics
Have you previously experienced similar signs and symptoms?
Are you currently taking any medications for the signs and symptoms?
What is your diet like? Do you eat a lot of fast food, spicy food, and fibre? How much
liquid do you consume daily? (also alcohol and coffee)
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What is your occupation? Does it require you to be sitting for prolonged periods of time or
lift heavy things?
Any constipation? Any diarrhea? Do you resist the urge to defecate?

Refer

Problem lasts for longer than 7 days
Patient is under the age of 12
Stool or mucous leaks from rectum between bowel movements
Hemorrhoid does not go back in place after a bowel movement
Rectal bleeding is present and is present in large amounts, is recurrent, is dark in colour
Patients at high risk of colorectal cancer
Patients who experience acute weight loss
Change in bowel habit (chronic constipation, sudden diarrhea)

Non pharmacological

Decrease risk factors
Treat constipation/diarrhea
Sitz bath (warm water) 3-4 times a day for 15 minutes to relieve irritation and pruritis by
relaxing the anal sphincter
Replace prolapsed hemorrhoids with a moist toilet tissue
Anurex for 6 minutes, twice daily to relieve pain and pruritis
Surgical options & other medical treatments

Treatment Plan

Anti-inflammatory agents = Hydrocortisone 0.5% (should not be used 7 days)
Astringent = ZnO (relieves irritation and burning sensation), calamine (5-25%)
Local anesthetic = Benzocaine (5-20%)
Antiseptics = Domiphen (0.05% cream/ointment)
Protectants = Glycerine, white Petrolatum, ZnO
Vasoconstrictor = Ephedrine, Naphazoline, Phenylephrine
Wound healing = Shark liver oil, yeast
Pregnancy = correct constipation and taking sitz bath
Analgesic = menthol, camphor

Education
Educate patient on product chosen, how to apply
Wash hands and anal area
Suppositories should not be inserted into the rectum; need contact with anus
Medications may help control symptoms but do not fix problem
Non-drug important for prevention
if symptoms persist >10 days, see physician
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Practice Station

Scenario # 1

A patient comes to you in the Pharmacy with a concern. Handle the situation and take the right
course of action.


Patient Name: Mr Andrew Comments: Hypertension
Age: 44 years Medications: Verapamil SR 180mg QD
Address: XYZ Tylenol #3 (Stopped 3mnths ago)
Dr: Gaucher


On the table:
Xylocaine rectal gel
Hydrocortisone gel
Psyllium powder
Senna tablets
Lactulose suspension




Scenario # 2

A patient approaches you for recommendation

On the table:
Anusol Plus suppositories
Anusol Plus ointment
Tucks wipes
Senokot
Metamucil
Soflax (Sodium Docusate)

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28
Nausea & Vomi t i ng, Mot i on
Si c k ness

Presentation Symptoms

Nausea and vomiting
Epigastic distress
Upper abdominal pain
Hypersalivation
Body warmth
Belching
Sweating
Drowsiness, headache, confusion, hyperventilation

Motion Sickness
Sensation of nausea or vomiting due to conflicting signals between the bodys balance system,
and the visual cues. In other words, the eyes see motion, but the body thinks its staying still.

Questions to ask:

Any other symptoms? (ear pain - OM, diarrhea - GI, abdominal pain food poisoning)
Has the patient had similar symptoms before?
Has the patient tried anything to solve the problem? Outcome?
Are there any aggravating factors that cause the motion sickness?

Non Pharmacological

Minimize motion sensation on transport
Fresh air, good ventilation
Get well rested before travel, sleep well during travel
Do not read during motion
Fix vision on horizon that isnt moving
Do not smoke, or drink alcohol
Eat light low fat not spicy meals
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Non salted soda crackers to absorb saliva and excess acid in gut
Follow BRAT (banana, rice, apple sauce, toast)
Drink carbonated beverages
Avoid caffeine
Slow deep breaths

Treatment

Non prescription drugs

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Practice Station

Scenario # 1

A young lady comes to you in the Pharmacy for your advice on a product she feels would be
helpful for her condition. Gather the necessary information from her and advice her
accordingly.


On the Table: Dimenhydrinate 25mg tablets and Pyridoxine Tablets)



Scenario # 2

A young lady comes with prescription:


Rx:

Diclectin tab. PRN 2 hrs before symptoms

Continue till Nausea and vomiting reduce

M: 90

Profile:
Patient Name: Billy
Age: 26 years
Address: Tips
Dr: Gaucher

Comments: Pregnancy induced nausea and vomiting
Medications: Multivitamins/Folic acid
Allergies: None

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Pi nw or m
Presentation symptoms

Many people are asymptomatic
Most common: nocturnal perianal or paerineal itching
Due to Scratching: Insomnia (due to itching), skin irritation, eczematous dermatitis,
bleeding or 2
o
bacterial infection
Migration to female genital area: vulvovaginitis, vaginal discharge
Heavy infestation: anorexia, irritability, abdominal pain

Questions to ask:

Any medical conditions? (epilepsy is important) allergies?
Who else is living in the same household? Because all need to be treated
Have they tried any treatments and did they work at all before?
Have you had this problem before?
Ask questions to find out if body lice or pinworms ie. ask where it is itchy (just anal area,
or elsewhere?)
Does itching get worse at night? (May be contributing to insomnia) basically ask about
signs and symptoms.
Any secondary infection from the scratching?
Do any of the children have a fever?
Are you pregnant? how far along into pregnancy?

Drug Related Problems

Failure to retreat in 2 weeks
Failure to treat infected family members or contacts
Failure to carry out concomitant nonpharmacological hygiene measures

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Nonpharmacological:
Take shower each morning
Regular cleaning or bedding, nightclothes, under wear and hand towels.
Hand wash, nail cleaning mainly before meals.
During week following treatment all family members should wear cotton underpants.
(washed in soap water). Worn day and night change twice daily.
Cleaning of floors of sleeping place.
Clean bedroom articles, curtains where high concentration of eggs.
Avoid shaking linens, curtains before wash.
Avoid thumb sucking in children.
Not effective: Cleaning or vacuuming entire house or washing sheets every day is
probably not effective for reinfection.
No problem: sharing dishes
Avoid sharing undergarments

Prevention:
1. Proper hygiene

Treatment

Non prescription drugs
Pyrantel pamoate (Combantrin)
Comes as suspension or tablet (mix with juice)
Take as single dose, repeat in 2 weeks!
>1yr 11mg/kg x 1 dose, rpt in 2 weeks max 1gm (also in 125mg tablet)
SE: anorexia, N/V/D,
Avoid with liver disease or pregnancy

Combantrin treatment plan:
Give 11mg/kg 1 dose, and make sure to repeat in 2 weeks! shake well before use.
Secondarily, if doesnt work, refer to doctor
Treat others in household who are asymptomatic.
For itch, can give calamine oil, cold compress, and anti-histamines. Avoid local anesthetics.
non pharms are important

Prescription drugs

Mebendazole (Vermox)
Single dose 100mg (repeated after 1 to 2 weeks)
> 2yrs old, minimal SE
Efficacy: 95% effective: Mebendazole > OTC drugs
CI in pregnancy
DI with ANTI SEIZURE drugs

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Key counseling Tips
Retreat, in 2 weeks.
Make sure everyone in household is treated
Get the patients weights, and make sure they know how to accurately measure the dose of
the meds they need to be taking
Letting school, playmates, etc. know to try to reduce spread in the community
When we say hygiene - we have to be careful of that cause pinworms is something that
can be very easily picked up not necessarily due to being in a dirty environment or
anything like that. Even if they are very clean, they could pick it up from somewhere!
So make sure patients are aware that this is very common, so they dont feel bad about it
and they dont worry that people will think theyre dirty and not tell you about their
hygiene

Practice Stations

Scenario # 1

A mother comes into your pharmacy requesting something to treat a childs pinworms. She
said her oldest son had been treated last year but she cannot remember what had been used and
how her youngest son has caught them.

Patients profile:
Three-year-old son
Weight about 45lbs (20kg)
After visit to a physician, doctor diagnosed son as having pinworms and recommended
a treatment that could be bought from a pharmacy
Symptoms: Scratching his bottom a lot
No pain or increased frequency in urination
Recently travel to Disneyland in Anaheim, California
Allergic to erythromycin
Medical history: Downs syndrome
Current Medications: None

Scenario # 2

A Father comes to take advice for his 3-year-old son who seems not to be himself. Assist him
as you would usually in the Pharmacy.

On the table:
Combatrin Tablets
Combantrin Oral Suspension, 5ml single dose
Benadryl syrup
Metamucil powder
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30
I nf ant c ol i c



Symptoms

Pattern of crying with no apparent cause (diagnosis of exclusion)
Wessels Rule of 3: Rhythmic, convulsive crying that lasts for >3 hrs/day, 3days/wk for
>3wks
Starts when baby is 2wks, most common at 4-6wks, then improves (uncommon at 3-4mts)
Baby is otherwise healthy and thriving
Inconsolable, clenched fist, arching of back, drawing up of babys legs to chest, flatus,
reddened face, abdominal distension

Questions to ask:

Age of child?
Signs and symptoms?
What time of day does the crying occur most often?
How long and how frequently has the baby had these symptoms?
Has the parent tried anything to solve the problem? Outcome?
Is the parent breastfeeding?
Reassure parent that infant colic is common, peaks at 4 to 8 wks and then subsides around
3-4mts, self-limiting
Cause is unknown

Refer

Fever
Vomiting
Infection or illness is suspected
Blood or mucus in stool

Treatment Plan

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Drug measures are generally NOT recommended and should not be used unless
recommended by a physician
If had to recommend one:
Flatulex/Simethicone 40mg/ml (anti-flatulent) unlabeled use for colic (Profs choice)
12% sucrose solution (possible analgesic effect <30min)
Herbal teas: chamomile, mint some antispasmotic activity, used in some cultures to
soothe infants (dont add sugar or honey)
Generally NOT recommended:
Gripe water (no evidence of benefit)
Dicyclomine (antispasmotic; not for <6mts)
Hypnotics, sedatives, muscle relaxants,alcohol, diphenhydramine, antispasmotic +
antichol combo

Non pharmacological

Try different Strategies
Soft rhythmic motions, whole body or belly massages
Car rides, walk, rock baby in arms
Create white noise playing music, vacuum cleaner, washer, fan
Skin-to-skin contact
Continue breastfeeding
Try removing cow milk from mom and babys diet for one week to see if symptoms lessen
Mother should avoid foods that aggravate colic (garlic, caffeine)
Substitute formula for soy or hypoallergenic formula- d/c if no benefit after 1 wk
Change frequency and technique of feeding the baby
Burp more frequently
Sleeping positions (Refer to Edu/Counselling)


Education

Sleeping positions: Baby should be placed face up on their backs for sleeping; can lay on
stomach for short time (supervise)
Foods that aggravate colic: Cruciferous vegetables (broccoli, cabbage, cauliflower), soy,
onions, peanuts, artificial sweeteners, eggs, chocolate
Feeding: Only feed baby when its hungry instead of every time it cries
Hold baby in vertical position to minimize swallowing air, burp after 30-60mL or every 5-
10 min
Use collapsible bag to decrease amt of air swallowed
If bottlefed- choose a nipple with the appropriate hole size to reduce amt of air swallowed
For gastric distress: do bicycle motions with babys legs
Discourage switching to formula in an effort to reduce colic can make situation worse
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Practice Stations

Scenario # 1

A mother comes in complaining that her baby has severe colic. She is now quite desperate, as
nothing seems to work.

Counsel the patient on how best to handle the infant.

Patient profile: (gives after pharmacist candidate requests)
Age; 3 months
Allergies: Not known
Current medications: None
Medical conditions: none

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31
Car di ovasc ul ar DRPs

Diuretics
Patients who are allergic to sulfa-containing drugs may be allergic to these medications.
It can cause frequent urination.
Patients should weigh themselves daily if possible every morning after urinating. If the
patient gains more than one pound a day or 3-5 pounds in a week should contact his/her
health care provider.
Muscle cramps, dizziness, excessive thirst, weakness, or confusion should be reported as
these are signs of overdiuresis.
Photosensitivity: Patient should avoid sun exposure or put sunscreen if cannot be avoided.

Angiotensin-Converting Enzyme Inhibitors (ACE Inh)
Breast feeding and pregnant mothers should not take ACE inhibitor. If they become
pregnant while on medication, they should contact their physician immediately.
Captopril should be taken in an empty stomach, 1 hour before or 2 hours after meal.
Use salt substitutes that contain potassium cautiously
Call doctor ASAP if you experience swelling of the face, eyes, lips, tongue, arms, or legs,
or if you have difficulty breathing or swallowing
These may cause cough

Beta-Blockers
May cause fluid retention or worsening of heart failure with initiation of therapy or an
increase in dose
Patients should weigh themselves daily if possible every morning after urinating. If the
patient gains more than one pound a day or 3 to 5 pounds in a week should contact his/her
health care provider.
Body or leg swelling or increased shortness of breath should be reported
Fatigue or weakness may occur in the first few weeks of treatment, but often may resolve
spontaneously.
Report any cases of dizziness, light-headedness, or blurred vision. These may be caused of
too low blood pressure or from bradycardia or heart attack.
Carvedilol should be taken with food
It is important not to miss doses or abruptly stop taking these medications.
Beta blockers may cause blood sugar to rise and mask the signs of hypoglycemia except for
sweating with diabetic patients.
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Warfarin

Hemorrhagic complications due to changes in INR (acute increase in bruises and
nosebleeds)
Skin necrosis uncommon but serious, occurs in first week of therapy (prevented by
initiation of heparin with warfarin)
Purple toe syndrome
Teratogenic
Skin rashes and alopecia occasionally occur

Nitrates

Nitrate tolerance develops with continuous use in most patients
Nitrate tolerance ] Loss of hemodynamic and antianginal effects during sustained therapy
Provision of nitrate-free period of 12 hours with all long-acting preparations is required to
limit or prevent tolerance from developing
ISDN schedule: TID on a QID schedule (7 a.m., 1 p.m., and 7 p.m.)

Amiodarone

Ocular corneal microdeposits (feels like sand in the eyes), reversible on discontinue
Thyroid hyperthyroidism, hypothoroidism
Respiratory pulmonary inflammation or pulmonary fibrosis (new respiratory symptoms)
Neurologic Dizziness, tremor, fatigue, headache
Dermatologic photosensitivity
GI nausea, vomiting, constipation

Digoxin

Patient should report to the health care provider if any of the following may occur:
Dizziness, lightheadedness, fatigue
Changes in vision like blurred or yellow vision
Irregular heartbeat
Loss of appetite
Nausea, vomiting, or diarrhea
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Practice Station

Scenario # 1

A patient comes to fill prescription:

Patient profile: (given by patient after pharmacist candidate request)

Patient Name: Amy
Age: 55 yrs
Address: Tips
Doctor: OZ

Medical Condition: hyperlipidemia and high B.P
Current Medications: Diovan HCT 80/12.5 mg po daily

Rx:
Lipitor
Sig: 20 mg po daily x 3 months
Mitte: 90 tablets
R: 2

Solve problem and counsel


Scenario # 2

A patient comes to fill prescription:

Patient Name: MK
Age: 62 years
Address: Pharmacy Prep
Doctor: MD

Medical Condition: DVT
Current Medications: Fragmin 15,000 IU s/c od x 7 days (filled 2 days ago)

Rx

Warfarin 5 mg po od or ud x 30 tabs
Mitte: 30

Solve problem and counsel
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___________________________________________________________________

Scenario # 3

Patient provides following Rx
Rx Isosorbide dinitrate
30mg TID on QID (6 hourly) schedule

Current Medications:
Hydralazine 25 mg tid
Ramipril 5 mg po od
Bisoprolol 5 mg po od
ASA 352 mg po od

Solve problem and counsel

Scenario #4

A patient approaches you for recommendation about cough syrup

Patient Profile:
Ramipril 10 mg po od (1 month)
Simvastatin 10 mg po od (1 year)
On the table: DM syrup, DM-E syrup

Solve problem and counsel


Scenario # 5

A doctor is calling with new prescription

Patients Profile:

Patients medical history:
Atrial Fibrilation, Dyslipidemia
Current medications
Diltiazem CD 180 mg po od
Simvastatin 20 mg po od
Warfarin 5 mg po od

Solve problem and counsel

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Scenario # 6

A patient presents following prescription

Rx

Amiodarone 200 mg po od

Patients Profile: (gives after pharmacist candidate requests)
Diltiazem CD 180 mg po od
Simvastatin 20 mg po od
Warfarin 5 mg po od

Solve problem and counsel

Scenario # 7

A doctor is calling with new prescription

Patient profile (present on the table)

Patient Name: OZ
Age: 60 yrs
Medical condition: Congestive Heart Failure, and Renal Insufficiency
Patients Body Weight: 50 kg
Current Medication: Enalapril 5 mg po BID

Solve problem and counsel

Scenario # 8

A patient has approached you for recommendations on anti-nausea medication

Patients profile:
Current medications: Enalapril 5 mg po BID, digoxin 125 mcg po daily

Patients medical condition:
Congestive Heart Failure, Renal Insufficiency

Solve problem and counsel
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Scenario # 9

A patient presents with the following Rx

Rx:
Adalat XL 30 mg po od
M: 30 tabs


Solve problem and counsel


Scenario # 10

A 48 year old man complains that he has been wheezing lately and a but short of breath. He
has just recently moved up from Vancouver and is now living in Toronto. Within the last week
he has been put on a medication for mild hypertension.

Counsel the patient.

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32
Hypert ension
Counselling Tips

Nonpharmacological Choices
Weight loss if overweight
Healthy diet high in fresh fruits, vegetables, and low-fat dairy products, low in saturated
fats and salt
Regular moderate intensity cardio respiratory physical activity
Low risk alcohol consumption 0 to 2 drinks/day less than 9 per week for women and less
than 14 per week for men
Smoke free environment
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Practice Station


Scenario # 1

Patient is inquiring if he can you Zostrix HP (Capsaicin cream) for his burning feet.
Patient is holding an old tube (used) of Zostrix HP cream.

On the table:
Tylenol ES
RUB A535 heat
Myoflex 15%


Scenario # 2

A patient comes to you in pharmacy for your advice, educate and counsel patient.

Patient Name: John
Age: 52 Years
Doctor: Tips
Address: xyz

Medical condition: Hypertension
Medications: HCT 25 mgQD (started 3 years ago)

New Rx:
Felodipine 5mg QD x 1/12 (4 refills)


Scenario # 3

The lady comes to you in the pharmacy. Solve her concern and take the steps necessary.

Patient Name: Mrs Kathy
Age: 52 years
Address: XYZ
Dr: Tips

Comments: Hypertension
Medications: HCT 25mg QD (5 yrs ago)
Enalapril 20mg (Started 2wks ago)
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OTC Medications: Benylin DM (Since 1wk)

On the table: Throat lozenges Codeine cough syrup


Scenario # 4

A very disturbed old lady comes to you in the pharmacy and asks for your assistance. Respond
the way you would in the pharmacy in daily life. Promote compliance.

Patient record: Presented on desk

Patient Name: Mrs. Harry
Age: 75 Years
Address: xyz
Doctor: Tips

Comments: Hypertension and Hyperthyroidism

Medications Doctor Name Repeats
Captopril 25mg TID Tips 0
Asprin 81 mg QD Tips 0
Propylthiouracil 50 mg BID Tips 0
HCT 12.5 mg QD Tips 0
K-DUR QD Tips 0


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Ant ihyperlipedemic Drugs
Statins

Usually administered in the evening because most hepatic cholesterol production occurs
during night
Lovastatin conventional tablets should be given with the evening meal since absorption is
better with food. For the extended-release lovastatin products should be taken at bedtime.
Lovastatin + Niaspan combination product should be taken at bedtime with low-fat snack
Non-extended release statins can be dosed once daily
Other regular dosage forms should be divided as the doses are raised above 40mg/d
Atorvastatin may be given any time of the day because of its longer half-life
Rosuvastatin dosage adjustment is required in patients with severe renal impairment.
Plasma concentrations of rosuvastatin increased to a clinically significant extent (about 3-
fold) in patients with severe renal impairment (CL
CR
30mL/min/1.73m
2
) compared with
healthy subjects (CL
CR
80mL/min/1.73m
2
). Dosage adjustment is also required in patients
with liver disease
Monitor LFTs and muscle toxicity.

Bile acid sequestrants (resins): Cholestyramine and colestipol:

Start with 1 dose daily with the largest meal. May be increased (after the patient adjust to
the resin) to two doses daily with the largest meals or divided between breakfast and dinner
Titrate doses slowly to avoid gastrointestinal side effects
Powdered doses can be mixed with food such as soup, oatmeal, nonfat yoghurt, apple sauce
among others. The mixture can also be chilled overnight to improve palatability
Do not use carbonated beverages to mix, as this promotes increased air swallowing
Drinking through straw may also help
Patients who suffer constipation with the resins may mix them with psyllium; however, this
mixture should be ingested immediately after mixing in order to prevent gel from forming
Counsel patient to rinse the glass to ensure ingestion of all resin
Colesevelam is a tablet formulation, which may be easier for some patients to self-
administer. However, the tablets are large, and some patients may not be able to swallow
them
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Monitor for adherence and gastrointestinal side effects for all resins.

Nicotinic Acid (Niacin)

Immediate-release (IR) niacin should be started at a low dose and slowly titrated upward
Start with 100mg tid and adjust upward the second week to 200mg tid; the next will
increase to 350mg tid. When 1500mg/d is reached and maintained for 4 weeks, assess
effectiveness before increasing the dose
If further titration is needed, go to 750 mg tid and assess effectiveness after 4 weeks before
increasing. Maximum dose is 1000mg tid
Aspirin 325mg or ibuprofen 200mg must be given 30 minutes before the morning dose to
minimize flushing and itching
Caution patients to avoid hot beverages and hot showers so as not to exacerbate the
flushing effect
Extended-release formulation (ER) should be taken at bedtime (500mg) and titrated weekly
to a maximum of 1500mg/d. Aspirin should be taken 30 minutes before the dose.
Sustained-release formulations are started at 250mg bid and increased at weekly intervals to
a maximum of 2000 mg/d. Aspirin should be given 30 minutes before the dose
Monitor for adherence and side-effects. The titration schedule for some patients may have
to be gradual due to flushing and itching.

Fibric Acids (Fibrates): Gemfibrozil

Gemfibrozil should be taken twice daily 30 minutes before meals
Tricor can be taken wit or without food once daily
Reduce dose in renal insufficiency and monitor for muscle toxicity, especially when used in
combination with statins and niacin

Cholesterol Inhibitors

Dosed once daily without regard to food
Can be taken simultaneously in combination with statins.

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Practice Station

Scenario # 1

The patient comes to you with a concern. Respond the way you would in the Pharmacy.

Patient record: (presented on desk)

Patient Name: Mr Harry Comments: Hyperlipidemia
Age: 48 years Type 2 Diabetes
Address: XYZ
Dr: Tips

Medications Qty
Atorvastatin 20 mg QD
Metformin 500 mg TID



(On the table: Tylenol 500mg tablets
Advil 200mg tablets
Centrum Multivitamins)


Scenario # 2

A 52-year-old male brings a prescription

Rx:
Questran powder
Take one 4g scoop in the morning
M: 1 can

Patients profile: (presented by patient after request)
Medical conditions: Hypertension, and high cholesterol
No known drug allergies
Medication: 3 prescriptions for Furosemide 40mg 1 tab qam, on for the last 1 year


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34
I sc hemi c Hear t Di seases

Counselling Tips

Nitrate tolerance develops with continuous use in most patients
Nitrate tolerance, Loss of hemodynamic and antianginal effects during sustained therapy
Provision of nitrate-free period of 12 hours with all long-acting preparations is required to
limit or prevent tolerance from developing
ISDN schedule: TID on a QID schedule (7 a.m., 1 p.m., and 7 p.m.)


Nitrates
Avoid alcohol consumption
May cause dizziness. Avoid driving, operating machineries, doing hazardous activities until
drug effect is known
To avoid abrupt drop of blood pressure when standing from sitting position, rise slowly.
Report to the physician if you feel dizziness, acute headache, or blurred vision

Nitroglycerin Sublingual tablets:
Keep tablets in their original container
Dissolve tablet under the tongue. Lack of tingling does not indicate a lack of potency
*Take one tablet at first sign of chest pain. If chest pain is unrelieved, seek emergency
medical attention

Nitroglycerin Translingual spray:
Spray under the tongue or onto tongue
Hold spray nozzle as close to the mouth or under the tongue
Do not inhale the spray or use near heat, open flame, or while smoking
Close mouth immediately after spraying
Avoid eating, drinking, or smoking for 5-10 minutes
If the pain does not go away after 1 spray, seek emergency medical attention

Nitroglycerin Transmucosal tablets:
Place between cheek and gum. Do not chew tablet; allow to dissolve over 3- to 5-hour
period
Touching the tablet with the tongue or hot liquids may increase release of the medication
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Nitroglycerin Ointment:
Measure the correct amount using the papers provided with the product
Use papers for the application, not fingers
Apply to the chest or back

Nitroglycerin Transdermal patches:
Tear the wrapper open carefully. Never cut the wrapper or patch with scissors.
Do not use any patch that has been cut by accident
Apply to a hairless area and rotate sites to avoid irritation. Be sure to remove the old patch
before applying a new one
Do not put the patch over burns, cuts, irritated skin
Remove the patch approximately 12-14 hours after placing it on every day. This prevents
tolerance to the beneficial effects of NTG
Used patches may still contain residual medication; use caution when disposing around
children and pets
Store the patches at room temperature in a closed container, away from heat, moisture, and
direct light. Do not refrigerate

Nitroglycerin Sustained-release tablets
Take at the same time each day as directed
Do not chew or crush tablets/capsules

Antiplatelet Drug Therapy:
Aspirin
Avoid additional OTC products containing ASA, NSAIDs, or salicylates ingredients
without the direction of a physician
Patient who have received a stent will need the combination of clopidogrel and aspirin
Notify physician of dark, tarry stools, persistent stomach pain, difficulty breathing, unusual
bruising or bleeding, or skin rash
Do not crush an enteric-coated product

Thienopyridines:
Combination with ASA is necessary in patients receiving stents
Avoid additional ASA, salicylates, and NSAID products unless under the direction of a
physician
Notify physician for unusual bleeding or bruising, blood in the urine, stool, or emesis; skin
rash or yellowing of the skin or eyes
Do not stop taking without discussing with physician

Statins
Usually administered in the evening because most hepatic cholesterol production occurs
during night
Lovastatin conventional tablets should be given with the evening meal since absorption is
better with food. For the extended-release lovastatin products should be taken at bedtime.
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Lovastatin + Niaspan combination product should be taken at bedtime with low-fat snack
Non-extended release statins can be dosed once daily
Other regular dosage forms should be divided as the doses are raised above 40mg/d
Atorvastatin may be given any time of the day because of its longer half-life
Rosuvastatin dosage adjustment is required in patients with severe renal impairment.
Plasma concentrations of rosuvastatin increased to a clinically significant extent (about 3-
fold) in patients with severe renal impairment (CL
CR
30mL/min/1.73m
2
) compared with
healthy subjects (CL
CR
80mL/min/1.73m
2
). Dosage adjustment is also required in patients
with liver disease
Monitor LFTs and muscle toxicity.

Practice Stations

Scenario # 1

A patient comes to pick up his new prescription he left at the pharmacy with you earlier today.
He also has a concern regarding his medications, solve as you would in the Pharmacy.

Patient Name: Mr Garry
Age: 62 Years
Address: Xyz
Dr: Tips

Comments: Rheumatoid Arthritis Angina Pectoris


Diclofenac Sr 75mg Qd Started 1 Wk Ago
Nitro Spray
Lisinopril 20mg Qd
Simvastatin Qd
Asprin 81mg Qd
Metoprolol Sr 100mg Qd


New Rx:
Nitroglycerin SL tablets 0.5mg PRN (dispense 1 bottle)

On the DESK: Nitroglycerin SL and Nitroglycerin Spray
CPS


Scenario # 2

A lady comes to you, the pharmacist, for your advice. Counsel her as you would in the
Pharmacy.
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Patient profile: (Presented by patient after request)
Patient Name: Ms. Jane
Age: 67 Years
Address: xyz
Doctor: Tips

Comments: Type 1 Diabetes Angina
Medications
Human Insulin 10 iu BID Since 10 years
Nitro Spray Since 2 months

On the Desk: Nitro lingual spray
On the desk: CPS


Scenario # 3

A 50 year old male comes into the pharmacy to collect his prescription for Nitrolingual spray.
He is a first time user.

Counsel the patient.
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35
Ant i c oagul ant s and War f ar i n
Management

Counselling Tips

Therapy to prevent Venous Thromboembolism:

Heparin, LMWH, Warfarin, Fondaparinux, Direct thrombin inhibitor

Heparin, Fondaparinux, thrombin inhibitors, thrombolytic are not applicable
LMWHs, Fondoparinux: patient should be taught to self-inject after hospital discharge
monitor for the signs and symptoms of bleeding or VTE recurrence
Avoid NSAIDs

Warfarin
Hemorrhagic complications due to changes in INR (acute increase in bruises and
nosebleeds)
Skin necrosis uncommon but serious, occurs in first week of therapy (prevented by
initiation of heparin with warfarin)
Purple toe syndrome
Teratogenic
Skin rashes and alopecia occasionally occur


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Practice Station

Scenario # 1

Patient comes into the pharmacy wishing to purchase Bengay (methyl salicylate ointment) for a
pain that he has in his ankle.

Name: Rick
Age: 45 years
Address: Tips
Doctor: MD

Comments: Ankle Pain
Current Medications: Warfarin 5mg 1 QD (Started 1 month ago)

Counsel the patient.



Scenario # 2

A patient comes to you in the Pharmacy and has questions regarding a certain product. Counsel
and advice the patient accordingly, and take the right course of action.

Patient Name: Mr John Comments: Deep Vein Thrombosis
Age: 45 years Medications: Warfarin 2.5mg QD
Address: XYZ
Dr: Gaucher

On the table:
Ginkgo Biloba capsules
Ginseng capsules


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36
Psyc hol ogi c al Di sor der s

Patient Concerns
Because many are embarrassed and demoralized by having a mental disorder, the patient,
his family, and his employer (when appropriate and after obtaining informed consent from
the patient) should be told that most often, depression is a self-limiting medical disorder,
with a good prognosis. SSRI

The Serotonin Syndrome (SS)
Results of excessive stimulation of the brain & spinal cord at the 5-HT receptors
Symptoms: confusion, agitation, diaphoresis, shivering, myoclonus, tremor, diarrhea, in
coordination.
Also, seizures, parasthesias, hypertension or hypotension.
Patients should be informed of the potential symptoms of SS & be referred to doctor should
these symptoms occur.

Serotonin Discontinuation Syndrome
Occurs if an SSRI is stopped abruptly
Occurs in 2 or 3 days or up to 1 week after discontinuation of treatment
Can last 1 to 2 weeks
Symptoms: dizziness, impaired coordination, gastrointestinal disturbances, flu-like
sensations, insomnia, nightmares, anxiety, agitation and mania
Symptoms are self limiting
To avoid taper SSRI gradually

To promote compliance pharmacists must emphasize:
Depression is a legitimate illness that is quite common.
Depression needs to be treated. Treatment can be successful, but success depends on
compliance.
Treatment will take a minimum of 6 months.
Antidepressants are non-addicting.
Most antidepressants need to be discontinued slowly.
Antidepressants have side effects. However, most side effects can be managed. Assure
patient that most side effects will not occur.
Encourage patient to call or see you if side effects occur or become bothersome.
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A response to the medication may take 2 to 4 weeks. The dose may have to be adjusted
before treatment is successful.
Encourage patients to keep a record/diary of how they are feeling: they can rate mood,
irritability, appetite, fatigue, etc.
Obtain the patients permission for follow up consultations.

Use of antidepressants in pregnancy
Discontinuing or modifying effective treatment is associated with an increased risk of
relapse, a greater severity of illness and in suicidality.
Uncontrolled depression during pregnancy many adverse outcomes for mother and baby
(unfavorable maternal/infant biochemical profile)
Maternal anxiety/depression ] reduced blood flow to the fetus (low birth weight, delayed
growth, and premature birth)
Virtually no medication can be described as completely safe during pregnancy
None of the antidepressants currently available in Canada are considered contraindicated in
pregnancy.
When making a decision regarding the use of antidepressants during pregnancy always
consider risks vs benefits of using these drugs.
Avoid abrupt discontinuation whenever possible

Use of antidepressants in pregnancy Risks
Paroxetine cardiovascular malformations rare and the absolute risks are relatively small
Sertraline no particular concern
Fluoxetine preferred drug
Citalopram no adverse association in 1
st
trimester
Venlafaxine, Mirtazapine no elevation of risk beyond the baseline rate of 1 to 3% for any
major malformation.
Use of antidepressants in pregnancy Benefits
Minimal/lack of symptoms
Suicide prevention
Reduction of depressive relapse
Improved quality of life
Better care during pregnancy and after
Prevention of post partum depression
Avoid potential problems with delivery
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Practice Station

Scenario # 1

A elderly lady approaches you to inquire about the side effects of the new drug that she
recently picked up from your pharmacy.

Pts profile: Presented on your desk
Citalopram 20 mg po od
Lorazepam 1 mg po hs prn
Ramipril 5 mg po od

Address her concerns.



Scenario # 2

A patient approaches you for recommendation

Profile:
Lithium Carbonate 300mg TID
Lorazepam 1 mg po hs PRN

On the table:
Pepto-bismol
Gravol
Immodium
Maalox



Scenario # 3
Patient comes with the following

Rx:
Zyprexa Zydis 5 mg po daily

Provide counseling and address all patients concerns

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Scenario # 4

A patient is asking for your recommendation

Profile:
Tylenol #3 1-2 tabs q4-6hrs prn x 35 tabs

On the table:
Metamucil
Glycerin supp
Fleet enema
Soflax (Sodium Docusate)
Sennokot tabs
Bisacodyl tabs
Citro-Mag


Scenario # 5

A very disturbed and confused patient comes to you in the Pharmacy and asks for the
Pharmacist for assistance. Counsel him as you would in the practice.

Patient Name: Andrew
Age: 32 Years
Address: Xyz
Dr: Tips

Comments: Major Depressive Disorder
Medications: Citalopram20mg QD

On the Desk:
Diphenhydramine 25mg

Reference: PSC and CPS


Scenario # 6

Patient comes to pick his new prescription and has some queries. Solve his concern and counsel
him.

Patient Name: Jack, Age: 33 years
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Comments: Major Depressive Disorder
Medications: Phenelzine Tablets 15mg tid started 2 months ago
Address: XYZ
Dr: Tips

New Rx: Paroxetine 20mg 1/12 (1 repeat)

On the DESK:
Paroxetine tablets
Phenelzine tablets

Reference: CPS


Scenario # 7

A patient comes to fill prescriptions


Patient Name: Jackson Medications: CBZ 400 mg TID (since 3 months)
Age: 36 Years
Address: Toronto
Doctor: Tips

New Rx: Bupropion 150mg QD x 3/7 then,
150mg BID x 8/52



Scenario # 8

A 90-year old, 40 kg patient wishes to purchase:

Patient profile: presented after request

Allergies: No known allergies

Current medications: warfarin (Coumadin) 2.5mg daily x 2 years
donepezil (Aricept) 5 mg daily x 2 months


Patient wants to buy Ginkgo biloba to improve his memory
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37
Neurological Disorders
Antiseizure drugs

Do not drink alcohol, CNS depressants or illegal drugs with this medication
The full effect of this medication may not be seen for several weeks, but still continue
to take the medication unless directed otherwise by your doctor
Make a diary of your seizure/s and keep regular appointments with the doctor to
determine whether the medication is working properly or not and if you are
experiencing unwanted side effects
If it (except Gabapentin) causes drowsiness, and blurred vision, do not drive nor
operate heavy machinery unless you have become accustomed to its effects.
Consult your doctor if you are pregnant, plan to get pregnant, or plan to breast feed
while taking this medication
Its important if you are a woman capable of having children that you must take 1 mg
of folic acid.
Do not stop taking this medication without your doctors advice. Some drugs have to
be stopped slowly. Let your doctor or pharmacist know if you stop taking this
medication
Ask your doctor or pharmacist before any or starting any new medication (prescription,
OTC, or even herbal products)

Missed doses:
Missed a dose: take it as soon as you remember unless it is almost time for the next
dose
If it is almost time for the next dose, skip the missed dose and resume to regular
schedule.
Do not take extra or double doses
If you missed two or more doses ask your doctor for further instructions
If skin rashes occurs contact your physician immediately


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Parkinsons Disease

Techniques to improve patient understanding
1-Examine your own attitude toward patient counselling in specific situations.
2-Emphasize key points. Telling patients beforehand, now this is very important may
help them to remember what follows.
3-Give reasons for key advice. Tell why it is necessary to continue taking the medication,
such as using an antibiotic even though symptoms disappeared.
4-Give definite, concrete, and explicit instructions. Any information the patient can
mentally picture is more easily remembered.
Use visual aids, photographs, or demonstrations.
5- Present key information at the beginning or end of the interaction. Experience has shown
that patients concentrate on the initial information given and remember best the last items
discussed.
6-Supplement the spoken words with instructions.
7-Finally, end the encounter by giving patients the opportunity to provide feedback about
what they learned. Ask patients to restate critical points of information to check for
accuracy.

Nonpharmacological Choices

Coping with impact on patients and caregivers lives
Assisting with depression
Physical therapy for ambulation and balance
Speech language assessments for speech and swallowing assisting


Strategies To Enhance Adherence To Medication Regimens
Integrate new behaviours in patient lifestyle.
Provide or suggest compliance or reminder aids.
Suggest patient self-monitoring.
Monitor use on an ongoing basis.
Refer patients when necessary.
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Practice Station
Scenarios # 1

A patient wants to fill a prescription

Patient Profile: (given on the table)

Current medications:
Lorazepam 1 mg po hs x 30 tabs
Temazepam 30 mg hs PRN x 30 tabs
Note that all Rxs from different Doctors

Allergies: none


Rx:
Clonazepam 0.5mg BID PRN x 20 tab


Scenarios # 2

A patient wants to fill a prescription

Profile: Relpax (eletriptan) 40 mg po qd PRN x 6 tab

Rx:
Topiramate 25mg daily x 7 days then
50mg daily x 30 tabs



Scenario # 3

A 28 year old female patient suffering from seizures and is on maintenance treatment with
Phenytoin has just found out that she is pregnant. She asks you whether she should continue
with the medication.

Counsel the patient





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38
Cont r ac ept i on
Choosing a right oral contraceptive options

Estrogen + progestin (combined oral contraceptives or COC)
Progestin only (Minipill)
Long-term injectibles or implantation products (Progestin only). Efficacy is high but
dependent on proper scheduled use
Oral contraceptives do not prevent the transmission of sexually transmitted diseases
Expect changes in characteristics of menstrual cycle
Use of a back-up contraceptive method is advised if more than one dose is missed per cycle
Warning signs of important complications:
Severe abdominal pain
Severe chest pain, shortness of breath, coughing up blood
Severe headache
Eye problem such as flashing light, blurred vision or blindness

Drug Interactions with OC

Anticonvulsants (barbiturates, carbamazepine, phenobarbital, phenytoin) enzyme P450
inducers level of hormones

Recommendations

Dont recommend OCs < 35g alone
Use first-day start method to interval between packs of pills
May suggest back-up method for the first 3 months
If no spotting during initial period can use 35g OC alone
If spotting prescribe 50g OC such as Ovral
Patch or Vaginal Ring Not recommended
IUD & Mirena or Depo-Provera can be used

Recommendations
All low-dose OCs have a beneficial effect on acne
Two OCs approved in Canada for the treatment of acne: Tri-Cyclen & Alesse
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Diane - 35: is indicated in cases of severe acne that do not respond to oral antibiotics or
other types of treatment. Diane-35 may not be used in Canada for contraceptive purposes
alone.
Handbook of Hormonal Contraception & Office Gynecology 2
nd
edition, by Rodolphe
Maheux

Emergency contraception (Plan B)

Plan B is an emergency contraception, indicated for use for unprotected sex (also in case of
sexual assault)
The first tablet should be used within 72 hours of unprotected sex. The second tablet 12
hours later.
It is not recommended as routine use as contraception. (Explain why ECP contains a
higher dose of hormones and Increase risk of side effects, nausea, vomiting, irregular
bleeding, fatigue)
Effects of menses
Experience of delay in menses for +/- 7 days
Lower abdominal pain
Contact physician
Plan B does not protect against infections or STD.
Woman should abstain from sexual intercourse or use an alternate contraception method
until the onset of next normal menstrual period.
If necessary pregnancy suspected do pregnancy test and discuss with your doctor.
Most common side effects
If vomit within 1 hour taking medication, then take another medication. (PSC page 669)
You may reduce n/v by taking this pill with food or at bedtime and by taking Gravol an
hour before each dose.
Use plan B in emergency situation. Taking ECP wont have any effect on your future
ability to get pregnant or have child.
Prevent unwanted pregnancy.

Evra Patch
A study of extended wear of an Evra patch has shown that norelgestromin and ethinyl
estradiol concentrations are maintained for 10 days
Patch adhesion is not affected by heat, humidity, swimming, bathing, and exercise or skin
moisture.
Most common S/E reported by patch users are breast tenderness & headache.
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Practice Stations

Scenario # 1

A female, comes to fill prescription:

Rx: Evra patch
3 months

Patient profile (presented after pharmacist request)

Name: Faith Hart
Age: 23 years old
Allergies: Not known
Current medication; None
Medical conditions: None





Scenario # 2

A doctor has a question for his patient?

Patient: 28 years old woman

Profile: Tegretol CR (Carbamazepine CR) 400mg BID


Scenario # 3

Father of one of your patients comes into the pharmacy very upset and angry

Patient: 16 years old

Profile: Alesse 28 x 3 pks



Scenario # 4

Doctor is calling for your recommendation for a 20 years old female, Which contraceptive
would you suggest for lady who has acne problem?
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Scenario # 5

A 20 years old female comes to your pharmacy with prescription

Rx: Diane-35 for 3 months



Scenario # 6

An extremely worried young 25 years old lady comes to you, the pharmacist, for your
assistance. Ask her what her concern is and help her with any product you feel would be
necessary for her condition.

On the table: Plan B

Patient profile: (presented after pharmacist request)
Allergies: not known
Current medication; none
Medical conditions: none
Age: 25 yo




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39
Diabet es
Presentation Symptoms

Hypoglycemia: Hunger, Nausea, Weakness, Headache, Sweating, Shaking (tremors), Skin
becomes pale (pallor), Numbness of lips or tongue, Irritability, Change in mood or behavior
Fast heartbeat (palpitations), Faster breathing, Confusion, Vision changes, Seizures, and Coma

Hyperglycemia: Increased thirst (polydipsia), excessive urination (polyuria), Nausea/vomiting
Weakness, fatigue, Headache, Visual disturbances (blurred vision), Positive urine test for
glucose, and elevated blood glucose readings

NORMAL = FPG = 5-6 MMOL/L, PPPG = 14 mmol/L, HbA1C = 6% (for 3 months), BMI =
25-27 and HBP + diabetes= > 130/80

Education program to teach the patient:
Basic understanding of diabetes
Role of diet, exercise and medication
How and when to self-monitor blood glucose and why it is necessary
Management of sick days
Recognition and treatment of hypoglycemia
Knowledge of major side effects of medications and how to adjust drugs in response to
changes in diet and activity
Care of feet

Nutritional Management
Counseling by a registered dietician
Instruct on nutrients from all basic food groups
In Type II diabetics reduce total caloric consumption so as to reduce weight and improve
metabolic control
For patients on insulin, tailor food intake into meals and snacks according to preference,
lifestyle and medication
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In Type I diabetics the amount and type of carbohydrate have the most immediate impact
on the level of blood glucose. Advise patient to fix carbohydrate consumption or count the
amount of carbohydrate ingested and adjust insulin accordingly

Self-monitoring of blood glucose levels
Results in improved diabetic control
Allows for recognition of low blood glucose levels and provides immediate feedback on the
effect of therapy
Patients on intensive therapy monitor before each meal and at bedtime, this is an absolute
minimum
Self-monitoring is an integral part of the treatment of Type I and Type II diabetics on
insulin and oral hypoglycemic
Also useful in diabetics treated with diet only

Physical activity and exercise
An integral part of the management of Type II diabetes
It improves cardiovascular function
Enhances insulin sensitivity
Lowers BP
Lowers lipid levels
Improves glycemic control
Adjust insulin dosage with exercise
Time meals and/or regulate food consumption to ensure safety of exercise regimen

Weight loss of 4 Kg or more if overweight
Histories and physical examination to detect comorbidities and complications and should
include:
BP measurement
Long-term control HbA1c every 3 to 4 months for patients on insulin and every six
months for those on nutritional therapy or on oral hypoglycemic
Assure accuracy of blood glucose measurements made by the patient
Reinforce skills learned in education and dietary counseling
Urinary albumin excretion rate using albumin-creatinin ratio annually
Fasting lipid profile at time of diagnosis and every one to three years if normal
Eye examination at time of diagnosis in Type II and five years following diagnosis. In
type I at the time of puberty and repeat at least every two years if initially normal

Diabetic foot care
Shoes (comfortable), large, no open toe
Socks no tight, cotton
Dont walk bare feet
Change shoes and socks daily
Keep feet dry and warm, moisturize (Uremol)
Inspect feet daily
Nail care (avoid ingrown nails)
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No self care for problems always go to podiatrist
Practice Station
Scenario # 1

A male is overweight and has just been diagnosed with type II diabetes. The doctor has not put
him on any medication and he asks you what he can do to improve his condition.

Counsel the patient.

Patient profile: (given after pharmacist candidate interview)
Age: 55 years old
Current medications: None
Medical conditions: none


Scenario # 2

A 60 year old male comes into the pharmacy and complains of going to the washroom
frequently and seems to be thirsty most of the time. In discussion he also complains of slightly
blurred vision. Asks you what he can take.

Counsel the patient.

Patient profile: (given after pharmacist candidate interview)
Age: 60 years old
Current medications: None
Medical conditions: none


Scenario # 3

A patient is asking for your recommendation
Profile:
Glyburide 10 mg BID
Metformin 500 mg 1& tab BID

On the table:
B-D Glucose tablets,
lifesavers candy,
DEX-4 tablets

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Scenario # 4

A patient comes for your recommendation

Profile:
Metformin 500mg BID
Glyburide 5 mg BID
Acarbose 100mg TID

On the table:
Pepto-Bismol
Zantac (Ranitidine) 75mg
Tums
Maalox
Gaviscon

Scenario # 5

A patient comes for your recommendation

On the table:
Dr. Scholl's one step corn remover
Dr. Scholl's Liquid Corn/Callus Remover


Scenario # 6

A prescription brings a new prescription

Patient Name: Billy
Age: 46 years
Address: XYZ
Dr: Tips

Comments: High cholesterol, Type II Diabetes and neuropathic pains

Medications:
Metformin 500 mg bid
Glicalizide 40 mg daily
Atorvastatin 40mg/Fenofibrate 100mg

Allergies: Penicillin
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New Rx: Lyrica 75 mg caps I po BID x 90 d

R: 3
Scenario # 7
A patient comes for your recommendation

Profile: Metformin 500 mg, 2 tabs BID

On the table:
Pepto-Bismol
Zantac (Ranitidine) 75mg
Tums
Maalox
Gaviscon


Scenario # 8
A 40 years old male patient presents prescription:

Profile: Metformin 500mg BID

Rx: Gluconorm (repaglinide) 2 mg TID
M: 1 month
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40
Thyroid Disorders

Hyperthyroidism Pharmacotherapy

Thionamides
It prevents excessive thyroid hormone production
It must be taken regularly in order to be effective.
Do not discontinue used without first consulting your physician
When there is fever, sore throat, unusual bleeding, rash, abdominal pain, or yellowing of
the skin patient should notify the physician

Iodides
Dilute with water or fruit juice to improve taste
Notify physicians if ever, skin rash, metallic taste, swelling of the throat, or burning of the
mouth occurs
Non pharmacologic Choices

Surgery in patients (medical therapy is often initiated prior to surgery to make patient
euthyroid if possible):
With thyroid nodules
With large goiter
Occasionally in Graves disease
For management of thyroid cancer (malignancy), control ectopic production of thyroid
hormone.
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Practice Stations

Patient Profile: Presented on desk

Patient Name: Jenny Comments: Hyperthyroidism
Age: 32 years Medication: Methimazole 10 mg BID
Address: xyz (3 weeks ago)
Dr: Tips

A patient comes to you in the pharmacy with a concern. Respond as you would in the
pharmacy.

On the table:
Tylenol Extra Strength tablets
Advil tablets



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41
Ast hma


Asthma Management

Assess: asthma control, triggers, compliance, inhaler technique & co-morbidities
Assessmentregular assessments of asthma technique, assess adherence to therapeutic
regimen, assess asthma control.
Education teach correct inhaler technique, demonstrate to confirm patient understands,
and explain the basic principles of the disease highlight inflammation and muscle
constriction. Ensure patients understand the role of the medications. Using inhaled
corticosteroids on a regular basis in order to achieve good asthma control is a key message
for pharmacists to focus on.


Questions to ask

Have you used these puffers before? (Review techniques)
Do you know what makes your asthma worse? (Avoid triggers-dust mite, mould, some
food, pet allergies, pollen) Keep diary.
Do you take any other Rx medications, such as beta-blockers, aspirin (they could
exacerbate asthma)
Have you had any changes recently-ask about non-allergic triggers cold and flu virus,
weather changes, thunderstorms; ask about exercise- often asthma symptoms triggered by
exercise; perfume and hairspray can irritate the airways. It is best not to use them. Some
women find that their asthma worse during pregnancy, periods or menopause.

Defining asthma control
Daytime symptoms < 4 days per week
Night-time symptoms < 1 night per week
Normal physical activity
Mild, infrequent exacerbations
No absenteeism due to asthma
< 4 doses/week of a fast-acting 2-agonist (apart from 1 dose/day before exercise)
Peak expiratory flow (PEF) 90% of personal best
Diurnal variability in PEF < 10-15%
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Treatment plan

Very Mild: short-acting 2-agonist PRN
Mild: ICS at low doses (if ICS is not an option, then LTRA, although less effective)
Moderate: if not adequately controlled by ICS, add LABA (alternatives: add LTRS or
#ICS to moderate dose, but less effective)
Severe: #ICS to high dose, if very severe add Prednisone PO.

Complementary Activity of ICS & LABA
ICS improve the effectiveness of LABA by up-regulation of 2 receptors
LABA improve the effectiveness of ICS, possibly by priming the glucocorticoid receptor
for activation

Budesonide/Formoterol single inhaler as maintenance & reliever

Prolongs time to first severe exacerbation
Reduces frequency of severe exacerbations
Improves asthma symptoms
PRN doses allow early intervention
(increasing ICS dose) thus preventing exacerbation before it occurs.

Formoterol for asthma relief

Has onset of action as fast as salbutamol, 1-3 minutes after inhalation
In combination with budesonide has been shown to be as effective & well tolerated as
salbutamol in relieving acute asthma
Formoterol: full 2-agonist
Salmeterol: partial 2-agonist with slower onset of action (not to be used as reliever)

Counseling on Symbicort

Maintenance of BID dosing is necessary
As effective in short term as short acting 2-agonists (i.e. salbutamol), and beneficial in the
long-term.
Maximum dosing: 8 inhalations per day
Symbicort SMART approach approved by Health Canada
SMART single maintenance and reliever therapy
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Practice Station

Scenario # 1
A very concerned lady comes to you, the pharmacist, asking for your help. Respond as you
would in the Pharmacy.

Patient Profile: Presented after pharmacist request

Patient Name: Mrs Jane
Age: 28 years
Address: XYZ
Dr: Tips

Comments: Asthma

Medications Dr
Salbutamol Inhaler PRN Tips
Advair Diskus 1puff BID Since 3 years ago Tips



Scenario # 2

A doctors station, wants to talk to you!

Patient Profile: (presented on desk)

Advair MDI 250 mcg I puff BID 250/25mcg
Bricanyl as reliever
Advair Diskus 250/50 I BID

Allergies: None
Medical conditions: Asthma for the past 2 years


Scenario # 3

A very concerned lady comes to you, the pharmacist, asking for your help. Respond as you
would in the pharmacy.

Patient profile (presented after pharmacist request)
Candesartan 8 mg po od
HCTZ 25 mg po od
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Fatigue, Nasal Congestion, Sore Throat No fever

On the table:
Tylenol, Sudafed,
NeoCitran total,
Otrivin,
Salinex NS,
Tylenol Cold,
Cepacol Lozenges,
Strepsil Lozenges
Salinex NS, Lozenges


Scenario # 4

A doctors has question for his asthma COPD patient.

Patient profile: (presented by patient after pharmacist request)

Combivent (ipratropium bromide/salbutamol) ii puffs QID


Scenario # 5

Address their concerns and their need for information.

On the table:
Tylenol
Sudafed
NeoCitran
Otrivin
Dristan
Salinex NS
Tylenol Cold
Cepacol Lozenges
Strepsil Lozenges
Ricolla Lozenges
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Scenario # 6

A mother comes into the pharmacy and complains that her 15 year old son who is using a
Sodium Cromoglycate bid inhaler seems to be getting more frequent asthma attacks and his
asthma seems worse at night. He also takes Salbutamol, which he has not been taking that
regularly. She asks whether she should increase the use of the Cromoglycate inhaler.

Counsel the patient.
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42
Col d, Cough, Congest i on and
Fever

Signs and symptoms

First sign is usually sore throat, described often as dry or scratchy sensation
Rhinorrhea and nasal congestion follow the sore throat. Nasal discharge is initially clear
and watery, but becomes thicker as the infection progresses
Congestion may lead to sinusitis and headache or to otic symptoms (especially in
children)
Postnasal drip is common and can cause coughing or laryngitis
A dry cough often follows the nasal congestion
Fever is common in children, but not in adults

Nonpharmacologic Choices

Bed rest
Drinking plenty of fluids
Humidifying the air

Pharmacotherapy

Salt water gargles and throat lozenges soothing to a sore throat
First generation antihistamines relieves rhinorrhea and watery eyes
Topical and oral nasal decongestants relieves stuffy nose and sinuses
Oral decongestants more effective than topical but produces more adverse systemic
effects
Expectorant, guaifenesin treats dry cough with chest congestion
Dextromethorphan to suppress dry, unproductive cough
Analgesic/antipyretic for body aches and fever in adults
Zinc controversial but zinc gluconate lozenges may reduce some symptoms of
common cold but may cause nausea and impart bad taste

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Practice Station

Scenario # 1

A young man comes to your Pharmacy asking for your assistance. He has got a concern
regarding his condition and wants to purchase something that he feels would help him.

On the table:
Echinecea Tablets
Pseudoephedrine 30mg tablets
Saline nasal drops
Dextromethorphan cough syrup


Scenario # 2

A male patient comes to you in the Pharmacy to purchase a certain product, which he believes
will benefit his condition. Advice him accordingly and give the necessary recommendations
regarding his condition.

On the table:
Echinecea Tablets
Garlic capsules
Vitamin E capsules
Ginseng capsules


Scenario # 3

A patient approaches you for recommendation about cough syrup

Patient Profile: (patient provides after pharmacist request)
Ramipril 10 mg po od (1 month)
Simvastatin 10 mg po od (1 year)
On the table: DM syrup, DM-E syrup

Solve problem and counsel

Scheme # 4

A young mother with a baby comes into the pharmacy and asks you for something to give her
baby as the baby have a fever.

Counsel the patient.
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43
Allergic Rhinit is
Patient presentation symptoms
Runny nose, watery eyes, itchy tongue, eye,

Questions to ask:

Is your nasal drainage clear, white, yellow, green (to rule out infection)? Is it thick or
watery?
Do you have a cough, fever, or sore throat?
How often do these symptoms occur?
Do you notice a change in different environments? Is it better indoors or outside?
Are your symptoms associated with specific activities (eg. gardening)?

Risk factors: age (usually before 20 years), family history of atopy (asthma, eczema)

Nonpharmacological Choices

Avoid allergens reduces medication use
Use air conditioning reduces pollen exposure
Remove pets reduces perennial symptoms caused by animal dander
Avoid dust reduces symptoms by 60%
Saline nose spray symptomatic; washes out mucus and inhaled allergens
Lubricant eye drops relieves conjunctival symptoms
Desensitization/ allergy shots (immunotherapy) indicated in difficult to control IgE
mediated sensitivity caused by pollen or dust mites
Antihistamine counseling? Patient advised to not drive. Non-sedating antihistamine rarely
effect skilled tasks, require caution. Pregnancy consider use: Chlorpheniramine,
hydroxazine, and cetrizine.

Suggested reference
Patient Self care pp135, 2002
Therapeutic choice 4
th
ed. Page 404

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Practice Stations

Scenario # 1


A doctor has recommended that a pregnant patient who is a regular customer at your pharmacy
takes Chlorpheniramine maleate for about a bad hay fever. She asks for your opinion and seeks
reassurance.

Counsel the patient.

Patient profile: (given by patient after pharmacist candidate request)

Name: Julia Bown
Age: 29 yo
Allergies: none
Current medications: OTC materna
Medical conditions: None
During discussion, she mentioned that she is 4 months pregnant.
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44
Canker and Cold Sores
Presentation symptoms

Canker sores
Painful, recurrent ulcers in the oral mucosa
3-10mm shallow lesions
Round with white centre and red halo
Persist for 7-14 days

Cold sores
Begins with prodromal symptoms of mild burning or itching on the lips
Small vesicles filled with clear fluid, which eventually ruptures and crust over
Last for 3 to 10 days

Differential diagnosis
Canker sores tend to arise inside the mouth on the inner lining of the lips or the cheeks or
on the tongue.
Cold sores tend to arise on the outside of the lips.

Counsel patients with canker sores to:
Rinse their mouth as often as possible with warm
Water, a saline solution or a mouthwash
Avoid any known precipitating factors and irritating foods and remove any cause of trauma
such as ill-fitting dentures
Ice applied within 24 hours of the prodrome can abort a cold sore. Ice should be applied
continuously in the area for 45 to 60 minutes as soon as possible after the prodromal
symptoms are felt.

Pharmacological Treatment
Goal alleviate pain and protect the lesion
Topical anesthetics contain up to 20% benzocaine
Applied to only small areas of the mouth to prevent a cotton-mouth feeling and loss of
oral sensation
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Protectants emollient mixtures or denture adhesives can alleviate pain
Chlorhexidine gluconate mouthwashes help resolve cankers
Burrows solution or cold compresses with tap water applied 3-4 times daily is helpful for
cold sores
Sunscreeen with SPF 15 recommended to prevent cold sores in those with recurrence
after exposure to sun

Useful Tips In Treating Cankers And Cold Sores

Try to avoid any of the known triggers of cankers and cold sores
Avoid touching a cold sore. Herpes virus can be spread by physical contact with other parts
of your body or with other people
Wash hands frequently, especially after applying medication to cold sores. Avoid sharing
washcloths, towels and linens
A cold sore can sometimes be prevented by applying ice for 45 to 60 minutes to the
affected area during the tingling or burning sensation that sometimes happens just before a
cold sore forms.
Apply pain-relieving medications to only small areas of the mouth. Applying too much
pain-relieving medicine or anaesthetizing too large an area of the mouth can result in a
cotton-mouth feeling, or can result in serious burns from hot foods and liquids
If sunlight seems to trigger cold sores, try using a lip balm containing a sunscreen



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Practice Station

Scenario # 1

A 20-year-old man comes to you to the dispensary counter to pay for a can of Vaseline that he
took from the self-selection area of the Pharmacy and asks if he can use it for his problem.
Assist and counsel him as would in the Pharmacy.

On the DESK: Ora-base (Benzocaine gel)
Reference: PSC and CPS



Scenario # 2

An 18-year-old male asks about a blister that has reoccurred on the same spot on his lip. He
had the same thing happen earlier this year.

Counsel the patient.
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45
Opht hal mi c Dr ugs



Presentation symptoms

Red, ITCHY (mod to severe), watery eyes
Mild eyelid swelling- may cause pain
Clear discharge
Foreign body sensation
Affects both eyes
+/- Clear nasal discharge, sneezing

Questions to ask:

How long has the patient had these symptoms? (Onset, duration)
Has the patient had similar symptoms before?
Has the patient tried anything to solve the problem? Outcome?
Are there any aggravating factors that cause the red, itchy, watery eyes? (i.e. Allergies,
certain times of the day or year, environment)?

For Differential Diagnosis (if allergy is less obvious), ask if
Purulent, sticky discharge (+/- fever, may be one eye)= Bacterial
Watery, inflamed conjunctiva, (+/- fever, usually one eye)= Viral
Burning, no discharge= Chemical
Itchy/ irritated, minimal discharge, both eyes= Dry eye

Refer
Moderate to severe SAC or those who dont respond to non-Rx tx w/in 48-72hrs
Acute bacterial conjunct in children, contact lens wearers, and those who dont respond to
non-Rx Polysporin eye drops w/in 48hrsNeed empiric broad spectrum antibiotic eye
drops like TMP/polymyxin B or erythromycin (FQ reserved for serious infections).
Normally its self-limiting, resolve w/in 2 wks, tx shortens course to 1-3 days (caused by S.
auerus, S. pneumo, H. influenza). Soak eyelids stuck together w/ warm compress, stop
contact lens wear, irrigate eyes w/ sterile saline, Polysporin (polymixin B/gramicidin) 2-
4x/day x 7-10d; continue for 2 days after symptoms resolve.
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Hyperacute bac conjunct (if suspect N. gonorrhea or N. meningitides)Need antibiotic
(ceftriaxone IM or cipro)
Chronic bac conjunct (>4 wks, assoc w/ blepharitis and makeup)Need oral antibiotic
(tetracycline or metronidazole)
Viral conjunct (if herpes simplex or zoster instead of adenovirus)HSV or zoster need
topical trifluridine or antiviral (ACV, FCV, VCV); Adenovirus treat supportively only:
warm or cold compress, avoid contact w/ other ppl (out of school, etc) for 7d
Dry eyes if symptoms dont resolve w/in a few days (if preservative free OTC artificial
tears not enough).

Non-pharmacological

Avoid allergens like grassy fields, trees, and flowers, keep pets outside, stay indoor in AM.
Keep windows shut, hardwood floors, avoid curtains so you dont collect dust or animal
dander
Dont wear contacts until symptoms resolve b/c they trap allergens, dirt, debris
Apply cool, moist compress
Irrigation w/ sterile saline to dilute allergen and decrease contact time to eye
Avoid rubbing/scratching eyes
Good hygiene, proper hand washing.

Treatment Plan

Non-prescription drugs
Oral antihistamine: Good if patient also has nasal symptoms and sneezing1
st
gen
Benadryl slightly faster onset, can cause drowsiness + QID, 2
nd
gen Claritan/Aerius OD.
Mast cell stabilizer eyedrops (Cromolyn, Opticrom): prevent release of histamine and most
inflammation mediators. Good for prophylaxis for entire allergy season: loading time 2
wks= little effect if histamine has already been released, not for acute attacks. BID-QID
Antihistamine/Decongestant (vasoconstricting) eyedrops (Naphcon A, Opcon A, Visine
Advance Allergy): best for immediate relief of red, itchy eyes, but SHORT term use only
b/c risk of rebound redness. Decongestant eye drops NOT for pts w/ glaucoma, HTN,
MAOI. BID-QID
Artificial Tears (Genteal, Tears Naturale II, Refresh Tears): lubricate + soothe eyes, dilute
allergen; freq dosing

Prescription drugs
Mast cell stabilizer/Antihistamine (Zaditor, Patanol): relief within minutes + long duration.
Best for long term prevention. BID
Ophthalmic antihistamine (Livostin= levocabastine, Emadine= emedastine): better than
antihistamine/decongestant combos for relieving itchy, watery eyes. TID-QID
Ophthalmic corticosteroids (FML, PredForte= prednisolone): save for more serious
conditions or as last resort. Can mask infection, lead to glaucoma, increase IOP
Ophthalmic NSAIDs (Acular= ketoralac): reduce inflammation, redness, but takes 2-3wks
for onset of action. Interact w/ ACEI, B-blockers QIDnot a good choice.
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Education:
How to instil eye drops (press corner of eye to decrease systemic SE; most have few SE,
some sting), cold compress
Dont use decongestant eye drops >3days, non-pharms to avoid allergen exposure
Wait 5-10 mins between instilling different eye drops so they dont dilute one another,
order doesnt matter
Once you open eye drops, discard w/in 1 month usually, some okay up to 2mo


Practice Station

Scenario # 1

An elderly man comes into your pharmacy claiming to need something for his eyes. They are
sore but not appear red.

Patients profile: (patient provides after pharmacist request)

Optometrist diagnosed his condition as dry eye
Eyes are not itchy, but irritation has lasted for month or so. They seem to be the most
sore when he is lying in bed to sleep
Tried eye drops but found it difficult to administer them, so he quit using them
Medical history: High cholesterol
No known drug allergies
Current medicines: a multivitamin and mevacor


Scenario # 2

A patient is asking for your recommendation.

On the table:
Tears Naturelle II
GenTeal Artificial tears
Polysporin eye/ear drops
Visine original


Scenario # 3
A patient comes for your recommendation

On the table:
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Visine Allergy
Cromolyn eye drops
Optichrom
Tears Naturelle II


Scenario # 4

A patient comes to fill prescription

Rx: Fucithalmic eye drops

Sig: 1 gtt ou bid x 7 days

Patient profile:

Name: Faith Hill
Age: 60 yo
Allergies: Not known
Current Medications: Atorvastatin 10mg
Medical conditions: High cholesterol
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Conj unc t i vi t i s

Allergic conjunctivitis

Presentation symptoms

Red, ITCHY (mod to severe), watery eyes
Mild eyelid swelling- may cause pain
Clear discharge
Foreign body sensation
Affects both eyes
+/- Clear nasal discharge, sneezing

Non Pharmacological therapy:
Allergen avoidance
Cold compress over the eyes offer considerable relief of symptoms

Viral conjunctivitis (Keratoconjunctivitis)
Non-Pharmacological: Give warm or cold compress to increase comfort.
Non Rx therapy: Ocular decongestants and/or lubricants may be useful.

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Practice Station

A young male patient comes to you in the Pharmacy. He is very worried and concerned about
his condition. Solve his concern and provide all relevant information that you feel would be
necessary.

On the table:
Polysporin Eye Drops
Phenylephrine Eye Drops
Sodium Chromoglycate Eye Drops


Patient profile:
Age: 30 yo
Allergies: None
Current medications: None
Medical conditions: none
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48
Ot i t i s Ex t er na


Presentation symptoms

Pain with tragus movement
Pruritis
Discharge
Difficulty hearing
Fever

Questions to ask:

What is the description of the problem?
Is ear itchy?
When did pain begin and how severe?
Discharge?
Difficulty hearing?
Fever?
Has the patient seen a physician?
What measures have been taken?

Refer
If blood in ear-this means tympanic membrane has been perforated
Significant edema or debris in the ear

Non pharmacological
Keep ears dry with low heat hair drier after shower
Use ear wick- not ear wig, promotes movement of drug into canal especially when there is
lots of inflammation-use for 12-36 hours
Use hot compress to alleviate pain

Pharmacotherapy
Antibiotics for bacterial infection
Fluoroquinolones: Ofloxacin 0.3% solution
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97% efficacy, no ototoxicity, only prescription antibiotic that can be used with a ruptured
tympanic membrane
Instil one to two drops twice daily
Analgesics for pain
Ibuprofen- (Advil)
Has anti-inflammatory effects which acetaminophen does not have, aspirin can be ototoxic
at high doses
Take one to two tablets every 4-6 hours as needed
Fast relief- a couple of hours

Prevention
Keep the ear canal as dry as possible
Use bathing caps when swimming
Do not clean wax out of ears
Ears are usually self-cleaning and the wax protects against infection do not use q-tips
Administering drops
Wash your hands
Hold the bottle between hands for 1 to 2 minutes to bring it to body temperature to avoid
dizziness
Lie on side with affected ear facing upward. Shake bottle well and instil drops.
The bottle tip should not touch ear, fingers, or other surfaces.
Gently pull the outer ear lobe upward and backward allowing drops to flow down ear canal.
Remain on side for 60 seconds. Repeat, if necessary, for the opposite ear.
Discard any unused medicine.
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Practice Station

Scenario # 1

A mother comes to you in the pharmacy complaining that her daughter is not doing that well.
Advice her and take the right action to help her.

On the table:
Tylenol syrup
Auralgan eardrops
Advil syrup
Gastrolyte sachets

Patient profile: (provided after pharmacist candidate request)
Daughter age: 3 yo female
Current Medication: None
Medical conditions: Not feeling well, complaining pain


Scenario # 2

A patient comes to fill a prescription

Rx:
Ciprodex ear drops
ii gtts into affected ear BID x 7 days

Patient profile: (provided by patient after pharmacist request)

Age: 18 yo
Allergies: Not known
Current medications: none (use contact lens)
Medical conditions: none, just ear pain


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49
Ver t i go and Di zzi ness



Vertigo is defined as sensation of motion where there is none or an exaggerated sense of
motion in response to given bodily movement. It is cardinal symptoms of Vestibular disease as
a result of lesions or disturbances in the inner ear.

Dizziness is defines as variety of sensations such as light-headedness, fainting, spinning and
giddiness.

Non pharmacological

All patients with vertigo should see a doctor to find out what is causing it.
Vestibular rehabilitation is a physical therapy program to improve balance, eye hand
coordination and habituate the patient to feelings of dizziness.
Salt restriction for Menieres disease
Bedrest for acute viral neurolabyrinthitis
If you suffer from attack for vertigo, avoid potentially hazardous activities.
Medication may be used to treat vertigo and any upset stomach it may cause.

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Practice Station


Scenario # 1

A man comes to your pharmacy, complaining variety of sensations such as light-headedness,
fainting, spinning and giddiness.

Patient profile: (patient presents after pharmacist candidate request)
Current medication: none
Medical conditions: none
Allergies: none
Age 40 yo


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50
Foot Sympt om Assessment


Plantar warts

Medication should go down to root. May take months to completely resolve, however you
may see improvement in 2 weeks.

Self care measures:
Keep feet dry
Avoid sharing personal items.
Do not go bear feet on swimming pools.
Patient 27 year old

Toenail infection

Itraconazole capsules (for toenail with or without finger nails) fungal infections.
1 cap bid for 7 days (3 weeks drug free period)
Take with food and after food
Avoid grapefruit juice

Ref: CPS page 1976, 2005
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Practice Station

Scenario # 1
A women comes with have painful lump on sole. Wants to buy Duofilm forte 27 gel compound
with liquid

Patient profile:
Name: Red Rose
Age: 45 yo
Current Medications: Metformin 500 mg bid, glicalizide CR 60 mg once daily and ASA 81 mg
Medical conditions: diabetes from past 5 yrs

On the desk: Reference: Patient Self Care



Scenario # 2

A 33-year-old female got a new prescription for toenail fungal infection

Rx
Sporanox 200 mg
1bid for 3 months

Patient profile: (provided after pharmacist candidate request)
Daughter age: 33 yo female
Current Medication: None
Medical conditions: not comfortable, nail bothers



Scenario # 3

A patient comes to fill a prescription

Patient Name: Michael Comments: Onchomycosis
Age: 26 years Medications: None
Address: XYZ Allergies: Sulphur
Dr: Gaucher



New Rx: Lamisil Cream, apply BID x 3/12

Prep Notes

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51
At hlet es Foot

Patient presentation
Most commonly presents as chronic infection between lateral toes, often spreading to
instep/sole
May also present as blisters, pruritus lesions, burning sensations, redness and inflammation;
skin may appear macerated, odour may be present
Differential diagnoses include disturbances of sweat mechanism, contact dermatitis,
eczema, erythrasma, psoriasis, bacterial infections

Patient concern

Patient may be upset/embarrassed about condition stress that it is common & curable
Patient should be monitored for possible allergic reaction to product - if one develops,
advise to discontinue use & refer to M.D.; also monitor for efficacy of treatment, if
symptoms show no improvement w/in 2 wks or if have not disappeared w/in 6 wks, refer to
M.D., chiropodist or podiatrist
Emphasize importance of finishing course of treatment to prevent recurrence, even if
symptoms improve
Emphasize that condition is contagious and provide suggestions to prevent transmission to
others
Tell patient to complete the full course of therapy for improvement (for 1 wk)


Pharmacotherapy
Treatment plan Effective antifungals include imidazoles (fungistatic, 70% effective,
bid, also have some anti-inflammatory and gram +ve antibiotic
effects), butenafine (fungicidal, 90% effective, od), terbinafine (Rx,
fungicidal, 90% effective, od for 1wk)
products containing chlorphenesin, tolnaftate, or undecylenic acid
have unknown or poor efficacy, and should not be recommended
If secondary bacterial infection is also present (diagnosed by M.D.),
Polysporin cream can also be used, bid-tid for 1wk
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Prescription oral antifungals (terbinafine, ketoconazole, itraconazole,
griseofulvin) are indicated for infections of the nail or infections
resistant to topical treatment
Tolnaftate Cream, Gel, Liquid, Powder, Spray Powder, not used under 2 year
age
Clotrimazole 1% not under 2 years of age, oral lozenges, topical cream 1%, topical
lotion, vaginal tablet, vaginal cream.
Miconazole nitrate
2%
cream, spray powder, not under 2 years

Oxiconazole 1% cream and lotion not under 12 years age
Tioconazole 1% Cream, not under 2 years
Butenafine 1%, Chlorphenesin 1%, Undecylenic acid

Nonpharmacologic Choices

The most important consideration is to keep feet clean and dry - advise pt to change socks
daily, allow shoes to dry completely before wearing again, dry feet thoroughly (esp.
between toes), use a clean towel every day, dont share towels, dont go barefoot in public
places (wear flip-flops), wear socks of natural material (eg. cotton, wool), wear shoes with
good ventilation (eg. leather, canvas)
Antiperspirant can be applied to feet to decrease sweating
Patients with hyperhidrosis of athletes foot can dust an antifungal power on feet (but dont
place in shoes may coagulate with moisture)
Separate toes with cotton ball to absorb moisture and decrease moisture build-up

Refer to physician
Patient with diabetes, Cancer or PVD, and immune compromised,
Elderly, Malnourished, Child <12yrs; if lesion is weeping, Severely inflamed, Oozing
purulent material, Eczematous, Painful; if toenails are thickened or discoloured.

Practice Station

Scenario # 1


Rx:
Lamisil 250mg tabs
Sig: 1 tab OD x 7days for athletes foot
M: 7 tabs

Patients Profile:
21 year old male
Codeine allergy
Past medical history: Amoxicillin 2 years ago, nothing more
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52
Di aper Rash


Patient presentation

Infant patient caregiver worried, afraid, frustrated; baby crying but not able to tell how
he/she feels.
Adult patient embarrassment, frustration, fear, language barrier, patient values

How to approach a problem?

Questions to ask

Medication history: Antibiotics or anticonvulsants. The risk of drug induced diaper
dermatitis in infants is higher than other patients because of the high surface-to-volume
ratio and the difference in drug metabolism and detoxification.
Frequency of diaper change
Specific location of the rash
What does the rash look like & how severe it is?
Did the rash change in severity from mild redness to tomato red plaques? (may indicate
Candida diaper dermatitis)
Have they tried using anything to get rid of the rash?

Drug Related Problems

Patient is not administering therapy properly.
Patient requires drug and non-drug therapy but is not using it.
Patient is experiencing adverse reaction secondary to use of products with lanolin,
fragrance, or other irritants.
Patient is using therapy, which is not required (eg. Topical antibiotic, anesthetic).
Patient is being administered inappropriate dose (eg. Zinc oxide).

Refer to physician

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Rash has been identified correctly but has failed to improve over a week of recommended
treatment
Increased pain, inflammation or itching, fever
Oozing blisters or pus present
Dermatitis has not healed in 7 to 10 days, or is chronic or recurs frequently
Complicated secondary infection UTI or infection of penis or vulva
Signs of immunodeficiency, deep ulceration, or abuse or neglect.

Treatment plan:
Prevention of diaper rash
Non-pharmacological + Zinc Oxide 15%
Complicated diaper rash
Non pharmacological + zinc oxide 40%+clotrimazole 1% cream
Order of application: Hydrocortisone, then antifungal, then barrier

Nonpharmacological Choices

The ABCDEs
Air drying: as long as is practical during and in between diaper changes
Barriers: avoid any type of powder
Cleansing use water with mild soap to clean the soiled area. Do not use the clean part of the
diaper or baby wipes with fragrance or alcohol
Diapers should be changed as frequently as practical to reduce occlusion & decrease
contact time of urine and feces with skin. If using cloth diapers wash with mild detergent
only and use a cup of vinegar in the final rinse cycle which lowers the pH.
Educate patients & caregivers on prevention & treatment of diaper dermatitis.
Compressing with tap water until blistering and wetness has stopped (1 minute on, 1 minute
off for 2 minutes a few times per day) if blisters are present.
Diet: avoid foods that increase urinary output and urinary & fecal pH (eg. high protein
diets, caffeine, citrus juices)

Pharmacotherapy
Barriers
Desitin Zinc oxide cream (37% zinc oxide) for treatment of diaper dermatitis (Note:
Zincofax Extra strength 40% contains lanolin so it may not a good recommendation).
Zincofax fragrance free 15% can be used for prevention. Apply at each diaper change. To
remove the cream, use mineral oil or water.
Vasoline (petrolatum) may be irritating to inflamed skin and can lead to maceration of
over-hydrated skin
Silicone Based: Dimethicone, dimethlypolysiloxane (No Sting Barrier) is a soothing cream,
but it may be irritating since it contains lanolin.
Antifungal
Clotrimazole (Canesten) 1% topical cream or miconazole (Monostat ) 2% applied q12h for
7 to 14 days.
Anti-inflammatory
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Hydrocortisone: 0.5% OTC.
Apply TID for no more than 1 week
Consult physician if under 2 yrs of age
Practice Station

Scenario # 1

A mother of a child comes to you in the Pharmacy with a concern about her 9-month-old baby.
She is really worried and needs your assistance. Advice her accordingly and solve her concern.

Patient profile: (present on the table)

Patient Name: Jim Comments: None
Age: 9 months Medications: Zinc Oxide 15% (6 months ago)
Address: XYZ Zinc Oxide 25% (2 months ago)
Dr: Tips

On the table:
Hydrocortisone Cream 0.5%
Miconazole Cream
Zinc Oxide 40%


Scenario # 2

A mother comes into the pharmacy with her baby and complains that the baby has a very red
bottom and she has also noticed that the skin is a little broken. She asks how she could prevent
this from happening.

Counsel the mother
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53
Head l i c e and Sc abi es

Patient presentation

Itching in respective areas (refer if due to drugs and other disease) due to lice
squirming/moving (Head lice back and sides of scalp & behind ears)
Scratching can cause inflammation, excoriations, crusts and secondary bacterial
infection (pustules)
Hypersensitivity reaction to bites itchy papules
Hatched nits are light/translucent, while unhatched live nits are darker colour
Extreme case: fever, fatigue, irritation
Body lice nocturnal pruritus, erythematous papules with central puncture point
(bite sites)
Pubic lice lice are small, yellow-brown to gray dots. Itching, burning, eye
irritation

Questions to ask:

Any allergies to chrysanthemum or ragweed? If so, describe symptoms
Other close contacts (family, friends, etc.) that could be infected?
Has the patient used a particular medication for lice before?
Is patient currently using a lice treatment? If so, how is it being used?
Is patient pregnant? History of seizures/epilepsy?
Does the itch get worse at night?
If pubic lice, have you been tested for STDs?

Drug Related Problem

Re-infestations due to lack of treatment of close contacts and fomites
Lack of nit removal
Not using medication properly (ie. not leaving on scalp for appropriate length of time,
etc.)
Not using enough of the medication/shampoo each time
Medication not working due to resistance

Refer
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Recurrent/unresponsive head lice
Patient contraindicated or resistant to use of pediculicides
Evidence of bacterial infection (redness, pus) may require antibiotics
Excessive itch still after treatment (it is normal to be itchy for several weeks after
treatment) may require a steroid (hydrocortisone) cream or antihistamine for relief

Pharmacotherapy
Treatment Plan
All available products are similarly effective when used correctly.
Generally: permithrin (most efficacious) > pyrethrins > lindane
Oral anti-histamines or topical corticosteroid (hydrocortisone 0.5% cream) itch
relief (caused by lice or pediculicide treatment)
Resistance: Try switching to another class of pediculicide. If that fails, try permethrin
5% cream left on hair overnight covered with shower cap, ivermectin 200 ug/kg po
(avail thru special access program in Canada), or combo of oral co-trimoxosole 10
mg/kg/day (BID x 10 days) plus permethrin 1% used daily for 10 min on days 1-7.

Permethrin 1% (Nix, Kwellada)
MOA: Good ovicidal activity and immobilizes lice
Caution in kids less than 2 months old
CI: Allergies to ragweed and chrysanthemum (but if it is just an inhaled ragweed
allergy, topical permethrins can still be used)
SE: Mild, transient itching, redness, swelling (less common: burning, stinging, rash,
tingling, numbness)
Alcohol base is more effective than aqueous, but aqueous is preferred in asthmatics
and pregnancies
Applying method: Apply to towel-dried hair, leave for 8-10 hours (off-label
recommendation better efficacy), then rinse. Apply second treatment 7-10 days
later. (Product monograph says leave on 10 min, but that is not as efficacious)

Pyrethins with piperonyl butoxide (R&C Shampoo/conditioner):

Low ovicidal activity
CI: Avoid in people with allergies to ragweed, chrysanthemum, or petroleum
products
SE: contact dermatitis
Sprays uncertain efficacy for inanimate objects
Applying method: Apply to dry hair for 10 min, and then add a little bit of water to
lather. Rinse thoroughly with water. Repeat treatment in 7 to 10 days.

Lindane 1% (Hexit shampoo, PMS-Lindane (generic))
Caution in children < 10 y.o., elderly, pregnancy/lactation, seizure disorders, inflamed
skin
Low ovicidal activity
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CI: People with extensively excoriated/open skin, elderly and children may have
enhanced percutaneous absorption and increased risk of toxicity
SE: slight local irritation, neurotoxic (dizziness, N&V, hallucinations, abnormal
movements, seizures)
Applying method: apply to dry hair for 4 min, and then add small amt of water to
lather. Rinse thoroughly with water. Repeat in 7 to10 days.

Non-pharmacological choices

Avoid sharing personal items such as clothing, combs, hats, hair accessories and
bedding
After each treatment, dead nits will still be attached to hair. Use nit combing/Bug
Busting. May apply formic acid 8% rinse to loosen nit
Clothes, linens, scarves, hats and other fomites should be dry-cleaned, washed in hot
water and dried in the hot cycle, or stored in plastic bags for at least 10 days.
Comb wet hair over white paper (to catch lice) using a fine-tooth nit comb. Comb
from scalp to the end of the hair. Then rinse and repeat.
Repeat every 3-4 days for 2 weeks.
Combs and brushes should be soaked in hot water for 5-10 min. or washed with a
pediculicide shampoo.
Clean comb with soap and hot water after use. (Can also use fingertips/nails or
tweezers to remove nits from hair)
If meds are CI, can use only Bug Busting (with conditioner to loosen nit). But this
only kills 50% of lice/not ovicidal.
Vinegar to loosen nits is not proven.
Furniture and rugs should be vacuumed for scabies
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Practice Station

Scenario # 1

A mother comes to you in the pharmacy complaining that her daughter is itchy and
irritatingll. Advice her and take the right action to help her.

Patient profile: (patient presents after pharmacist candidate request)
Age: 9 yo, goes to elementary school, grade 3
Current medication: none
Medical conditions: none
Allergies: none

On the table











Scenario # 2

A mother comes into the pharmacy and explains that there is a lice epidemic at her 8 year
old daughters school. She has used the lice shampoo, but still believes there are lice in
the hair. She has difficulty in seeing the lice and asks what she should do.

Counsel the mother
54
Der mat i t i s


Patient Presentation Symptoms

Acute: itching & inflammation (redness, swelling, pain, warmth)
Chronic: scratching, scaling, inflammation, dryness
Acute lesions erosions with serous exudate or intensely itchy papules and vesicles
on an erythematous base
Subacute lesions characterized by scaling, excoriated papules, or plaques over
erythematous skin.
Chronic phase less red; skin shows lichenification and pigmentary changes
(increased or decreased) with excoriated papules and nodules.
Pattern of disease varies based on the age of the patient
Areas: face (esp. infants), neck, upper trunk, wrists, and hands (esp. adults) and, folds
(esp. children)

Questions to ask:

Do you have (or do you have a family history of) asthma, hay fever, or allergy, atopic
dermatitis?
Is it itchy? Does it disrupt sleep / daily activities?
How long have you had it? Previous history?
Are others affected? Occupation? Contact?
Age/distribution (may vary w/ age)
Area of involvement, blisters?
What makes it better/worse?
What have you tried already?

Drug Related Problems

Using unnecessary drug (e.g. topical anti-histamine)
Experiencing adverse effects (e.g. allergic reactions to topical)
Inappropriate use of topical corticosteroids (continuous, excessive use over long
periods)
Requires prevention measures (non-drug and hydrating agents)

Treatment Plan

Avoid trigger factors and pruritus
Suppress inflammation, Lubricate skin, use moisturisers and
Acute: itching & inflammation (redness, swelling, pain, warmth) should 50% w/in
7-10 d; no progression/extension to other sites.
Chronic: scratching, scaling, inflammation, dryness - control by 4-8 weeks. No
progression. Lengthen symptom-free periods.

Pharmacotherapy
For itch and inflammation that have appeared:
Topical corticosteroids: consider age, location, extent, vehicle, frequency, and
concentration
Hydrocortisone 0.5% (OTC) face, scalp, skin folds
Stronger steroids: not for use on face of skin folds
Low potency twice weekly with emollients for chronic, dry AD
Mid-to-high potency for acute exacerbation
Apply a thin layer to affected area BID-QID
Avoid using for >2 weeks (tachyphylaxis)
Taper when scaling, itching is subsiding: from BID to daily to alternate-day
dosing while using emollients
AE: atrophy, hypopigmentation, striae, telangiectasia, thinning of the skin
Target root cause: topical calcineurin inhibitors (2
nd
line)
Tacrolimus 0.1%, 0.03% (Protopic) and Pimecrolimus 1% (Elidel) non-steroid
creams
Reduce itching and redness of eczema; use in >2 y.o
No skin atrophy and no systemic effects. Local burning.
Other: 1
st
generations Oral Antihistamines antipruitic by helping patient sleep
through the night

Non-pharmacological

Moisturize skin often and liberally
Bathing (once daily): use warm (not hot) water; mild soaps (Dove, Aveeno, Cetaphil,
Spectrogel)
Moisturize with emollient w/in 3 min after shower
Emollients control dryness (creams better than lotions): Aquaphor, Eucerin, Glaxal
base, Lipikar, Moisturel, Vaseline
Lubrication:
Chronic bath oils (Alpha, Keri) at end of bath to damp skin
Acute colloidal oatmeal (Aveeno) dispersed in water for dry, itchy skin
Hydrating Agents attract H
2
O hydrate/soften skin (better than emollient for dry
skin): Uremol (10%, 20% - also antipruritic)
Wear cotton gloves or mittens to prevent scratching
Acute AD (weepy): wet compress for 20 min (4-6xdaily); avoid ointments and occlusions
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55
Psor i asi s

Presentation symptoms

Chronic plaque psoriasis (most common): on sites: scalp, arms, legs, palms, soles,
nails
Thickened red plaque, or adherent silvery scales or well demarcated
Punctate bleeding spots when scales scraped off
Other types include: flexural (in body folds/flexures w/o scales), scalp (w/ silvery
scales)
Acute/Subacute forms: guttate (after viral/strep infection), pustular (on palms and
soles), erythrodermic (generalized erythematic w/o lesions)

Questions to ask:

Allergies, current drugs, other medical conditions? (Drugs that cause BB, ACEI,
ASA, steroids, antimalarials, lithium, alcohol)
Family history? (Genetic risk factor)
How long has the patient had these symptoms? (Onset, duration)
Has the patient had similar symptoms before?
Has the patient seen a doctor about it and was it diagnosed?
Has the patient tried anything to solve the problem? Outcome?
Is the patient using any other topical products on it?
Are there any aggravating factors? (stress, obesity, UV light, excessive alcohol, What
makes it better?

Drug Related Problems

Not on a medication and requires drug therapy (ex. Needs to start on steroid +/-
steroid sparer)
Experiencing side effects of the medication (ex. Staining from anthralin)
Experiencing tachyphylaxis with medication (ex. Using HC for long periods of time)
Using too low of a dose (ex. Using 0.5% HC on thicker skin while 0.5% HC is only
good for scalp and flexures)


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Treatment plan
1
st
line treatment for Mild to moderate = topical steroids
1
st
line treatment severe extensive psoriasis = systemic treatment warranted
Strategies for steroid sparing: 5d steroid + 2 d sparer OR 4d steroid + 1d sparer. As
psoriasis improves, gradually number of sparer applications until it almost
completely replaces steroid.
Topical steroids (limit to 2-3wks treatment w/ steroid sparing agents)
0.5% HC (OTC): Cortate, Cortef only for face/folds; ung most effective,
lotions on scalp. Appl BID-TID
Stronger steroids (Rx) for trunk/extremities

Topical Steroid + steroid sparing agents:

Petrolatum can appl ring of petrolatum around steroid to avoid irritation of
surrounding skin
Salicylic acid
Coal Tar: Targel, Denorex for scalp and extremities; OD; 0.5%-10%; SE: odor,
staining, inflam of hair follicles, apply in direction of hair growth (dont rub in
circular motion)
Anthralin: Micanol 1%, 3% best for scalp; OD; scat short contact anthralin
therapy using 2-4% for 20min-2hrs; SE: staining of skin and clothes, burning,
discolor blonde hair
Calcipitriol (Rx) can use on face and flexures, better vs tazarotene
Tazarotene (Rx) cannot use in face/folds, pregnancy; SE: skin irritation, burning,
photosensitivity

Biologicals for unresponsive psoriasis; Anti-TNF, Anti-Tcell agents

Light therapy PUVA (psoralen po/cr/bath + UVA) 2-3x/wk; SE: acute burns, skin
cancer, pigmentation, photoaging

SYSTEMIC THERAPY Oral retinoids (Acitretin, isotretinoin) CI in pregnancy;
Sulfasalazine; Methotrexate; Cyclosporin

Non-pharmaceutical

Avoid triggers and skin irritants (soap)
Bathing (use tepid water)
Cool air humidifier
Aqueous creams (can be used as cleanser and emollient)
Most important to keep skin moist!
Handle stress
Dont remove scale
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Saran wrap (used to occlude area and enhance penetration of topical agent)

Prevention:

Avoid triggers
3Ps: Prevent injury, Persistence in avoiding over treatment, pauses or rest periods in
treatment


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56
Der mat ol ogi c al DRPs


Practice Station


Patient wants your recommendation

On the table:
Rubbing Alcohol
Hydrogen Peroxide
Polysporin cream
Polysporin ointment





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57
Acne
Patient presentation

Patient concern

Patient may be upset/embarrassed about condition stress that it is common & curable

Question to ask

Duration, onset and severity; Location and distribution of ache
Seasonal variation; present and past treatments;
Family history. For females (menstrual period; pregnancy status; scalp hair thinning;
contraceptive method).
Other skin disorders or medical problems: allergies; use of cosmetics; moisturizer; pomade;
areas of skin irritation or friction.

Drug related problem

Drug side effects, causing acne like symptoms
Interaction with exipient of emollients, hydrators, or cleansers
Taking retinoids in pregnancy and continuing with acne medications
Taking an excessive amount of benzoyl peroxides at day time
Not avoiding excessive sun exposure
Too little drug
Unnecessary drug
Putting antibiotic on unbroken skin

Non-pharmacologicals:
Treat as soon as it appears to avoid complications such as scarring.
Discontinue use of greasy cosmetics, hair pomades/sprays.
Avoid environmental irritants: coal tar, mineral oil, petroleum oil, humidity, heat
Use make-up infrequently if possible, oil-free products and remove at bedtime.
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Wash twice daily with a mild, non-alkaline soap or soapless cleanser (Cetaphil), don't rub
or scrub skin.
Shampoo hair regularly if it is oily, keep hair off face (occluding factors)
Men: shave in the direction of hair growth (try electric and manual razor for best comfort)
Do not manipulate lesions: avoid picking, scratching, popping or squeezing.
Eliminate mechanical friction: headbands, violins, chinstraps, orthopaedic braces etc
Use an oil-free sunscreen and avoid benzophenone type (apply after cleansing and before
acne meds)

Pharmacotherapy

Treatment plan
1
st
line try OTC benzoyl peroxide
Apply acne meds to the entire affected area; allow 6-8 weeks of treatment before assessing
improvement.
Some meds cause initial reddening or worsening that subsides with treatment
Lesions on back/ extensive distribution cannot use topical, require systemic treatment
Inflammatory acne requires antibacterial therapy (topical or systemic depending on
distribution)

Benzoyl Peroxide (up to 5% OTC, >5% require prescription):

Most effective OTC 1
st
line therapy
Bactericidal effects, anti-sebum effects, anti-inflammatory effects, and is also weak peeling
agent
eg. Solugel 4 OTC- hydrophase base, which is well absorbed and does not leave a film
Start with once daily application, wash face with soapless cleanser, pat dry with towel,
apply to the affected area (not just lesions), leave on for 15 mins for the first night, then
wash off (this is to let the skin get used to the meds and reduce potential drying and
irritation). Repeat each night leaving the benzoyl on for twice as long each time, until it is
left on for about 4h. Thereafter, it can be left on over night.
Twice daily application may be started after about 1-2 weeks of usage and can be applied
once in the morning and once at night.
SE: redness, skin irritation initially (usually resolves w/ continued tx), stains clothes,
linens; breakdown product gives off odour

Prescription drugs

Topical Antibiotics (clindamycin, erythromycin and combos w/benzoyl peroxide):
Antibacterial action against intrafollicular P.acnes
Use for inflammatory acne that does not adequately respond to benzoyl peroxide

Topical Retinoids (tretinoin, adapalene, tazarotene) :
Effective peeling agents
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Use for non-inflammatory acne that doesn't respond to benzoyl peroxide and topical
antibiotics

Oral Antibiotics (tetracycline, minocycline):
Systemic antibacterial action against intrafollicular P.acnes
Use for inflammatory acne that does not adequately respond to topical antibiotics OR has
extensive involvement (ie. Back)

Oral Isotretinoin (Accutane):
Extremely strong, stops comedogenesis through peeling action and antisebum properties
Reserved for patients with severe nodulo-cystic acne that does not respond to a variety of
treatments
Extensive list of serious adverse effects including teratogenic effects and association with
suicide (pts who are depressed can exacerbate depression when put on accutane)

Nonpharmacological Choices

Balanced diet no specific food causes acne (acne is not influence by diet)
Do not squeeze pimples increases risk of scarring
Cosmetic use:
o Avoid excessive use
o Cosmetics should be oil-free rather than water base or non-camedogenic
Comedo extraction avoid unnecessary manipulation
Sunshine not recommended due to UV radiations carcinogenic potential and increased
risk of photosensitivity (patients taking antibiotic and isotretinoin).
Washing the face should be at least 2x/day with mild soap.
Shave with sharp blades, slightly and frequently.
Sunshine helps acne but is carcinogenic and may cause photosensitivity hence not advice.
Patients should use sunscreen of SPF15 with alcohol or oil free bases.
Avoid benzophenone (oxybenzone and dioxybenzone) as they are acnegenic.
Sunscreen should be applied first and then the medication
Heat, humidity, pressure, friction, excess scrubbing, or washing can exacerbate existing
acne.
Emotion (excess anger/stress) can increase acne.
Corticosteroids can also increase acne but not hydrocortisone (doesnt inhibit protein
synthesis)

Refer to physician

Drug induced acne
Experiencing scarring
No response to non prescriptions products or presents with infection or systemic symptoms

References
Therapeutic Choices, 4
th
ed. page 660.
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58
Art hrit is
Osteoarthritis
Nonpharmacologic Choices
Team approach to treatment occupational therapists, physiotherapists, social workers,
pharmacists
Patient education sessions as per Arthritis Society
Physical therapies may be beneficial TENS; laser therapy
Aids canes, walkers, for hip and knees OA
Bracing of affected joints
Exercise with or without physiotherapy
Patient Education. Note: No benefit from Ultrasound in knee OA or Acupuncture (Note
that acupuncture therapy did not show any benefit in treatment of OA)
Weight loss (if overweight), aerobic exercise, physical therapy
Assistive devices. Joint protection (by avoiding trauma on joint, e.g. over standing),
Thermal therapy (though theres lack of evidence)
Risk Factor: Age, obesity and hereditary (genetic susceptibility). Can also occur in
younger patients due to trauma.
Rheumatoid Arthritis
Nonpharmacologic Choices
Multidisciplinary team approach focusing in patient education and rehabilitation
Patient education e.g.:
Balancing rest, activity and exercise
Heat and cold application
Adjustment to activities of daily living
Maintenance of joint range of motion and muscle strength
Dynamic exercise
Increases aerobic capacity and muscle strength
Evaluation for spirits, orthotics, proper footwear, and surgery
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Gout and Hyperuricemia
Nonpharmacological Choices
Dietary factors can precipitate an attack
o Fasting
o Overindulgence in purine rich foods (kidney, liver, anchovies, sardines)
o Beer and wine
Weight reduction however aggressive caloric restriction may increase uric acid and
precipitate a gouty attack.
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Practice Station

Scenario # 1

Patient profile: (Present on the table)\

Patient Name: MB
Age: 52 yrs
Address: Tips
Doctor: MD

Medical condition: RA
Current Medications: diclofenac sodium 50 mg tid

Rx:

Methotrexate 2.5mg tablets
Sig.7.5 mg weekly
D/C Diclofenac
Mitte 1 month


Scenario # 2

A patient with osteoarthritis in the right elbow has approached you for recommendation

Patient Name:
Medical History:
Osteoarthritis
Medication Profile:
Actonel 35 mg po weekly
Aspirin 81 mg po daily












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Scenario # 3

Doctor asking for recommendation to switch from C.E.S for osteoporosis patient does not want
to take estrogen anymore.

Patient profile: (Present on the table)\

Patient Name: Oz
Age: 55 yrs
Address: Tips
Doctor: MD

Medical condition: Menopause
Medications: OTC: Calcium carbonate, vitamin D
Allergies: Not known

On the desk: Therapeutic Choice


Scenario # 4

A patient comes in with a concern and to pick his new medication. Respond as you would in
the Pharmacy.

Patient Name: Andrew Comments: Rheumatoid Arthritis
Age: 58 years Medication: Prednisone 40mg QD (Started 2wks ago)
Address: xyz
Dr: Tips

Rx:
Methotrexate 7.5mg Q week


Scenario # 5

A patient presents with a prescription fill.
Rx:
Arthrotec tabs
Sig: 1 tab BID
M: 60 tabs

Patients profile: (presented after pharmacist candidate request)

31 year old female
No known drug allergies
Medical conditions: Arthritis, pregnant (due date, in next 2 months)
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Previously she used Indomethacin 25mg TID
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59
Ost eoporosis
Nonpharmacologic Choices

Regular exercise (especially impact type or weight bearing, e.g. walking & jogging.
Swimming is not weight bearing exercise); Reduce risk of falling; improve strength and
balance;
Adequate protein, Calcium and vitamin intake;
Stop smoking, avoid excessive and alcohol intake.
Inactivity or prolonged periods of bed rest; sedentary life style smoking history; excessive
alcohol or caffeine intake.
Prevention: Calcium; Vitamin D (best source is diet); exercise.

Pharmacotherapy

Treatment plan

Calcium supplements
Separate doses to achieve a dose of 1000-1500 mg/day (approximately only 500mg of
calcium can be absorbed from GI at a time)
Calcium carbonate contains the highest level of elemental calcium
Calcium citrate may be administered without regard to meals

Vitamin D Therapy:
It is used in the conjunction with calcium supplement dietary phosphorus restriction and
phosphate binding agents
Therapy may need to be temporarily discontinued if calcium and phosphorus are elevated
If there is weakness, headache, decreased appetite, lethargy, health care provider should be
notified

Bisphosphonates: Alendronate, Risedronate
Bisphosphonates must be taken with full glass of water (8 oz) 30 minutes prior to the first
meal of the day
Remain in an upright position for at least 30 minutes following ingestion
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Take medication on a regular basis
Compliance may be increased by once-weekly dosing

Estrogen replacement Therapy:
Patient must discuss and weigh benefits and risk of estrogen or combined hormone
replacement therapy with her physician

Selective estrogen receptor modulator: raloxifene (Levista)
This medication may be taken without regard to food
Concomitant use with estrogen therapy is not recommended
It will not treat symptoms of menopause such as hot flashes
In instance of prolonged immobilization, discontinue raloxifene 3 days prior to and during
the immobile period when possible

Calcitonin (Miacalcin)
If it is administered as an injection, it should be given in the upper arm, thigh, or buttocks.
Proper education regarding administration of the injection and the nasal spray preparation is
necessary
When miss a shot, administer it as soon as possible. Do not administer the shot if it is
almost time for your next dose.
Store the nasal spray in the refrigerator until time for use.
Warm the spray to room temperature

Practice Station

Scenario # 1

One of your patients comes to you in the Pharmacy with a concern and asks you for your
advice on a product. Assist her as you would in the Pharmacy.

Patient profile: (Present on the table)\

Patient Name: Mrs Stacey Comments: Osteoporosis
Age: 58 years Medication: Alendronate Sodium
Address: XYZ -Fosamax.
Dr: Tips 70 mg Q week
(Started 3 weeks ago)
On the table:
Maalox suspension
Gaviscon suspension
Calcium tums
Ranitidine 75mg tablets


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60
Pain Management and
Analgesics

Counseling on Triptans
Onset and duration of action of specific triptan (when can pt repeat the dose)
Adverse effects (chest discomfort, dizziness, drowsiness, nausea, fatigue)
Check for drug interactions
Do not use a triptan within 24 hours after using another triptan

Low Back Pain

Nonpharmacological Choices
Avoid unnecessary bed rest for uncomplicated back pain. As well as premature physical
therapy
Symptomatic relief for acute recurrent back pain of less than 3 weeks:
Encourage patient to resume activity and work as soon as tolerated
Educate patient to expect early recovery
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Practice Station


A lady comes to you with a new prescription and has a few concerns about the medication that
she has been prescribed. Assist her accordingly.

Patient profile: (Present on the table)\

Patient Name: Mrs Fiona Comments: Migraine HA
Age: 32 years Medications: None
Address: XYX
Dr: Gaucher

New Rx: Sumatriptan 50mg PRN (4 tablets)

On the table: Tylenol 500mg caplets and Advil 200mg Tablets



A patient is asking for your recommendation to treat Sprain injury to a ligament caused by
over-stretching or twisting

Patient profile: (Presented by patient after pharmacist candidate request)

Patient Name: TD
Age: 49 yrs
Address: Tips
Doctor: M. Patel

Medical condition: Sprain injury to a ligament caused by over-stretching or twisting
Current Medications: None
Allergies: ASA



On the desk:
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Practice Station


Patient profile: (Present on the table)\

Patient Name: Ms. Lee Comments: Trigeminal Neuralgia
Age: 18 Years
Address: xyz
Doctor: Gaucher
Medication: Morphine SR 30mg BID (stopped 6 months ago)


New Rx: Gabapentin 100 mg OD x 7/7 then, 100 mg BID x 7/7 then, 200 mg BID x 1/12


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Dysmenorrhea
Nonpharmacologic Choices

Explain to Patient:
o A common, exaggerated but natural phenomenon
Reassure Patient:
o That pain does not indicate an organic process or abnormality
Local Heat
Regular exercise:
o Provide some relief by decreasing stress
o Regular aerobic exercise, reducing stress, cessation of tobacco, decrease fat and
increase omega 3 polyunsaturated fatty acids intake, warm bath, and applying heat
pads.
Therapy is based on the specific symptoms and previous therapy.

Practice Station

Scenario # 1

A 25 year old female comes to the pharmacy complaining of what she considers is
premenstrual tension. She wants you to recommend something natural.

Counsel the patient and recommend a natural remedy if appropriate.


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62
Menopause
Menopause is cessation of menstrual periods.

Postmenopausal Hormone replacement Therapy

Estrogen and Progestin
Side effects due to estrogen may be diminished by starting with a low dose and may be
alleviated by changing products. Fewer side effects are associated with the transdermal
preparation
Side effects due to progestin may be alleviated or diminished by changing products or
changing from a continuous to a cycle regimen
Report immediately any vaginal bleeding
Contact physician immediately if there is:
Abdominal tenderness, pain, or swelling
Coughing up blood
Disturbances of vision or speech
Dizziness or fainting
Lumps in the breast
Numbness or weakness in an arm or leg
Severe vomiting or headache
Sharp chest pain or shortness of breath
Sharp pain on the calves

Nonpharmacological Choices

Exercise: Do the pelvic floor exercises
In women experiencing vaginal dryness, increasing sexual activity tends to be more
beneficial than avoiding it (this increases blood flow to the pelvic region resulting to
decrease dryness and dyspareunia).
Diet = decrease alcohol, caffeine and spicy food intake.
Dress in layers so that clothes can be removed as temperature increases (heat exacerbates
symptoms).
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As menopause lead to decrease estrogen environment, one of the outcome could be
osteoporosis. It is essential to take calcium (1g/day) and Vitamin D (400-800iu/day)
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63
Sex ual Dysf unc t i on and DRPs

Drugs that cause sexual dysfunction
Trazadone Priapism
SSRI alternate bupropione, mirtazepine, and meclobemide
Sildenafil, verdanafil and taldanafil priapism contact doctor
(priapism= continous erection longer than 4 hours)
Finesteride and dutesteride male genitalia defect in fetus, pregnant women should not
touch

Practice Station

Scenario #

Doctor wants to write prescription for 50-year-old male patient with renal disease and diabetic
condition.

Patient profile: (Present on the table)
Allergies: none
Current medications: insulin long acting
Medical history: Renal disease Creatinin clear 30ml/min
Medical conditions: diabetes, renal disease, and low sexual libido

Rx

Sildenafil (Viagra) 50mg
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64

Vagi ni t i s

Presentation Symptoms

Burning & itching in vaginal area
Abnormal vaginal discharge grey/white, thick, pasty, curdy, clumpy, odorless
Cottage cheese like discharge
pH of discharge 4.5

Questions to ask:

Have you had similar symptoms before? If so, how long ago? How long did it last? Did you
see a physician about it? Did the physician diagnose s/s as a yeast infection?
If had before & symptoms are same
How often have you had a yeast infection in the past year?
Recurrence = 4 episodes/year [may need to refer for prophylaxis or treatment for 14days]
Do you have a fever, pain upon urination, sores, and profuse discharge? (refer for STDs)
Delicate topic assess if pt has high-risk sexual behavior (ie. Unprotected intercourse,
multiple partners, casual encounters, etc)
Tell me about the discharge (Fishy? Color? Thick or thin? Amount/Purulence?
Is the area burning or itchy?
Are you taking any meds? Are you taking antibiotics or have you taken them recently?
[antibiotics may risk of vaginitis]
Other medical conditions? Pregnant? (Pregnancy is risk factor)

Refer:

Pre-pubertal (under age 12 yo)
1
st
episode
Recurrence of VVC within 2 months of last episode (complicated cases may need RX)
Symptoms not improving w/in 3d of TX, or persisting >7d of TX
Underlying disease (diabetes, HIV, immunosuppressed) or pregnant
At risk for STDs (Hx of unprotected intercourse, multiple partners)
Uncharacteristic s/s (fever, pelvic pain, malodorous, colored disch)
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** Women who have symptoms of vaginitis & have had previous drug are eligible for self
treatment

Treatment Plan
Non prescription azoles if patient is eligible for self treatment
All durations/products have equal efficacy (~85%)
Symptomatic relief within 3d & resolve in 7d
1 day treatments may be more irritating because higher dose
S/E minimal may warn about irritation, burning, redness if pts symptoms get worse,
advise to stop treatment and see doctor.

Non prescription drugs

Clotrimazole (Canesten)
1 day: Tablet (500mg), Cream (10%)
3 day: Tablet (3x200mg), Cream (2%)
6 day: Cream (1%)

Miconazole (Monistat)
1 day: Ovule (1200mg)
3 day: Ovule (3x400mg), Cream (4%)
7 day: Ovule (7x100mg), Cream (2%)
Combi-paks available which incl. small tube of external cream


Prescription

For persistent or recurrent (>4/yr) cases or for those with greater tendency to develop vaginitis
(ie. Immunosupp)

Fluconazole (Diflucan)
Single 150mg oral dose
patient may prefer this choice for convenience (high acceptability& compliance)
well tolerated [SE: rare: GI upset, headache, and pain]
DI: warfarin, phenytoin, theophylline, rifampin; CI: pregnancy

Terconazole (Terazol)
3 day: Ovule (3x80mg), Cream (0.8%)
7 day: Cream (0.4%)
Recurrenceusually due to diff strain of candida (C. glabrata) Can recommend boric
acid 600mg gelatin caps (1 capsule p.v. BID x 14-28days), compounded, or refer for
prophylaxis (ie. Fluconazole 150mg once wkly x6mo)


Non pharmacological Choices
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Good genital hygiene, keep vaginal area clean & dry
Shower > Bath, Wipe front back
Avoid vaginal deodorants, douching, soaps & perfumed products
Avoid tight clothing &synthetic, plastic underwear instead wear cotton underwear &
loose fitting clothes
Avoid wearing wet clothes for extended periods of time
Diet can try to avoid high sugar foods & consumption of yogurt with lactobacilli, but
evidence is lacking
Probiotics (L acidophilus) effectiveness questionable


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Practice Station

Scenario # 1

A young lady patient comes to you in the Pharmacy asking you for assistance regarding her
condition. Solve her concern and give her all the necessary information regarding her
condition.

On the table:
Canesten 3 Cream 3%
Miconazole Ovule 400mg x 3

Patient profile: (presented by patient after pharmacist candidate request)
Allergies: None
Current medications: None
Medical conditions: None


Scenario # 2

A 38 year old female comes into the pharmacy with severe prutiritis of the vaginal area and
complains of a cottage cheese discharge.

Patient profile: (presented by patient after pharmacist candidate request)
Allergies: None
Current medications: metformin 500 mg bid, glicalizide 30 mg daily
Medical conditions: Diabetes for past 1 years
She does not have other symptoms like fever, burning at the time of urination etc.


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65
Beni gn Pr ost at i c Hyper pl asi a


Practice Station

Patient profile: (Present on the table)\

Patient Name: Mr Jim Comments: Benign Prostratic Hyperplasia
Age: 38 years
Address: XYZ
Dr: Gaucher

New Rx: Finasteride 5mg QD x 1 / 12 (8 Repeats)

Wife comes to pick up prescription.
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66
Ant i c anc er dr ugs and
Chemot her apy



Chemotherapy
All drugs are carcinogenic, teratogenic, and mutagenic.
Medications may cause sterility
Tell your dentist that you are on chemotherapy, due to an increase risk of bleeding and
infections
Hydration and mesna therapy are recommended for C and I
Notify your doctor if you have burning upon urination

Antimetabolites: S-phase-specific
Avoid crowded place and sick people
You may be asked to chew ice if receiving fluorouracil (5-FU) to reduce damage to
mucosal lining in your mouth
Contact your physician if you have uncontrolled nausea or vomiting, excessive diarrhea, or
pain, swelling, or tingling in palms and soles of feet (hand-foot syndrome)
Call the doctor if you feel dizzy, lightheadedness, or have trouble urinating (clofarabine).
You should be receiving folic acid and vitamin B
12
injection if you are receiving
pemetrexed.
Nelerabine may cause sleepiness and dizziness

Antitumor antibiotics
Anthracyclines; Mitomycin; Dactomycin; Bleomycin
Contact doctor for fast, slow, or irregular heartbeats and/or breathing difficulties
Anthracyclines may cause a change of urine color or whites of eyes to a bluish-green or
orange-red
Bleomycin may cause a change in skin color or nail growth


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Hormones and antagonists
Avoid to use in pregnant
Some agents may cause weight gain and menstrual irregularities among women
Be aware of leg swelling or tenderness (it may be a sign of DVT), breathing problems, and
sweating
Transient muscle or bone pain, problems urinating, and spinal cord compression may occur
initially in patients receiving LHRH agonist
a) Take exemestane after meal

Plant Alkaloids
Call doctor for uncontrolled diarrhea (irinotecan), nausea or vomiting, signs and symptoms
of an infection
Patient should receive prophylaxis for emesis, pretreatment for anaphylaxis or peripheral
edema (taxanes)
Patient should receive a prescription for loperamide and atropine with irinotecan therapy

Biologic Response Modifier
Let your doctor know if you have severe fatigue, trouble breathing, or irregular heart
rhythm.
Chills, fever, depression, and flu-like symptoms are just common
There is taste and smell alterations with levamisole
Monoclonal antibodies can cause infusion-related reactions such as fever and chills.
Blood pressure, protein test in your urine should be checked regularly if patient receive
Bevacizumab
For patient receiving Cetuximab, you should avoid excessive exposure and should wear
sunscreen
You should take medication for thyroid if you are receiving Tositumomab.
Do not try to conceive until 12 months after finishing therapy for both men and women
Women who are taking Thalidomide and lenalidomide should not be pregnant
Two forms of birth control must be used, including men on the drug that have sexual
contact with women of childbearing age

Cyclophosphamide
SE: Myelosuppression, Nausea and vomiting, Hemorrhagic cystitis (toxic metabolites)
Alopecia, Cardiomyopathy (rare), Interstitial pneumonitis,

Hemorrhagic cystitis:
Urotoxicity occurs because bladder contains very low concentration of thiol compounds,
which neutralize reactive chemicals
Symptoms: painful urination, frequency & hematuria
Prevention: adequate hydration to flush toxic metabolites out of the bladder

Pulmonary Toxicity:
Not schedule or dose related and may occur after discontinuation
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Symptoms: dyspnea, fever, dry cough, etc

Practice Station

Scheme # 1

A 52 years old male, patient is to fill prescription

Medical History: cancer

Rx: Cytoxan (Cyclophosphamide) 50 mg
500 mg po od x 5 days

Provide counseling

Patient profile:
Allergies: none
Current medications: tylenol for headache and multivitamins

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67
Ant i mi c r obi al s DRPs


Practice Station

A patient is asking for your recommendation

Profile:
Tylenol #3 i-ii tabs q 4 to 6 hours prn x 50
Cephalexin 500mg qid x 40

On the table:
Senokot tabs
Soflax (Docusate Na)
Metamucil pwder
Glycerin suppositories
Fleet enema
Milk of Magnesia
Dulcolax (Bisacodyl) tabs


Scenario # 2

A male patient, 50 years old comes to fill a prescription

Rx:
Biaxin 500 mg BID x 10 days
Flagyl 500 mg BID x 10 days


On the table: Information sheet about herbal product


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Scenario # 3

A patient presents with the following Rx

Rx:
Ciprofloxacin 500mg po bid x 7 days

Provide counseling and address all the concerns.


Scenario # 4

A healthy 33-year-old male, he presents with prescription for ciprofloxacin 500 mg twice daily
for three days. Your determine that he is traveling to Mexico the following week for business
meeting, and the doctor told him that he may need this drug to treat diarrhea, if it develops.
The doctor also instructed him to buy some Lopramide.

Rx:
Cipro 500 mg bid f 3d

Loperamide

Scenario # 5

Patient profile: (Present on the table)

Patient Name: Casie Comments: Community Acquired
Age: 29 years Pneumonia
Address: XYZ Medications: Materna Multivitamins
Dr: Gaucher (Started 4 months ago)



New Rx: IV Levofloxacin 500mg Q24HRS x 10 / 7


Scenario # 6

A patient comes to fill a prescription

Rx
Rifampin 300mg
Sig: 2 tabs od x 14 days for prophylaxis treatment of H. influenza type B
M: 28 tabs
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Patient profile: (given by patient after pharmacy candidate requests)
Allergies: None
Current medications: none
Medical conditions: None


Scenario # 7

A doctor prescribes Zithromax for one of your patients. Patient has been diagnosed with
community-acquired pneumonia.

Patient profile: (provided on the table)

Allergies: clarithromycin
Medical conditions: Pneumonia and Renal disease
Current medications: Enalapril 5 mg

Discuss this prescription with the doctor.


Scenario # 8

A patient comes in to collect a prescription for Amoxicillin. Prescribed by a dentist to be taken
just before dental treatment. The patient profile shows that the patient is allergic to penicillin.

Discuss an alternative with the dentist.

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68
Urinary t ract infect ions

Symptoms

Frequency and urgency of urination.
Burning with urination
Fever and chillsimmediately refer to the physician
Itching and irritation

Question to ask

Have you experienced a urinary tract infection?
How recently?
Do you have currently any hemorrhoid or menstrual bleeding?

Patient counseling:

Consumption of cranberry juice has been shown beneficial in postmenopausal
woman.
In prevention:
Drink adequate daily water (8 glasses)
Empty bladder at regular intervals.
Consider other birth control methods than diaphragm, tampons, and spermicidal.
Discourage use of phenazopyridine (non prescription medication)





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69
Wei ght Loss

How to approach the problem

Communicate in non judgmental way
Express concerns about the health risks associated with the condition
Help patient to set achievable, individualized goals
Educate One thing that seems to be very important for most patients is physical activity.
What are your thoughts about increasing your activity level?
Consider social and environmental cues that lead to undesired eating (eating while
watching television)


Counsel on benefits of weight loss

(Health advantages gained by a 10 kg weight loss)
30-40% reduction in diabetes-related deaths
20-25% decrease in total mortality
Reduction of 10/20 mmHg Blood Pressure
Reduction of LDL cholesterol by 15%
Reduction of 10% total cholesterol
Reduction of 30-50% in fasting blood glucose
Even loss of 5% fo body weight can improve insulin action & fasting blood glucose
levels & the need for medications

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Practice Stations
Scenario # 1

Patient profile: (present on the table)

Patient Name: K. S
Age: 25 years
Address: Tips
Dr: Tips

Comments: Obese
Allergies: None

Medication: Cipralex 20 mg po od

New Rx: Meridia 10 mg po od
M: 30 Capsules
Rep x 2


Scenario # 2

A patient is here to fill a prescription:

Patient profile: (present on the table)

Patient Name: Long ly
Age: 38 years old woman
Address: pharmacy prep ave
Dr: Tips

Comments: obesity
Allergies: None

New Rx: Xenical 120 mg po tid with meals
M: 1 box (84 tabs/1 month)

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70
Smok i ng Cessat i on

Presentation symptoms
Irritability, insomnia, weight gain, headaches, anxiety poor concentration (Withdrawal
symptoms)
GI upset (improper gum use)
Nicotine overdose: smoking with gum use, exercise with patch
Heart racing (overdose symptoms)


Questions to ask:

Determine what stage in smoking cessation. (Pre-contemplation, contemplation, preparation,
action, maintenance)
What is your motivation to quit?
How long have you been smoking?
How many cigarettes do you smoke per day?
Have you tried to quit smoking before? How? What failed?
Where and when most often do you find yourself smoking?

Refer
Heart disease
<18 yo
Pregnancy

Nicotine replacement therapy
Gum: onset 30 min; 4mg = 1cig/h, 20 pieces / day; 2mg = cig/h, 30 pieces / day;
gradually decrease 3-6 months
indigestion, salivation, bloating, jaw ache, throat sore
Patch: onset 6 hours; 24 hour patch, 7, 14, 21 mg; gradually decrease 3-4 months
Irritation, headache, insomnia, dizziness, indigestion, NV, bowel change
Inhaler: oral absorption, 2mg / cartridge, lasts 20 min, 6-12 cartridges for 1-3 months, then
decrease over 2-3 months
First week: cough, irritation, nasal congestion, dizziness, NV
CI in: pregnant, <18 yo, CV disease
Buproprion (Zyban) Rx product
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Antidepressant that reduces withdrawal symptoms
Dry mouth, insomnia, dizziness, tremor, taste perversion
CI in: depression with other antidepressants, seizures, heavy alcohol, diabetics, asthma
Varenicline (Champix)
Nicotinic acetylcholine receptor partial antagonist, reduce withdrawal and decrease
pleasure from smoking
NV, insomnia, abnormal dreams, constipation, gas,

Nonpharmacological Choices
Nicotine withdrawal: Symptoms to be monitored in case of nicotine withdrawal are: Severe
craving, Anxiety or irritability, Restless, nervousness, difficulty with concentration sleep
disturbance, and headaches.
Overdose symptoms Increase appetite or eating behavior, palpitation (heart racing),
difficulty in breathing, Nausea, vomiting, and diarrhea

Education
Reassure quitting smoking is very hard, and often takes multiple attempts
Convince patients to keep trying despite failing
Applaud their decision to quit smoking, and reassure them of their frustration, anxiety
Educate patient on the positives from quitting (lifestyle and health)
Educate patients on importance of nonpharmacolical aids with pharmacological therapy
Set up quit date
Follow up is very important to maintain
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Practice Stations
Scenario # 1

A male patient who picked up his Nicorette gum 1 week ago from your Pharmacy has got a
concern regarding his medication. Solve his concern and counsel him as you would in the
Pharmacy.

Patient profile: (given by patient after pharmacist candidate request)

Patient Name: J.K. Comments: Smoking cessation
Age: 29 years Medications: Nicorette gum 4 mg
Address: Tips
Dr: Tips





Scenario # 2

A very concerned patient comes to you, the Pharmacist, asking for your assistance. Solve his
concern and take the right course of action.

Patient profile: (given by patient after pharmacist candidate request)

Patient Name: J.K. Comments: None
Age: 29 years Medications: None
Address: Tips
Dr: Gaucher

On the table:
Nicoderm Patches 14mg
Nicorrette gum 2mg


Scenario # 3

A very concerned patient comes to you in the Pharmacy and asks for your assistance. Solve his
concern as you would in the Pharmacy.

Patient profile: (given by patient after pharmacist candidate request)

Patient Name: Jack Jill Comments: None
Age: 33 years Medications: Nicotine Polacrilex Gum
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Address: XYZ (Started 3 weeks ago)
Dr: Gaucher


Scenario # 4

A patient comes to fill a prescription

Patient profile: (given by patient after pharmacist candidate request)

Patient Name: Pink Rose Comments: None
Age: 43 years Medications: Bupropion Tablets 150mg
Address: XYZ BID (started 2 weeks ago)
Dr: Tips OTC Medications: Nicoderm Patches 14gms
(Started yesterday)


New Rx: Carbamezapine 100mg TID x 5/7 then,
200mg TID x 1/12

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71
Al l er gi es and Hyper sensi t i ve
Reac t i ons

Anaphylactic Reaction
Symptoms: Difficulty breathing, Wheezing, Abnormal breathing sound, Confusion, Slurred
speech, Rapid or weak pulse, Blueness of the skin (cyonosis), including lips, or nail.
Fainting, light headedness, dizziness, Hives, and generalized itching. Palpitation
(heartbeat), nausea and vomiting, diarrhea, abdominal pain or cramping. Skin redness,
Nasal congestion and cough.
Swelling of throat, lips, and tongue or around the eye.
Note: Symptoms develop rapidly often with seconds or minutes of allergen or factors
causing anaphylactic shock.
Commonly caused by: Insect bite, and Peanut
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Practice Station


Scenario # 1

A lady patient comes to pick up her medication. Counsel her and provide all necessary
supporting measures. You may also advice her any non-prescription product you believe would
help her.

Patient profile: (presented on table

Patient Name: Miss Kelly Comments: Hypersensitivity to pea nuts
Age: 15 years Medication: None
Address: Tips
Dr: Gaucher

New Rx: Epipen auto injector, Inject 0.3ml SC as needed






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72
Phot osensi t i vi t y

Presentation Symptoms

Exaggerated sunburn on sun-exposed areas (forehead, cheeks, chin, rim of ears, chest, neck,
hands)
Three types of responses:
A strong delayed erythema & edema (begins 8 to 24 hrs after sun esposure & lasts 2 to 4
days). May involve hyper pigmentation & appear darker red than sunburn
Rapid, transient erythema with immediate onset (30 min), lasting 1 to 2 days, without
edema
Rapid transient wheals and flares, with a burning sensation

Photoallergy Clinical Presentation

Eczematous eruptions, usually pruritus, appear on exposed areas within 24-48 hours of re-
exposure to the photo allergen
Solar urticaria (multiple pruritus, raised areas on the skin that occur following exposure to
sunlight)
Photo allergic contact dermatitis: occurs after topical application of a photo allergen.
Lesions are well demarcated and mostly symmetrical.

Drugs associated with photosensitivity

Tetracyclines: may also induce persistent pigmentation on sun exposed areas
Floroquinolones: photo toxic reactions with redness, blistering and peeling
Sulfonamide derivatives (sulfonamides, oral hypoglycemic, diuretics)
Amiodarone
NSAIDs (Indomethacin with lowest photochemical activity)
Topical agents: sunscreens (PABA), retinoids, coal tar (intense burning & stinging within
minutes)

Photosensitivity reactions
Photosensitivity adverse drug reaction that can be caused by topical or systemic
administration of medication
Two types of photosensitivity reactions: phototoxicity and photoallergy.
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Phototoxicity

Results from direct cellular damage produced by the photo-product
No immunologic mechanisms are involved
Manifest during an initial exposure

Photoallergy
Less common than phototoxicity, however it is usually more severe
Occur as a result of cell-mediated (delayed) or humoral-mediated (immediate)
hypersensitivity to an allergen activated or produced by the effect of light (UVA) on a
drug.

Management

Stop the offending agent
Avoid exposure to UV light
Treat similarly to that of sunburn
Symptom relief (cool wet dressings, soothing gels and oatmeal baths)
Oral antihistamines may help to reduce itching
Topical antibacterial creams to prevent infection of broken skin blisters
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Practice Stations
Scenario # 1

Patient is asking for your recommendation about what appears to be sunburn.

On the table:
Ombrelle SPF 30
Tylenol ES
Advil
Aveeno lotion
Aloe Vera gel
Benadryl tablets
Benadryl Cream
Calamine Lotion

Patient profile: (given by patient after pharmacist candidate request)
Allergies: None
Current medications: none
Medical conditions: none

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73
I nsomni a

Good Sleep Hygiene Measures
Maintain a regular schedule
Go to bed only when sleepy
Avoid daytime naps
Avoid caffeine & nicotine especially within 4-6hrs of bedtime
Do not drink alcohol (especially within 4hrs of bedtime), since it causes fragmented sleep
Avoid heavy meals before going to bed, but a light carbohydrate snack before bedtime is
acceptable
Do not eat chocolate or large amounts of sugar before bedtime
Avoid drinking excessive amounts of fluid in the evening
Minimize noise, light & extreme temperature in the bedroom
Exercise regularly during the day, but avoid vigorous exercise within 3 hrs of retiring
Develop relaxing rituals (e.g. reading, listening to music) before bedtime
Get out of bed & go to another room if unable to sleep within 20 minutes. Return when
sleepy
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Practice Station


One of your patients comes to you in the Pharmacy, looks confused and asks for your
assistance. Take the right course of action based on your professional judgement. Advice the
patient accordingly.

Patient profile: (present on the table)

Patient Name: Andy Mutt Comments: Insomnia
Age: 37 years Medications: Lorazepam 0.5mg QD
Address: XYZ (3 refills) last refill: 15 days ago
Dr: Tips



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74
Vac c i nes

Flu vaccine (flu shot)

Generally people over 65 years old and people with another serious condition should
take flu shot to prevent any attack. You are in a high-risk group, therefore I strongly
recommend you to do flu shot. If you have flu, it might develop to much worse
condition. Influenza may aggravate your COPD, and even you may need to be
hospitalized.

I understand your concern. But not all people taking flu vaccine experience s/e, they
are very mild and could be prevented by taking Tylenol you should not be scarred.

Its advisable (health Canada recommends you have to do flu shot every year,
because the virus is changing every year, thats why its so important to keep
composition of vaccine updated annually. Each year new vaccine is produced that
provides protection against the most common strains.

Flu shot is the most effective way to protect you from flu. Regular hand washing is
another way to help minimize your risk become sick. Keep on alcohol based sanitizer
handy at work, home and in the car.
Wash hands at least 5 times a day. Cover your mouth and nose with tissue when you
cough.

The benefits of flu shot far outweigh the risks. The flu vaccine cant cause influenza
because it doesnt contain any live virus.

The most common S.E are soreness at the site of injection, fever, and fatigue, muscle
aches within 6-12 hours after your shot. These effects may last a day or two in most
cares these effects are mild and will disappear within 48 hours.

Many people confuse the flu with a cold. The flu vaccine will not protect against
cold.
If you didnt get a flu shot last year and didnt get sick, it doesnt mean that you will
not get sick this year.

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Every year different strains of the flu virus circulate. By not getting the flu shot, you
are increasing your chances of becoming ill.

Protection from the vaccine develops by 2 weeks after the flu shot, and may last up to
one year (4-6 months).
After you get a flu shot, your immune system produces antibodies against the strains
of virus in the vaccine, when you are exposed to the influenza virus, the Ab will help
to prevent infection or reduce severity of ill

Who should get the shot?
Everyone, everyone aged 6 months or older can benefit from getting flu shot. Also,
its very important for some group of people because they have greater risk of
developing complications from the flu. Or they may spread it to others at high risk
because they are in close contact.
A few people are severely allergic to eggs they shouldnt get flu shot.

Is the flu just a bad cold?
*The flu is much worse than a cold. Cold symptoms and complications are much
milder than that of the flu.

Is the flu shot highly effective?
A flu shot is about 70-90 percent effective in preventing flu in healthy adults, when
the vaccine is a good match with the strains. The vaccine can help prevent pneumonia
and hospitalization in about six out of ten people, and is up to 85% effective in
preventing death. However, vaccine effectiveness varies from one person to another.

Why your kids should get the flu shot.
Healthy young children aged 6 to 23 months are at increased risk of being admitted to
the hospital because of flu symptoms compared with healthy older children and
young adults. And once the children enter daycare, school, or begin playing with
groups of children, their close contact enables the flu virus to spread quickly and
easily among them.
This helps make children one of the main spreader of the virus both in the school and
in household.

Facts about children, the flu and vaccination:
Only children 6 months of age and older can be vaccinated.
Children under 9 years old getting vaccinated for the first time need tow doses of
vaccine-the second dose at least one month after the first.
Children and teenagers (6 months-18 years) who have been treated with aspirin for
long periods may have an increased risk of developing Reyes syndrome if they get
the flu.

Indications for vaccine
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Age 65 years and older Nursing Home and Chronic care residents Chronic
cardiopulmonary disease (e.g. Asthma): all ages Chronic disease requiring frequent
hospitalization Long term Aspirin use under age 18 years Prevents Reye's Syndrome

Vectors , Health care workers , Nursing home personnel Family members of high risk
patients

Essential service providers Students in Institutional settings Second or third
trimester of pregnancy Human Immunodeficiency VirusTravel to tropics any time of
year Travel to Southern Hemisphere April to September Pregnancy (second and third
trimester) Breast Feeding.
Schedule: Annually
Flu season in Canada: Oct to April
Immunization season: Oct to Mid Nov
Vaccine Efficacy Prevents illness in 70% healthy people age <65 yearsPrevents 30-
70% Pneumonia hospitalizations in elderlyContraindications to Vaccination:
Anaphylaxis to eggs or other vaccine components Reaction to thimerosal (in contact
lens solution) Adults with acute febrile illness History of Guillain Barre Syndrome
Children from 6 month age to 2 years is high risk
Children up to 8 years taking first time should receive
two shots 1 month apart


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74-4
Hepatitis vaccines

Product Age recommendation

Engerix B pediatric dose


Neonates, infants, children, and adolescents up to 19
years, inclusive

Engerix B adult dose

Adults 20 years and over

Twinrix junior (Hepatitis A&B)

Children and adolescents from 1 year to 18 years

Twinrix adult (Hepatitis A&B)

Adults 19 years and over*

Havrix 720 Junior (Hepatitis A)


Children and adolescents from 1 year up to and
including 18 years of age

Havrix 1440 (Hepatitis A)

Adult 19 years and over

Hepatitis A Vaccine
Indications Travelers to endemic Hepatitis A areas, Children living in endemic states
Preparation Hepatitis A Vaccine (Havrix, Avaxim, Epexal, Vaqta) Twinrix
(Combined Hepatitis A and Hepatitis B Vaccine) Adults: 720 EU/20 ug (1.0 ml) Not
approved for use in Children under one year? Requires 3 doses as in Hepatitis B
Vaccine schedule
Contraindications Not indicated for under age 1 years Use Hepatitis A
Immunoglobulin instead Efficacy Protective antibodies by 4 weeks in 98-100% of
patients Protection lasts at least 10 years after series.

Hepatitis B Vaccine
Indications
All Newborns (at birth, age 2 months, and age 6 months) All health care personnel
Hemodialysis patients Patients requiring frequent blood transfusion Staff and
residents at developmentally disabled home Male homosexuals and their sexual
contacts Intravenous Drug Abuse Sexual contacts of chronic HBsAg carriers
Contraindications Anaphylactic reaction to baker's yeast
Available Preparations Recombivax HB Infants, Children and Adolescents: 5 ug/dose
Adults: 10 ug/dose Immunosuppressed Adult: 20 ug/dose Energix-B (SKB) Infants
and Children: 10 ug/dose Twinrix (Combined Hepatitis A and Hepatitis B Vaccine)
Adults: 720 EU/20 ug (1.0 ml)
Not approved for use in Children
Requires 3 doses as in Hepatitis B Vaccine schedule



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74-5
Varicella zoster infection (chickenpox)

Dose: healthy children 12 months to 12 year age One dose adults and adolescent >
13 Two dose of vaccine is given 4 to 8 wks apart.
Vaccinate all susceptible adults
Contraindication: Pregnancy
Complications of herpes zoster include post-herpetic neuralgia, bacterial infections
and paralysis.
Inform patient of the importance of hygiene, especially thoroughly.
washing their hands before and after touching their lesions to prevent secondary
infections.
Provide patient with information on treating their lesion and easing their discomfort.
Compresses of cool tap water to lesions for 20 minutes several times a day.
Application of a sterile non-occlusive, non-adherent dressing over the involved
dermatome will help protect the lesions from contact with clothing.
Application of capsaicin cream to affected area 3-4 x/day, once healed
(warn patient about potential burning sensation).
Inform the patient to avoid contact with young children (especially neonates),
pregnant women and immunosuppressed persons since the active lesions are
potentially infectious.
(Patient with HZ can only infect someone who is seronegative for VZV).
Discuss with the patients the possible side effects for each medication used in the
management of PHN.

Gardasil: Human papilloma quadrivalent

9 to 26 yrs administered 0, 2, 6 months im
Prevents:
External genital warts caused by HPV 6, 11, 16 and 18 strains.
Cervical carcinoma, cervical dysplasia, vulvar dysplastic lesions.
Counseling: Immunization will not eliminate the need for cervical cancer screening in
the foreseeable future as not all strains will be covered by a vaccine. Also, it is
unclear if the vaccines will offer therapeutic action against established infections.
Annual pap smear is required as the vaccine does not protect against all HPV strains
Not recommended in pregnancy
Can be used in nursing mothers
Side effects: Pain, swelling, erythema and pruritus at injection site, headache, fatigue.





Dukoral vaccine
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Inactivated cholera vaccine BS-WC
Indications: Travelers diarrhea (E.coli) and cholera
2 doses at least 1 week but <6 weeks apart
If > 6 weeks elapse between doses, restart the primary immunization.
Children aged 2 to 6 years: one-half the amount of buffer solution is discarded, and
the remaining part is mixed with the entire contents of the vaccine vial.
Typhoid vaccine

Inactive typhoid vaccine (shot):
Should NOT be given to children UNDER 2
A booster is needed every 2 YEARS for individuals who remain at risk
Live typhoid vaccine (oral):
Should NOT be given to children UNDER 6
4 doses, given 2 days apart, are required for protection
A booster is needed every 5 YEARS for people who remain at risk
C/l in immunocompromised and cancer patients

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Practice Stations
Scenario #1

A male concerned about flu, his medical history includes COPD.

Patient profile: (patient presents after pharmacist candidate request)

Patient Name: David Comments: None
Age: 32 years Medications: None
Address: XYZ
Dr: Tips


Scenario # 2

A doctor wants to know that his patient is schedule to receive his annual influenza
vaccination. What is your concern at this time?

Patient profile: (presented on table)
Allergies: None
Medical conditions: Deep vein thrombosis
Current medication: Warfarin 6.0 mg
Lab test: INR 2.0-3.0

Scenario # 3

A women bring a varivax vaccine to your pharmacy and wants to know more information
on varivax vaccine.

Patient profile: (patient presents after pharmacist candidate request)
Age: 30 yo
Allergies: None
Current medication: none
Medical conditions: none



Scenario # 4

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A patient presents with a prescription to fill:

Patient Name: David Comments: None
Age: 32 years Medications: None
Address: XYZ
Dr: Gaucher
On the desk
Rx:
Dukoral oral vaccine
M: 2 doses








Oral antidiarrheal vaccine (for travelers diarrhea) and also prevents Cholera.
Dukoral
Taken 2 oral dose (1 week apart)
2
nd
dose should be within 6 wks of first dose.
If you exceed 6 weeks, should start from 1
st
dose
Dissolve and take with water.



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75
Pr egnanc y & Lac t at i on



Immunization in pregnancy
Factors to address when considering immunization during pregnancy
Likelihood of infection exposure
Risk of infection to mother and/or fetus
Maternal Immune status for disease in question
Risk of adverse effects from immunization

Summary of potential risks associated with selected diseases in pregnancy

Disease Maternal Risk Fetal Risk
Cholera Dehydration; potential increased
severity in 3
rd
trimester
Premature labor
Hepatitis A Potential increased disease severity in
3
rd
trimester, miscarriage
Potential increase in
prematurely
Hepatitis B Potential increased disease severity in
3
rd
trimester
Chronic infant infection
Influenza Increased risk of maternal morbidity,
serious complications, hospitalization
Stillbirth
Measles Increased risk of encephalitis,
pneumonia
Premature delivery, stillbirth
Rabies Close to 100% fatality (regardless of
pregnancy status)
Depends on severity of maternal
illness
Rubella Increased risk of miscarriage;
susceptibility is 8% to 15% among
adult women
Congenital rubella syndrome
(serious malformations),
stillbirth
Tetanus Tetanic muscle contractions, death
(regardless of pregnancy status)
Infant born to a non-immune
mother is at risk of neonatal
tetanus, which can be fatal
Typhoid Increased risk of miscarriage Depends on severity of maternal
illness
Varicella
booster
Increased risk of pneumonia, death Congenital varicella syndrome
(serious malformations)
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Yellow fever Fatality can be >50% Depends on severity of maternal
illness


Practice Station

A pregnant woman came to your pharmacy and she is concern about her daughter who has
chicken pox. What will you advice this patient?



A young lady comes to you in the Pharmacy for your advice on a product she feels would be
helpful for her condition. Gather the necessary information from her and advice her
accordingly.

(On the Table: Dimenhydrinate 25mg tablets and Pyridoxine Tablets)


Patient Name: Ms Casie Comments: Community Acquired
Age: 29 years Pneumonia
Address: XYZ Medications: Materna Multivitamins
Dr: Gaucher (Started 4 months ago)

New Rx: IV Levofloxacin 500mg Q24HRS x 10 / 7

Patient pregnant and admitted to ward hence suggest appropriate alternative i.e 2
nd
/3
rd
gen
cephalosporin + macrolide


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76
Tr avel Ti ps
Travelers Diarrhea
Non Pharmacological
Boil it, cook it, and peel it
Bottled water only
No ice
Hygiene (brushing teeth)
Dont eat from street vendors
Avoid cold cuts and uncooked food (sea food)
Avoid buffets where food has been sitting there for a while

Malaria Prophylaxis
DEET (N, N-Diethyl-m-toluamide) should be applied on the skin before outdoor
activities during the main hours of malarial transmission.

Diabetes Management While Traveling

Planning Ahead
Diabetes should not stop you from doing the things you want to do. If you have
diabetes, you must plan ahead carefully as traveling can be stressful sometimes and
can raise blood glucose levels. Being well prepared can help you avoid undue stress.
It is very good idea to meet your doctor for a checkup several weeks before you
leave. Take your travel itinerary to your health care team and work out plans for your
meals and medication, especially if you are traveling through different time zones.
Ask for a list of your medications (including the generic names and their dosages), if
you are taking insulin- what type of insulin and whether the insulin is sort,
intermediate or long acting. Photocopy the list and carry one copy with you at all
times. Carry identification with you at all times stating that you are diabetic.

Packing
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Divide your medications and diabetes supplies and pack them in more than one bag,
in case you lose one of your bags. It s important to keep some supplies on your carry
on luggage. Take extra supplies in case of accidental destruction. Also consider
taking some of the other supplies you may need for treatment for hypoglycemia, food
supplies, nausea, diarrhea, etc.

While Flying
Tell your travel agent that you are diabetic and most airlines offer special meals for
diabetic passengers. Be aware of time zone changes ad schedule your meals
accordingly. Carry all our insulin with you as manufacturers indicate that insulin
should not be exposed to X-rays as it may lose potency. Inspect your insulin before
every injection.
Do some activity during your journey to improve blood circulation

Storage Conditions
Insulin retains its potency at room temperature for 30 days. It must be stored properly.
If you are traveling in hot temperatures, insulin must be kept in a cooled thermos /
insulated bags. If you are skiing, camping or working in a cold climate, keep insulin
from freezing.

Keeping Blood Glucose Levels Under Control
While on a vacation, test your blood glucose levels frequently using a meter. It is a
good idea to keep the instruction manual for the glucose meter and keep spare
batteries and test strips.

Packing List For Diabetic Travelers
Extra supply of insulin or oral agent for diabetes
Extra supply of syringes, needles and an extra insulin pen if used
Blood glucose testing kit and record book
Fast acting insulin for high blood glucose and ketones
Fast acting sugar to treat low blood glucose
Extra food to cover delayed meals such as a box of cookies or crackers
Urine ketone testing strips
Anti nausea and anti diarrhea pills
Pain medication
Sun block
Insect repellant
Large amount of bottled water if necessary
Comfortable walking shoes
Glucagon (used if person is severely hypoglycemic and unconscious)
Telephone numbers of your doctor
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Practice Station

Scenario # 1

A patient comes in the Pharmacy to pick up his medication and also has a few questions
about certain other products on the outside shelf. Counsel him and advice him
accordingly about the product. Also give him the necessary tips.

Patient profile: (present on the table)

Patient Name: David cox Comments: None
Age: 32 years Medications: None
Address: XYZ
Dr: Tips

New Rx: Ciprofloxacin 500mg tablets QD
(15 tablets)

(On the Table: Bismuth subsalicylate suspension
Immodium Capsules 2mg
Oral Rehydrate sachets)




A lady patient comes to pick up her medication. Counsel her and provide all necessary
supporting measures. You may also advice her any non-prescription product you believe
would help her.

Patient profile: (present on the table)

Patient Name: Miss Kelly Comments: None
Age: 38 years Medication: None
Address: ZYZ
Dr: Tips

New Rx: Mefloquine 250mg tablets Q Week (8 tablets)
(On the table: DEET spray 31%)



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77

Subst anc e of Abuse
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Why OTC drugs get abused:
Cheap
Readily accessible
Carry no stigma of abuse (like cocaine or heroine)
Carry minimal risk of detection

Antihistamines
Dimenhydrinate (Gravol)
adolescents become high when they consume anywhere between 750-1,250 mg (15-25
tabs)
chronic abusers have been reported to take up to 5 gm (100 tabs) daily

Diphenhydramine (Benadryl)
usually taken by patients with schizophrenia and chronic insomnia
reported cases of chronic abuse include daily consumption of 1,250-2,500 mg (50-100 tabs)

Gravol
At high doses: feelings of well-being, euphoria, hallucinations
At large doses: sluggishness, paranoia, agitation, memory loss, increased blood pressure
and heart rate, and difficulty swallowing and speaking.
Overdose: confusion, irrational behaviour, muscle uncoordination, high fever, convulsions,
heart & breathing problems.

Dextromethophan (DM)
Teenagers and adolescents abuse DM to get high
high - state of separation from the environment or out of body experience
Euphoria; increased perceptual awareness; altered time perception; feelings of floating;
tactile, visual & auditory hallucinations; visual disturbances; paranoia and disorientation.
At high doses: nausea, vomiting, psychosis, mania, seizures and respiratory depression.

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Dose-dependent "plateaus of DM
(Dose in cough syrups ranges from 10 mg to 15 mg per 5 ml )














Laxatives
Stimulant laxatives (bisacodyl, castor oil, senna) have been abused in the attempt to control
weight
Act on the colon, not on the stomach
By the time food reaches the colon, all of the calories from the food have already been
absorbed by the body
May feel like you have lost weight, but the only thing you lost is water
Within 48 hours of using a laxative the body retains water to make up for all that it has lost

Laxative abuse may cause:
Chronic Diarrhea (after repeated use of laxatives you eventually lose control of your
rectum)
Bloating
Dehydration
Nausea & Vomiting
Electrolyte Disturbances (may lead to heart arrhythmias and heart attacks)
Chronic Constipation
Dependency (larger & larger doses needed to produce bowel movement)
Permanent damage of your bowels
Pseudoephedrine regulations

As established by federal government Precursors A ephedra, ephedrine, pseudoephedrine
Precursors B solvents/reagents (i.e. acetone) used to produce CM.
Pseudoephedrine & its salts as a single entity - Schedule II (as of April 10 2006)
Pseudoephedrine & its salts in combination products Schedule III


Dissociative sedation 500 -1500 4th
Distorted visual perceptions
Loss of motor coordination
300 600 3rd
Euphoria and hallucinations 200 400 2nd
Mild stimulation 100 200 1st
Behavioral Effects Dose (mg) Plateau
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Government of Canada invests $10 million to prevent illicit drug use in youth
On January 30th, 2008 The Government of Canada announced an additional $10 million
investment into its new National Anti-Drug Strategy.
The goal of the CCSA's project is to reduce illicit drug use among Canadian youth between
the ages of 10 and 24, including high-risk youth, focusing on risk and protective factors
before drug use begins.
Health Canada, News Release, January 30 2008

Street drugs

Drugs taken for nonmedical reasons
Examples: Marijuana, Gamma hydroxybutyric acid (GHB), heroin, MDMA or ecstasy,
Crystal Methamphetamine, Cocaine, Lysergic acid deithylamide (LSD), etc.
Reasons for use:
Curiosity
Pleasure
Peer pressure
Medical purposes (pain relief)

Pseudoephedrine Crystal Methamphetamine (CM)
Pseudoephedrine is extracted in underground labs to produce CM
CM use is approaching an epidemic proportions in Canada
$10 worth of CM can get person high from 5 to 48 hours
One line of cocaine produces high that lasts 20-30 minutes and costs $60-80

Crystal Methamphetamine (CM) powerful and addictive CNS stimulant
MOA: neuronal release of large amounts of dopamine & smaller amounts of norepinephrine.
Effect:
Heightened sense of well-being, euphoria, & alertness that can last for hours
mimics the fight-or-flight response ( in heart rate, BP & blood sugar), also alertness,
awareness & motivation, and appetite, hunger & fatigue

Crystal Methamphetamine (CM) powerful and addictive CNS stimulant
Onset:
Injected: seconds
Smoked: seconds
Inhaled: 5 minutes
oral ingestion: 20 minutes
Distribution: readily crosses BBB
Metabolism: CYP 450 2D6
t: ~12 hours (max 48 hours)
Elimination: renal (4-5 hours with Nr Renal Fnx)

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Crystal Methamphetamine (CM)
Chronic use leads to tolerance
Withdrawal: begins 24 hours & peaks at 72 hours after last dose (excessive sleepiness, GI
symptoms, huge appetite) anxiety, agitation & depression ] may last for several month
Adverse effects: tachycardia, hypertension, anorexia, insomnia, diaphoresis, psychosis,
aggression, paranoia, hyperthermia, seizures, etc.

Crystal Methamphetamine (CM) (chronic use)
Striking feature: jitteriness & Parkinsons disease-like symptoms (CM depletes
dopamine, damage cells)
Compromised immune system
Hallucinations and paranoid psychosis
Movement disorder (continuous shaking)
Memory impairment, verbal skill deficiencies
Anhedonia (lack of enjoyment) & suicidal tendencies

Cocaine

Cocaine hydrochloride: snorted or injected
Chemically changed cocaine can be smoked ("crack")
At low doses: energetic, talkative, alert and euphoric;
more aware of their senses: heightened sound, touch, sight and sexuality;
hunger and the need for sleep are reduced
At high doses:
panic attacks;
psychotic symptoms: paranoia (feeling overly suspicious, jealous, or persecuted),
hallucinations (seeing, hearing, smelling things that aren't real) & delusions (false beliefs)
erratic, bizarre and sometimes violent behavior
Dangerous Effects:
hypertension, stroke, heart attack, seizures and heart failure, sinus infections and loss of
smell, lung damage (can be fatal), violent behaviors, psychiatric symptoms

Ecstasy

3,4-methylenedioxymethamphetamine (MDMA)
causes release of high level of serotonin in the brain
At low doses:
feelings of pleasure and well-being, increased sociability and closeness
stimulant effects: can make users feel full of energy and confidence
At high doses:
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jaw pain, sweating, blood pressure and heart rate, anxiety or panic attacks, blurred vision,
nausea, vomiting and convulsions
after-effects: confusion, irritability, anxiety, paranoia, depression, memory impairment or
sleep problems
Dangerous Effects:
body temperature, blood pressure and heart rate, which can lead to kidney or heart failure,
strokes and seizures
Ecstasy may cause jaundice and liver damage
A lot of ecstasy-related deaths are due to the dehydration and overheating

Dangers of Illicit Drugs

Harmful effects on the body
Risk of addiction
Compromised purity (there are no controls over the strength and purity of the drugs
produced, contaminants may be present)
May contain combination of two or more illicit substances
Interact with Rx medicines and alcohol
Illegal

Herbals as drugs of abuse
Ginseng at high doses immediate effect of stimulation
Long term use of ginseng may lead to CNS excitation (hypertension, nervousness,
sleeplessness, skin eruptions and diarrhea), blood glucose level disturbances
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Practice Stations
Scenario # 1

Patient: female, 36 years old

Rx:
Effexor (Venlafaxine) XR
37.5mg po daily x 7 days, then
75 mg po daily x 30 days

Provide counseling

Scenario # 2

A Male asking you to refill his Rx for Ativan SL tablets only.

Patient Profile:

Current medication
- Sertraline 25 mg po od x 30 capsules (30 days ago)
- Ativan SL 1 mg po hs prn x 15 tablets (30 days ago)

No allergies

Medical Conditions: depression
Meds history: Tylenol for Headache.
Age: 33

Lifestyle: works at Rogers Cable (technical support), Moderate exercise, and drinks socially,
doesnt smoke.

Scenario # 3

A lady comes to you with the following question: Can you please tell me the side effects of
Citalopram (Celexa)

Patient profile: (provides after pharmacist candidate requests)

Current medications:
Citalopram 20 mg po qd (filled 5 days ago)
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Lorazepam 1 mg po qhs
HCTZ 25 mg po qam
Atenolol 50 mg po daily

Allergies: None
Medical conditions: depression

Scenario # 4

A young man approaches your pharmacy asking for sleep aid.


Patient profile: (gives after pharmacist candidate requests)

Current medications: None
Medical conditions: none
Allergies: none
Age: 22

On the table:
Nytol (diphenhydramine)
Sleep-ezz,

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Par t 3
Non-I nt er ac t i ve
St at i ons
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78
Non-I nt er ac t i ve St at i ons

There are two types of non interactions stations, 1-Prescription errors and 2-Dispensing
errors

Prescriptions Errors
Verifies their authenticity and appropriateness
Prescriber information on prescription
Prescribers name and Title
Prescribers office address
Prescribers license No. (5 digits)
Methadone license number

Patient information on prescriptions:
patients name
patients age (DOB) Not mandatory
date on which Rx was written

Dispensing errors
Drug information on prescription
1-Drug name, strength
2- Quantity to be dispensed
Sign directions to patient
refill instructions
Prescribers signature

TIPS:
Fill the Rx without guesswork
Benzodiazepines: Should not be filled or refilled (if any refills are indicated) more than 1
year after the script is issued to the patient
A carefully screened Rx order can avoid many potential unnecessary problems and
confusion.
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Scenario # 1

Mr. J a 5-year-old boy
Rx
Captopril 5mg tid

Mitte 90

Dispensed: 20 tablets of 25mg strength

Scenario # 2

Rx
Mr O, weight 44 lbs

Ondansetron HCl 0.15mg/kg/tsp
cherry syrup qs 60 ml

dispensed: 10 tablets of 4mg

Scenario # 3

Rx #1
Mr JS
New Rx for chicken pox
Acyclovir 200mg
1-tab 5 x days
F 7 day

Scenario # 4

Rx # 2
Mr D. New Rx for depression
Celexa 60 mg Qd
1month


Scenario # 5

Rx #3
Mr PF
Rx for stable angina
Nitrodur 0.4 mg/hr
Apply 1 patch qd and remove before bed
3 months

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Scenario # 6

Rx #4
Mr. BW, weight 20 kg
Rx for otitis media
Amoxil 125mg/5mL
1tsp tid F7d


Scenario # 7

Rx#5
Ms TB
New Rx
Lipitor 10 mg
Sig: 1 tid
1month
Mitte:
Repeat 6
Dr. TIPS


Scenario # 8

Rx # 6
Mr. LM
Allergy to Penicillin (shortness of breath and hives)
Losec 1-2-3A
F 7 days
Dr. TIPS


Scenario # 9

Rx #7
Mr. MK
For malaria Prophylaxis
Lariam 250mg
1qd
3months

Dr. TIPS
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Scenario # 10

Rx#8
Ms. SL
Estracomb patches
Apply 3 times a week
3 months
Dr. TIPS

Scenario # 11

Rx#9
Ms SH
For Onychomycosis
Lamisil cream 30 g
Apply AA bid R x4

Dr. TIPS

Scenario # 12

Rx#10
Ms JS
For osteoporosis
Fosamax 70mg
1qw pc for 3 months
Dr. Misbah
Dr. TIPS

Scenario # 13

Rx # 11
Mr. MF
Atenolol
1qd
60 tablets
Dr. TIPS

Scenario # 14

Rx#12
Ms LB
For toe nail fungal infections (Onchomycosis)
Sporanox 200 mg
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Dr. TIPS

Scenario # 15

Rx#13
Mr. RK
Age 8-year-old weight 20kg
New Rx for sinusitis
Cipro 250 mg
1 bid F7d
Dr. TIPS


Scenario # 16

Rx#14
Mr PF
For migraine
Imitrex 100mg
1qd
3 months
Dr. TIPS

Scenario # 17

Rx#15
Ms SF
Monocor
1qd
3months
Dr. TIPS




Scenario # 18

Rx # 16
Ms LS
Rx for osteoporosis
Actonel 35mg
1qd for 3 months

Dr. TIPS

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Scenario # 19

Rx# 17
Mr. WP
Rx for scabies
Nix 1% cream 1 bottle
Rinse
Dr. TIPS


Scenario # 20


Rx#18
Mr. SF
Salmeterol 25mcg
Inhaler
1puff q4h prn
Refills 3
Dr. TIPS


Scenario # 21

Rx 19:
Ms LG
Tylenol # 3
1tab qid prn
120 tabs
R x 4
Dr. TIPS




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79
New Appr oved Dr ugs

Finasteride 5mg and 1mg

Selective 5alpha reductase inhibitors type 1 isoenzyme?
5mg Treatment of BPH,
Major SE: Sexual dysfunction (Men only drugs)
1mg treatment of alopecia

Dutasteride 0.5 capsule QD capsule QD x 1/12

5alpha and beta reductive inhibitors, type 1 and type 2 isoenzyme?
Take one capsule every day
Contraindicated in women
It is important use condoms

Clarus:

Take 2 capsules once a day
Take with food
Helps to dry up your fluid in acne
Swallow it with water
Completely contraindicated in pregnancy
Initially acne can get worst, this may take few weeks to take effect
Store in original container
Even stopping your medication, you should continue using contraception for 1 month
No blood donation up to 6 months after stopping medications.

Escitalopram 10mg QD:

It helps to elevate mood
Onset of effect 3- 4 wks
Optimal effect 6 wks
Escitalopram is safe with Tylenol that codeine because, however SSRIs (CYP 2D6)
drugs are require caution with Tylenol # 2, 3 and 4 require caution. (escitalopram
have least drug interactions)
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Pregabalin
Indicated for diabetic peripheral neuropathy and post herpetic neuralgias.
It can cause addiction and dependence. Abrupt discontinuation can cause d/c
symptoms

Concerta 36mg capsule QD
Advantage of this medication of over Ritalin (TID) is once a day
You notice capsule shell in stools.
Combine with Ritalin can lead to overdose
Encourage social activities (Martial arts- Karate)

Solifenacin succinate

Take with lots of fluids
Recommended dose is 5mg once daily, should be taken with liquid, with or without
food.
Maximum effect takes 4 weeks.
Anticholinergic side effects
For dry mouth, take small sip of water
Before start a new anticholinergic drugs, wait for one week
NP: pelvic exercise.
Note: film coated tablets can be crushed

Fosavance 1 tablet Qwk x 1/12 (6 repeats)
Combination of alendronate and vitamin D
3

Indicated for osteoporosis
If your taking alendronate, stop, and start new drug.
No need of vitamin D supplement
Continue taking calcium supplements

Memantine HCL 10 mg tablets
Indicated for dementia
Take with or without food

Sativex Spray PRN (dispense 1 unit)
Spray in mouth

Niaspan 500mg BID

It is niacin the niacin products are niacinamide, it is not substitutable with niacin
(niaspan)
Increase uric acid levels in blood.
Prep Notes


Par t 4

NAPRA
Compet enc i es
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81
Regul at i ons
These drugs must have a N symbol in the upper left portion of the label. The list of
narcotic drugs also appears under Schedule N, The Food and Drugs Act (FDA).
Narcotics








Straight Narcotics
Requirements for prescribing, dispensing and record-keeping

Narcotic drugs
C
Narcotic Drugs
Preparations C
Written Permitted Permitted
Prescription
Verbal Not Permitted Permitted
Written Not Permitted Not Permitted
Refills or repeat
Verbal Not Permitted Not Permitted
Written Permitted O Permitted O
Part Fill
Verbal Not Permitted Permitted O
Transfers Not Permitted Not Permitted
Record Keeping 2 years 2 years
Sales Report Required O Not Required
Loss & Thief
Reports
Yes O Yes O

Tylenol # 4 Tylenol # 2 and 3
1 or 1+1 1+2

Straight
Narcotics
1 or 1+1
Narcotic preparations
Or Verbal narcotics
1+2
OTC or exempted
Narcotics
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Benzodiazepine regulations

Requirements for prescribing, dispensing and record-keeping

Benzodiazepines & Targeted Substances

Written Permitted
Prescription
Verbal Permitted
Written Permitted
Refills
Verbal Permitted
Written Permitted O
Part Fill
Verbal Permitted O
Transfers Permitted once onlyO
Record Keeping 2 years
Sales Report Not required
Loss & Thief
Reports.


Yes O

Control substances
Requirements for prescribing, dispensing and record-keeping
Controlled Drugs

Part I C Part II C Part III C
Written Permitted Permitted Permitted
Prescription
Verbal Permitted Permitted Permitted
Written Permitted Permitted Permitted
Refills
Verbal Not Permitted Permitted Permitted
Written Permitted O Permitted O Permitted O
Part Fill
Verbal Permitted O Permitted O Permitted O
Transfers Not Permitted Not Permitted Not Permitted
Record Keeping 2 years 2 years 2 years
Sales Report Required O
Not Required
O
Not required
Loss & Thief
Reports


Yes O Yes O Yes O

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Destroying Narcotics

Step 1- Count all the medication and note them on this book
Step 2- To destroy this drugs we have to follow certain regulations
We should contact to Office of control substances and send our request.
Step-3: You will then receive letter-acknowledging receipt of your request from the
office of controlled substances.
You may destroy the products once this confirmation has been received.

The destruction must be witnessed by another health professional such as pharmacist,
pharmacy intern or field representative from college of pharmacy.

The inventory of destroyed material is to be signed and dated by both parties.
For narcotics: Wait for response from office of control drug and substances
permission

Outdated Narcotics and Controlled Drugs

Unopened bottles of narcotics and controlled drugs may be returned to a distributor or
manufacturer depending on their return policy for credit after obtaining written or
faxed permission to do so.
For part bottles, permission to destroy must be obtained form Health Canada.
A request including a list of expired drugs and quantities can be faxed and destroyed
after authorization has been given.
The destruction of these drugs must be witnessed by another health professional such
as another pharmacist, pharmacy intern or a field representative form college.
The inventory of destroyed or stapled to the Pharmacys Narcotic and Controlled
Drug Register.

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Practice Station

A pharmacy intern wants to know how destroy return benzodiazepines. Advise him
accordingly.




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82
I nf or mat i on Resour c es

The familiarity with the following pharmacy practice references is essentials to effectively
offer patient centred care.

Compendium of Pharmaceutical Specialties (CPS)
Patient Self Care
Therapeutic Choices
Drugs in Pregnancy by Briggs and Briggs
Food & Drug guide, Health Canada




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A Step-By-Step Approach How to use the CPS
The contents of the CPS are well known from its first page CPS at a Glance.
These are:
Discontinued products (white pages at the beginning of CPS)
Brand and Generic name index (blue pages)
Therapeutic guide (Pink pages)
Product identification (Pages containing photographs of the medicines)
Directory (yellow pages)
Clini-info (lilac pages)
Monographs (white pages)
Appendices (white pages at the end of the CPS)

There are additional pages, which are of benefit to the student in the exam, and these are:
Glossary of abbreviated Latin prescription, which are of benefit for the student in
the exam or in the real practice.
Glossary of abbreviated terms of many classes of medications and laboratory tests
that the student is not familiar with.
Microorganism abbreviations, which more often the student cant differentiate if
which type bacteria (e.g. pneumonia) whether it is chlamydia or clostridium or
cryptosporidium or campylobacter.

Discontinued Products: many times a student is confronted with a certain medication where
he can not find it in the brand and generic name index (blue pages) and forgets to go to the
discontinued Products pages, and he loses a lot of time searching for nothing. He simply can
go alphabetically to the discontinued Products pages and find out whether the product is
discontinued or not.

Brand and Generic name index: These blue pages have the brand and generic name
alphabetically whereby the students can pick the brand name and go to the monograph (White
pages) directly. However the difficulty here is not everything mentioned in the blue pages, so
that one can find full complete monographs. Sometimes only short paragraphs which the
students cant benefit a lot.
So how can we differentiate those that have monograph in detail from ones that have short
monographs?

This is simple, by looking at the medications that are underlined. Those that are underlined
have long monographs while those are not underlined have very short monographs.

E.g. Acetaminophen/ Brompheniramine Maleate/Phenylephrine HCl. Dimetapp oral Infant
Cold & Fever Drops has long monographs because it is underlined.
Accolate, Prandase, Accupril, Accuretic have long monographs while, ZeaSorb, Amphojel,
Amcort cream, Alcaine have short monographs.
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It is also easier to study such monographs and to grasp the information than going specifically
to each individual medication within the same class.
Other examples: Bisphosphonates, Calcium channel blockers, carbonic anhydrase inhibitors,
systemic cephalexin, Benzodiazepine, and SSRIs.
The only thing, these monographs lack is the supplied information where you have to go to
the individual monographs if you want some information about the strength of the medication,
its delivery system and storage temperature.

Product identification: These pages are helpful when you want to know directly how many
dosage forms for medication and how much strength, by following the trade name
alphabetically without going into the monograph. The individual monograph will tell you the
different strength but you should go to other pages to look for other dosage forms whether the
medication is in liquid form, injection or sustained released form which takes more time to
search for, in contrast when you use the page of the product identification and this is very
useful in nonintercative stations to save time.
Also these pages are helpful to look at the product (device) and see its shape, color, size, and
how you can identify the different pills of the same medication with different strengths which
is also of benefit in non-interactive stations or in stations when there is an overdose due to
dispensing error.

Directory: The important here is section II that contain Health Organizations which are
supporting group to different disease conditions. These are important to provide their phone
numbers and their websites to patients suffering from certain disease in certain stations of
OSCE.
You can follow these health organization alphabetically and it id prudent for each candidate to
be familiar with these health organizations.

Clin-Info: It is important how to measure body surface area for children and adult. To be
familiar with this, it is important for measuring antineoplastic doses. A straight edge is placed
from the patients height in the left column to his weight in the right column and where the line
intersects the body surface area column indicates the body surface area.
How to covert SI & traditional units is important for different laboratory data.
To convert from traditional to SI units, multiply the traditional value by the conversion
factor found in the table for that of the laboratory tests. To convert from SI to traditional
unit, divide the SI value by conversion factor. This thing also applies for conversion factors
for serum drug concentration.
Recommendations for serum drug concentration monitoring are very important especially in
determining the time to reach the steady state and when to adjust the dose. These informations
are somewhat difficult to get them from the monographs. It takes time to look under the
In these pages we see CphA monographs. They direct you to CPhA monographs shaded in
gray. They are comprehensive medications monographs or comprehensive monograph of a
class of medication. E.g. ACE inhibitors (CPhA Monograph), which contain the information
needed for all ACE inhibitors, like Benazepril HCl, Captopril, Clizapril, Enalpril Maleate,
Enalprilat, Fosinopril, Lisinopril, Perindopril Erbumine, Quinapril HCl, Ramipril, Trandolapril.
Such monographs prevents different tables to compare with different medications within the
same class regarding pharmacokinetics, labeled indications dosages for comparison which you
dont find it in specific monographs of individual medications.
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pharmacokinetics of the individual monograph, whereby here we can get it easily with some
informations of the required drug concentration, and when to do the sampling.

Drugs use in pregnancy. Here the informations are not for all medications and it is preferable
to go to the individual monograph, and go to use of drug in pregnancy which mostly come
after the precaution in the monograph.

Drugs during lactation. It doesnt mention all medications and it is preferable if needed to go
to the monograph of the medication.

Drugs in Dentistry. It is prudent for the student to look at this page before the exam to know
the scope of practice of dentists regarding medications, which are mostly analgesics,
antibiotics, and some antihypertersensitivity medications.

Tables of endocarditis after certain procedures are well mentioned here and the student should
be well familiar in knowing the information mentioned. It is the only place within the well-
known references that we find a summary of the management of endocarditis (we can not find
that in therapeutic choices, psc, or cps)

Medical Emergencies. One has to be familiar with these like oxygen, epinephrine, ASA
(indicated in suspected MI or unstable angina), diphenhydramine or chlorpheniramine,
nitroglycerine, and salbutamol.

Perioperative management of medications. It is important to know which medications are
continued perioperatively and which are withheld. E.g. withholding Sinemet will result in
withdrawal of Levodopa-carbidopa, which has been associated with neuroleptic malignant-like
syndrome. Another example is SSRI and NE reuptake inhibitors should be discontinued 2
weeks preoperatively because of possible interaction with Opioids such as fentanyl and
meperidine. So the table gives a lot of informations in carrying out patients pre and post
operatively using different kind of medications. Looking at these tables enrich the students with
a lot of clinical interactions, in addition to giving periods of washout before doing the
operation, and it is important to know them because they could be presented in Doctors stations
or in non-interactive stations

Routine Immunization Schedules. This is a very important schedule for infants and children
and also for adults. Only MUR and varicella vaccine are contraindicated in pregnancy, all the
other vaccines should be susceptible during pregnancy to rubella (German measles) should be
given rubella vaccine postpartum)
The page of routine immunization mentions the priority of those vaccines especially the
influenza, pneumococcal and tetanus for many diseased conditions.

Drugs in older Individuals. This page mentions the necessity of reducing the doses for most
medication when administered to elderly due to hepatic and renal impairment. Thus all
medications should be reduced in dosages and adjusted on renal function and rate of
metabolism. Therefore lower starting doses and slower upward titration is recommended.
ACE inhibitors, hypoglycemics, NSAIDs can be stopped abruptly while all CNS medications,
cardiac drugs (with the exception of ACE inhibitors, corticosteroids, HRT and Opioids should
be tapered).
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Drugs which have minimal pharmacokenitic changes with aging are; Valproic acid, CBZ,
Clopidogrel, and amiodarone.
Adverse drug reactions in elderly are mostly in:
CNS (mental confusion)
Cardiovascular system (CHF, hypertension, orthostatic hypotension), and stroke
GIT (ulcer, bleeding, perforation, esophagitis, strictures, bowel erosive disease,
constipation
Renal and urinary retention (acute renal failure, fluid and electrolyte disturbance,
involuntary loss of urine and urinary retention)
Withdrawal of selected medications in older individuals. It is an important page in CPS where
the student should know which medications could be stopped abruptly and which medications
should be tapered.

Malaria prevention: This page is the best page to get the information about malaria
medication because the CPS lacks the detailed monographs for Chloroquine phosphate. So the
student is referred to this page when he wants to get information about antimalarial and not to
waste time in monographs. The student can find the table sufficient informations regarding the
doses in adult and children, adverse effects, and some comments to different antimalarial
medications.
According to CPS (2005), the monographs available to antimalarial medications are malarone
(atovaquone 250mg/proguanil HCl 100mg), and Doxycycline (vibra-tabs) only.

Cytochrome P450 Drug interactions: This page is good to get general informations about
certain medications whether they are enzyme inducers, inhibitors or substrates. However it is
prudent to go to the individual monographs to see whether these interactions (pharmacokinetic
or pharmacodynamic interactions) are contraindicated because of certain clinical impacts or
could be monitored and are classified under precautions and warning or there is no clinical
impact from these interactions.
Drug Administration and Food: In OSCE stations, it is better to search whether the
medication is administered with or without food by looking at the dosage in the monograph of
that medication prior to going to lilac ages and looking at the drug and Food. It is mentioned
whether the drug is to be taken with or without food or on empty stomach. Actually this is used
to save time. In case if nothing is mentioned about the drug administration, then one can go
quickly to the table of drug administration and food. The medications in that table are
mentioned alphabetically under the scientific name; so thats why it is better to go to the
monograph first where we can have the brand name and generic name, and if there is no
indication to the administration, one can go to the table of drug and Food directly afterwards.

Drug Administration and Grape Juice: In general, grape juice is an inhibitory of CYP3A4
(intestinal). There appears to be a prolonged inhibitory effect of grapefruit juice on intestinal
CYP3A4-medicated metabolism.
Sweet orange juice does not appear to cause the same interaction, however sour (Seville)
orange juice and limejuice have similar enzyme inhibitory effects. The quantity of grapefruit
juice consumed is important to be considered, since as little as 250 ml can cause significant
inhibition of Cytochrome 3A4.

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Nutrient requirements: The tables provided in that page are important if you dont have a
patient self care book, as a reference in the station or other specific references dealing with
nutrient requirements. The information includes dietary supplementation to infants, pregnant
and lactating mothers, strict vegetarians and older individuals. Also smokers who have to take
ascorbic acid (Vitamin C) and individuals with little or no exposure to sunlight, a Vitamin D
may be required.

Ethanol-containing Pharmaceuticals: Ethanol is often used as preservative and solvent in
pharmaceutical preparations. Certain medications and conditions influence the need for
awareness of the ethanol content of pharmaceuticals. Disulfiram-like reactions characterized
by flushing, headache, nausea, sweating and/or tacchycardia may occur when ethanol is taken
with metronidazole, Chlorpropamide, and some cephalosporins (e.g. cefotetan). Ethanol is a
CNS depressant, when taken with drugs such as sedatives, hypnotics, antihistamines, and
antidepressants, the CNS effects of ethanol may be enhanced. Ethanol content of oral products
should be assessed in individuals with diabetes. Avoidance or use of low-ethanol content
products is preferred for children.
In general, elixirs, syrups, liquid, solutions, lotions, vials, gels, and aerosol contain alcohol in
different percentages. The table listed in CPS worth to be considered in certain diseased
conditions and when medication have high or moderate percentage of alcohol.


Gluten-containing pharmaceuticals: The students can use this page or in the supplied section of
the CPS product monograph, he statement containing gluten refers to the gluten derived from
wheat, barley, oats, and rye.
Celiac disease is intolerance to the gliadin fraction of ingested gluten, resulting in
immunologically mediated inflammatory damage to the lining of the small intestine. The
inflammation may lead to malabsorption by reducing the amount of surface area available for
absorption of the nutrients, fluids, and electrolytes.

Lactose-containing Pharmaceuticals: Many medications that use as filler may cause symptoms
of lactose intolerance in those who take multiple lactose-containing medications. Lactose
intolerance occurs in individuals with deficiency of the intestinal enzyme lactase and leads to
symptoms including abdominal cramps, diarrhea, distention, and flatulence. Administration of
the enzyme lactase can increase lactose tolerance of lactose-intolerant individuals. Lactose is
also contraindicated in individuals with the fructose-galactose malabsorption syndrome called
galactosemia.
It is preferable to go to the supplied where quicker information about the availability of the
lactose or not.

Sulfite-containing Pharmaceuticals: Sulfiting agents are used as antioxidants in the preservation
of foods and drugs. Here the condition is not like lactose intolerance. Hypersensitivity reactions
such as urticaria, nausea, diarrhea, wheezing, and dyspnea have been reported most frequently
after the ingestion of restaurant foods treated with sulfites, but they also occur after exposure to
the drug products containing sulfites. The concentration of sulfites in pharmaceuticals is
usually low but adverse reactions to sulfites are not always related.

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Tartrazine-containing Pharmaceuticals: Most common reactions to tartrazine are asthma or
urticaria. Although the overall sensitivity to tartrazine is low, it may occur more frequently in
ASA-sensitive and NSAID-sensitive individuals as a cross-sensitivity.

Peanut oil, Soybean oil, or Soya lecithin: Soya and peanuts both belong to the legume family
and there may be potential for cross-reactivity. Peanut allergic individuals may develop a soya
allergy in 5%-15% of cases. Soya lecithin and soybean oil ingredients found in some
pharmaceuticals may contain small amounts of soya protein. Medications that contain soya
lecithin and soybean oil should be avoided in individuals with severe soya allergy unless
otherwise advised by their doctor. However peanut allergy is not contraindicated to use of soya
products unless there is a c0-existing soya allergy.

Monographs:
It is very important for the student to have a certain strategy in dealing with different
monographs of medications.
We all know that there are short and long monographs but in either one the student should not
spend more than 2 minutes to be safe in finishing his station and in presenting the most
useful aspects of that medication. So the strategy depends on the task of the station. If the task
is just simple counseling, it is better to look first at the indication and pick up the indication
that most relevant to the information that gathered from the patient. The student can pick the
indication as the doctor told that to the patient in case if the patient said that the doctor told him
that this medication is used for this purpose. Many of the indications of certain medication may
fit certain hidden conditions in the patient where you have to prove and gather informations
that are relevant to that medication.
For example ACE inhibitors; they are indicated for:
Management of hypertension
Slow progression of nephropathy in D.M., which is independent of blood pressure
reduction.
Considered standard therapy in post-MI patients
First line treatment of systolic heart failure
So we can see here, there are different indications so if after asking the patient (what did the
doctor tell you about this medication is for?) and he informed the pharmacist about it; so you
can simply then confirm what the doctor has told the patient. In a different case where the
patient doesnt inform the pharmacist, then our job is to probe more and get relevant
information to the indication.

After that the student should go directly to the dosage and read carefully the dosage that is
related to that medication, for example:
You see a monograph of Betaloc and Betaloc durules. They share a common monograph, but
when you go to the dosage, you should be careful to go to the dosage of the one that is
requested like Betaloc only or Betaloc durules, since each one has different dosage. Betaloc is
immediate release, and Betaloc durules is sustained release, and the dosage will duffer
accordingly.

The other thing is to focus while you are looking for the dosage, on the way of administration
(swallow whole, crush, chew, or not crush or chew) with water or is it dispersible, or inhaled,
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or any route of administration and look whether before or after meal, because this could be
mentioned under the dosage paragraph if not go quickly to the lilac pages to confirm that.

So dont go to the lilac pages before you check that in the dosage mentioned in the monograph,
and then check the dosage that is on label or in the prescription with that in the monograph that
is relevant to that condition.

Doing these things you picked a lot of information to inform patients like the indication, the
dosage, the administration, the route of administration, and the frequency. Just underneath the
dosage you can have a glance to the supplied to know the storage and sometimes they
mention about the delivery system of certain medications when they are sustained release.

Then you go to the side effects, which could be gathered promptly, from any table about side
effects if present or go and read quickly most common side effects and at least one rare side
effect. Then take a glance to the bold letters under warnings and precautions, afterward start to
convey those information to the patient, in addition to self care measures that you should
already know them to tell the patient about them.

In other stations when there is a visible drug interaction, it is better to go directly to the
contraindication, in an attempt not to waste more time since some interactions are
contraindicated and you can finish the station by calling the doctor directly without going and
searching for the drug-drug interaction under drug interactions or warnings. However if it
is not mentioned anything about the drug interaction in the contraindication then definitely in
that case, you go and look under precautions warnings. It is advisable for every student to go
over all charts that are mentioned in the CPS to be familiar with them and go over all bold
letters in the monographs to gain more information. Actually this I will not take more than 7
days.

It is advisable to understand these tables especially those, which require dosage adjustment due
to renal failure and dose adjustments for neutropenia and Thrombocytopenia.


Therapeutics Guide
Drugs are listed under alphabetically arranged therapeutic indications (e.g. acne, diarrhea).
Drugs may be further classified under pharmacologic or chemical subheadings within a
therapeutic indication.

Therapeutic Guide is very essential when you dont have any other reference book like
therapeutic choices or Patients self care or any other clinical book. If information about
medication used in hypothyroidism like thyroid desiccated and you want to change this
medication into another one which is also used for this purpose, you cant find directly in CPS
unless you go to therapeutic guide under hypothyroidism and you see three medications
listed which are Levothyroxine, liothyronine, and thyroid desiccated; whereby you can choose
anyone and go to its individual monograph to use, it is an alternative for any purpose the
physician wants.

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Something with nausea and vomiting medications if you want any medication to act as
antinauseant and act as an alternative to certain antinauseant medication, let say dopamine
antagonists (like metoclopromide) you go simply to nausea & vomiting in the therapeutic
guide and pick the suitable medications to be used as an alternative after going their individual
monographs. Thats how you can use a reference book that deals with medications not with
disease like CPS book, use its therapeutic guide for different conditions by which we cant opt
different medications for the same targeted disease.

In the last example as antinauseant and vomiting we have:
Anticholinergics like scopolamine
Antihistamines like dimenhydrinate, hydroxyzine, and promethazine
Cannabinoids like dronabinol, nabilone
Dopamine antagonist like chlorpromazine, metoclopromide, perphenazine, prochloroperazine,
and trifluperazine.
Serotonin CS-HT
3
antagonist like dolasetron mesylate, granisetron HCl, ondansetron
hydrochloride dihydrate.

Otherwise we cant depend on our memory in this regard. So this is a way to go from one
medication to another within the same class or within different classes as an alternative when
the doctor asks you for that or when you want to present certain alternatives to the doctor due
to any reason requested.

Appendices: The most important one is appendix 1: narcotic, controlled drugs,
Benzodiazepines and other targeted substances.



This appendix could be used when you have some suspicion or lack of certain legal
information that you forgot. So it is very simple just to go to Appendix 1 where all the legal
requirements for narcotic drugs, narcotic preparations, and controlled drug part I and II,
controlled drugs, benzodiazepines, and other targeted substances.