Dispensing 2 Notes

Medication Order
Prescription - Written order for a medication that will be administered.
- Written order by a physician directing the pharmacist to prepare and - Military time format.
dispense pharmacological agents for the diagnosis, prevention, or - Required before a nurse can administer medications.
treatment of a disease. Validity: 6 months, unless refilled - Must include specific information.
Rx Parts of a Medication Order
- “recipe”, take though (old English); you take (modern English) - Patient Information
Who can Prescribed? - Date (of Admission)
- Physician - Date (of Administration)
- Veterinarian - Name of drug
- Dentist - Dosage and frequency
Parts of a Prescription - Route of administration
- Date - Name and signature of physician
- Prescriber Information
- Patient Information
- Complete Name Prescription Errors
- Age Erroneous Prescriptions
- Birthdate - Brand name precedes the generic name
- Gender - Generic name is the one in parenthesis
- Height - Brand name is not in parentheses
- Weight - More than one drug product is prescribed on one prescription form
- Superscription (Rx symbol) - Shall be filed; confiscate and report.
- Inscription Violative Prescriptions
- Main part of the prescription - Generic name is not written
- Information of the drug formulation - Generic name is not legible and a brand name which is legible is written
- Generic name - Brand name is indicated, and instructions added (such as the phrase “no
- Brand name substitution”) which tend obstruct, hinder, or prevent proper generic
- Subscription dispensing.
- Unit dosage - Shall not be filed; confiscate and report.
- Important instruction of physician to pharmacist. Impossible Prescriptions
- Dosage form and number of doses. - Only the generic name is written but it is not legible.
- Transcription (Px symbol) - Generic name does not correspond to the brand name.
- Instruction of physician to patient. - Both generic name and brand name are not legible.
- Signature - Drug product prescribed is not registered with FDA.
- For validity and legality of the prescription - Shall not be filed; confiscate and report.
- PRC# → renewed every 3 years (birthdate of professional).
- S2License # → for physicians to prescribe controlled substances or
dangerous drugs.
- PTR (Professional Tax Rate) # → renewed yearly; to be acquired in
the city or province of practice.
- Special Instructions
Medication Review Care Plan Evaluation
- Service for the patient by the pharmacist. Guidelines
- Promote safe and effective use of medications. - Check the therapeutic classifications.
- Improve outcomes. - Check for appropriate prescription of medications.
Why is it needed? - Check for therapeutic duplications.
- Assess the patient’s health conditions while under medication. - Check for correct dosage forms.
- Analyze how the medications have been affecting the patient. - Check for correct dosage regime (dose) and frequency.
- Determine whether the medications are effective or are working
according to the treatment goals.
- Document medications and the existing care plan.
- Develop new and improved care plans (if some problems are
found with regards to the old care plan).
- Help patients reap the best results from their medications.
- Assess the performance of the medications the patient is taking.
- Monitor the results of a revised care plan.
Who needs it?
- Patient
How does it work?
- Patient approaches and give all information about medications.
- Pharmacist interviews the patients on the following:
- What OTC meds are taken?
- What vitamins are taken?
- What food supplements are taken?
- What herbal products are taken?
- What prescription medications are taken?
Types of Review
1. Medication Review – Standard (MR-S)
- Pharmacist reviews patient’s Best Possible Medication History
(BPMH) to understand the medications to be taken.
2. Medication Review – Pharmacist Consultation (MR-PC)
- Only necessary when the pharmacist detects Medication
Management Issue (MMI).
- Collaboration between the patient, pharmacist, and physician to
solve
3. Medication Review – Follow-up (MR-F)
- After MR-S or MR-PC
- If there is medication change to determine if the goal is
successfully achieved or needs alterations.
Dispensing Week 3 Notes Classification of ADRs
Type A – Augmented
Medication-Related Problems (MRPs) - Extension effects; adverse effects.
- An undesirable event experienced by a patient that involves or is suspected - Examples:
to involve drug therapy and actually or potentially interferes with a desired - Benzodiazepines – sedation
patient outcome. - Furosemide – water and electrolyte imbalance
- Heparin – hemorrhage
- Insulin - hypoglycemia
Classification of MRPs Type B – Bizarre
• Ineffective drug therapy - Idiopathic; immunological reactions.
• Unnecessary drug therapy - Examples:
• Wrong drug - Pyrazinamide – hepatotoxicity
- Streptomycin – ototoxicity
• Incorrect administration
- Captopril – cough
• Low/High dosage
- Simvastatin – rhabdomyolysis
• Adverse drug reaction
- Propranolol – bronchial asthma
• Drug interaction
- Tetracycline – hypoplasia of teeth
Type C – Continuous
- Long-term use; dose and duration-related
Factors Affecting MRPs - Examples:
• Multiple disease - Ethambutol
• Multiple medication - NSAIDs – hepatotoxicity
• Multiple prescription Type D – Delayed
• Physiologic changes - Carcinogenesis; Teratogenesis
• Lack of knowledge - Examples:
• Compliance issues - Thalidomide – 1960s incidence of Phocomelia
- Vitamin A (Retinol)
Type E – End of Use
How to Prevent MRPs - Withdrawal syndrome
• Communication - Examples:
- Communicate with patients - Benzodiazepines – rebound insomnia
- Communicate with health care providers - Clonidine – rebound hypertension
- Corticosteroids – acute adrenal insufficiency
• Medication - Opioids – narcotic withdrawal
- Medication management Type F – Failure of Efficacy
- Counterfeit medication
- Underdosing
Adverse Drug Reactions (ADRs) - Drug-Drug interactions (Warfarin and Vitamin K)
- Drug-Food interaction (Simvastatin – Grapefruit)
- Any response to a drug which is noxious and unintended, and which occurs
- Drug-Disease interaction (NSAIDs – fatty liver)
at doses used in man for prophylaxis, diagnosis, or therapy.
- According to the WHO, ADRs do not include:
- Drugs administered in error
- Drugs given by erroneous methods

Adverse Drug Experiences (ADEs)

- Any response to a drug which is noxious and unintended, and which occurs
at doses used in man for prophylaxis, diagnosis, or therapy, which goes
UNREPORTED.
Dispensing Week 4 Notes

Patient Compliance
- The extent to which a patient’s behavior (in terms of taking medications,
following diets or executing other lifestyle changes) coincides with the
clinical prescription.

Types of Non-Compliance
• Failure to have the prescription dispensed or renewed (refilled)
• Omission of doses
• Errors of dosage
• Incorrect administration
• Errors in the time of administration
• Premature discontinuation

Pharmacoeconomics
Cost of Illness Evaluation
- Identifies and estimates the overall cost of a particular disease for defined
population.
- Direct or indirect costs.
Cost Benefit Analysis
- Identifies, measures, and compares the benefits and cots of a program or
treatment alternative.
Cost Minimization Analysis
- Determination of the least costly alternative when comparing two or more
treatment options.
- Assumptions: Same safety and efficacy
Cost Efficacy Analysis
- Way of summarizing the health benefits and resources used by
competing healthcare programs so that policy maker can choose among
them.
- Cost and benefits are expressed as a ratio (benefit-to-cost ratio).
- Assumption: Different safety/efficacy
Cost Utility Analysis
- Includes patient preference and health related quality of life when
comparing competing alternatives.
Incompatibility b. Change in temperature
- Conflict, disagreement, differences in reactions. • Endothermic Reaction- absorbs heat = increase temperature of solution
- Interaction of two or more substances that result in changes to the medical, = increase solubility.
physical, or chemical properties of the pharmaceutical dosage form. • Exothermic Reaction – gives off heat = decrease temperature, decrease
- Occur during: solubility of the solution.
• Compounding
• Formulation 3. Liquefaction
• Manufacturing a. Deliquescence
• Packaging - Absorbs moisture = liquefy
• Dispensing - Example: NaCl
• Storage b. Eutaxia
• Administration of drugs - Due to lowering of MP of two solids combined at room temperature
- Eutectic compounds
Incompatibility • Phenol
• ASA
• Salol
• Thymol
In-vitro In-vivo - Eutectic mixture:
• Menthol + Ibuprofen
c. Efflorescence
Physica Chemical Therapeutic - Releases water of crystallization.
Incompatibility Incompatibiity Incompatibility - Example: Citric acid

In-vitro → outside the body 4. Vaporization

In-vivo→ inside the body - Aka: Volatilization
- Increase vapor pressure
- Liberation of the Atmospheric Pressure Ionization (API).
In-vitro - Examples:
Physical Incompatibility • Volatile oils
- Due to conflicting physical properties between drugs. • Ketone
- Leads to visibly recognizable changes. • Esters
- Changing in color, taste, texture, odor, viscosity, and morphology. • Nitroglycerin
Manifestations: • Aldehyde
1. Incomplete Solution • Alcohol
a. Insolubility
- Happens between solid and liquids. 5. Polymorphism
- Inability of the solid material to dissolve in a particular solvent system. - Ability of a substance to exist in different crystalline forms.
- Gum + alcohol (change alcohol to water); gum is better dissolved in water - Examples:
- Iodine (oldest antiseptic) + water • Cocoa butter (alpha, beta)
b. Immiscibility • Beta form – used in suppositories
- Two or more liquids fail to mix homogenously.
- Oil + water (addition of gum) 6. Water Loss
- Reverse of liquefaction
2. Precipitation - Examples:
a. Salting-out • Emulsions → cracking
- Results when highly hydrated inorganic ions (e.g., Cl-, K+, Na+) deprive • Gels → syneresis
organic ions and molecules to remain dissolved. • Ointment → crumbling
- Electrolytes and non-electrolytes compete for water molecules.
- Non-e- + H2O + e- = decrease solubility of non-e
Chemical Incompatibility Hydrolysis
- Reaction between two or more substances which lead to change in chemical - Most common cause of degradation.
properties of pharmaceutical dosage form. As a result of this a toxic or inactive or - Examples:
product may be formed. • Ester (ASA, local anesthetics)
1. Oxidation • Amide (Procainamide, local anesthetics)
- Dehydrogenation • ASA (salicylic acid + acetic acid)
- VILEORA (valence increase, loss electron, oxidation, reducing agent)
- Examples:
• Ascorbic acid (white → yellow) Photochemical Degradation
• Epinephrine (yellow → pink) - aka: Photooxidation, Photolysis
- Examples:
2. Reduction • Nifedipine
- Hydrogenation • Nitroprusside
- VDGEEROA (valence decrease, gain electron, reduction, oxidizing agent) • Riboflavin
Types of Chemical Incompatibility • Doxorubicin
• Based on chemical interactions
- Tolerated incompatibility – changing the order of mixing
- Adjusted incompatibility – change in the formulation
Racemization
- Conversion of an optically active drug to an optically inactive drug.
• Based on nature of chemical reaction
- Product: Racemic Mixture
- Immediate incompatibilities – chemical reaction takes place
immediately. • 50% dextro (R, +)
- Delayed incompatibility – chemical reaction proceeds at a very slow • 50% levo (S, -)
rate. - Examples:
• Thalidomide
• Based on Prescriber R → for morning sickness
- Intentional – prescriber knowingly prescribes the incompatibility S → Teratogenic
drugs.
- Unidirectional – prescriber prescribes the drugs without knowing that
there is incompatibility between the prescribed drugs. Gelatinization
- Formation of gels.
- Example:
Acid-Base Reactions • Acacia + Fe salts
Precipitation
- Examples:
• Ca(OH)2 Tropical solution Cementation
• Ca(OH)2 + CO2 → CaCO3 (ppt) + H2O - Formation of cake.
Evolution of Gas (evolution of CO2) - Example:
- Examples: • Acacia + Bismuth salts
• Effervescent granules (NaHCO3, citric acid, tartaric acid)
NaHCO3, citric acid → Na citrate + Co2
CO2 – masks unpleasant taste
Acid + Base = Neutralization (neutralized salt + water + evolution of gas)
In-vivo
Therapeutic Incompatibility
- The modification of the therapeutic effect of one drug by the prior concomitant
administration of another.
- Undesirable pharmacological interaction between two or more ingredients.
- Examples: ADR and Drug interaction
Drug Interaction
- Situation in which the effects of one drug (object drug) are altered by prior or
concurrent administration of another drug (precipitant drug).
- Pharmacological effect of one or both drugs may be increased or decreased, or a
new and unanticipated adverse effect may be produced.
• Object drug – drug being altered.
• Precipitant drug – drug that causes alteration/changes.
Types of Drug Interaction:
a. Drug-Drug Interaction
- Mechanisms:
• Pharmacokinetics (ADME)
• Pharmacodynamics (Synergism, Antagonism, altered cellular, Transport effect
on receptor site).
Alteration in Gastric pH
- Absorption of some drugs from GIT is dependent on the pH of the fluid in
absorption site.
- Concurrent use of a precipitant drug that alters the pH of the GI fluid can change
the rate of absorption of the first drug or the amount of drug absorbed.
- Weakly acidic drug better absorbed in acidic environment
- Examples:
• Ketoconazole + Antacid = decrease absorption of Ketoconazole
• Bisacodyl + Antacid = gastric irritation, premature liberation of Bisacodyl
Complexation
- Some drugs may form irreversible chelates in the presence of another drug
rendering both drugs inactive.
- Chelates are poorly absorbed.
- Examples:
• Tetracyclines + Metals (Ca2+, Mg2+, Al3+) = decrease absorption of
Tetracyclines.
Tetracyclines (Doxycycline) – used to treat bacterial infections (UTIs); not
allowed for patients 12 years old and below because it could affect their bone
structure which could result to stunted growth and discoloration of teeth.
• Fluoroquinolones + Metals = decrease absorption of Fluoroquinolones
Fluroquinolones (Ciprofloxacin, Levofloxacin, Ofloxacin)
• Penicillamine + Metal-containing drugs = decrease absorption of metal-
containing drugs
Penicillamine – used for heavy metal poisoning.
Adsorption
- Non-specific binding of a drug to another agent.
- Example:
• Cholestyramine + Warfarin = non-absorbed → thrombosis
Cholestyramine – lowers cholesterol
Alteration in GET
- The time it takes for the stomach to empty its content.
- Normal GET = 3 hours
- Increase GET = decrease rate of absorption.
- Examples:
• Cathartics + Antacid = decrease efficacy of antacid
Antacid neutralizes pH in the stomach; Cathartics fasten peristalsis.
Cathartics increase GET, moved the Antacid faster thus shorten its exposure
to the stomach hence decrease in efficacy.
• Atropine + Antacid = increase efficacy of antacid
• Atropine + Ketoconazole = increase efficacy of Ketoconazole
Atropine decreases GET of Antacid & Ketoconazole, results slow movement,
prolonged exposure thus increase in efficacy.
Alteration in GI Flora
- Example:
• OCP + Antibiotic = Biliary recycling → unwanted pregnancy
OCP (Oral Contraceptive Pill) is conjugated with normal flora in the intestines,
but with Antibiotic, it kills microorganisms (bacterial) in the body including the
normal resident flora hence resulting to ineffectiveness of OCP.
Alteration in Distribution
- Displacement from plasma protein binding site.
- Acidic drugs (bound with albumin); Basic drugs (bound with glycoprotein)
- Examples:
• Phenylbutazone + Warfarin → decrease protein binding → hemorrhage
Warfarin is bound to albumin since it is acidic, but with the existence of
Phenylbutazone, it displaces the Warfarin, increases the percentage of
Warfarin to be bounded to the receptor thus increases its potency leading to
excess bleeding.
• Sulfonamides + OHA (Tolbutamide) = decrease protein binding →
hypoglycemia
OHA stimulates the beta cells in the beta cells to secrete insulin to lower the
blood glucose level in the body, but with Sulfonamide, it displaces from being
bounded to the protein, thus more insulin secretion resulting to hypoglycemia.
Alteration in Metabolism
- Metabolism – process by which drugs are converted into more polar and
hydrophilic molecules to make it easier to eliminate through the kidneys.
- Site: Liver (through the action of enzymes in the CYP450 system).
- Enzyme inducers & inhibitors are the precipitant drugs.
 • Enzyme induction – enhances the action of an enzyme towards another drug • Alteration in Active Transport
resulting in a faster inactivation of a drug increase enzymatic activity = - Example:
increase metabolism - Penicillin + Probenecid = decrease excretion of Penicillin
- Example: Phenobarbital + Warfarin = thrombosis Decrease excretion of Penicillin will result to more contact with
- Enzyme inducers: (PRC COP SGC) microorganisms, increase effects.
- Phenytoin
- Rifampicin
- Chronic Alcoholism Pharmacodynamic Interactions
- Carbamazepine - Occur when one drug alters the effect of another drug at its site of action without
- Omeprazole altering the systematic concentration of a drug.
- Phenobarbital - Interaction between drugs with similar pharmacologic effect: Additive effect,
- St. John’s wort Synergism, Potentiation.
- Griseofulvin - Interaction between drugs with opposing effect: Antagonism
- Cigarette Smoking
Addition (1+1=2)
• Enzyme inhibition – inhibits the action of an enzyme towards another drug - Concurrent administration of two drugs acting on the same mechanism, the final
resulting in a slower rate of metabolism. effect of which is the same as the algebraic sum of their separate effects.
- Enzyme inhibitors: (MED3 Vv2I2C2 KGA2 - Examples:
- Metronidazole • BZD + Antihistamine = sedation
- Erythromycin (Macrolides) • Beta blockers + Non-DHPs (Verapamil & Diltiazem) = heart block
- Diltiazem, Diphenhydramine, Disulfiram
- Valproic acid, Verapamil Synergism (1+1=>2)
- Isoniazid, Indinavir - Results when two drugs acting on similar mechanism enhance the action of each
- Cimetidine, Chloramphenicol other to produce an effect much greater than the sum of each drug actin
- Ketoconazole separately.
- Grapefruit juice - Example:
- Allopurinol, acute alcoholism • Co-Trimoxazole (Trimethoprim + Sulfamethoxazole) = increase antibacterial
effect
- Example: Disulfiram + Ethanol
Ethanol –alcohol dehydrogenase → Acetaldehyde (toxic) –aldehyde Potentiation (1+0=2)
dehydrogenase inhibitors (released by the liver) → acetic acid (by- - occurs when two drugs acting on different mechanism or receptors a taken
product) together and one of them intensifies the action of the other.
But, since Disulfiram inhibits the aldehyde dehydrogenase, preventing - Examples:
Acetaldehyde to be converted to acetic acid will longer its toxicity resulting • Amoxicillin + Clavulanic acid = increase antibacterial effect of Amoxicillin
to longer hangover for alcohol drinkers. Clavulanic acid has no therapeutic use but only inhibits the enzyme that could
possibly make the bacteria resistant.
Alteration in Excretion • Ampicillin + Sulbactam (Sultamicillin) = increase antibacterial effect of
• Alteration in urinary pH Ampicillin
- Examples: • Piperacillin + Tazobactam = increase antibacterial effect of Piperacillin
- NaHCO3 + ASA = decrease excretion of ASA • Levodopa + Carbidopa = increase antiparkinsonism effect of Levodopa
- NaHCO3 + Amphetamine = increase excretion of Amphetamine
NaHCO3 is basic and ASA is acidic. Antagonism (1+1=<2)
NaHCO3 + Amphetamine → positive result in urine drug test. - Two drugs with opposing action may result in the reduction or cancellation of the
Acidic (orange, lemon, or calamansi juice) + Amphetamine → effect of one or both drugs.
negative result in urine drug test because it will delay elimination - Patents may have a false sense of security that the drugs they are taking works.
(decrease excretion) of Amphetamine. - Examples:
• Naloxone + Morphine
• Flumazenil + BZD
Naloxone & Flumazenil are for opioid and BZD overdose, respectively.
 b. Drug-Food Interaction
- Examples:
• Warfarin + Green leafy = decrease efficacy of Warfarin
Green leafy vegetables produced Vitamin K which is a clotting factor.

• Tetracyclines + Dairy products (Ca2+) = decrease absorption of

Tetracyclines
• MAOIs + Tyramine-rich Foods = increase Epinephrine, Dopamine
MAOIs (Monoamine oxidase inhibitors) – used for treatment of depression.
Tyramine-rich foods (cheeses and meat)

• Spironolactone + Banana = hyperkalemia

Spironolactone raises potassium level, banana is rich of potassium = excess
amount of potassium (hyperkalemia).

Factors Contributing to the Occurrence of Drug Interactions

1. Multiple pharmacological effects
2. Multiple prescribers
3. Use of nonprescription products
4. Patient Noncompliance
5. Drug Abuse
Patient Variables
• Age
• Genetic Factors
• Disease States
• Renal Function
• Hepatic Function
• Alcohol Consumption
• Smoking
• Diet
• Individual Variation

Reducing the Risk of Drug Interaction

1. Identify the patient risk factors.
2. Take a thorough Drug History.
3. Be knowledgeable about the actions of the drugs being used.
4. Consider therapeutic alternatives.
5. Avoid complex therapeutic regimen when possible.
6. Educate the patient.
7. Monitor therapy.
8. Individualize therapy.