ICM II: Therapeutics

1. ICM II: Therapeutics Hour 1: Prescribing a New Medication Hour 2 & 3: Small groups Acupuncture American Indian Traditional Healing Chiropractic Integrating Conventional and Alternative Tx Mind Body Medicine Naturopathy Occupational Therapy Physical Therapy Wound Care (videotaped – to be posted next week)

2. Prescribing a New Medication Why do I need to know how to do this? Outpatient clinics: You will often be asked to write the prescription for patients you see, and your resident or attending will cosign. Inpatient services: You will often write admit orders on your patients, and will need to order drugs correctly. You are the most likely team member on some services to have time to counsel your patients about meds – especially at discharge Major potential patient safety problem – and your attendings may not always do it right!!

3. Glenn Kuz, Pharm.D, BCPS Clinical Pharmacist, UWMC February 25, 2011

4. UW Medical Center Outpatient Pharmacy Glenn Kuz PharmD

5. The Prescription (Rx) • Rx = an order for a medication, therapy, or therapeutic device. • Rx = assuming responsibility for clinical care. • Rx = a legal document.

6. Objectives • By the end of this session you will be able to: • Write a prescription correctly, clearly, & safely. • Describe the most common Rx writing errors. • Check for major drug interactions. • Be able to counsel a patient on their medication. • Understand medication reconciliation.

7. U2258979 Letterman, David Penicillin = rash 4-12-47 Codeine = N/V OMEPRAZOLE 20MG PO BID #60 One (1) 6-1-10 GI Clinic MD1234567 Amanda Smith Dr. A Smith

8. Case 1 • A 56 yo man presents with postprandial burning chest and upper abdominal pain, relieved with Maalox. It used to occur only after very spicy food but has become increasingly frequent. In the last 2 months, he’s used Maalox 2-5 times per day. Other PMHx include CAD, s/p LAD stent in 10/2008, HTN, DM-II. He has allergy to penicillin (rash) in the past. • You decide on a trial of an acid blocking medication and upper endoscopy if symptoms are not resolved. • Current medications: • Clopidogrel 75 mg PO daily • Atenolol 50 mg PO daily • Metformin 1000 mg PO BID • Acetaminophen PRN

9. U2258979 Letterman, David Penicillin = rash 4-12-47 Codeine = N/V OMEPRAZOLE 20MG PO BID #60 One (1) 6-1-10 GI Clinic MD1234567 Amanda Smith Dr. A Smith

10. Late Night Top 10Reasons to page you • Incomplete prescription. • Illegible, cursive handwriting. • Unapproved & Dangerous Abbreviations • Look Alike – Sound Alike Errors • Wt-based dose and not calculated (need wt on Rx) • PRN order, no reason for use

11. Choose the best answer • Nabumetone 10mg po qid • Varenecline 1.0mg po bid • Namenda 10mg po qhs • Any of these are possible!!!

12. Choose the best answer • Both are four times daily. • Both are once daily. • KCL is 4x/day, Flomax 1x/day

13. Choose the best answer • Prednisone 40mg qam hold for GERD • Pravastatin 40mg po qam • Protonix 40mg po qam

14. Consequence of Illegibility

15. ISMP Error-Prone Abbreviations http://www.ismp.org/tools/errorproneabbreviations.pdf

16. Protamine – Protonix Tramadol – Trazadone Valtrex – Valcyte ISMP Confused Drug Names Zocor – Cozaar Rituximab – Infliximab Keflex – Keppra Celebrex – Celexa Abelcet – Amphotericin B Hydrozyine – Hydralazine Actonel - Actose Beano – B & O (belladonna and opium) Elavil – Enalapril Xanax – Zantac Amantadine – Amiodarone Cetirzine – Sertraline Ditropan – Diprivan Lamotrigine – Lamivudine Luvox – Lasix Clonidine – Clonazepam Celebrex-Cerebryx Prilosec – Prozac Clonidine – Clonazepam Cetirzine – Sertraline Darvon – Diovan Alprazolam – Lorazepam Paxil – taxol Prilosec – Prozac Amlodipine - Amiloride Dopamine – dobutamine Allegra – Viagra Inderall – Adderall Leveteracetam – levofloxacin Benadryl – Benazepril Naloxone – Lanoxin

17. Classes of drugs A. Over the Counter Drugs (OTC's) B. Herbals/Natural Products C. Legend Drugs D. Controlled Substances Schedule I (Heroin, cocaine) Schedule II (Morphine, Oxycodone) Schedule III (Ketamine, narcotics, steroids) Schedule IV (Benzodiazepines) Schedule V (Antitussive, antidiarrheal)

18. Drug Information Resources • Micromedex • DRUGDEX • Excellent for dosing in renal and hepatic dysfunction • Excellent for POIVPO conversions, liver vs kidney elimination, half-life of drugs • Adverse Drug Reactions • Lists EVERYTHING!!! (good for “possible” reactions) • Monitoring Parameters • Drug Interactions – Comprehensive, lists all! • Therapeutic Use – FDA and non-FDA approved uses • Identidex for product identification (“it’s the pink one”) • Trissels Compatibilities (iv med compatibilities)

19. Drug Information Resources • How much albumin should I give for a therapeutic paracentesis of 5 liters? • My patient has SBP, my senior says to give albumin but I don’t know how much. How much should I write for? • Micromedex • Up-To-Date

20. Drug Information Resources • Lexicomp • Natural Medicines Database (herbal products) • Facts and Comparisons • product identification • Cochrane Library • Hansten & Horn - Top 100 Drug Interactions • AHFS

21. Case #2 • A 61yo female with DM-2 has a HbA1c of 8.7 despite maximum dose metformin (tolerating well). Only other medical problem is HTN, treated with HCTZ • You plan to add an additional medication, and are trying to choose between a sulfonylurea, exenatide, basal insulin or a glitazone • The clinic nurse asks: “What do you want me to write her for?” • What factors do you consider? • Consider that the patient is paying for her meds out of pocket and asks which would be most affordable

22. $$$How much does it cost?$$$ • Sources of cost information • Hospital formulary • www.drugstore.com • Discount pharmacies • WalMart, Fred Meyer, Target, Costco • Web Sources for patient assistance • www.needymeds.org • www.rxhelpforwa.org • www.accesstobenefits.org • www.together-rx.com • www.rxoutreach.com • www.medicare.gov/prescription/home.asp • www.institute-dc.org • www.themedicineprogram.com • www.phrma.org/patients • www.helpingpatients.org • www.rxhope.com • www.rxassist.org

23. Case #3 • A 43 year old man presents to the ER after being mugged and is found to have fractures of the R 5th and 6th ribs • CXR shows no pneumothorax, and labs and VS are normal • He’s otherwise healthy, on no meds • Your resident tells you to discharge him with a prescription for Vicodin – write it and he’ll cosign • What do you write? • What do you tell the patient?

24. Counseling Patients

26. Patient counseling • Name of medication • Include both brand and generic names • Dose and route of administration • Never assume a patient knows!!! • Scheduled vs PRN • If PRN, give the reason and explain how to decide • Every six hours vs QID (should pt wake up at night?)

27. Patient Counselling • What to expect – EFFICACY • Onset? Duration? How will they know it’s working? • What to watch out for – TOXICITY • How much is too much information? • Most common and most severe reactions • Follow-up or monitoring required • Example: warfarin therapy • Pharmacist’s role and obligation

28. Case #4 • A 68 year old woman with a recent diagnosis of AF and a history of recurrent UTIs presents to the clinic with dysuria • A urine dip is positive for leukocyte esterase and nitrates, and you send a sample for culture to the lab • With her last 3 UTIs, culture was positive for a pan-sensitive E. coli • She tells you she has been treated with Cipro, cephalexin, and TMP-SMX • What do you choose? Is there any more info you’d like from her?

29. What is Med Recon? • Choose the best answer A. A super-secret Military unit designed to investigate and destroy medications of mass destruction B. A Joint Commission National Safety Goal designed to prevent medication errors C. When two medications “make up”

30. Medication Reconciliation • “Accurately and completely reconcile medications across the continuum of care." • A process for obtaining and documenting a complete list of the patient's current medications • To communicate "a complete list of the patient's medications to the next provider of service upon referral or transfer to another setting”

31. Medication Reconciliation Medication list on admit Medication list on transfer Medication list on discharge

32. Obtaining an Accurate Med List • Review and verify home medication list • Avoid asking leading questions • “You are taking your metformin 500mg twice daily, right?” Vs. • “What medications are you currently taking on a regular basis?” • Do you know the strength of the pills? • How many times a day do you take this medication? • Don’t forget about OTC and herbal products • Do you remember how you will benefit from taking this medication? • In your notes cite your source! A med list copied from 2 years ago is certainly better than nothing, but is considered very differently than a list obtained from the patient at the current visit!

33. Questions?