OSCE-book-2010

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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
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In our teaching strategies, we utilize lecture-discussion, small group discussion,
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guides, selected reading assignments, computer assisted instruction (CAI), and interactive
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©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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Content
SECTION A: Communication Skills and Techniques
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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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Qualifying Pharmacy Review
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: Contraception’s
 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
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Prep Notes
Part 1
Communication
Skills
Number 1: Communication
Number 2: Communication
Number 3: Communication
2
MISBAH’S
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
 Don’t 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 patient’s 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 patient’s complaint / symptom?
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 Are any of the patient’s complaints or abnormal objective/physical findings related to
drug therapy?
 What are some other possible causes of the patient’s 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 i’ve 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 physician’s 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
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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 you’ve got it. Please don’t 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 haven’t 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
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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
↓
Patient’s present knowledge about medication and condition.
 Potential problems
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Identify problems and Educational needs
Discussion to prevent or resolve problems and educate
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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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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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Communication Skill:
Counselling On Refill Prescription
Opening discussion
Introduction
Offer privacy
Empathy
↓
Discussion to gather information and identify problems
MAMA
TOPS
↓
 Patient’s 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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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
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Name
Purpose
Directions
Side effects
Precautions
Future treatment
Self care recommendation
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Advice patient to see physician
Suggest non-drug treatment
Give self care recommendation
Reassurance
 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.
Do’s
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.
Don’ts
 “ You do know how to take medication, don’t you? (leading questions)
 “Did the doctor tell you about side effects” (close ended question)
[Type text]
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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 patient’s best interest.
The pharmacist’s ability to persuade depends on his or her style of communication,
effective methods of presenting information, organizing information, and confidence and
credibility of information.
Do’s
 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 don’t stop suddenly.
Although it is problem free, it could cause drug withdrawal symptoms.
Don’ts
 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 patient’s exact words is another techniques that encourage patient to
talk more about a particular topic.
Do’s
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Repeat the patient exact words..
Are you saying that……
Is your concern is…..
Don’t
Repeating frequently patient’s exact words, it would be annoying
Summarizing
 Summarizing is useful techniques to end a series of asking questions or probing.
[Type text]
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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.
Do’s:
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.
Do’s
What if patient interrupts with other topic while your communications? After briefly
discussing the patient’s comments, the pharmacist can return to
[Type text]
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8
Communication Skills:
Giving Instructions
Do’s
Use future forms,” softens your language: for example:
Be + going + infinitive
“You’re going to take one pill in the morning and one at bedtime.”
Be + going + to be + V-ing
“You’re going to be taking this tablet once a day at bedtime.”
Will + be + V-ing
“You’ll be taking one tablet at breakfast one at lunch, and one at dinner.”
Don’t’ (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
Do’s
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

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.”
Don’t (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
Do’s
 Try to use se short statements. Use simple (lay) language, as to talk to 6th or 7th
graders
 When giving instructions to patients, it’s 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.”
Don’t
 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:
 It’s important to wash your hands first.
 It’s 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 Patient’s Understanding
Confirm that the patient has understood your instructions by using the following
language:
 Just to make sure I’ve explained myself completely, would you mind telling me
how you’re 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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Do’s
 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
Do’s
 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.
Don’t
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.
Do’s
 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.
Don’t
 Don’t 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
 Tuck’s 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
Do’s




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
Don’t
 Don’t be taskmaster
 Don’t counsel in an authoritative and aggressive manner
 Don’t be judgemental
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 Don’t 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
Do’s
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
Don’t
 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 (ò 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 ñ or ò 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 ò in warfarin effect (drop in INR) in pts taking ginseng &
warfarin
 Patients should avoid ginseng due to possible reduction in INR.
St. John’s 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. John’s 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 Pglycoprotein
 Mycophenolate (CellCept®) & SJW, no effect
St. John’s 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. John’s 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. John’s Wort (SJW) & Antidepressants
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




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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. John’s Wort (SJW) & Antidepressants
 Pharmacokinetic interaction with amitriptyline
 Amitriptyline is metabolized by CYP2D6, CYP3A4, CYP2C19 & is a substrate of Pglycoprotein
 Efficacy of amitriptyline may be ò 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 ñ &
drug resistance ñ(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 Alzheimer’s 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. John’s 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 50’s
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.
Do’s
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 noncompliance, 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
Do’s
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
Do’s
 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, H2
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 4month-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
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:
Do’s
 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.
Don’t
 Do not make judgments on the physician’s 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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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 patient’s 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 patient’s 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
Age: 52 years
Address: XYZ
Dr: Gaucher
Comments: Breast Cancer
Parkinson’s disease
Medications: Pergolide 1mg TID
(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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Scenario # 3
You are supposed to have a dialogue with the Doctor, who will be inside the room
waiting for you. Go through the patient’s 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
Age: 28 months
Address: Prep Ave
Dr: Tips
Comments: Otitis Media
Medications: Amoxicillin Suspension
(Stopped today)
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 patient’s 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
Age: 29 years
Address: Prep Ave
Dr: Tips
Comments: Community Acquired
Pneumonia
Medications: Materna Multivitamins
(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 patient’s 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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Patient Name: Mrs Jacky
Age: 55 years
Address: Prep ave
Dr: Tips
OSCE a step by step approach
Comments: Osteo-Arthritis
Medications: Tylenol 1000mg QID
(Started 2 months ago)
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
Age: 9 years
Address: Prep Ave
Dr: Tips
Comments: Asthma & phenylketonuria
Medications: Salbutamol Inhaler PRN
Fluticasone Inhaler 1puff BID
(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
Age: 82 years
Address: Prep Ave
Dr: Tips
Comments: hypothyroidism and Hypertension
Medications: Levothyroxin tablets
Chewable Aspirin 81mg QD
Metoprolol SR 100mg QD
On the desk: CPS
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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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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 doctor’s 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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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 cashier’s 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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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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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 person’s 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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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, don’t 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
won’t 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 ½ 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 onehalf 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. Don’t 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
Age: 40 years
Allergies: Unknown
Gender: Male
Patient Profile
Pulmicort turbohaler 200μg 1x2
Serevent Diskus 50μg 1x2
Ventolin inh 1-2 puff prn
Rx
Advair Diskus 250μg
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 patient’s well being
-determine if any medication was ingested or used
- do not deny
Action to be taken
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-
-
-
-
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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
immediately replace the incorrect
item with the proper one – personally
deliver/taxi as needed
If used
- immediately return medication for
professional evaluation
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?
Do’s




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
Current medications
Captopril 25 mg tid
Aspirin 81 mg QD
Propylthiouracil 50mg Bid
Hydrochlorothiazide QD
K-Dur QD
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
Hydrochlorothiazide 25 mg QD
Zoloft QD
Break fast
Lunch
Dinner Bedtime
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?
Do’s
 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 patient’s 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.
Do’s
 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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Part 2
Problem
Solving
Skills
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23
GI Symptoms 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 tetracycline’s, 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 12hours or after taking an H2RA
 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 Chron’s 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
 Tuck’s 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 Peptobismol 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 21’s (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
Age: 45 years
Comments: Ulcerative Colitis
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Address: XYZ
Dr: Gaucher
OSCE a step by step approach
Medications: Ferrous Sulphate (started 6 months ago)
Allergies: Septra
New Rx: Sulfaslazine 1.5gms TID x 1 / 12
On the Table: CPS and TC
Solve Problems and Counsel
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24
Heartburn
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
Diarrhea
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
Traveller’s 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
Constipation
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 -- Don’t 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 21’s (6 mo)
 Palafer 300 mg 1 cap TID (1 week)
On the table:
 Sennokot
 Metamucil
 Soflax
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27
Hemorrhoids (Piles)
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
Age: 44 years
Address: XYZ
Dr: Gaucher
Comments: Hypertension
Medications: Verapamil SR 180mg QD
Tylenol #3 (Stopped 3mnths ago)
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
 Tuck’s wipes
 Senokot
 Metamucil
 Soflax (Sodium Docusate)
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28
Nausea & Vomiting, Motion
Sickness
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 body’s balance system,
and the visual cues. In other words, the eyes see motion, but the body thinks it’s 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 isn’t moving
Do not smoke, or drink alcohol
Eat light low fat not spicy meals
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




OSCE a step by step approach
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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29
Pinworm
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 2o 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 doesn’t 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 don’t feel bad about it
and they don’t worry that people will think they’re dirty and not tell you about their
hygiene
Practice Stations
Scenario # 1
A mother comes into your pharmacy requesting something to treat a child’s 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.
Patient’s 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: Down’s 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
Infant colic
Symptoms
 Pattern of crying with no apparent cause (diagnosis of exclusion)
 Wessel’s 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 baby’s 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 (Prof’s choice)
 12% sucrose solution (possible analgesic effect <30min)
 Herbal teas: chamomile, mint  some antispasmotic activity, used in some cultures to
soothe infants (don’t 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 baby’s 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 it’s hungry instead of every time it cries
 Hold baby in vertical position to minimize swallowing air, burp after 30-60mL or every 510 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 baby’s 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
Cardiovascular 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
Patient’s Profile:
Patient’s 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
Patient’s 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
Patient’s 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
Patient’s profile:
Current medications: Enalapril 5 mg po BID, digoxin 125 mcg po daily
Patient’s 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
Hypertension
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
Captopril 25mg TID
Asprin 81 mg QD
Propylthiouracil 50 mg BID
HCT 12.5 mg QD
K-DUR QD
Doctor Name
Tips
Tips
Tips
Tips
Tips
Repeats
0
0
0
0
0
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33
Antihyperlipedemic 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 3fold) in patients with severe renal impairment (CLCR 30mL/min/1.73m2) compared with
healthy subjects (CLCR 80mL/min/1.73m2). 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 selfadminister. 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
Age: 48 years
Address: XYZ
Dr: Tips
Comments: Hyperlipidemia
Type 2 Diabetes
Medications
Atorvastatin 20 mg QD
Metformin 500 mg TID
Qty
(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
Patient’s 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
Ischemic Heart Diseases
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 3fold) in patients with severe renal impairment (CLCR 30mL/min/1.73m2) compared with
healthy subjects (CLCR 80mL/min/1.73m2). 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
Nitro Spray
Lisinopril 20mg Qd
Simvastatin Qd
Asprin 81mg Qd
Metoprolol Sr 100mg Qd
Started 1 Wk Ago
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
Nitro Spray
Since 10 years
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
Anticoagulants and Warfarin
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
Age: 45 years
Address: XYZ
Dr: Gaucher
Comments: Deep Vein Thrombosis
Medications: Warfarin 2.5mg QD
On the table:
 Ginkgo Biloba capsules
 Ginseng capsules
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36
Psychological Disorders
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 patient’s 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 1st 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.
Pt’s 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
Age: 36 Years
Address: Toronto
Doctor: Tips
Medications: CBZ 400 mg TID (since 3 months)
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
It’s 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 doctor’s 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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Parkinson’s 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 patient’s 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
Contraception
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







Don’t recommend OCs < 35μg 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 35μg OC alone
If spotting – prescribe 50μg 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 2nd 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 won’t 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
Diabetes
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
 Don’t 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&½ 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
Age: 32 years
Address: xyz
Dr: Tips
Comments: Hyperthyroidism
Medication: Methimazole 10 mg BID
(3 weeks ago)
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
Asthma
Asthma Management
 Assess: asthma control, triggers, compliance, inhaler technique & co-morbidities
 Assessmentregular 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 β2-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 β2-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 β2 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 β2-agonist
 Salmeterol: partial β2-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 β2-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
Salbutamol Inhaler PRN
Advair Diskus 1puff BID
Since 3 years ago
Dr
Tips
Tips
Scenario # 2
A doctor’s 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 doctor’s 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
Cold, Cough, Congestion 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 Rhinitis
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 4th 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
 Burrow’s 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
Ophthalmic Drugs
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 don’t respond to non-Rx tx w/in 48-72hrs
 Acute bacterial conjunct in children, contact lens wearers, and those who don’t respond to
non-Rx Polysporin eye drops w/in 48hrs—Need empiric broad spectrum antibiotic eye
drops like TMP/polymyxin B or erythromycin (FQ reserved for serious infections).
Normally it’s 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) 24x/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 don’t 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 don’t collect dust or animal
dander
 Don’t 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 sneezing—1st gen
Benadryl slightly faster onset, can cause drowsiness + QID, 2nd 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 QID—not 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
 Don’t use decongestant eye drops >3days, non-pharms to avoid allergen exposure
 Wait 5-10 mins between instilling different eye drops so they don’t dilute one another,
order doesn’t 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.
Patient’s 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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



OSCE a step by step approach
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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46
Conjunctivitis
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
Otitis Externa
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
Vertigo and Dizziness
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 Meniere’s 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 Symptom 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
Age: 26 years
Address: XYZ
Dr: Gaucher
Comments: Onchomycosis
Medications: None
Allergies: Sulphur
New Rx: Lamisil Cream, apply BID x 3/12
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Athlete’s Foot
51
Athlete’s 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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Tolnaftate
Clotrimazole 1%
Miconazole nitrate
2%
Oxiconazole 1%
Tioconazole 1%
Athlete’s Foot
Prescription oral antifungals (terbinafine, ketoconazole, itraconazole,
griseofulvin) are indicated for infections of the nail or infections
resistant to topical treatment
Cream, Gel, Liquid, Powder, Spray Powder, not used under 2 year
age
not under 2 years of age, oral lozenges, topical cream 1%, topical
lotion, vaginal tablet, vaginal cream.
cream, spray powder, not under 2 years
cream and lotion not under 12 years age
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, don’t share towels, don’t 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 athlete’s foot can dust an antifungal power on feet (but don’t
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:
Sig:
M:
Lamisil 250mg tabs
1 tab OD x 7days for athlete’s foot
7 tabs
Patient’s Profile:
 21 year old male
 Codeine allergy
 Past medical history: Amoxicillin 2 years ago, nothing more
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52
Diaper 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 ABCDE’s
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
Age: 9 months
Address: XYZ
Dr: Tips
Comments: None
Medications: Zinc Oxide 15% (6 months ago)
Zinc Oxide 25% (2 months ago)
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 lice and Scabies
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 STD’s?
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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
OSCE a step by step approach
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 daughter’s 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
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Dermatitis
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 (2nd 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: 1st 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 H2O 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
Psoriasis
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
 1st line treatment for Mild to moderate = topical steroids
 1st 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 (don’t 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
Don’t remove scale
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 Saran wrap (used to occlude area and enhance penetration of topical agent)
Prevention:
 Avoid triggers
3P’s: Prevent injury, Persistence in avoiding over treatment, pauses or rest periods in
treatment
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56
Dermatological 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
 1st 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 1st 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 radiation’s carcinogenic potential and increased
risk of photosensitivity (patient’s 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 SPF≥15 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 (doesn’t 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, 4th ed. page 660.
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58
Arthritis
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 there’s 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
Age: 58 years
Address: xyz
Dr: Tips
Comments: Rheumatoid Arthritis
Medication: Prednisone 40mg QD (Started 2wks ago)
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
Patient’s 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
Osteoporosis
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
Age: 58 years
Address: XYZ
Dr: Tips
Comments: Osteoporosis
Medication: Alendronate Sodium
-Fosamax.
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
Age: 32 years
Address: XYX
Dr: Gaucher
Comments: Migraine HA
Medications: None
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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61
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
Sexual Dysfunction 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
Vaginitis
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)
1st 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 pt’s 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%)
 Recurrenceusually 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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Benign Prostatic Hyperplasia
Practice Station
Patient profile: (Present on the table)\
Patient Name: Mr Jim
Age: 38 years
Address: XYZ
Dr: Gaucher
Comments: Benign Prostratic Hyperplasia
New Rx: Finasteride 5mg QD x 1 / 12 (8 Repeats)
Wife comes to pick up prescription.
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66
Anticancer drugs and
Chemotherapy
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 B12 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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Antimicrobials 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
Age: 29 years
Address: XYZ
Dr: Gaucher
Comments: Community Acquired
Pneumonia
Medications: Materna Multivitamins
(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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Urinary tract infections
Symptoms




Frequency and urgency of urination.
Burning with urination
Fever and chillsimmediately 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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Weight 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 & ò fasting blood glucose
levels & ò 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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Smoking Cessation
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 = ½ 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.
Age: 29 years
Address: Tips
Dr: Tips
Comments: Smoking cessation
Medications: Nicorette gum 4 mg
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.
Age: 29 years
Address: Tips
Dr: Gaucher
Comments: None
Medications: None
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
Age: 33 years
Comments: None
Medications: Nicotine Polacrilex Gum
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Address: XYZ
Dr: Gaucher
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(Started 3 weeks ago)
Scenario # 4
A patient comes to fill a prescription
Patient profile: (given by patient after pharmacist candidate request)
Patient Name: Pink Rose
Age: 43 years
Address: XYZ
Dr: Tips
Comments: None
Medications: Bupropion Tablets 150mg
BID (started 2 weeks ago)
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
Allergies and Hypersensitive
Reactions
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
Age: 15 years
Address: Tips
Dr: Gaucher
Comments: Hypersensitivity to pea nuts
Medication: None
New Rx: Epipen auto injector, Inject 0.3ml SC as needed
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72
Photosensitivity
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 reexposure 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
Insomnia
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
Age: 37 years
Address: XYZ
Dr: Tips
Comments: Insomnia
Medications: Lorazepam 0.5mg QD
(3 refills) last refill: 15 days ago
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OSCE a step by step approach
74
Vaccines
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.
 It’s advisable (health Canada recommends you have to do flu shot every year,
because the virus is changing every year, that’s why it’s 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 can’t cause influenza
because it doesn’t 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 didn’t get a flu shot last year and didn’t get sick, it doesn’t 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,
it’s 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 shouldn’t 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 Reye’s 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 3070% 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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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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Varicella zoster infection (chickenpox)
 Dose: healthy children 12 months to 12 year age à One dose adults and adolescent >
13 à 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
Age: 32 years
Address: XYZ
Dr: Tips
Comments: None
Medications: None
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
Age: 32 years
Address: XYZ
Dr: Gaucher
Comments: None
Medications: None
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)
 2nd dose should be within 6 wks of first dose.
 If you exceed 6 weeks, should start from 1st dose
 Dissolve and take with water.
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75
Pregnancy & Lactation
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
Cholera
Hepatitis A
Hepatitis B
Influenza
Measles
Rabies
Rubella
Tetanus
Maternal Risk
Dehydration; potential increased
severity in 3rd trimester
Potential increased disease severity in
3rd trimester, miscarriage
Potential increased disease severity in
3rd trimester
Increased risk of maternal morbidity,
serious complications, hospitalization
Increased risk of encephalitis,
pneumonia
Close to 100% fatality (regardless of
pregnancy status)
Increased risk of miscarriage;
susceptibility is 8% to 15% among
adult women
Tetanic muscle contractions, death
(regardless of pregnancy status)
Typhoid
Increased risk of miscarriage
Varicella
booster
Increased risk of pneumonia, death
Fetal Risk
Premature labor
Potential increase in
prematurely
Chronic infant infection
Stillbirth
Premature delivery, stillbirth
Depends on severity of maternal
illness
Congenital rubella syndrome
(serious malformations),
stillbirth
Infant born to a non-immune
mother is at risk of neonatal
tetanus, which can be fatal
Depends on severity of maternal
illness
Congenital varicella syndrome
(serious malformations)
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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
Age: 29 years
Address: XYZ
Dr: Gaucher
Comments: Community Acquired
Pneumonia
Medications: Materna Multivitamins
(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 2nd/3rd gen
cephalosporin + macrolide
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76
Travel Tips
Travelers Diarrhea
Non Pharmacological
 Boil it, cook it, and peel it
 Bottled water only
 No ice
 Hygiene (brushing teeth)
 Don’t 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
Age: 32 years
Address: XYZ
Dr: Tips
Comments: None
Medications: None
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
Age: 38 years
Address: ZYZ
Dr: Tips
Comments: None
Medication: None
New Rx: Mefloquine 250mg tablets Q Week (8 tablets)
(On the table: DEET spray 31%)
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77
Substance 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 )
Plateau
Dose (mg)
Behavioral Effects
1st
100 – 200
Mild stimulation
2nd
200 – 400
Euphoria and hallucinations
3rd
300 – 600
Distorted visual perceptions
Loss of motor coordination
4th
500 -1500
Dissociative sedation
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
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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 (ñ in heart rate, BP & blood sugar), also ñalertness,
awareness & motivation, and ò 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
•
t½: ~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” & Parkinson’s 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, ñblood 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,
doesn’t 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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Part 3
Non-Interactive
Stations
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78
Non-Interactive Stations
 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:
patient’s name
patient’s 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
cherry syrup
0.15mg/kg/tsp
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
Rx4
Dr. TIPS
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79
New Approved Drugs
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 D3
 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.
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Part 4
NAPRA
Competencies
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81
Regulations
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
1 or 1+1
Narcotic preparations
Or Verbal narcotics
1+2
OTC or exempted
Narcotics
Straight Narcotics
Requirements for prescribing, dispensing and record-keeping
Prescription
Refills or repeat
Part Fill
Transfers
Record Keeping
Sales Report
Loss & Thief
Reports
Written
Verbal
Written
Verbal
Written
Verbal
Narcotic drugs

Permitted
Not Permitted
Not Permitted
Not Permitted
Permitted 
Not Permitted
Not Permitted
2 years
Required 
Narcotic Drugs
Preparations 
Permitted
Permitted
Not Permitted
Not Permitted
Permitted 
Permitted 
Not Permitted
2 years
Not Required
Yes 
Yes 
Tylenol # 4
1 or 1+1
Tylenol # 2 and 3
1+2
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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 
Part Fill
Verbal
Permitted 
Transfers
Permitted once only
Record Keeping
2 years
Sales Report
Not required
Loss & Thief
Yes 
Reports.
Control substances
Requirements for prescribing, dispensing and record-keeping
Controlled Drugs
Part I 
Part II 
Part III 
Written
Permitted
Permitted
Permitted
Prescription
Verbal
Permitted
Permitted
Permitted
Written
Permitted
Permitted
Permitted
Refills
Verbal
Not Permitted
Permitted
Permitted
Written
Permitted 
Permitted 
Permitted 
Part Fill
Verbal
Permitted 
Permitted 
Permitted 
Transfers
Not Permitted
Not Permitted Not Permitted
Record Keeping
2 years
2 years
2 years
Not Required
Sales Report
Required 
Not required

Loss & Thief
Reports
Yes 
Yes 
Yes 
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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 Pharmacy’s 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
Information Resources
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 can’t 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 can’t 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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In these pages we see CphA monographs. They direct youOSCE
to CPhA
a step
monographs
by step approach
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
don’t find it in specific monographs of individual medications.
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 patient’s 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
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ACE inhibitors, hypoglycemics, NSAIDs can be stopped abruptly
CNS
medications,
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OSCE a while
step byallstep
approach
cardiac drugs (with the exception of ACE inhibitors, corticosteroids, HRT and Opioids should
be tapered).
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 doesn’t 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 wellknown 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.
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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 that’s 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 don’t 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 ½ 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 doesn’t 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 don’t 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 don’t have any other reference book like
therapeutic choices or Patient’s 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 can’t 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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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.
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. That’s 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 can’t 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-HT3 antagonist like dolasetron mesylate, granisetron HCl, ondansetron
hydrochloride dihydrate.
Otherwise we can’t 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.
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