Friday, July 24, 2015

Meetings, Meds, and Monographs: Drug Information Rotation

Posted by Stephanie Burke at Friday, July 24, 2015

Already done with rotation 2 – time flies! I had my Drug Information (DI) rotation these past 5 weeks, and I learned a ton! I’ve got a pretty good grasp on where to find information for different types of DI questions. The questions I received ranged anywhere from ‘what are the clinical manifestations that could result following accidental injection of a nasal solution of drug A’ to ‘can drug X be crushed and flushed through a G-tube’ to ‘we have a patient who is allergic to sulfites – can you review the ingredients of the attached list of medications for presence/absence of sulfites?’ Not your typical, everyday stuff, but now I have some familiarity with the types of clinical questions that could arise and where I could look to find information. I consider it a great skill to have acquired early on in my rotation schedule.

In addition to answering phone calls and emails from the inquiring minds of our UM providers and researchers, the DI folk also attend a number of different committee meetings. On this rotation, I went to committee meetings for anesthesia, cancer, pain, inventory, and glycemic control. It’s great having our DI pharmacists present because they bring a solid understanding of the available literature, and the meetings help the DI staff stay up-to-date on new information. My personal favorite was the Glycemic Committee meeting given my interest in diabetes mellitus. There was a monograph presentation on Afrezza, the newer inhaled insulin product, and also a discussion on the concentrated insulins that have been surfacing in recent years. Lots of cool stuff in my opinion!!! My hope is to continue attending these monthly meetings in future rotations when I am back in Ann Arbor (out of area rotation 3). If that is the case, I’m sure you’ll see more fun stuff on that in future posts J

One of my other favorite components of this rotation was the monograph project (or in my case, 3 total monographs!). The monographs I prepared will be presented at future Pharmacy and Therapeutics Committee meetings for consideration for formulary addition. The first drug assigned to me was mifepristone. This is a very interesting (and controversial) medication. Used as an investigational drug since 1985, mifepristone was FDA-approved in 2000 for termination of pregnancy through 49 days gestation. The drug had already been adopted in a number of European and Scandinavian countries prior to its approval in the United States. The brand name for this indication was MifeprexTM, produced by Danco Laboratories. Twelve years later, mifepristone was approved for another indication – management of hyperglycemia in patients with impaired glucose tolerance or type 2 diabetes secondary to endogenous Cushing’s syndrome. This brand, KorlymTM, was produced by Corcept Therapeutics. Same active ingredient, two different brands, indications, and manufacturers. Take a look at the pharmacology of mifepristone to see how it could work for two very different conditions!

The third monograph I wrote was for U-300 glargine (ToujeoTM). Again related to diabetes, it was of significant interest to me. The clinical trials that Sanofi-Aventis completed showed, overall, that U-300 glargine was non-inferior to Lantus in blood glucose control, and in some cases, produced less nocturnal hypoglycemia. There were no significant differences in adverse effect profiles between the two. The primary concern we see with adding U-300 glargine to formulary is safety. There have absolutely been medical errors when someone draws up the concentrated product thinking it’s the unconcentrated, or a provider fails to correctly calculate the volume needed given the number of units of insulin. Many things could go wrong here when used in the inpatient setting. For those unaware, insulin is a high alert medication, and there must be effective and appropriate protocols in place to ensure safe use of insulin products.

Drug Information was an excellent experience. It challenges you to dig deep into the inquiries that come in, and also to consider all the data you’ve gathered and make a clinical recommendation. The rotation also better familiarizes you with drug information resources which will be invaluable to any type of work that you do.


Thursday, July 23, 2015

Rotation 2: Prednisone Tastes like Rancid Mints and Other Pearls from Pediatric Generalist

Posted by Emily at Thursday, July 23, 2015

What does a generalist do?  The short answer: everything!

Here's what a typical day looked like on rotation as a pediatric generalist-in-training:

0730-0930 - work up patients at the hospital
On the first day of rotation, my classmate and I were both assigned to a specific pediatric general medicine service that we would continue to follow for the rest of the month.  These services see kids with all different kinds of chief complaints ranging from intractable vomiting to osteomyelitis to febrile seizures to premature babies who are simply admitted for feeding and growth monitoring; basically patients who are too sick to go home but not sick enough to be sent to the PICU or assigned to a specialty service like heme/onc.  Patient duration of stays also varied greatly, so our patient lists changed every morning as our old patients were discharged and new ones were admitted.  This kind of variety is the hallmark of a general service and because of it I gained exposure to an array of disease states and medications that I hadn't previously seen.  We reviewed our patients and recommendations with our preceptor before starting rounds.

0930-1100 - rounding with the medical team
My favorite part of the day!  Pediatric generalist is a teaching service, so my team consisted of an attending physician, medical residents, medical interns, med students, and a dietitian.  I benefited from the attendings' teaching points just as much as the medical students did, and sometimes I was even able to answer the attendings' questions when the medical students couldn't.  (What do we want to monitor with linezolid?  Weekly CBC!)  Rounds was also my opportunity to make recommendations, though because of the fact that these patients tended to be less complicated than, say, my BMT patients last month, and because the medical students and interns were all working to develop their own autonomy, I feel like the generalist pharmacist wasn't as valued/utilized as the specialists pharmacists are during rounds.  Nonetheless, the team DID turn to me with questions from time to time, and I was also able to recommend a few therapeutic interventions of my own. :D

1100-1500 - review patients, do med recs/med histories, do medication teaching, review TPN orders, work on projects, eat lunch
Remember how I said generalists do everything?  Our afternoons were left open for completing the myriad tasks that generalists are responsible for.  We'd review our patients again with our preceptor after rounds to let her know if there were any significant updates, and then we were free to complete medication histories and medication reconciliations for all the patients who had been newly admitted to the floors.  For patients being discharged with new prescriptions for Diastat (diazepam rectal gel for seizure emergencies), EpiPens, or enoxaparin, my classmate and I were available to review proper medication administration technique with parents and families.  We were also tasked with reviewing total parenteral nutrition (TPN) orders to make sure that all changes made to the TPN composition were appropriate based on that morning's labs, and that the changes made were appropriate for each patient's age and weight.  In addition to these patient care activities, we had a handful of projects to complete during our five week rotation block.  These included three informal topic discussions (I presented on perinatal HIV, preeclampsia/eclampsia, and pediatric acetaminophen toxicity), a journal club on a randomized controlled trial of aerosolized versus subcutaneous injection measles vaccine, and a formal patient case presentation on Kawasaki's disease.

1500-1600 - attend topic discussions, journal clubs, and case presentations
The last hour of the day was often devoted to topic discussions led by various pharmacy staff.  Topics included an introduction to pediatric pharmacy, how to properly conduct a medication reconciliation, pediatric emergency services, a pharmacokinetics review, how to verify TPNs, and a discussion of lines and tubes.  But our most fun (and most disgusting) afternoon activity by far was the infamous TASTE TEST.

Many pediatric patients are not able to swallow pills and thus are prescribed liquid medication formulations.  To gain a better understanding of what we're expecting our patients to endure when we recommend a liquid formulation, we participated in a taste test of over twenty different liquid medications.  Armed with bottles of pop and chocolate sauce to cleanse our palates in between each medication, we were given a drop or two of commonly prescribed pediatric drugs (everything from azithromycin to Zofran) on a plastic spoon to sample.  The results ranged from legitimately delicious (amoxicillin) to horrifyingly vile (metronidazole).  Knowing how these medications taste gave me a much greater appreciation of why it can be so difficult for parents to get children to take their medicine.  As a pharmacist, it's easy to say "take 15 mL twice a day" and to stress the importance of completing a full course of therapy, but if a medicine has a completely intolerable taste the kid isn't going to take it no matter how much ice cream she chases it with.  In fact, the day after the taste test, my attending prescribed Bactrim rather than clindamycin for a six month old patient because (aside from being less likely to cause C. diff) Bactrim is MUCH more palatable.  Bactrim tastes like medicinal Kool Aid.  Clinda tastes like sadness.  This is the kind of practical knowledge you can only gain from being out on the front lines, and it’s such a refreshing change after three years of textbooks and lectures.

note sheet and snacks from the liquid medications taste test

Interestingly, three years ago I completed my first P1/P4 shadowing experience while my P4 was on this exact rotation.  In my post-shadowing write up, I said, "I feel connected to the pediatric patient population, but I worry that I lack the emotional fortitude to work within this specialty."  For the most part, this rotation has not been as emotionally demanding as I was expecting it to be.  Most of the kids on a general service are not too sick - not sick enough to be in the PICU, at least.  We also don't see hematology/oncology patients.  In short, most of our kids aren't dying.  That said, I still saw some difficult cases this month, the most striking of which was a seven week old baby boy who was admitted for "non-accidental trauma" (e.g. child abuse).  His x-rays showed more than twenty fractures in various states of healing.  While it was hard to know that such a cute little guy had had such a rough start, it was incredibly rewarding to be a member of the team that was ensuring he would be safe and responsibly cared for in the future.  In fact, I enjoyed working with the kiddos so much that I've added pediatric rotations and PGY2 offerings in pediatrics to my PGY1 residency search list.

Tuesday, July 21, 2015

A DI Rotation: Drug interactions? No, Drug Information!

Posted by H. Tran at Tuesday, July 21, 2015

We are in our last week of our second rotation. I’m currently on my Drug Information rotation in Ann Arbor and it’s been a great experience. My daily tasks have revolved around sharing phone duties with another P4 student, which entails answering drug information questions that come in. These questions could come from anyone -- nurses, physicians, pharmacists, psychiatrists, etc., and could be about anything.  Some of the more interesting ones I’ve received were questions regarding appropriateness of using medications off-label (not FDA-indicated). For starters, a psychiatrist inquired about using N-acetylcysteine (NAC) for an autistic patient’s aggressive behavior who had experienced tardive dyskinesia (adverse effect) from their risperidone.  Specifically, they were asking if NAC would cause problems for this patient.  Another interesting request I had was to find a recipe to compound a topical cream of paromomycin for cutaneous leishmaniasis.  You are probably thinking, “Paramo—leishmani—what?!” That was exactly my reaction.

To address these questions, the first thing I did was review the patient’s charts to assess appropriateness of the requested therapy given the patient’s medication list and medical diagnoses. The review includes side effects, kidney/liver function, drug interactions, and any other precautionary measures that would ensure safe and efficacious use of the therapy. I then referred to the literature to support any responses I would provide the requester. Because these therapies were off-label uses, the literature would be the most appropriate resource to support my response. NAC is FDA-indicated and routinely used in case of acetaminophen overdoses, but luckily, NAC has been recently studied for neurologic disorders. I pulled the evidence from the literature and provided the articles to the requester for him to make his own clinical decision based off the outcomes from these studies. From a pharmacy standpoint, I acknowledge whether or not a therapy is appropriate given a medication and problem list. Once I’m ready to make my response/recommendation, I bring it to my preceptor to sign off on, and away it goes!

The request for a recipe was a little more difficult.  Paromomycin is an antibiotic that isn’t on formulary where the requester is situated.  It comes only as a capsule formulation, so finding a recipe was a challenge. Through a literature search, I found a military-based recipe that I provided the requester.  Topical paromomycin is so uncommonly used that it came down to utilizing a recipe that one doctor created for military use. Some of the other drug information questions I received were related to drug stability, drug interactions, if a drug would be safe for a given patient, and alternative therapy options.

When I’m not on phone duty, I work on various projects.  My main project is to create monographs of new drugs that are/may be considered for formulary. I give a rundown of the drug (general description, indication, mechanism of action, side effects, costs, clinical studies, etc.) and compile it all into a monograph.  The drugs I’m working on are ivabradine and combination product sacubitril/valsartan, which are new heart failure medications. The ivabradine monograph will be presented at the Pharmacy and Therapeutics Committee meeting for review of approval and addition to formulary, while sacubitril/valsartan has a novel mechanism of action that will likely be considered for addition to formulary as well. Separately, I also looked into revising guidelines on ketamine use in the emergency department. I surveyed policies and guidelines from various institutions across the nation and compiled the data for the pain management committee to review.

All in all, I never thought drug information was like this. It’s something new every day with different questions for you to problem-solve through. Whether or not you’re interested in drug information, the skills you develop in efficient navigation of references (and knowing what references to use!) would help pharmacists in any setting. I’m glad I had this as my second rotation as it has already made feel more comfortable and efficient in searching through references and studies for answers during my future rotations.

Sunday, July 19, 2015

Rotation 1: The Art of Pimping

Posted by Unknown at Sunday, July 19, 2015

What is ambulatory care like in Ann Arbor?
My first rotation started off in your local doctor’s office with nurse practitioners and physician assistants called ambulatory care pharmacy. Here pharmacy acts as a consult service for the physicians. Since my preceptor, Dr. Anne Yoo, specializes in chronic conditions of diabetes mellitus, hypertension, and hyperlipidemia, our pharmacy service was consulted when patients has uncontrolled diabetes (Hemoglobin A1C >9%), uncontrolled blood pressure (BP>140/90 for diabetic and chronic kidney disease patients or BP >150/90 for adults over the age of 60 years old without diabetes or chronic kidney disease). Hyperlipidemia are usually accompanied in patients with diabetes or hypertension. Additionally, in recent year, the guidelines have changed and there is no longer a goal target range for lipoproteins (i.e. LDL, HDL).
Ambulatory pharmacist have full autonomy under a specific collaborative practice agreement with the physicians in the office. With regards to our specific practice agreement, we can start, discontinue, or adjust dosages of patient’s diabetic, hypertensive, or hyperlipidemia medications and order any relevant labs. Additionally, there is a new program that was recently started called comprehensive medication review, where patients are recruited if they have 5 or more chronic medications. This service allows patients to meet with clinical pharmacist one-on-one to go over their medications, safety concerns, appropriate indications for each medications, and/or cost issues. The main aim is to catch any medications errors, duplication in therapy, and/or address any concerns the patients had. Additionally, it increases awareness to the broad service pharmacy can provide to the public and to the clinic.

What is the learning curve on this rotation?
As my first one, I had a lot to learn. Our classes prepare us for majority of the real life as a P4, specifically our P1 year communication class, our P2 year community IPPE, and P3 year chronic diseases management course. The biggest gap I had to make up was my ability to manage time and stay efficient. First hill I had to overcome was my data collection skills. Our University of Michigan system is fortunate to have an electronic medical record synch with inpatient and outpatient setting, allowing us to easily access past documentations and lab results. But it was challenging for me to quickly seek out pertinent information. Second hill goes hand-in-hand with my first, creating your own monitoring form. You will have practice during P3 disease management class, but the key is to tailor it specifically to our clinic’s need and present to your preceptor the most relevant information. For instance, if we are only have 15 minutes to see this patient for his or her blood pressure management, it is important to present on factors that may increase blood pressure. Your own monitoring form will prevent you from missing any relevant information and help you build a foundation within your own mind crucial labs or information to look out for when treating each condition. Overall, this rotation should be a refresher for your chronic diseases, but it should push you to perfect your time management skills and efficiently delivering patient presentations.

What makes this rotation difficult?
There are two main reasons. First, patient work load gradually increases over the course of 5 weeks. It would go up from 4 patients ---> 6 ---> 8-10 ---> 16-18. Typical full day involves 17-18 patients. Work for each patient involves initial work-up, patient specific questions/concerns, and post- note writing. Initial work-up is when you collect pertinent data about the past medical history of patient, current medications and dosing, and labs for your patient presentation to your preceptor. Patient specific questions is researching about a concern a patient may have brought up during the last visit that needs to be addressed during this one. This could range from herbals supplements to alternative drug therapy. Finally, post-note writing is exactly what it sounds, the note you write documenting the recommendations made at the visit.  Second, the art of pimping. This is a phrase used by Dr. Yoo when she fires off questions. Questions usually involve what evidence was used in your recommendation, what are the common side effects of a medication, what is your plan B and plan C if plan A does not work, what are the trends on this lab result etc. I struggled each time I received pimping; however, I felt those were the times I learned the most and recall it quickly at a later time.

Final thoughts?
This rotation is highly recommended for those that wish to pursue more direct patient communication and have a passion for preventive care. Even though you will become the treatment expert, majority of the time will be spent on you coaching your patient through their chronic conditions and being their support and encouragement. I enjoyed this rotation a lot as it made me realize to always look up the evidence that supports each recommendation and not rely on the words of your preceptor. It was a mistake I made which probably left a weak impression on the patient. So don’t shy away from these pimping questions when put to the test. Be glad you are getting pimped now rather than when you become a pharmacist.