Who You Gonna Call? Drug Info!

Posted by Rachel Lebovic at Wednesday, January 08, 2014

While I don’t want to become a drug information pharmacist, my drug information rotation at the Ann Arbor VA was a worthwhile experience. When any health care professional in the Ann Arbor VA doesn’t know the answer to a medication-related question, they have the opportunity to call the drug information pharmacist (my preceptor, Dr. Ed LaHaie). Most often, the physician, nurse, or pharmacist with the question already looked at a few drug information resources and either couldn’t find the answer or found conflicting information. Then, it was my turn to delve deeper into drug information resources, primary literature, and/or call the manufacturer to try to answer the clinician’s question.

I received a wide variety of questions during my time at the VA. For example, one practitioner asked if losses in word-finding ability have been reported with gabapentin, a medication often used in diabetic neuropathy. A pharmacist called to ask if there were any clinically relevant drug interactions between a patient’s current medications and konjac root, an herbal product reported to lower cholesterol and stimulate weight loss. A physician wondered if alendronate, a medication for osteoporosis, would be absorbed in a patient whose stomach had been surgically removed due to gastric cancer. Yet another clinician asked if there were data to support the use of mifepristone, an abortifacient, in patients with Cushings disease. After responding to these questions and many more, I feel I have a better understanding of which references are best suited to answer different types of questions.

In addition to answering drug information questions, I also wrote a new drug monograph and prepared an hour-long presentation to the pharmacists at the VA. My new drug monograph explained the efficacy and safety of vortioxetine, a new anti-depressant medication. One of the most time-consuming but educational parts of the monograph was the appendix, in which I created a detailed chart comparing the data from eleven clinical trials that studied vortioxetine. The hour-long presentation I created on this rotation was titled, “Update on the Management of Crohn’s Disease.” Since I am interested in teaching pharmacy students as part of my career, I enjoyed the process of researching a topic and developing an engaging presentation that I thought the audience would find useful. I was proud that the pharmacists in the audience seemed interested in the presentation and asked pertinent questions.

Lastly, throughout this rotation I gained insight into some of the administrative roles a drug information pharmacist might have. My preceptor, Dr. LaHaie, approves (or denies) all of the non-formulary drug requests for the Ann Arbor VA. Non-formulary medications are those that are not allowed to be ordered for a patient, unless the patient’s case warrants special approval. I enjoyed discussing some of these non-formulary drug requests with my preceptor because they frequently involved interesting ethical dilemmas. Dr. Lahaie also serves on the Pharmacy and Therapeutics (P&T) Committee and the Drug Shortages Committee at the VA, so I was able to attend these meetings and gain insight into the decisions and work that goes on behind the scenes to determine which medications will be on the formulary and ways to work around drug shortages.

In all, I gained valuable experience during my drug information rotation at the VA. I missed seeing patients and I still think I am better suited for a clinical specialist position on an inpatient multidisciplinary team, but the drug information skills I developed will help me be a better clinical pharmacist.

Happy Holidays from the Ann Arbor VA!!

Posted by Anna Polk at Wednesday, December 21, 2011

Can you believe 2011 is almost over?!  This semester has flown by and rotations are now over halfway over!  I am finishing up my ambulatory care rotation at the Ann Arbor VA.  I always had a feeling that I would enjoy the practice environment at the VA and also the patient population and I’m finding this to be absolutely true.  Pharmacists play an integral role in ambulatory care at the VA, seeing patients in all sorts of clinics, from arthritis and anticoagulation to pain management and geriatrics.  I have had the opportunity to rotate through several of the clinics- I think I’ve had a pretty similar experience to Nina and am enjoying it just as much as she did!  

I am also happy to report that I’ve had a major breakthrough in terms of my long-term goals and aspirations while on this rotation.  After spending a lot of time in the pain and arthritis clinics, and speaking with my preceptor, I’ve discovered that I really enjoy practicing in areas where there several shades of gray.  Let me clarify- rather than trying to cure the patient or get their condition to a predetermined goal, I enjoy working with patients with less clear-cut goals.  I have always loved working with the geriatric population; I like how you are not trying to cure them or get all of their conditions to their recommended targets, but instead the focus is on quality of life and functional status.  I am finding that this interest is not limited to geriatrics, but rather areas that I like to think of as ‘empathy-driven care.’  These are areas where listening to your patient and developing a solid trusting relationship are essential.  You can’t treat numbers and there are few hard and fast rules to follow.  I think this helps explain why I enjoyed my psych rotation so much, as well!  

With residency application deadlines fast approaching this revelation could not have come at a better time.  I am feeling particularly passionate about pharmacy right now, and I was so excited to talk to all of the programs at the Midyear Meeting in New Orleans earlier this month.  I have ‘narrowed down’ my list of programs to apply to (I’ll admit it- there were ten that I just couldn’t bear ruling out) and am now putting all of my energy into my cover letters.

To any current or future pharmacy students:  get excited for your P4 year!!  I cannot believe how much fun I am having actually getting to practice these things that we spent so much time preparing for in the classroom!  What an exciting field we have chosen!  I guess I'll just end this post on that note- enjoy your time off for the holidays!!

It's Not Boring, I Swear.

Posted by Matthew Lewis at Tuesday, October 25, 2011

Hello Readers.

I'm already in the groove for my newest rotation, which is drug info. This is my second rotation in the Veteran's Affair group of hospitals, but there is a huge difference between the hospitals, and I think that is because of financial support. For example, the Detroit VA does not have a residency program but Ann Arbor (and Battle Creek) do.

[As a side note on residencies, several students from my class hope to be placed in the VA system, but I've been told that there aren't any residencies available at the Ann Arbor VA site this year. This situation isn't unique to VA as the demand for pharmacy residencies continues to outpace the supply nationwide. That means increasingly intense competition for limited slots. Michigan has one of the highest pharmacy residency placement rates in the country, but being a Michigan PharmD does not automatically make you the preferred candidate for a residency. Landing a residency still comes down to polished interviewing skills and an ability to package your talents in ways that make you stand out from the crowd.]

Back to the story at hand. As I mentioned, my current rotation is drug info. My preceptor, Dr. Ed Lehaie is a great guy and was recognized as preceptor of the year for 1999. The first day was all about getting paperwork in and computer access. I even answered some questions. Today, I answered a few more questions, particularly on replacements for the pain medication fentanyl because there is a drug shortage looming on the horizon. First, I did not even realize there were other drugs in the fentanyl family, so learning about those was interesting. I compared onsets and found appropriate doses through literature searches for sufentanil, remifentanil, and alfentanil. Finally, I did a little cost analysis.

You may have heard about drug shortages in the news, since they have gotten so bad people are dying from not getting proper medications on time. Part of drug information's job is to figure out how to work around these shortages. The other major part of drug information's job is to ... well, dispense drug information. This is usually in the form of approving medication requests that are off-label or extremely costly, such as cancer medications. We will also present new drugs and new research to our pharmacy and therapeutics (P&T) committee, where they can discuss what additional restrictions they want to place on drugs. VA P&T committees are quite different from normal P&Ts, in that each hospital has to follow the nationally mandated formulary decided upon by the national P&T. The local hospitals can only further restrict use.

That's the nuts and bolts of this rotation. I'm definitely going to be getting some weird questions, so I'll keep in touch to share them all.

Staff pharmacist

Posted by Matthew Lewis at Thursday, October 06, 2011

This rotation is all about figuring out what it would be like to be a general staff pharmacist, and it's at the VA (veteran's affairs) if you haven't read my previous post. The first thing that stuck me was where this VA is, which is right next to a college (Wayne State) and several other hospitals (Detroit Medical Center and Karmanos Cancer Institute to name a few) so it's at the heart of a medical complex. I've already done quite a few different things. The life of a staff pharmacist can pretty much be what you want to make it. You could be asked to take charge of the anticoagulation clinic, or make decisions about non-formulary medications. Your job might be to check physician orders and medication fills mostly.

Speaking of checking medications, the hospital inpatient setting employs a tech-check-tech system where properly trained and trusted pharmacy technicians check each other's work for accuracy. You might think it unsafe, but literature has shown that this system is just as accurate as a pharmacist check. tech-check-tech is an up and coming practice which allows pharmacists to get out onto the floor more often and help the medication ordering and administration process, which is where most medication errors occur.

Making IVs was fun, and interesting. You have to scrub in and gown up according to our fairly new industry practice of USP 797 guidelines which dictates how sterile IVs should be made. The actual mixing of the standard IVs isn't hard since most medications aren't toxic to any degree. I did not get the special chemo drug training though, since that is so dangerous even to people who follow the guidelines and have the two pairs of gloves on, the sterile disposable jacket, hair covering, mask, eye protection, mixing hoods with particular airflow and filters put in place among other things (As you can see, there are a lot of things to consider when implimenting USP 797.).

Now I'm just going on rounds and offering suggestions to the team to best manage the medications. Part of the job the pharmacist I round with is to make sure the vancomycin troughs are appropriate, and all the anticoagulation pharmacy follows is done by this pharmacist as well. I've learned quite a bit from that pharmacist as to the real-life application of medications which have narrow therapeutic ranges. In school, we learn with the impression that we can get patients' drug concentrations to the exact middle of our precise desired range, but in real practice there are mistakes as to when patients get lab draws, physicians of varying experience might not take your recommendations, or the patient might not "fit the mold" and metabolize the medication in some super fast or slow manner just to name a few things fighting against a pharmacist trying to get that perfect concentration.

That's what this rotation is all about for now, I'll keep you updated as things change.