Clincal Pharmacy: answer a question, pose a question

Started by WVUPharm2007
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WVUPharm2007

WVUPharm2007

imagine sisyphus happy
Verified Member
Pharmacist
20+ Year Member
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Rules are simple. Answer the previous question, then come up with your own...


I'll start off with an easy one.

Bob the medical resident just diagnosed the acute anemia patient on 5 North, Mrs. Fondaleaux, with pyelonephritis caused by E.coli. He wants a reco from his pharmacy peoples. She also has comorbidities of T1DM, HTN, hyperlipidemia, and morbid obesity. Krzysztof the pharmacy student on his service recommended Macrobid. Dr. Sprain the ID pharmacist proceeded to scold Krzysztof for choosing said medication and sleeping through his ID lectures. Why is Macrobid a poor choice for this patient pharmacologically?
 
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I am probably wrong but I will take a stab at it. Macrobid is not the DOC for pylo since pylo is considered a systemic infxn. Macrobid doesn't do well for systemic infxns, and mainly concentrates in the urine below the bladder. I don't know it thats what your looking for...but at least I tried.

as for my question..hmmmm....I will post one when I think of a good one...
 
DrgsRmyLife said:
I am probably wrong but I will take a stab at it. Macrobid is not the DOC for pylo since pylo is considered a systemic infxn. Macrobid doesn't do well for systemic infxns, and mainly concentrates in the urine below the bladder. I don't know it thats what your looking for...but at least I tried.

as for my question..hmmmm....I will post one when I think of a good one...
Click to expand...

Ok, just say "Poor tissue perfusion"...
 
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WVUPharm2007 said:
I was going for "both induce increased innervation of various serotonin receptors"...but I guess you're right, too.

Now ask some ****, foo....damn people not following the rules...
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You don't need me posting quesitons... y'all can't answer it.. :meanie:
 
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Epic said:
alrighty then..

What are some of the challenges of 5HT3 inhibitor usage at hospitals today?
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1. PRN orders (no data to support, certainly not over other agents for acute episodes of nausea).
2. Most of the data used PO dosing
3. Who needs palonosetron?

These may be outdated challenges, but what the hell, I'm the student here.
 
WVUPharm2007 said:
That's pretty damn open ended......
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You know... in my line of work.. most of my questions are open ended...my projects are open ended... and answers are rarely black and white..

It's real life.. not school...yo.
 
Priapism321 said:
1. PRN orders (no data to support, certainly not over other agents for acute episodes of nausea).
2. Most of the data used PO dosing
3. Who needs palonosetron?

These may be outdated challenges, but what the hell, I'm the student here.
Click to expand...

We're getting warm..
 
Priapism321 said:
Well, my answer to that question would be..........probably no one, at least not over ondansetron.
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how are you going to argue with delayed emesis... on outpatient. Are there studies to prove ondansetron is just as effective as Aloxi?
 
Epic said:
You know... in my line of work.. most of my questions are open ended...my projects are open ended... and answers are rarely black and white..

It's real life.. not school...yo.
Click to expand...

The entire point is to answer a question, then pose another one. If it's open ended like that, there is no definite answer and nobody will be prompted to ask a new question....jeeeeeeeeez.....
 
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WVUPharm2007 said:
The entire point is to answer a question, then pose another one. If it's open ended like that, there is no definite answer and nobody will be prompted to ask a new question....jeeeeeeeeez.....
Click to expand...

well consider it threadjacked.
 
Epic said:
how are you going to argue with delayed emesis... on outpatient. Are there studies to prove ondansetron is just as effective as Aloxi?
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Well, one argument is that the ASCO 2006 update no longer recommends 5HT3 antagonists for prevention of delayed emesis after highly emetogenic chemotherapy. However, the recommendation is a combo of aprepitant and dexamethasone. For moderate emetogenic risk, ASCO does not prefer one agent over any other. But once again, for an anthracycline plus carboplatin, they do recommend aprepitant.
 
Priapism321 said:
Well, one argument is that the ASCO 2006 update no longer recommends 5HT3 antagonists for prevention of delayed emesis after highly emetogenic chemotherapy. However, the recommendation is a combo of aprepitant and dexamethasone. For moderate emetogenic risk, ASCO does not prefer one agent over any other. But once again, for an anthracycline plus carboplatin, they do recommend aprepitant.
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That doesn't quite answer our concerns.. what would you do if a family member is about to go through chemo? I would load them up with 5HT3 inhibitors... + Emend.. bring on the Aloxi..
 
Epic said:
That doesn't quite answer our concerns.. what would you do if a family member is about to go through chemo? I would load them up with 5HT3 inhibitors... + Emend.. bring on the Aloxi..
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Well, I am going to have to go to bed on this one. I would just say that there are several studies showing that adding a 5HT3 to dexamethasone is no better at preventing delayed emesis that dex alone. The only substantial trial using palonosetron was not a "fair fight" so to speak, as they gave compared it to SINGLE DOSE ondansetron. And, palonosetron was not better at preventing cisplatin induced delayed emesis, and cisplatin, until recently, was the only known chemotherapeutic agent to cause the phenomenon. Therefore, no need in my book.
 
Priapism321 said:
Well, I am going to have to go to bed on this one. I would just say that there are several studies showing that adding a 5HT3 to dexamethasone is no better at preventing delayed emesis that dex alone. The only substantial trial using palonosetron was not a "fair fight" so to speak, as they gave compared it to SINGLE DOSE ondansetron. And, palonosetron was not better at preventing cisplatin induced delayed emesis, and cisplatin, until recently, was the only known chemotherapeutic agent to cause the phenomenon. Therefore, no need in my book.
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hmmm... not bad...
 
SpirivaSunrise said:
We'd never hear you say...bring on the Dapto AND Zyvox AND Vanco. And throw on some Synercid for the hell of it too.
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ahhhh....contrary to belief.. I once quit a job because corporate demanded I not dispense Dapto to a patient who needed it. I clinically justified why patient needed it then soon left that job.

My last question when making a formulary decision...is ask "is it appropriate for my family memeber?" and if it is, I push forward with a full conviction.

I will always recommend appropriate therapy...
 
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Epic said:
ahhhh....contrary to belief.. I once quit a job because corporate demanded I not dispense Dapto to a patient who needed it. I clinically justified why patient needed it then soon left that job.

My last question when making a formulary decision...is ask "is it appropriate for my family memeber?" and if it is, I push forward with a full conviction.

I will always recommend appropriate therapy...
Click to expand...

That's my point. You can get away with loading on the 5-HT3 antags a lot easier than you will with antibiotics. Which makes it the issue...Would they get on your case for pushing Dapto the same way they would for Aloxi?
 
SpirivaSunrise said:
That's my point. You can get away with loading on the 5-HT3 antags a lot easier than you will with antibiotics. Which makes it the issue...Would they get on your case for pushing Dapto the same way they would for Aloxi?
Click to expand...

well...now no one gets on my case about anything!!👍

But I'm concerned with Aloxi use yes..of course. Zofran and Kytril are generic.. and here came the Emend and Aloxi.
 
Epic said:
OK...what's the equivalent dosing between Advair and Symbicort?
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That's pretty freaking tricky. According to my notes from the GINA Expert Panel 3, the equivalent medium daily doses of budesonide and fluticasone are around 400-800mcg and 250-500mcg/day, giving us roughly a 40:25 (or 8:5) budesonide:fluticasone ratio.

As to formoterol and salmeterol, my notes say that 12mcg of formoterol is equivalent to 50mcg of salmeterol (a 12:50 ratio). Both of these are generally dosed BID (up to 24 mcg qd for formoterol and up to 100mcg qd of salmeterol).

The problem lies in the formulation of the inhalers. Symbicort comes in two strengths: 80/4.5 and 160/4.5. The Advair Diskus comes in three strengths (colors): 100/50, 250/50 and 500/50 (the HFA comes as 45/21, 115/21, and 230/21.) There just isn't a mathematical way to get ~400/12 dose of symbicort equal to a 250/50 dose of advair. The closest way to get equivalent doses would be 2 puffs BID of the 160/4.5 Symbicort to 1 puff BID Advair (I know that this is actually "considered" to be equivalent, but it isn't exactly).

Soooo... even though I may be off the mark for Epic's question, I'll pose one of my own (probably pretty easy): What, if any, drug therapy alternatives are there to hydralazine for preeclampsia or gestational hypertension?
 
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Moxxie said:
I'll pose one of my own (probably pretty easy): What, if any, drug therapy alternatives are there to hydralazine for preeclampsia or gestational hypertension?
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methyldopa
It's Cat B.

How would you manage chronic sinus infections in a kitty cat? My vet has to come up with an answer too :meanie:. I'm going today...
 
PharmDstudent said:
methyldopa
It's Cat B.

How would you manage chronic sinus infections in a kitty cat? My vet has to come up with an answer too :meanie:. I'm going today...
Click to expand...

I am no vetrinary expert, but I was looking at a website, and I don't know how reliable it is, but some "Cat sinus infections" may be in their teeth.There was owners talking about how a few extractions helped the problem. I don't know though, but it is a guess.


My question, what recommendation would you make for a young (20-24) year old female who wants to take "the pill" as her method of birth control and she has a seizure disorder tha is controlled on Tegretrol?
 
firefighter9015 said:
I am no vetrinary expert, but I was looking at a website, and I don't know how reliable it is, but some "Cat sinus infections" may be in their teeth.There was owners talking about how a few extractions helped the problem. I don't know though, but it is a guess.


My question, what recommendation would you make for a young (20-24) year old female who wants to take "the pill" as her method of birth control and she has a seizure disorder tha is controlled on Tegretrol?
Click to expand...
You have good insight! (I didn't say anything about extractions to vet.)

Kitty's diagnosis: feline herpes stomatitis
No extractions needed right now 😀. Kitty is only two years old, so they may need to be pulled later, but hopefully not. For now, we're just going to stick with the dry food diet(to reduce plaque build-up) and hope for the best. When the infection gets bad enough, she'll have to get a round of antibiotics.
It should be obvious, but there's no cure and the treatments will only help with the symptoms.
Here's a link about this disease:
http://www.dvmnews.com/dvm/article/articleDetail.jsp?id=162427&pageID=1&sk=&date=

I can't really answer your question, per se, but I wouldn't recommend "the pill" after reading this:
"Hormonal birth control (eg, birth control pills) may not work as well while you are using Tegretol . To prevent pregnancy, use an extra form of birth control (eg, condoms)"
-http://www.drugs.com/cdi/tegretol.html

So WVU, I didn't mess up the order here, because I didn't actually answer Firefighter's question, so I don't have to pose a question. Hopefully someone else will answer his question.
Thanks for addressing pharmacy-related stuff again. I don't feel guilty for spending time on SDN when I can really learn about drugs and diseases. Maybe I won't have to leave for an entire semester. Just don't vote me off the island, k? 😉
 
firefighter9015 said:
I am no vetrinary expert, but I was looking at a website, and I don't know how reliable it is, but some "Cat sinus infections" may be in their teeth.There was owners talking about how a few extractions helped the problem. I don't know though, but it is a guess.


My question, what recommendation would you make for a young (20-24) year old female who wants to take "the pill" as her method of birth control and she has a seizure disorder tha is controlled on Tegretrol?
Click to expand...

Could the Nuva-Ring work because it has a more local effect and may avoid some of the P450 action?

There are higher dose estrogen pills, and the progestin-only mini pills but I would worry about compliance.
 
njac said:
Could the Nuva-Ring work because it has a more local effect and may avoid some of the P450 action?

There are higher dose estrogen pills, and the progestin-only mini pills but I would worry about compliance.
Click to expand...


You hit the nail on the head with the higher dose estrogen. Nuva Ring and the progestin only mini-pills are also options, however many patients are still going to want COCs, so you can go with the higher dose estrogen component. There are also some COC's with desoergostel which is an estrogenic progesterone, so it can help combat the increased estrogen metabolism with Tegretrol. It is important to counsel your patient about the fact that any breakthrough bleeding might be a sign that the patient is not getting enough estrogen and they need to talk to their doctor. Also, it is important to counsel about prevention of DVTs.
 
I just think the side-effects from a higher estrogen dose would be hellacious. I know I've been only a couple different pills and I had to change off of Desogen/Alesse and onto Loestrin because I couldn't handle the estrogen component.

Then again, that formulation may not act like such a high estrogen dose due to the more extensive metabolism. Dunno.

Now when you said "COC"s, did you mean Cyclic Oral Contraceptives or? There are just so many different abbreviations out there. Again, I've found that I prefer the monophasic pills.
 
firefighter9015 said:
You hit the nail on the head with the higher dose estrogen. Nuva Ring and the progestin only mini-pills are also options
Click to expand...

I agree with the high dose estrogen (at least 50 mcg) but I dont agree with Nuva Ring because it contains low dose estrogen and it depends on systematic absorption in order to be effective so the interaction may be too much of a risk. Another option is to switch to an antiepileptic that do not seem to interact with OC such as Lyrica, Keppra, Dapakene.

firefighter9015 said:
It is important to counsel your patient about the fact that any breakthrough bleeding might be a sign that the patient is not getting enough estrogen
Click to expand...

This is half true. If a patient experiences early or mid cycle breakthrough bleeding then it indicates estrogen deficiency. However, if a patient experiences late breakthrough bleeding (after 14 days), then that's an indication of progestin deficiency.
 
BMBiology said:
I agree with the high dose estrogen (at least 50 mcg) but I dont agree with Nuva Ring because it contains low dose estrogen and it depends on systematic absorption in order to be effective so the interaction may be too much of a risk. Another option is to switch to an antiepileptic that do not seem to interact with OC such as Lyrica, Keppra, Dapakene.



This is half true. If a patient experiences early or mid cycle breakthrough bleeding then it indicates estrogen deficiency. However, if a patient experiences late breakthrough bleeding (after 14 days), then that's an indication of progestin deficiency.
Click to expand...

Thanks for the clarifications, I am still in the process of learning all of this stuff.
 
No problem.

The Claritin-D commercial states that the company is true to its formulation and it doesn't want to change its pseudoephrine formulation to PE. However, what is the true reason as to why it can't switch to PE?
 
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