Therapeutic Sessions
Renal Dosing
July 8, 2009
We had our second therapeutic session of the year today and the topic was renal dosing. I learned the “Process” of renal dosing (i.e. is there an alternative? how sick is the patient? is the response to the drug needed ASAP?).
A few other interesting tidbits I also took away:
1) “Gault” from the Cockcroft Gault equation was an Alberta physician who died three years ago.
2) Carvedilol is the only beta blocker proven to have cardiac benefits in renal patients.
3) Using the modified CG equation without the weight is probably the best way to adjust doses.
4) Waist circumference is a signficant risk factor for chronic kidney disease (along with diabetes, CVD).
Interpretating Microbiologic Lab Data
August 7, 2009
We had a session with Curtis Harder regarding microbiologic lab data. What I took away from the session was:
1) What Vitek and KB mean in Powerchart
2) For blood cultures, two sets (4 bottles) should be sent to the lab for testing. They should also be drawn 10 minutes apart.
3) To look at the “whole picture” when determining therapy for a patient or when monitoring a patient. Do not just focus on labs! Consider temperature, clincal improvement, etc.
Liver Function & Drugs
August 15, 2009
On Wednesday, I attended a therapeutic session on liver function and drugs. This is an area I have never felt comfortable with, mainly because I have not dealt with patients who have liver disease. The “process” for dosage adjustment is not as clear-cut as with renal impairment. I also find all the different types of liver function tests a bit confusing too. The main points I learned from the session include:
1) There are 3 types of drug-induced liver injury: Hepatocelluar, Cholestatic and Mixed
2)Albumin, pre-albumin and PT are tests of a liver’s synthetic capabilities.
3) Dieting depletes glutathione levels and increases a patient’s potential for acetminophen toxicity.
4) In alcoholics, you often see an AST to ALT ratio of 2 (or more) to 1 with an increase in GGT
Chronic Pain
August 15,2009
Friday, we learned about chronic pain. It was a good extension of our DPC rotation as we were dealt with two patients in the pain clinic. I realized over the past couple of weeks that I had no idea how to assess a patient for pain. Donna developed a good nnemonic ABCD (not E) and F. A-ask, B-behavior, C-characterize pain, D-depression and F-function. I will definitely use this and also the PQRST to help characterize pain. A few things I took away from the session:
1) Although pain scales are helpful, it better measure of pain control is function (ADLs, IADLs, social/recreational activities) because ultimately that is what is important to the patient.
2) Depression and pain often co-exist. It is important to assess for depression when doing a pain assessment.
3) I always forget how to convert doses of opioids off the top of my head. I learned an easy way to remember it:
Codeine 100 mg = Oxycodone 5 mg (to 7.5 mg) = Morphine 10 mg = Hydromorphone 2 mg (parenteral doses are usually half the PO dose and morphine 60-100 mg is roughly equivalent to a 12.5 mcg/hr fentanyl patch)
Aminoglycosides – Empiric Dosing
August 27, 2009
We had a therapeutic session on aminoglycosides yesterday. It was primarily focused on empiric dosing and treatment. It was a really good review of AGs. We worked together to develop an algorithm to help us assess orders for AGs. I felt that was a really effective way of having the session and I retained more from it then simply being presented a topic.
The session re-iterated how important it is to monitor for ototoxicity and nephrotoxicity. Serum levels don’t necessarily correlate with toxicity so it’s important to ask the patient daily if they have any new onset of nausea or vomiting, tinnitus, dizziness, hearing loss etc and also monitor SCr/Urea at least twice weekly.
I think one thing I will always try to do as a pharmacist is to get my patient OFF aminoglycosides if there is a safer effective alternative out there.
Depression
September 3, 2009
Yesterday, we had our therapeutic session on depression with Dr. Bree Zehm. The session was a nice review and I also learned a few new things.
1) Seroquel XR is indicated as monotherapy for depression.
2) Sertraline has relatively few drug interactions with the exception doses which exceed 150 mg/per day. It exhibits CYP 2D6 inhibition at higher doses.
3)Venlafaxine doses greater than 300 mg per day are more likely to cause an increase in blood pressure.
4) Acutely suicidal/psychotic patients and pregnant patients are people most likely to receive ECT.
I am looking forward to doing my psych rotation in April. Psychiatry is an area I really feel I need more exposure to as I am not usually comfortable making recommendations with psych meds!
Side note: Bree is going to try to arrange for me to watch a patient getting ECT when I am on rotation with her. I am looking forward to that!
Acute Renal Failure – Therapeutic Session
On Wednesday, we had our session of ARF. We went through a real patient case and discussed how ARF could have been prevented in this patient. A few interesting things I learned were:
– A increase in > 100 micromol/L of SCr is indicative of ARF
– Having “Normal” aminoglycoside (or other nephorotoxic drugs) levels does not necessarily mean ARF will be prevented.
– Rifampin has been known to cause acute interstitial nephritis.
– Hydration is key in ARF, followed by diuretics if fluid overload is occuring. This gets the kidneys per fusing.
– Earthquakes victims who are caught under rumble are at increased risk of hyperkalemia when they are “rescued”. People in Turkey (where earthquakes are common) keep kayxelate in their earthquake disaster kits.
Aminoglycosides
November 25, 2009
Today we had a therapeutic session with Curtis Harder. We critically appraised an article which basically developed the Hartford Nomogram for once daily aminoglycoside dosing. This nomogram was something I remember being discussed during school but when we actually went back to look at the literature it’s actually not validated! It was also only studied in 20 patients. The average age was 43 and doens’t apply to many patients in Victoria at least who might be on aminoglycosides. The good thing is that most pharmacists at VIHA don’t use the nomogram but rather their “clinical judgement” to adjust once daily aminoglycosides. I also didn’t know that the risk of nephrotoxicity increases after ~ 5-7 days as it takes time for ATN to occur. This correlates with a study rise in SCr.
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