Exam 1 Flashcards
Accessibility
OTCs are available 24/7
-Almost 70% parents report giving child OTC late at night to treat a sudden symptom
If no OTCs then the underserved population would depend more heavily on the Emergency room for simple issues
-1 of 4 Medicaid patients + 1 of 10 uninsured patients
-81% of adults use OTC medicines as a first response to minor ailments
-If OTCs weren’t available 82% of consumers would’ve gone to primary dr instead
Affordability
OTCs are highly affordable and would save the government 5.2 billion annually if OTCs were prescribed instead of going to the dr
-For every $1 spent on OTCs the US healthcare system saves $7.33
Trust
Physicians and consumers agree that OTCs are the preferred first line of treatment
-2/3 of consumers take an OTC vs a prescription Rx
-3/4 of all primary care physicians will recommend OTC before Rx
Empowerment
OTCs make it easy to self care for minor health conditions
Adults prefer to self treat and treat their children with OTCs
Whiting vs Rite Aid Pharmacy 2014
Patient came in for advice on an OTC and the pharmacist argued that her duty of care did not require giving adequate OTC advice as a result patient had complications
Patient won and reaffirmed that pharmacists must know OTCs
Self care consultations
- Evaluate the situation
Gather info
Obtain physical data
Evaluate gathered data to determine cause and severity
Identify if patient at risk for complications - Recommend course of action
Select self care treatment in collaboration with patient/caregiver
-Educate patient
-Determine appropriate follow up
Multiple conditions that can interfere with OTC use
HTN, DM, asthma, hypothyroidism, glaucoma, chronic kidney disease, chronic liver disease, HF, BPH
When to refer patient
-Symptoms too severe to be endured without definitive diagnosis and treatment
-Persistent minor symptoms that are not the result of an easily identifiable cause
-Symptoms that repeatedly return with no cause
-When pharmacist is in doubt
Mental Health Equity
Consider how the pharmacist’s roles regarding mental health equity can be associated with self-care consultations
Pharmacists patient care process
Collect
Assess
Plan
Implement
Follow-up: Monitor and Evaluate
QUest
Quickly and Accurately assess the patient
Establish that the patient is an appropriate self care candidate
Suggest appropriate self-care strategies
Talk with the patient
Scholar
Symptoms
-What are the main and associated symptoms
Characteristics
-What is the situation like? Is it stable or changing?
History
-What have you done so far to try to relieve the symptoms?
Onset
-When did the condition start?
Location
-What is the precise location of the problem or symptoms?
Aggravating factors
-What makes it worse?
Remitting factors
-What makes it better?
MAC
Medications
Allergies
Conditions
Drug facts label
Contains active ingredient at the top
Has a uses section: what it is used for
Warnings:
Potential diseases it can interact with as well as side effects
Directions on how to use
Other information: Storage instructions
Inactive ingredients
Poor Mental Health Outcomes
Lack of access
Mental Illness stigma
Distrust of healthcare system
Language barriers
Lack of diverse mental health providers
Uninsured/underinsured
Discriminations
Trouble finding culturally competent providers
Low awareness about mental health
How can pharmacists address mental health crisis
A lot of actions to address mental health can be done in a community pharmacy
*Awareness is the first step towards action
*Pharmacists can give greater access to underserved populations that need care
Which method should I use?
No one method is perfect, some are incomplete
The goals of patient assessment include:
-Patient-centered process
-Collect enough information to determine if patient appropriate for self-care
-If condition appropriate for self-care, gather enough information to make recommendations that resolve the condition (drug, non-drug, or referral)
self-care
The independent act of preventing, diagnosing, and treating one’s illnesses with or without seeking professional advice
Premature
born prior to 37 weeks gestation
Neonate
birth to 1 month
Infant
1 to 24 months
Child
2 to 12 years
Adolescents
12 to 16 years
Pharmicokinetics
What the body does to drug
Pharmicodynamics
What drug does to body
Differences in adults vs children
Growth and development
Neonates, infants, children: extra concern with med use
-Pharmacist interaction with parent/caregiver is especially important during the COLLECT process
PCCP considerations for peds
Collect
-patient age
-weight
-Caregiver factors
-Childcare or school schedules
Assess
-exclusions for self care
(no ibuprofen under 6 months)
-Adverse effects
Plan and implement
-Nonpharmacologic therapy
-Appropriate dosing and administration
Pediatric medication administration + pill swallowing
Metric Units: Use mL only
Nearest tenth or whole number
Avoid trailing zeros
Dosing:
Use oral syringes with mL
Dosing cup
Counseling strategies
Pediatric dosing devices
dosing cup
oral syringe with colored cap
oral syringe for infants
dosing spoons
med dropper
Open flow restrictors
Plastic disc with small hole in center
Closed flow restrictors
Plastic disc with elastic valve in the hole
*Works much better
Pill Swallowing
Up to 30% adolescents have difficulty swallowing pills
Mostly a mental barrier
How to overcome pill swallowing issues
Be Very Careful Flavoring Her Soup
Behavioral Therapy
Verbal technique instruction
Candy practice
Flavored throat spray
Head posture training
Specialized cup device
*Best time to learn
When child isn’t sick
Age 7 - 10 yr old
Warning for drug administration in kids
Medication not candy
How to manage bad taste
How to involve the child
Don’t use chewable tablets before they have teeth and when they are losing teeth
Ibuprofen dosing younger than 12 years
*Ibuprofen smaller word than Acetaminophen so smaller dose
5-10 mg/kg
Every 6-8 hours
300 mg per dose up to 4 doses or 40/mg/kg/day
do not exceed 1200 mg in 24 hours
Acetaminophen dosing: Younger than 12 years
*Acetaminophen is a larger word than ibuprofen so larger doses
10-15 mg/kg
Every 4-6 hrs
480 mg per dose up to 5 doses or 75 mg/kg per day
do not exceed 2400 mg in 24 hours
Acetaminophen dosage forms
Suppository 80 120 325 mg
Oral suspension 160 mg/5mL for child and infant
Chewable tablets
80, 160 mg
Dissolvable packs (6-11 yr old) 160 mg
Ibuprofen dosage forms
Oral suspension
infant: 50 mg/1.25 mL
child: 100 mg/5mL
Chewable tablets
50, 100 mg
Jr Strength tablets (swallow)
100 mg
Etiology
Eruption of teeth through gingiva
Etiology pathology
Mild pain
Gingival irritation, redness
Drooling
Mouth biting + gum rubbing –> Counter pressure
Age: Early as 3 months
Duration: 8 days per tooth
Treatment for teething: Non-drug
Gum massage
Cold teething ring
(Liquid no dishwasher or fridge)
Washcloth: damp, twisted, frozen
AVOID teething necklaces, bracelets, anklets –> Choking
If they can chew
-dry toast
-teething biscuits
-AVOID high sugar/carb foods
Treatment for teething: drug
No Topical agents
-anything ending in caine
Systemic agents
-Acetaminophen (preferred)
-Ibuprofen
1938 Food Drug and Cosmetic Act
Elixir of Sulfanilamide Tragedy - Put antifreeze out onto the market
Made it so you have to prove something is safe before selling it
1951 Durham Humphrey Amendment
Separation of drugs into two classes
Legend (Rx)
Non-Legend (OTC) –> Consumer can take drug by following instructions
How OTC drugs are created
Manufacturer may request the switch by submitting a an application
Manufacturer may petition the FDA
Drug may be switched through the OTC drug review
Wide safety margin –> To a point
OTC benefits
By switching a Rx to OTC there is increase in purchase and multi-billion dollar social benefit
Ex: Nicotine replacement therapy
Consumers save money by avoiding prescription costs and office visits
people become knowledgeable in self treatment
Disadvantages of OTC
Subject to regulations
Label and labeling requirements
All text approved by FDA
Label
Includes label on the container as well as the box containing the container
Labeling
All other material including a package insert
OTC label requirements
- Name of product, general drug category, principal action
- Name and address of manufacturer, packager or distributor
- Net contents of package
- Cautions and warnings
- NDC number
- Adequate directions for use
Adequate directions for use
-Dosage for use and persons
-Freq of dosing
-Duration of dosing
-Timing of dosing
-Route
-Preparation (shake well)
“Drug facts” label
Active ingredients (including amt)
Purpose of the med
Uses/indications
Specific warnings
Inactive ingredients
Questions?
Phone number
Tamper evident packaging
Having one or more indicators or barriers to entry which, if breached or missing, can assume that tampering has occurred
Packaging of OTC drugs
All OTC must be packaged in a tamper evident package
*Except dermatological, dentifrice, insulin, lozenge
Tamper evident packaging requirements
- Identify all tamper evident features and any capsule sealing tech used
2.Be prominently placed on the package - Be so placed that it will be unaffected if the tamper evident feature of the package is breached or missing
Dietary supplements
Vitamins, minerals, herbs, amino acids, metabolites, extracts
DSHEA 1994
Not regulated as drugs
No clinical trials needed
No criteria for safety data
7 considerations for OTC use in pregnant people
- OTC therapy is often more appropriate at any stage of pregnancy especially during 1st trimester
- Importance of determining stage of pregnancy
- Recommend lowest possible dose
- Medication taking issues due to nausea and vomiting
Also true for lactation
5. Topical or local dosage forms preferable to systemic
6.Advise against extra/max strength or long acting products
7. Avoid combo products
6 considerations for OTC use during lactation
- Recommend timing of med with feeding/nursing
-Immediately after breastfeeding
-Before infant sleeps for a long time - Recommend drug that has been shown to be safe in infants
- Recommend product with shortest half-life
Also true for pregnancy
4. Topical or local dosage forms are preferable to systemic
5. Advice against extra/max strength or long acting products
6. Avoid combo products
-To minimize amount infant exposed to
Serious drug reactions in older adults
- Altered PK
- Altered PD
- Impaired kidney function
- Decreased liver blood flow
- Decreased liver size
- Increased body fat
- Decreased lean body mass
- Changes in receptor sensitivity
- Concomitant medical conditions
OTC medication issues in older adults
Selective medication taking habits because they think they are controlling their chronic health conditions
Limited Health literacy
60% of adults > 65
Unintentional misuse
-Exceed max dose
-Incorrect dose timing
-Used more than one product with same active ingredients
Slower processing info
-Being more careful about their decisions
Family care
-Alzheimer’s disease patients and family care givers
1/3 of patients and caregivers take at least one inappropriate Rx or OTC
Potentially inappropriate OTC meds
Anticholinergics (1st gen antihistamines)
confusion
difficulty urinating
Avoid: cog. impaired or prostate issues
Aspirin (primary cardiovascular prophylaxis)
H2-receptor antagonists
cognitive function
Mineral oil (oral)
aspirate and cause respiratory irritation
Non Cox selective NSAIDS
ulcers in stomach
Proton pump inhibitors
increased falls
cDIF
pneumonia
Why were Phenylephrine and Pseudoephedrine removed?
Risks are not unique to older adults
Disease/syndromes should avoid which OTCS
Heart failure–> NSAIDS
Dementia/cog impair: 1st gen antihistamines, H2 receptor antagonists
Falls, fractures –> Proton pump inhibitors
Gastric, ulcers –> ASA > 325 mg/day, NSAIDS
Kidney disfunction–> NSAIDS
Lower urinary tract symptoms, BPH –> 1st gen antihistamines, Oral decongestants
Osteoarthritis and pain
81% of older adults with Peptic Ulcer Disease
and GI bleed is cause of NSAID use
-95% of these people are using OTCs
NSAID can cause what?
Impair kidney function, raise BP, retain fluid
Pharmacist role in monitoring safe use of OTC
Self medication practices need to be monitored by a healthcare professional to prevent adverse drug reactions and dangerous medication interactions
*The use of OTCs may mask underlying symptoms of a more serious disease process
Practices that contribute to med mismanagement
-Failure to follow recommendations for consumption with food or avoidance of certain foods
-Keeping poor records
-Mixing OTC with Rx for same problem
-Taking an additional dose if symptoms are not relieved
-Taking the wrong dose
-Using the wrong techniques with inhalers, suppositories or nasal sprays
How a pharmacist can assist an older adult with safe OTC use
Use a patient assessment process to obtain background information
Implement a self care medication reconciliation process when dispensing or during consult
QUEST SCHOLAR MAC
What percentages of older adults were unable to identify max OTC doses and when they shouldn’t use OTCs
1/3 of older adults cannot identify the max dose in medication information leaflets and are unaware of contraindications
4 types of drug misuse
drug-drug interaction: determined by comparing each OTC to the patient’s med list
drug-disease interaction: determined using Beers criteria for OTCs that exacerbated a disease or syndrome
drug-age interaction: misuse of OTC selected appeared on Beers criteria for inappropriate med use in older adults
drug-label misuse: deviation from label instructions
What percentage of older adults at risk for OTC misuse?
95%
Pharmacokinetic primary facets and how they change in older adults
Absorption -> increased GI secretions and motility; decreased surface area and blood flow; increased pH
Distribution -> decreased total body water and muscle mass; increased body fat
Metabolism -> decreased hepatic blood flow and enzyme activity
Elimination -> decreased renal function
Polypharmacy
Concurrent use of 5 or more medications and high risk of ADEs
-More than 1 in 3 older adults take 5 or more prescriptions medications concurrently
-1 in 6 adults are at risk for major drug-drug interactions
Multiple chronic disorders
Almost 3 in 4 people > 65 have multiple chronic disorders
Alteration in sense
1/6 older adults have impaired vision
1/4 older adults have impaired hearing
Cognition and memory changes
Although aging and memory loss are not synonymous, 1 in 10 people > 65 years old have Alzheimer disease
Dysphagia
-Difficulty swallowing
-Affects 15% of the older adult population
What percentage of adults consider OTCs safe
OTC considered safe by up to 75.5 % of older adults and are often purchased without oversight by a medical professional or pharmacist
How are OTC consultations associated with pharmacist job satisfaction?
Large part of their responsibility in the pharmacy
Postitive association between job satisfaction and OTC medication counseling
Pharmacists who have enough time to provide OTC med counseling have higher job satisfaction
How often do older adults actually read doses on OTC labels? How often do they read the side effects and warnings
22% read the dosage labels
and
19% read the side effects and warnings
This may contribute to the high proportion of misuse
Explain 3 methods of enhanced pharmacist OTC counseling hint
-Pharmacist consult to assess the self care complaint
-Make appropriate recommendations on patient selection of OTCS
-Patient Satisfaction
Dr. Chui’s senior section
An intervention consisting of a curated section of meds generally considered safe for older adults to use for pain, sleep, cough/cold and allergy
Pharmacist perceptions of OTC consults after Senior Safe was implemented
Perceived the consultations to be of better quality and more efficient following the implementation of the senior section and well integrated into their workflow
Implementation of senior section on staff engagement with patients before and after
52% to 63% increase for pharmacist-patient interactions
68.4% to 77.8% increase for pharmacy tech patient interactions
The frequency of long encounters decreased from 15.8 to 3.7%
Senior section effect on OTC misue
OTC misuse decreased for 7 of 11 categories
Takeaway message for Chui article
No single intervention can effectively prevent OTC misuse in all older adults
Conclusion of Chui article
Given older adult perceptions of having high self efficacy when selecting and taking medications, the described interventions meet a critical need for pharmacies to maintain older adult autonomy while connecting them with pharmacy staff for necessary med education
Social Identity
Usually defined by physical, social, mental aspects of individuals
Examples:
-Race/ethnicity
-Gender
-Socioeconomic status/class
-Sexual orientation
-Ability/disability
-Religion/religious beliefs
Cultural Humility
-A lifelong commitment to self-evaluation and self-critique to address power imbalances and advocate for others
5R’s of Cultural Humility
Reflection
Respect
Regard
Relevance
Resiliency
Implicit Bias (also unconscious bias)
-Attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner
-Biases can be both favorable and unfavorable assessments
-They are activated involuntarily and without an individual’s awareness or intentional control
-Associations develop over the course of a lifetime beginning at a very early age through exposure to direct and indirect messages
Learn technique
Listen with empathy
Explain
Acknowledge if they’re similar
Recommend treatment
Negotiate
4 C’s
What do you CALL the problem?
What do you think CAUSED the problem?
How do you COPE with the problem?
What CONCERNS do you have about the problem or treatment?
Why does cultural humility aid provider patient interactions?
-Practicing cultural humility helps mitigate implicit bias, promotes empathy, and respect for patients’ individuality
-Emphasizes the responsibility of providers to connect with patients rather than being the expert on the patients’ culture and dimensions of social identities.
Administration guidelines for infants
-Use a calibrated dropper or oral syringe
-Squirt med into side of cheek
-Don’t put med into baby formula because of taste
-Support infants head while holding in lap
-Give small amounts of med at a time
-Crush non enteric coated or non sustained release tablets into powder and put into food (if introduced to solids)
-Provide physical comfort to help calm
Administration guidelines for toddlers
-Allow toddler to choose position to take med
-Disguise taste with small volume of flavored drink
-If medicine not palatable ask pharmacy for flavoring service
-Med not candy
-Simple commands for cooperation
-Allow toddler to choose which med to take first
-Provide verbal and tactile responses to promote cooperative taking of meds
-Allow toddler to become familiar with device
Administration guidelines for preschool children
-Place tablet or capsule near back of tongue and provide water for rinse
-Do not use chewable tablets if teeth loose
-Follow up with flavored drink to avoid bad taste
-Allow child to make decision about dosage formulation, place of administration, which med to take first, and type of flavored drink to use
Common resources for pregnancy and lactation
CDC Med and Pregnancy: An overview –> Brief background, statistics, common questions, resources
U.S HHS Office of Women’s Health –> General information about pregnancy and medicines with Q&A, resources
MotherToBaby –> Pregnancy and lactation info & fact sheet in English and Spanish
LactRx website + app –> Free app for database of meds, vaccines, misused drugs during lactation
Which of the following can decrease flow (but not production) of breast/chest milk?
Diphenhydramine
