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Dispensing > Interactions and Incompatibilites > Flashcards

Interactions and Incompatibilites Flashcards

1
Q
  • occurs inside the body

- cannot be seen

A

Interaction

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2
Q
  • problem which could arise when two or more substances interact during, before, or after drug administration
  • occurs outside the body
  • usually visible
A

Incompatibility

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3
Q

Forms of Incompatibilities

A
  1. Pharmaceutical Incompatibilities
    a. Physical Incompatibilities
    b. Chemical Incompatibilities
    c. Pharmaceutic
  2. Therapeutic Incompatibilities
    a. Drug Interactions
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4
Q

interaction between two or more ingredients that leads to a visibly
recognizable change
- same drug is present
- state is altered

A

Physical Incompatibilities

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5
Q
  • insolubility
  • immiscibility
    Example:
    • gum and alcohol
    • pectin and alcohol
    • resin and water
    • oil and water
A

Incomplete Solution

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6
Q
  • salting-out process
  • solute which is originally dissolved in the solvent is thrown out of solution
  • factors affecting solubility: solvent, pH, temperature
    Example:
    • aromatic water and salt
    • spirits and salt solution
    • camphor solution and water
A

Precipitation

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7
Q

Management of precipitation

A
  • know the drug’s solubility
  • use the salt or ester form
  • know or calculate for the drug’s pH
  • add solubilizers or co-solvents
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8
Q

Four types of Liquefaction of a Solid Ingredient

A
  • deliquescence
  • efflorescence
  • eutexia
  • hygroscopicity
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9
Q

A liquefaction of solid ingredient that absorbs moisture and dissolves.

A

deliquescence

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10
Q

A liquefaction of solid ingredient that release of water of crystallization.

A

efflorescence

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11
Q

A liquefaction of solid ingredient that lowering of melting point. Occurs at room temperature.

A

eutexia

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12
Q

A liquefaction of solid ingredient that absorbs moisture but does not dissolve.

A

hygroscopicity

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13
Q

Solid ingredients that can undergo deliquescence.

A

NaCl

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14
Q

Solid ingredients that can undergo efflorescence.

A
  • citric acid
  • atropine sulfate
  • ferric sulfate
  • alum
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15
Q

Solid ingredients that can undergo eutexia.

A
  • menthol
  • phenol
  • thymol
  • camphor
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16
Q

Solid ingredients that can undergo hygroscopicity.

A

• silica gel

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17
Q

Management of liquifaction.

A
  • solvates and hydrates must be stored and dispensed in tight containers
  • substitute anhydrous form
  • add adsorbent
  • place product in a low humidity environment
  • separate and protect potential eutectic mixtures
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18
Q

collective term for absorption and adsorption of drugs onto containers, IV tubing, devices,
closures

A

Sorption

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19
Q

Management for sorption

A
  • shorten contact time
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20
Q
  • liberation of the active ingredient

- compounds with high vapor pressure

A

Vaporization (or Volatilization)

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21
Q

Another term for vaporization

A

Volatilization

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22
Q

An example of a compound with high vapor pressure based on maam ka’s reviewer lols

A

nitroglycerin (Monday disease)

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23
Q

Management for Vaporization

A
  • store in tight containers

- reduce the vapor pressure

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24
Q

existence of one or more crystalline and/or amorphous forms

A

Polymorphism

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25
Q

Examples of compounds are amorphous based on maam ka’s reviewer lols

A
  • aspirin
  • Theobroma cacao
  • chloramphenicol
  • sulfanilamide
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26
Q

Cubic

A

NaCl

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27
Q

Monoclinic

A

sucrose, ritonavir (form I)

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28
Q

Tetragonal

A

urea

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29
Q

Hexagonal

A

iodoform

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30
Q

Triclinic

A

boric acid

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31
Q

Rhombic

A

iodine

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32
Q

Orthorhombic

A

ritonavir (form II)

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33
Q
  • reverse of liquefaction

- dehydration due to extreme conditions in the environment

A

Loss of Water

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34
Q

loss of water for emulsions

A

phase inversion in o/w emulsions; cracking

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35
Q

loss of water for suspensions and solutions

A

increased potency

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36
Q

loss of water for ointments

A

crumbling

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37
Q

loss of water for gels

A

syneresis

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38
Q

Management for Loss of water

A
  • store in tight containers
  • store in correct conditions
  • add humectant
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39
Q

reaction between two or more ingredients that leads to a change in its
chemical properties
- a visible change is not necessarily observed
- original drug is no longer present
- may or may not retain form or state

A

Chemical Incompatibilities

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40
Q
  • loss of electrons
  • reducing agents
  • dehydrogenation
  • increase in oxidation state
  • triggered by oxygen, light, metals
  • manifests as change in color
A

Oxidation

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41
Q

Example of drugs that may undergo oxidation based on maam ka’s reviewer

A
  • ascorbic acid

* epinephrine

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42
Q

Management of oxidation

A
  • protect from oxygen and light
  • add antioxidants
  • keep oxidizing agents and reducing agents away from each other
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43
Q
  • gain of electrons
  • oxidizing agents
  • hydrogenation
  • decrease in oxidation state
A

Reduction

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44
Q

Test for reducing sugars

A

Tollen’s test

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45
Q
  • neutralization
  • evolution of gas
  • changes in color
A

Acid-Base Reaction

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46
Q

An evolution of gas applied in drug dosage forms

A

effervescence

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47
Q

effervescent tablets composes of

A

NaHCO3 + tartaric acid/citric acid

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48
Q

Example of drugs with effervescence based on reviewer that starts with p

A

p-aminosalicylic acid

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49
Q
  • involving water as solvent
  • breaking-up of bonds with water
  • most common type of incompatibility
  • most common mechanism of drug degradation
A

Hydrolysis

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50
Q

Examples of drugs that involves degradation through hydrolysis based on reviewer

A
  • lactams (penicillins, cephalosporins)
  • esters (cocaine, physostigmine, aspirin, tetracaine, procaine, methyldopa)
  • amides (dibucaine)
  • imines (diazepam)
  • glycosides
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51
Q

Management of hydrolysis

A
  • store in tight containers
  • add desiccants
  • control pH
  • refrigeration
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52
Q
  • interaction of drug with solvent other than water
A

Solvolysis

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53
Q
  • action or process of changing from an optically active compound into a racemic compound
    or an optically inactive mixture
  • racemic mixture: equal amounts of dextro- (+) and levo- (-) isomers
A

Racemization

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54
Q

Examples of drugs involved in racemization based on reviewer

A
  • thalidomide
  • catecholamines
  • local anesthetics
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55
Q
  • formation of epimers

- interconversion of one epimer to another epimer

A

Epimerization

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56
Q

compounds with two or more chiral centers

A

Epimer

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57
Q

Examples of drugs that undergo interconversion of one epimer to another epimer

A
  • tetracycline

* pilocarpine

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58
Q
  • salting-out process

- two or more drugs interacting to form a new substance

A

Precipitation

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59
Q

Ca(OH)2 + CO2 → CaCO3↓ + H2O

A

Precipitation nani lols

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60
Q

-reducing agent (RA) + oxidizing agent (OA)

A

Explosive Mixture

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61
Q

Name two examples of an explosive mixture based on reviewer!!!!!!!!

A

• sugar + KMnO4 • glycerin + KMnO4

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62
Q

-cake formation

A

Cementation

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63
Q

An example of cementation

A

acacia + Bi salts

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64
Q

An example of gelatinization

A

acacia + Fe salts

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65
Q

-gel formation

A

Gelatinization

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66
Q
  • formation of 5-hydroxymethylfurfural from dextrose
A

Polymerization

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67
Q
  • degradation by light
  • photooxidation
  • photolysis
  • remedy: protect from light; given at night; cover IV line with carbon paper
  • manifests as change in color
A

Photochemical Degradation

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68
Q

Examples of drugs that can undergo photochemical degradation

A
  • nifedipine
  • nitroprusside
  • riboflavin
  • phenothiazines
  • Adriamycin
  • cisplatin
  • amphotericin B
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69
Q

management of photchemical degradation

A

protect from light

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70
Q
  • caused by a chemical or physical incompatibility when two or more drugs are mixed together
  • occurs when drugs are mixed inappropriately in syringes or infusion fluids prior to administration
A

Pharmaceutic (in general najud ni sis. physicochemical instability najud)

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71
Q

phenytoin sodium will precipitate in an acidic pH. true or false?

A

true

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72
Q

aminophylline (basic pH) should be mixed with epinephrine which decomposes at
alkaline pH

A

false. it should not be mixed with epinephrine sis. daot jud na kay alkaline si aminophylline.

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73
Q

two or more drugs are administered, and response is different from
what is expected
- undesirable pharmacological interaction between two or more ingredients that leads to:
• potentiation of the therapeutic effects of the ingredients
• destruction of the effectiveness of one or more of the ingredients
• occurrence of a toxic manifestation within the patient

A

THERAPEUTIC INCOMPATIBILITIES

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74
Q

increase or decrease in pharmacological response due to the presence of another
drug, herbal medicine, food or drink, treatment, or environmental chemical agent

A

DRUG INTERACTIONS

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75
Q

drug, chemical, or food causing the interaction

A

Precipitant drug

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76
Q

drug affected by the interaction

A

Object drug

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77
Q

supported by well-proven clinical studies

A

Established

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78
Q

very likely but might not be proven clinically

A

Probable

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79
Q

might occur and some data might be available

A

Suspected

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80
Q

could occur and limited data are available

A

Possible

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81
Q
  • doubtful

- no good evidence of an altered clinical effects is available

A

Unlikely

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82
Q

Drug interactions include:

A
  1. Drug-herbal
  2. Drug-food
  3. Drug-laboratory test
  4. Drug-drug
    • pharmacokinetic
    • pharmacodynamic
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83
Q

(Drug+Herbal) What interaction will happen with digoxin and st. john’s wort

A

decreased conc. of digoxin

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84
Q

(Drug+Herbal) What interaction will happen with warfarin, LMWH, heparin and garlic

A

bleeding or hemorrhage!!!!!!!!!!!

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85
Q

(Drug+Herbal) What interaction will happen with warfarin and asian ginseng?

A

decreased conc. of warfarin

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86
Q

(Drug+Herbal) What interaction will happen with barbiturates, BZDs and valerian

A

“double sedation”

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87
Q

(Drug+Herbal) What interaction will happen with hypoglycemic agents and ginseng

A

increased hypoglycemic effect

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88
Q

(Drug+Herbal) What interaction will happen with anti-HTN and licorice

A

antagonism

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89
Q

(Drug+Herbal) What interaction will happen with MAOIs, PPA, epinephrine,
caffeine and ma huang

A

increased blood pressure; irregular heart rate

90
Q

(Drug+food) CNS depressants and caffeine

A

antagonism

91
Q

warfarin and green leafy veggies

A

antagonism

92
Q

tetracycline,

quinolone + dairy products

A

chelation/complexation causing decreased

tetracycline absorption

93
Q

MAOIs + tyramine-rich food (beer,
cheese, wine, chicken
liver)

A

decreased metabolism of norepinephrine causing

hypertensive crisis

94
Q

INH + histamine-rich food
(cheese, tropical fish,
tuna)

A

flushing reaction with headache, difficulty of

breathing, nausea, tachycardia

95
Q

bisacodyl + milk

A

alteration of pH causing premature liberation of

bisacodyl

96
Q

ASA + caffeine

A

alteration of pH causing increased ASA

absorption

97
Q

metronidazole + alcohol (wine, beer)

A

disulfiram-like effect

98
Q

spironolactone + banana

A

hyperkalemia

99
Q

digoxin + oatmeal

A

decreased A of digoxin

100
Q

bisphosphonates + any food

A

decreased BA

101
Q

drugs increased by food

A 
acarbose
griseofulvin
itraconazole
metoprolol
theophylline
phenytoin
metolazone
102
Q

drugs decreased by food

A 
alendronate
captopril
erythromycin stearate
isoniazid
penicillamine
penicillins
tetracycline
quinolones
103
Q

drugs that absorption can be increased by high fat-containing food

A

griseofulvin, theophylline, phenytoin, and metolazone

104
Q

___ and ___are affected only to a lesser extent

A

doxycycline and minocycline

105
Q 
(Drug + Lab) penicillin,
chloramphenicol,
vitamin C,
INH, 
streptomycin and glucose in urine (Benedict's test)
A

false positive result

106
Q

(Drug + Lab) chlordiazepoxide and thyroid function test (I131)

A

false negative result

107
Q

(Drug + Lab) rifampicin
vitamin B2
chloroquine
metronidazole and urinalysis

A 
change in color:
red-orange
intense yellow
brown
ash gray
108
Q

(Drug + Lab) allopurinol and blood cholesterol levels

A

false positive result

109
Q
  • processes of ADME of drugs

- “what the body does to the drugs”

A

Pharmacokinetics

110
Q

Alterations in Absorption (A)

A
  • Alteration of pH
  • Complex Formation
  • Decreased Gastric Emptying Time
  • Increased Gastric Emptying Time
  • Increased GI Motility
  • Adsorption of Drug
  • Interruption of Enterohepatic Circulation
  • Inhibition of GI Microbial Flora
111
Q

(Alteration of pH) antacid + bisacodyl

A

premature liberation of bisacodyl

112
Q

(Alteration of pH)antacid + ketoconazole

A

decreased ketoconazole A

113
Q

(Alteration of pH) antacid + salicylates

A

decreased salicylate A

114
Q

(Complex Formation) tetracycline + metal-containing drugs

A

decreased tetracycline A

115
Q

(Complex Formation) fluoroquinolones + metal-containing drugs

A

decreased fluoroquinolone A

116
Q

(Complex Formation) cholestyramine + digoxin

A

decreased digoxin A

117
Q

(Complex Formation) cholestyramine + warfarin

A

decreased warfarin A

118
Q

(Complex Formation) penicillamine + metal-containing drugs

A

decreased penicillamine A

119
Q

(Complex Formation) sucralfate + levothyroxine

A

decreased thyroxine A

120
Q

(Decreased Gastric Emptying Time) atropine + antacid

A

increased antacid A

121
Q

(Decreased Gastric Emptying Time) atropine +amphetamine

A

decreased amphetamine A

122
Q

(Increased Gastric Emptying Time)

nicotine + antacid

A

decreased antacid A

123
Q

(Increased GI Motility) laxative or cathartic + any drug

A

decreased drug A

124
Q

(Adsorption of Drug) adsorbent + any drug

A

decreased drug A

125
Q

(Interruption of Enterohepatic Circulation) antibiotics + OCP

A

decreased OCP A

126
Q

(Inhibition of GI Microbial Flora) antibiotics + digoxin

A

increased digoxin A

127
Q

erythromycin decreases bacterial inactivation of digoxin. true or false.

A

true

128
Q

Alterations in Distribution (D)

A

-Displacement from Protein Binding Sites

129
Q

warfarin + phenylbutazone

A

hemorrhage

130
Q

glibenclamide + phenylbutazone

A

hypoglycemia

131
Q

OHA + ASA

A

hypoglycemia

132
Q

bilirubin + salicylates

A

kernicterus

133
Q

phenytoin + warfarin

A

gingival hyperplasia

134
Q

tolbutamide + sulfonamide

A

hypoglycemia

135
Q

epinephrine + lidocaine

A

restricted blood flow

136
Q

Alterations in Metabolism (M)

A

Enzyme INDUCERS and Enzyme INHIBITORS

137
Q

Enzyme INDUCERS

A 
(GSMPRC)
Griseofulvin
St. John’s Wort
Meprobamate
Phenytoin
Phenobarbital
Rifampicin
Carbamazepine
Chronic 
Alcoholism
Cigarette 
Smoking
or 
(BS CRAP GPS)
Barbiturates
St. John’s Wort
Carbamazepine
Rifampicin
Alcoholism (chronic)
Phenytoin
Griseofulvin
Phenobarbital
Sulfonylureas
138
Q

Enzyme INHIBITORS

A 
(MEDVICKSGAO)
Metronidazole
Erythromycin
Disulfiram, Diltiazem
Valproic acid, 
Verapamil
Isoniazid, Indinavir
Cimetidine
Chloramphenicol
Ciprofloxacin
Clarithromycin
Ketoconazole
Saquinavir
Grapefruit juice
Acute Alcoholism
Omeprazole

or

(SICKFACES.COM)
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Acute Alcoholism
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Grapefruit juice
139
Q

potent enzyme inhibitor

A

Grapefruit

140
Q
  • regular beer =
A

12 fl. oz.

141
Q
  • malt liquor =
A

8-9 fl. oz.

142
Q
  • table wine =
A

5 fl. oz.

143
Q

Alterations in Excretion (E)

A
  • Alteration of Urinary pH

- Alteration of Active Transport

144
Q

(Alteration of Urinary pH) salicylates + NaHCO3 →

A

increased renal E of salicylates

145
Q

(Alteration of Urinary pH) amphetamine + NH4Cl →

A

increased renal E of amphetamine

146
Q

(Alteration of Active Transport) probenecid + penicillin

A

decreased renal E of penicillin

147
Q

(Alteration of Active Transport) probenecid + indomethacin

A

decreased renal E of indomethacin

148
Q

(Alteration of Active Transport) NSAIDs + lithium salts

A

decreased renal E of lithium salts

149
Q

(Alteration of Active Transport) NSAIDs + methotrexate

A

decreased renal E of methotrexate

150
Q

(Alteration of Active Transport) quinidine + digoxin

A

decreased renal and non-renal E of digoxin

151
Q

(Alteration of Active Transport) amiodarone + digoxin

A

decreased renal and non-renal E of digoxin

152
Q

(Alteration of Active Transport) corticosteroids + ASA

A

increased renal E of ASA

153
Q

– the MOA and pharmacologic effects of drugs

- “what the drug does to the body”

A

Pharmacodynamics

154
Q
  • 1 + 1 = 2

- response is equal to the combined effects of individual drugs

A

Additive Effects

155
Q
  • 1 + 1 = 3 or > 2

- response is greater than the combined effects of the individual drugs

A

Synergistic Effects

156
Q
  • 1 + 0 = 2

- a drug with no inherent activity will enhance the effect of another drug

A

Potentiation

157
Q
  • 1 + 1 = 0

- a drug inhibits the effect of the other

A

Antagonism

158
Q
  • alcohol + barbiturates →
  • alcohol + antihistamines →
  • alcohol + CNS depressants →
  • alcohol + chloral hydrate →
  • benzodiazepine + antihistamine →
A

increased sedation

159
Q

alcohol + chlorpropamide

A

increased hypoglycemic effects

160
Q

flecainide + verapamil

A

increased negative inotropic and chronotropic effects

161
Q

prazosin + beta-blocker

A

orthostatic hypotension

162
Q

beta-blockers + non-DHP CCBs

A

heart block

163
Q

antidepressants + azithromycin

A

QT interval prolongation

164
Q

sulfamethoxazole + trimethoprim

A

co-trimoxazole

165
Q

sulfadoxine + pyrimethamine

A

Fansidar

166
Q

amoxicillin + clavulanic acid

A

increased amoxicillin’s antibiotic effect

167
Q

ampicillin + sulbactam

A

increased ampicillin’s antibiotic effect

168
Q

piperacillin + tazobactam

A

increased piperacillin’s antibiotic effect

169
Q

levodopa + carbidopa

A

increased levodopa’s effect

170
Q

(antagonism) phenoxybenzamine +

A

catecholamines

171
Q

(antagonism) warfarin +

A

vitamin K

172
Q

(antagonism) heparin +

A

protamine sulfate

173
Q

(antagonism) opioids +

A

naloxone

174
Q

(antagonism) benzodiazepine +

A

flumazenil

175
Q

(antagonism) atropine +

A

physostigmine

176
Q

(antagonism) procaine +

A

sulfonamides

177
Q

(antagonism) epinephrine +

A

acetylcholine

178
Q

(antagonism) propranolol +

A

albuterol

179
Q

(antagonism) OHAs +

A

glucocorticoids

180
Q

(antagonism) levodopa +

A

antipsychotics or neuroleptics

181
Q

(antagonism) tetracycline +

A

penicillin

182
Q

aminoglycoside + loop diuretic

A

increased nephrotoxicity and ototoxicity

183
Q

aminoglycoside + neuromuscular blocker

A

increased muscle relaxation or paralysis

184
Q

diuretic + neuromuscular blocker

A

increased hypokalemia causing increased muscle

relaxation or paralysis

185
Q

diuretic + digitalis

A

increased hypokalemia causing digitalis toxicity

186
Q

diuretic + tetracycline

A

increased BUN levels

187
Q

Risk for drug interactions:

A
  1. Multiple drugs – more drugs, more potential for drug interactions
  2. Multiple prescribers
  3. Patient risk factors – elderly, predisposing illness (diabetes, asthma, alcoholism)
188
Q

Prevention:

A
  1. Review drug history and patient risk factors

2. Avoid complex therapeutic drug regimens

189
Q

Management:

A
  1. Be knowledgeable on the MOA of the drugs being used
  2. Suggest a different drug for significant drug interactions or consider therapeutic alternatives
  3. Instruct patient as to timing of the medication
  4. Educate the patient
  5. Monitor the patient for response, adverse events, and drug levels
190
Q

Alcohol + sedative-hypnotics,
opioid analgesics,
TCAs,
antihistamines

A
  • additive CNS
  • depression
  • sedation
  • ataxia
  • increased risk of accidents
191
Q

aminoglycosides + loop diuretics

A

enhanced ototoxicity

192
Q

antacids + iron supplements,
fluoroquinolones,
ketoconazole,
tetracyclines

A

decreased gut absorption

193
Q

antibiotics + estrogens, including oral

contraceptives

A

many antibiotics lower estrogen levels

and reduce contraceptive effectiveness

194
Q

antihistamines (H1-blockers) + antimuscarinics,

sedatives

A

additive effects with the drugs involved

195
Q

antimuscarinic drugs + drugs absorbed from small intestine

A

slower onset of effect

196
Q 
barbiturates (esp. 
phenobarbital) + azoles,
CCBs,
propranolol,
quinidine,
steroids,
warfarin,
and many other drugs metabolized in 
the liver
A

increased clearance of the affected

drugs

197
Q

beta-blockers + insulin

A

masking of symptoms of hypoglycemia

198
Q

beta-blockers + prazosin

A

increased “first-dose” syncope

199
Q

bile acid-binding resins + acetaminophen,
digitalis,
thiazides,
thyroxine

A

reduced absorption of the affected

drugs

200
Q 
carbamazepine + doxycycline,
estrogen,
haloperidol,
theophylline,
warfarin
A

reduced effect of the affected drugs

201
Q 
cimetidine + benzodiazepines,
lidocaine,
phenytoin,
quinidine,
theophylline,
warfarin
A

increased effect

202
Q

disulfiram,
metronidazole,
certain cephalosporins + ethanol

A

increased hangover effect

203
Q

erythromycin + cisapride,
quinidine,
sildenafil,
theophylline

A

risk of toxicity

204
Q 
ketoconazole and other 
azoles + benzodiazepines,
cisapride,
cyclosporine,
fluoxetine,
lovastatin,
omeprazole,
quinidine,
tolbutamide,
warfarin
A

risk of toxicity

205
Q

MAOIs + catecholamine releasers

amphetamine, ephedrine

A

increased NE in the sympathetic nerve

endings

206
Q

MAOIs + tyramine-containing food and

beverages

A

hypertensive crisis

207
Q

NSAIDs + anticoagulants

A

increased bleeding tendency

208
Q

NSAIDs + ACE inhibitors

A

decreased antihypertensive efficacy

209
Q

NSAIDs + loop diuretics,

thiazides

A

reduced diuretic efficacy

210
Q 
phenytoin + doxycycline,
methadone,
quinidine,
steroids,
verapamil
A

increased metabolism of drugs involved

211
Q

quinidine + digoxin

A

increased digoxin levels

212
Q 
rifampicin + azole antifungals,
corticosteroids,
methadone,
theophylline,
tolbutamide
A

decreased efficacy of the drugs involved

213
Q

salicylates + corticosteroids

A

additive toxicity to gastric mucosa

214
Q

salicylates + heparin,

warfarin

A

increased bleeding tendency

215
Q

salicylates + methotrexate

A

decreased clearance of drug involved

216
Q

salicylates + sulfinpyrazone

A

decreased uricosuric effect

217
Q

SSRIs + MAOIs,
meperidine,
TCAs

A

Serotonin syndrome

218
Q

thiazides + digitalis

A

increased risk of digitalis toxicity

219
Q

thiazides + lithium

A

increased plasma levels of lithium

220
Q

warfarin + cimetidine,
erythromycin,
lovastatin,
metronidazole

A

increased anticoagulant activity

221
Q 
warfarin + anabolic steroids,
aspirin,
NSAIDs,
quinidine,
thyroxine
A

increased anticoagulant effect

222
Q

warfarin + barbiturates,
carbamazepine,
phenytoin,
rifampicin

A

decreased anticoagulant effect

Dispensing (6 decks)

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