The Pharmacist Dream

Thoughts and memos about pharmacy by a fourth year pharmacy student studying in Canada

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Retail Pharmacy

SO, there's this lovely Facebook blog that I follow: The Cynical Pharmacist.

I first found this blog online, but now there's also the FB one, which is easier for me to enjoy because... I'm always on Facebook. I use to read this blog when I was preparing for Pharmacy Interviews to get an "insider look into the real pharmacy life". It's quite amusing. But sadly, some of it is so true. 

I'm pretty sure the authors are from the States... so that's already saying something about their clientele. Customers tend to be nicer here, but not always. 

Anyways, my point is. It's a funny read, and it's nice to know that there are other pharmacists out there facing the same frustrations that I sometimes face in the retail pharmacy scene. 

P.S. I assume the two blogs are related because of the same name... But I don't know for sure. 

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Something I forgot to announce back in June...

BY THE WAY.... 

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P406 - Week 11: Toxicology: Drug Misuse, Abuse and Overdose

One thing I learned from today’s session that I didn’t know before. This lecture was also pretty interesting. I learned about the 4 common toxidromes:  —> Opioid: decreased Level of Consciousness, decreased respiration, miosis —> Cholinergic: Salivation, lacrimation, vomiting, diarrhea, sweating, miosis —> Anticholinergic: Increased HR +/- increased BP, delirium, mydriasis, decreased Bowel sounds, dry flushed skin —> Sympathomimetic: Increased HR, Increased BP, hyperthermia (increased T), agitation, sweating, mydriasis 

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients. Using the above symptoms for these toxidromes, I would be able to identify which type of drug/substance a person has overdosed on and assist the person get help. 

What further issues from today’s session do I want to follow-up on for my own learning?  I would like to be able to better identify which drugs can cause which toxidrome. So far, I can identify the toxidrome based on the symptoms, but I would like to predict the symptoms based on the drug as well. 

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P406 - Week 10: Toxicology in Pediatrics

This lecture was quite interesting. 

One thing I learned from today’s session that I didn't know before:  I learned the drugs that have the potential to kill children with only 1-2 doses/pills/units: -Amphetamines: including MDMA (ecstasy)  -Antidepressants: TCAs, Bupropion -Beta Blockers -Calcium Channel blockers  -Clonidine  -Hydroxychloroquine/chloroquine  -Opioids: Fentanyl, Methadone, Morphine, Oxycodone  -Sulfonylureas 

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients. From the above information, I would be able to caution patients who have young children in their household, or patients who are around young children, to make sure to keep their medications out of children's reach (Although, all medications should be kept out of reach of children, this may give them more incentive to pay closer attention to their medications). 

What further issues from today’s session do I want to follow-up on for my own learning?  I would like to find out the incidence of medication errors due to administration from parents for my own interests.

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P406 - Week 9: Street Drugs

One thing I learned from today’s session that I didn't know before:  This lecture was very interesting because I don't really know anything about street drugs! I learned about how common street drugs work, like GHB aka Gamma Hydroxybutyrate aka Date Rape Drug, and what their clinical effects are.

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients. From the information presented in the lecture, I would be able to better recognize potential drug interactions between conventional medications and street drugs. Also, I would be able to recommend some common antidotes or things to do if the patient is overdosed or sick from taking too much street drugs. 

What further issues from today’s session do I want to follow-up on for my own learning?  I would like to find out what household items people would need to purchase in order to make crystal meth so I could alert the appropriate authorities if any of my customers buy mass amounts of the products. I'm not talking about pseudoephedrine... More of what they would need to buy to have "red phosphorus" and "ammonia-lithium".

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P406 - Week 8: Hypersensitivity

One thing I learned from today’s session that I didn't know before: I learned the drug risk factors for developing hypersensitivity:  --> More complex drug structure  --> Larger molecular weight  --> Topical and IV are at higher risk than oral drugs  --> Longer course, or repeated course of drug treatment 

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients.   From the above knowledge, I would be able to better caution my patients or better monitor any patients on drugs with many risk factors for hypersensitivity reactions. 

What further issues from today’s session do I want to follow-up on for my own learning?  I would like to find out what makes cetirizine different pharmacologically than loratadine to allow cetirizine to have a faster onset. 

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P406 - Week 7: Pregnancy and Lactation

One thing I learned from today’s session that I didn't know before: I learned that the most crucial time of exposure to a teratogenic drug is during the embryonic period, which is days 18-60 after contraception.  

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients: Based on the above response, I would be more alert of potential harm the mother taking medications would be during those crucial weeks. I am also aware of the drugs that are teratogenic, which is super important. 

What further issues from today’s session do I want to follow-up on for my own learning? I would like to understand HOW all of the teratogenic drugs affect the embryo/fetus.

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P406 - Week 6: Age-Related Drug Safety Issues and Medication Errors

One thing I learned from today’s session that I didn’t know before: I learned that besides "The BEERS List" of inappropriate drugs for elderly patients, there are other screening tools for inappropriate prescribing, including:  --> STOPP: Screening Tool for Older Persons' Prescriptions  --> START: Screening Tool to Alert doctors to Right Treatment --> IPET: Improved Prescribing in the Elderly Tool (Canadian Criteria) 

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients: For one, I could use the IPET tool as a Canadian guideline. Further, I would be able to better assist the older patient populations in my practice with medication choice and safety.

What further issues from today’s session do I want to follow-up on for my own learning? I would like to look into what the STOPP criteria is all about since the instructor said it was the most helpful screening tool besides BEERS.

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P406 - Week 5: Drug Interactions Part 2

Second day of Drug Interactions

One thing I learned from today’s session that I didn't know before: I learned more about QT prolongation - what it is, how drugs cause it, and the consequences of it. This concept was never clear to me, so I was glad there was a whole hour dedicated to it.  There are a number of "causes" of QT prolongation, including: Gene mutations, Drugs that block the Ikr channels, Electrolyte imbalances (hyPOkalemia, hyPOmagnesemia), Hypothyroidism, and Extreme Bradycardia. Any of these could cause changes in ionic movement across the neural membranes, leading to unsynchronized or delayed action potentials... throwing off the heart's rhythm and rate... which could lead to torsades des pointes and ventricular fibrillation. 

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients. I learned the importance of being vigilant of medications that may increase the risk of QT prolongation and the development of torsades des pointes. I learned where I can look up medications that may cause QT prolongation and which medications to avoid when a patient is already on a QT prolonging medication. 

What further issues from today’s session do I want to follow-up on for my own learning?  Today, we also learned about vaccination interactions. For my own learning, I would like to memorize which vaccinations are live to know to avoid administering them within 4 weeks of each other.

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Enough with weekly journals for a second.

Here's something kinda funny... pseudoephedrine, a commonly used decongestant found in cold medications, may be used illicitly to make crystal meth.

Source: http://www.kickinthehead.org/2011/12/09/covert-cold-medicine/ 

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P406 - Week 4: Drug Interactions Part 1

Drug Interactions - this was one of the main reasons why I decided to take this Drug Safety course! 

One thing I learned from today’s session that I didn't know before: I learned more about the meaning behind the KROLL Drug interaction alerts! 

** Clinically significant = significant toxicity or deterioration in medical condition

** Major = life threatening or permanent damage

** Moderate = requiring additional treatment

** Clinically insignificant interaction = no action required  I also learned about the different kinds of drug-interactions ** Pharmaceutical/ Physiochemical: DDIs that occur independent of the patient, i.e. will occur even before the patient is exposed to it  ** Pharmacokinetics (ADME): DDI that results in changed Cmax or AUC; this type of interaction is especially important for drugs with narrow therapeutic index.  ** Pharmacodynamic: DDI that involves additive, synergistic or negative effects ** Pathologic: Medication and disease interaction ** Combination of any of the above

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients:  I am more aware of the types of drug interactions and where/how it may affect the patient. This way, I could better assess my patient's medications for DDIs and what I can do to manage/address them.

What further issues from today’s session do I want to follow-up on for my own learning? I will go through the optional supplementals and problem sets for further solidify my understanding.

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P406 - Week 3: Pharmacovigilance: A Study in HIV

(Yes, I know I'm posting these 3 weeks late! I have to play catch-up now.)

The third week was about pharmacovigilance with it's demonstration in HIV, a topic we don't get much lectures on.  It was by a guest speaker, KL.

One thing I learned from today’s session that I didn't know before: I learned what pharmacovigilance is (and that it exists). Pharmacovigilance programs keeps track of the ADR reports to look for "signals", which are the first alert that there may be a safety concern with the drug. A signal could be a single case report, but is more likely to be a collection of many cases.  After a signal is found, an investigation is started to find out more about the safety concern. 

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients is to always remember to report any and all ADRs that deviate from "normal" or "common" ADRs associated with the drug.  My report of the uncommon ADR may end up being a signal for further research! 

What further issues from today’s session do I want to follow-up on for my own learning? I would like to clarify how Protease Inhibitors cause insulin resistance and diabetes. 

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P406 - Week 2: Adverse Drug Reactions

Week 2 was about the many, many adverse drug reactions that we may encounter as a pharmacist later on, as well as how to fill out the ADR reporting form to Health Canada. 

1. Today I learned about the DoTS system of classification for Adverse Drug Reactions (ADRs), which takes into account the Dose, Time Course and Susceptibility of the Drug.

A) Dose, relating to the drug

Hypersusceptibility reactions: are ADRs that occur at doses LOWER than a beneficial dose, i.e. benefit << risk

Collateral reactions are ADRs that occur at doses similar to beneficial doses, usually causing common side effects 

Toxic reactions are ADRs that occur doses above the beneficial doses, usually due to overdoses

B) Time, relating to the EFFECT of the drug

Independent of time = usually toxic reactions

Dependent of time = could for multiple time-related reasons: - drug is given too quickly, e.g. vancomycin and "red man syndrome", a type of hypersensitivity reaction  - reaction to only first dose, e.g. concomitant use of alpha-antagonist and ACEI leading to hypotension   - reaction that decreases as time goes on or with repeat exposure, e.g.  nitrate-induced headaches - reaction within the first few weeks or month but not after, e.g. neutropenia with clozapine (less lab testing as treatment proceeds) - late reaction, that increases with time, e.g. tardive dyskinesia with dopamine agonists  - delayed reaction, that occurs after a period of time, even if the drug is withdrawn; e.g carcinogenesis with diethylstilbestrol (DEB)

C) Susceptibility, relating to the patient's response 

Genetic variability, e.g. porphyria and G6PD deficiency 

Age, e.g. neonates and chloramphenicol (gray baby syndrome)

Sex, e.g. psychiatric effects in women taking mefloquine 

Physiologic Variations, e.g. phenytoin in pregnancy

Exogenous factors, including interactions with other drugs or fruits, e.g. grapefruit and statins 

Diseases, e.g. lithium and renal sufficiency

Today, I also learned that there are 2 different scales for causality assessment: 

Naranjo scale

WHO criteria 

2. One thing that I could apply to my practice is:  The way to fill out the Canada Vigilance report that's available from www.medeffect.ca 

3. An issue I would to follow up on my own is: 

come up with a list of common drugs that have narrow therapeutic indexes and can cause prolonged QT (cause arrthymias)  

Refresher with BEERS List

Some resources from this class: crediblemeds.com

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P406 - Week 1: BC Drug and Poison Information Centre (DPIC)

Week 1 was about DPIC and Dr. K and RL showed us examples of typical drug information or poison information questions that the pharmacists at DPIC are asked on a typical work day. Dr. K took us through examples and the types of questions we should ask when trying to address these issues. She didn't give answers to some of the issues... 

Today, I learned that there were two parts to DPIC, one side is "drug information" and the other is the "poison line".  Even though it's a little obvious now that I think about it, since it's the *Drug* and *Poison* Information Center, I'd always thought it was just combined together. But really the Drug Info is only for health care professionals, like pharmacists, while the Poison Control Line is for the public's use as well.  Today, I also learned that DPIC is interprofessional. 

From this session, I realize that DPIC is a very useful resource, considering that it's free for all Health Care Providers (HCPs) to use. I will definitely consider calling DPIC if I were unsure of what to do, or to double check what should be done for that patient. 

Further issues to follow up on? Try to answer those questions that were posted on one of the slides as "food for thought" 

Drug INFO Line of DPIC can only be accessed M-F 9-4pm, but the Poison Control Line is accessible 24 hours.  

Drug Information Centre 604-707-2787 1-866-298-5909

Poison Control Centre  604-682-5050 1-800-567-8911

"Don't Guess, Be Sure"

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Phar 406 Weekly Blogs

So, for my new elective at school called "Drug Safety", I have to write weekly reflective journal entries about that week's lecture.  These are the questions that the prof would like me to answer: 

One thing I learned from today's session that I didn't know before

One thing I took away from this session that I can apply in my pharmacy practice to enhance or improve drug safety for my patients.

What further issues from today's session do I want to follow-up on for my own learning? 

Sounds simple enough. 

My instructors are Dr. K, and ML so you'll see me refer to them throughout the next 3 months. This course sounds like it would be useful to me, as I sometimes need help applying the things I learned to practice, so I'll definitely keep taking it for marks (I could choose to "audit").  Keep in mind, these next 13 journal posts will be handed in to my profs at the end of the year so they may sound a little "formal" at times. But, that's because they're going to be graded. 

Cheers.

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any ideas/advice to share for someone going to year 1?

Congratulations on getting into pharmacy!

You're going to have a blast. :) 

Some general advice I have include: 

1. Start working at a pharmacy if you haven't already. It will really help you apply the things you are learning in school. If you are already working at a pharmacy, ask your manager to see if you can be more involved in the pharmacist's roles. At my pharmacy, I am fortunately enough to have a very support manager who pushes me to counsel the patients like a registered pharmacist!  (of course, I only counsel if I'm comfortable and think I'm knowledgable enough!)  

2. Keep up with your studying. Many of the things you learn are going to be memorized... so I don't know about you but I definitely cannot "Cram" memorize! 

3. When learning/going through classes, think "I will need this later once when I'm a registered pharmacist", instead of thinking "this is just one more thing I need to know for the exam". Try to see the relevance in what you are studying!

4. Be involved in the pharmacy student life! You'll have more fun, and once pharmacy school is over, you'll have something to show for it! 

Hope that helps!Good luck with this year! Remember to take breaks and have fun once in a while :) Cheers. 

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Why did you want to become a pharmacist instead of a doctor ?

There are many reasons! 

1. I worked in a pharmacy before deciding that I would like to pursue pharmacy - it turned out to not be "boring" because it's not just about counting pills like I had thought! (Actually, many people think this is all pharmacists do - count pills and push drugs - totally NOT true). 

2. I enjoy being at the frontlines of community health care - we are accessible to the community at almost all hours of the day - depending on where you're living or which pharmacies you have access to, some pharmacies are opened 24 hours! Being accessible means that the public don't have to make an appointment and wait hours to see me!

3. Regular hours, and I don't have to bring my work home.

4. I find pharmacy to be less stressful than medicine.. But that is just my opinion. 

5. I enjoy helping people with minor ailments, answering their questions, and to be able to see them often to really develop a good professional/therapeutic relationship with them.

6. AND TBH I'm tired of school and hardly want to spend another 6 years (at least) studying medicine. 

Those were the top 6 reasons I had when deciding which profession to pursue. 

But, I know many of my classmates and friends who are, or who are becoming, great doctors. If you think you can handle the workload of medical school first, and then the stress of the actual residency and job, then go for it! I'll just ask for one favour on behalf of all pharmacists : please write your prescriptions neatly and return our calls! kthx! :)

Hope that helped.