Next week I will lead the discussion with a patient I worked-up on Friday. Adherence is one of the key points of discussion. My preceptor and I had a discussion about how one can check adherence. This is the list we came up with:
1. Pill count
2. Timing (including interaction with other drugs)
3. Ease of administration, is patient okay with remembering? (Ways they can remember: blister packing, dosettes, timer, team-up with roommate/partner)
4. Have they missed any doses?
5. Missed vs. late doses
6. If applicable are they taking doses with or without food
Drug Interactions: Taking any other drugs?
Experiencing any side effects?
Review the labs
What is the plan for this patient?
Other topics discussed:
Pathophysiology of HIV:
Good source: http://www.niaid.nih.gov/topics/hivaids/Pages/Default.aspx
When to start therapy?
When should you genotype a patient?
1. Baseline: May be the patient has primary resistance
2. Suspected resistance: virologic failure
Best scenario when patient is on treatment when he/she shows first sign of virologic breakthrough
Routine check for CD4/viral load: every months unless patient is <40 (undetectable), then every 2-3 months
Recommendations for initiating Antiretroviral treatment (ART) in treatment-naive adults with HIV-1 infection:
ART recommended regardless of CD4 count:
Symptomatic HIV disease
HIV-1 RNA >100 000 copies/mL
Rapid decline in CD4 cell count, >100/uL per year
Active hepatitis B or C virus coinfection
Active or high risk for cardiovascular disease
HIV associated nephropathy
High risk for secondary HIV transmission e.g. serodiscordant couples
Antiretroviral therapy (ART) is recommended for all HIV-infected individuals. The strength of this recommendation varies on the basis of pretreatment CD4 cell count:
CD4 count 500 cells/mm3 (BIII)
Drugs available through BC Centre for Excellence: http://www.cfenet.ubc.ca/sites/default/files/uploads/HIV-AIDS%20Drugs%20available%20through%20the%20BC-CfE.pdf
This is the last rotation of my residency! I am glad I am finishing with an elective and that too HIV/AIDS.
My goals for this rotation are:
1. Gain understanding of the pathophysiology of HIV infection and how it progresses to AIDS.
2. Become familiar with the anti-retrovirals currently used
3. Become familiar with drug interactions associated with anti-retrovirals and how to manage them
4. Counsel at least one patient on ARVs.
5. Work-up at least one new patient every day starting week 2
6. Know when to start ARVs and what to start
7. Gain understanding of opportunistic infections and know how to prevent and treat them especially PCP
Spending a day with neurologists examining Parkinson’s patients at UBC clinic was an interesting day. Learning about the disease sitting in a class vs. actually seeing the patients in person and listening to their stories is a totally different experience as it allows you to apply the theoretical knowledge gained in class. The two neurologists I followed were super helpful! I was curious about different neurology examinations and ways to adjust medications. They helped me answer questions and put things into perspective.
I learnt about different uses of Botox (a purified neurotoxin complex protein produced from the bacterium Clostridium botulinum). For example I did not know that it is used for dystonia. Patients get a repeat dose every 3-4 months. It takes 48 hrs for onset and reaches peak in about 2 weeks.
One of the patients received it for central dystonia and the other one got it for Meige’s syndrome.
The time spent at the clinic reinforced the fact that the timing of medication is extremely important in Parkinson’s disease patients. Therefore, when they are admitted to the hospital, the pharmacist should learn the dose times and make sure the patient gets it at the same time in hospital as well.
Domperidone is used for both nausea and orthostatic hypotension (usually given half an hour before the levodopa dose)
– Inhibit the vasodilating and natriuretic effect of dopamine and increase noradrenaline release by blocking receptors for dopamine which exhibits inhibitory control of noradrenaline.
– EPS and tardive dyskinesia limits their long-term use.
Some patients experience Sinemet addiction wanting more even when not required??
Donepezil can worsen confusion in some cases ( very rare)
Some research to do:
Mirtazapine’s use for tremor??
Rasagiline has been shown to have neuroprotective effect??
Donepezil for orthostatic hypotension??
Parkinson’s Disease and Multiple Sclerosis
Attended Neuro Grand Rounds
Case Presentation Neurology
Friday: Warfarin and Dabigatran teaching
Goals for last week:
See more patients: Work up at least 2 new patients every day
Choose patients with other neurologic conditions besides Stroke/TIA
Speak slowly and louder with patients (esp. elderly)
Tuesday: Multiple Sclerosis Clinic at Burnaby Hospital
Thursday: Case Presentation
Attended Stroke Clinic on Thursday at ARRH with Dr.Constantino at Abottsford Hospital.
It was a great experience as I saw the neurologist conduct different examinations to find neurologic deficits in terms of sensory and motor symptoms.
One of the patients had been on combination of ASA + clopidogrel for few months after a stroke even though evidence shows that there is no evidence of using the combination therapy beyond a month (FASTER trial). Therefore, clopidogrel was discontinued.
I also realized that non-drug measures play a huge role in preventing stroke especially smoking cessation and diet.
The visit to the clinic provided me with an insight of what happens after stroke patients leave hospital and how they are managed as out-patients.
My learning objectives:
1. Interpret pharmacokinetics of phenytoin in at least 2 patients and document it in the chart
2. Understand the pathophysiology, incidence, treatment options and pharmacology of drugs used in parkinson’s disease. Work up at least 1 patient with Parkinson’s disease
3. Discuss the pathophysiology, incidence, treatment options and pharmacology of drugs used in multiple-sclerosis with preceptor and opportunity comes work up a patient with the disease condition.
Tasks performed so far:
1. Worked up 3 patients with TIA, 1 patient with Pseudo-seizures
2. Assessed phenytoin levels of 2 patients
3. Presented journal club on: Alteplase vs. Tenecteplase in acute ischemic stroke
4. Topics discussed: Stroke and secondary prevention of stroke (Incidence, pathophysiology, treatment options, evidence behind different treatment options)
5. Attended journal club presented by fellow resident Anita Rasoda and SPEP student
6. Attended Symposium on Stroke oragnized by Fraser Health on April 14/2012
Medication reconciliation: discontinued two anti-depressants patient was not taking but was started on at the hospital, facilitated initiation of patient’s own medication
Initiated DVT Prophylaxis in a patient with subdural hemorrhage
A nurse asked me a question and I ended up reading a consult which led me to look up some terms e.g.
Levophed: I didn’t know this is the brand name for norephinephrine
Pentaspan: Penta-starch. It is a plasma volume expander like albumin, dextran, hetastarch and tetrastarch used as adjunctive treatment in the management of shock.
Acute tubular necrosis (ATN) follows a well-defined 3-part sequence of initiation, maintenance, and recovery. The tubule cell damage and cell death that characterize acute tubular necrosis usually result from an acute ischemic or toxic event.
Academic Half Day on Endocarditis: This academic half day was very informative and applicable to our practice.
The residents did a great job of going over different treatment options in different scenarios.
What this rotation helped me achieve?
I have become more familiar with medications used in the emergency setting, become better at writing more succinct notes, analyzing pharmacokinetics of medications (digoxin, phenytoin, vancomycin etc.)
I have developed more faith in the contributions made by pharmacists. I have come to realize that pharmacists have the ability to prevent a lot of medication errors be it by medication reconciliation, finding drug related problems, educating a doctor or nurse about a new medication and it’s adverse effects or finding the drug cause of a medical problem.
Some other new concepts I learnt:
Subdural hematoma: collection of blood on the surface of the brain. This is a serious condition since the increase in intracranial pressure can cause damage to brain tissue and loss of brain function.
Bethanechol: Treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention; treatment of neurogenic atony of the urinary bladder with retention