GERD: BCPS 2013 Review

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GI Notes Just For You! GERD

  1.  Lifestyle modification
  2. Antacids
  3. Acid suppression (prn/scheduled)
    1.  PPI
    2. H2RA
    3.  Promotility agents

 

AGA Guideline Recommendations

  • Empiric drug therapy is appropriate for patients with uncomplicated heartburn
  • Use of antisecretory drugs for pts with esophageal GERD symptoms (with or without esophagitis) is strongly recommended (grade A).
  • Data are weak to support using PPIs or H2RAs above standard doses.  However, BID dosing of PPIs is appropriate in patients who continue to have symptoms on once-daily PPI therapy (grade B)
  • Antacids are the fastest acting drugs and should be used for those patients that wants to take medications for symptoms.  Safe to take with H2RA or PPIs.
  • On-demand therapy is not recommended for erosive esophagitis.
  • No evidence of improved efficacy by adding a bedtime dose of H2RA to twice-daily PPI therapy
  • Data weak to support the use of PPIs in patients with extraesophageal symptoms

 

AGA Guildeline – Extraesophageal symptoms (chronic cough, laryngitis, and asthma)

  • The presence of extraesophageal symptoms in the absence of esophageal GERD is rare.
  • Evidence is fair for the use of once-or twice-daily PPI therapy in patients with an extraesophageal syndrome and a concomitant esophageal GERD syndrome (grade B).  A two month trail of twice-daily PPI therapy would be an appropriate therapy for these patients.
  • Evidence is for the use of once-or twice-daily PPI therapy in patients with an extraesophageal symdrome in the absence of an esophageal GERD syndrome (grade D).
  • Evidence is insufficient to recommend once-or twice-daily PPI therapy for patients with suspected reflux cough syndrome.

The Drugs

  1. ANTACIDS – calcium, aluminum, magnesium OTC.  Neutralizes acid and raises intragastric pH resulting in decreased activation of pepsinogen and increased LES pressure; rapid onsent of action but short duration, necessitating frequent dosing.  FIRST LINE for intermittent (< 2 times/week) symptoms or as breakthrough therapy for those on PPI/H2RA therapy; not appropriate for healing established esophageal erosions
    1.  Adverse effects

i.      Constipation (aluminum)

ii.      Diarrhea (magnesium)

iii.      Accumulation of aluminum/magnesium in renal disease with repeated dosing.

  1. Drug interactions

i.      Chelation (fluoroquinolones, tetracyclines),

ii.      Reduced absorption because of increases in pH (ketoconazole, itraconazole, iron, atazanavir, delavirdine, indinavir, nelfinavir)

iii.      Increases in absorption leading to potential toxicity (raltegravir, saquinavir)

 

  1.  HISTAMINE-2 RECEPTOR ANTAGNOSITS – Reversibly inhibit histamine-2 receptors on the parietal cell.  All available OTC.
    1. Adverse effects

i.      CNS effects like dizziness, h/a, fatigue, somnolence, and confusion mostly with elderly and compromised renal function.

ii.      Prolonged cimetidine – rare development of gynecomastia

  1.  Drug interactions

i.      Drugs dependent on lower pH for absorption:  ketoconazole, itraconazole, iron, atazanavir, delavirdine, indinavir, nelfinavir

ii.      Increases in absorption leading to potential toxicity:  raltegravir, squinavir

iii.      Cimetidine inhibits cytochrome P450 (CYP) enzymes 1A2, 2C9, 2D6, and 3A4 – Warfarin, theophylline, and other agents may be affected.  Cimetidine also competes for tubular secretion in the kidney.

 

 

  1.  PROTON PUMP INHIBITORS – Irreversibly inhibit the final step in gastric acid secretion
    1. Most effective before meals; for divided dosing, give evening dose before evening meal instead of at bedtime
    2. Adverse effects – h/a, dizziness, nausea, diarrhea, and constipation.  Long-term use is not associated with significant increases in endocrine neoplasia or symptomatic vitamin B12 deficiency.

i.      Cohort study – ELEVATED risk of CAP with these agents (H2RA and PPI) – immunocompromised, the elderly, children, and those with asthma or COPD

ii.      Prospective cohort study – increased risk of HAP in nonventilated patients who were prescribed PPIs

iii.      Increased risk of fractures – not recommend bone density screening or calcium supplementation.

iv.      C diff infection – increased risk

v.      Hypomagnesiumia

  1.  Drug interactions

i.      Inhibition of CYP45 – inhibits the metabolism of substrates such as diazepam through CYP2C19 inhibition

ii.      Reduced effect of clopidogrel (CYP2C19) – omeprazole most implicated

iii.      High dose IV MTX – higher risk of MTX toxicity.  Either switch to ranitidine or hold PPI dose for 2 days before and after MTX admin may help

iv.      pH-dependent absorption (ketoconazole, itraconazole, protease inhibitors)

 

  1.  PROMOTILITY AGENTS – guidelines recommend against the use of metoclopramide as adjunctive therapy or monotherapy in patients with both esophageal and extraesophageal symptoms because the risk of adverse effects (EPS/tardive dyskinesia) outweighs the benefit (grade E).  Metoclopramide has a black box warning for Tardive Dyskinesia.
    1. Works through cholinergic mechanisms to facilitate increased gastric emptying.

i.      Metoclopramide – dopamine antagonist; needs to be dosed several times a day; associated with dizziness, fatigue, somnolence, drowsiness, EPS, and hyperprolactinemia.  New 5- and 10-mg ODT formulations.  Indicated for GERD and diabetic gastroparesis

ii.      Bethanechol – Cholinergic agonist; poorly tolerated because of adverse effects such as diarrhea, blurred vision, and abd cramping; may also increase gastric acid production

iii.      Cisapride – Restricted.  Removed from market for torsades when used in combination w/drugs inhibiting CYP3A4.

How One Patient Pharmacist Relationship Can Change Your Life

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One patient can completely change your life.  Brenda was her name.   The website where there is an online cemetery mirroring how it looks in real life.  There are moments in my career where I sit back and remember the impact she had on my life.  Not only was she so vibrant (even over the phone) but she was also inspiring.  We were in the same generation though my life was about a young man I had met (and later married) and hers was about fighting for her life.  I was her pharmacist while she was at home battling breast cancer.  She had a boyfriend with the same maiden name as me, and well it was cool Brenda and I had the same initials. pharmacist patient relationshipI always want to connect with patients, but unfortunately my current job does not afford me the opportunity very often.  I lingered outside one patient's room at the hospital yesterday wanting to go in and introduce myself letting him know I wished him the best with his new situation and just say hello.  I have to do this more often.  There is nothing at work keeping me from opening the door and saying hello.  I guess I worry the patients are bothered enough all day and night by nursing and physicians and lab techs and all.  They get little rest, and they are sick.  Perhaps some would want a friendly face just saying hello and asking them if they need anything.

It was a little easier for me in home health because I had to call to find out how they were doing on their supplies, how nursing was handling things with the home IV antibiotics or TPN and it made it easier for me since I have this southern accent that sounds more southern even TO a southerner.  Ha!  That in itself was always an easy icebreaker.  "Where are you from?"  It always went from there.

Brenda wanted to go to Florida and jet ski.  With her pain pump.  We made it happen.  I'm proud of that memory.  I'm proud that I finally went out to meet her in person though I should have gone earlier when she was not in the final stage of life.  I saw a picture of her healthy.  Beautiful and full of life... same as most of us now.  We just can't waste this life we have!

I may have blogged about her before.  I haven't gone back to look because today I am thinking about her... it's been ten years, but I still think about how her life focus shifted with knowing she had little time left.  I am guilty of complaining quite a bit about my current job at times.  There are so many things that bug me mostly dealing with how things are handled, how pharmacists have those in control snowed, and how there's very little incentive (promotion, opportunities, salary increases, etc...) to even go above and beyond.  A new schedule comes out and I think why in the hell did I decide to do this job?  I mean, yes, it could be worse.  I know this.  But, could it not be better?

I think I am going to try to make these interactions with patients happen more often somehow.  If you have any ideas on how I can at the hospital, let me know... or if you have made it happen let me know.  These moments define major influences in my life (in the past), and I don't want to lose them by allowing my current situation to completely stifle who I am as a pharmacist.  Don't let your job dumb you down professionally or personally.

 

ACCP: Update in Therapeutics (my thoughts)

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Well, here I sit in the Reno airport waiting on my flight to LAS.  My brain hurts a bit, but really enjoyed my stay at the Peppermill with my friend.  She is taking the exam for the first time, and if you have been following me for any amount of time know its my second attempt at this certification.  I feel what the in-person attendance vs the audio recordings can provide is the dedicated time to only listen to pharmacy all day for four days.  I really have my days mixed up so forgive me if I quoted that wrong.  The instructors for the most part were more than adequate presenting their material save for the always dry statistics lecture that made more sense since it's probably my 21st time hearing it. I can quote that infectious disease lecture almost verbatim at this point.  Maybe even in Dr. Smith's accent.

I enjoyed the changes in cardiology.  The material seemed much more organized and flowed better.

What my plan is for the next few months is to really learn the guidelines and as soon as the new lectures arrive (CDs), I will be the soccer mom in a van not listening to Top 40 but the lectures ad nauseum.  I guess there comes a point where all of this material coalesces and makes sense.  It was such a treat, I might add, to see Shannon Finks present since we attended UT Memphis School of Pharmacy together.  I love seeing UT students make such huge impacts in our profession.

So for now, I am reviewing cardiology at the moment.  And my friend and I did spend some time in the hotel room listening to the High Yield Med Reviews online lectures.  The stats one, she remarked, made more sense of the ACCP material... if that helps any.  I also purchased a couple of books.

Good luck to all of you who are now going to study like never before.  Do NOT wait.  Start now.  We have 5-5.5 months left.  That's really just around the corner considering I just received last years results 4 months ago.  Time flies.

And, I got the great opportunity to meet the winner of the giveaway -- Yvonne!  Like me, she sees the value in getting this, especially if you have been out of pharmacy school for any amount of time.  Jobs are more scarce, guidelines change and if you don't show that you have kept or are keeping up (demonstrated by passing this test), then you may be in trouble.  Just do it!!!

BCPS 2013: Some Pharmacoeconomics

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Pharmacoeconomics are on the test more than I would have thought.  Some notes for you.  Enjoy! Definitions

A. Pharmacoeconomics—the description and analysis of the costs and consequences of pharmaceuticals and pharmaceutical services and its effects on individuals, health care systems, and society. These costs and consequences typically include both economic and humanistic assessments.

1. A division of outcomes research; however, NOT all outcomes research is pharmacoeconomic research.

B. Outcomes research—broadly defined as studies that attempt to identify, measure, and evaluate the end results of health care services in general

1. Clinical effects as well as economic & humanistic outcomes (i.e. functional status, well-being, satisfaction w/ care).

2. Proposed that evaluation of drug therapy and related services should always include assessments of economic, clinical, and humanistic outcomes.

 

A. Economic, clinical, and humanistic outcome (ECHO) model

1. Economic outcomes—direct, indirect, and intangible costs compared with the consequences of medical treatment alternatives.

2. Clinical outcomes—medical events that occur as a result of disease or treatment

3. Humanistic outcomes—consequences of disease or treatment on patient functional status, or quality of life, measured along several dimensions, e.g., physical functioning, social functioning, general health perceptions and well-being.

B. The ECHO model recognizes intermediary outcomes

1. Economic intermediaries à introduced from the clinical and humanistic side of the model.

a. Clinical à direct costs of medical care assoc’d with each treatment, not just the direct cost of the pharmaceutical products (i.e. lab testing, ED visits, inpt hospitalizations, and costs of retreatment from product failure)

b. Humanistic à

i. Indirect, or productivity costs assoc’d with the time lost from work

ii. Direct nonmedical costs à transportation to the hospital, or physician’s office for treatment

2. Humanistic intermediaries à affect the indl’s subjective evaluation of outcomes

a. Examples: side effects; efficacy/effectiveness; patient’s willingness or ability to pay; adherence to drug regimen (compliance); patient’s knowledge; drug dosing schedules

Economic outcomes assessment

**Balance cost vs consequences

A. Costs

1. Direct medical costs—costs incurred for medical products and services used for the prevention, detection, and treatment of a disease.

a. Examples: hospitalization, drugs, laboratory testing, supplies

i) Fixed costs represent overhead costs

ii) Variable costs—vary as a function of volume

2. Direct nonmedical costs—costs for nonmedical services that are the result of illness or disease, but do not involve purchasing medical services.

b. Examples: special food, transportation for health care, family care

3. Indirect costs—costs of morbidity and mortality resulting from illness or disease.

a. Examples: lost productivity, premature death

4. Intangible costs—costs of pain, suffering, grief, and other nonfinancial outcomes of disease and medical care

5. Incremental costs—additional costs incurred to obtain an additional unit of benefit from an alternative strategy.

6. Opportunity costs—the value of the next best use that is forgone

B. Consequences

1. Positive versus negative

a. Full evaluations must measure both desirable and undesirable outcomes.

2. Intermediate (“surrogate outcomes”) versus final

a. Intermediate outcomes are commonly used to demonstrate clinical efficacy because their usage reduces the costs and time required to conduct a clinical trial.

C. Perspectives: The pharmacoeconomic question being asked usually determines the appropriate perspective or viewpoint to be used.

1. Patient—costs are what they pay for a product or service (the portion not covered by insurance).

2. Provider—the health care professional or care organization; costs are the actual costs of providing a product or service, regardless of the charge

3. Payer—insurers, government, or employers; the costs are the charges for health care products and services allowed (reimbursed) by the payer.

4. Society—costs include patient morbidity and mortality costs, and the overall costs of giving and receiving medical care (**PREFERRED FOR CEA)

 

Economic Assessments

A. Full economic evaluation helps to assess the economic benefit of a program, service, or treatment

a. Requires (1) comparison of  >2 treatment alternatives and (2) BOTH costs and consequences of the alternatives are examined

Methodology

Cost Unit

Outcome Unit

Example

COI

$

Not assessed

Yields total cost of a disease

CMA

$

Comparative groups assumed to have = outcomes

Determine the least costly alternative

CBA

$

$

Net cost or benefit usually* or cost:benefit ratio

Used to decide how to allocate scarce resources

CEA

$

Natural units or units of effect

Used to compare competing programs or tx alternatives that differ in therapeutic outcome**

CUA

$

QALY

Used to compare txs or programs using terms of patient preference, quality of health care, or when outcomes can’t be expressed in monetary terms

COI = Cost of illness, CMA = Cost-minimization analysis; CBA = Cost-benefit analysis; CEA = Cost-effectiveness analysis; CUA = Cost-utility analysis; QALY = Quality-adjusted life years

*Example: if cost for treatment is $100 and value of outcome of treatment is $1000, cost-benefit ratio is:

benefit ÷ cost = $1000 ÷ $100 = 10/1 benefit of $1 million and cost of $100,000 also yields cost-benefit

ratio of 10/1 VS. net benefit = $900 ($1000 - $100)

**Results are expressed as average cost-effectiveness ratios, or as the incremental cost of using one alternative

over another.

Example: drug A has 90 percent cure rate, drug B has 95 percent cure rate; drug A costs $50,000 to

treat 100 patients, drug B costs $100,000 to treat 100 patients

-Calculation of average cost-effectiveness ratios:

drug A costs $50,000/100 patients ÷ 90 cures/100 patients = $555/cure

drug B costs $100,000/100 patients ÷ 95 cures/100 patients = $1053/cure

-Calculation of incremental cost-effectiveness ratio:

$100,000 - $50,000

95 cures - 90 cures      = $10,000/additional cure with drug B

 

Techniques for analysis

A. Discounting

1. Definition—an analysis that adjusts (reduces) future costs and consequences to reflect present fiscal value.

2. Discounting costs—based on the time value of money; because the value of money decreases over time, future costs must be adjusted (discounted) to present time values.

3. Discount rate of 3–8 percent should be used (often reflective of current interest rates used by banking institutions). Health care uses 5%.

B. Sensitivity analysis

1. Definition—an analysis that tests robustness of study conclusions; sensitive variables (or assumptions) are varied over a range of plausible results and the impact on study results is observed.

2. Variables include percent efficacy (or effectiveness), incidence of specific adverse drug reactions, and dominant costs.

C. Incremental cost analysis

1. Definition—an analysis that examines the extra cost of one program or treatment alternative relative to the additional effect provided by that alternative.

2. Formula: _Cost B – Cost A_

Effect B – Effect A

 

Applied Pharmacoeconomics

A. Definition—putting pharmacoeconomic principles, methods and theories into practice to assess the value of pharmaceutical products and services used in “real-world” practice settings

B. Primary application—to inform local decision making. Examples:

a. Formulary management

b. Clinical guidelines

c. Drug use policies

d. Service or program evaluation

e. Individual patient treatment decisions

BCPS 2013: Geriatrics

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Geriatric pharmacy is a field that will continue to grow due to the aging population.  Not only do you need to remember the physical changes that geriatrics experience, but the current guidelines.

Know your guidelines!

PK/PD

Organ System Physiologic Change with Aging Resulting Effect on PK
GI ↑ stomach pH

↓ GI blood flow

Slowed gastric emptying & GI transit

 ↓ absorption of basic drugs and nutrients

↓ in 1st-pass metabolism

Rate of absorption may be prolonged
Skin Thinning of dermis

Loss of SQ fat

 ↓/↔ to drug reservoir formation with transdermal formation
Body Composition ↓total body water

↓ lean body mass, ↑body fat

↑ α1-acid glycoprotein

↓/↔ serum albumin

 ↑ VD and accumulation of lipid soluble drugs (i.e. BZDs)

 

↑ free fraction of highly bound acidic drugs and ↓ free fraction of basic drugs
Liver ↓ liver mass

↓ blood flow to the liver

 ↔ in phase II drug metabolism

↓/↔ phase I metabolism

↓/↔ CYP450 enzymes

↑ half-life and ↓ CL of drugs with high 1st-pass metabolism
Renal ↓ GFR and renal blood flow

↓ tubular secretion

↓ renal mass

 ↓ renal elimination of many meds

↑ half-life of renally eliminated drugs and metabolites

Salts of acid drugs: sodium (sodium naproxyn), calcium (atorvastatin calcium), potassium (penicillin G potassium)

Salts of basic drugs: HCl (tetracycline HCl), sulfate (atropine sulfate)

Medications to AVOID in the elderly

  • Beer’s List: includes consensus drugs only
  • Anticholinergic medications (anti-SLUDGE)

 

DEMENTIA

Delirium

Dementia

Depression

SUDDEN, RECENT ONSET

Lasts hrs to weeks

Look for changes in meds, setting, and infection; often reversible

Slow, progressive onset

Irreversible, memory impairment

In the present, with you in the moment (good attention)

Slow or recent onset

Withdrawn and/or sad

Flat affect but emotional

Answers with “I don’t know”

Medication causes of mental status change (reversible):

 

  • Anticholinergics
  • Opioids
  • Glucocorticosteroids
  • BZDs and other sedative/hypnotics
  • Antiparkinsonian med

 

MMSE (mini-mental status exam) Scores:

  • Normal cognitive function= > 24 (out of 30)
  • Mild Alzheimer’s Disease= 21-24
  • Moderate AD= 10-20
  • Severe AD= <10
  • Expected point decline in untreated pt= 2-5 points/year

Also assess a patient’s function (IADLs) and global assessment (CIBIC-Plus)

 

AD Pharmacological Treatment:

1st line: cholinesterase inhibitors (CIs); all equal efficacy; risk of bradycardia and syncope increased for all CIs

  • Donepezil (Aricept): 5mg/d (10mg-23mg/d); also ODT tabs; mild-mod AND severe AD
  • Rivastigmine (Exelon): 1.5-6mg tabs BID [also 9mg (delivers 4.6 mg/d) and 18mg (delivers 9.5 mg/d) patches]; ADRs of  N/V/D more intense than w/ other CIs; mild-mod AD & mild-mod dementia with PD
  • Galantamine (Razadyne): 4-12mg BID or 8-24mg/d (ER formulation); administer with food; syncope at high doses

2nd line/adjunct: glutamatergic therapy (NMDA antagonist; blocks glutamate)

  • Memantine (Namenda): 5mg/d up to 10mg BID; mod-severe AD, may be used in combo w/ Aricept; well tolerated but sometimes confusion seen

**NOTE: CIs and memantine show stat sig improvement in cognition, global assessment, and ADL in high-quality studies but NOT clinically significant!

 

> 50% of pts with dementia have psychosis and agitation

1. Determine cause

2. Non-pharmacological interventions (i.e. educate caregivers, have routine, improve environment)

3. Pharmacologic

A. CIs: ? efficacy; can increase agitation; 1st line for psychosis in Lewy body dementia

B. Atypical Antipsychotics (APs): NO FDA-APPROVED AP for tx of dementia-related psychosis

  • No clear standard on when to use, use for shortest time possible
  • Cochrane review suggests olanzapine and risperidone have most evidence for use in psychosis and aggression; however, use quetiapine if pt has comorbid PD or Lewy body dementia
  • High rate of ADRs: sedation, orthostasis, ↑ risk of stroke/death (OR 1.54 (CI 1.06-2.23), p=0.02)

URINARY INCONTINENCE

Type

Description

Drug-induced causes

Drug Tx

Comments
Urge or Overactive Bladder Loss of mod amts of urine w/ an ↑ in need to void; can result from CNS damage from stroke Cholinergic agents (stimulate bladder; i.e. CIs) Anticholinergic agents (i.e. darifenacin, oxybutynin, solifenacin, tolterodine) -1st line agents

-Oxybutynin has highest CNS effects
Stress incontinence Loss of urine w/ ↑ ab pressure (i.e. sneezing, coughing) α-blockers α-agonists (i.e. PSE and phenylephrine)

Topical estrogens and Duloxetine

 -All variable efficacy

-SURGERY normally 1st line
Overflow incontinence Loss of urine b/c of excessive bladder volume caused by outlet obstruction or an acontractile detrusor Anticholinergics, CCB, opioids ↓ detrusor contractions α-blockers (outlet obstruction)

Add-on 5-α reductase inhibitors or bladder antispasmodics (i.e. oxybutynin, tolterodine) à advanced BPH or refractory sxs

Cholinomimetic (bethanechol)
Functional incontinence Inability to reach toilet due to mobility constraints Sedating meds cause confusion; diuretics Remove barriers and obstacles, provide toilet scheduling; assist pt on/off toilet
Mixed incontinence UI w/ >1 cause; usually stress and overactive bladder   Focus on dominating symptoms

Reversible causes of UI: DIAPERS (Delirium, Infection, Atrophic vaginitis and urethritis, Psychiatric disorders, Excessive urine output, Restricted mobility, and Stool impaction)

 

BPH Treatment:

1st line: α-blockers (↓ smooth muscle contraction in urethra); all can cause hypotension!

  • Nonspecific α-blockers: doxazosin (Cardura), prazosin (Minipress, not FDA-approved for BPH), and terazosin (Hytrin)
  • Selective α1-blocker: tamsulosin (Flomax)- less hypotension but ↑rate of ejaculatory dysfunction
  • Selective post-synaptic  α1-blocker: alfuzosin (Uroxatral)

2nd line: α-reductase inhibitors (prevent conversion of testosterone to DHT, DHT stimulates prostate growth)

  • Finasteride (Proscar) and dutasteride (Avodart); decreased libido
  • DO NOT IMMEDIATELY REDUCE SXS! At least 6 mo’s needed for benefit
  • Need baseline PSA to monitor for prostate cancer

Combo therapy for men w/ lower urinary tract symptoms, larger prostate size (>40g) and elevated PSA

  • Dutasteride w/ tamsulosin FDA-approved

Saw palmetto- conflicting efficacy data; may decrease efficacy of reductase inhibitors if used together

Surgery- for severe sxs and those with mod sxs not responding to meds

 

OA

Weight-bearing joints, unilateral, increased with age

Treatment

1st line: APAP up to 4 g/d (< 2.6 g/d if EtOH abuse); 2nd line: opioids, NSAIDs should seldom be used

Other options with ?efficacy: gabapentin (if neuropathic pain), baclofen if muscle spasms, topical agents (i.e. capsaicin, licocaine 5% patch), glucosamine +/- chondroitin

 

RA

Autoimmune disease, common in women (3:1 vs men) and younger people; bilateral inflammation in small joints of hands, wrists, and feet; (+) RF, ESR, C-reactive protein, and normochromic normocytic anemia

Treatment: goal = control inflammation à disease remission

  • 1st line tx: methotrexate (7.5-15mg/week) or potentially other DMARD; 3 months of use before effects seen!
    • For IMMEDIATE tx of pain and inflammation: NSAIDs (analgesic effects w/in hrs, antiinflammation 1-2 weeks) and glucocorticosteroids…both used SHORT-TERM
    • 2nd line if methotrexate does not work: TNF (etanercept, infliximab, adalimumab, etc) or IL inhibitor

 

Canada Pharmacy Reviews from Best Price RX Pharmacy

BCPS 2013: Asthma (a refresher of guidelines)

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BCPS AsthmaThe BCPS Test contains questions the ACCP calls Ambulatory Care which has a few subtitles, one of which is asthma.  Charts and charts and memorization for the BCPS 2013:  Asthma.  Fun stuff right?  I do remember questions detailing patient has this many night symptoms and this many weekly, what category and what treatment.  So know these charts (embeded PDF files) Asthma is a chronic inflammatory disorder of the airways characterized by paroxysmal or persistent symptoms, such as shortness of breath, wheezing, cough, sputum production, and chest tightness, accompanied by variable airway hyper-responsiveness and degrees of airway obstruction.

Asthma diagnosis is confirmed by spirometry which includes an improvement in obstructed FEV1 by >/= 12 % from baseline and 200 mL at 5 minutes after using inhaled short-acting beta-2 agonist OR an increase > 10% of predicted FEV1 after inhalation of short-acting bronchodilator.

Acute or chronic?

Severity is determined by lung function and frequency and duration of symptoms (including at night).  Classification to determine treatment regimen.  Once asthma is well controlled, severity may be judged by determining minimal treatment needed to maintain acceptable control.

[embed]http://theblondepharmacist.com/asthmaclassification.pdf[/embed]

[embed]http://theblondepharmacist.com/asthmacontrol.pdf[/embed]

[embed]http://theblondepharmacist.com/5-11yearoldasthma.pdf[/embed]

[embed]http://theblondepharmacist.com/inhaledcorticosteroids.pdf[/embed]

There's also a great resource for guidelines that are relatively cheap if downloaded digitally.  Here's the asthma one!

 

High Yield Med Reviews: A Giveaway!

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I am so excited to be teaming up with High Yield Med Reviews to offer one of my readers a free subscription to their BPS (can be BCPS, BCACP or BCPP) Online Review Course!  See the value below.  We will make this easy!  Just retweet or share this post on your facebook or twitter and you will have an entry into the contest!  Post you did in the comments, and a random generator will decide who the lucky reader is!  The winner will be announced on April 1st! Comment on the post to confirm you have shared and you are entered automatically!

High Yield Med Reviews