Mcphs Clinical Therapeutics Pa General Principles Of Prescribing

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This is the schedule of drug that has the following finding requirements:

A-The drug or other substance has high potential for abuse

B-The drug or other substance has no currently accepted medical use in treatment in the US.

C-There is a lack of accepted safety for use of the drug or other substance under medical supervision.

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Schedule I

Front 2

This is the schedule of drug that has the following finding requirements:

A-The drug or other substance has a high potential for abuse

B-The drug or other substance has a currently accepted medical use in treatment in the US or a currently accepted medical use with severe restrictions

C-Abuse of the drug or other substances may lead to severe psychological or physical dependence

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Schedule II

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This is the schedule of drug that has the following finding requirements:

A-The drug or other substances has a potential for abuse less than the drugs or other substances in schedules I and II.

B-The drug or other substance has a currently accepted medical use in treatment in the US.

C-Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence

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Schedule III

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This is the schedule of drug that has the following finding requirements:

A-The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule III

B-The drug or other substance has a currently accepted medical use in treatment in the united states

C-Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule III.

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Schedule IV

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This is the schedule of drug that has the following finding requirements:

A-The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule IV

B-The drug or other substance has a currently accepted medical use in treatment in the US

C-Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule IV.

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Schedule V

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This is a generic, common name for a drug.

Examples:
Generic name - trade name
Acetaminophen - Tyelnol, Datril
Ibuprofen - Motrin, Advil
Aspirin - Bufferin, Empirin

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Nonproprietary name

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This is a trade name given by the manufacturer to identify their brand. Same drug may have several different brand names.

Examples:
Generic name-Trade name
Amoxicillin - Trimox, Amoxil, Polymax

Lidocaine - Xylocaine, Octocaine, Nervocaine

Hydrocodone - Vicodin, Lortab, Stagesic

Ibuprofen - Motrin, Advil, Nuprin

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Proprietary name

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This is when a drug has one active ingredient (ie ibuprofen, amoxicillin)

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Single

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This is when a drug has more than one active ingredient (ie acetaminophen with hydrocodone, lidocaine with epinephrine)

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Combination

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What are the various oral forms of drugs? (8 of them)

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1. Tablet
2. Capsule
3. Caplet
4. Liquid
5. Troche
6. Cream
7. Gel
8. Rinse

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This is when the active ingredient in a drug is usually in unit dose in mg (ie. ibuprofen 200mg, hydrocodone 5mg, lidocaine 2% 36mg)

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Unit Doses

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What is step one in prescribing medications? This includes CC, Hx, PE, Lab, DDx

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Step 1 - Evaluate and clearly define the patient's problem

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What are the five things that should be included step one of prescribing?

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CC, Hx, PE, Lab, DDx

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This is step 2 of prescribing, it allows the PA to direct prescribing to a clear goal with expected outcomes.

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Step 2 - Specify the therapeutic objective

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Example of step 2 in prescribing - specify therapeutic objectives:

A 29 year old woman has presented to the office. She is obese, has type 2 diabetes, and is reporting elevated blood pressures measured at home and at work. You are considering starting her on an angiotensin converting enzyme (ACE) inhibitor.

What therapeutic objectives should be specified?

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1. This involves monitoring this woman's type 2 diabetes and the added diagnosis of hypertension

2. One therapeutic objective would be to obtain sustained blood pressure readings of less than 130/80 mm Hg

3. Second therapeutic objective is to assess her DM2 control and continue to manage it with a goal of achieving and maintaining her HgA1C < 6.5.

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What is step 3 of prescribing?

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Select the appropriate drug therapy.

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What does the WHO suggest to clinicians when you are selecting an appropriate drug (step 3) for a patient?

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The WHO suggests that clinicians develop a formulary of personal drugs (P-drugs) that are:

Effective
Safe
Well-tolerated
Inexpensive

The clinician chooses those medications that he/she regularly prescribes to treat common problems.

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These are the drugs you have chosen to prescribe regularly, and with which you have become familiar.

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P-drugs

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The P-drug concept is more than just the name of a pharmacological substance, it also includes?

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The dosage form

Dosage schedule

Duration of treatment

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What is the WHO STEPS approach to prescribing?

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Safety
Tolerability
Effectiveness
Price
Simplicity

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When following step 3 of prescribing (selecting the appropriate drug therapy) what is the first criterion for selection of a therapeutic?

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Efficacy

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To compare groups of effective drugs you need what four types of information?

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Efficacy
Safety
Suitability
Cost

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What is step 4 of prescribing?

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Initiate therapy with appropriate details

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What are the general details of completing step 4 of prescribing (Initiate Therapy with Appropriate Details)?

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Prescriptions should be clear, legible, written in plain English, and in black ink.

To be effective prescribers should eliminate nonstandard abbreviations that are easily misread, such as non-English characters.

Avoid multiple route prescribing

State dose as grams, mg, mcg etc.

Make administration of once weekly drugs clear.

Prescriptions should include specific indications for anticipated duration of therapy - ex. write out "as needed for severe back pain" instead of using PRN.

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Step 4 - Initiate therapy with appropriate details involves what specific requirements when writing the prescription

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1. State patient details clearly (name, address, date of birth, age (children/elderly).

2. Take account of any allergies and complete relevant paperwork.

3. Use generic drug names

4. State drug, dose, strength, route and frequency

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What is step 5 of prescribing?

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Give information, instructions and warnings.

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What is necessary to fulfill step 5 of prescribing (Give information, instructions and warnings)?

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Describe how the medication should and should not be administered, including any important relationships to food, time of day, and other medications being taken by the patient.

Dispense written information in plain language about drugs to advice patients.

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What is step 6 of prescribing?

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Evaluate therapy regularly

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What are the three things associated with step 6 (evaluate therapy regularly)?

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A - Systematically review medications at ever visit

B - A medication review may include:
Revising a diagnosis
Evaluating possible side effects
Searching for drug interactions
Ceasing unnecessary medications

C-Monitor the therapy

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When following step 6 for prescribing and you are monitoring the therapy, what are the two types of monitoring?

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Passive monitoring - Explain to the patient what to do if the treatment is not effective, is inconvenient or if too many side effects occur. In this case monitoring is done by the patient.

Active monitoring - You make an appointment to determine yourself whether the treatment has been effective.

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What are the types of information the physician assistant must take responsibility for?

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Age
Weight
Renal and hepatic function
Concurrent disease states
Laboratory test results
Concurrent medications
Allergies
Medical/Surgical/Family History
Pregnancy/Lactation status

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What is step 7 when prescribing medications?

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Consider drug cost when prescribing.

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What is step 8 in prescribing medications?

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Use computers and other tools to reduce prescribing errors.

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What are the drugs to avoid prescribing with pregnancy?

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Avoid all drugs if possible - but especially ACEI, Gentamicin, Carbimazole, Isotretinoin, Misoprostol

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What are the drugs to avoid with breast feeding?

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Avoid most drugs - Especially ciprofloxacin, amiodarone

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What are the drugs to avoid with renal/hepatic impairment?

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Avoidance, or change in dose - gentamicin, opiates

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What are the advantages of PO medications?

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Convenient: Portable, safe, no pain, easy to take.

Cheap: no need to sterilize

Compact: Multi-dose bottles, automated machines produce tablets in large quantities.

Variety of dosage forms available - fast release tablets, capsules, enteric coated, layered tablets, slow release, suspensions, mixtures.

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This is when drugs are absorbed orally and transported to the general circulation via the liver. Thus drugs which are extensively metabolized will be metabolized in the liver during absoprtion.

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First Pass Effect

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What are the disadvantages of PO medications?

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Sometimes inefficient - High dose or low solubility drugs may suffer poor availability, only part of the dose may be absorbed.

Local effect - ABX may kill normal gut flora and allow overgrowth of fungal varieties. Thus, antifungal agent may be included with an antibiotic.

Unconscious patient - Patient must be able to swallow solid dosage forms. Liquids may be given by tube.

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These are drugs that are taken as smaller tablets which are held in the mouth or under the tongue. These are buccal or sublingual dosage forms.

These are often harder tablets ( 4 hour disintegration time) designed to dissolve slowly.

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Buccal and Sumblingual (SL) dosage route.

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What are some examples of ROA for Buccal and Sublingual?

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Nitroglycerin, testosterone, oxytocin, nicotine chewing gum.

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What is the advantages of ROA Buccal and Sublingual?

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First pass - The liver is by passed thus there is no loss of drug by first pass effect for buccal or sublingual administration. Bioavailability is higher.

Rapid absorption - Because of the good blood supply to the area of absorption is usually quiet rapid, especially for drugs with good lipid solubility.

Drug Stability - pH in the mouth is relatively neutral (cf. stomach-acidic). Thus a drug may be more stable.

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What are the disadvantages of ROA Buccal and Sublingual?

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Holding the dose in the mouth is inconvenient. If any part of the dose is swallowed that portion must be treated as an oral dose and subject to first pass metabolism.

Usually more suitable for drugs with small doses.

Drug taste may need to be masked.

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Drugs given by the rectal route are most commonly given as what two things?

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Suppository or Enema

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What are a few examples of drugs given this route?

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Aspirin
Theophylline
Chlorpromazine
some Barbiturates

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What are the advantages of Rectal ROA?

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By pass liver - Some, but not all, of the veins draining the rectum lead directly to the general circulation thus by passing the liver. Therefore there may be a reduced first pass effect.

Useful - This route may be most useful for patients unable to take drugs orally or with younger children.

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What are the disadvantages of Rectal ROA?

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Erratic absorption - Drug absorption from a suppository is often incomplete and erratic.

Absorption from solutions used as an enema may be more reliable

Not well accepted. May be some discomfort.

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When doing ROA through the skin, what are the five types of ROA in this category?

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Subcutaneous
Intramuscular
Intravenous
Transdermal
Implantation

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This is when drugs may be given into a peripheral vein over 1 to 2 minutes or longer by infusion. Rapid injections are used to treat epileptic seizures, acute asthma, or cardiac arrhythmias.

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Parenteral - IM, IV, SC, ROA

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What are the advantages of the IV route of administration?

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Rapid - A quick response is possible. Plasma concentration can be precisely controlled using IV infusion administration.

Total dose - The whole dose is delivered to the blood stream. That is the bioavailability is generally considered to 100% after IV administration. Larger doses may be given by IV infusion over an extended time.

Poorly soluble drugs may be given in a large r volume over an extended time period.

Veins relatively insensitive - to irritation by irritant drugs at higher concentration in dosage forms.

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What are the disadvantages of IV ROA?

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Suitable vein - It may be difficult to find a suitable vein. There may be some tissue damage at the site of injection.

Maybe toxic - For drugs where this is a particular problem the dose should be given as an infusion, monitoring for toxicity.
Requires trained personnel - Trained personnel are required to give intravenous injections.

Expensive - Sterility, pyrogen testing and larger volume of solvent means greater cost for preparation, transport and storage

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Intramuscular injections are often given in ?

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the deltoid, vastus lateralis, ventrogluteal and dorsogluteal muscles.

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What are the advantages of IM injections?

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Larger volume than SC can be given by IM. They may be easier to administer than IV injections.

A depot or sustained release effect is possible with IM injections, e.g. procaine penicillin.

The site of injection will influence the absorption.
Absorption can be rapid from aqueous solution.

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What are the disadvantages of IM injections?

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Trained personnel required for injections.

Absorption is sometimes erratic, especially for poorly soluble drugs, e.g. diazepam, phenytoin.

The solvent maybe absorbed faster than the drug causing precipitation of the drug at the site of injection.

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This involves administration of the drug by injection just under the skin. Commonly used for insulin injection.

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Subcutaneous Injection

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What are the advantages for subcutaneous injection?

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Can be given by patient, e.g. in the case of insulin.

Absorption can be fast from aqueous solution but slower with depot formulations. Absorption is usually complete.
Improved by massage or heat.

Vasoconstrictor may be added to reduce the absorption of a local anesthetic agent, thereby prolonging its effect at the site of interest.

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What are the disadvantages for subcutaneous injection?

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Can be painful. Finding suitable sites for repeat injection can be a problem.
Irritant drugs can cause local tissue damage.

Maximum of 2 ml injection thus often small doses limit use.

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ROA May be used for a local effect, e.g. bronchodilators. Can be used for systemic effect, e.g. general anesthesia.

Rapid absorption by-passing the liver.

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Inhalation

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ROA with Local effect - ear drops, eye drops or ointment, antiseptic creams and oinments, sunscreens, callous removal products, etc.

Systemic effect - e.g., nitroglycerin ointment.

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Topical or Transdermal ROA

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What can maximize absorption of transdermal ROA?

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An occlusive dressing may be used to improve absorption.

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What is the advantage of transdermal ROA?

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Transdermal patches can provide prolonged or controlled (iontrophoresis) drug delivery.

Systemic absorption (transdermal) is better with low dose, low MWt, lipid soluble drugs.

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What are the disadvantages of transdermal ROA?

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Generally absorption is quite slow.

Absorption through the skin especially via cuts and abrasions or from sites were the skin is quite thin can be quite marked.

There may be some skin irritation.

Drug absorption will vary by site of administration, skin condition, age and gender.

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Other routes of administration apart from oral, IV, SQ, IM, rectal are?

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nasal, some systemic absorption has been demonstrated for propranolol and some low dose hormones

intra-arterial for cancer chemotherapy to maximize drug concentrations at the tumor site

intrathecal directly into the cerebrospinal fluid

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Others routes with limited systemic absorption but with local utility include:

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Ocular
Vaginal
Urethral
Intrasynovial