In the Aisle Consults for OTCs

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Spencer Fletcher
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1 In the Aisle Consults for OTCs Jennifer Fix, PharmD, MBA, BCACP, BCGP Associate Professor Session Objectives Understand and use the pharmacist patient care process in OTC consults Review and use the encounter worksheet and Quest-Scholar-Mac in gathering patient information Observe a patient consult and complete an encounter worksheet downloaded from 1

amenable to self-care Review OTC medications that are high risk for use in older patients Ask lots of

2 Session Objectives Review expectations for IPPE and APPE students when consulting with patients about OTC choices Review treatment options, design, and implement a care plan for heartburn and other conditions amenable to self-care Review OTC medications that are high risk for use in older patients Ask lots of questions Outcomes Did it work? Treat or Refer Educate + Counsel Care Plan downloaded from 2

3 I-Clicker Quest-Scholar-Mac is primarily utilized during which element of the patient care process? a. Collect b. Assess c. Plan d. Implement downloaded from 3

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6 I-Clicker Determining if a patient is eligible for a nonprescription product for use in self-care occurs during which phase of the Pharmacist Patient Care Process? a. Assess b. Plan c. Implement d. Follow up downloaded from 6

7 Patient Case #1 Presented by P2 Students Taylor Tinsley and Sarah Edwards Patient Case #1 Please work with a partner Complete Encounter Worksheet 5-8 minutes Feel free to ask students about case details downloaded from 7

8 Patient Case #1 Heartburn Review Encounter Worksheet Q and A Related to the encounter Goals of Treatment For heartburn and dyspepsia: Provide complete relief of symptoms Reduce recurrence Prevent and manage unwanted effects of medications downloaded from 8

9 Product Selection for Heartburn Depends on: Frequency, Duration, Severity Assess: Is this a candidate for self-care? This is the EXCLUSIONS LIST, ie REFER downloaded from 9

10 Self-Care Dosing for PPIs Once daily for 14 days, may repeat in 4 months. Example Nexium Safer to recommend an H2RA before starting a PPI. Example Pepcid Non-Drug Therapy Always Elevate torso raise the head of the bed 6 8 inches wedge pillow Quit smoking Avoid foods and drinks that trigger ex. Alcohol, caffeine, juices, spicy foods Heartburn Diary correlate symptoms with worst food triggers Three (or four) balanced meals per day Smaller meals Reduced number of fatty and spicy meals Avoid eating late night meals up to 3 hours before bedtime Wear loose fitting clothing Cease NSAIDs, unless absolutely necessary Lose weight if obese downloaded from 10

11 Onset and Duration of Action: Products: Antacids: H2Inhibitors PPIs Tums Zantac Prilosec Mylanta Pepcid Prevacid Maalox Axid Nexium Alka seltzer Tagamet Dose Frequency Repeat Q 1 2 hours BID Once daily Severity of Symptoms Mild, less frequent mild, less frequent Severe To moderate when H2RAs fail. > 2x/wk or more Duration of action: minutes 4 10 hours hours May take 1 4 days for full relief. Onset of action: < 5 minutes minutes. Can be given 30 1 before food for prevention dosing. 2 3 hours I-Clicker What is the definition of frequent heartburn? a. Greater than two time per day b. Greater than two times per week c. Greater than two times per month d. Greater than two times per year downloaded from 11

12 Studies draw link to risks with PPIs CKD Study compared PPI and H2RAs. 28% in PPI group were more likely to develop CKD and 96% more likely to develop ESRD C Difficile Fractures Dementia Increase in ph of the stomach impairs body s natural defense against bacteria PPI use greater than 1 year increase risk of fracture of hip, wrist, and spine Study in post menopausal women and older men found an increase from 30% to 56% Calcium absorption from diet is reduced 41% after 14 days of PPI use. Statistically significant impairment in visual memory, attention, and working and planning function Studies draw link to risks with PPIs Long term use of Proton Pump Inhibitors linked with Dementia Chronic Kidney Disease Additional published data indicates that PPIs may increase the risk of: C. difficile infection Reduced magnesium levels Wrist, hip, or spine fractures Community acquired pneumonia PPIs have been added to the Beer s List Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Clinical Guidelines recommend on demand dosing downloaded from 12

13 GERD Clinical Guidelines Non-drug measures adjust diet, etc RX - for erosive esophagus PPI for 8 weeks plus additional 8 weeks if clearly needed (total 16 weeks) PPI if patient is on a long term NSAID. has diagnosed Barrett Esophagus has severe esophagitis, grade C or D has documented history of bleeding ulcer No recommendation for PPI use greater than one year Convert PPI to on demand dosing Can switch to H2RA for safer long term option I-clicker Approved instructions for us of an over the counter proton pump inhibitor is which of the following? a. Take 1 daily for 14 days, may repeat in 4 months if needed b. Take 1 daily indefinitely c. Take 1 daily for 30 days then stop d. Take 1 twice a day downloaded from 13

Case #1 Recommend non drug measures Pepcid OTC Twice a day 30-60 minutes AC.

gained in the OTC Therapies course in a pharmacy practice setting with actual patients and under the direct

14 Case #1 Recommend non drug measures Pepcid OTC Twice a day minutes AC. Could also add probiotic 10B units Objective for students at your site Practice utilizing their knowledge and skills gained in the OTC Therapies course in a pharmacy practice setting with actual patients and under the direct supervision of a pharmacist preceptor Develop their problem-solving and communications skills Develop life long learning skills downloaded from 14

QuEST-SCHOLAR-MAC Qu Quickly and accurately assess the patient E Establish if a candidate for self-care S Suggest appropriate strategies T Talk with the patient and explain plan S C H O L A R

15 QuEST-SCHOLAR-MAC Qu Quickly and accurately assess the patient E Establish if a candidate for self-care S Suggest appropriate strategies T Talk with the patient and explain plan S C H O L A R QuEST-SCHOLAR-MAC Symptoms? Characteristics of the situation? What are the symptoms like? History what have you tried? Has this occurred before? Onset when did it start? Location where is the problem? Aggravating factors what makes it worse? Remitting factors what makes it better? downloaded from 15

16 QuEst-SCHOLSR-MAC M Medications-Rx, non-rx, supplements, complementary and alternative therapy (CAM) A Allergies-Meds, foods, substance, reaction C Coexisting conditions? Present Case to Pharmacist Preceptor Student practices presenting patient to the preceptor in a Handoff SBAR format S Situation B Background A Assessment R Recommendation Pharmacist provides encouraging feedback to the student and helps the student build confidence in their ability to gather enough information, assess if the condition can be treated by self-care, create a plan, educate the patient, and plan for follow up. downloaded from 16

could occur Serious side effects related to the product Explain expected results and timeline of results Provide instructions for follow up

17 Patient Education Points Student Should Include Name of product recommended for the condition What it will do to help the patient When will the patient notice any effects Dose and directions for use including route of administration and duration of use Common side effects that could occur Serious side effects related to the product Explain expected results and timeline of results Provide instructions for follow up Case #2 Insomnia Complete encounter worksheet 5-8 minutes Ask students questions to clarify facts about the case downloaded from 17

18 High Risk Drug List for patient > 64 First-generation years old Antihistamines brompheniramine chlorpheniramine carbinoxamine cyproheptadine diphenhydramine clemastine Doxylamine hydoxyzine Promethazine triprolidine Second-generation antihistamines cetirizine fexofenadine loratadine desloratadine levocetirizine Insomnia Exclusions - Refer Men with BPH Angle-Closure glaucoma History or Angina or Arrhythmias Underlying Dementia Avoid alcohol Patients > 64 years old downloaded from 18

19 Non-Drug Measures Sleep Hygiene Diphenhydramine for Insomnia Approved for the management of transient and short term insomnia. Antihistamine: blocks H1 receptors Sleep Latency time till light sleep Improves sleep quality Time in REM sleep REM latency Next Day Sleepiness Tolerance develops within days of use 50mg nightly is the recommended dose for sleep 3 days use then an off day to assess sleep quality Do not use more than 7 10 days in a row refer for evaluation Caution additive sedation with other meds downloaded from 19

20 Diphenhydramine for Insomnia Drug Interactions (metabolized in the liver) CYP2D6 Inhibitor Reduced clearance of Metoprolol (especially in women 2 fold decrease in the clearance Propranolol Venlafaxine Codeine Diphenhydramine for Insomnia Counseling points: Take 30 to 60 minutes before you want to go to sleep Can cause morning grogginess or excessive sedation, dry mouth, blurred vision, constipation and difficulty urinating Do not take with alcohol; leads to additive CNS effects Do not take with prescription sleep aids to improve further sleep Avoid driving or operating heavy machinery Avoid if causes paradoxical effect excitation rather than drowsiness Caution: drug interactions with prescription medications that cause drowsiness or anti-cholinergic side effects. downloaded from 20

21 Melatonin for Insomnia Melatonin FDA approval for sleep problems in blind patients Used for insomnia, jet lag, shift work related sleep issues Makes attempts to go to sleep more successful. Note Does not cause drowsiness Works by regulating sleep and circadian rhythms It s release is induced by darkness and suppressed by light Melatonin for Insomnia Dosing: Insomnia: mg min before bedtime Jet Lag: 2-5mg the evening of arrival at destination and At bedtime for the following 2-5 days Shift work: - Evidence does not support AEs: rare N/V, HA, increased HR, Irritability and worsening of depression and morning hangover. Drug interactions with: Fluvoxamine (Luvox ), MAOIs, TCAs, Benzodiazepines Valproate Chemotherapy downloaded from 21

22 I-Clicker These patients have no comorbidities; which of these is eligible for the use of diphenhydramine? a. 78 year old with insomnia b. 48 year old with insomnia c. 18 month old with a runny nose What to expect from students: Phone call or contact prior to start of rotation Two 5-hour shifts with at least 24 hours between Licensed preceptor must be on duty Student must complete at least one Self-Care Encounter Worksheet to turn in Students should wear pharmacy appropriate attire and white coat Students to view the layout of the OTC section downloaded from 22

23 What students expect from preceptors: Students are expected to do thorough consults Show me preceptor demonstrates how to meet, greet, and consult with OTC patients Please show student where in the pharmacy to discuss the handoff SBAR Coach the student accordingly Goal for the student Utilize recently learned knowledge Provide appropriate patient education Develop problem-solving and communication skills Develop the discipline for life-long learning and understand the dynamic nature of care guidelines downloaded from 23

24 Questions Students or instructor downloaded from 24

Heartburn, also referred to acid reflux, happens when stomach acid flows back (refluxes) into your esophagus.

Heartburn, also referred to acid reflux, happens when stomach acid flows back (refluxes) into your esophagus. WHILE almost everyone experiences mild heartburn from time to time and many individuals have some antacids or another medication on hand for its relief, talk to your doctor, if you have heartburn more