5 Clinical Pearls on Alpha Blockers

1. Alpha blockers in females:  I remember a urologist getting frustrated with pharmacists who would always question why he was using Flomax (tamsulosin) in female patients.  You will see alpha blockers used off label in females with bladder outlet obstruction/ureteral stones.
2. Dosed at night: Why?  Because of the risk of first dose syncope, it is recommended that these medications are dosed at night, right before bed.
3. Tamsulosin 0.8 mg daily dose.  Patient adherence is one of the greatest challenges facing the healthcare system in relation to medications.  I’ve seen this dose restarted a couple times when the patient had not been taking it for a while.  If patients are on tamsulosin 0.8 mg daily, and therapy gets interrupted for several days, it is recommended to start over at the lower dose (per Lexicomp).
4. Alpha blockers drop blood pressure (duh…used for hypertension).  What this leads to clinically, and especially in the elderly is the risk for falls.  The highest risk time for orthostatic hypotension is when the medication is first started or increased.  Another situation to keep a close eye on is when another antihypertensive is added.
5. Alpha blockers work quickly: In a patient with worsening retention due to BPH, alpha blockers provide relief quickly compared to the 5 alpha reductase inhibitors (finasteride, dutasteride) which can take up to months to start providing relief.

Preceptor Roles in Teaching Clinical Problem Solving

Preceptor Roles in Teaching Clinical Problem Solving

"Preceptors must demonstrate a desire and an aptitude for teaching that includes mastery of the four preceptor roles fulfilled when teaching clinical problem solving (instructing, modeling, coaching, and facilitating). Further, preceptors must demonstrate abilities to provide criteria-based feedback and evaluation of resident performance. Preceptors must continue to pursue refinement of their teaching skills."

1. Direct Instruction

Direct instruction is the teaching of content that is foundational in nature.   Direct instruction fills in information that is necessary to acquire before skills can be applied or performed.  For example, before a resident can learn to develop a medication regimen for an asthmatic patient, he or she needs to master information about asthma, potential treatments for asthma, the latest research and its implications and other pertinent information about asthma and its treatment.  Direct instruction in the form of assigned books, lectures, articles and discussions help a resident acquire this information.  This preceptor role is appropriate at the beginning of a residency or learning experience when foundational information is needed before assuming a responsibility. 

Direct Instruction of Residents vs Students

Direct instruction of residents differs from classroom instruction of students. When a resident has a knowledge gap, it is usually most appropriate to refer them to relevant resource materials and then check their understanding of the material. Mini-lectures that resemble classroom instruction of students should be avoided or minimized, keeping in mind residents' greater ability to be independent in acquiring knowledge as compared to students.

2. Modeling

 Modeling is demonstrating a skill or process while "thinking out loud" so the resident can witness the thoughts or problem-solving process of the preceptor, as well as the observable actions.  For example, the resident observes a preceptor develop a medication therapy regimen and monitoring plan for an asthma patient while the preceptor simultaneously explains the thought and problem-solving process that would normally go on silently.  The resident sees and prepares to emulate the modeling example(s). 

This preceptor role is most appropriate after it has been determined that the resident has the appropriate amount of background information and is ready to begin to learn to perform a task or responsibility.  

3. Coaching

Coaching is allowing a resident to perform a skill while being observed by the preceptor, who provides ongoing feedback during the process.  For example, after the resident has acquired the necessary background information (direct instruction) and observed the preceptor model the development of a medication therapy regimen and monitoring plan for an asthma patient (modeling), the preceptor allows the resident to develop a regimen and monitoring plan for another asthma patient and asks the resident to "think out loud" so the preceptor can observe the resident's thoughts and actions.  The preceptor gives feedback during the process. 

This preceptor role is appropriate after the resident has had the opportunity to observe modeling of the process he/she is about to take on but is not yet ready for independence.  The coaching process allows fine tuning of the resident's skills as well as assuring the preceptor that the resident is ready to move to greater independence.  When the preceptor no longer feels the need to provide corrective feedback to the resident while they perform the task at hand, it is time to move to the next preceptor role: facilitating.

4. Facilitating

 

Facilitating is allowing the resident perform independently, while the preceptor remains available if needed and de-briefing with the resident after the fact.  Facilitating occurs when the preceptor has coached the resident and is confident in his/her ability to function independently.  For example, after assigning readings on asthma, modeling and coaching the development of medication therapy regimens for asthma patients, the preceptor has observed the resident do this successfully and no longer needs to provide corrective feedback.  The facilitator gives his/her contact information to the resident, sets up an appointment to meet with him/her later and leaves him/her with the responsibility for the asthma patients. This preceptor role is appropriate when both the preceptor and resident feel confident of the resident's ability to function independently.  This role normally occurs toward the end of a learning experience and the residency as a whole.

Once you have reached the facilitating role, be sure to make residents responsible for progressively more complex patients. If they are able to treat typical asthma patients, ensure they can treat asthma patients with multiple conditions that must also be considered. It is important to keep challenging residents at this stage of their training.

Acute Coronary Syndrome (ACS)

Understanding Acute Coronary Syndrome (ACS)

Albumin and Phenytoin, You Can Have a Lot of One Without the Other

Albumin is a protein found in the bloodstream of the body, and it can have a significant impact on medications.  One of those classic medications that albumin can impact is phenytoin.  Albumin and phenytoin stick together.

How does this matter clinically?  When albumin levels are higher (or normal) there is more albumin available to “stick” to phenytoin.  When albumin levels go lower, there is less albumin for the phenytoin to bind to.  When albumin is low, what this leads to is a significantly higher amount of free phenytoin which can exert its activity in the body.

The most common scenario I’ve seen low albumin in is in malnourished patients.  You may see a higher likelihood of phenytoin toxicity even at “normal” total blood concentrations in a patient who has a low albumin.

There are a few ways to monitor for this.

1. Monitor for signs/symptoms of toxicity and or seizures (if that is the indication).
2. Checking albumin to see if it is trending downward (if concerned about toxicity).
3. Use a corrected phenytoin level based upon the current albumin (always remember that this should go hand in hand with clinical monitoring of a patient).
4. The other option would be to do a free phenytoin level.  This may be more expensive and may have to be sent out if you work in a more rural setting.
    

Lithium NSAID Interaction – Case Study

Lithium NSAID Interaction – Case Study

A 44 year old male has a past medical history of IBS, bipolar disorder, and depression.  Today he presents to an urgent clinic with symptoms of nausea and vomiting.  He also states that he feels weak and has been shaky.  Upon further investigation, he recently has been complaining of back pain due to an injury at work.

He had a clinic appointment about 2 months ago and his lab work was unremarkable at that time.  His lithium level was 0.8.  A lithium level was now drawn today and came back at 1.9.  Kidney function has remained stable for this patient.

Upon investigating his medication regiment, he has been taking ibuprofen.  The lithium NSAID interaction is well known.  Lithium is an incredibly important drug for patients who require this medication.  There are lots of clinical pearls with this medication and risk of drug interactions is a very big one.

Concentrations of lithium can be elevated by the use of NSAIDs and at a minimum, we need to monitor our patients closely and educate them about the risks of the lithium NSAID interaction.

What Advantages Does Warfarin Have Over NOACS?

What Advantages Does Warfarin Have Over  New Oral Anticoagulants (NOACS)?

We all know the negatives of warfarin, but lets take a look at the advantages of warfarin.  NOACs are gaining in popularity, no doubt about that.  No matter which anticoagulant we are using, we must recognize that there are always positives and negatives.  It is incredibly important to recognize those positives and negatives to best take care of our patients.  So what advantages does warfarin have over the newer oral anticoagulants like the factor 10A inhibitors and direct thrombin inhibitors?

1. Valves; Warfarin is indicated and we have experience with it in the treatment of atrial fibrillation in patients who have had a valve replacement.  At this time, there isn’t any of the NOACs that have the indication to use with artificial valves.
2. INR; Is lab monitoring a good thing or a bad thing?  For most patients lab monitoring is definitely frustrating.  Coming in monthly or more often can be a big inconvienece in their life.  Frequent dose changes can potentially increase the risk for something to go awry.  The good side of INR monitoring?  The INR can help guide us as far as patient adherence.  If a patient stops taking their NOAC or is very inconsistent, by the time we find out, it may be too late.  Adherence is something you should take VERY seriously with the new oral anticoagulants
3. Kidney disease; In later stages of kidney disease, warfarin is the medication with the most experience of use and will likely be the drug of choice.  Contraindications and/or dose adjustments exist with the NOACs.

Rifampin and Phenytoin Interaction

Drug interactions can make medication management challenging.  Here’s a classic case demonstrating the rifampin and phenytoin interaction.  A 47 year old patient with diabetes and seizure disorder is diagnosed with new onset osteomyelitis. The patient’s seizures were well controlled on phenytoin as they had not had one in well over a year.  The latest total phenytoin level was 11.


As part of the antibiotic regimen for the osteomyelitis, the patient is placed on rifampin. Within 3 weeks of starting rifampin, the patient had a seizure.  At the time of the seizure, the labs were checked and revealed a substantial deviation from previous phenytoin levels.  The phenytoin level was 6.7 likely due to the rifampin and phenytoin interaction as the patient had been previously well controlled.

It was decided that the dose of phenytoin would be increased with close monitoring for toxicity as well as for seizures.  They wanted to stay on top of the levels, so it was elected to check the phenytoin level on a weekly basis.  This allowed for adequate monitoring when the course of rifampin for osteomyelitis had been completed.

Pharmacist recognized for natural approach to health - Mississauga

   

Pharmacist recognized for natural approach to health - Mississauga

In order. Pharmacist Fahd Bahrani has received the Order of Merit from the World Organization of Natural Medicine for his practice of combining medicine with natural supplements, vitamins and herbal and homeopathic treatments to optimize the healing process. Here, he stands proudly next to his award in the dispensary of his family-owned Village Pharmacy and Health Food in Port Credit. Supplied photo

MISSISSAUGA — The World Organization of Natural Medicine recently awarded Fahd Bahrani the prestigious Order of Merit for his commitment to natural medicine and healthcare.

In North America, pharmacists are seen as linking health sciences with the chemical sciences. Awards for natural medicine aren't all that common.

Bahrani works at Village Pharmacy and Health Food, at 225 Lakeshore Rd. E. in Port Credit. The store is owned by his family.

After attending elementary and secondary school in Mississauga's village by the lake, Bahrani headed off to Ohio Northern University to acquire his Doctor of Pharmacy degree and furthered his education at the University of Florida.

He has made a practice of dispensing traditional medicine and advising customers on the benefits of herbal and homeopathic treatments, and how to complement the healing process with vitamins, supplements and herbs.

It's a uniquely holistic approach to healthcare that customers can access with free consultations with pharmacists, homeopaths and other health professionals.

The store also stocks an inventory of natural and health foods.