• Improve health literacy about medications
• Allows last-step assessment of understanding
• May minimize patient errors in drug administration
• Professionally: demonstrates our knowledge and skill

• Patient's perception/understanding of the need for counseling
• Time (pharmacist/patients)
• Pharmacy environment
• Pharmacist's self-confidence
  

• Pharmacists shall provide oral consultation to his/her patient or the patient's agent in all care settings

1. Upon request or whenever the pharmacist deems it is warranted
2. Whenever the Rx drug has not been previously dispensed
   

• This is not required when the patient refuses such consultation
  

• Name and description of the medication
• Route, dosage form, dosage, and duration
• Special directions for use and storage
• Precautions for preparation/administration
• Importance of compliance with directions
• Theraoeutic contraindications and relevant warnings
• What to do with a missed dose
• Refill information
  

• Establish relationship with patient and develop trust
• Demonstrate concern and care
• Help patient manage and adapt to their medication
• Prevent/minimize problems associated with side effects or poor adherence
• Develop patient's capacity to deal with such problems
• Help patient and other health care professionals work together toward shared-decision making
  

• Provide information appropriate to the particular individual and problem
• Provide skills and methods that the patient can use to optimize the usage and effects of the medication
• Present information and instruction using educational methods tbat are appropriate to the particular individual and situation
• Educate other health care professionals about drug-related issues
  

• Introduce yourself
• Identify the patient or the patient's agent
• Ask if the patient has tiem to discuss medication
• Explain the purpose of the counseling session
  

• Ask what patient understands about their medicine. Also, ask what they understand about their disease
• Ask if the patienthas any concerns
  

• Name, indication, route
• Dosage regimen
• Problem taking as prescibed?
  
• How long before medicine takes effect
• Duration of therapy
• Common/important side effects and how to manage
• Rare side effects
• Drug-drug interactions
• Storage and ancillary recommendations
• Discuss activities to avoid
• Discuss beneficial activities (non-drug counseling)
• What to do if a missed dose
• When to come back for a refill
  

How do you close the session during a patient counseling?

• Check for understanding by asking patient to repeat back key information
• Recheck for additional questions or concerns
• Advise patient to always check their medicines before leaving the pharmacy
• Set up a follow up plan

• What did your doctor tell you this medicine is for?
• How did the doctor tell you to take this medicine?
• What did the doctor tell you to expect?
• Very medicine focused: need to bring in other (helping) elements of patient counseling
  

• Qu: quickly and accurately assess the patient (SCHOLAR - symptoms, charactersitics, history, onset, location, aggravating factors, remitting factors)
• E: establish whether patient is appropriate for self-care
• S: Suggest appropriate self-care strategies
• T: Talk with the patient about those strategies
  

• Counsel fully, if possible. But if not, possible, pick your counseling battles
• high risk drugs - narrow TI drugs which can be dangerous,
  
• high risk patients - new rxs, patients with multiple medications, history of poor adherence)
• Counseling should improve safety
  

Fatty foods - alcohol - spicy foods - caffeine - carbonated beverages - citrus fruits and juices - chocolate - salt and salt substitutes - garlic - onions - mint

• Tobacco
• Exercise
• Obesity
• Stress
• Supine body position
• Tight fitting clothing around waist
• Pregnancy

1. Gastroparesis
2. Schleroderma
3. Peptic ulcer disease
4. Zollinger-Ellison syndrome (gastrin secreting tumor)
   

1. NSAID's
2. Aspirin
3. COX-2 Inhibitors
4. Biphosphonates
5. Potassium supplements
6. Iron supplements
7. Tricyclic antidepressants
8. Calcium channel blockers
9. Beta blockers
10. Theiphylline
11. Nitrates
    

Antacids - for mild pain                             

-Magnesium salts (OH, CO3, Si3)

-Aluminum salts (OH, PO4)

-CaCO3

-NaHCO3

-Take as needed

-Repeat in 1-2 hrs

-Do not exceed max daily dosing

Histamine-2 Receptor Antagonists - mild to moderate pain

-Famotidine (Pepcid) - 10mg(mild) to 20mg(moderate)

-Ranitidine (Zantac) - 75mg (mild) to 150mg(moderate)

-Nizantidine (Axid XR) - 75mg

-Cimetidine (Tagamet) - 200 mg

-Take as needed up to twice a day

-Famotidine 10mg/CaCO3 800mg/MgOH 165mg (Pepcid Complete)

      *Take after a meal as needed

-Antacids neutralize acid and increase LES pressure/tone

-H2's decrease gastric acid secretion by competitive and selective inhibition of histamine-2 receptors on parietal cells

• frequent heartburn > 3 months
• OTC meds unresponsive after 2 weeks
• Rx therapy unresponsive
• nocturnal heartburn
• pregnancy
• Breastfeeding mothers
• Chest pain radiating to arm/neck/jaw and accompanied by sweating
  

• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• upper GI bleed (vomiting blood; tarry black stools)
• Continuous nausea/vomiting/diarrhea
• Unexplained weight loss
• Anemia

• Render the patient symptom free
• Prevent meal or exercise related symptoms
• Improve the quality of life
• Prevent complications

-Mg products: diarrhea

-Ca products: constipation

-Al products: constipation, hypophosphatemia

-CO3/HCO3: flatulence, belching

1. antibiotics (fluoroquinolones, tetracyclines, macrolides)
2. Rilpivarine, atazanavir, phenytoin
3. Ketoconazole, enteric coated drugs

Mitigated by taking antacids two hours after these drugs.

headache - nausea - diarrhea - constipation - dizziness/drowsiness - thrombocytopenia (rare)

-Cimetidine: impotence, gynecomastia (breast enlargement in males)

ripivarine - atazanavir - phenytoin - ketoconazdle.

For cimetidine (CYP450 inhibitor): wafarin, phenytoin, theophylline

-Renal disease

-CHF: NaHCO3

• Weight loss
• Elevate head
• Eat smaller meals
• avoid laying down after 2-3 hours of eating
• Limit dietary risk factors
• Stop smoking
• Avoid tight fitting clothes
• Promote salivation (chew gum)
  

Proton Pump Inhibitor

-Irreversible inhibition of proton pumps on parietal cells

-Omeprazole (Prilosec) - 20 mg

-Lansoprazole (Prevacid) - 15mg

-Omeprazole/NaHCO3 (Zegerid) - 20/1100mg

Take once a day by mouth 30 minutes before eating for two weeks.

Any drugs that require low pH for uptake. HIV meds such as rilpivarine, atazanavir, phenytoin, and ketoconazole

.

Omprazole/esomeprazole > lansoprazole/dexlansoprazole > pantoprazole/rabelprazole (CYP450 2C19 inhibitors)

   -decrease clopidogrel levels

1. Bleeding
2. Esophageal strictures
3. Erosive esophagitis
4. Barrett's Esophagus
5. Esophageal cancer
   

• Epigastric discomfort
• Bloating
• Belching
• Nausea
• Satiety
• Heartburn/acid regurgitation (sometimes)
  

• NSAIDs
• Bisphosphonates
• Iron supplements
• Digoxin
• Theophylline
• Eryhromycin
• Ampicillin
  

• Peptic Ulcer Disease (PUD)
• GERD (Gastroesophageal Reflux Disease)
• H. pylori
• GI dysmotility

1. Render the patient symptom free
2. Prevent meal or exercise related symptoms
3. Improve the quality of life
4. Prevent complications

1. Lower esophageal spincter - muscle at bottom of esophagus
2. Bicarbonate base in saliva - neutralizes acid
3. Intrinsic mucosal resistance
4. Esophageal contractions
5. Gravity when upright
   

• Cardia
• Fundus
• Antrum

Mucus Neck Cells

-Located in cardia

-Secrete mucus

-Protect gastric epithelium against acidic pH

Chief cells

-Located in fundus

-Secrete pepsinogen=> pepsin at low pH. Breaks down protein.

Parietal Cells

-Located in fundus

-Contain 3 proton pumps - gastrin pump receptor, Ach receptor, histamine receptor (H2RA-specific)

-HCl combines with pepsin to form proteolytic complex

G Cells

-Located in the antrum

-Secrete gastrin (hormone)

-Stimulates HCl secretion on parietal cells, histamine secretion on ELC cells.

-Regulates gastrin by negative feedback from acid levels in stomach

How do NSAIDs contribute to Peptic Ulcer Disease?

NSAIDs inhibit prostaglandin synthesis and directly irritate gastric and duodenal mucosa. Prostaglandins inhibit gastric acid secretion and stimulate bicarbonate mucus production. NSAIDs results in lot of acid build up with little mucus production

• Discontinuation can lead to acid rebound
• Decreased absorption of nutrients (minimal effect with OTC 2 week treatment)
• Increased risk of hip fractures
• Increased risk of enteric infection. If patient experiences diarrhea that won't go away, refer!
  

• What is the nature of the symptoms?
• What is the severity of the symptoms?
• How long has the patient had these symptoms?
• When do the symptoms usually occur?
• Has the patient tried anything yet? What has worked? What has not?
• Does the patient have any medication allergies?
• Is the patient currently taking any other medications?
• Does the patient have nay lifestyle factors that are triggers?
  

• Physiologic changes - decreases GI tract, renal impairment
• Average older patient takes 6.5 meds
• Older patients are at higher risk of developing complications
  

• Full assessment of patient
• Antacids should be used after full assessment; use lower doeses of H2RAs, avoiding use in elderly patients with or with high risk of developing dementia or CNS issues
  

1. Symptoms may be different: anorexia, dysphagia, failure to thrive, wheezing, coughing
2. More often, refer: poor weight gain, spitting up unexpected contents, breathing/feeding problems, lethargy
3. Lifestyle modifications: elevate head of crib, smaller feedings, loose clothings/diapers, antiregurgiant formula

Rilpavarine.

Plavix + Omeprazole

PPIs + Methotrexate

• Name/Address of patient
• Name/quantoty of drug and directions for use
• Date of issue
• Name/addresss/telephone of prescriber. If controlledm license classification and DEA
• Indication of drug (if requested by patient)
• Signature of presciber issuing order
• It is NOT required in CA to list # of refills
• Applies to all prescriptions, even over the counter.
  

• Does not need to include doctors address/telephone/DEA
• Does not need to have patients address
• Chart order signed by practitioner, if present, or if not present within 48 hours.
  

Before meals

1. Increase awareness of at-risk patient populations
2. Avoid abbreviations and nomeclature
3. Recognize look-alike and sound-alike medications
4. Focus on high-alert medications
5. Report errors
6. Educate patient
   

1. Identify purpose of patients visit
2. Uncover facts about patient history
3. Discuss patient condition
4. Discuss current management plan
5. Revise and adjust management plans to make them realistic for the patient
   

1. Develop relationship with patient
2. Develop trust with patient
3. Obtain patient's perspective on their health
4. Respect for the patient and yourself
5. Empathy for the patient's situations
6. Nonjudgmental attitude
   

Environmental

-small counseling space that do not promote privacy

-high counter, phone ringing, counseling on the phone

Personal (pharmacist) barriersL

-differences in languages, gender, cultural, age

-Different personal belief or values

Patient related barriers

-Western vs eastern medicine, patients with disabilities, patients disease state

Administrative barriers

-Time, expectations, insurance

• Physical Distance
• Eye contact
• Touch
• Body movements
• Facial expressions
  

1. Reduce or remove barriers to effective communication
2. Practice using lay language
3. Ask questions that elicit more information
4. Listen actively and respond
5. Be aware of the role non-verbal communication can play in a successful interaction

1. Demographic information: age, weight, address, telephone number
2. Insurance information
3. Pharmacy used
4. Dietary information
5. Allergies: description of rxn, treatment
6. Medication: prescription, non-prescription, and dietary/herbal - drug name, dose, frequency, indication, length of therapy, and prescribed length of therapy, prescribed length of therapy, perceived effectiveness and any side effects, and medication adherence.
7. Lifestyle factors: tobacco, caffeine, drugs
8. Sensitive issues

1. Smoking harms nearly every organ in the body, causing many diseases and reducing the health of smokers in general
2. Quitting smoking has immediate as well as long-term benefits, reducing riks for diseases caused by smoking and improving health in general
3. Smoking cigarettes with lower machine-measured yeilds of tar and nicotine provides no clear benefit to health
4. The list of diseases caused by smoking has been expanded.
   

Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction. The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs

Nicotine - 2 hrs

Cotinine - 16 hours

• Irritability/frustration/anger
• Anxiety
• Difficulty concentrating
• Restlessness/impatience
• Depressed mood/depression
• Insomnia
• Impaired performance
• Increased appetite/weight gain
• Cravings
  

Environment

-Tobacco advertising

-Conditioned stimui

-Social interactions

Physiology

-Age, sex

-Genetic disposition

-Coexisting medical conditions

Pharmacology

-Alleviation of withdrawal symptoms

-Weight control

-Pleasure, mood modulation

• Physiological - the addiction to nicotene
• Behaviorial - the habit of using tobacco

Treatment shoudl address both aspects of dependence

Ask: about tobacco use

Advice: tobacco users to quit

Assess: readiness to make a quit attempt

Assist: with the quit attempt

Arrange follow up care

Relevance

Risk

Rewards

Roadblocks

Repetition

• Helps patients to understand when and why they use tobacco
• Identifies activities or situations that trigger tobacco use
• Can be used to develop coping strategies to overcome the temptation

• Review commitment to quit
• Distractive thinking
• Positive self-talk
• Relaxation through imagery
• Mental rehearsal and visualization

• Control your environment
• Use substitutes for smoking
• Relaxation techniques
• Actively work to reduce stress, obtain social support, and alleviate withdrawal symptoms

• Cold turkey
• Unassisted tapering
• Assisted tapering (quitkey - computer developed taper based on patient's smoking level)
• Formal cessation programs (self-help, telephone counseling, group programs, web based)
• Acupuncture
• Hypnotherapy
• Massage therapy

• Nicotine replacement therapy - gum, patch, lozenge, nasal spray, inhaler
• Psychotropics - sustained release bupropion
• Partial nicotinic receptor agonist - varenicline

• Smokeless tobacco users
• Individuals smoking less than 10 cigarettes a day
• Adolescents

Patients with a recent myocardial infarction

Serious arrhythmias

Serious or worsening angina

Adv: satisfies oral cravings, might delay weight gain (4mg), patients can titrate therapy to manage withdrawal symptoms, a variety of flavors available

Dis: Need for frequent dosing, might be problematic for patients with dental work, patients must use proper chewing technique to minimize side effects, gum chewing may not be socially acceptable

Adv: Satisfies oral cravings, might delay weight gain, easy to use and conceal, patients can titrate therapy to manage withdrawal symptoms, several flavors

Dis: Frequent dosing needed, GI side effects may be bothersome

Adv: provides consistent nicotine levels. Easy to use and conceal. Once daily dosing associated with fewer compliance problems

Dis: Patients cannot titrate the dose to acutely manage withdrawal symptoms. Allergic rxns may occur. Patients with dermatologic conditions should not use the patch

Adv: patients can easily titrate therapy to rapidly manage withdrawal symptoms

Dis: Need for frequent dosing can compromise compliance. Nasal/throat irritation may be bothersome. Higher dependence potential. Patients with chronic nasal disorders or severe reactive airway disease should not use the spray.

• Mild irritation of the mouth or throat
• Cough
• Headache
• Rhinitis
• Dyspepsia

Do not eat or drink 15 mins before or while using inhaler.

Adv: Patients can easily titrate therapy to manage withdrawal symptoms - the inhaler mimics the hand to mouth ritual of smoking.

Dis: Need for frequent dosing - initial throat/mouth irritation can be irritating - cartridges should not be stored in very warm/cold conditions - patients with bronchospastic disease must use the inahler with caution

generic: Bupropion SR

Therapeutic class: sustained-release antidepressant

Indication: Tobacco addiction

Bioavailability: 5-20%

Metabolism: Hepatic (CYP2B26)

Elimination: Urine (87%) and feces (10%)

Half life: 21 hours, metabolites - 20-37 hours

Patients with seizure disorder

Patients taking Wellbutrin, MAO inhibitors in preceding 14 days

Patients with anorexia or bulimia nervosa

Patients undergoing abrupt discontinuation of alcohol or sedatives

• Neuropsychiatric symptoms and suicide risk
• Patients should stop bupropion and contact a health care provider immediately if agitation, hostility, depressed mood or changes in thinking of behavior are observed

-Patients with history of seizure

-Patients with cranial trauma

-Patients taking medications that lower seizure threshold (antidepressants, systemic steroids)

-Patients with severe hepatic cirrhosis

-Patients with depressive or psychiatric disorders

150 mg by mouth every morning for 3 days. Then 150 mg by mouth twice a day. Duration of therapy: 7-12 weeks.

No tapering necessary, if no significant progress toward abstinence is made by week 7, discontinue treatment as it is likely ineffective

Common: insomia (avoid bedtime dosing), dry mouth.

Less common: tremors, skin rash

Adv: Easy to use oral formulation - twice daily dosing might reduce compliance problems - might delay weight gain - might be beneficial for patients with depression

Dis: Increased risk for seizure - several contraindications and precautions in some patients

Absorption: Virtually complete after oral admin; not affected by food

Metabolism: Undergoes minimal metabolism

Elimination: Primarily renal through glomerular filtration and active tubular secretion; 92% exctreted unchanged in urine

Half life: 24 hours

Changes in mood, psychosis, hallucinations, paranoia agitation.

Patients should stop varenicline and contact a health care provider immediately if agitation, hostility, depression mood, or changes in thinking or behavior.

Day 1-3: 0.5 mg once a day

Day 4-7: 0.5 mg twice a day

Day 8 to end (up to 12 weeks): 1 mg twice a day.

Take after eating with a full glass of water.

Stop taking at first sign of rash with mucosal lesions. Contact HCP immediately.

Stop taking if swelling of face, mouth, neck are noted.

Adv: easy to use oral formulation; twice daily dosing might rduce compliance; offers new mechanism of action

Dis: May induce nausea; potential for neuropsychiatric symptoms

Products work best in alleviating the withdrawal symptoms when used correctly, and accord to the recommended dosing schedule

How much smoker's nicotine yield per cigarette?

• Social determinants
• Access to care
• Health care

• Providing care and services for at risk pop
• Helping patients navigate the health care system
• Identifying sources of and facilitating access to devices/medications/medical supplies for those who cannot afford it
• Facilitating continuity of care between different health care settings where care and services are accessed. provided, and/pr delivered
• Communicate effectively by tailoring communication to a patients or family's health literacy and language preferances
  
• Educating patients about their health, health management, medications, devices, and supplements