Foot, skin and mucous membranes
Due vascular changes and
peripheral neuropathy à alter nerves that
control blood flow and skin hydration
Infection by staph,
beta-hemolytic strept, fungus à cutaneous infection (furunculosis, carbuncles), Candida (genital,
upper thighs, under breast), cellulites, lower-extremity vascular ulcers
Atrophic round painless lesions,
diabetic dermopathy (red-brown popular spots) esp. in lower extremities.
Necrobiosis lipoidica
diabeticorum (ulcerative necrotic lesion)
Peripheral neuropathy à loss of protective sensation, inability to detect minor
trauma à ulcers
Infection, injury, neuropathy,
vascular disease à gangrene
Sensory exam of feet (protective
sensation) à 10 g monofilament
Protective footwear (deep sole
shoes, molded shoes, orthotics)
Significant interactions affecting glycemic control
Hyperglycemia (direct glucogenic effect): corticosteroids, furosemide, thiazides, sunburns,
nicotinic acid, phenytoin, pentamidine, protease inhibitors, sympathomimetics,
isoniazid, sulfinpyrazone, theophylline toxicity.
Hypoglycemia: MAO-I,
fluoxetine, salicylates (↑
dose), alcohol, fenfluramine, pentamidine
Prolonged hypoglycemia / masking hypoglycemic symptoms: B1 beta blockers (e.g. propranolol)
Therapy
Medical nutrition therapy (MNT)
Carbohydrate counting: 50% of total calories. DM
therapy may include pre-meal short acting bolus insulin (lispro, regular,
semilente). Otherwise, maintain
consistent CHO intake.
Fat: limitations
on type and amount. Critical for weight
loss and treating hyperlipidemia. Target: < 30% of calorie intake and <
300 mg/day cholesterol.
Protein: important
in end stage renal disease and may delay dialysis.
Fiber: bran, beans, fruits, vegetables may help BG and lipids.
Alter diet based on stress,
illness, exercise, etc.
Spaced meal intervals help match
hypoglycemic therapy effect.
Physical activity
Careful exercise ↑ cell glucose uptake à ↓ BG
Careful if patient has severe
retinopathy.
Patients with cardiovascular
disease or over 45 à cardiovascular
evaluation and stress test.
Aerobic activity: e.g.
swimming, walking, running, preferred due to positive effect on BG (↓), cardiovascular, BP, lipids, circulation, weight loss.
Anaerobic activity: e.g.
weight lifting, should be avoided.
Potential negative cardiovascular, BP, retinopathy effects.
Insulin and insulin analogues
For type 1 DM and only
uncontrolled type 2.
Mechanism / structure: see above
Factors ↑ insulin requirement: infections,
weight gain, puberty, inactivity, hyperthyroidism, Cushing’s disease
Factors ↓ insulin requirement: renal
failure, weight loss, ↑
exercise, nutrient malabsorption, hypopituitarism, adrenal insufficiency.
Concentration: U-100
or U-500 for insulin resistance.
Source: human,
bovine, porcine, synthetic (Lispro insulin, Humalog), or a mixture. Human
insulins are made by enzymatic conversion of terminal amino acid of porcine
insulin (Novolin, semisynthetic), or by recombinant DNA (Humulin). Human
insulin à ↓
antigenicity.
Short-acting: Lispro à synthetic, shortest onset and duration. Regular à soluble insulin with neutral pH, only clear insulin
(IV), only insulin that can be mixed freely.
Semilente (prompt insulin
zinc suspension) à finely divided amorphous prep, use acetate buffer, mix only with
other lente, similar duration to Regular,
Aspart insulin analogues.
Intermediate-acting: NPH (isophane insulin suspension) à similar to protamine zinc but with no excess protamine. Lente (insulin zinc suspension) à mixture of 70% ultralente crystals and 30% semilente
powder.
Long-acting: Protamine zinc à use phosphate buffer.
Ultralente (extended release
zinc suspension) à large crystalline. Glargine
insulin analogue (very long acting).
Pre-mixed insulin: 50/50 Regular/NPH,
70/30 Regular/NPH, 75/25 Lispro/Protamine Lispro à regular as pre-meal bolus and NPH intermediate for later
control of hyperglycemia. Other mixtures
can be prepared extemporaneously for tailored ratios.
DM Type 1 example: pre-breakfast
is 2/3 of total daily dose (TDD) 1:2 short : intermediate. Bedtime is 1/3 of TDD 1:2 like
pre-breakfast. Or give pre-supper
rapid/short and then bedtime intermediate.
DM type 2 example: bedtime
only or 2-3 daily injections.
Subcutaneous: for
routine administration. Absorption of
regular insulin is fastest from abdomen > arm > buttock > thigh. Monitor variations in absorption. Randomly rotate injection site to avoid
lipohypertropy. If ↑ variations à avoid random rotation of injection site. Exercise, hot showers,
baths, massages à ↑ blood flow to
injection site. Abdomen is least likely
to have ↑ absorption à preferred site for pre-exercise insulin.
Continuous Intravenous (insulin drip): provide Regular
insulin for acute hyperglycemia, ketoacidosis, HHNK, or during surgery.
Continuous SC infusion (insulin pump): short acting insulin is infused continuously during the
day to deliver ↓ doses (basal
insulin). Bolus dose (determined by
algorithms) is delivered by the patient before each meal. Offers tighter
glycemic control. Used for diabetics with ↑ BG fluctuations, irregular work schedules, lifestyles,
or meals. Require frequent SMBG (BG
self-monitoring) and training.
SE: hypoglycemia (tachycardia,
sweating, hunger, convulsions and insulin shock), hypersensitivity, injection
site local irritation.
Insulin secretagogues
Drugs (all acidic): Sulfonyrlureas: First gen: chlorpropamide, tolbutamide, acetohexamide, tolazamide,
more lipid-soluble, more potent. Second gen: glyburide, glipizide,
glimperide. Also repaglinide.
Mechanism: block
ATP-sensitive potassium channels à ↑ insulin pancreatic release (primary), and also as
sensitizers with time (secondary).
Use: Type 2
(useless in type 1, require functioning beta cells).
Chlorpropamide: longest
duration of action. CI in liver and
kidney disease. ↑ SE severity and frequency, disulfiram-reaction (also
with tolbutamide).
Use insulin instead during
stressful conditions (↑
risk of hyperglycemia due to ↑
counter-regulatory hormones release).
SE: severe /
prolonged hypoglycemia (esp. in the elderly, w/ glipizide / glyburide), GI upset,
sulfa sensitivity, sun sensitivity, headache, rash, tachycardia, hematologic
problems, cholestatic jaundice.
CI: allergy to
sulfa drugs, pregnancy, lactation.
Altered protein binding of sulfonylureas: alcohol, salicylates, NSAID’s, methyldopa, chloramphenicol,
MAO-I, clofibrate, probenecid.
Therapy failure: due
to ↓number of functioning
beta cells. Primary: failure to control BG within 4 weeks. Secondary:
initial control of BG, but fails to maintain control, due to progression of
DM.
Repaglinide: less
hypoglycemia.
Insulin sensitizers
Drugs: biguanides (metformin, basic drug), thiazolidinediones
(rosiglitazone, pioglitazone).
Mechanism: anti-hyperglycermic
not hypoglycemic. ↑ sensitivity
to insulin, à (metformin à work on liver, ↓ hepatic glucose production, gluconeogenesis),
(glitazones à ↑ sensitivity / ↓ insulin resistance in muscle and adipose tissue). Thiazolidinediones bind to PPARs.
Use: significant
insulin resistance.
Biguanides SE: fatal
lactic acidosis, metallic taste, GI upset, ↓ vitamin B12, no hypoglycemia. May be
fatal if at ↑ risk of lactic
acidosis (liver / kidney disease, hypoperfusion, hypoxia, radiography).
Phenformin was d/c.
Glitazones SE: liver
toxicity / failure (monitor), weight gain, edema, GI upset, no hypoglycemia. Troglitazone
was d/c due to liver toxicity. CI: liver disease. May resume ovulation in premenopausal women.
Highly protein bound (99%).
Alpha-glucosidase inhibitors
Drugs: acarbose (polysaccharide),
miglitol (basic monosaccharide)
Mechanism: inhibit
intestinal enzyme alpha-glucosidase à ↓ absorption of complex
carbohydrates (starch, dextrins, disaccharides). Use only glucose or lactose
for correcting hypoglycermia if it occurs.
Use: significant
post-prandial hyperglycemia. Minimal effect on pre-prandial or fasting BG. Good
combination with insulin secretagogues. Take with first bite of meal.
SE: GI (diarrhea,
abdominal pain, flatulence) due to undigested carbohydrates in the lower GI, no
hypoglycemia. CI: GI conditions (inflammatory bowel, colonic ulcer, obstructive
bowel, intestinal gas), liver cirrhosis (monitor liver function), pregnancy.
52. Thyroid Disease
Physiology
Thyroid hormone regulation / function
Thyrotropicn-releasing
hormone (TRH): secreted by the hypothalamus, triggers the release of TSH
through negative feedback mechanism.
Thyroid stimulating
hormone (TSH): released by the anterior pituitary gland, controls thyroid
hormone secretion and transport.
Thyroid gland
produces thyroxine (T4), triiodothyronine (T3) (both for growth,
development, metabolic rate), and calcitonin (↓ blood calcium).
Thyroid hormone is transported in the circulation by
thyroxine-binding globulin (TBG), and albumin.
Protein binding protects hormone from premature metabolism, excretion,
and prolongs its t1/2.
Metabolism: T4àT3
conversion in pituitary gland, liver, kidneys.
Degradation: by
deiodination à
feces / urine excretion.
Function: Activate
mRNA and ↑ protein synthesis or catabolism (↑ dose). ↑ growth, development, ↑ basic metabolic
rate, ↑ blood flow, ↑ cardiac output, ↑ heart rate, fine muscle tremor, fatigue
wakefulness, ↑ lipid mobilization and degradation, ↑ bone remodeling (rate of
resorption > rate of formation).
Biosynthesis
Dietary iodine: critical
for thyroid hormone synthesis, reduced to inorganic iodide then exracted from
plasma by the thyroid by iodide trapping (iodide pump).
Organification: oxidation
of iodide by peroxidase. Synthesis
starts with iodide-tyrosine binding à modoiodo then dioiodo-tyrosine.
Thyroid function studies
Serum total thyroxine (TT4):
Most direct reflection of thyroid function by indicating
hormone availability in tissues. Total (free and bound) T4 is determined by
radio-immunoassay (sensitive, rapid).
TBG ↑ during pregnancy à misleading results (bound T4).
↑ TT4 à
hyperthyroidism, and vice versa
Serum total triiodothyronine (TT3):
Measures total (free and bound) T3. TT3 rise before TT4, useful for early
detection. ↑↑ in hyperthyroidism (more
than T4), responsible for symptoms.
Pregnancy à ↑
TT3.
Resin triiodothyronine (RT3U):
Evaluates the binding capacity of TBG. Clarifies whether abnormal T4 is due to
thyroid disorder or abnormal protein binding. If abnormal thyroid in the blood à
RT3U changes in same direction (↑ in hyperthyroid). If abnormal protein binding à
RT3U changes in opposite direction (↓ in hyperthyroid).
Serum thyrotropin (TSH) assay:
Serum TSH assay: most
sensitive test for hypothyroid, but nor reliable in hyperthyroid (TSH is
suppressed).
Sensitive TSH assay: uses
monoclonal antibodies known as immuno-radiometric or immunometric (IMA) method
(vs. the older radio-immunoassay). ↑
sensitivity, ↑ cost, more commonly used to control over treatment of
replacement therapy.
Free thyroxine (T4) index (FTI):
Not a separate test but rather an estimation of free T4
level by a calculation involving serum T4 and RT3U. ↑ FTI à hyperthyroid or ↓ TBG.
Strategies for testing
Most common and ↓ expensive: TT4, RT3U, FTI.
Thyroid disease screening for healthy population is not cost
effective. Screen only target population (elderly, chronic disease
hospitalization,
Use FTI and Sensitive TSH for disease diagnosis.
Hypothyroidism
Classification
Primary
hypothyroidism: due to gland destruction or dysfunction caused by disease
or therapy (radiation, surgery).
Secondary
hypothyroidism: due to ↓ TSH secretion (pituitary disorder). Thyroid gland
is normal but not enough TSH stimulation.
Tertiary
hypothyroidism: ↓ TRH (hypothalamus) to stimulate pituitary
Causes
Hashimoto’s
thyroiditis: chronic autoimmune thyroiditis.
Treatment of
hyperthyroidism: e.g. radioactive iodine, subtotal thyroidectoym,
antithyroid drugs.
Goiter: enlargement
of the thyroid gland. Endemic goiter: due to inadequate
dietary iodine (malnutrition). Sporadic goiter: due to foods or drugs
containing progoitrin (inactive à
hydrolysis à
active goitrin) à ↓
oxidation of iodine to iodide.
Goitrogenic drugs: propylthiouracil (PTU), iodides, cobalt, lithium,
phenylbutazone. Other causes: thyroiditis, thyroid cancer.
Surgical excision
Signs and symptoms
Vague early symptoms: lethargy, fatigue, sensitivity to
cold, weight gain, constipation. Later:
features of Myxedema such as dry
flaky inelastic sin, coarse hair, puffy face / hands / feet, eyelid droop, slow
speech / thought, ↓ libido, coma (if not controlled).
Myxedema coma
Life threatening condition in old patient with undiagnosed
hypothyroidism
Precipitating
factors: alcohol, sedative / narcotic use, antithyroid overdose, d/c
thyroid replacement, infection, cold exposure, radiation, surgery.
Symptoms: coma,
hypothermia, ↓ respiratory rate à
failure, hypometabolism à
fluid / electrolyte retention à
fluid retention, hyponatremia, ↓ heart rate / contractility, ↓ heart
output.
Treatment: rapid
restoration of T3 and T4 to normal levels.
IV bolus levothyroxine, oral liothyronine, then oral levothyroxine.
Drugs
Desiccated thyroid
preparations: not commonly used anymore.
Different preparations are not bioequivalent (varying amounts of actives
depending on source (bovine, ovine, porcine).
Fixed ratio (liotrix)
preparations: standard ratio of T4/T3.
T3 is, however, unnecessary (T4 converts to T3) à cause SE tremor, headache,
palpitations, diarrhea.
Levothyroxine: agent
of choice, predictable results, no T3.
Individual variable response to different preparations à
care if to switch. Use ↓ dose for
elderly or chronically ill patients.
Results start after 2 wk, full response after 4-5 months (TSH levels ↓
to normal levels).
Precautions
Careful in the elderly and in case of cardiac disease. Start with ↓ doses.
Watch for cardiac complications (palpitations, arrhythmia,
angina).
Monitor thyroid levels (T4, RT3U, FTI, sensitive TSH).
Long term levothyroxine therapy can cause
thyrotoxicosis.
Accelerated bone loss due to over treatment à
nontraumatic fracture.
CI: cholestyramine
(bile acid sequestrant) à
↓ thyroxine bioavailability. Separate
drug by 6 hours.
Hyperthyroidism / thyrotoxicosis
Grave’s disease (diffuse toxic goiter)
Most common form.
Occurs usually in young women.
Autoimmune disease, antibodies (long-acting thyroid
stimulators, LATS) bind to and activate TSH receptors (does not actually
increase TSH itself).
Symptoms: enlarged
goiter, exophthalmos, stare, nervousness, irritability, anxiety, insomnia, heat
intolerance, ↑ sweating, ↑ appetite, ↓ weight, muscle tremor / weakness,
tachycardia, palpitations, diarrhea.
Signs:
Plummer’s disease (toxic nodular goiter)
Less common. Common
in the elderly. Caused by adenoma
nodules autonomously secreting excessive thyroid.
Symptoms: same as
Grave’s with nodular masses rather than diffusion enlargement.
Other forms
Jodbasedow
phenomenon: hyperthyroid due to ↑↑ iodine ingestion or amiodarone.
Factitious
hyperthyroidism: due to abusive ingestion of thyroid replacement drugs to
lose weight.
Drugs
Beta blockers – propranolol
Propranolol ↓
peripheral symptoms (tachycardia, sweating, tremor, nervousness). It also ↓ peripheral T4àT3
conversion (deiodonation).
Antithyroid drugs
Examples: propylthiouracil
(PTU), methimazole.
Mechanism: interferes
with thyroid hormone synthesis by ↓ iodide oxidation. PTU ↓ peripheral T4àT3.
Dosing: initial
dose (2 mo), maintenance dose (12 mo), gradual withdrawal (2 mo). Restart therapy if signs of hyperthyroidism
appear.
Monitor serum thyroid, FTI and goiter size.
SE: skin rash,
urticaria, pruritus, hair loss, skin piementation, drowsiness, myalgia,
arthralgia. Severe SE: blood (agranulocytosis, granulocytopenia,
thrombocytopenia), monitor blood count.
Radioactive iodine (RAI)
Mechanism: thyroid
gland picks up the radioactive element iodine-131 as it would regular
iodine. Radioactivity destroys
cells.
Advantages: ↑
cure rate (100%), avoid surgical risks, ↓ cost
Disadvantages: risk
of delayed hypothyroidism, delayed effect.
SE: only for
women past childbearing years. Response
is hard to gauge (too much, too little).
Subtotal thyroidectomy
Partial removal of the thyroid gland. Last resort.
Advantages: ↑
success rate, rapid cure.
SE: thyroid
storm, permanent hypothyroidism.
Complications
Hypothyroidism: may
follow Grave’s disease.
Thyroid storm
(thyrotoxic crisis): is a sudden exacerbation of hyperthyroidism caused by
rapid release (leakage) of thyroid hormone (↑↑ T4) à fever, tachycardia,
restlessness, tremor, hyper-meabolism à dehydration, shock, death if not treated
rapidly. Precipitating factors: thyroid trauma, surgery, radiation,
infection, sudden d/c of antithyroid therapy.
Treatment: PTU, methimazole,
proproanolol, potassium iodide (↓ intrathyroidal iodine intake), supportive
therapy (rehydration, cooling, AB, rest, sedation).
54. Cancer Chemotherapy
Principles of oncology
Cancel cells
Tumors arise form a single abnormal cell, which continues to
divide indefinitely. Characteristics: no
growth control, can invade local tissues, can spread (metastasize).
Incidence
Second leading cause of death in the US.
Affects 30% of all people at some point in life.
Some forms of cancer are curable if detected / treated
early.
Etiology
Viruses: Epstein-Barr
virus, hepatitis B, human papilloma viruses.
Environmental /
occupational exposures: ionizing / UV radiation, chemicals (benzene,
asbestos, vinyl chloride).
Life-style: ↑
fat, ↓ fiber diet, ethanol, tobacco.
Medications: alkylating
agents, immunosuppressants.
Genetics: inherited
mutations, cancer-causing genes (oncogenes).
Detection / diagnosis
Warning signs:
CAUTION. Change in bowel / bladder
habits, A sore that does not heal, Unusual bleeding / discharge, Tissue thickening or lumps (e.g.
breast), Indigestion of difficulty
swallowing, Obvious change in a wart
or mole, Nagging cough or
hoarseness.
Guidelines for
screening: for asymptomatic people à
mammography (breast cancer), fecal occult blood test (colon cancer), Pap smears
(cervical cancer).
Tumor markers: biochemical
indicators of the presence of neoplastic proliferation in serum, plasma, other
body fluids. Not definitive. Include: prostate specific antigen (PSA),
carcinoembryonic antigen (CEA), alpha fetoprotein (AFP).
Tumor biopsy: definitive
test for cancer cells is pathology of a biopsy.
Imaging studies: x-ray,
computerized tomography scans, MRI, positive emission tomography.
Lab tests: complete
blood count, blood chemistries.
Staging
It is the categorizing of patients according to extent of
the disease. Used to determine prognosis.
Two system are used for neoplasm staging.
TNM: T = tumor
size (0-4), N = regional lymph node
spread (0-3), M = presence of
absence of distant metastases (0-1).
Example: T2N1M0.
AJC: by the
American Joint Committee on staging.
Scale: 0-IV.
Survival
Depends on tumor size, disease extent, treatment received.
60% survive more than 5 years, but not all survivors are
cured. “Complete response or remission” when no evidence of disease after
treatment. Slow growing tumors à 10-15 disease free years.
Cell life cycle
Phases of the cell cycle
M phase (mitosis): cell
divides into two daughter cells
G1 phase (postmitotic
gap): synthesis of RNA and proteins
S phase (synthesis): synthesis of DNA
G2 phase (premitotic
/ postsynthetic gap): production of RNA and topoisomerisae I/II enzymes
(important for DNA replication and RNA transcription).
G0 phase (resting): cell
is not dividing. Cells now are not sensitive to chemotherapy. Recruitment:
resting cells re-enter actively divided cell cycle caused by some chemotherapy
agents.
Cell growth kinetics
Cell growth fraction:
proportion of the cells in the tumor dividing or preparing to divide. Large
tumor à ↓ nutrients and blood supply to some cells à
↓ cell growth fraction.
Cell cycle time: average
time for a cell that has just completed mitosis to grow and again pass through
mitosis (divide). Cycle time is specific
for each individual tumor.
Tumor doubling time: time
for the tumor to double in size. Large tumor à ↓
cell growth fraction à ↑ doubling time
Gompertzian growth
curve: illustrates cell growth kinetics concepts.
Tumor cell burden
Number of tumor cells in the body. Number required for
clinical symptoms: 109 (large number) à
tumor may be in plateau phase of growth curve when detected. Body immunologic defenses may be able
to keep tumor cells less than 1000 under control.
Each cycle of cancer chemotherapy kills a certain percentage
of tumor cells (depending on the dose). When tumor cells are killed à
Cells in G0 phase may be recruited to G1 phase à
tumor regrowth. Therefore, repeated cycles of treatment are required for
complete response or remission.
Drug reliance on cell cycle kinetics for cytotoxic effect
Phase specific
agents: M à vinca alkaloids / taxanes, G1 à asparaginase / prednisone, S à antimetabolites, G2 > bleomycin / etoposide.
Phase nonspecific
agents: effective when cell are at any phase of the active cycle. Examples: alkylating agents, cisplastin,
antitumor antibiotics.
Cell cycle
nonspecific agents: effective in all phases including G0. Example: nitrosoureas, radiation.
Combination of drugs that are active in different cell cycle
phases will result in greater cell kill.
Chemotherapy
Therapy objectives
Cure: sought with
aggressive therapy for long time to eradicate all disease. Example for
leukemia: remission induction, attempt maximal cell kill and therapy
consolidation to eradicate all clinically detectable disease and get tumor cell
count ↓ 1000.
Palliation: goal
is to control symptoms when complete eradication of tumor is unlikely or if
patient refuses aggressive therapy.
Adjuvant: given
after more definitive therapy (e.g. surgery) to eliminate any remaining
disease.
Neoadjuvant: goal
is to ↓ tumor burden before surgery or radiation.
Dosing
May be bases on body weight, BSA or AUC. BSA is preferred
(correlates with cardiac output which determines renal / hepatic blood flow /
elimination). Adjust dose for liver or kidney dysfunction.
Dosing is usually given as short courses in cycles.
Combination chemotherapy
To overcome or prevent resistance, achieve cytotoxicity to
resting and dividing cells, enhance biochemical effect, rescue normal cells.
Acronyms are often used to indicate certain combinations.
Administration
IV is the most common
Inrathecal: for methotrexate, hydrocortisone, cytarabine,
thiotepa.
Response to chemotherapy
Does not always correlate with survival.
Complete response: disappearance
of all disease (clinical, gross, microscopic).
Partial response: >
50 reduction in tumor size for a period of time.
Response rate: defined
as complete response + partial response.
Progression or no
response: > 25 increase in tumor size or appearance of new lesions.
Classification of chemotherapeutic agents
Alkylating agents
Prototype: mechlorethamine
(nitrogen mustard)
Mechanism: cross-linking
and abnormal base-pairing of DNA strands à ↓
DNA replication.
Nitrogen mustards: chlorambucil, cyclophosphamide,
ifosfamide, mechlorethamine, melphalan.
Ethylenimines / methylmelamines: thiotepa, altretamine.
Alkyl sulfonates: bisulfan
Nitrosoureas: carmustine,
lomustine, semustine, streptozocin.
Triazenes: dacarbazine
Platinum coordination complexes: cisplatin, carboplatin
Substituted ureas: hydroxyurea
Others: procarbazine, temozolomide.
Antitumor antibiotics
Most come from Streptomyces
Mechanism: alkylation
(mitomycin) or intercalation. Intercalation:
drug slides between DNA base pairs and ↓ DNA synthesis.
Anthracyclines: daunorubicin
(daunomycin), doxorubicin (adriamycin, hydroxydaunorubicin), epirubicin,
idarubicin.
Anthracendiones: mitoxantrone
Others: bleomycin,
dactinomycin, mitomycin, plicamycin (mithramycin).
Antimetablites
Structural analogs of naturally occurring substrates for
biochemical reactions.
Mechanism: false
substitution in production of nucleic acid à ↓
DNA synthesis.
Adenosine analogs: cladribine,
fluudarabine, pentostatin (deoxycoformycin).
Folic acid analogs (folate antagonists): methotrexate, trimetrexate, raltitrexed.
Purine analogs (purine antagonists): mercaptopurine, thioguanine
Pyrimidine analogs (pyrimidine antagonists): fluorouracil,
capecitabine, cytarabine, gemcitabine.
Plant alkaloids
Vinca à prevent formation of the mitotic
spindle à arrest cell division. Examples: vinblastine, vincristine,
vindesine, vinorelbine.
Camptothecins à
inhibit topoisomerase I. Examples:
irinotecan, topotecan.
Podophyllotoxins à
inhibit topoisomerase II. Examples:
etoposide, teniposide.
Taxanes à
↑ microtubule assembly / stabilization à ↓
cell division. Examples: taxol (paclitaxel), taxotere (docetaxel).
Hormones
Androgens: testosterone, fluoxymesterone
Antiandrogens: bicalutamide,
flutamide, nilutammide.
Antiestrogens: tamoxifen, toremifene.
Aromatase inhibitors: letrozole, anastrozole, exemestane,
aminoglutethimide.
Corticosteroids: prednisone, dexamthasone
Estrogens: ethinyl estradiol, diethylstilbestrol.
Estrogen/nitrogen mustard: estramustine
Progestins: medroxyprogesterone, megestrol
Luteinizing hormone releasing hormone analogs: leuprolide, goserelin
Asparaginase
Mechanism: enzyme
that causes the degradation of essential AA asparagine to aspartic acid and
ammonia. Normal cells can synthesize asparagine but tumor cells can not.
Biologic response modifiers
Mechanism: alter
the patient’s immune system to fight cancer or to ↓ SE of cancer treatment.
Examples: Bacillus Calmette-Guerin (BCG), Colony-stimulating factors
(erythropoietin, filgrastim, sargramostim), interferons (alpha, beta, gamma),
interleukins (IL-2, IL-11), levamisole, monoclonal antibodies (rituximab,
trastuzumab).
Toxicity of chemotherapeutic agents
Most toxic to the most rapidly proliferating cells (mucous
membranes, cells, hair, GI tract, bone marrow).
Bone marrow depression
Most life threatening SE.
Effect is dose related.
↓ WBC (especially
neutrophils; neutropenia) à serious infections.
Colony stimulating
factors: used to ↓ extent of neutropenia.
↓ platelets
(thrombocytopenia) à bleeding à
give platelet transfusion.
Anemia is not as common because RBC lifespan is 120 days.
Time course: onset
à
1 week, lowest count point (nadir) à 2
weeks, count recovery à 3 weeks.
Dermatological
Alopecia: partial
or complete, can not be prevented.
Local necrosis: results
from extravasation during administration of vesicant drugs à
immediate pain / burning + possible delayed reaction à
tissue damage, necrosis, ulceration à
require plastic surgery. Treatment: cold for all drugs except vinca and taxanes
(use heat).
Skin changes: dryness,
sun sensitivity (methotrexate, fluorouracil).
GI toxicity
Nausea and vomiting
Most distressing SE from the patient’s viewpoint.
Acute, delayed or anticipatory.
Antiemetics are used for prophylaxis.
Vomiting à dehydration, electrolyte
imbalance, esophageal tears à d/c therapy.
Stomatitis
Common with methotrexate, fluorouracil (same as skin
changes)
General inflammation of the oral mucosa or other areas of
the GI with rapid turnover of cells.
Symptoms: erythema, pain, mouth dryness, lip tingling /
burning, ulceration, bleeding à infection, inability to
eat.
Time course: starts in 1 week, resolve in 2 weeks.
Other SE: fluorouracil
à
diarrhea, vincristine à constipation.
Pulmonary
Irreversible and may be fatal. Especially with bleomycin,
mitomycin.
Symptoms: breath shortness, unproductive cough.
Cardiac
Acute: transient
ECG abnormalities. Not important.
Chronic: irreversible
CHF due to drugs or radiation.
Dexrazoxane: cardioprotective
(use with doxorubicin).
Neurotoxicity
Due to intrathecal or systemic therapy.
Autonomic /
peripheral neuropathy: due to vincristine. Vincristine is fatal if given
intrathecally.
Peripheral neuropathy
/ ototoxicity: due to cisplatin.
Arachnoiditis: due
to intrathecal methotrexate, cytarabine.
Hemorrhagic cystitis
Bladder toxicity due to cyclophosphamide and ifosfamide. Acrolein: metabolite of these drugs à
chemical irritation of bladder mucosa à
bleeding. Prevention: aggressive
hydration with frequent urination, mesna
(binds to acroltein à prevents it from contacting
bladder mucosa).
Other
Hypersensitivity: may
be life threatening (anaphylaxis).
Chills / fever: especially
with bleomycin.
Hepatoxocity: ↑
liver function tests, jaundice, hepatitis.
Nephrotoxicity: ↑
serum creatinine, ↑ BUN, electrolyte imbalance. Use amifostine to protect the kidney if using cisplatin.
Secondary
malignancies: such as leukemia, solid tumors, lymphoma.
Female infertility: may
be temporary or permanent .
Other chemotherapeutic modalities
Surgery: can be
diagnostic or therapeutic
Radiation: ↑
doses of ionizing radiation directed at the cancerous tissue. SE: stomatitis,
myelosuppression, GI (nausea, vomiting, diarrhea).
It’s common to combine drugs, surgery and radiation.
55. Pain Management
Definitions
Pain: unpleasant sensory and emotional
experience that usually is associated with structural or tissue damage. No objective measurement.
Acute pain: lasts
< 30 days. Occurs after muscle
strains and tissue injury. Self
limiting, ↓ w/ time as injury heals, linear process
with beginning and end, ↑ autonomic NS: ↑ heart
rate, ↑ breath rate, ↑ BP,
mydriasis, anxiety.
Chronic pain:
persistent or episodic, > 6 months.
Chronic non-malignant pain:
complication of acute injury, disease (osteoarthritis, rheumatoid arthritis,
fibromyalgia, degenerative disorders).
Cyclic, constant, does not improve w/ time. No ANS stimulation. Depression, insomnia, weight loss, sexual
dysfunction
Chronic cancer pain: similar
to non-malignant pain, depression, fear, anger, agony. Due to cancer therapy or tumor (bone
metastasis, compression of nerves, occlusion of blood vessels, obstruction of
bowel, infiltration of soft tissue).
Breakthrough pain:
intermittent, transitory ↑ in pain.
Principles of pain management
Comprehensive pain management: chronology, history, symptomatology, onset,
location, intensity, duration, quality, distribution, provoking factors,
underlying disease / trauma, allergies, analgesic response, side effects.
Pain management targets: ↑ patient
comfort (may aid healing in acute pain), break pain cycle (chronic pain), ↓
breakthrough pain, improve sleep, well-being, self-esteem, mobility,
psychology, etc.
Individual management regimens: dose,
intervals, mode of administration, adjunct therapy. Avoid narcotics for chronic non-malignant
pain. Long acting analgesics (round the
clock) for cancer pain. Intermittent prn
short-acting analgesics for breakthrough and acute pain. Reassess and change regiment as needed.
Analgesics
Non narcotic analgesics
General uses: antipyretic,
anti-inflammatory (except acetaminophen), analgesic ceiling effect, no
tolerance, no dependence. OTC: aspirin,
acetaminophen, ibuprofen, ketoprofen, naproxen (low doses).
General SE
1. Gastro-intestinal:
Due to PG inhibition. With all except acetaminophen, COX-II
inhibitors, choline magnesium trisalicylate, etanercept.
Symptoms:
dyspepsia, ulceration, bleeding, perforation.
Especially in the elderly,
ulcers, smokers, alcoholics.
Avoid by combo therapy with GI
protectants (PPI, misoprostol, H2-antagonists, antacids, sucralfate)
or enteric coating (aspirin).
2. Hematologic:
Exceptions: acetaminophen,
choline mg trisalicylate, etanercept.
Inhibit platelet aggregation by
reversibly inhibiting PG synthase.
Aspirin is an irreversible inhibitor.
Contraindicated with
anticoagulants (warfarin, heparin, etc)
3. Renal:
PG inhibition, interstitial
nephritis, impaired renin secretion, ↑ tubular water/Na reabsorption à reversible abrupt oliguria
Salicylates
Chemistry: derivatives
of salicylic acid (from Willow
bark). Weak acids with excretion ↑ by ↑
pH. Aspirin is acetyl salicylic acid,
hydrolyses easily, unstable in water, moisture.
Other salicylates:
diflunisal, methyl salicylate (topical, wintergreen oil), salsalate,
mesalamine, olsalazine, sulphasalazine, sodium thiosalicylate (injection),
choline salicylate (oral liquid).
Pharmacology: ↓ cyclooxygenase (COXI/II) à ↓ local PG à analgesic, antipyretic, anti-inflammatory. Aspirin is the only salicylate that ↓ COX irreversibly by covalent acetylation. Also, ↓ platelet COX à ↓ thromboxane A2
formation à ↓
platelet aggregation / thrombus formation.
Indications: analgesics
(skeletal muscle pain, headache, neuralgia, myalgia, spasmodic dysmenorrhea),
anti-inflammatory (arthritis, rheumatic fever), antipyretic (avoid in children
with viral infection à Rye’s
syndrome), prophylaxis of MI.
Mesalamine, sulphasalazine, olsalazine à ↓ inflammation in
inflammatory bowel disease, Crohn’s disease.
Methyl salicylate à topical counter
irritant.
SE: GI upset
(nausea, vomiting, discomfort, irritation, ulceration, hemorrhage), ↑ bleeding, delayed labor, ↑ depth of respiration, hyperglycemia, glycosuria. Low dose (2 g) à ↓ urate excretion (↑ blood level).
High dose (5 g) à opposite. Toxicity:
salicylism (tinnitus). Oral methyl
salicylate can be fatal. Sulphasalazine à male infertility. Acute
hypersensitivity (asthma, rhinitis, urticaria, shock, etc). May have cross-sensitivity to other NSAID
DI: Oral anticoagulants (due to platelet inhibition and gastric mucosal damage à↑ bleeding). Methotrexate:
↑ toxicity with
salicylates by blocking methotrexate renal tubular secretion.
NSAIDs
Examples: (x-profen) ibuprofen, ketoprofen, fenoprofen, flurbiprofen, naproxen
(sodium), indomethacin, piroxicam, diclofenac, ketorolac (oral, IM), etodolac,
oxyprazocin, tolmetin, sulindac, meclofenamate, mefanemic acid,
nabumetone. COXII inhibitors: celecoxib, rofecoxib, valdecoxib.
Chemistry: Many
are acid derivatives. Most are from
propionic (x-en) or acetic acid. Others:
fentamates, oxicams or anthanilic acid derivatives. COX-II inhibitors à pyrazole derivatives.
Pharmacology: COX-I produces PG cytoprotective of stomach lining.
COX-II produces PG for pain / inflammation.
NSAIDs:
↓ COXI/II à ↓ local PG synthesis. COX-II inhibitors: ↓ COXII only.
Indications:
NSAIDs: mild to moderate pain,
rheumatoid arthritis, osteoarthritis, gout, additive analgesia with
narcotics. COX-II inhibitors: rheumatoid arthritis and osteoarthritis.
Ketorolac IM: for
moderate to severe pain (strongest NSAID for analgesia) when narcotic are
undesirable (addicts, respiratory depression, sedation).
Indomethacin:
strongest NSAIDS for inflammation, ↑ CNS SE. Use for
ductus arterisous in premature infants.
SE: NSAIDs: GI
upset (dyspepsia, mucosal erosion), CNS depression / drowsiness, ↓ platelet function, skin rash, kidney damage. COX-II
inhibitors: kidney damage, ↓
GI upset.
DI: NSAIDs ↓ effect of diuretics (due to ↓ renal perfusion). COXII
inhibitors are CI in allergy to sulfonamides, aspirin, NSAID’s
p-Aminophenols
Acetaminophen is the prototype
(APAP, acetyl para-amino phenol). Also,
phenacetin.
Mechanism: ↓ central PG à analgesic, antipyretic. No
peripheral PG blocking à no effect on
inflammation, platelets.
Use: alternative
antipyretic, analgesic to salicylate.
Unlike aspirin, safe as antipyretic for children with viral infections.
SE: ↓
at normal doses (skin rash). Acute
overdose à liver failure. Antidote: N-acetyl cysteine. CI: alcoholism.
Pyrazolones
Chemistry: prototype
is phenylbutazone, its metabolite is oxyphenbutazone. Also sulfinpyrazone.
Mechanism: ↓ PG synthesis, stabilize lysosomal membrane à analgesic, antipyretic, anti-inflammatory,
uricosuric. Sulfinpyrazone à only uricosuric à↓ hyperuricemia in gout.
Use: (oxy)phenylbutazone
à short term treatment of rheumatoid arthritis and gout
(not first choice).
SE: ↑ SE. blood dyscrasias (agranulocytosis,
thrombocytopenia, anemias), GI uspet, ulceration, kidney damage, hyperglycemia,
skin rash, CNS (drowsiness, headache).
Narcotic analgesics (opioids)
Chemistry
Include natural opiate alkaloids
and synthetic analogs
Derived from opium (oldest drug)
from poppy seed capsule.
Morphine: phenolic
hydroxyl group is critical for
activity. Most important alkaloid
(pharmacologically and quantitatively).
Amphoteric structure à erratic oral absorption.
Agonists: morphine,
codeine, heroin, oxycodone, oxymorphone, hydromorphone, hydrocodone,
dihydrocodone, meperidine, fentanyl (transdermal), propoxyphene, loperamide,
methadone / levorphanol (both long t1/2),
diphenoxylate, sufentanil, dezocine.
Antagonists: methyl
group on nitrogen atom is replaced by bulkier group. Examples: naltrexone, naloxone, levallorphan (?).
Mixed agonists-antagonists: nalbuphine, buprenorphine, butorphanol, pentazocine, can
ppt withdrawal symptoms if used after agonists.
Mechanism
Endogenous peptides (enkephalins,
endorphins, dynorphins) provide self-pain relief. Opioid receptors: in the brain / spinal cord
(Types: μ, κ, σ, δ, ε)
Effects of mu receptor stimulation (morphine-like): analgesia, sedation,
miosis, euphoria, physical dependence, respiratory depression, bradycardia
Other actions: cough
suppression, CTZ stimulation (nausea, vomiting).
Opioids mimic the action of
endogenous opioid peptides at CNS opioid receptors à ↑ pain threshold and tolerance.
Clinical use
Moderate to severe pain, acute
or chronic, of visceral or somatic origin, e.g. MI, cancer, labor, etc.
Pre-anesthesia and adjuncts during anesthesia. Anti-tussives (codeine,
dextromethorphan). Antidiarrheal (loperamide, diphenoxylate).
Pure antagonists are used as
antidotes to reverse SE of agonists or agonists-antagonists (respiratory
depression, CV depression, drowsiness).
Naltrexone is used for opioid addition.
Dose is increased gradually
until the appearance of limiting SE
Mixed agonist-antagonist
preferred for acute pain respiratory
depression risk is ↑. Avoid with chronic opioids à withdrawal.
Oral: preferred
esp. for chronic stable pain. CR
morphine and oxycodone available for continuous pain (e.g. cancer)
IM, SC: used
post-operatively. Absorption is not
predictable.
IV bolus: most
rapid, predictable onset for breakthrough pain
IV infusion: to
titrate pain relief rapidly for unstable chronic pain, esp. morphine.
IV PCA: for acute
post-operative pain. Small doses
delivered at frequent intervals (10 min).
Epidural / intrathecal: for acute post-operative pain and chronic cancer
pain. Intrathecal dose = 0.1 epidural
dose. Must be preservative free due to
neurotoxicity of parabens and benzyl alcohol.
Intrathecal local SE: itching, urinary retention. Epidural: ↓
brain level à ↓ SE à give if respiratory depression
risk is ↑. Labor à meperidine (less
neonatal respiratory depression).
Rectal: alternative
to oral. Patient un-preferred, poor
absorption.
Transdermal: CR
fentanyl (3 days). Alternative to oral
for chronic pain. Slow onset, require
oral supplement.
Adverse effects
Constipation: due
to ↓ intestinal tone and
peristalsis. After several days (↑ with codeine).
Prophylaxis: laxative / stool softener combo (bisacodyl / docusate) if
to be used chronically.
Respiratory depression: most serious. Monitor
respiratory rate if at risk. Use IV
naloxone (antagonist) to reverse life-threatening depression, but may ppt
withdrawal if on chronic opiates.
Nausea / vomiting: due
to central stimulation of chemoreceptor trigger zone, esp. in parenteral dosing
for acute pain. May need anti-emetic
(hydroxyzine, prochlorperazine), but may ↑ sedation.
Sedation: dose-related
and ↑ with other sedatives
(BZD, anti-emetics). Tolerance develops
if chronically used. May need CNS
stimulant (methylphenidate, dextroamphetamine).
Different from physiological sleep (pain is controlled à patient rests).
Anticholinergic: dry
mouth, urinary retention.
Hypersensitivity: not
true allergy. Itching or wheel at
injection site due to histamine release, esp. with intrathecal or epidural.
Meperidine à CNS excitation: seizure-like,
esp. in renal failure patients. Due to
accumulation of normeperidine metabolite.
Tolerance: to
analgesic, sedative and euphoric effects.
Combo with NSAID may help overcome this problem.
Other SE: miosis,
euphoria, confusion / hallucinations, coma, orthostatic hypotension,
arrhythmias, histamine release (itching, vasodilation à ↓ BP, bronchoconstriction).
Dependence: Withdrawal symptoms: anxiety, irritability, insomnia, chills, salivation,
rhinorrhea, diaphoresis, nausea, vomiting, GI cramping, diarrhea,
piloerection. Long t1/2 à less intense / delayed withdrawal. Reduce acute withdrawal by using antagonist
(naloxone) or agonist-antagonist (pentazocine).
Drug interactions: additive
CNS depression (alcohol, anesthetics, antidepressants, antihistamines,
barbiturates, benzodiazepines, phenothiazines).
Meperidine with MAO inhibitors à hypertension, excitation, rigidity.
Tramadol
Oral, centrally acting,
non-controlled, analgesic with weak opiate (mu) activity for moderate to severe
pain. Chemically unrelated to opioids.
Mechanism: bind to
opiate receptors à ↓ norepinephrine, serotonin reuptake. Naloxone is a partial antagonist.
SE: GI (nausea,
constipation, dry mouth), CNS (dizziness, drowsiness, headache), ↓↓ respiratory depression, histamine release.
DI: ↑
sedation with alcohol and hypnotics.
Inhibits MAO à avoid with MAO
inhibitors (à seizures)
Miscellaneous agents
Glucosamine sulfate and chondroitin sulfate
For degenerative joint disease (arthritis)
Glucosamine: substrate
and stimulant for biosynthesis of hyalouronic acid and glucosaminoglycans
forming proteoglycans in structural matrix of joints. SE: GI, drowsiness, headache, rash.
Chondroitin:
substrate for formation of healthy joint matrix
Analgesic adjuncts
Other drugs affect non-opiate
pain pathways à may help with certain
types of pain (e.g. neurogenic / neurologic), or to ↓ SE
Examples: tricyclic
antidepressants, anticonvulsants, BZD, neuroleptics, corticosteroids,
antihistamines, amphetamines.
Non-pharmacological pain management
Include Cognitive Behavioral Interventions (education, instruction,
relaxation, biofeedback, hypnosis), and Physical
methods (acupuncture, physical therapy, compression gloves, orthotic
devices, heat / cold, massage, immobilization, exercise, rest, transcutaneous
electrical nerve stimulation (TENS)
56. Nutrition and the Hospitalized Patient
I. Nutritional problems in hospitalized patients
a. Malnutrition:
Pathologic state
resulting from the relative or absolute deficiency or excess of one or more
essential nutrients.
b. Marasmus:
Chornic state (over
months or years) that result from deficiency in the total calorie intake à depletion of fat stores and skeletal
proteins to meet metabolic needs.
Visceral protein is
preserved (normal serum albumin, prealbumin, transferrin).
Immune competence,
wound healing and ability to handle short term stress are preserved
Aggressive
nutritional repletion can result in metabolic distrubances (e.g. hypokalemia,
hypophosphatemia)
c. Kwashiorkor
Acute pricess
(within weeks) due to inadequate protein intake
Visceral protein
depletion, impaired immune function
Hypermetaboism (e.g.
trauma, infection, surgery) + protein deprivation à kwashiorkor malnutrion, hypoalbuminemia,
edema
Aggressive
nutritional protein repletion is warranted
d. Mixed marasmus kwashiorkor
Severe
protein-calorie malnutrition when marasmic patients are hypermetabolic
II. Nutritional assessment of metabolic requirements
A. Nutritional assessment
1.
Subjective global assessment (SGA): relies on patient history
2. Prognostic nutritional index (PNI)
Derived from a
formula that quantifies patient’s risk of developing complications based on
markers of nutritional status such as: serum albumin (visceral protein),
triceps skn fold thickness and delayed hypersensitivity skin-test reactivity
(immune competence).
PNI<40 à low risk,
PNI>50% à high risk.
3. Body composition analysis: measure and compares the ratios of body
compartments.
a. Bioelectrical impedence: calculates lean body mass based on
resistance to electrical current.
Inaccurate in critically ill patients, and those with fluid or
electrolyte abnormalities.
b. Dual energy x-ray
absorptiometry: measures fat
and lean body mass. Depend on hydration status
c. Total body potassium: uses whole body counter to measure potassum
isotope concentrated in lean tissue à measures lean body mass
d. Total body water:
measures lean body mass from deuterium total body water (impractical).
e. In-vivo neutron activation analysis: divides the body into compartments. Requires large dose of radiation.
4.
Test of physiologic function:
Quantify
malnutrition based on decrease in muscle strength due to amino acid
mobilization.
a. Maximum voluntary grip
strength: measured with
isokinetic dynamometry and correlates to total body protein.
b. Electrical stimulation of the ulnar nerve: measures muscle contraction.
B. Metabolic requirments:
1. Energy requirments
Determined as
nonprotein calories (NPC). Can be
measued by:
a. Indirect calorimetry or Measured Energy Expendure
(MEE)
Most accurate. Directly measures O2 consumption and CO2
production.
Energy requirment is
directly related to oxygen consumption.
Respiratory quotient
(RQ) = CO2 produced / O2 consumed
Oxidation of
nutrients: carobohyrates RQ = 1.0, fat RQ = 0.7,
Lipogenesis:
conversion of excess carbohyrate calories to fat, produces more CO2 than
oxidation.
b. Estimated energy expendure (EEE)
Requires calculation
of basal energy expendure (BEE) from Harris-Benedict equation. BEE is then multiplies by stress and
substrate utilization factors.
c. Simple nomogram
Based on patient
weight, least accurate. Range from 2535
Kcal/kg/day depending on degree of stress.
2. Protein (nitrogen) requirments
a. Nitrogen balance techniques
16% of protein is
comprised of nitrogen
Nitrogen balance =
24hr nitrogen intake – 24hr nitrogen output
Nitrogen output =
urine urea nitrogen + nonurea urine nitrogen (ammonia, creatinine) + nonurine
nitrogen loss (skin/feces)
Positive nitrogen
balance of 3-6 g is the goal (not for the renally impaired)
b. Nomogram method: estimates protein needs based on lean body
weight (1.5-2.0 g protein/kg/day)
c. Nonprotein calorie to nitrogen (NPC:N)
ratio: normally 125-150:1
3. Essential fatty acids (EFAs):
EFAs are
polyunsaturated fatty acids not synthesized by humans.
Linoleic acid:
principal EFA. It’s omega-6
polyunsaturated fatty acid.
Linoleic acid
deficiency à diarrhea,
dermatitis, hair loss
Prevent EFAs
deficiency by giving ~5% of patient’s calorie intake as linoleic acid from
lipid emulstion.
4. Vitamins:
Fat soluble: A, D, E, K; Water soluble: B, C
Vitamin A: essential for vision, growth, reproduction. IV form binds to plastic and glass.
Vitamin D: regulate calcium / phosphorous homeostasis together with calcitonin and
parathormone.
Vitamin E: antioxidant, ↓ oxidation of free unsaturated fatty acids. Need to ↑ Vitamin E in diets ↑ in unsaturated
fatty acids.
Vitamin K: critical for synthesis of clotting factors.
Vitamin B1 (thiamine): coenzyme in phosphogluconate, structural
component of nervous system membranes.
Deficiency à acute pernicious beriberi. Prolonged deficiency à Wernicke’s encephalopathy.
Vitamin B2 (riboflavin): coenzyme in oxidative phosphorylation. No intracellular stores maintained.
Vitamin B3 (niacin): conenzyme in oxidative phosphorylation. Deficiency à pellagra.
Vitamin B5 (pantothenic acid): functional form is coenzyme A, essential for
all acylation reactions.
Vitamin B6 (pyridoxine): coenzyme in enzymatic reactions. Deficiency when taking isonizid,
penicillamine, cycloserine.
Vitamin B7 (biotin): synthesized by intestinal floar. Involved in carboxylation reactions.
Vitamin B9 (folic acid): folate cofactors are needed for purien and
pyrimidine (DNA) synthesis. Deficiency
in B12 à deficiency
in (B9) folate à
megaloblastic anemia. Deficiency during
pregnancy à neural tube
fetal defects.
Vitamin B12 (cyanocobalamin): large stores à deficiency develops in years. Deficiency: megaloblastic (pernicious) anemia,
peripheral neuropathy (needed for myelin synthesis).
5. Trace minerals
Iron: necessary for hemoglobin and myoglobin production, enzymatic reactions
(cofactor). Deficiency: hypochromic,
microcytic anemia, immune deficiency.
Zinc: necessary for RNA, DNA synthesis and enzymatic reactions
(cofactor). Deficiency: imparied wound
healing, growth retardation, hair loss, anorexia. risk of deficiency in long-term steroid therapy, mal-absorption,
surgery.
Copper: necessary for heme synthesis, electron transport, wound healing. Deficiency: anemia, leukopenia, neutropenia.
Manganese: involved in protein synthesis
Selenium: for antioxidant reactions.
Deficiency: muscle pain, cardiomyopathy.
Iodine: component of thyroid hormones.
Deficiency: goiter
Chromium: critical for glucose use, insluin effect. Deficiency:
hyperglycemia, glucose intolerance.
Molybdenum: essential to xanthine oxidase
100. The Patient Behavioral Deterimants
102. Drug Education
103. Patient compliance
Definition: extent to which an
individual’s behavior coincides with medical or health advice. Noncompliance
can be intentional or unintentional.
About 50% of the population is
noncompliant with drug therapy in some way.
Causes in the elderly: complicated drug regimen, inability to read labels, difficulty opening
lids, etc.
Noncompliance can affect and
bias the results of clinical studies.
Types of noncompliance
Not filling Rx: because
they do not feel they need or want the Rx.
Example: an infection with Tylenol is feeling better and improving. May be because of cost.
Omission of doses: common
for drug that are taken frequently for long time.
Wrong dose: amount
of does or frequency of administration is incorrect.
Incorrect administration: for example, not using the right technique with aerosols,
or wrong route of administration.
Wrong time: for
example, drug taken at the wrong time in relationship to meals. Drugs such as
tetracycline, fluoroquinolones, erythromycin should be taken on empty stomach.
Diuretic should be taken in the morning.
Premature d/c: common
with antibiotics (symptoms subside) or chronic drugs such as for ↑ BP
(asymptomatic).
Storage: improper
storage and improper disposal of unused drugs.
Consequences of noncompliance
Over and under utilization have
major economic impact.
Always, the benefits from ↑
compliance outweigh the costs of compliance enhancing programs.
Overutilization: may cause
toxicity. Examples: double dose to make
up for missed dose, if one pill is good then more must be even better.
Noncompliance is one of the most
commonly missed diagnoses (e.g. poorly controlled BP).
Consequences of noncompliance
are not always negative. Some patients
are “intelligent noncompliant” where they alter the dose based on SE emergence
while treatment goals is still achieved.
Detection of noncompliance
Diagnosis of the problem is a
key. Behavior may change with time.
Ideal detection takes place at
the time and place of taking the medication.
Indirect measures:
Self-reports and interview: simplest, but overestimates compliance. “Most people have trouble remembering to take
their medicine. Do you have trouble
remembering to take yours?”
Pill count: commonly
used in clinical studies. Pill dumping
is a common problem (study participants try to deceive physicians). Overestimate compliance. Change of weight of
MDI can be used.
Achievement of treatment goal: examples: normal BP, BG, intraocular pressure. However, patients may load-up on medication
or use other regimens (diet) before doctor visit. This is called toothbrush effect (people toothbrush
before dentist visit).
Computerized compliance monitors: most reliable indirect method. Started with electronic eye-drop
dispensers. A microprocessor is located
in the cap of the container. Time and
date are recorded every time the patient removes the cap. Very useful in clinical studies.
Refill rate: commonly
used in community pharmacy settings.
Direct measured:
Direct methods are more
reliable. Use of at least 2 methods is
recommended.
Biological markers and tracer compounds: indicate patient compliance over extended period. Example: glycosylated hemoglobin assesses BG
control over the preceding 3-months.
Tracer compounds: small
amounts of agents such as Phenobarbital or digoxin (long half life, indicate
compliance for past weeks) are added to drugs and measured in biological
fluids.
Drug concentration in biological fluids: limited usefulness due to variability between
individuals, does not indicate the timing of the dose, can be fooled by
loading-up prior to biological fluid sampling.
The noncompliant patient
No consistent pattern has been
observed regarding noncompliance with certain age, education, occupation,
socioeconomic status, personality, race, severity or type of illness, etc.
Intentional noncompliance is
more common in patients who used two or more drugs or two or more physicians.
Health Belief Model: developed
initially to explain preventative health behaviors such as immunizations and
prophylactic dental care. It also
applies to compliance with prescribed medical regimen.
Third Generation Model: focuses on health decisions.
Health Decision Model: combines decision analysis, behavioral decision theory, and health
beliefs to give a model for health decisions and resultant behavior.
Compliance and health beliefs: patient has to believe that: he has the illness
diagnosed, illness can cause severe consequences to daily functioning,
treatment will ↓ present and future severity of condition, benefits or regimen
outweigh perceived disadvantages and costs.
Stimulus to
trigger positive health behavior can be internal (patient’s concern) or
external (interaction with physician or pharmacist).
Myths: “need to take medication only when
experiencing symptoms”, “need to d/c
medication occasionally to prevent dependence and maintain efficacy”.
Other factors: patient
who live alone are more noncompliant.
Patient may have fear of dependence for any drug that is used
chronically. They may d/c or ↓ dose
occasionally to prevent this or to prove to themselves that is not the case.
Factors associated with noncompliance
Disease
Psychiatric patient are more
noncompliance due to an attitude or inability to cooperate.
Patients with chronic
asymptomatic disease are more noncompliant (hypertension, hypercholesterolemia,
tuberculosis).
Occurrence of significant
symptoms upon d/c may ↑ compliance.
↑ disability caused by the
disease à ↑ compliance.
No general correlation between
disease severity and compliance.
Therapeutic regimen
Multiple drug therapy: ↑ number of drugs à ↑ noncompliance (e.g. in geriatrics).
The similarity in appearance of drugs may lead to confusion. Combination drugs may help but therapy should
start with individual drugs and then switched to the combo when optimum dose is
reached.
Frequency of administration: may cause interruption of normal routine or work schedule
à inconvenience, embarrassment, forget. Very critical factor in compliance. However, patient may be skeptical about the
effective of a QD drug.
Duration of therapy: rate
of noncompliance ↑ as duration ↑.
Adverse effects: change
dosage or use alternative drugs if possible.
Big problem when the medication makes the patient feel worse than before
(e.g., BP drugs). Sexual dysfunction is
common cause (e.g. with antipsychotics, antihypertensives). Just communicating potential SE may cause the
patient not to take the drug.
Asymptomatic conditions: includes lack of symptoms before the drug, lack of
appearance of symptoms if drug is d/c, disappearance of symptoms (antibiotics).
Cost: ↑ cost à Rx not filled, ↓dose is taken, ↓frequency, prematurely
d/c.
Administration: for
example, incorrect measure of liquid medications, MDI use, oral antibiotic
drops for ear infection instilled in the ear, using suppository by the oral route.
Taste: common for
oral liquid in children (e.g. liquid KCl).
Patient/pharmacist interaction
Psychological support should be
provided in a compassionate manner.
Patients are ↑ compliance with a
physician they know and respect.
Not appreciating importance of therapy: if therapy does not meet their own or taught expectations
à noncompliance.
Poor understanding of instructions: “as directed” should be avoided on label. “every 8 hours” is more specific than “three
times a day”. Auxiliary instructions are
also key. Example: apply one
nitroglycerin patch a day, patient got confused and added a new patch without
removing the old ones.
Improving compliance
Identification of risk factors
All patients should be viewed as
potential noncomlpiers. Evaluate the probability of being noncompliant based on
the risk factors.
Development of treatment plan
Recommend longer acting drugs or
dosage forms.
The more actively participating
patient in the plan is more compliant.
Plan should be individualized.
Tailor regimen to ↓
inconvenience and forgetfulness by fitting it to regular activities in the
patient’s schedule. Indicate specific
times of the day to take medications if possible.
Patient education
Effective communication is the
key for ↑ compliance.
Patients should be asked to
repeat the instructions to show understanding.
Key points: name of medication,
action, how much to take, when, for how long, food interactions, possible SE,
what to do about SE, information sheet.
Oral communication / counseling: more important than written, as it gives patient a chance
to interact and ask questions. Ensure
privacy and ↓ distractions. Separate
consultation area is ideal. Call the
patient if possible if face to face is not possible.
Written communication: important is a future reference for the patient as he is not expected
to remember all details. Written info ↑
compliance only for short term therapy (e.g. antibiotics).
Audiovisual materials: very useful in certain situations (e.g. insulin, sumatriptan, MDI).
Controlled therapy: it
is recommended that patients start self-medication before hospital discharge to
transition them from complete dependence in the hospital to complete
independence at home.
Special compliance programs: example: behavioral program for schizophrenics. Training include learning on obtaining
information about drug benefits, correct self-administration and evaluation of
effects, identify SE, talking about issue with professionals. Programs may be useful also for sight or
hearing impaired patients.
Patient motivation
Good knowledge about the illness
and medication does not necessarily translate to ↑ compliance. Patients need to be motivated not only
educated.
Information must be presented in
a manner that is not coercive, threatening, or demeaning. Use special packaging or reminder systems if
possible. A contract approach may be
useful with some patients where agreement is reached on specific actions.
Compliance aids
Labeling / auxiliary: must
be clear, accurate and specific
Calendars / Reminder charts: helps the patient understand which medication to take and
when to take it.
Special containers / caps: for example, system with four compartments for different
time periods (morning, noon, evening, bedtime) for each day of the week. Special caps can display the time of the day
when the last dose was taken. It flashes
/ beeps when it is time for the next dose.
Compliance packaging: defined
as pre-packaged unit that provides one treatment cycle of the medication. Usually based on blister packages. A good example is special packaging for birth
control pills. Another example:
prednisone decreasing dose regimen. Child-proof
caps may be a problem for the elderly or patients with arthritis.
Dosage forms: for
example ER, XR and transdermal patches.
Monitoring therapy
Self monitoring: by
the patient of the treatment regimen, response parameters.
Pharmacist monitoring: based on inadequate frequency of refills, follow up by phone or mail
reminders. Automatic phone call reminder
systems have been used. Brown bag program: elderly pull all
medications in a bag and take them to a professional for review.
Directly observed treatment: watch patient swallow drug (e.g. in TB).
112. Pharmacoeconomics
Innovative roles for pharmacists: home IV therapy, drug level monitoring, parenteral
nutrition management, self-care counseling.
Pharmacy services may provide
positive outcomes by ↓ morbidity, ↑ therapeutic control, ↓ cost of treatment by
using efficient therapy, ↓ # of physician visits, ↓ rate of drug related
hospitalization, ↓ incidence and intensity of SE.
Extra years of life for a
patient population can be converted to dollars for society.
Economic methods
Technique
|
Inputs
|
Outputs
|
Classical operations analysis
|
Units (e.g. pharmacy hrs)
|
Units (e.g. patients
monitored)
|
Cost effectiveness analysis
|
Dollars
|
Natural units
|
Cost benefit analysis
|
Dollars
|
Dollars
|
Cost utility analysis
|
Dollars
|
Utiles/preferences
|
Cost minimization analysis
|
Dollars
|
Assumed equal
|
Cost benefit analysis
Medical care is an investment
good (in human capital) and a consumption good.
Measure of investment benefit:
present value of a person’s lifetime productivity.
Both inputs (costs) and outputs
(benefits) have to be quantified in dollars.
Both $ amounts are discounted to
their present value at a certain interest rate.
Economic value =
present value of benefits – present value of costs.
Benefits may be difficult to
measure or to convert to $, or both.
Benefits
Benefits: defined
as the ↓ in costs realized due to program implementation. Can be direct, indirect, or intangible.
Direct benefits: savings
on direct costs in medical care. Easy to
measure.
Indirect benefits: savings
on indirect costs in the medical care.
Difficult to measure. It’s
avoidance of earnings and productivity losses which would have been incurred
without the health program.
Intangible benefits: difficult,
if not impossible, to measure.
Intangible costs are psychological (pain, suffering and grief).
Discount rates
Discount rate is the conversion
of dollar amount to present values through the use of interest rate.
↑ discount rate: favors projects
with benefits occurring in distant
future.
↓ discount rate: favors projects
with costs occurring in distant
future.
Commonly used discount rate is
the yield rate on long term gov bonds.
Mathematical models are used to
calculate benefit/cost ratio.
Net Present Value (NPV): a new model for
calculating benefits-costs. Very popular
and currently recommended by many economists.
Rate of Return on Investment: calculates the interest rate from an initial program
investment over a potential stream of benefits over time.
Cost effectiveness analysis
Alternative ways are compared
for achieving results (↓BP,
life expectancy).
Similar output measurements must
be achieved to compare programs.
Cost Benefit Analysis
|
Cost Effectiveness Analysis
|
Output: dollar values
|
Output: units not dollars
|
Determines maximum benefit or
investment
|
Determines least cost
combination
|
Assumes limited resources
|
Assumes adequate resources
|
Fast comparison of programs
|
Different ways to reach same
objectives
|
Less flexible
|
More flexible
|
Economic perspectives
A pharmacy service with positive
benefit/cost ratio may be good for the society as a whole but not to every
segment of the society. Example: drug
regiment that ↓ # of patient days in acute care is good for the society but may
not be good for the hospital that depends on patient stays for revenue.
Always consider who pays the
costs and who receives the benefits.
Quality of life outcomes and patient decisions
Quality of life and satisfaction
with service are critical. Elements may
include: probability of success, associated pain, likely outcomes, etc.
Example: the quality of years
within life extension (healthy years?).
Example: untreated hypertension
may not critical affect daily life, but a MI would ↓ quality of life.
Health-related quality of life
(HRQL) is a humanistic outcome.
Using decision-analysis
techniques, a decision tree can be made of what happens to the patient from
diagnosis to cure.
The FDA has been leery of drugs
that ↑ quality but ↓ life expectancy.
Diseases are associated with
physical, mental and social impairments (which can be difficult to
measure).
Pharmacy Management (PDF files)
Basic accounting
Accounting: process
of collecting, recording, summarizing, using financial data
Auditing: accounting
that deals with verifying that records are kept and computations are made.
Bookkeeping: process
that documents flow of resources ($$, goods) into / out of the business, and
claims of creditors / owners to those resources
Dual effects of accounting: most transactions are recorded twice with the result of a
balanced sheet.
T Account: with
debt on the left and credit on the right. Debits
= Credits.
Transactions: fiscal
/ financial events that are recorded.
Accounting period: period
of time over which transactions are recorded, at the end of which income is
measured. Usually 1 year. Not always a calendar year.
Methods of recording transactions: Accrual: transactions are recorded at the time they occur. Cash: transactions are recorded when
cash transfers hands.
Revenue: measurement
of goods sold or services rendered for which the business receives cash or the
promise of cash.
Expenses: resources
used up during a period of time to earn revenue.
Types of accounts: owner equity = assets -
liabilities.
Assets: resources
owned by the business, e.g. cash, account receivable, buildings, inventory,
equipment, furniture, prepaid insurance.
Liabilities: debt
owned by the business to creditors. It arises when business borrows cash (e.g.
bank loan) or purchases goods or services on credit. Examples: accounts
payable, notes payable.
Owner equity (Net Worth): claim of the owners to the assets of the business after
all creditors have been paid. It ↑ when owners make investments in business or
when revenue is earned. It ↓ when expenses are paid. Examples: contributed
capital, sales revenue, service revenue, expense accounts.
Expenses: not a
liability because they are used up resources that require the immediate payment
of cash for the amount in full, otherwise à liability.
Prepaid expenses are assets because they’re resources that have not yet
been used up.
Income = revenues
– expenses.
Cost of Goods on Hand: on last day of accounting period à physical inventory to determine cost of inventory not
sold. No physical inventory is needed if perpetual inventory is kept by
computer systems.
Fixed assets: tangible,
long-lived resources used in business operation, e.g. building, machinery,
fixtures, equipment, etc.
Current assets: resources
owned by the business which are expected to be realized in cash, sold or
consumed in one year, e.g. account receivable, inventory, etc.
Depreciation: wear
and tear that occurs on fixed assets calculated as an expense. Most fixed assets, except land, are
depreciated.
Contra (offset) accounts: reside directly below the fixed asset account to which
they pertain.
Income statement
Summary of operations, income
earned during accounting period.
Constructed using revenue and
expense account balances.
Revenue: sales of good and
services
Cost of goods sold: such as
inventory and transportation expenses.
Gross margin = revenue
– cost of goods sold.
Net profit (income) = revenue
– all expenses.
Net income = net
profit – income tax
Balance sheet
Presents the financial position
of the business at a certain point in time
Constructed using all asset
account, liability accounts, OE accounts
Retained earnings: link
income statement and balance sheet.
Purchasing and inventory
Inventory management
Involves planning, organizing,
controlling inventory for profitability
Inventory control objectives: ↓ investment, ↓ purchasing / carrying costs, balance
supply and demand.
Inventory is the largest pharmacy
investment à critical to manage.
Total inventory costs = acquisition costs + stock out costs + carrying costs +
procurement costs.
Acquisition costs: amount
the pharmacy pay for the product.
Stock out costs: cost
of not having the product available when needed
Carrying costs: storage,
handling, insurance, loss/theft, damage, capital
Procurement costs: cost
of placing orders, receiving items, stocking shelves, processing documentation
Objective of holding inventory: to guard against fluctuations in demand and later
delivery, take advantage of bulk discount.
Goals of inventory management: minimize investment in carrying and procuring inventory
by balancing supply and demand.
Inventory costs à significant
impact on financials. ↓ procurement and
carrying costs, ↑ sales by avoiding stock-outs
Cash flow: prompt
payment, ↓ COGS, ↑ gross margin
Inventory turn-over rate (ITOR) = COGS/average inventory. Target: ↑ ITOR to ↑ return on
investment in inventory, ↓ investment in inventory to free up capital for other
ventures.
Inventory return on investment = net profit/average inventory.
What to buy? product,
manufacturer, competitor consideration.
Where to buy? consider
order cycle time, minimum order required.
How much and when to buy?
difficult to determine.
Cycle stock: inventory
kept on hand to fulfill orders
Buffer/safety stock: inventory
for case of supply/demand fluctuations.
Anticipatory/speculative stock: inventory for expected ↑ in demand
Steps of purchasing
Cost of goods sold (COGS): have dramatic effect on profits
Purchasing objectives: right
product / variety, quality, quantity, price, time
1. Market research: to
determine needs/wants of patients / prescribers, identify pharmacy image and
business goals, space limitations, potential sales. Determining needs: usage reports, other
pharmacies, pharmacy employees, questionnaires, sales reps, published top X
drugs, formularies. Example: area with
young families à children items, older families à elderly items. Consider special disease management areas,
e.g. asthma, diabetes.
2. Effective purchasing policies: Use “open-to-buy purchase budget”. Control total $ investment in inventory. Use prior year data to forecast purchase
budget for each month in the upcoming year, based on sales and COSG. Adjust (↑ / ↓) each month purchases based on
previous month sales and purchases. Gross margin = sales – COGS.
3. Selecting supply sources: must be dependable, prompt, frequent delivery, good
return policy, ↓ frequency of out-of-stock, customer service, price, financing
arrangement. Options: wholesales, manufactures, buying groups, rack jobbers,
etc. Wholesales: advantages include storage of good until needed, rapid
delivery, financing options, help with advertising promotions, store layout and
design. Rack jobbers: stock and
maintain a specified assortment of goods (e.g. eyeglasses) in a fixture in the
pharmacy. Manufacturers: not common, large minimum purchases. Central
purchasing groups: pool buying power of independent pharmacies for better
terms.
4. Negotiating terms: price,
discounts, dating, return policy. Pharmacy margin = suggested retail
price – pharmacy cost. Quantity discounts: cumulative (generic
rebate) or non-cumulative ($ or % per quantity). Cash
discount: for prompt payment (typical: 2% if paid in 10 days, net amount
due in 30 days), or discount for Electronic Fund Transfer. Final price is calculated after subtracting
trade, quantity and cash discounts. Dating:
time for discount and payment (prepayment, collect-on-delivery (COD),
delayed). Returned goods policy: full credit within x days, partial credit
after y days, non-returnable after z days. Check shelves regularly for items
not sold. Consider using a returned
goods service company (charge a fee).
5. Transferring merchandise
title (?)
6. Receiving, marking, stocking: count shipment, check for damage, check invoices, mark
prices (merchandise, computer), stock.
Stock depth considerations: average demand, review time, lead time, safety
stock. Inventory control includes the
following:
1. Visual: look at
# of units in inventory and compare with how many should be carried, order more
if needed.
2. Periodic: count
stock on hand at certain intervals, compare to minimum target levels, order
more if needed.
3. Perpetual: monitor
inventory all the time (usually using a computer).
Computer systems: sales,
analysis, trends, perpetual, automatic ordering, interface inventory and
dispensing systems at point of sale.
Financial analysis / planning
Comparative analysis: express
each financial statement component as percent of sales, and compare with Digest
data.
Ratio analysis: compare
financial ratios with ratios for the same company during recent years, and
similar group of pharmacies in NCPA Pharmacia Digest.
Solvency: overall
ability to pay legal debts. Calculate Current and Acid Test ratio
Current Ratio = current
assets / current liabilities. Target > 2
Acid Test Ratio = (Cash
+ account receivable) / current liabilities. Target > 1
Other solvency ratios: current liabilities / inventory, total liabilities / net worth,
long-term liabilities / net working capital, fixed assets / net worth,
Efficiency: how
well available capital is used.
Inventory turnover ratio.
Inventory turn over ratio = COGS / average inventory.
Target: 5-6.
Other efficiency ratios: net sales / inventory, account receivable and account
payable collection period, net working capital turnover.
Profitability: the
bottom line, important but not the only measure of success.
Return on net worth = net
profit / net worth. Target 25%.
Net worth = total assets – total
liabilities.
Net profit / net sales: target
5%.
Net profit / total assets. Target 15%.
Net profit / inventory. Target 20%.
Expenses: salaries,
wages, rent, utilities, accounting / legal fees, taxes, licenses, insurance,
interest, equipment, depreciation.
Balance sheet: includes
assets and liabilities. Current assets: cash,
account receivables, inventory. Current liabilities: account payable,
accrued expenses.
Pricing
Components of price =
ingredient cost + service cost (dispensing) + income.
Actual Acquisition Cost (AAC): price the pharmacy pays for the product. Varies depending on source, volume,
incentives and deals, type of pharmacy
Average Wholesale Price (AWP): NOT (?) the average price the wholesalers sell the
product at. Cost assigned to product by
manufacturer, overstates AAC
Estimated Acquisition Cost (EAC): established by third party payers to estimate AAC.
Usually a percentage of AWP (e.g. 90%).
Service cost: average
or per unit cost of providing a service. Covers expenses such as salaries,
rent, utilities, depreciation. Includes
cost to dispense.
Direct costs: results
directly from providing the service. No
direct cost if service is not provided.
Dispensing direct costs: labels, containers, computer, delivery costs,
patient education materials, pharmacy licenses.
Indirect costs: costs
shared by all services, e.g. rent,
utilities, salaries, benefits, advertising, etc.
Cost of providing a service =
all direct costs + “fair share” of indirect costs.
Cost allocation: determining
the fair share of indirect costs. Difficult. Estimate % of employees time and
facility space devoted to dispensing.
Cost to dispense (COD): total dispensing costs / expected Rx volume. It is an
estimation of the average cost to dispense Rx.
Sensitive to volume.
Differential costs; differ
among alternative courses of action, i.e. additional costs the pharmacy incurs
for providing a new service.
Non-cost factors: demand,
competition, image, quality signaling, goals, non-monetary costs.
Demand: quantity
consumers will be at a certain price.
Function of price.
Elasticity of demand: measures
sensitivity of demand to price ∆.
Elastic demand: small
↓ in price results in big ↑ in demand.
Sellers make money by lowering the price. Inelastic demand is opposite (↑ price à ↑ profit)
Consumers are more sensitive to
price when: cost of product is large part of total cost, ↓ differences among
products, comparisons are easy, consumers can judge quality, switching costs
are small, commodity.
Image: consumers
can select based on perceptions of pharmacy image. Image is affected by:
prices, size, location, services offered, personnel, promotions, etc
Price as a signal of quality: more likely when consumers cannot judge quality, more for
services than products.
Penetration pricing: ↓ price to
↑ sales volume. Loss leader pricing: ↓ Rx prices to ↑ OTC sales. Price skimming: ↑ price for superior service.
Basic Management
Management components: self, controllable surroundings, uncontrollable surroundings, external
environment.
Management activities: satisfy various entities, deal with emergencies, purchasing,
recruiting, accounting, training, planning, negotiating, sales, dealing with
regulatory officials.
Management actions: identify
tasks, organize resources, monitor performance / task completion, plan for
future requirements, deal with problems.
Functions of management actions: target setting, problem solving, leadership, team
building, dealing with emergencies.
Management functions: controlling,
directing, organizing, planning, staffing
Controlling: establish
standards based on objectives, measure / report performance, take corrective /
preventative actions.
Directing: motivation,
communication, performance appraisal, discipline, conflict resolution.
Organizing: division
of labor, delegation of authority, departmentalization, span of control,
coordination.
Planning: vision,
mission, objectives, coals
Staffing: recruiting,
selecting, hiring, training, retaining
Know self, who we are, what we
aspire to become, new info, what we need to know, who else need to work with
us, etc.
Manager’s skills: intellectual,
technical, ethical, interactive, emotional.
Intellectual skills: logical
thinking, problem solving
Ethical skills: define
right from wrong
Interactive skills: communicate
intelligently and create an atmosphere that facilitates communication.
Most problematic issues: poor communication, developing people, empowerment, lack
of alignment, entitlement, balancing work / personal life, confronting poor
performance, coaching senior management, cross-functional strife, fascination
with programs.
Decision making: identify
objectives, analyze relevant factors, consider all alternatives, selection best
option, implement the decision, evaluate the results
Management style: depends
on organization, situation, personal values, personality, chance.
Self-development methods: observation, reflection, guided readings, attachments /
visits, seeking feedback, seeking challenges.
Strategic planning: must
complement strategic thinking / acting. Includes where we are going (mission)
and how we get there (strategy).
SWOT analysis: strengths,
weaknesses, opportunities, threats.
Vision of success: mission,
basic philosophy, core values, goals, strategies, performance criteria,
decision rules, ethical standards.
Environment: stability,
complexity, market diversity, hostility, competition
Cascade of information: should flow not only downward, but also upward
Project management failures: lack of focus / attention, inability to cope with
different project characteristics, feeling being used / exploited, lack of
experience
Project management process: develop ideas and proposals, approve the project, project
kick-off / start, monitoring / reporting / managing, termination.
Project management 10 commandments: concentrate on interfacing, organize project team, plan
strategically / technically, remember Murphy’s law, identify stakeholders,
manage conflict, expect the unexpected, listen to intuition, apply behavioral
skills, take corrective actions.
Project management functions: scope / quality / time / cost management
PDCA Cycle: Plan,
DO, Check, Act
Problem solving: define
the problem à identify the criteria à weight importance of criteria à generate alternatives à rate alternatives on each criterion à compute the optimal decision
Continuous Quality Improvement (CQI): philosophical / structural / healthcare-specific
elements. Use PDCA cycle.
Philosophical elements: strategic focus (mission, values, objectives), customer
focus (patient, provider, payer), systems focus.
Structural elements: process
improvement teams, top management commitment, statistical analysis, customer
satisfaction measures, benchmarking, seven tools (flow charts cause/effect
diagrams, check sheets, histograms, etc).
Healthcare specific elements: epidemiological studies, governance processes (QA,
committees, peer review), risk-adjusted outcome measures, cost-effectiveness
analysis.
Barrier to quality transformation: lack of constancy of purpose, emphasis on short-term
profits, personal view system, management mobility, using only visible figures,
↑↑ cost of employee healthcare, ↑↑ cost of warranty / insurance.
5. Extemporaneous Prescription Compounding
18. Nuclear Pharmacy
19. Pharmaceutical Care and Disease Management
21. Adverse Reactions and Post Market Surveillance
34. Clinical PK and Therapeutic Drug Monitroing
53. Renal Failure
57. Immunosuppressants in organ transplantation
58. Outcomes Research and Pharmacoeconomics
Health care system
Preferred Provider
Organization (PPO): Broad network of providers available, generally
management is less strict. 52%
Point of Service
(POS): HMO plan with the option of going outside the narrow provider
network if willing to pay higher cost-sharing. 18%
HMO: Narrow
choice of providers, tighter management.
26%
Types of outcomes:
Humanistic outcomes:
Health Related Quality of Life, Patient
Satisfaction, Caregiver Impact, Patient Preferences, Functional Status
Economic: Cost
Analysis, Cost-of-Illness, Cost-Minimization, Cost-Benefit, Cost-Effectiveness,
Cost-Utility
Clinical: Efficacy,
Safety, Impact of therapy on “natural history” of the disease
Methods for setting health insurance rates
Experience rating:
everyone in a specific area is charged the same premium based on the average
cost of providing health services to all people in the area
Community rating: premium adjusted
individually according to a person’s or group’s average health history, risk,
and past claim experienc
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