Family Medicine & Pharmacy Podcast

Management of Onychomycosis in Canada in 2014 http://www.ncbi.nlm.nih.gov/pubmed/25775640 Drug name: Brand: SA SA Criteria SA Approval period Direction SE Monitoring Ciclopirox 8% Penlac (nail lacquer) No Not covered N/A Nail lacquer: Apply bid to adjacent skin and affected nails daily. Remove with alcohol every 7 days (treat 4 weeks) dermatitis, dry skin, local burning sensation Efinaconazole Jublia (nail lacquer) Not covered Not covered N/A Apply to affected toenails once daily for 48 weeks Ingorwn nail (2%), dermatitis Terbinafine tablets Lamisil tablets Yes Severe onychomycosis PLUS functional disability PLUS positive KOH or dermatophyte culture of nail from a licensed lab. First approval: Three months Renewals: If required, up to three months. 250mg once daily for 6 weeks (fingernail); 250mg once daily for 12 weeks (toenails) Headache (13%), diarrhea (6%), nausea, liver enzyme disorder (3%) Monitor AST/ALT prior to initiation, repeat if used >6 weeks Itraconazole Sporanox Yes 1. Immunocompromised pts/ Or 2. Pulse treatment for severe onychomycosis with functional disability PLUS confirmed lab results for candida or dermatophyte infection. 1. Immunocompromised pts approval is indefinite 2. 3 months approval for 2nd group of pts (No need for SA approval if prescribed by HIV/AIDS Dr) Fingernail involvement: 200mg capsule twice daily for 1 week. repeat 1 week course after 3 week off time Toenails due to Trichophyton rubrum or T mentagrophytes: 200mg once daily for 12 consecutive weeks With or without fingernaikl involvement: 200mg once daily for 12 consecutive weeks Canadian labelling "Pulse dosing": 200mg twice daily for 1 week, then repeat 1 week course twice with 3 week off time between each course Diarrhea, nausea, headache, skin rash Liver function in patients with pre-existing hepatic dysfunction, and in all patients being treated for longer than 1 month fluconazole Diflucan Yes 1. Immunocompromised patients. OR2. Exceptions on an individual basis for fungal infections resistant to first-line medications. 1 day to indefinite (no need for HIV and AIDS Dr to apply for SA)

We are back! (Or your money back!) In this episode, Billy and Tina discuss the PharmaCare coverage status of different classes of diabetes medications. Sources: BC PharmaCare Formulary: https://pcbl.hlth.gov.bc.ca/pharmacare/benefitslookup/ BC PharmaCare Special Authority: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority CDA Formulary Listings for Diabetes Medications in Canada by provinces and territories (Jan 2016): http://www.diabetes.ca/getmedia/c87009a8-29b6-4061-a52a-963d0b077e47/pt-formulary-listing-jan-18-2016.pdf.aspx *In case the link doesn't work: pt-formulary-listing-jan-18-2016 Class drugs Other therapeutic considerations coverage SA criteria Biguanide metformin covered Alpha-glucosidase inhibitor (acarbose) acarbose Improved postprandial control, GI side-effects delisted Incretin agent: DPP-4 Inhibitors linagliptin (Trajenta) SA same as onglyza sitagliptin (Januvia) delisted saxagliptin (Onglyza) SA As part of a combination treatment for type 2 diabetes mellitus, 1) When insulin NPH is not an option AND 2) After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea. Incretin agent: GLP-1 receptor agonists liraglutide (Victoza) GI side-effects not listed Insulin rapid acting (Humalog, novorapid, apidra) No dose ceiling, flexible regiments partial coverage short acting (Humulin R, Novolin Toronto) covered NPH covered Premixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50) covered Premixed (Humalog mix 25, mix 50, Novomix 30) partial coverage glargine (Lantus) SA A) Type 1 DM or B) Type 2 DM > 17 years old, and 1) requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing AND 2) Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management OR 3) Has experienced or continues to experience severe, systemic or local allergic reaction to existing insulin treatment. detemir (Levemir) SA same as Lantus new glargine (Toujeo) not listed Insulin secretagogue: Meglitinide repaglinide (gluconorm) Less hypoglycemia in context of missed meals but usually requires TID to QID dosing not listed Insulin secretagogue: Sulfonylurea glyburide Gliclazide and glimepiride associated with less hypoglycemia than glyburide covered gliclazide SA (listed everywhere else in Canada) Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses. SGLT2 inhibitors canagliflozin (Invokana) UTI, genital infections, hypotension, hyperlipidemia, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia) 1 year manufacturer coverage with special plan dapagliflozin (Forxiga) 1 year manufacturer coverage with special plan empagliflozin (Jardiance) not listed TZD rosiglitazone CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect delisted pioglitazone SA same as onglyza Weight loss agent (orlistat) orlistat GI side effects not listed Combination Drugs sitagliptin and metformin (Janumet) delisted linagliptin and metformin (Jentadueto) SA same as onglyza

This is planned to be an 8-part series highlighting the take-home points I picked up during the St. Paul's Hospital CME Conference 2014. Pearls from Part 1 "Internal Medicine": Alcoholism - Dr. Paul Farnan Screen alcohol use disorders routinely to catch those of whom do not appear to have a significant social or occupational impairment. Use assertive statements to convey the concern regarding someone's alcohol use. Peer support is strongly recommended. Patients should try multiple meetings at different groups before concluding that they are not helpful, as the groups vary in their structure and member characteristics. Medical treatments may be considered in select patients: naltrexone, acamprosate, disulfiram. Gout - Dr. Hyon Choi Screen for HLA-B*5801 in Asians (esp. Chinese, Thai, and Korean patients) before starting alopurinol. Look for concurrent metabolic disorders. "Medication in the pocket" strategy for acute flares: colchicine 1.2mg po x1 then 0.6mg po in 1 hour. Use losartan or CCB for concurrent hypertension. Low-carb diet and avoid foods with highest purine content. Cellulitis - Dr. Val Montessori Non-purulent cellulitis, most likely caused by Group A Strep, treat with cephalexin (Keflex) 500mg po QID Purulent cellulitis, most likely Staph Aureus but still possibly GAS, treat with Septra DS PO BID, and cover GAS with Keflex. Complicated wounds, consult ID. HCV - Dr. Edward Tam New therapy more tolerable and has a 95% cure rate, but also exceedingly expensive. Refer all HCV RNA positive patients to hepatologists for assessment of treatment. This Changed My Practice - Dr. Steve Wong http://thischangedmypractice.com/ OSA - Dr. Pearce Wilcox Co-morbidities with metabolic syndrome -> screen for metabolic syndromes in patients with OSA, and vice versa  

After a 6-month hiatus, Tina - now a newly-hatched PHARMACIST! - and Billy teamed up to relaunch this pet project with a plan to make it more interactive and less sleep-inducing. Did it work with this unscripted episode?

Tina concentrates on the details of ADHD medications and invites your attention to the following: Non-pharmacological therapy behavioural therapy Stimulants methylphenidate amphetamines Non-stimulants atomoxetine clonidine other antidepressants and antipsychotics (to be covered in future episodes)  

*This episode was recorded in January 2014. This is the topic that started it all. As Tina planned to study ADHD for school, we discussed how this would be useful information for other pharmacy students and medical trainees as well. We looked to the comprehensive CADDRA guideline for the assessment, differential diagnoses, and treatment strategies for ADHD. CADDRA Guideline: http://www.caddra.ca/pdfs/caddraGuidelines2011Chapter02.pdf ADHD Checklist on CADDRA ADHD Assessment Toolkit, page 8.20 http://www.caddra.ca/pdfs/caddraGuidelines2011_Toolkit.pdf  

Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis:  UK NICE Guideline: Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84 CPS Guideline: Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy History: onset of diarrhea and/or vomiting (gastro is sudden in onset) duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days) sick contact pathogen exposure travel history History suggestive of increased risk of dehydration: young age (esp 5 diarrhea in 24h >2 vomiting in 24h no oral intake signs of malnutrition Think about differential diagnosis if: fever >38 in children younger than 3 months fever >39 in children older than 3 months (fever workup required) shortness of breath or tachypnoea altered conscious state neck stiffness bulging fontanelle in infants non-blanching rash blood and/or mucus in stool bilious (green) vomit severe or localised abdominal pain abdominal distension or rebound tenderness.   SSx of dehydration and shock Table 1 in NICE Increasing severity of dehydration No clinically detectable dehydration Clinical dehydration Clinical shock Symptoms (remote and face-to-face assessments) Appears well Red flag Appears to be unwell or deteriorating – Alert and responsive Red flag Altered responsiveness (for example, irritable, lethargic) Decreased level of consciousness Normal urine output Decreased urine output – Skin colour unchanged Skin colour unchanged Pale or mottled skin Warm extremities Warm extremities Cold extremities Signs (face-to-face assessments) Eyes not sunken Red flag Sunken eyes – Moist mucous membranes (except after a drink) Dry mucous membranes (except for 'mouth breather') – Normal heart rate Red flag Tachycardia Tachycardia Normal breathing pattern Red flag Tachypnoea Tachypnoea Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses Normal capillary refill time Normal capillary refill time Prolonged capillary refill time Normal skin turgor Red flag Reduced skin turgor – Normal blood pressure Normal blood pressure Hypotension (decompensated shock) Table 2 in CPS TABLE 2 Clinical assessment of degree of dehydration * Mild (under 5%) Moderate (5-10%) Severe (over 10%) Slightly decreased urine output Slightly increased thirst Slightly dry mucous membrane Slightly elevated heart rate Decreased urine output Moderately increased thirst Dry mucous membrane Elevated heart rate Decreased skin turgor Sunken eyes Sunken anterior fontanelle Markedly decreased or absent urine output Greatly increased thirst Very dry mucous membrane Greatly elevated heart rate Decreased skin turgor Very sunken eyes Very sunken anterior fontanelles Lethargy Cold extremities Hypotension Coma *Some of these signs may not be present   SSx of hypernatremic dehydration: jittery increased muscle tone hyperreflexia convulsions drowsiness or coma Labs: No routine blood work Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia Blood gas if shock suspected Stool culture if: blood and/or mucus in stool immunocompromized septicemia suspected travel history diarrhea not improved by day 7 uncertainty about diagnosis of gastroenteritis

AAP Guideline on Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months http://pediatrics.aappublications.org/content/128/3/595.long UK NICE guideline: Urinary tract infection in children http://guidance.nice.org.uk/cg54 Summary: For children with fever, UTI should be suspected. For children at a very low risk for UTI, or greater than 3 years of age, a bag urine for urinalysis is an appropriate first step. If the urinalysis is suspicious for UTI, such as being positive for leukocyte esterase or nitrite, or if the children is not at a very low risk for UTI, then a catheterized urine sample should be obtained for urine culture prior to starting empiric antibiotics. If the culture comes back negative, then antibiotics treatment covering UTI can be stopped. Febrile UTI is presumed to be pyelonephritis, and should be investigated with Bladder and Renal Ultrasound. If the ultrasound shows structural abnormalities, or if the child has recurrent febrile UTIs, a VCUG should be considered, especially in younger children.  

The bulk of this episode is based on the UK NICE guideline: Feverish illness in children under 5, published in 2013. http://guidance.nice.org.uk/CG160 The guideline covers: Thermometers and the detection of fever Clinical assessment of the child with fever (using the traffic light system) Management by remote assessment Management by the non-paediatric practitioner Management by the paediatric specialist (investigations summarized below) Antipyretic interventions The Traffic Light System in assessing risk for serious infection This assessment tool takes into consideration color/appearance, activity, respiratory, circulation and hydration, and "other" parameters. For each parameter, their associated signs and symptoms are assigned a color code: "green" (low risk), "amber" (intermediate risk) and "red" (high risk). The table can be found here. Age-appropriate investigations for pediatric fever Once the risk for serious infection is determined, the following investigation should be performed: Age CBC diff BC CRP UA/UC LP CXR Stool culture 15 or =3mo, RED yes yes yes yes yes yes if indicated >=3mo, AMBER yes yes yes yes if 39 and WBC >20 if indicated >=3mo, GREEN no no no yes no no if indicated And at the same time, empiric parenteral antibiotic coverage for meningitis (3rd generation cephalosporin plus ampicillin/amoxicillin) should be started if LP is indicated.

Antiplatelets: ASA Clopidogrel Anticoagulants: Warfarin Apixaban Dabigatran Rivaroxaban Clotting Cascade: Clotting Factor Song, by Emily Anne Nagler: http://www.youtube.com/watch?v=TG9yPHH3FmY Twelve, eleven, nine, it’s clotting factor time 8 and 9 to 10a 5, that’s how we stay alive Don’t forget to say: the tissue factor way 7 to 7a helps 10 go to 10a Then 2 to thrombin, and 1 to fibrin And that’s how it ends  

Tina discusses the following rhythm control medications for atrial fibrillation: Class 3 antiarrhythmics: blocks potassium channels and prolongs action potential duration Amiodarone Dronedarone Sotalol Class 1 antiarrhythmics: blocks sodium channels, which results in a slowed atrial conduction, lengthens atrial refractoriness, and suppresses automaticity propafenone flecainide Indiana University's P450 Drug Interaction Table: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/ References: CCS Guideline www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext UptoDate uptodate.com  e-CPS www.e-therapeutics.ca/ RXFiles www.rxfiles.ca Lexicomp www.lexi.com

Tina discusses the following rate control medications for atrial fibrillation: Beta blockers Bisoprolol Metoprolol Atenolol Calcium channel blockers (non-dihydropyridines) verapamil diltiazem Digoxin   References: CCS Guideline www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext UptoDate uptodate.com  e-CPS www.e-therapeutics.ca/ RXFiles www.rxfiles.ca Lexicomp www.lexi.com

The CHADS2 and HAS-BLED predictive index are useful in assessing a patient’s thromboembolic risk and in predicting which antithrombotic therapy is most suitable; and that is either aspirin, clopidogrel, or anticoagulants. The 3 new anticoagulants may be simpler to use and may have less intracranial hemorrhage side effect than warfarin, there has been longer clinical experience with warfarin and an antidote is present if needed. As for rate control and rhythm control, there is no significant difference in controlling survival and mortality between the two. Therapy is chosen based on patient’s symptoms and preference. Rate control medications include BB, non-dihydropyridine CCB, and digoxin. And rhythm control includes dronedarone, flecainide, sotalol, and amiodarone. We will go over details of these medications in the next episode. Catheter ablation is mainly for symptom control. It may be first line for highly selected patients,  is often considered 2nd line after multiple drug therapy, or for patients who failed on multiple antiarrhythmic therapy and maintenance of sinus rhythm is still desired. Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control http://www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure http://www.onlinecjc.ca/article/S0828-282X%2812%2901379-7/abstract Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Catheter Ablation for Atrial Fibrillation/Atrial Flutter http://www.onlinecjc.ca/article/S0828-282X(10)00012-7/fulltext

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Etiology and Initial Investigations http://www.onlinecjc.ca/article/S0828-282X(10)00016-4/fulltext CHADS2 Score http://www.mdcalc.com/chads2-score-for-atrial-fibrillation-stroke-risk/ HAS-BLED Score http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/ Mayo Clinic on A Fib http://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/basics/definition/con-20027014

Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well: Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone Loop diuretic: furosemide Digoxin Vasodilators: hydralazine and isosorbite dinitrate For a quick summary of the CCS 2013 recommendations: ACE inhibitors: all asymptomatic patients with an EF 55 years with mild to moderate HF during standard HF treatments with EF ≤ 30% (or ≤ 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or with elevated BNP or NT-proBNP levels after an MI with EF ≤ 30% and HF or EF ≤ 30% alone in the presence of diabetes EF