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Week 4 - May 27th, 2015
One thing I LOVE about this rotation is that I’m learning so many little things I would never learn in school. I might have already said that previously in the blog already. Doug is so well versed in pharmaceutical history and board of pharmacy rules and regulations.
Some highlights from today:
- I fill guanfacine a lot at CVS, and I saw it every so often at HealthSmart. Being at CVS, where it’s so fast paced, I don’t always have time to look up and read up on drugs I don’t know by heart. I decided to look into guanfacine, and of course, another interesting brand/generic fact that I should know. There are two brand names, Intuniv and Tenex. When filling the generic, it’s important to know there is a generic for both brand names. Intuniv is extended release, and Tenex is immediate release. Guanfacine is has two indications: ADHD and high blood pressure. So can you guess which brand name typically corresponds to which indication? Intuniv is typically used for ADHD in children in addition to their other ADHD medication. Guanfacine was originally indicated for high blood pressure but they noticed it’s effects for ADHD.
- Jeannine was explaining to me how emergency fills work. According to the North Carolina Board of Pharmacy, a pharmacist may provide a patient with up to a 30 day supply of any drug (except for CIIs), as long as they contact their provider within 72 hours to get a new prescription. A patient’s dad called asking for an emergency refill on his the patient’s QVar (an inhaler for daily use). Jeannine authorized an emergency fill, since the patient was having breathing problems. However, upon looking at the fill history, I noticed we had already given her an emergency fill last month, and a few days later, the doctor rejected the refill request. Ultimately, we couldn’t fill it for them, and encouraged them to go to Urgent Care if necessary, and go see their doctor for a new script.
- I also learned a bit about loss prevention and how to handle the loss of a controlled substance. Controlled substances are medications under categorized schedules (I through V), which must be strictly kept in check with perpetual inventory. I learned some good tidbits about what you can and can’t do that I actually wont post on here, since it’s not officially posted online or anything (to prevent bad things form happening….).
- Doug and I also went over needle sizes today. To be honest, I can’t remember if we went over all of the needle sizes during our immunization certification. If so, I don’t remember them. Every time a patient at CVS asks me to find them a needle, or when I have to give shots, I take forever to find what is needed. (there’s gauges, length of the needle AND those units in European units which always confuse me). Doug clarified some of it up for me so I think moving forward it wont be so difficult!
Week 2 - May 11th, 2015
Medication Therapy Management (”MTM”) is a broad name for services offered by pharmacists to their patients on an individualized basis. Services include consultation, cost efficacy management, education and monitoring. We practice MTM in our curriculum at school, and it is one of the requirements on our checklist of to-dos during our community rotation. I asked Jeannine about MTMs today, so she explained to me that they use contracting companies to prepare, log, and get reimbursed for their MTM interactions. Thus began my training with one of these companies: Outcomes. To be continued…
Week 3 - May 18th, 2015
Today I made six compounds: Tretinoin 0.08% cream, BiEst 80/20 1mg/test 4/gram, omeprazole suspension (with chocolate flavoring!), Paviols scalp solution, tacrolimus solution, and naltrexone capsules. If you aren’t familiar with compounding, it’s a lot of trial and error, making batches over and over until you’ve perfected what you want. If a tablet calls for 10 mg of testosterone, you’ll need to figure out how much the tablet cell can hold, and what you’d want to use as your excipient (the inactive part of the drug). This part of the compounding process is actually pretty fun, and I look forward to new compound prescriptions, or having to troubleshoot what is wrong with a current one. In two of the scripts we received today, we realized that the last compound may have not been executed correctly OR was documented incorrectly. It’s like a little mystery game - and anyone who knows me knows I love games, so it’s fun to try to figure it out.
As I stated previously, this pharmacy does a lot of hormone replacement therapy (HRT) for patients. This includes for post-menopausal women, transexuals, and men with low testosterone. You name it. We make sublinguals, capsules, tablets, creams, ointments. Basically anything. Post-menopausal patients who are on HRT therapy have a higher risk of developing cancer (look it up!), so Doug actually doesn’t like compounding or dispensing oral HRT (but hey, gotta run a business). He truly believes in the creams and ointments, so that’s why we’re constantly compounding those. Often times, doctors will fax over their patients’ lab work, and Doug will determine what to initiate, or how to change their current HRT regimen. For instance, the patient we saw today was currently taking BiEst (estradiol and estriol), testosterone and progesterone. After looking at the labs, we saw that the estrogen was low, so we increased her BiEst cream dose. Jeannine later showed me the documentation and follow-up paperwork that goes along with all the HRT patients.
Also… I spent about an hour compounding naltrexone capsules today. Even though there is a machine to help us make it, it still takes awhile, and it’s a hot mess with all of the powder. After you each compound, you are required to document all ingredients used, their lot number and expiration date. I finished documenting them, and put all the ingredients back. Then, Doug walked in and said “Aw man, you didn’t get my joke!” I had no idea what he was talking about, so he took the drug stock bottle from the cabinet and told me to look at it. I didn’t see anything weird. “Read it,” he said. I read “Naloxone” and flipped out, because I thought I wasted all that product by using the wrong drug. Turns out, when I was done compounding, he switched the Naltrexone bottle for the Naloxone bottle as a joke. AHHH. Thank goodness, haha.
Week 1 - May 4th, 2015
Day 1 at HealthSmart Pharmacy
Today I began my first day at my final IPPE rotation: an independent community pharmacy in Mooresville, NC called HealthSmart. HealthSmart is owned by my preceptor, Doug Balog, RPh. I’ve only been here for 10 hours, but it has already opened my eyes to how exciting and fun retail can be! I was lucky enough to be placed at a site that makes over 250 compounds a month, so I am looking forward to all of the new compounding knowledge I will gain throughout this experience. Here are some highlights of my day:
1. One of the first things Greg told me started with “So this tends to freak out a lot of students here…” Uh oh. “Our drugs are organized by the brand name.” Um what? For those who don’t know, most pharmacies organize their drugs by generic name. It makes it much easier because all bottles have to have the generic name on them, but not the brand name. That is, generic drugs don’t have to have the brand name on them, but brand names must specify what it’s generic is. His rationale was simple. 15 years ago, when he first got into business, there were not a lot of generic drugs out there. Most drugs on the market were only available in brand name. Lucky for us, this isn’t the case anymore, and these days you can get most drugs generic. This definitely poses as a challenge to me, because not only do I need to identify the brand name of the drug I am holding to put back, but I also need to know all of the brand names of everything on the shelf next to it to properly alphabetize it. Challenge accepted, HealthSmart.
2. I met the other wonderful staff today including: technicians Brandy, Meghan, and Kenny, cashier Ciera, and pharmacist Jeannine.
3. Like I said, I am so excited to be at a site that places a strong emphasis on compounds. “They’re the money-makers!” Says Doug (I also love learning his tidbits about business). Since I have a lot of retail experience, I spent most of my day in the compounding room. It was incredible. He had all of the equipment we learned about in lab and more! This includes flavoring agents for “tuna,” “beef,” and “chicken.” These are for the cats he compounds medications for. Brilliant! I compounded baclofen liquid (for muscle spasms), estradiol 1mg/.5mL suspension (for menopause symptoms), Biest cream (for hormone therapy), progesterone PLO cream (for hormone therapy), and a cream consisting of prilocaine, lidocaine, BHT, meloxicam and topiramate (for neuropathic pain). Look out for a photo above.
4. I loved learning the differences between an independently owned pharmacy, and a corporate company, like where I work at CVS/Pharmacy. Some differences include, how they store their CIIs (Adderall, Oxycodone, etc) and what their technicians are allowed to do. I love the relationships that are formed between the patients and the pharmacist. Not only that, even the technicians know the names of almost every patient who walks in—find that at your local Walgreens or CVS. This can be attributed to the difference in prescriptions filled. My CVS fills >450, while this store fills >200 a day.
It was quite a busy day. I can’t wait to see what the rest of the month has in store!