Drug formulations & patient counsouling

ghost shells apear in what type of medications

OROS (osmotic release oral system)

can oral tablets/capsules be crushed or chewed ?

NO with execption to toprol XL and sinemet CR

t/f patient with nasal gastric can have extended release

f

when its a suspension you must

shake well before use and provide measuring device

What should a patient do if they miss a dose of most medications?

Take it ASAP unless close to the next dose; skip if near the next dose; never double dose.

What are the exceptions for missing doses of medications?

Anticoagulants, oral contraceptives, prandial insulin.

How should most medications be stored?

In a cool, dry place (not in the bathroom) and kept away from children and pets.

Which medications must be refrigerated but are stable at room temperature for a short time after opening?

Insulin and Ozempic®.

Why should some medications be kept in their original packaging?

For stability; examples include Zofran® ODT and Nitrostat® SL tabs.

What three things should you assess when evaluating medication adherence?

Indication for therapy, refill history, and the patient's own report.

What counseling method helps assess medication adherence?

Motivational interviewing, which uses open-ended questions, empathy, and no judgment.

What does frequent refilling of PRN medications like albuterol indicate?

Poor disease control or incorrect use of maintenance medications.

What is a Black Box Warning (BBW)?

The FDA's strictest warning for serious or life-threatening risks; not an absolute contraindication but requires caution and a Medication Guide.

What is the BBW for opioids such as oxycodone and hydrocodone?

Addiction, misuse, abuse; life-threatening respiratory depression.

What is the BBW for fluoroquinolones like ciprofloxacin and levofloxacin?

Increased risk of tendon rupture, especially in the elderly.

What is the BBW for thiazolidinediones such as pioglitazone?

Increased risk of heart failure.

What is the BBW for antipsychotics like quetiapine, olanzapine, and risperidone?

Increased mortality in elderly patients with dementia-related psychosis.

Compressed tablets

The most common and cheapest drug formulation.

Olanzapine (Zyprexa®)

A drug with multiple formulations including IR tablet, ODT, short-acting injection, long-acting injection, which improves flexibility for patient needs.

Major types of drug formulations

Oral, injection, transdermal patch, topical, nasal spray, eye drops (ophthalmic), ear drops (otic), rectal, inhalation.

Long-acting oral formulations

Examples include XL, XR, ER, LA, SR, CR.

OROS system

Osmotic Release Oral System; provides immediate then extended release. Example: Concerta® (methylphenidate).

Counseling for long-acting oral tablets/capsules

Do not crush/chew; may see shell in stool; do not cut (except Toprol XL® and Sinemet CR®).

Liquid suspensions/solutions

Useful for patients with difficulty swallowing (children, elderly, altered mental status, animals).

Counseling for oral suspensions

Shake well; measure with dropper, syringe, or cup.

Chewable tablets

Used for children unable to swallow (example: Singulair®).

Lozenges/troches

Used for local treatment in mouth (slowly dissolves). Examples: Mycelex®, Cepacol®.

Orally disintegrating tablets (ODTs)

Useful for dysphagia, nausea/vomiting, non-adherence, inability to swallow.

Counseling for ODTs

Use dry hands to peel foil, place on tongue to dissolve.

Sublingual/buccal formulations

Beneficial for faster onset than oral tablets; useful for adherence and swallowing issues.

Counseling for sublingual vs buccal

SL: hold under tongue 60 sec before swallowing. Buccal: place between cheek and gum, no food/drink 15 min after.

Granules/powders/capsules

Used for patients with swallowing difficulty (pediatric, geriatric, NG tube).

Counseling for granules/powders/capsules

Sprinkle in approved food/beverage, take immediately, do not chew long-acting beads, do not add to hot food, follow labeling.

Routes of injection formulations

SC, IM, IV, ID, IA.

SC injections

Used for rapid effect or drugs not absorbed orally.

Long-acting IM injections

Used to improve adherence (e.g., depot antipsychotics).

IV injections

Used for fast response.

Intraarticular injections

Injection into joints.

General counseling for injections

Wash hands, prepare properly, clean site, rotate injection sites, never reuse needles, let refrigerated meds warm, do not shake protein meds.

Examples of long-acting injectable antipsychotics

Invega Sustenna®, Risperdal Consta®, Zyprexa Relprevv®.

Benefits of long-acting injectable antipsychotics

Decrease pill burden, increase adherence, decrease level fluctuations, reduce relapse.

Benefits of transdermal patches

Non-invasive, painless, steady dosing, improve adherence.

Example of contraceptive patch vs oral pill

Xulane® weekly patch vs daily oral contraceptive.

Counseling: Can I cut a patch?

No (except Lidoderm®).

Counseling: Can patches be exposed to heat?

No, avoid heat (risk of toxicity).

Counseling: What if patch irritates skin?

Rotate site, avoid irritated skin, trim hair (don't shave).

Counseling: Do patches need removal before MRI?

Yes, if they contain metal (e.g., Catapres-TTS®).

Counseling: What if patch doesn't stick?

Do not cover with tape (except Catapres-TTS® has adhesive cover). Press firmly 10-30 sec. Avoid oily skin.

Counseling: How to dispose patches?

Fold adhesive sides together; follow manufacturer instructions (e.g., flush Duragesic®).

Common patch application sites

Upper chest, back, thigh, outer arm, sometimes ear or hip (check labeling).

Topical formulations

Used for local or systemic effects.

Examples of local topical uses

Muscle/joint pain, acne, eczema, cold sores, fungal infection, rash, hair loss.

Muscle/joint pain

Examples of local topical uses.

Acne

Examples of local topical uses.

Eczema

Examples of local topical uses.

Cold sores

Examples of local topical uses.

Fungal infection

Examples of local topical uses.

Rash

Examples of local topical uses.

Hair loss

Examples of local topical uses.

Androgel®

Examples of systemic topical formulations.

Vivelle-Dot®

Examples of systemic topical formulations.

Advantages of nasal sprays

Faster onset, bypass GI, localized or systemic effects.

Afrin®

Examples of localized nasal sprays (congestion).

Flonase®

Examples of localized nasal sprays (allergies).

Narcan®

Examples of systemic nasal sprays (opioid overdose).

Imitrex®

Examples of systemic nasal sprays (migraine).

Counseling before nasal spray use

Shake gently, prime pump (if unused for 7-14 days), blow nose.

Steps for using nasal spray

Close one nostril, insert applicator, inhale and press, exhale through mouth, wipe applicator, replace cap, discard after labeled sprays, do not blow nose right after.

Eye drops must be sterile and near body pH

To avoid pain upon administration.

Can eye drops be used in ears?

Yes.

Can ear drops be used in eyes?

No.

Xalatan®

Example of refrigerated eye drop (discard after set time once opened).

Counseling steps for eye drops

Wash hands, tilt head back, pull eyelid, drop medication without touching tip, press nasolacrimal duct 1 min, blot excess.

How long to wait between eye drops?

Same med: 5 min. Different meds: 5-10 min. Gel/ointment: 10 min after solution.

Correct order of ophthalmic formulations

Solution → suspension → gel/ointment.

Counseling with contact lenses and eye drops

Remove before use, wait 15 min before reinserting. BAK preservative may irritate.

Counseling steps for ear drops

Warm solution in hands, tilt head with affected ear up, pull ear up/back (adult) or down/back (<3 yrs), drop meds, keep ear up 5 min, don't touch dropper tip.