6- Drug formulations and patient counseling

Which transdermal patches are applied once daily?

Diclofenac patch (Licart), methylphenidate patch (Daytrana), nicotine patch (Nicoderm CQ), rivastigmine patch (Exelon), rotigotine patch (Neupro), selegiline patch (Emsam), testosterone patch.

Which transdermal patches are applied twice daily?

Diclofenac patch (Flector).

Which transdermal patches are changed every 72 hours?

• Fentanyl patch

• scopolamine patch (Transderm Scop)

Which transdermal patches are applied twice weekly?

• Estradiol patch (Vivelle-Dot)

• oxybutynin patch (Oxytrol)

Which transdermal patches are applied weekly?

Donepezil patch (Adlarity), buprenorphine patch (Butrans), clonidine patch (Catapres-TTS), estradiol patch (Climara), ethinyl estradiol/norelgestromin patch (Xulane, Zafemy), ethinyl estradiol/levonorgestrel patch (Twirla).

Which patches have special daily on/off schedules?

Lidocaine patch (Lidoderm) is on for ≤12 hours then off 12 hours, nitroglycerin patch is on for 12-14 hours then off 10-12 hours.

What is the indication for lidocaine patch (Lidoderm)?

Neuropathic pain such as postherpetic neuralgia.

What is the mechanism of lidocaine patch?

Blocks sodium channels by decreasing neuronal permeability to sodium ions, preventing nerve conduction.

What is the dosing schedule for Lidoderm?

Apply daily with 12 hours on and 12 hours off.

What is the maximum number of Lidoderm patches that may be applied at once?

Up to 3 patches simultaneously.

Where should Lidoderm patches be applied?

Clean, dry, intact skin over the painful area.

Can Lidoderm patches be cut?

Yes, they may be cut into smaller pieces before removing the release liner.

What are common adverse reactions of Lidoderm?

Application site erythema, burning, mild irritation.

What should be done if Lidoderm causes irritation?

Remove the patch until irritation resolves.

What is proper otic drop administration technique by age?

Under 3 years pull ear downward and backward, age 3 years or older pull ear upward and backward.

How should a child be positioned for otic drops?

Place child on side with affected ear facing upward.

How long should patient remain positioned after otic drops?

Remain for 2-5 minutes for absorption.

Is massaging the ear needed after otic drops?

No, massaging is unnecessary and may irritate the canal.

Why should otic drops be warmed to room temperature?

Cold drops can cause vestibular reaction with dizziness and vomiting.

How should the otic dropper be placed?

Hold near entrance without touching canal to avoid contamination and discomfort.

Where are clotrimazole troches used for Candida infection?

Oral cavity (mouth).

What are key counseling topics for self-administered SC injections?

Storage, handling, inspection, site selection, injection technique, disposal.

How long should refrigerated injections sit before use?

Warm naturally to room temperature for 15-30 minutes.

Should external heat sources be used to warm injections?

No, never microwave or apply external heat.

When should an injectable medication be discarded?

If cloudy, discolored, or contains particles unless expected appearance.

What is an example of medication that is normally cloudy?

Insulin NPH.

What is hand hygiene counseling for injections?

Wash hands with soap and water before and after injection.

How far from the navel should injections be given?

At least 2 inches away.

What is the injection site rotation rule?

New site should be at least 1 inch from previous site.

What is the typical SC injection angle?

Usually 90 degrees.

Should patients rub the injection site afterward?

No, rubbing worsens irritation and bruising.

Why avoid rubbing after enoxaparin injections?

Prevents bruising and hematoma formation.

What is proper sharps disposal counseling?

Discard needle or device immediately into a sharps container.

Should patients remove needles from autoinjectors?

No, increases risk of needlestick injury.

Should monoclonal antibody injections be shaken?

No, shaking can destroy proteins.

What is the best abortive migraine formulation in vomiting patients?

Intranasal nasal spray.

Why avoid oral migraine medications in vomiting patients?

Oral meds may not be tolerated or absorbed.

What is an advantage of intranasal administration?

Fast onset and high bioavailability.

What is buccal formulation counseling?

Place between cheek and gum and allow to dissolve slowly.

What is buccal formulation food and drink restriction?

Do not eat or drink for 15 minutes after dose.

What is chewable formulation counseling?

Chew completely before swallowing.

Are liquids required with chewable tablets?

Not required but may aid swallowing.

What is orally disintegrating tablet (ODT) counseling?

Place ON TONGUE and allow to dissolve in under 60 seconds.

Do ODTs require water?

No liquids required.

What is sublingual formulation counseling?

Place under tongue and allow to dissolve, hold liquid 60 seconds before swallowing.

Which transdermal patch can be applied to the buttock?

Xulane patch.

What are approved application sites for Butrans patch?

Upper outer arm, upper chest, upper back, or side of chest, not buttock.

What is the approved application site for Daytrana patch?

Hip area only, alternate sides daily.

What are approved application sites for Exelon patch?

Upper or lower back, upper arm, or chest.

What is the approved application site for scopolamine patch?

Behind the ear.

What are long-acting injectable (LAI) antipsychotics used for?

Maintenance therapy for schizophrenia.

What is the administration type of LAI antipsychotics?

Depot injection releasing drug over weeks to months.

What are advantages of LAI antipsychotics?

Improved adherence, early detection of nonadherence, reduced daily pill burden, reduced drug level fluctuations, reduced relapse risk.

What are examples of LAI antipsychotics?

Risperdal Consta, Zyprexa Relprevv.

What are key differences between topical vs systemic NSAIDs?

Topical acts locally with lower GI, renal.

When are topical NSAIDs preferred?

Localized pain and inflammation

When are systemic NSAIDs preferred?

Widespread or severe inflammation

What are examples of topical NSAIDs?

Diclofenac patch (Flector), diclofenac gel (Voltaren)

What are examples of systemic NSAIDs?

Ibuprofen, naproxen, meloxicam tablets, ketorolac IV/IM

Why are small molecules feasible orally and sometimes transdermally?

They are stable and lipophilic enough for absorption

Why are biologics not feasible orally or transdermally?

Degraded by gastric enzymes and too large/hydrophilic to cross skin barrier

What are common biologic administration routes?

Subcutaneous or IV injection

What is lyophilization?

Freeze-drying to remove water and stabilize proteins

What is the purpose of lyophilization?

Maintains structural integrity and potency during storage

What is the cause of phenylketonuria (PKU)?

Phenylalanine hydroxylase deficiency due to genetic mutation

What is PKU pathophysiology?

Impaired conversion of phenylalanine to tyrosine leading to elevated phenylalanine

What are complications of untreated PKU?

Severe irreversible neurologic dysfunction such as intellectual disability and epilepsy

How is PKU diagnosed?

Universal newborn screening and serum amino acid analysis

What is the cornerstone of PKU treatment?

Strict phenylalanine-restricted diet

What foods should be avoided in PKU?

Eggs, meat, nuts, protein-rich foods

What artificial sweetener must be avoided in PKU?

Aspartame

Why is aspartame dangerous in PKU?

Contains phenylalanine which cannot be metabolized

Which oral formulations commonly contain aspartame?

Chewables, granules, ODTs, liquid suspensions

Why do coated tablets and capsules rarely contain sweeteners?

Swallowed without prolonged taste exposure

What is the general missed-dose rule for most chronic meds?

Take as soon as remembered unless next dose is soon, never double up

Which medications have special missed-dose protocols?

Oral contraceptives, anticoagulants, time-sensitive medications

Why do oral contraceptives require special missed-dose rules?

Timing affects ovulation suppression and pregnancy prevention

How does systemic intranasal drug delivery work?

Absorption through highly vascular nasal mucosa into circulation

What are advantages of intranasal administration?

Avoids first-pass metabolism, high bioavailability, quick onset

What are clinical uses of intranasal drugs?

Acute migraine, vomiting patients, suspected opioid overdose

What is contact lens counseling with eye drops?

Remove soft lenses before drops and wait 15 minutes before reinserting

Why should the eye dropper tip not be touched?

Prevent contamination

What are benefits of sublingual nitroglycerin?

Avoids first-pass metabolism, rapid onset

What is sublingual route definition?

Beneath the tongue

What is buccal route definition?

Between gums and inner cheek

What is translingual route definition?

Onto or under the tongue

What are benefits of oral mucosal absorption?

Faster onset than swallowed oral forms, useful for dysphagia or nausea/vomiting

What are examples of sublingual tablets?

Nitrostat, Edluar, Fentora

What are examples of lozenges absorbed in mouth?

Actiq, Nicorette Mini

What is nicotine gum counseling?

Chew then park in buccal space

What is an example of oral film formulation?

Suboxone

What is an example of aerosol spray formulation?

NitroMist

What is the difference between ophthalmic vs otic drops?

Ophthalmic drops are sterile and isotonic, making them safe for otic use

What is the OROS system?

Osmotic controlled-release oral delivery system for extended release

What are OROS system components?

Insoluble shell, active drug layer, push layer with osmotic excipients

How does OROS release drug?

Water absorption creates pressure pushing drug out through laser-drilled opening

What is Concerta formulation type?

OROS methylphenidate with immediate-release overcoat plus extended release core

What are advantages of OROS tablets?

• Decreased frequency

• rapid onset

• reduced serum fluctuations

What is key OROS counseling?

Do not crush or chew extended-release OROS tablets

What is ulcerative colitis disease pattern?

Begins in rectum and extends proximally in continuous manner