Drug formulations and Counseling points

Reasons to use long acting oral capsules/tablets

Release drug slowly to avoid nausea or provide a long duration of action

• provides smooth level of drug release to reduce high “peaks” which reduces side effects

Counseling points for long acting capsules/tablets

• Do not crush or chew

• some capsules can be opened can be opened and contents sprinkled on food

  • capsule contents must not be chewed or crushed

  • consult package labeling as not every formulation can do this

• Some can be cut at the score line(i.e Toprol XL, Lineament ER)

• OROS(ghost tablets/capsule) may be present in stool but drug has been released

Reasons to use Liquid formulations?

• patients with swallowing difficulty

• patients unable to follow directions

Counseling points for suspensions and solutions?

Solutions: Do not need to be shaken before use

Suspensions: Shake before use

Reasons to use chewable tablets

• those unable to swallow tablets

  • primarily used in children

Reasons to use lozenges/troches?

Helps treat conditions in the oral mucosa

Reasons to use Orally disintegrating tablets?

• unable to swallow

  • i.e dysphagia from stroke, children

• improve adherence →prevents cheeking

Counseling points for ODT and Oral films

• for ODTs: do not push the tablets through the foil backing as they are friable(easily broken)

• place on tongue & it will dissolve in seconds

Reasons to use SL or Buccal Formulations?

• unable to swallow

• improve adherence →prevents cheeking

• faster onset of action than tablet or capsule that is swallowed

• less drug is loss to gut degradation and first pass metabolism

Reasons to use granules, powders, or capsules that can be opened & sprinkled into food and water?

• patients who have difficulty swallowing

• allows for minimization of IV formulations; can be given via NG tubes

Counseling points for formulations that can be opened

• Only open capsules specifically labeled/instructed as safe to open and sprinkle.

• Do not crushing/chew any long acting pellets or beads

• Do not let the mixture sit too long; entire mixture should be ingested 

• Do not add anything warm or hot

How can Montleukast(Singulair) be given?

Formulation can be opened

Can be put in applesauce, carrots, rice, or ice cream

How can Lisdexamfetamine (Vyvanase) be given?

Formulation can be opened

Can be put in water, yogurt, and orange juice 

What sweeteners are used in drug formulations and their risks?

Sorbitol →gas/cramping/bloating

Phenylalanine → contains aspartame which is dangerous for those with PKU

Lactose → issue if lactose intolerant

Reasons to use SQ formulations?

• rapid onset of effect

• Used for drugs that would degrade, not be absorbed, or tolerated if given PO

Reasons to use long acting IM injections

• improved adherence

• decrease need for frequent injections

Why do we use the IV injections?

• bypasses PO route

• rapid onset of effect

• Avoids drugs that wouldn’t be tolerated if given PO due to N/V

Injections Steps

Step 1: Wash hands thoroughly with soap and water before handling supplies.

Step 2: Prepare the injection (draw up medication or prime the pen device).

Step 3: Select and clean the injection site using an alcohol wipe; allow to air dry.

Step 4: Inject the medication into the subcutaneous site as instructed.

Step 5: Discard used syringes, pen needles, or single-use assemblies immediately into an FDA-cleared sharps container.

Injection counseling points

• inject at least 1 inch away from previous injection site

• Never reuse a needle

• For single-use devices, discard the needle or the entire assembly directly into a sharps container.

• Do not rub the site after injecting Anticoagulants

• let injections sit at room temperature for ~15–30 minutes before administration.

• Do not use solutions that appear discolored, cloudy, or has particles

What is a bio-similar?

A biologic that is highly similar to an already FDA-approved biologic (called the reference product).

• It has no clinically meaningful differences in terms of safety, purity, or potency (effectiveness).

What is an interchangeable bio similar?

be substituted for the reference product at the pharmacy level (without consulting the prescriber)

• Not all biologic are interchangeable; need to be FDA approved 

Consult purple book for biosimilars 

What patches that have Rx to apply twice daily?

Diclofenac (flector)

What patches that have Rx to be applied once daily with no special instructions

TRANSDerm

• T – Testosterone (Nightly, non-scrotal)

• R – Rivastigmine(Exelon) & Rotigotine (neupro)

• A – ADHD: Methylphenidate (Daytrana – QAM 2 hrs before school)

• N – Nicotine (NicoDerm CQ)

• S – Selegiline (Emsam)

• D – Diclofenac (Licart)

What patches are applied Once daily with special instructions?

• Lidocaine (Lidoderm): 1–3 patches on for up to 12 hrs, off for 12 hrs

• Nitroglycerin: On 12–14 hrs, off 10–12 hrs

What patches are applied every 72 hours?

• Fentanyl

• Scopolamine

What patches that have Rx to be applied twice weekly?

Estradiol (Vivelle-Dot)

Oxybutynin (Oxytrol)

What patches to be applied once weekly

ABC-DE

• A – Donepezil (Adlarity)

• B – Buprenorphine (Butrans)

• C – Clonidine (Catapres-TTS)

• D – Dual hormones (Contraceptives):

  • Ethinyl estradiol/norelgestromin (Xulane)

  • Ethinyl estradiol/levonorgestrel (Twirla)

• E – Estradiol (Climara)

Patch counseling points

• Do not cut patch unless Lidocaine patch

• avoid heat exposure

• never apply to same spot or on skin that is irritated→can apply topical steroid after use

• Some patches need to be taken off prior to MRI

• Most patches can not be covered with tape.

  • Exceptions:

    • Buprenorphine is permitted with only Biocluisve or Tegaderm dressing

    • Clondine has its own adhesive cover

• When removing patch, press adhesive surfaces together

What patches containing metal need to be taken off prior to MRI?

• Clonidine

• Rotigitone

• Scopolamine

• testosterone

Reasons to use Nasal sprays

• faster onset than PO

• useful for acute conditions that can be treated quickly

  • bypass gut absorption and 1st pass metabolism

• can treat local symptoms(i.e Flonase and Afrin)

Counseling points for Nasal spray?

1. Shake bottle gently

2. Prime before first use or if not used for ~7-14 days

3. Blow nose to clear nostrils

4. close one nostril & insert nasal applicatior to nose

5. breathe in through nose and press firmly and quickly on applicator

6. Breathe out through mouth & Do not blow nose right after using

7. Wipe applicator with clean tissue

use bottle for labeled number of sprays

Reasons to use eye/ear drops

• Used for local effects

• Eye drops must be sterile and close to the pH of the body

  • eye drops can be given in the ear but not vice versa

Ophthalmic Drops Counseling

1. Wash hands.

2. Shake bottle & if its a gel flip it

3. Pull down lower eyelid, look up, drop into space between eye and lower lid. Close eye and press finger on naso-lacrimal duct (inner corner) for ≥ 1 minute.

4. if you need to put more than one drop:

• Same medication, two drops → wait 5 minutes between drops (never put two drops at once)

• Different medication in the same eye → wait 5–10 minutes

• If using a gel → wait 10 minutes

If eyedrops containBenzalkonium chloride(BAK) and someone wears contacts?

Remove soft contact lenses prior to administration

Wait 15 minutes before reinserting

Counseling points for Otic(Ear) drops?

1. If cold, Gently roll bottle in hands for 1–2 mins to warm; do not use cold medication

2. Face the affected ear up

3. after adminstration, keep ear upright for 5 mins

Reasons for rectal administration?

used for local or systemic treatment

Enemas counseling

1. Empty bowels first for best results

2. Lie on left side: left leg straight, right leg bent forward

3. Gently insert tip pointing toward the navel

   

4. Aim nozzle toward the back, squeeze slowly to deliver medication, then remove and discard bottle

5. Stay in position at least 30 minutes (or overnight)

Suppositories counseling

1. Empty Bowel

2. Remove foil wrapper carefully

3. Avoid handling excessively (body heat melts it).

4. Insert pointed end first into rectum

5. Keep in rectum for at least 1–3 hours for best results.

Reasons to use inhalations?

Drug is delivered directly to lungs which minimizes systemic toxicities