Ch. 6 Drug Formulations & Patient Counseling

Stabinsky

long acting oral formulation

provide a long duration of action

reduces side effects

provides a smooth level of drug release over time & reduces peaks

DO NOT CRUSH OR CHEW --> could release all medication at once and cause a fatal dose to be released

some can be opened and sprinkled on food, but contents should not be crushed or chewed

long acting formulations that can not be crushed but can be cut along the score line:

toprol XL

carbidopa/levodopa ER

the following suffixes indicate a long-acting formulation

XL, XR, ER, LA, SR, CR, CRT, SA, TR, cont

OROS delivery

long acting

the tablet/capsule shell may be visible in the patient's stool (ghost tablet)

allows for fast drug delivery, followed by an extended release

liquid oral suspensions and solutions

useful in children and patients who have difficulty swallowing

suspensions must be shaken

solutions do not need to be shaken

chewable tablets

used for children

chewable calcium products are popular for adults also because they are large and harder to swallow

lozenges/troches

used to treat a condition in the oral mucosa

ODTs

useful when a patient can not swallow due to dysphagia --> paralysis of the throat muscles due to a stroke is the most common cause

useful in children who can not swallow pills

they dissolve quickly, avoiding non-adherence and cheeking

sublingual or buccal

same benefits as ODT

onset of action is faster

less drug is lost to gut degradation and first pass metabolism

granules, powders, or capsules that can be opened and sprinkled into soft food or water

primarily for pediatric or geriatric patients

do not chew any long acting

do not let the mixture sit for too long

take the entire mixture

do not add to anything warm or hot

*** not all capsules should be opened

risks of sweeteners

sorbitol metabolism produces gas, cramping, and bloating

phenylalanine is found in the sweetener aspartame which is used in many ODT, chewable, and granule medications --> dangerous for those with phenylketonuria (PKU)

lactose is most commonly use --> lactose intolerance

SC injections

used for rapid effect for drugs that would degrade or not be absorbed if given orally

long acting IM injections

improve adherence

decreases need for more frequent injections

IV injections

bypasses the oral route

fast response

avoids loss of drug

injectable medication counseling

1. wash hands

2. prepare injection

3. select and clean injection site

4. inject

5. discard

inject at least 1 inch away from the previous injection site

never use the same needle more than once

discard the needle in the sharps container

do not rub the skin near anticoagulant injections --> bruising

do not use any device to heat up injections --> let sit at room temp for 20 min

do not use if it is discolored

common patch application sites

chest

back

upper arm

flanks

exelon patch application sites

chest

back

upper arm

patches used to treat local pain

flector

lidoderm

salonpas

qutenza

daytrana patch application site

hip

transdermscop application site

behind the ear

patches changed twice a day

diclofenac

patches changed daily

daytrana (every morning --> 2 hours before school)

nicoderm CQ

exelon (rivastigmine)

neupro (rotigotine)

emsam (selegiline)

androderm (testosterone) --> nightly, not on scrotum

patches changed daily with special instructions

lidocaine --> 1-3 patches as needed, on for 12 hours on and 12 hours off

nitroglycerin --> on for 12-14 hours, then off for 10-12 hours

patches changed every 72 hours

fentanyl --> if it wears off after 48 hours, then change to 48 hours

scopolamine (transdermscop)

patches changed twice weekly

estradiol (alora, vivelle-dot)

oxybutynin (oxytrol)

patches changed weekly

donepezil (adlarity)

buprenorphine (butrans)

clonidine (catapress-TTS)

estradiol (climara)

estradiol/levonorgestrel

ethinyl estradiol/norelgestromin (xulane, zafemy) and ethinyl estradiol/levonorgestrel (twirla) --> weekly for 3 weeks, off for 1 week

can i cut the patch?

no, except lidoderm and qutenza

the patch is bothering my skin, what can i do?

never apply to skin that is irritated

alternate application site

do not shave right before applying

a topical steroid can be applied after the patch is removed

can the patch be exposed to heat?

no, heat causes rapid absorption

which patches need to be removed before an MRI?

patches containing metal --> will burn the skin

clonidine (catapress-TTS)

rotigotine (neupro)

scopolamine (transderm scop)

testosterone (androgel)

can the patch be covered with tape?

most patches cannot be covered

fentanyl and buprenorphine (butrans) can be covered only with the permitted adhesives --> bioclusive or tegaderm

catapress-TTS comes with its own adhesive cover

how do i dispose of used patches?

press adhesive surfaces together

highly potent narcotic patches (fentanyl, butrans, and daytrana) should be flushed

where is the drug located in a patch?

can be in a raised pouch, a reservoir, or directly incorporated into the adhesive of the patch

topicals

can be used for both local or systemic effects

topical meds for local effects have less systemic side effects

common conditions treated topically:

muscle/joint pain or inflammation

cold sores

acne

eczema

skin infections

hair loss

nasal sprays

faster onset than oral and is useful for acute conditions

bypass first pass metabolism

some proteins that would be destroyed in the gut can be given nasally

afrin and flonase are used primarily to treat localized symptoms

nasal spray counseling

shake the bottle gently and remove the cap

prime before first use or if you havent used it in 7-14 days

blow your nose to clear your nostrils

close one nostril

start to breathe in through your nose and press firmly and quickly down

breathe out through your mouth

use the bottle for the labeled number of sprays

do not blow your nose right after using the spray

eye and ear drops

used for local effects

eye drops MUST be sterile and close to the pH of the body

eye drops can be administered in the ear, but ear drops can NEVER be administered in the eye

eye drop counseling

shake it a few times

gels should be inverted and shaken once before use

look up and pull down your lower eyelid

without touching your eye, release the drop between your eye and lower eyelid

close your eye

press a finger between your eye and the top of your nose for at least 1 minute

if you need to use more than one drop, wait 5-10 minutes to put a second medication. wait 10 minutes if applying a gel

if the eye drop contains a preservative called benzalkonium chloride (BAK), remove contact lenses prior to administration and wait 15 minutes to reinsert them

ear drop counseling

if cold, gently shake or roll in hands. do not drop cold drops into ear

lie down or tilt so that the affected ear faces up

gently pull the earlobe up and back for adults

pull down and back for children <3

after administering, keep the ear facing up for 5 minutes

rectal medications

can be used for local or systemic treatment

include enemas and suppositories

enema counseling

empty the bowel before use

lay on your left side with the left leg extended and the right leg flexed forward

gently insert the medication or applicator tip into the rectum, pointed slightly toward the naval

grasp the bottle firmly, then tilt slightly so that the nozzle is aimed towards the back.

remain in this position for 30 minutes

suppository counseling

empty the bowel before use

do not handle the suppository too much --> can melt

insert the pointy in first --> lubrication can be used if needed

keep in rectum for 1-3 hours

vaginal medications

for local or systemic effects

suppositories, creams, ointments, inserts, and tablets

inhalations

provide immediate and long-lasting benefits

delivered directly to the lungs --> minimizes systemic toxicities

health literacy

the degree to which individuals are able to obtain, process, and understand basic health and medication information to make appropriate health decisions

different from being able to read or being well educated

low health literacy is linked to:

poor health outcomes

can be an issue for any patient, but is common in the elderly, minority populations, those with lower income, poor health, and limited english proficiency

effective communication and education strategies

use non-medical language

ask open-ended questions

avoid leading questions

confirm understanding --> ask the patient to repeat the info

use different communication strategies --> verbal, written, visual aids

use active listening

speak clearly, make eye contact, introduce yourself

missed doses

most meds follow a general rule -->

take it as soon as you remember. do not take 2 doses at the same time

exceptions -->

high-risk drugs

oral contraceptives

drugs that must be taken at specific times (phosphate binders, pancreatic enzymes, insulin)

storage

cool, dry place

not in a bathroom

adherence counseling and monitoring

review refill histories

find the cause --> not sure how to take it, is experiencing side effects, needs help remembering

use motivational interviewing techniques