LIPITOR - Counseling Essentials

Summary:
1. Lipitor or Atorvastatin is the number 1 drug prescribed in Canada. It belongs to a class of drugs called HMG CoA Inhibtors and is indicated for a variety of disorders related to reduction of Cholesterol in the body.

HMG-CoA Inhibitors:
1. Atorvastatin
2. Simvastatin
3. Lovastatin
4. Pravastatin
5. Rosuvastatin
6. Fluvastatin
7. Ceruvastatin - Discontinued (LIPOBAY) due to the side effects of Rhabdomylosis

Important Points to Remember:
1. Atorvastatin is the only agent approved for peadiatric patients.
2. All statins can be taken without regard to meals but Lovastatin is better absorbed when taken with meals.
3. CYP3A4 Inhibtors and substrates interact with Lovastatin, Atorvastatin and Simvastatin. (You can use Fluvastatin or Pravastatin)
4. Fluvastatin interacts with CYP2C9 substrates
5. Patients should avoid taking grapefruit juice, Sour (Seville)orange juice and lime juice while on this medications as this inhibits the CYP3A4 enzyme system; thereby increasing the levels of the statins in the body making the patient more prone to adverse side effects due to increased levels of the statin
6. Major Drug –drug interactions include:
a. Bile acid sequestrants – decreased bioavailability of statins – Administer the bile acid sequestrants one hour before or 6 hours after statins
b. CYP3A4 substrates and Inhibitors (Amiodarone, Erythromycin, Clarithromycin, Cyclosporin, Diltiazem, Grapefruit juice, Itraconazole, ketoconazole, Protease Inhibitors)
- In certain situations discontinue statins during CYP3A4 interacting substance therapy
- You could use fluvastatin or pravastatin
- Use concurrently but monitor for side effects – unexplained muscle pain, tenderness, muscle weakness, Darken urine
c. CYP2C9 substrates – (NSAID’s, Phenytoin) – Monitor for side effects
d. Fibric Acid Derivatives- (Benfibrate, Fenofibrate, Gemfibrozil)
- Avoid combination if possible
- Educate patients to watch signs of myopathy
e. Niacin – Monitor for side effects
f. Rifampicin – Decreases plasma levels of statins
- Monitor for therapeutic effect or clinical response
- use pravastatin
g. Warfarin – Inhibition of warfarin metabolism, increased anti coagulant effect, increased risk of bleeding
- close monitoring of INR
- discontinue or change dose of statin
7. Pregnancy – Its contraindicated in Pregnancy and lactation as cholesterol is required for fetal development. Discontinuation of statin during pregnancy does not pose an immediate risk to the mother

LIPITOR – Counseling Essentials

Thank you for waiting Mr / Ms……………………
Your Doctor has prescribed you Lipitor 20mg tablets which contains Atorvastatin 20mg as the active ingredient and you have been dispensed 90 tablets
This has been prescribed to reduce your cholesterol. It belongs to a group of drugs called statins and it blocks cholesterol production by the liver by inhibiting an enzyme called HMG CoA reductase
Did the doctor mention to you how to take this medication?
Oh ok…Well that’s right / That’s okay…This medication is supposed to be taken once daily with or without food preferably in the evening as the liver produces most cholesterol in the early hours of the morning
You should start seeing an effect after 4 weeks.
Its important you avoid taking grapefruit juice along with this medication as it will increase the drug levels in the body exposing you more to the more serious side effects of the drug
Medications, in additional to beneficial effects, unfortunately also carry some side effects which you may or may not experience. Did the doctor mention anything in this regard?
Okay…some people may experience abdominal pain / cramps, nausea and vomiting , diarrhea or constipation, flatulence or a headache. These should not cause any major problems but if they persist or become bothersome, please contact us and we can discuss them further.
However if you experience unexplained muscle pain, tenderness, muscle weakness or your urine darkens, you are experiencing a serious side effect to the drug and you need to get in touch with your doctor immediately
This medication should be stored in a cool and dry place away from reach of children.
Along with your medication, ensure that you drink plenty of water to remain hydrated and that you eat a well balanced diet with a lot of fibre, avoiding foods containing saturated fats and / or cholesterol. Also ensure that you exercise regularly as all these will keep you healthy and fit.
I am giving you a drug information sheet that will explain more about your medication.
Do you have any questions or concerns?
Please do not hesitate to contact us if you have any concern.
If you don’t see any improvement or if you experience the serious side effects explained earlier, you should get in touch with your doctor.
If you don’t mind I will call you in a few days to see how you are doing.
I hope you feel better soon. Thank you for choosing our pharmacy and have a good day / evening.

PATIENT COUNSELING: THE FIRST INTERACTION.

I walk into a General Store with a list of items I require and the shop keeper glances at the list and proceeds to remove them and place them neatly on the counter. He then goes to the cash register to charge those items, occasionally glancing up at me informing me on how fresh some of the products are or how some of them need to be used, giving basic directions. He then proceeds to pack them nicely in a bag and collects the money smiling at me to come back again.

This scenario is not only played in a General Store but in Retail Pharmacies in many countries too. Agreed that many of them are run by non-professionals and not Pharmacists but sadly there are places run by professional Pharmacists who have adopted the ‘commercialized’ version of Pharmacy as a business without any regard to the attributes of this noble profession.

The end point of any Pharmacist interaction with a Patient should be the Patient’s health and well being and in order to fully justify that objective, we as Pharmacists need to conduct ourselves in a more professional attitude. They say ‘first impressions’ matter and in the Pharmacy that could not be more true. Let’s discuss how to deal with a new Patient who comes for the first time to your Pharmacy to fill a Prescription.

1. Salutation and Introduction:

How would you feel or what impression would you have of a person when you walk into his shop, and he just looks at you and proceeds to ask what you want without acknowledging you with a greeting or introducing himself to you? Are you God to know he is the shopkeeper who can help you? Hence it’s important to acknowledge the Patient with a smile and greeting and introduce yourself to him.

“Good Morning Sir / Madam. My name is………………..and I am the Pharmacist on duty. How may I help you?”

2. Identify the Patient and verify the details on the Prescription:

It’s important to verify the Prescription which is handed over to you. Is the name on the Prescription that of the Patient or is the Prescription for someone else?

This Prescription is for …………… is that you?

If the Prescription is for a child proceed to ask the weight / age of the child. As you are aware children’s dosages are different from adult ones and are based on mg/kg basis hence it’s important to verify that the correct dose has been prescribed.

And how much approximately does your son / daughter currently weigh?

Or

How old is your son / daughter?

3. Confidentiality

It’s important to reassure the Patient that you will not discuss his issues with the whole world, so you may want to ask him to join you in a private area where you can discuss his situation on a one to one basis and without interruption.

Ok. Mr. / Ms…………Why don’t we step this way into the counseling room, where we can continue our conversation privately

Or

Please have a seat in our private counseling area and we shall continue talking about this.

4. Find out more about the Prescription and show that you are there to help (Show Empathy)

It’s important to know why he is taking a particular medication as there may be many indications for a particular drug. Never assume that a Patient is taking a drug for a particular indication. You may be in for a rude shock!! For example I was dispensing a medication called Metamucil (containing Psyllium husk) to a Patient, and I said, “This is a bulk forming laxative and it will help to improve your bowel movement or and relieve your constipation,” and the Patient got confused. “But I don’t have constipation. I was told to use this medication as it will help me reduce my cholesterol!!” L It’s therefore important to know why he has been prescribed that medication and the Patient can inform you upfront or give hints or clues, if only you take the time to find out from him.

What did the doctor tell you this medication is for?

Or

What made you go to the doctor?

Oh ok….It sounds like…….we will try our best to help you…That’s what we are here for

5. Ask Permission to Counsel & Assure Confidentiality

Certain Patients tend to get defensive when asked questions as they feel you are trying to pry into their personal life, especially in Western countries where the threat of identity theft is rampant. For this reason, it’s important to request permission to counsel and explain to them why you need that information.

With your permission, I would like to ask you a few questions just to ensure that you will be getting the best benefit from the medication prescribed. I assure you that this information will remain strictly confidential…Is that Ok?

6. Ask about Allergies / Sensitivities (A3)

Ideally, you should ask Patients about their sensitivities to three things (hence the term A3). These are, Medication, Food or Other Substances.

Do you have any allergies / sensitivity to any Medications, Food or Other Substances?

Once you get an affirmative…Confirm the drug, food or substance. In case a Patient mentions a group e.g. sulfa allergy, confirm the drug.

Can you tell me specifically what the drug was?

Thereafter the very next question should be

1. Would you please tell me when you took this drug and what happened when you first took it?

Sometimes a side effect of a medication can be mistaken for an allergy. I have had dozens of Patients telling me they are “allergic” to Penicillin, but upon inquiring, they experience nothing more than diarrhea after using the drug. It is therefore important to differentiate a true allergy from a mere side effect, and educate the Patient accordingly.

Probe more about the allergic reaction…For example if the Patient says that he developed a rash after taking a medication

2. Where was the rash? How did it first appear? It must have been terrifying for you when you first observed it…Show empathy

3. When did this happen? (Immediately after taking the medications, few hours, few days or few weeks / months after taking it?)

4. What did you do when you saw the rash?

5. What did the doctor tell you to do?

7. Ask about any Medical Conditions (MC)

Do you suffer from any other medical conditions like high blood pressure or high blood sugar that I need to be aware of? Have you had any recent surgery carried out?

If yes,

How long have you had this condition, and what have you been doing for it? When did you go for surgery? What kind of surgery was it?

8. Inquire about Medication Usage? (Mdn-4)

Are you currently taking any Medication – Prescription drugs, Over the Counter (OTC) Medication, Herbal supplements or Vitamins / Nutritional supplements?

1. What Medication are you on?
2. What do you take it for?
3. Do you remember the strength of the Medication?
4. How many times a day do you take it?
5. Has it helped you? OR Do you feel any improvement after taking this Medication?

9. Patients Lifestyle (CASDEP)

It’s important to inquire about the Patient’s lifestyle as this can also affect the efficacy of the medication. Smoking acts as an enzyme inducer and may reduce the effect of some drugs. Furthermore, it is strictly contraindicated in women over 35 who are on Combined Oral Contraceptives. Alcohol can interfere with drugs like Metronidazole causing a severe Disulfiram type reaction. It can also interfere with blood sugar, causing hyper or hypoglycemia depending on the Alcohol level. A sedentary lifestyle can prove to be deadly for a heart Patient, certain kinds of diet interfere with certain drugs, for example a diet rich in Vitamin K may prove to be detrimental to a Patient who is on Warfarin. Caffeine may cause a mild increase in blood pressure, and also interfere with the effect of some sleeping pills by acting as a CNS Stimulant. And of course, giving Category X Drugs to a woman who might be pregnant might turn out to be a Pharmacists worst nightmare.

I also need to ask you some questions about your lifestyle, as it may affect the way the Medication works.

C – Do you drink Caffeinated beverages such as coffee? How often? How much per day?

A – How about Alcoholic beverages? How often How much per day?

S – It may or may not apply to you but I need to ask…do you Smoke? How many packs a day?

D – Do you follow any special Diet? In other words are you a vegetarian / non vegetarian? Are there any restrictions in your diet that I should be aware of?

E – Do you get a chance to Exercise regularly?

P – I also need to ask you if you are Pregnant or planning to become pregnant? What about nursing? (This is for women only J Please be sharp to realize not to ask this question to men and geriatric or post menopausal women!)

10. Thank the Patient for his Time

Well Mr. / Ms……………..Thank you very much for answering all my questions and giving me the information. Let me check the references / prepare the medications and I will get back to you shortly.

To conclude, the following protocol should be followed in gathering information when a new Patient comes to your Pharmacy. Many of us don’t practice this in actual life but let’s not forget that this is what is required of us and more importantly this is what separates us from all the ‘quacks’ around us.

Some people may argue that we do not have the time to ask such questions especially when we don’t even know whether it’s worth it or not, since more often than not, the Patient has no clue of what is happening. In other words, quite simply, this would not work in our Pharmacy setting. Many of us believe in the old adage that “When in Rome, do as the Romans do.” That is true in a sense but then remember that our ‘Rome’ really isn’t our immediate environment any more. It includes Pharmacists all over the world. The world has truly become a Global Village with the advent of social networking sites like Facebook and Twitter, and there is so much out there to learn. The learning process never ends.

I am Back

Sorry for the long silence...

Life has been much like a roller coaster and it has taken me places where I least expected to go.... Anyways now that I am back in the picture, we shall proceed from where we left off.

As per my first post, I would like to continue to serve in the interest of the pharmacy profession. The past two years has been an adventure to say the least...the journey hasnt ended but there is alot of information that can be useful to one and all. Therefore watch this blog!!!