Clinical Cases in Pharmaceutics

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					                                                                     History of Cases in Pharmaceutics
                                                                         • Book of pharmaceutics cases was 
                                                                           collected by AACP Teachers of 
  Clinical Cases in Pharmaceutics                                          Pharmaceutics Section in the mid‐
                                                                           1990s
                                                                            – Wendy Duncan‐Hewitt (editor)
          Robin H. Bogner., R.Ph., Ph.D.
            University of Connecticut




        Bloom’s Taxonomy                                                     Bloom’s Taxonomy

     Synthesis                                                            Synthesis 

    Evaluation                                                           Evaluation

      Analysis                                                             Analysis

   Application                                                          Application

Comprehension                                                        Comprehension

   Knowledge                                                            Knowledge

                  Pre          P‐1    P‐2         P‐3          P‐4                     Pre          P‐1    P‐2         P‐3          P‐4




        Bloom’s Taxonomy                                                     Bloom’s Taxonomy
                                      Cases                                                                Cases
     Synthesis                       Real Clinical                        Synthesis                       Real Clinical 
                                      Problem                                                              Problem
    Evaluation                                                           Evaluation

      Analysis                                                             Analysis

   Application                                                          Application
                                      Vignette                                                             Vignette
Comprehension                                                        Comprehension

   Knowledge                                                            Knowledge

                  Pre          P‐1    P‐2         P‐3          P‐4                     Pre          P‐1    P‐2         P‐3          P‐4
         Bloom’s Taxonomy                                                                      Contrast
                                       Cases                          Vignette                          Real Clinical Problem
      Synthesis                       Real Clinical                   • Concocted                       • Collected from practice
                                       Problem                        • Simple                          • Complex
     Evaluation                                                       • One answer                      • Open‐ended answer
       Analysis                                                       • Not open to interpretation      • Open to disagreement
                                                                      • Students are asked              • Students ask the key 
    Application                                                         questions to lead them to         questions to be answered 
                                       Vignette                         the right answer                  to generate a solution
Comprehension                                                         • All necessary information is    • Only limited information is 
                                                                        provided                          provided along with some 
    Knowledge                                                                                             extraneous information
                                                                      • Comfortable for students        • Uncomfortable for students
                   Pre          P‐1    P‐2         P‐3          P‐4




What makes a “pharmaceutics” case?                                    What makes a good “pharmaceutics” case?

 A problem that requires the application of                                                   Real Problem
                                                                                       • Collected from practice
 •pharmacokinetics
                                                                                       • Complex
       • biopharmaceutics                                                              • Open‐ended answer
 •physical pharmacy                                                                    • Open to disagreement
 to solve a problem related to a patient’s                                             • Students ask the key 
                                                                                         questions to be answered 
 therapeutic outcome,  such as                                                           to generate a solution
 •choice of product or preparation                                                     • Only limited information is 
                                                                                         provided along with some 
 •administration of product or preparation                                               extraneous information
 •quality of product or preparation                                                    • Uncomfortable for 
                                                                                         students




    3 Examples of Pharmaceutics                                                   P‐2/GenChem Joint Lab
               Cases
• P‐2 students compound a suspension which is                                    Goals described to students
  assayed by General  Chemistry students                                  •P‐2 students: prepare 2 bottles of “calamine lotion”
     • Lab‐based case                                                     Calamine Topical Suspension, USP
     • Inter‐professional interaction                                     •Gen Chem students:  assay the preparations for iron
                                                                          •Both: prepare a report of findings with explanations 
• P‐3 students in a small elective class each find                        for any deviations from expected
  their own case and “solve” the clinical problem.                        •Both: contribute to answering an open‐ended 
                                                                          question
• P‐4 academic rotation students develop cases 
  for use in a case‐based integrated course.
         P‐2/GenChem Joint Lab                                         P‐2/GenChem Joint Lab

                     My Goals                                                      Delivery
•Provide a pharmacy‐related activity for pre‐pharmacy         •All on‐line interaction of 5‐student groups composed 
students                                                      of P‐2 and general chemistry students
•Obtain feedback to pharmacy students on the quality                              Challenges
of their product
                                                              •Coordination of delivering preparations to general 
•Give students the opportunity to work on open ended 
                                                              chemistry
problem to prepare them for real cases
                                                              •Coordination of groups
•Utilize preparations from pharmacy students rather 
                                                              •Motivation of groups
than disposing of them
                                                              •Conflict resolution within groups
•Provide opportunities for senior class members to 
                                                              •TIME
mentor pre‐pharmacy students




         P‐2/GenChem Joint Lab                                    P‐3/Advanced Compounding

                    Outcomes                                        Goals described to students
•Not a true clinical case, but it involved measuring of       •With a prescriber, identify three patients with 
quality of compounded preparation                             therapeutic problems that you think can be best solved 
•Foci of complaining                                          by compounding a new preparation
•Compiled results are not available yet.                      •Work with the instructor, other students and the 
                                                              prescriber to develop the compound
                                                              •Prepare a report on the background including 
                                                              biopharmaceutis, pharmacokinetics, stability, 
                                                              administration and patient consultation for your new 
                                                              compound




    P‐3/Advanced Compounding                                      P‐3/Advanced Compounding

                     My Goals                                                      Delivery
•Provide students with an authentic compounding               •15 students all working on different projects over the 
experience                                                    course of a semester with 4 labs devoted to individual 
•Integrate knowledge of pharmaceutics with that of            projects. Midterm is interim report. Final.
other courses (therapeutics, patient communications,                              Challenges
sociology, ethics, etc) to solve a problem for the patient 
                                                              •Students underestimate the difficulties in finding a 
in his/her environment
                                                              prescriber to work with them
•Build the market for compounding in the region
                                                              •Interacting with each student on a separate project 
•Learn new compounding strategies from students
                                                              takes:
                                                              •TIME
     P‐3/Advanced Compounding                            P‐4/Academic Rotation Case‐Writing

                    Outcomes                                      Goals described to students
 •Students have a great sense of accomplishment in        •Identify three patient problems that require significant 
 putting together their accumulated knowledge,            pharmaceutics knowledge to find a solution
 literature support, and creativity to prepare a new      •Work with the instructor to develop at least one of the 
 compound.                                                three patient problems to find a set of solutions
 •Students report a sense of confidence going into 
 clinical rotations.
 •Intellectual satisfaction for the instructor.




P‐4/Academic Rotation Case‐Writing                       P‐4/Academic Rotation Case‐Writing

                     My Goals                                                           Delivery
 •Solidify pharmaceutics background of senior students    •2 students per month work together to identify 
 •Identify any weaknesses/misconceptions and address      possible cases, with twice weekly feedback from the 
 them                                                     instructor.
 •Tap the students’ experience for real world                                         Challenges
 pharmaceutics cases for the new curriculum
                                                          •Students are focused on the disease state rather than 
 •Learn new and relevant examples to use in class and 
                                                          the patient 
 keep me up‐to‐date
                                                          •Feedback to students to develop good cases take:
                                                          •TIME




                                                         MT is a 58 year old Caucasian female who sees her favorite pharmacist behind the
                                                         counter at the pharmacy in the grocery store. She is scheduled for a follow up visit
P‐4/Academic Rotation Case‐Writing                       with her primary care physician tomorrow, but she is inquisitive about her new
                                                         diagnosis.

                                                         CC: “I found out that I have osteoporosis and I can’t swallow very well. I am going
          Outcomes – Two Cases                           to the doctor’s tomorrow, and I would like to know what my options for treatment
                                                         are?”
 •MT has newly diagnosed osteoporosis
                                                         PMH:
 •AP has been having break‐through seizures              Esophageal Cancer (1998)-Received chemotherapy & radiation-in remission
                                                         Hypothyroidism
                                                         Hypertension
                                                         Osteoporosis
                                                         All/Intolerances: NKDA
                                                         Meds::Levothyroxine 125 mcg daily   ; Lisinopril 10 mg daily

                                                         Supplemental Information:
                                                         MT had chemotherapy and radiation for throat cancer in 1998 and her epiglottis was
                                                         removed. She is now unable to swallow solids, but has taught herself to swallow
                                                         liquids, small amounts of soft food, and even very small “pills”. Also, MT does not
                                                         produce saliva. She reports trouble tolerating intranasal medications.
1. Define osteoporosis.                                                                  AP is a 34-year-old male that presented to the ambulatory care clinic .
                                                                                         He had recently undergone a Roux-en-Y gastric bypass (5 weeks
2. What are all the available medication options and their available                     ago), is feeling well and has no complaints. His wife is with him today
dosage forms for treating osteoporosis? (Drug class, brand and generic                   and claims that AP has been exhibiting seizure symptoms at home
name, dosage form, dose and frequency of administration, cost per                        including staring off, “blanked face”, and periods of fast blinking.
month, appropriateness for this patient)
3. Rule out the options that are not possible for MT.  Take into account tablet          PMH: Absence seizures x 20 years
size/shape and the possibility of splitting or crushing tablets.                              Obesity x 15 years
                                                                                              Hypertension x 6 years
4.   Which options are appropriate for MT? Explain why.
5.   Are there any drug interactions that MT should be made aware of?                    SH: Lives at home with wife and 3-year-old son
                                                                                             Denies alcohol use, illicit drug use and tobacco
6.   Cost is an issue for MT.  What are the most affordable options?
7. 6 months later MT is started on Nexium (esomeprazole) for gastrointestinal reflux     Medications:
disease (GERD).  Is this an appropriate option for MT?  Should her medication regimen           Depakote Delayed-Release: 3000mg/day (1500mg BID)
be changed?                                                                                     Lisinopril 20mg/day

8. 1 year later it was discovered that she has an iron deficiency anemia.  She was       The clinic physician wants the pharmacist’s advice on adjusting AP’s
started on ferrous sulfate.  Any there any counseling points you can make MT aware       medication.
of?




         Roux‐en‐Y Gastric Bypass:                                                                             Final Thoughts
         Most common gastric bypass procedure.  
         This surgery is the “gold standard” of weight loss surgeries.  
                                                                                         • Pharmaceutics cases help students integrate 
                                                                                           physical pharmacy, biopharmaceutics, and 
         What it entails:                                                                  pharmacokinetics into their clinical problem 
           Creation of a small, (15–30 mL/1–2 tbsp) thumb‐sized 
           pouch from the upper stomach.  
                                                                                           solving.
                                                                                         • Calcium supplementation and gastric bypass 
            The small bowel is divided about 45 cm (18 in) below the 
            lower stomach outlet, and is re‐arranged into a Y‐
                                                                                           provide rich lines of discussion.  Others?
            configuration, to enable outflow of food from the small                      • By integrating other knowledge areas into the 
            upper stomach pouch to the lower duodenum                                      pharmaceutics case, we can make it relevant.
            This surgery bypasses the entire duodenum.                                   • Have high expectations for students.  Many of 
                                                                                           them will surprise you!




                      Acknowledgements
     •    Melissa Davis, PharmD (Class of 2008)
     •    Deanna Joubert, PharmD (Class of 2008)
     •    Tyson Miller, PhD (Dept of Chemistry)
     •    Christine Cardillo, PhD candidate (Chemistry)
     •    Countless other students and colleagues