AP401 Fake Exam Answers





Substance Misuse I – Drug Use and Dependence

- "some kind of case study": describe using the Zinberg model (drug, user - 'set', environment - 'setting')
drug: dose, effects, addictive potential, purity, method of administration, use with other drugs, longer-term sequelae of use
user (set): age, gender, health (physical and mental), previous use of the drug (?tolerance), expectation of the drug experience, concomitant use of other drugs
setting: environment

Mary Lim is a 20 year old office worker who enjoys a cigarette with her colleagues on the footpath outside her Grenfell St office a number of times a day. Use the model (above) to explain this drug use situation. (3 marks)

drug: cigarette (nicotine), 100/100 addictive potential, inhaled, used often
user (set): 20 year old female, smokes a number of times a day
setting: with colleagues on the footpath outside her Grenfell St office

- list a few points of criteria of drug dependence (ICD-10 and/or DSM IV)
Need to have at least 3 of:
- tolerance
- withdrawal
- taking in larger amount or over a longer period of time than intended
- persistent desire or unsuccessful efforts to cut down or control
- spending a great deal of time and effort on activities to obtain or use the substance
- giving up other significant activities
- continuing use despite problems known to be caused by the substance

Substance Misuse II – Determinants of Drug Use, Pharmacotherapies of Drug Dependence
- describe the theory of deservingness, and why it is hard for people with alcohol or drug disorders to seek quality health care
people with alcohol or drug disorders receive poorer quality health care due to the stigma attached because of their problem. Therefore they receive less access to health care, further exacerbating their poorer health outcomes. This can be explored using psychological phenomena, where people with alcohol or drug disorders feel out of the group and experience non-belongingness, as society blames the victim rather than think of their circumstances (actor-observer bias). According to Freeman (2006), we assign deservingness (hence, whether the patient deserves assistance) based on our values, our feelings towards the patient and if we feel that they are responsible for where they are.

- pharmacotherapies for alcohol withdrawal, cannabis withdrawal
Alcohol
Benzodiazepines: diazepam (lorazepam/oxazepam):
i.e. sedative + anticonvulsant plus thiamine/ multivitamins/other anticonvulsants/ antipsychotics/analgesics/ anti-emetics
Inpatient:
– alcohol withdrawal assessment scales
– loading dose: 60mg-100mg (wt determined), then 20mg oral 2-hourly until withdrawal score lowered (10 or less)
Home:
-10mg qid and tapering

staying stopped
Acamprosate: orally 3 divided doses (1.3-2G/day) for 1 year (poor absorption/ variability)
Naltrexone: 50mg once daily orally

Cannabis
Immediate: supportive management inc short-term
symptomatic medications
• diazepam 5-10mg QID prn for maximum of 7-10 days
• metoclopramide 10-20mg TDS prn
• analgesia (e.g. paracetamol)
• pericyazine 2.5-5mg TDS prn (+ benztropine)

Longer-term:
• pattern of use major determinant
• psychosocial counselling (extended)- CBT, MET
• lifestyle modifications
• relapse prevention strategies
• oral THC may be useful; lithium limited (Hart 2005)

Future:
CB 1 cannabinoid antagonist rimonabant- more research

Substance Misuse III – Harm Minimisation Strategies
- what are the three principles of harm minimisation, with examples
Three principles of harm minimisation:
supply reduction: scheduling of medications
demand reduction: health and education campaigns
harm reduction: opioid substitution treatment program, clean needle program

- calculation of 25mg methadone using a 5mg/mL solution
Methadone dose (mg)/5 = Methadone dose (mL)
e.g. Rx for 25mg methadone = 5mL methadone

- when do you give the first dose of buprenorphine to a heroin user (after how long after their last heroin use)? why is that?
The first treatment dose should be given 12 hours after last heroin use, to prevent withdrawal by administering a partial agonist.

- "picture of prescription": is this valid? (dose not in both words and figures or something similar)
Valid Prescription
- Patients name, address, DOB

- Signed, dated by accredited prescriber
- Prescribers name address, ph. no.
- Daily dose in WORDS and FIGURES
- No. of take away (T/A) doses authorised
- Expiry date (period of supply)
- The receipt of a new script cancels previous scripts


- comparison of suboxone effects (buprenorphine/naloxone) on different scenarios

Scenario
Sublingual
Intravenous
Non-heroin/methadone/opiate user (opiate naive)
good
good
Heroin/methadone user not in withdrawal
bad - receive partial agonist
very bad - receive full agonist
Heroin/methadone user in withdrawal
good - receive partial agonist
ok
Subutex user
good
ok

- patient claims vomiting from subutex (buprenorphine) and demands a new prescription (vomiting only affects methadone - requires a new prescription anyway)
common errors
- administering repeated doses for claimed vomiting - no replacement doses without new prescription

- course of action when client presents intoxicated: chance occurrence and if an ongoing problem
Client presents intoxicated ⇒ Do not dose and report
- Sedated
- Slurred speech
- Ataxia (benzos, alcohol, stimulants)
- Smell of alcohol


If a chance occurrence - tell them to come back in the afternoon for their dose
If an ongoing problem - report

- success of opioid substitution treatment program (harm reduction goals)

Community view
• Aims of Tx achieved ⇒Harm Reduction goals
■ illicit drug use
■ ⇓ blood borne disease transmission
■ ⇓ criminal behaviour
■ ⇑ social functioning and mortality
rates

Pharmacy view
• Attend regularly
• Do not present intoxicated
• More stable personal life
• Take their dose to the satisfaction of the pharmacist
• Employment or education/training
• Children are cared for
• Medical needs are attended to

Medication Safety


Pharmacy Nutrition


Weight Management


Infant Feeding and Special Dietary Needs
-
benefits of breastfeeding to both the mother and infant
Mother
• Promotes bonding
• Oxytocin release
• Use of fat stores
- promotes maternal recovery from childbirth (reduced risk of haemorrhaging), possible accelerated weight loss
Child
Infant feeding & special dietary needs
• Reduction of nutritional problems
• Nutritional and immunological (cow's milk allergy)
• Bonding
• Associated with a decrease in incidence of some childhood illnesses (reduced asthma, type 1 diabetes, inflammatory bowel)
Financial
• Nothing to buy!
Ecological
• Nothing to store or throw away!

- significance of differences between formulae (when changing/hopping)
• Make sure correct age for formula - different protein/electrolyte content - higher requirements when older
• Avoid ‘formula hopping’ - instructions can change, leading to mistakes

- why is cow's milk unsuitable for infants? (when can we introduce it?)
Problems:
• high protein and electrolyte content
• increased renal solute load
• deficient in Vitamins A,C,E
• low Fe content
Unsuitable for infants < 6 months
• Should not be introduced as primary milk source for infants < 12 months

- disadvantages of bottle feeding
- Cost
• Time
• Need for safe water, utensils, sterilisation of equipment
• Knowledge and ability to follow recipe
• Possibility of overfeeding
• Temptation to add other substances to bottle (sugar!)

• Requires care
• Should always be made up to correct strength, as per the instructions on can
• Instructions and scoop size vary - always use the scoop that comes in the can
• Prepare with cooled boiled water

- consequences of introducing solid foods earlier or later than 6 months of age
When?
• for breastfed babies 6 months of age (WHO, Cochrane).
• developmental signs of readiness (4-6 months – digestive, renal & immune system ‘maturity’)

Not earlier because
• may cause a decrease in breast milk supply
• decrease in volume of formula consumed
• encourages overfeeding
• extra work for parents
• increase the chance of developing a food allergy
• solid foods with a high sodium content – renal immaturity

Not later because
• increased risk of nutritional deficiencies / faltering growth
• textural and behavioural feeding difficulties may arise

- consequences of mixing medications and food (infants and toddlers)
Taste and formulation may lead to problems of compliance with medications
• Bitter taste of liquid preparations
• Tablets may require crushing

Mixing medicines with drinks/foods – impacts:
• Effect infant’s milk feed intake (milk may remain bitter, child may no longer like milk, or not receive the full dose)
• Reducing an already limited variety of foods
• Potential for drug–food interactions (binding)

Avoid mixing medication with food/formulae
• If necessary can mix with small amounts of jam/honey/fruit pulp (good for short-term use, not chronic)
• Give the dose ‘neat’ and follow with drink/food (dose without dilution)
• Can be a problem for chronic medication regimens
• Consider solid dose forms as soon as appropriate (less taste, sugar-coated - give drink beforehand to prevent capsule sticking, and wash with water after)

Immunisation
- definitions of control, elimination etc.
Control
- When there is reduced incidence, prevalence, morbidity or mortality of the disease to a locally acceptable level as a result of deliberate efforts. Continued intervention is required.
Elimination
- Permanent reduction to zero of incidence of infection from a specific disease in a defined geographic region. Continued intervention required.
Eradication
Permanent reduction to zero of worldwide incidence of infection from a specific disease. No further intervention required.
- Extinction
Irreversible removal of an organism from the environment.
- Vaccination
Injection of a killed/altered microbe in order to stimulate the immune system against the microbe, thereby preventing disease.
- Immunisation
Immunisation means both receiving a vaccine and becoming immune to a disease, as a result of being vaccinated against that disease

- practice points for packing a Cooler/'Esky'
- Remove ice bricks from freezer to sweat/condition for at least 60 minutes prior to packing with vaccines
- Place Freeze Watch card & Min/Max thermometer with packed vaccines
- Ensure a barrier between ice bricks and vaccines (shredded paper/polystyrene chips)
- Secure the lid of transporting container
- Cooler should be large enough to accommodate a barrier around the vaccine
- Temperature needs to be checked before leaving the pharmacy, when vaccines arrive at the destination & before vaccines are administered

- counselling side effects of immunisation
Immunisation side effects
- Like all medications and natural medications, vaccines may have side effects
- Most side effects are short-lived and do not lead to any long-term problems
Mild fever, unsettled, pain/soreness/redness swelling at the injection site, mild ‘flulike’ like symptoms, fever, crying and lack of appetite
- Refer any other unexplained serious reactions/concerned parents to the doctor/hospital

Dermatology I – Introduction and Psoriasis
- principles of diagnosis (physical examination and history)
Physical Examination
- conduct in good light
- palpation (to detect tenderness, thickened, hardened, or soft lesions)
- morphology of lesions (type, colour,size)
- distribution & arrangement of lesions
- all skin should be examined (mouth, nails, hair, genital areas and eyes)

History
- Chronology (date of onset, duration, previous episodes)
- Evolution of lesion (first location and appearance)
- Medications (topical and systemic therapies)
- Recent and Past illness (infections, diabetes, atopy, skin conditions)
- Other (occupation, environmental conditions, travel, family history, psychological factors)

- clinical presentation of psoriasis, Auspitz sign and Koebner phenomenon

Clinical Presentation
Well demarcated pink to red erythematous plaques with white to silver scale
Plaques vary in thickness and size
- Sites most commonly affected
- elbows & knees
- scalp
- trunk & lower extremities
- fingernails and toenails
- flexures may have thin plaques

Auspitz sign
diagnostic for psoriasis
- characterised by small punctate areas of bleeding evident upon removal of scale
Koebner phenomenon
- occurrence at a site of physical trauma eg surgical scar, burn
- may precipitate first lesions and pre-existing lesions rendered more recalcitrant

- precipitating factors of psoriasis
skin injury
- mechanical, ultraviolet or chemical injury emotional factors
- stress
infections
- viral, HIV, streptococcal drugs
- NSAIDS (indomethacin)
- Lithium, Quinine/chloroquine, quinidine
- beta-blockers, some ACE inhibitors
- systemic corticosteroids (withdrawal)

- how to apply dithranol
- wear gloves
- localise to lesion by using stiff paste + talc
- surrounding skin protected by white soft paraffin
- removed with liquid paraffin
apply betamethasone 0.02% to irritated skin

- side effects to topical corticosteroids
Epidermal & dermal atrophy
– atrophy (clinical thinning of the skin)
– telangiectasia (blood vessels on face), purpura (bleeding into skin), striae (stretch marks)
‘Corticosteroid face’ & peri-oral dermatitis
– pustulation
Impeded healing, masking/spread of infection (due to immunosuppressant)
• local hypertrichosis
• systemic absorption
• glaucoma

- practice points for PUVA
erythema induced by PUVA is delayed & may take up to 24 hours to develop
- following a single oral dose skin sensitivity to UVA occurs within 1-2 hours

Adverse effects of PUVA
- Nausea (10%)
- mottled skin
- generalised itch (10%)
- headache and dizziness (paracetamol beforehand)
- phototoxicity reactions (wear sunscreen, sunglasses etc.)
- cataract formation (psoralen can deposit in eye - wear goggles to prevent UV activation)
- carcinogenesis - increased risk of squamous cell carcinoma

- patient complains of psoriasis getting worse upon starting acitretin
Response to treatment
- causes desquamation after 7 days with flattening of lesions and change from red to pink colour
- may see increase in severity initially
- central healing of plaques evident after 3 weeks
- head to toe direction, flexures and lower extremities last to heal

- counselling points for acitretin (pregnancy, LFT, photosensitivity, cholesterol)
Most Common
- skin and inflamation (part. soles & palms) 30-40%
- inflammation mucous membranes, cheilitis 80% (cracked lips - vaseline)
- dry nose/ epistaxis (nose bleeds)
- blurred vision, conjunctivitis, corneal opacities
- alopecia 50% (can be reversible)
- skin thinning & oily feeling (fine layer of baby oil feeling - increased mucin cell secretion)
- hyperirritability
- athralgia, muscle cramps (leading to ceasing of drug)

- hypertriglyceridaemia (25% pts on 1mg/kg)
- hepatotoxicity - raised enzymes, hepatitis
- pseudo-tumour cerebri - benign intracranial hypertension (combination with tetracycline)
- bone pain/tenderness
- photosensitivity
- teratogenicity (Category X drug - avoid use in pregnancy) - effective contraception for one month pre and 2 years post-treatment

- do not donate blood (up to 2 years)
- avoid vitamin A preparations
- use of broad spectrum sunscreen
- avoid use in existing lipid abnormalities
- monitoring of lipids/liver function

- class contraindication for biological/antibody therapies, what medical conditions are a contraindication in some
Class precaution for infections (serious and fatal infections have been reported) and malignancies (can cause lymphoma - as TNF helps prevent cancer)
• Contraindication for Cardiac (may worsen CHF)
• Precaution for CNS disorders

- brief explanation of PBS indications of biological/antibody therapies
Initial treatment as systemic monotherapy for patients who
• have severe chronic plaque psoriasis for at least 6 months
• have not received any prior PBS-subsidised treatment with a biological agent; and
• have signed a patient acknowledgement form indicating that they understand and acknowledge that PBS-subsidised treatment will cease if they do not respond according to PBS criteria; and
• have failed to achieve an adequate response, as demonstrated by a Psoriasis Area and Severity Index (PASI) assessment, to at least 3 of the following 4
treatments:
– phototherapy (UVB or PUVA); and/or
– methotrexate at a dose of at least 10 mg weekly; and/or
– cyclosporin at a dose of at least 2 mg per kg per day; and/or
– acitretin
If treatment with any of these treatments is contraindicated
• If intolerance to treatment has developed
• Failure of response to these treatments is defined as
– A PASI score > 15 preferably on treatment, but no longer than 1 month following cessation of the most recent prior treatment.

Dermatology II – Eczema and Contact Dermatitis
-
explain the three morphological stages of eczema
acute
- intensely pruritic papules and vesicles on a background of erythema or extensive erosions with serous exudate (weeping)
subacute
- excoriated, scaling, erythematous papules or plaques grouped or scattered over erythematous skin
chronic
- lichenification (thickening) due to scratching, fibrotic nodules and postinflammatory hyper or hypo pigmentation

- management of eczema (general, acute exacerbations and chronic)
Management - general
• Avoid offending agents
• drying agents (soaps, hot water, low humidity)
• wool clothing, pets
• complex topical medications, perfumed products
• stress or certain foods (if applicable)
• regular bland emollients - aqueous /sorbolene cream
• soap substitutes - cleansing lotions
• paraffin bath oils - Hamilton’s bath oil

Management : acute exacerbations
• Hydration
• Tepid bathing 2-3 times a day
• wet packs and emollient creams
• aluminimum acetate (Burow’s solution) - astringent/antibacterial
• Hydration will increase the absorption of topical creams if applied immediately
• oatmeal packs or NaHCO3 are soothing

• Topical corticosteroids are the mainstay
• moderate strength preparation for body eg betamethasone valerate 0.02% cream
• 2/24 under occlusion/wet packs (1-2days)
• use a mild corticosteroid for the face eg hydrocortisone 1% (or alclometasone 0.05%)
• lotion for the scalp
• reduce frequency of application and strength of steroid as condition improves

• sedating antihistamine eg trimeprazine
• systemic antibiotics/antivirals if infection occurs

Severe, refractory cases
• oral corticosteroids
• oral cyclosporin
• 2.5-5mg/kg/day in a bd dose
• Use lowest dose for shortest time frame
• Se Cr, BP monitoring

Management - chronic
• Hydration
• avoidance of preciptating factors
• mild to moderate topical corticosteroids prn
• mild tar preparations for scaly, lichenified eczema eg Liqour Picis Carbonis (LPC or coal tar solution) 1-5% and salicylic acid 1-5% in simple ointment or aqueous cream at night.
• Ultraviolet light (UVB) or PUVA
• cyclosporin, tacrolimus, pimecrolimus

- management of seborrhoeic dermatitis (scalp and skin)

Scalp - first line
- selenium sulphide, zinc pyritihione or ketoconazole 2% shampoo
- keratolytic agents eg tar/salicylic acid shampoo
- shampoos should be left in for at least 5 minutes
Scalp - second line
- topical corticosteroid lotions eg mometasone furoate 0.1%, betamethasone dipropionate 0.05%
- sulphur/salicylic acid/tar pomade left over night

Skin - first line
- hydrocortisone 1% cream
- ketoconazole or miconazole 2% cream
- sulphur 1% with salicylic acid 1% cream
Skin - second line
mometasone 0.1% cream/ointment

relapse is common - maintenance therapy

Dermatology III – Warts and Drug Eruptions, Acne
- how to apply wart paint
• Wart paints are applied daily (or weekly)
• before application, abrade or pare surface with pumice stone/scalpel (not anogenital warts)
• protect surrounding area with white soft paraffin or plaster
• apply with cotton bud/applicator
• apply occlusion
• allow to dry and leave for 6-8 hours
• wash with soap and water

- management of exanthem, urticaria, photosensitivity, erythema multiforme, Stevens-Johnson syndrome, Toxic Epidermal Necrolysis
Exanthem
• Treatment - withdrawal + emollients, topical corticosteroids

Urticaria
avoid trigger factors and vasodilators (alcohol, heat), substances which trigger histamine release
• Sedating antihistamines eg promethazine, chlorpheniramine, cyproheptadine
• Less sedating antihistamines eg cetirizine, loratadine
• Oral prednisolone, IM antihistamine, sc adrenaline

photosensitivity
Treatment - withdrawal or use of sunscreens
• emollients +/- topical corticosteroids

erythema multiforme
• Usually mild and self-limiting

Stevens-Johnson syndrome
Treatment - withdrawal, care of mucous membranes
• oral prednisolone 0.5-1.0mg/kg/day until lesions cease.

Toxic Epidermal Necrolysis
Treatment - ICU or burns unit, avoid renal failure and electrolyte imbalance, barrier nursing to avoid sepsis.
• Oral predisolone or cyclosporin

- four factors of pathogenesis of acne
• increased sebum production
• abnormality in keratinisation
• Propionibacterium acnes
– inhabitants of the skin and usually non-pathogenic. Are slowgrowing, gram-positive anaerobic bacilli.
– P.acnes colonisation occurs 1-3 years prior to puberty, mainly on the face and upper thorax.
• Inflammation
– in the lipid-rich microenvironment of the hair follicle, P. acnes contributes to production of inflammatory mediators

- clinical features and management of mild, moderate and severe acne
Mild acne - scattered comedones and/or papules with few pustules
- Benzoyl peroxide (daily, increase to overnight for 7-14 days)
- topical tretinoin (Retin-A, Stieva-A), isotretinoin (Stiefel) - response evident after 2-3 weeks, more than 6 weeks treatment usually required
- clindamycin 1% lotion (Clindatech) - improvement after 6 weeks (need 8-12 weeks)
- Erythromycin 2% gel (Eryacne) - apply twice a day for 3-4 weeks, up to 12 weeks
other agents:
• Salicylic acid 2% /sulphur 2% (less frequently used now)
• adapalene 0.1% gel
• azelaic acid 20% cream

Moderate acne - more papules and pustules present
Systemic antibiotics
- tetracycline 500mg bd or doxycycline 50-200mg daily or minocycline 50-100mg daily (courses should be 6 weeks) - interact with retinoids
- low dose OC or cyproterone/oestrogen combinations (slow response rate - 3-6 months)

Severe acne - nodulo-cystic lesions predominate, may be painful
Oral Isotretinoin - 4-6 months, some patients require treatment up to 12 months

Aims of treatment - prevent scarring, limit duration and reduce psychological stress
• Presenting history, medical history and medications used (esp OC, antibiotics and
corticosteroids)
• patients should be advised that 6-8 weeks treatment required
• lesions on the face resolve more quickly than others

Wound Care
-
common acute/chronic wound presentations (leg ulcer etc.)
Acute
- Traumatic wounds – lacerations, abrasions, blistering (subsequently debrided in hospital)
- Induced wounds – surgical incisions

Chronic - greater than 30 days for healing to occur
Ulcers
- Pressure ulcers - skin and structures broken down (bed sores)
- neuropathic (diabetes, motor vehicle accidents, leprosy)
- Venous
Dehiscence (wound not cleaned appropriately)
Burns - full or partial thickness (can be acute or chronic, usually treated as chronic)

- assessment of a wound
Wound type
- Healing type
- Tissue loss
- Clinical appearance
- Location (non-weight bearing vs weight bearing)
- Size
- Exudate (clear serous vs pus or blood, change in amount)
- Pain (not a good indicator)
- Infection (presents with dirty wound, clean first)

- factors that affect wound healing (medical conditions, other factors)
-
Medical conditions (ie diabetes, anaemia, malignancy, renal diseases)
- Poor Circulation (claudication - calf pain)
- Autoimmune disorders (ie RA)
- Infection (including biofilms)

- Medications (review if chronic wound)
- Nutritional status (long term alcoholism - B6 deficiency, delays wound healing)
- Immobility (decreases blood flow, increases pressure on skin)
- Smoking (reduced peripheral circulation)

- properties of the 'ideal dressing'
- Maintain moist environment (if dry, kills superficial tissue - interrupts healing)
- Absorbent
- Allow gaseous exchange
- Insulating
- Bacterial barrier
- Free from particulate/toxic components
- Atraumatic on removal (woven gauze - capillary groups can grow into gauze, removal leads to spot bleeding)
- Comfortable and conformable
- Protect the wound from further trauma
- Cost effective

- when not to use certain dressings (infection, surface of foot, level of exudate, thyroid problems etc.)
- Films - not if high friction, movement, high exudating
- Foam dressings - require a secondary dressing
- Hydrogel - require a secondary dressing, not in high exudating (washes gel away)
- Hydrocolloid - not for high exudating, infected wounds (holds in exudate), not on plantar surface of foot (turns up into a ball - creates wounds)
- Hydroactive dressing - not if infection present (holds in exudate)
- Alginates - painful
- Hydrofibre
- Cadexomer iodine - painful (especially if hypersensitive), thyroid problems, not if large wound
- Silver dressings - do not use saline to activate

Paediatrics Pain/Common Paediatric Conditions
- pain assessment in children (non-verbal clues, various scales)
Non - verbal clues
• facial expression
• posture
• crying / talking
• movement
• palmer sweating
• blood pressure
• heart rate
• oxygen saturation
• respiratory rate

Wong-Baker faces
Oucher scale

- paediatric dose of paracetamol
15 – 20 mg/kg/dose oral / PR 4 to 6 hourly (maximum 90mg/kg/day)

- benefits of using tramadol
decreased risk of resp. depression and constipation

- know the summary at the end of the lecture
- Identify source of pain (anti-spasmodic vs analgesic)
- Anticipate predictable painful procedures (give sufficient analgesic in advance)
- Use multi modal therapy
- Use appropriate doses
- Administer regularly (reduce 'relapse' of pain)
- Recognise side effects and treat
- Administer for adequate duration
- Consider needs post discharge (otherwise they'll return to hospital)

Coughs and Colds/Cystic Fibrosis
- WCH approach to treating the common cold in children <2yrs
- Normal oral hydration (safe and beneficial for all ages)
- Saline Nasal Drops (suitable for all ages, used before feeds in young babies)
- Paracetamol (suitable for infants older 1 month if irritable)
- Ibuprofen ≥ 3 months
- Demulcents Soothing syrups (safe/comforting - honey/lemon)

- use of nasal decongestants

CNS toxicity in those under 2 years
- < 2years: Normal Saline drops only
- > 2years: Otrivin 0.05% (‘junior’)
- > 12years: Otrivin 0.1%

- what to avoid when treating the common cold
Not recommended
- Nasal decongestants
- Combination cough & cold preps
- Antihistamines
- Steam inhalation
- Aspirin
- Chest rubs
- Zinc, Echinacea

- treatment of PA eradication/colonisation
eradication
± IV therapy - 2/52 tobramycin PLUS one of
- ticarcillin-clavulanate (Timentin)
- ceftazidime,
- meropenem
- aztreonam
oral ciprofloxacin up to 3 months (caution sunlight and milk)
- inhaled colistimethate / tobramycin 3 months

colonisation
chronic inhaled colistimethate or tobramycin
acute exacerbations
- 2 weeks IV antibiotics (tobramycin PLUS one of ticarcillin-clavulanate, ceftazidime, meropenem, aztreonam, ciprofloxacin)

- why azithromycin is used in CF
- Anti-staph
- Interfere with neutrophil function
- Inhibits alginate production
- Reduces adherence of PA to epithelial cells
- others

- pancreatic insufficiency
Good nutrition → good lung function
- Pancreatic insufficiency 90%
- Lack lipase, amylase, protease
- Creon®, Cotazyme®
- Titrate dose to bowel actions
- High calorie diet
- Fat sol vits – A D E K

liver disease
Ursodeoxycholic acid

CF-related diabetes
- Early detection
- Education
- Nutrition
-120-150% RDI energy
- High calorie not diabetic diet
- Insulin

Bone health
chronic malabsorption
- ↑ increased risk of osteoporosis, osteopenia and arthropathy

reproduction
men
- almost always infertile (no vas deferens)
- otherwise normal sexual function
- women
anatomy normal
- ?decreased fertility - thick cervical mucous
- menstrual irregularities, annovulation

Wound Care Exercise


Introduction to Complementary Medicines
- know the three CAMs in the tutorial questions (echinacea, ginkgo, St John's Wort)


Common Complementary Medicines - Naturopathy
- know St John's Wort, Vitex, Paeonia (White Peony), Shatavari
St John's Wort
Traditionally used to treat depression, melancholy and other mental conditions
- 'smelled so bad it scared the evil spirits away'
- research confirms use in mild to moderate depression

Vitex
increases progesterone levels (presumably via pituitary)
- dose dependent effect on prolactin (increases at very low dose, inhibits at high dose)
- main uses: luteal phase defect, PMS

Paeonia (White Peony)
reduces testosterone production from ovaries, but not adrenals
- main use: PCOS
- not researched on males

Shatavari
Ayurvedic sexual tonic
- "gives a woman the energy to have a hundred husbands"
- subtle oestrogen modulating activity

Men’s Health
- treatment options for prostate cancer (including watchful waiting)
- watchful waiting (non-treatment - not indicated or desirable)
- surgeries (prostatectomy - possible infection)
- radiation therapies
pharmaceutical
- GnRH agonists (gonadotropin releasing hormone)
- anti-androgens
- cytotoxics
- radiopharmaceuticals

- why men are at an increase risk for non-gender specific diseases (which you should also list)
men are at an increased risk for:
hypokinetic diseases (lack of exercise/proper diet)
- cardiovascular disease
- type 2 diabetes
- obesity (and associated conditions)
sexually transmitted infections
various cancers
- melanomas (not putting on sunscreen)
- lung cancer (smoking)
- bladder cancer
suicide and self-inflicted injuries
all forms of accidents (especially MVAs)
risk behaviours (illicit drug, unprotected sex)

- barriers for men to seek help/health services
- waiting times (especially GPs)
- non-normative (functional incapacity)
- weakness (effeminate, power relations)
- fear (poor prognosis)
- lack of confidentiality (others finding out)
- feminised health services (HS environment - sense of caring etc.)

- what psychological factors and other medical conditions are gay men more likely to experience
- increased rate of suicides/psychological distress
- poor self esteem/self image
- extreme dieting/eating disorders
- use of supplements, including anabolic steroids (increased creatine in organs - long term effects?)
- exercise addiction/dependence
- sexual dysfunction/anxiety
- personality disorder
- social isolation
- suicide
if dissatisfied with body, decreased chance of looking after body

- drug use (psychostimulants etc.)
- increased risk of HIV/AIDS, STIs

Cancer Introduction
- what kind of cells are affected during anti-cancer therapy
Anticancer therapy:
Most are antipoliferative
Cause DNA damage / induce apoptosis
Affect rapidly dividing cells
- Bone marrow (neutropenia)
- GIT epithelium (mucositis)
- Natural healing mechanisms
- Any normal growth (hair, bone etc)

- common cancers for males and females
Males
Prostate
Colorectal
Lung
Melanoma

Females
Breast
Colorectal
Melanoma
Lung

- describe trends in cancer incidence (effect of prostate screening)
Cancer incidence in males jumped significantly after 1993, which was due to the introduction of prostate screenings. This lead to the slight decrease in cancer mortality rates, as cancers were detected (and treated) earlier and better drugs were developed. Often, males end up dying of a different disease.

- signs and symptoms of prostate cancer
- Difficulties starting and stopping urination
- Pain or a burning sensation when passing urine
- Urinating more often than usual, particularly at night
- The feeling that the bladder can’t be fully emptied
- Dribbling urine
- Blood in the urine or semen
- Pain during ejaculation

Risk factors
- Age
- Family history
- Ethnicity

- PSA testing and prostate cancer (and why it can be inaccurate: age etc)
Prostate specific antigen (PSA) is normally produced by prostate cells, which is increased during benign prostatic enlargement, prostatitis and cancer. Follow up is recommended when the levels exceed 4.0ng/mL (where the risk of prostate cancer is 27%), but this level is considered normal in those over 60yrs of age. Therefore men over 60 are more likely to experience false positives as their naturally high PSA level would be considered as caused by cancer rather than age.

- types of cancer screening in Australia
BreastScreen Australia
National cervical screening program (pap smear, Gardasil)
National bowel screening program

Cancer Case Studies
- rationale of management of tumour lysis syndrome
Chemotherapy causes massive release of breakdown products from tumour cells (lysis, not apoptosis)
- hyperkalaemia (arrhythmias), hyperuricaemia, hyperphosphataemia (if renal problems, difficult to excrete
- Urate may precipitate in distal renal tubule
Treatment
- Increase hydration (decrease concentrations)
- Prophylactic use of allopurinol (stop purine metabolism, give for 2 days prior to chemotherapy)
Additionally NaHCO3 capsules may be used
- Alkalinise urine to promote urate excretion (reduce crystallisation, but could increase metabolic alkalosis, increasing Ca2+, depositing in tissues)

- complications of chemotherapy-induced nausea and vomiting, treatment of acute and delayed N/V (how crucial is it to treat?)
Complications
Dehydration, electrolyte imbalances, GI tearing, aspiration pneumonia, impaired nutrition, inability to continue chemo

Acute
Prophylaxis
- 5-HT3 antagonists (e.g. tropisetron, ondansetron)
- Steroid (pre-med dexamethasone dosing)
Breakthrough
- Metoclopramide/domperidone, prochlorperazine, lorazepam

Delayed
Begins 1 or 2 days after chemo (high dose IV chemo) - may last several days (mechanism poorly understood)
- Aprepitant (oral neurokinin-1 receptor antagonist)
Australia: Indicated for prevention (with other agents) of acute and delayed N/V associated with highly emetogenic chemotherapy

- when to use protocol and prn use of G-CSF, common side effect and why we shouldn't use ibuprofen to treat
Granulocyte colony stimulating factors (G-CSF)
- Filgrastim, pegfilgrastim, lenograstim
- Stimulate production and differentiation of neutrophils from blood precursor cells

Protocol
use as protocol if the patient has a low white cell count and/or if chemotherapy is expected to lower the WCC.

prn use
use on a prn basis if patient has a high WCC or if chemotherapy is not expected to lower the WCC

Bone pain common adverse effect - use paracetamol prn, ibuprofen is not recommended as chemotherapy often leads to thrombocytopenia and NSAIDs can further reduce the ability to clot.

- why is mucositis important to prevent
- Painful, swallowing difficulties (hard to take supportive therapies for cancer treatment)
- increased risk of infection

Treatment goals
- Prevent local / systemic infection
- Pain relief
- Promote healing
- Quality of life / improve therapeutic outcomes

- prevention and treatment of mucositis
Prevention
- Good oral hygiene (reduce plaque accumulation)
- Salt water mouth rinse
- Chlorhexidine gluconate M/W (consider alcohol, teeth staining (formulation), coffee)
Prevent infection
- Nystatin oral suspension (increase supply, swallow)
- Amphotericin lozenges
- Soft bristled toothbrush
- PPI usage (e.g. pantoprazole, omeprazole, etc)

Treatment
Difficult to control mucositis once it develops
- Mouthwashes
- Cleanse mucosa (salt water M/W)
Provide pain relief
- Ice chips
Systemic or topical analgesics
- Anaethetics, anti-inflammatories (e.g. lignocaine, benzydamine, triamcinolone in orabase)
- Use before eating
- Consider anaesthetised mouth, absorption

- supportive therapy of cancer (identify possible interactions with chemotherapy)
- Metoclopramide 10mg po qid prn (N/V)
- Tropisetron 5mg daily (N/V)
- Norfloxacin 400mg po bd (ecreases bacterial load in the GI)
- Itraconazole Syrup 10mg/mL 200mg po bd (antifungal)
- Nystatin mouthwash 5mL po qid (antifungal)
- Famciclovir 500mg po bd (herpes prophylaxis)
- Pantoprazole 40mg po daily (stomach irritation prevention)
- Allopurinol 300mg po daily (prevention of Tumor Lysis Syndrome)

Itraconazole (3A4 inhibitor) can interact with vincristine (3A4 substrate), causing increased concentrations of vincristine leading to peripheral neuropathy.

- explain to the patient why supportive therapy is important with cancer treatment
Treatment goals
- Prevent local / systemic infection
- Pain relief
- Promote healing
- Quality of life / improve therapeutic outcomes
- Ability to take cancer treatment (prevent mucositis, nausea and vomiting)

Skin Cancer
- treatments for non-melanoma skin cancers and melanomas
NMSC
- surgical excision (would require plastic surgery - may not use on cancers of the face)
- local chemical destruction (5-fluorouracil, diclofenac - topical, acts as an acid)
Melanoma
- surgery (and staging)
- radiotherapy
- chemotherapy

- skin cancer risk factors
- fair skin
- family history
- red or blonde hair
- propensity to 'burn' rather than 'tan'
- cumulative UV exposure (squamous cell carcinoma)
- intermittent/binge UV exposure (basal cell carcinoma, cutaneous melanoma)
- immunosuppression (immune system involved in surveillance of damaged cells)
- genetic factors (xeroderma - inability to repair DNA, albinism etc)
- exposure to pollutants (cigarette smoke - squamous cell carcinoma of lip and mouth)

- strategies for preventing skin cancer
- protection from UV light (slip, slop, slap and wrap etc)
- melanin (melanotan - injection of melanin analogue)
- DNA repair (inject endonuclease - DNA repair enzyme)
- boost immunity (inject inactivated melanoma cells)
- chemoprevention

- chemoprevention of skin cancer
- NSAIDs
- celecoxib
- green tea extract
- fruit extracts
- retinoids
- statins
- flurbiprofen

- early detection of skin cancer
- crusty non-healing sore
- small lump (red, pale or pearly)
- new spot, freckle or mole
- change in thickness, colour or shape of existing spot

Urinary Incontinence
- explain the types of incontinence (urge, stress, overflow, functional), including cause, what receptors to target, pharmacotherapy


- what are some potentially reversible causes of incontinence (DIAPPERS)

D - Delirium (confusion)
I - Infection (UTI)
A - Atrophic vaginitis or urethritis (hormone treatment)
P - Pharmaceuticals
P - Psychological disorders
E - Endocrine disorders (diabetes insipidus, increased Ca2+/PTH)
R - Restricted mobility (arthritis)
S - Stool impaction (constipation)

- medications that may cause incontinence
- Diuretics
- Caffeine
Anticholinergics (if overflow problem)
- antihistamines, antipsychotics, antidepressants
- Sedatives/hypnotics (less likely to reach toilet - oversedation)
- Alcohol (diuretic and sedative)
- Narcotics
- α-adrenergic agonists/antagonists (depending on type of incontinence - use agonists in stress, antagonists in overflow)
- Lithium (polyuria)
- Verapamil (constipation)
- ACEi (may induce coughing)

Bioequivalence and Generic Medicines
-
explain what a generic medicine is
When a patent on a drug runs out (with usually 7-10yrs of exclusivity), then other drug companies may market the compound under certain circumstances. Without having to recuperate the costs associated with research, development and clinical trials, generics are sold at a much lower price than the market leader/innovator. However, bioequivalence studies must be conducted to show that the generic formulation has a similar time-concentration profile than the innovator formulation, to allow for safety when switching between brands.

- when and why conduct a bioequivalence study
Clinical trial versus market-image

Generic versus innovator
- both companies are required to do this

New method of manufacture
- change in formulations (compressed vs form-filled tablet)
- includes changes during the development process to improve stability and shelf life (to prove that improved formulation is similar to previous)

New supplier of raw material
- will need to conduct another study due to change in formulation
- particle size and crystal form differences (changes dissolution rate)

- how the rate of dissolution and changes in particle size can affect the need for a bioequivalence test
Dose --k dissolution--> Drug in solution --K absorption--> Absorbed drug
- if slow dissolution, changes in particle size would require a bioequivalence test

- what pharmacokinetic markers are important in a bioequivalence test
We are interested in Cmax and AUC (area under the curve), Tmax is highly variable and is not considered
- not based on a single profile, need to know variance in order to be confident that the two formulations are the same

- why conduct a balance two-way cross-over study? (some patients start with generic A and others start with generic B)
Not every subject should take drug A in period 1 then drug B in period 2, the order that they are given should be randomised
- this will reduce the effects of auto-induction of enzymes

- what is the amount of leeway allowed for mean ratio and 90% CI when judging whether two medications are bioequivalent, what do we do if the mean ratio or 90% CI is outside of this range
If the mean AUC ratio (product A to product B) is 1.05, it means that on average, the AUC value for product A is 5% greater than that for product B
- however, we need a 90% CI tell us how confident we are that the products are 'bioequivalent'
- the mean AUC ratio should be within 10% (90-110%), and the 90% CI needs to be between 80-125% in order to prove 'bioequivalence'

If the mean AUC ratio is outside 10%, increasing the number of subjects will not improve the outcome (not bioequivalent - need to reformulate)
- if the mean AUC ratio is within 10%, but the 90% CI is outside 80-125% (not bioequivalent), either increase the number of subjects or argue the position that Cmax is irrelevant etc.

- consequences of switching from one generic to another
- bioequivalence is measured between a generic and the market leader
- however, if generic 1 is 10% lower and generic 2 is 10% higher than the market leader, might be worried about switching from one generic to another
- although 20% difference should be ok

Medicines Scheduling in Australia
- what the NDPSC considers during decision making of scheduling medicines
- toxicity and safety: if high, keep out of supermarkets
- risks and benefits: access vs risk
- potential hazards: requires at least two years of local clinical use or local post-marketing experience before considering downscheduling
- extent and patterns of use: prn or ongoing
- dosage and formulation: different schedule in different sizes and formulations
- need for access (compared with similar substances): access vs risk
- potential for abuse: diversion (using drug to create illicit drug - pseudoephedrine)
- purposes for use: severity of the indication
- anything else necessary to protect public health
labelling, packaging and presentation of a substance: adding more information on the packaging can help downschedule a medicine

- process of downscheduling (how long must drug be on market etc)
Drug companies want downscheduling of their medications to increase access, leading more sales and profits.

The process of downscheduling normally requires at least two years of local clinical use or local post-marketing experience (pick up rare SEs that weren't noticed in trials). Otherwise evidence needs to be provided:
- Evidence from comparable overseas countries where the medicinal substance is available in non-prescription products (such as Canada, Sweden,
Netherlands, New Zealand, United States, United Kingdom and Europe generally); or
- Any available information from post-marketing surveillance (spontaneous and any post marketing surveillance studies, local or overseas); or
- Relevant previous Australian consideration of scheduling or experience of the medicinal substance (e.g. different route of administration).

Changes in pack sizes (smaller) or packaging (includes more information) can warrant a downscheduling.

- basic criteria for upscheduling (pharmacists not counselling appropriately, changes in consumer behaviours)
- if medications are misused or the pharmacists do not provide adequate information, medications can move back to S3 or S4.
- changes in consumer behaviours (diversion of pseudoephedrine to illicit drugs)

- which schedule is a new therapeutic substance put on
New therapeutic substances are placed in S4 as the safety and efficacy of which may require further evaluation.

Forensic Pharmacy – Legislative Overview, Privacy Principles
- section 33 authority: what are some exceptions, including prescribing without an authority at all
If prescriber authorised: "Section 33 authority"
recorded with the DDU
- dependent persons
- non-dependent persons receiving >2 months
- only one authorised prescriber per patient

exceptions to Section 33 authority

>70 year old
- except dextromoramide, hydromorphone or pethidine (due to SE profile, abuse potential)
life expectancy <12 months (Minister informed, each prescription endorsed "NPCP" - notified palliative care patient)
- except drugs mentioned above
inpatient of a hospital with existing Section 33 authority (must notify authorised prescriber)
- another prescriber authorised and only while in hospital
- may be being treated for drug dependence (dose restrictions)
inpatient of government hospital without authority (duration not >14 days)
prescriber works in same practice or is locum for authorised prescriber (and treatment with approval of that prescriber)


- how long can we legally supply someone with an S8 drug for? (what about if unknown patient or prescriber)
Schedule 8 drugs should only be supplied according to time period specified (maximum of one month at one time)
Patient or prescriber unknown
- ensure that prescription (or copy if repeat) is signed and dated by person collecting drugs
- must verify by contacting prescriber
- use photo ID to verify patient
- not > 2 days supply until verified

- some kind of situation involving disclosure of personal information, what is the decision process of knowing if it is ok to disclose