Management of Onychomycosis in Canada in 2014 http://www.ncbi.nlm.nih.gov/pubmed/25775640

Drug name:

Brand:

SA

SA Criteria

SA Approval period

Direction

SE

Monitoring

Ciclopirox 8%

Penlac (nail lacquer)

No

Not covered

N/A

Nail lacquer: Apply bid to adjacent skin and affected nails daily. Remove with alcohol every 7 days (treat 4 weeks)

dermatitis, dry skin, local burning sensation

Efinaconazole

Jublia (nail lacquer)

Not covered

Not covered

N/A

Apply to affected toenails once daily for 48 weeks

Ingorwn nail (2%), dermatitis

Terbinafine tablets

Lamisil tablets

Yes

Severe onychomycosis

PLUS

functional disability

PLUS

positive KOH or dermatophyte culture of nail from a licensed lab.

First approval: Three months

Renewals: If required, up to three months.

250mg once daily for 6 weeks (fingernail); 250mg once daily for 12 weeks (toenails)

Headache (13%), diarrhea (6%), nausea, liver enzyme disorder (3%)

Monitor AST/ALT prior to initiation, repeat if used >6 weeks

Itraconazole

Sporanox

Yes

1. Immunocompromised pts/ Or 2. Pulse treatment for severe onychomycosis with functional disability

PLUS

confirmed lab results for candida or dermatophyte infection.

1. Immunocompromised pts approval is indefinite 2. 3 months approval for 2nd group of pts (No need for SA approval if prescribed by HIV/AIDS Dr)

Fingernail involvement: 200mg capsule twice daily for 1 week. repeat 1 week course after 3 week off time Toenails due to Trichophyton rubrum or T mentagrophytes: 200mg once daily for 12 consecutive weeks With or without fingernaikl involvement: 200mg once daily for 12 consecutive weeks Canadian labelling "Pulse dosing": 200mg twice daily for 1 week, then repeat 1 week course twice with 3 week off time between each course

Diarrhea, nausea, headache, skin rash

Liver function in patients with pre-existing hepatic dysfunction, and in all patients being treated for longer than 1 month

fluconazole

Diflucan

Yes

1. Immunocompromised patients.

OR2. Exceptions on an individual basis for fungal infections resistant to first-line medications.

1 day to indefinite (no need for HIV and AIDS Dr to apply for SA)

We are back! (Or your money back!)

In this episode, Billy and Tina discuss the PharmaCare coverage status of different classes of diabetes medications.

Sources:

BC PharmaCare Formulary: https://pcbl.hlth.gov.bc.ca/pharmacare/benefitslookup/

BC PharmaCare Special Authority: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority

CDA Formulary Listings for Diabetes Medications in Canada by provinces and territories (Jan 2016): http://www.diabetes.ca/getmedia/c87009a8-29b6-4061-a52a-963d0b077e47/pt-formulary-listing-jan-18-2016.pdf.aspx

*In case the link doesn't work: pt-formulary-listing-jan-18-2016

Class

drugs

Other therapeutic considerations

coverage

SA criteria

Biguanide

metformin

covered

Alpha-glucosidase inhibitor (acarbose)

acarbose

Improved postprandial control, GI side-effects

delisted

Incretin agent: DPP-4 Inhibitors

linagliptin (Trajenta)

SA

same as onglyza

sitagliptin (Januvia)

delisted

saxagliptin (Onglyza)

SA

As part of a combination treatment for type 2 diabetes mellitus, 1) When insulin NPH is not an option

AND

2) After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea.

Incretin agent: GLP-1 receptor agonists

liraglutide (Victoza)

GI side-effects

not listed

Insulin

rapid acting (Humalog, novorapid, apidra)

No dose ceiling, flexible regiments

partial coverage

short acting (Humulin R, Novolin Toronto)

covered

NPH

covered

Premixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50)

covered

Premixed (Humalog mix 25, mix 50, Novomix 30)

partial coverage

glargine (Lantus)

SA

A) Type 1 DM or B) Type 2 DM > 17 years old, and 1) requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing

AND

2) Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management

OR

3) Has experienced or continues to experience severe, systemic or local allergic reaction to existing insulin treatment.

detemir (Levemir)

SA

same as Lantus

new glargine (Toujeo)

not listed

Insulin secretagogue: Meglitinide

repaglinide (gluconorm)

Less hypoglycemia in context of missed meals but usually requires TID to QID dosing

not listed

Insulin secretagogue: Sulfonylurea

glyburide

Gliclazide and glimepiride associated with less hypoglycemia than glyburide

covered

gliclazide

SA (listed everywhere else in Canada)

Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses.

SGLT2 inhibitors

canagliflozin (Invokana)

UTI, genital infections, hypotension, hyperlipidemia, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia)

1 year manufacturer coverage with special plan

dapagliflozin (Forxiga)

1 year manufacturer coverage with special plan

empagliflozin (Jardiance)

not listed

TZD

rosiglitazone

CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect

delisted

pioglitazone

SA

same as onglyza

Weight loss agent (orlistat)

orlistat

GI side effects

not listed

Combination Drugs

sitagliptin and metformin (Janumet)

delisted

linagliptin and metformin (Jentadueto)

SA

same as onglyza

This is planned to be an 8-part series highlighting the take-home points I picked up during the St. Paul's Hospital CME Conference 2014.

Pearls from Part 1 "Internal Medicine":

Alcoholism - Dr. Paul Farnan

Screen alcohol use disorders routinely to catch those of whom do not appear to have a significant social or occupational impairment.

Use assertive statements to convey the concern regarding someone's alcohol use.

Peer support is strongly recommended. Patients should try multiple meetings at different groups before concluding that they are not helpful, as the groups vary in their structure and member characteristics.

Medical treatments may be considered in select patients: naltrexone, acamprosate, disulfiram.

Gout - Dr. Hyon Choi

Screen for HLA-B*5801 in Asians (esp. Chinese, Thai, and Korean patients) before starting alopurinol.

Look for concurrent metabolic disorders.

"Medication in the pocket" strategy for acute flares: colchicine 1.2mg po x1 then 0.6mg po in 1 hour.

Use losartan or CCB for concurrent hypertension.

Low-carb diet and avoid foods with highest purine content.

Cellulitis - Dr. Val Montessori

Non-purulent cellulitis, most likely caused by Group A Strep, treat with cephalexin (Keflex) 500mg po QID

Purulent cellulitis, most likely Staph Aureus but still possibly GAS, treat with Septra DS PO BID, and cover GAS with Keflex.

Complicated wounds, consult ID.

HCV - Dr. Edward Tam

New therapy more tolerable and has a 95% cure rate, but also exceedingly expensive.

Refer all HCV RNA positive patients to hepatologists for assessment of treatment.

This Changed My Practice - Dr. Steve Wong

http://thischangedmypractice.com/

OSA - Dr. Pearce Wilcox

Co-morbidities with metabolic syndrome -> screen for metabolic syndromes in patients with OSA, and vice versa

After a 6-month hiatus, Tina - now a newly-hatched PHARMACIST! - and Billy teamed up to relaunch this pet project with a plan to make it more interactive and less sleep-inducing. Did it work with this unscripted episode?

Tina concentrates on the details of ADHD medications and invites your attention to the following:

Non-pharmacological therapy

behavioural therapy

Stimulants

methylphenidate

amphetamines

Non-stimulants

atomoxetine

clonidine

other antidepressants and antipsychotics (to be covered in future episodes)

*This episode was recorded in January 2014.

This is the topic that started it all. As Tina planned to study ADHD for school, we discussed how this would be useful information for other pharmacy students and medical trainees as well.

We looked to the comprehensive CADDRA guideline for the assessment, differential diagnoses, and treatment strategies for ADHD.

CADDRA Guideline:

http://www.caddra.ca/pdfs/caddraGuidelines2011Chapter02.pdf

ADHD Checklist on CADDRA ADHD Assessment Toolkit, page 8.20

http://www.caddra.ca/pdfs/caddraGuidelines2011_Toolkit.pdf

Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis: 

UK NICE Guideline: Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84

CPS Guideline: Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy

History:

onset of diarrhea and/or vomiting (gastro is sudden in onset)

duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days)

sick contact

pathogen exposure

travel history

History suggestive of increased risk of dehydration:

young age (esp <6mo)

low birth weight infants

>5 diarrhea in 24h

>2 vomiting in 24h

no oral intake

signs of malnutrition

Think about differential diagnosis if:

fever >38 in children younger than 3 months

fever >39 in children older than 3 months (fever workup required)

shortness of breath or tachypnoea

altered conscious state

neck stiffness

bulging fontanelle in infants

non-blanching rash

blood and/or mucus in stool

bilious (green) vomit

severe or localised abdominal pain

abdominal distension or rebound tenderness.

 

SSx of dehydration and shock

Table 1 in NICE

Increasing severity of dehydration

No clinically detectable dehydration

Clinical dehydration

Clinical shock

Symptoms (remote and face-to-face assessments)

Appears well

Red flag Appears to be unwell or deteriorating

–

Alert and responsive

Red flag Altered responsiveness (for example, irritable, lethargic)

Decreased level of consciousness

Normal urine output

Decreased urine output

–

Skin colour unchanged

Skin colour unchanged

Pale or mottled skin

Warm extremities

Warm extremities

Cold extremities

Signs (face-to-face assessments)

Eyes not sunken

Red flag Sunken eyes

–

Moist mucous membranes (except after a drink)

Dry mucous membranes (except for 'mouth breather')

–

Normal heart rate

Red flag Tachycardia

Tachycardia

Normal breathing pattern

Red flag Tachypnoea

Tachypnoea

Normal peripheral pulses

Normal peripheral pulses

Weak peripheral pulses

Normal capillary refill time

Normal capillary refill time

Prolonged capillary refill time

Normal skin turgor

Red flag Reduced skin turgor

–

Normal blood pressure

Normal blood pressure

Hypotension (decompensated shock)

Table 2 in CPS

TABLE 2

Clinical assessment of degree of dehydration *

Mild (under 5%)

Moderate (5-10%)

Severe (over 10%)

Slightly decreased urine output

Slightly increased thirst

Slightly dry mucous membrane

Slightly elevated heart rate

Decreased urine output

Moderately increased thirst

Dry mucous membrane

Elevated heart rate

Decreased skin turgor

Sunken eyes

Sunken anterior fontanelle

Markedly decreased or absent urine output

Greatly increased thirst

Very dry mucous membrane

Greatly elevated heart rate

Decreased skin turgor

Very sunken eyes

Very sunken anterior fontanelles

Lethargy

Cold extremities

Hypotension

Coma

*Some of these signs may not be present

 

SSx of hypernatremic dehydration:

jittery

increased muscle tone

hyperreflexia

convulsions

drowsiness or coma

Labs:

No routine blood work

Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia

Blood gas if shock suspected

Stool culture if:

blood and/or mucus in stool

immunocompromized

septicemia suspected

travel history

diarrhea not improved by day 7

uncertainty about diagnosis of gastroenteritis

AAP Guideline on Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

http://pediatrics.aappublications.org/content/128/3/595.long

UK NICE guideline: Urinary tract infection in children

http://guidance.nice.org.uk/cg54

Summary:

For children with fever, UTI should be suspected.

For children at a very low risk for UTI, or greater than 3 years of age, a bag urine for urinalysis is an appropriate first step. If the urinalysis is suspicious for UTI, such as being positive for leukocyte esterase or nitrite, or if the children is not at a very low risk for UTI, then a catheterized urine sample should be obtained for urine culture prior to starting empiric antibiotics.

If the culture comes back negative, then antibiotics treatment covering UTI can be stopped.

Febrile UTI is presumed to be pyelonephritis, and should be investigated with Bladder and Renal Ultrasound. If the ultrasound shows structural abnormalities, or if the child has recurrent febrile UTIs, a VCUG should be considered, especially in younger children.

The bulk of this episode is based on the UK NICE guideline: Feverish illness in children under 5, published in 2013. http://guidance.nice.org.uk/CG160

The guideline covers:

Thermometers and the detection of fever

Clinical assessment of the child with fever (using the traffic light system)

Management by remote assessment

Management by the non-paediatric practitioner

Management by the paediatric specialist (investigations summarized below)

Antipyretic interventions

The Traffic Light System in assessing risk for serious infection

This assessment tool takes into consideration color/appearance, activity, respiratory, circulation and hydration, and "other" parameters. For each parameter, their associated signs and symptoms are assigned a color code: "green" (low risk), "amber" (intermediate risk) and "red" (high risk). The table can be found here.

Age-appropriate investigations for pediatric fever

Once the risk for serious infection is determined, the following investigation should be performed:

Age

CBC diff

BC

CRP

UA/UC

LP

CXR

Stool culture

<1mo

yes

yes

yes

yes

yes

if indicated

if indicated

1-3mo

yes

yes

yes

yes

if unwell, or WBC >15 or <5M/mL

if indicated

if indicated

>=3mo, RED

yes

yes

yes

yes

yes

yes

if indicated

>=3mo, AMBER

yes

yes

yes

yes

if <1yr

if fever >39 and WBC >20

if indicated

>=3mo, GREEN

no

no

no

yes

no

no

if indicated

And at the same time, empiric parenteral antibiotic coverage for meningitis (3rd generation cephalosporin plus ampicillin/amoxicillin) should be started if LP is indicated.

Antiplatelets:

ASA

Clopidogrel

Anticoagulants:

Warfarin

Apixaban

Dabigatran

Rivaroxaban

Clotting Cascade:

Clotting Factor Song, by Emily Anne Nagler:

http://www.youtube.com/watch?v=TG9yPHH3FmY

Twelve, eleven, nine, it’s clotting factor time

8 and 9 to 10a 5, that’s how we stay alive

Don’t forget to say: the tissue factor way

7 to 7a helps 10 go to 10a

Then 2 to thrombin, and 1 to fibrin

And that’s how it ends