Tadalafil, Cialis and Adcirca

Part of my daily routine is to unpack medicines that we ordered in, and one particular special order caught my eye.

This medicine cost around about $900 to order from the supplier. 

Initially I did not recognise the brand Adcirca, however the generic name of Tadalafil certainly rang a bell.

As you may have guessed, Tadalafil is the generic name for Cialis: a popular medication used for erectile disfunction. 

Although the active ingredient and tablet strength for both Cialis and Adcirca is the same, the indication for the tablets are completely different. 

Cialis is marketed for erectile disfunctions, while Adcirca is marketed for pulmonary hypertension. 

Pulmonary hypertension is a condition where there is a build up of pressure in the pulmonary circulation. A common cause for it is in left ventricular heart failure. This is because the heart is lacking the ability to pump blood efficiently causing a buildup of blood in the lungs. 

The mechanism of action for tadalafil in pulmonary hypertension is to relax the smooth muscle in the pulmonary vascular bed producing vasodilation and reduction in pulmonary vascular resistance. 

The dosage is twice daily which explains the large box of 56 tablets.

Another difference between Cialis and Adcirca is the price. 

Cialis is considered a recreational medication that is not essential to keep a person alive. This means that Cialis is not covered by the PBS scheme and thus patients need to pay for the full price. Cialis usually comes in a box of 4 tablets or 8 tablets (10mg, 20mg strength) and could cost between $80-$160. 

On the other hand, as Adcirca helps manage a patient's disease state, it is covered by the PBS scheme. This means that eligible patients to the PBS criteria only need to pay either $36.10 or $5.90 for this medication. I feel quite amazed considering that the patient gets 56 tablets (vs 8 tablets) for only a fraction of the price.

I wonder if the patients on Adcirca get the benefits of Cialis. It is the same active ingredient at the same strength. I hope side effects such as priapism would not be a side effect...

Adenine and Thymine

A-T, G-C. The building blocks of our DNA.

While watching Vsauce, I came across an A-T base pair necklace. I joked with my girlfriend "Hey, that pair matches our initials! It would be cute if we got a set."

Here I am a few weeks later, $90 short but with a pair of Adenine and Thymine necklaces. 

It may be nerdy, but I'm happy!

You should check it out:

http://store.madewithmolecules.com/product/dna-rna-base-pair-friendship-necklaces

Dealing with the unknown

From a customer's point of view, I am expected to have knowledge of the products I sell. The unfortunate truth is that there are things I do not know or have just forgot. Ever since working in the pharmacy as a student, I have been challenged to counsel patients on products that I am unfamiliar with.

After years of practice, I have developed a set of techniques to wing my way through a counseling session without looking unprofessional.

1) Buy yourself some time:

For example,

Me: Good morning Madame, here is your medication. Have you used this product before?

Patient: nope.

Me: Okay! Well let me get you a print out.

(Now quickly leave the patient and go behind the counter to print out a consumer medicine information leaflet)

Once you have bought yourself some time, 

2) download as much information into your brain while the leaflet is being printed.

Quickly consult your usual resources such as the CMI, AMH, eMIMS etc to get the vital information.

Info such as:

what the medicine is 

What it is used for

How it works (not crucial)

How to take the medicine.

What to look out for on the medicine

Side effects

3) regurgitate the information to the patient, without looking like you are regurgitating

For example:

Me: thank you for waiting Madame.

So I've got your information leaflet right here. 

So, this mediation is commonly used for ( insert indication)

Is this what you are using it for?

Ok good, so has the doctor told you how to take the medicine?

Yep, that is correct, he instructs you to (read the label)

As all medicines have side effects, with this medicine you may need to watch out for (read 1-2 common side effects)

As this is your first time taking this medicine, I would like you to watch out for ( insert symptoms to watch out for or other crucial information)

Do you have a follow up appointment with the doctor?

That's good! I hope the medicine works well for you!

If you have any problems, do not hesitate to give us a call or come back. We are more than happy to help you!

Have a nice day!

-----------------------------------

Each unfamiliar product I counseled has been a learning opportunity. 

Now that I'm 7 months into my internship, I'm happy to say I at least know a bit about most products I see each day. 

I still come across products I've never heard of before, but hey, I've got a long way to go!

Our professional boundaries

One of my Webster pack patients has been ill. Her daughter tells us that she is constantly nauseous, and on occasion will vomit back up a dose of medications once she takes them.

This can be a problem as she misses out on her daily dose, so the daughter is asking us to give them extra tablets. This way when she vomits, the daughter will have spare tablets to give her accordingly.

Our pharmacy decided to supply her with a whole weeks worth of medications packed into a Webster pack. Later on, we received a call from the doctor's surgery. The nurse had found out on what we did for the patient, and was upset with our actions.

She said that we have no way of knowing how much the drug was absorbed when the patient vomits them up, thus it is dangerous to give the patient extra medicine to take. For all we know, they could be double dosing. She said we over stepped our boundary as a pharmacist and made a therapeutic decision without contacting the doctor. 

Reflecting on this case, this has been a learning experience for me. Firstly it taught me to be aware of the professional boundaries as a pharmacist. I have become more cautious when giving advice /making decisions ever since. 

Secondly, I do not agree with what the nurse said. As a pharmacist if it is impossible for us to know how much a drug was absorbed, how on earth would the doctor be able to know? As for Webster packing services, we keep patients medications to put them into packs. This is not a staged supply of medicines. We are not locking away the patients medicines, but more or less keeping them in the pharmacy for our convenience. The patient has every right to ask for their own medicine. If the tablets were at home with the daughter, she would have given them to the mother without letting us know. 

Indeed it is hard to judge how much the drug has been absorbed, but we had no reason not to give her extra tablets. 

As I said before, what I've learnt from this case is not that we did the wrong thing, but to be more considerate of the doctor's role. If I come across a similar situation, I would give the doctor a call ask for their opinion. I bet they would have made the same decision too.

********

Recently, this patient has passed away. I hope she is in a better place and is no longer suffering. Thank you very much for the learning experience.

Complications with our PBS system

Australia's Pharmaceutical Benefits Scheme (PBS) is a wonderful system where the government pays for the cost of medicines for the its people. All Australians who own a medicare card are entitled to the PBS scheme, and essentially patients do not need to pay more than $36.10 for medications no matter if the medicine's actual price costs hundreds or thousands of dollars. Concession patients pay up to a maximum of $5.90 per item, and the rest is paid by our government. 

Although there are people who complain they pay a lot for their medicines, I suspect they do not know the actual savings they are making with this generous subsidy from PBS scheme. 

An additional feature of the PBS system is called the Safety Net. The safety net ensures further subsidy to patients who spend more than a certain amount on medicines in a calendar year. For general patients, the safety net amount is $1,390.xx. Once they have spent more than that amount, the pharmacy will issue them a Concession safety net card which entitles them to have scripts that cost no more than $5.90 for the rest of the year. For concession patients whom pay $5.90 for scripts, once they reach 60 scripts in a year, the pharmacy issues an Entitlement safety net card. This allows them to receive any additional medications for FREE* for the rest of the year.

*Additional out-of-pocket charges may apply to certain medications, but anywhoo.

It is part of a pharmacist's daily job to dispense medications and issue out safety net cards to those who have reached the requirements. For customers who stick with one particular store, life for the pharmacist would be quite easy. The dispensing software would prompt the pharmacist to issue a card, and then it would print out a list of all the medicines that the patient paid for within the calendar year. We would then get the patient to sign the print out, take out a safety net card with a specific code, register it with the associated paper work (by writing the card number onto the print out) and then issuing the card to the patient. 

Once the pharmacist has collected 12 or more of these paper works, he/she then sends of the paperwork to medicare to officially activate the issued safety net cards.

To make life more complicated for a pharmacist, patients are not legally bound to go to only one pharmacy. As pharmacies do not share dispensing information with each other, it makes it difficult for the system to keep track of when the patient reaches safety net. To over come this problem, medicare has safety net record forms available for patients. This record form is a sticker collector that allows pharmacists to stick specific stickers onto the form as physical evidence of the purchase of medication. This allows patients to go from pharmacy to pharmacy and still reach safety net without missing out on their entitlement. 

Curse you Record Form! As fun as a sticker board sounds, after 6 - 7 months of collecting stickers, it becomes a messy, dirty, floppy board of peeling stickers that we need to sort through to ensure the patient checks out. The night mare begins when the pharmacist has to add up 74 slimy stickers worth of medicines to make sure the total adds up to $1390!!  

I am positive that in our current day and age, we are way past using hard copies to operate the safety net system. We lack a overlaying system that would unify all pharmacy dispensing data. With current cloud technology, I believe this is certainly possible to achieve, however impossible to implement. If the government is having trouble implementing a unified system for doctors, I doubt the safey net would see any differences in the near future.

Sigh... back to counting stickers

45, 46, 47 .... what number was I up to again? Darn it!

 

Why you should not sell drugs.

 This is the story I heard from my friend's colleague. From this information, I cannot ensure how credible it is, but the message it sends is valid none the less.

The is the story of a pharmacist who decided to steal Fentanyl patches from the store she worked at and sold them illegally to customers without prescriptions. For those who don't know, fentanyl is an opioid analgesic, and like all opioid medicines have an addictive potential. Patients who become dependent on opioids will experience withdraw symptoms when they don't have the drug in their system, and on occasion exhibit drug seeking behavior to get hold of the medication. As of such, the government schedules these medicines as Controlled Drugs (S8 medicines), and require them to be locked up in a safe when stored in a pharmacy. The regulations to how these medicines can be obtained is a lot stricter compared to regular medicines.  Combining the strict regulations to obtain the medicine legally and the nature of this medicine, it is plain to see that there is a market for selling this medicine illegally. 

In order to make some extra money on the side, the pharmacist was selling the medication illegally to patients without a prescription. Unfortunately, the person she sold a fentanyl patch to had passed away from drug over dose. I have not heard what happened to the pharmacist, but I am sure she is in a lot of trouble. 

Putting obvious legal and ethical reasons aside to why we shouldn't break the law and sell controlled medicines illicitly. Selling S8 medicines would have its economical perks. Compared to the official dispensing price of $5.90 for 25 temazepam tablets, I have heard that on the street can go up to hundreds of dollars per tablet. Surely if these tablets are this lucrative, us pharmacists must be selling the product wrongly if we only charge patients $5.90 a box!

It is understandable why this pharmacist took the risk of selling the patches. But judging from the outcome, it does not seem worth the risk. How much money would she have made from selling fentanyl patches? $100 a patch? $200 a patch? Selling 10 of them would get you $2000 dollars. I do not think she would have made more than $15,000 on the side, however she has ended up killing a patient. 

From what I feel, she would now have her license revoked, and possible face a jail sentence. Was this all worth the $15,000?

I don't know how she feels at the moment, but I feel my freedom is worth more than just $15,000.

Difference between a PS Vita and an iPhone

I'm considering to buy a PS Vita. However while looking at the console in the shop it occurred to me that when it comes to gaming, there is a subtle difference between playing with a game on your phone versus a game on your console.

During lunch breaks, I would feel more comfortable to play a game on my phone rather than on a gaming console. Something is telling me that the console would make me look more "into" gaming and thus a more intense gamer?

Call me old-fashioned but I don't think it is appropriate to bring your "Gameboy" to work. Something just doesn't feel right for me to play a PS Vita at work. However, games on the phone do not seem to trigger this feeling. Smart phones are now such a common item that for a grown-up to kill some time on his phone with "Cut the Rope" would not be an uncommon sight.

Ok.... I guess I'll hold off from buying one for now... back to Plants vs Zombies 2

My first post

After graduating university for 7 months, I'm finally getting used to the routine of working as an intern pharmacist.

Every day I would travel to work, clock on and begin my daily ritual.

I would unpack the order, dispense medications, counsell the patients, refill the CONSIS (dispensing robot) and alongside other miscellaneous tasks.

After doing this routine for 7 months, I did not think I have learnt anything new since graduating. However it wasn't until our pharmacy took in a 4th year pharmacy placement student did I realise that how far I've come since I was in her place one year ago.

I would like to use this blog as a place for me to share what I learn, and as a reminder for me to see how far I would go!