Dr. Billy Lin (family doctor and clinical instructor at UBC) and Ms. Tina Lien (community pharmacist) team up to bring you important topics in the practice of family medicine and community pharmacy. Review guidelines, medication information, and explore current evidence. Website: fppodcast.org.
Management of Onychomycosis in Canada in 2014 http://www.ncbi.nlm.nih.gov/pubmed/25775640
SA Approval period
Penlac (nail lacquer)
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
Jublia (nail lacquer)
Apply to affected toenails once daily for 48 weeks
Ingorwn nail (2%), dermatitis
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
1. Immunocompromised pts/ Or 2. Pulse treatment for severe onychomycosis with functional disability
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
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)
Diabetes Medications and BC Coverage Information
We are back! (Or your money back!)
In this episode, Billy and Tina discuss the PharmaCare coverage status of different classes of diabetes medications.
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
Other therapeutic considerations
Alpha-glucosidase inhibitor (acarbose)
Improved postprandial control, GI side-effects
Incretin agent: DPP-4 Inhibitors
same as onglyza
As part of a combination treatment for type 2 diabetes mellitus, 1) When insulin NPH is not an option
2) After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea.
Incretin agent: GLP-1 receptor agonists
rapid acting (Humalog, novorapid, apidra)
No dose ceiling, flexible regiments
short acting (Humulin R, Novolin Toronto)
Premixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50)
Premixed (Humalog mix 25, mix 50, Novomix 30)
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
2) Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management
3) Has experienced or continues to experience severe, systemic or local allergic reaction to existing insulin treatment.
same as Lantus
new glargine (Toujeo)
Insulin secretagogue: Meglitinide
Less hypoglycemia in context of missed meals but usually requires TID to QID dosing
Insulin secretagogue: Sulfonylurea
Gliclazide and glimepiride associated with less hypoglycemia than glyburide
SA (listed everywhere else in Canada)
Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses.
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
1 year manufacturer coverage with special plan
CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect
same as onglyza
Weight loss agent (orlistat)
GI side effects
sitagliptin and metformin (Janumet)
linagliptin and metformin (Jentadueto)
same as onglyza
What I learned from St Paul’s CME 2014 Part 1
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
OSA - Dr. Pearce Wilcox
Co-morbidities with metabolic syndrome -> screen for metabolic syndromes in patients with OSA, and vice versa
Family Pharm Podcast – RELAUNCHED!
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?
ADHD 2: medications
Tina concentrates on the details of ADHD medications and invites your attention to the following:
other antidepressants and antipsychotics (to be covered in future episodes)
ADHD 1: CADDRA Guideline
*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.
ADHD Checklist on CADDRA ADHD Assessment Toolkit, page 8.20
Customer ReviewsSee All
Wish there could be enough practical insight
Great effort, but if the topics could be more of a dialogue instead of just Tina reading off of a script, it would be more engaging.