28 episodes

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.

Family Medicine & Pharmacy Podcast Billy Lin, MD and Tina Lien, BSc Pharm

    • Science

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.

    Onychomycosis

    Onychomycosis

    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)

    • 23 min
    Diabetes Medications and BC Coverage Information

    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.

    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

    • 21 min
    What I learned from St Paul’s CME 2014 Part 1

    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

    http://thischangedmypractice.com/

    OSA - Dr. Pearce Wilcox

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

     

    • 23 min
    Family Pharm Podcast – RELAUNCHED!

    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?

    • 3 min
    ADHD 2: medications

    ADHD 2: medications

    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)

     

    • 20 min
    ADHD 1: CADDRA Guideline

    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.

    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

     

    • 16 min

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