Family Pharm Podcast - priority topics for family medicine and community pharmacy

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Family Pharm Podcast priority topics for family medicine and community pharmacy

Onychomycosis January 30, 2016Episodeciclopirox, fluconazole, fungus, infection, itraconazole, jublia, nail, onychomycosis, terbinafinebilly

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

Drug name:Brand:SASA CriteriaSA Approval periodDirectionSEMonitoringCiclopirox 8%Penlac (nail lacquer)NoNot coveredN/ANail lacquer: Apply bid to adjacent skin and affected nails daily. Remove with alcohol every 7 days (treat 4 weeks)dermatitis, dry skin, local burning sensationEfinaconazoleJublia (nail lacquer)Not coveredNot coveredN/AApply to affected toenails once daily for 48 weeksIngorwn nail (2%), dermatitisTerbinafine tabletsLamisil tabletsYesSevere 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 weeksItraconazoleSporanoxYes1. 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 courseDiarrhea, nausea, headache, skin rashLiver function in patients with pre-existing hepatic dysfunction, and in all patients being treated for longer than 1 monthfluconazoleDiflucanYes1. 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 January 23, 2016Uncategorizedbilly

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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 doesnt work: pt-formulary-listing-jan-18-2016

ClassdrugsOther therapeutic considerationscoverageSA criteriaBiguanidemetformincoveredAlpha-glucosidase inhibitor (acarbose)acarboseImproved postprandial control, GI side-effectsdelistedIncretin agent: DPP-4 Inhibitorslinagliptin (Trajenta)SAsame as onglyzasitagliptin (Januvia)delistedsaxagliptin (Onglyza)SAAs 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 agonistsliraglutide (Victoza)GI side-effectsnot listedInsulinrapid acting (Humalog, novorapid, apidra)No dose ceiling, flexible regimentspartial coverageshort acting (Humulin R, Novolin Toronto)coveredNPHcoveredPremixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50)coveredPremixed (Humalog mix 25, mix 50, Novomix 30)partial coverageglargine (Lantus)SAA) 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)SAsame as Lantusnew glargine (Toujeo)not listedInsulin secretagogue: Meglitiniderepaglinide (gluconorm)Less hypoglycemia in context of missed meals but usually requires TID to QID dosingnot listedInsulin secretagogue: SulfonylureaglyburideGliclazide and glimepiride associated with less hypoglycemia than glyburidecoveredgliclazideSA (listed everywhere else in Canada)Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses.SGLT2 inhibitorscanagliflozin (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 plandapagliflozin (Forxiga)1 year manufacturer coverage with special planempagliflozin (Jardiance)not listedTZDrosiglitazoneCHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effectdelistedpioglitazoneSAsame as onglyzaWeight loss agent (orlistat)orlistatGI side effectsnot listedCombination Drugssitagliptin and metformin (Janumet)delistedlinagliptin and metformin (Jentadueto)SAsame as onglyza

What I learned from St Pauls CME 2014 Part 1 November 18, 2014St Paul CMEbilly

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This is planned to be an 8-part series highlighting the take-home points I picked up during the St. Pauls 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 someones 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 QIDPurulent 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

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