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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5334_Библиотеки_им_академика_М_И_Перельмана
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over taking multiple medications, and other factors. Frequently, patients
forget whether they have taken their medications. Special compliance aids
are available to assist patients in their proper scheduling of medications.
These devices include medication calendars, reminder charts, special
containers, and smartphone apps.
Patient nonadherence is not entirely the problem of ambulatory or
noninstitutionalized patients. Patients in hospitals, nursing homes, and
other inpatient settings are generally more compliant because of the efforts
of health care personnel who are assigned the responsibility of issuing and
administering medication on a prescribed schedule. Even in these settings,
however, a scheduled dose of medication may be omitted or administered
incorrectly or in an untimely fashion because of human error or oversight.
The consequences of patient nonadherence may include worsening of
the condition, the requirement of additional and perhaps more expensive
and extensive treatment methods or surgical procedures, otherwise
unnecessary hospitalization, and increased total health care cost. Students
interested in additional information on medication adherence are referred
to other sources of information.8–
10
Medication nonadherence has been measured in a number of ways,
including by biological sample (i.e., determining medication blood levels),
patient surveys, monitoring the on-time refilling of prescriptions,
examining prescription drug claim (insurance) data, and by other means.
Consider the following illustrations.
If the prescription was filled initially on April 15, on about what date
should the patient return to have the prescription refilled?
Answer: 90 tablets, taken 1 per day, should last 90 days, or
approximately 3 months, and the patient should return to the pharmacy on
or shortly before July 15 of the same year.
How many milliliters of medicine should be dispensed?
Answer: 5 mL/dose × 4 doses/day = 20 mL/day × 10 days = 200 mL
A pharmacist may calculate a patient’s percent compliance rate as
follows:
What is the percent compliance rate if a patient received a 30-day supply
of medicine and returned in 45 days for a refill?
In determining the patient’s actual (rather than apparent) compliance rate,
it is important to determine if the patient had available and used extra
days’ dosage from some previous filling of the prescription.
Medication disposal is an important consideration for safety and
environmental concerns. Medications that are no longer used or are out of
date may be disposed of by the following methods: (a) “take back”
programs for disposal by pharmacies; (b) mixing medications with kitty
litter, coffee grounds, or other such materials and disposing along with
household trash; and (c) flushing medications down the drain for specific
drugs as approved by the FDA.
11
CASE IN POINT 4.2
A 72-year-old male who is diabetic is admitted to the emergency room
with shortness of breath and general weakness. Tests reveal anemia,
hypotension, atrial fibrillation, and coronary artery blockage. During 2
weeks of hospitalization, the patient receives intravenous infusions, oral
medications, and blood transfusions; four cardiovascular stents are
inserted; and the patient is discharged with the following prescriptions:
Clopidogrel bisulfate (PLAVIX) tablets, 75 mg, 1 tab q.d.
Pioglitazone hydrochloride (ACTOS) tablets, 15 mg, 1 tab q.d.
Pantoprazole sodium (PROTONIX) tablets, 40 mg, 1 tab b.i.d.
Simvastatin (ZOCOR) tablets 40 mg, 1 tab q.d. h.s.
HUMULIN 70/30, inject 35 units q.d. am and 45 units q.d. pm
Carvedilol (COREG) tablets, 3.125 mg 1 tab b.i.d. × 2 wk; then 6.25
mg 1 tab b.i.d.
Amiodarone hydrochloride tablets, 200 mg, 2 tabs b.i.d. × 7 d; then 1
tab b.i.d. × 7 d; then 1 tab q.d.
Duloxetine hydrochloride (CYMBALTA) capsules, 30 mg, 1 cap q.d.
× 7 d; then 1 cap b.i.d.
a. How many total tablets and capsules would the patient initially be
taking daily?
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1.
2.
b. If HUMULIN contains 100 units per milliliter, how many
milliliters would be administered each morning and each
evening?
c. How many amiodarone hydrochloride tablets would constitute a
30-day supply?
d. If 60 CYMBALTA capsules were initially dispensed and the
patient requested a refill after 17 days, is medication
nonadherence and thus the patient’s well-being a reasonable
concern? Show calculations.
PRACTICE PROBLEMS
Authors’ Note: some abbreviations used in these practice problems may
appear only infrequently in practice and are included here for
instructional purposes.
Interpret each of the following Subscriptions (directions to the
pharmacist) taken from prescriptions:
a. Disp. supp. rect. no. xii
b. Disp. 30 tabs.
c. M. div. in pulv. no. xl
d. DTD vi. Non rep.
e. M. ft. ung. Disp. 10 g
f. M. ft. caps. DTD 48
g. M. ft. susp. 1 g/tbsp. Disp. 60 mL
h. Ft. cap. #1. DTD no. xxxvi N.R.
i. Water q.s. 50 mL
j. M. ft. IV inj.
k. Label: hydrocortisone, 20 mg tabs
Interpret each of the following Signas (directions to the patient)
taken from prescriptions:
a. ii gtt. each eye q4h p.r.n. pain.
b. 1 tbsp. p.o. q6h
c. Apply am & pm p.r.n. itching
d. 4 gtts a.d. m. & n.
e. 1–2 tabs p.o. q4–6h u.d.
f. Appl. ung. left eye ad lib.
g. Caps i c aq. h.s. N.R.
3.
4.
h. Gtt. v each ear 3 × d. s.o.s.
i. Tab. i sublingually, rep. p.r.n.
j. Instill gtt. ii o.u. of neonate
k. 1 cap p.o. h.s. p.r.n. sleep
l. Cap. ii 1 h prior to departure, then cap. i after 12 h
m. i tab p.r.n. SOB
n. 1 tab qAM HBP
o. Tab ii q6h ATC UTI
p. ʒii 4 × d p.c. & h.s.
q. ℥ss a.c. t.i.d.
r. Add crushed tablet to pet’s food s.i.d.
Interpret each of the following taken from medication orders:
a. AMBIEN 10 mg p.o. q.h.s. × 5 d
b. 1000 mL D5W q8h IV c 20 mEq KC1 to every 3rd container
c. Admin. prochlorperazine 10 mg IM q3h p.r.n. N&V
d. Minocycline HCl susp. 1 tsp p.o. q.i.d. DC after 5 d
e. Mesalamine 1.2 g p.o. q.d. c food
f. NPH U-100 insulin 40 units subQ every day am
g. Cefazolin sodium 1 g IM 30 min prior to procedure
h. Potassium chloride 15 mEq p.o. b.i.d. p.c.
i. Vincristine sulfate 1 mg/m2 pt. BSA
j. Flurazepam 30 mg at HS prn sleep
k. D5W + 20 mEq KCl/L at 84 mL/h
l. 2.5 g/kg/day amino acids TPN
m. Epoetin alfa (PROCRIT) stat. 150 units/kg subQ. 3 × wk × 3–
4 wk
n. MTX 2.5 mg tab t.i.d. 1 ×/wk
o. HCTZ tabs 12.5 mg q.d. am
(a) If a 10-mL vial of insulin contains 100 units of insulin per
milliliter, and a patient is to administer 20 units daily, how many
days will the product last the patient?
(b) If the patient returned to the pharmacy in exactly 7 weeks for
another vial of insulin, was the patient compliant as indicated by the
percent compliance rate?
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5.
6.
7.
8.
9.
10.
11.
A prescription is to be taken as follows: 1 tablet q.i.d. the first day; 1
tablet t.i.d. the second day; 1 tablet b.i.d. × 5 d; and 1 tablet q.d.
thereafter. How many tablets should be dispensed to equal a 30-day
supply?
In preparing the prescription in Figure 4.3, the pharmacist calculated
and labeled the directions as “Take 1 teaspoonful by mouth every 12
hours.” Is this correct or in error?
Refer to Figure 4.1 and identify any errors or omissions in the
following prescription label:
Refer to Figure 4.4A and identify any errors or omissions in the
following prescription label:
Refer to Figure 4.5 and identify any errors or omissions in the
following prescription label:
Refer to Figure 4.2 and identify any errors or omissions in a
transcribed order for the first three drugs in the medication order:
a. Propranolol, 40 mg orally every day
b. Flutamide, 20 mg orally every morning
c. Flurazepam, 30 mg at bedtime as needed for sleep
Refer to Figure 4.6 and identify any errors in the following
prescription label:
12.
13.
14.
15.
16.
In a clinical study of drug–drug interactions, the following drugs
were coadministered:
Ritonavir: 600 mg b.i.d. p.o. × 7 d
Theophylline: 3 mg/kg q8h × 7 d
Translate the directions.
Translate “10 mIU/mL.”
The package insert for interferon alpha-2b states the dose based on
body surface area (BSA) for the treatment of Kaposi’s sarcoma as
30 MIU/m2/dose TIW administered IM or SC for up to 16 weeks.
Translate the directions.
Interpret the following from the literature: “lopinavir/ritonavir 500
mg/125 mg b.i.d. + efavirenz 600 mg q.d.”
Using the information in Figure 4.5, calculate (a) the number of
milligrams of metoclopramide HCl in each milliliter of the
prescription; (b) the number of milliliters of nasal spray that would
provide a patient with an 80-mg dose of metoclopramide HCl; and
(c) how many full days the prescription would last if the patient
administered the stated dose three times daily.
CALCQUIZ
4.A. Interpret the underlined portions taken directly from current
product references12:
a. Initial dose of fluphenazine: 2.5 to 10 mg/day divided t.i.d. or
q.i.d.
b. Dose of epoetin alpha: 150 units/kg SC TIW
c. Dose of acetylcysteine: 140 mg/kg loading dose followed by 70
mg/kg q4h × 17 total doses
d. Pediatric dose of cefuroxime axetil: 30 mg/kg/day, divided b.i.d.
e. Dose of ciprofloxacin hydrochloride: 750 mg tablet q12h or 400
mg IV q8h
f. Dose of fentanyl transdermal patch: 50 mcg/h; apply new patch
q72h
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g. Infusion rate, rocuronium bromide: 4 mcg/kg/min
h. Albuterol metered-dose inhaler: 1–2 inhalations q4–6h p.r.n.
i. Dose of voriconazole: 200 mg p.o. q12h × 21d
j. Dose of certolizumab pegol: 400 mg + MTX q4wk
4.B. The following are hospital medication orders and, in parentheses,
the product available in the pharmacy:
a. Furosemide 80 mg IV q.d. (10 mg/mL in 4-mL syringes)
b. Erythromycin 750 mg IV q6h (500 mg/vial)
c. Acyclovir 350 mg IV q8h (500 mg/vial)
d. Megestrol acetate 40 mg PO q.i.d. (40 mg/mL oral suspension)
e. Ceftazidime 2 g IV q8h (1 g/vial)
For each, indicate the quantity to be provided daily by the
pharmacy.
ANSWERS TO “CASE IN POINT” AND
PRACTICE PROBLEMS
Case in Point 4.1
a. Since aa. means “of each,” 10 mg lisinopril and 10 mg
hydrochlorothiazide (HCTZ) are needed for each capsule. And
since D.T.D. means “give of such doses,” 30 capsules are to be
prepared. Thus,
10 mg lisinopril/capsule × 30 capsules = 300 mg lisinopril and
10 mg HCTZ/capsule × 30 capsules = 300 mg HCTZ are needed
to fill the prescription.
b. Since q.s. ad means “a sufficient quantity to make,” the total in
each capsule is 300 mg. The amount of lactose per capsule would
equal 300 mg minus the quantity of the other ingredients (10 mg
+ 10 mg + 40 mg), or 240 mg. Thus,
240 mg lactose/capsule × 30 capsules = 7200 mg = 7.2 g lactose.
c. Take 1 capsule in the morning before breakfast.
Case in Point 4.2
a. 12 total tablets and capsules.
1.
2.
b.
c. First 7 days: 2 tablets/dose × 2 doses/day × 7 days = 28 tablets
Next 7 days: 1 tablet/dose × 2 doses/day × 7 days = 14 tablets
Next 16 days: 1 tablet/dose × 1 dose/day × 16 days = 16 tablets
28 + 14 + 16 = 58 tablets
d. 1 capsule/dose × 1 dose/day × 7 days = 7 capsules
1 capsule/dose × 2 doses/day × (next) 10 days = 20 capsules
7 + 20 = 27 capsules taken with 33 capsules remaining.
The patient has requested a refill approximately 2 weeks early.
Thus, nonadherence would be a concern.
Practice Problems
a.Dispense 12 rectal suppositories.
a. Dispense 30 tablets.
b. Mix and divide into 40 powders.
c. Dispense six such doses. Do not repeat.
d. Mix and make ointment. Dispense 10 g.
e. Mix and make capsules. Dispense 48 such doses.
f. Mix and make a suspension containing 1 g per tablespoon.
Dispense 60 mL.
g. Make one capsule. Dispense 36 such doses. Do not repeat.
h. Add water to produce a sufficient quantity of 50 mL.
i. Mix and make an intravenous injection.
j. Label: hydrocortisone, 20 mg tabs.
Instill 2 drops in each eye every 4 hours as needed for pain.
a. Take 1 tablespoonful by mouth every 6 hours.
b. Apply morning and night as needed for itching.
c. Instill 4 drops into the right ear morning and night.
d. Take 1 to 2 tablets by mouth every 4 to 6 hours as directed.
e. Apply ointment to the left eye as needed.
f. Take 1 capsule with water at bedtime. Do not repeat.
g. Instill 5 drops into each ear three times a day as needed.
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3.
h. Place 1 tablet under the tongue; repeat if needed.
i. Instill 2 drops into each eye of the newborn.
j. Take 1 capsule by mouth at bedtime as needed for sleep.
k. Take 2 capsules 1 hour prior to departure, then 1 capsule after 12
hours.
l. Take 1 tablet as needed for shortness of breath.
m. Take 1 tablet every morning for high blood pressure.
n. Take 2 tablets every 6 hours around the clock for urinary tract
infection.
o. Take 2 teaspoonfuls four times a day after meals and at bedtime.
p. Take 1 tablespoonful before meals three times a day.
q. Add crushed tablet to pet’s food once a day.
a.AMBIEN 10 mg by mouth every day at bedtime for 5 days
a. 1000 mL of 5% dextrose in water every 8 hours intravenously with
20 milliequivalents of potassium chloride added to every third
container
b. Administer 10 mg of prochlorperazine intramuscularly every 3
hours as needed for nausea and vomiting.
c. 1 teaspoonful of minocycline hydrochloride suspension by mouth
four times a day. Discontinue after 5 days.
d. 1.2 g of mesalamine by mouth daily with food
e. 40 units of NPH 100-unit insulin subcutaneously every day in the
morning
f. 1 g of cefazolin sodium intramuscularly 30 minutes prior to
procedure
g. 15 milliequivalents of potassium chloride by mouth twice a day
after meals
h. 1 mg of vincristine sulfate per square meter of patient’s body
surface area
i. 30 mg of flurazepam at bedtime as needed for sleep
j. 20 milliequivalents of potassium chloride per liter in D5W (5%
dextrose in water) at the rate of 84 milliliters per hour
k. 2.5 grams per kilogram of body weight per day of amino acids in
total parenteral nutrition
l. Start epoetin alfa (PROCRIT) immediately at 150 units per
kilogram of body weight subcutaneously and then three times a
week for 3 to 4 weeks
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
m. Methotrexate tablets, 2.5 mg each, to be taken three times a day
once weekly
n. Hydrochlorothiazide tablets, 12.5 mg, to be taken once each day in
the morning
a. 50 days
b. Yes
40 tablets.
Correct.
Prescription calls for tablets but label indicates capsules.
Sig: “in the morning” has been added, which may be correct if that
is the prescriber’s usual directive.
Refill “5” times is incorrect; the original filling of a prescription
does not count as a refill.
Drug name, strength, and quantity are missing from the label.
The words “all of the medicine” have been added; this clarifies the
directions and thus is positive.
250 mL in the drug strength should be 250 mg.
Patient’s name is incorrect.
The active drug name only on the label is proper for a compounded
prescription. The other ingredients are inactive excipients.
a. “QID” means four times a day
b. Drug name is incorrect.
c. Correct
Correct label. “By mouth” has been added to the directions for
clarification.
Ritonavir: 600 mg twice a day orally for 7 days.
Theophylline: 3 mg per kilogram of body weight every 8 hours for 7
days.
10 milli-international units per milliliter.
30 million international units per square meter of body surface area
per dose three times a week administered intramuscularly or
subcutaneously for 16 weeks.
(The drug combination of) lopinavir, 500 mg, and ritonavir, 125 mg,
taken twice a day, plus efavirenz, 600 mg, taken once every day.
a. 100 mg metoclopramide HCl/mL
b. 0.8 mL nasal spray
c. 41 days
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