Transcript Advanced Pharmacotherapy I PPS 946

Advanced Pharmacotherapy I
PPS 946
Daniel Wermeling, Pharm.D.,
Professor and Course Coordinator
Syllabus
Administration Section Review
The Philosophy of Learning by
Alexandre’ Dumas in the Comte de
Monte Cristo
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The abbe smiled. Alas my boy, said he, "human knowledge is confined within very
narrow limits; and when I have taught you physics, mathematics, history, and
three or four modern languages with which I am acquainted, you will know as
much as I do myself. Now, it will scarcely require you two years for me to
communicate to you the stock of the lessons of learning I possess."
"Two years!" exclaimed Dantes; do you really believe I can acquire all these things
in such a short period of time?"
"Not their application, certainly, but their principles you may; to learn is not to
know; there are the learners and the learned. Memory makes the one,
philosophy the other."
"But one can not learn philosophy!!".
"Philosophy can not be taught! it is the application of the sciences to truth; it is
like the golden cloud in which the Messiah went into heaven.".
Course Description
• Why is applied therapeutics different than the other
courses you have taken?
– Knowledge/Content versus Process
– Use of accumulated knowledge
– How to apply knowledge – a process
• Problem-solving
– Exercising professional judgment
• How do you make a decision or recommendation?
• Student versus Apprentice roles
• End-goal – independent competence
– See pyramid on syllabus
• What constitutes professional competence?
– Skill in critical thinking and expression
Critical Reading
What is the essential question?
• After reading a document/report/problem, can you:
– Concisely state the thesis of the work in your own words in
one sentence
– Elaborate on the thesis with additional explanation
– Give one or more example
– Illustrate the thesis with a metaphor or analogy
• Can you then apply to clinical problems and solutions?
• Is the question posed the essential question or “a”
question?
• What is the essential question posed in the problem?
• What else is unknown; What else do you need to
know?
Linear and Simplistic Problem Solving
Mechanics
Elder and Paul
What Kinds of Questions Are There?
Simple NSAID analgesic example
Clinical Questions
Some Are “Simple” and Some Are Not
What
you will
need to
learn
now
What
you
have
done
so far
Elder and Paul
Questioning Concepts –
Simple Versus Complex
Simple
• Question at hand is basic
and linear
• Settled through definitions
of problem alone
• Facts simply bear out the
answer to the problem
• Primarily knowledge based
to answer the question
Complex
• Question is complex, multifaceted and settled through
argumentation
• More than one set of key
concepts involved
• Could have conflicting analysis
of concepts
• Resolving the problem
requires critical thinking and
logic, using available
knowledge, to reason an
answer
Elder and Paul
Elements of Clinical Reasoning:
A Systematic Thought Process
What is known?
What do you need
to know?
There are
unknowns!!
What are the likely
outcomes of a
decision?
Risk-rewards?
Elder and Paul
How Do Pharmacists Really Think?
Integration of Knowledge, a
Structured Approach, and Clinical
Reasoning Leading to Therapeutic
Decision Making
Pharmacists Patient Care Process
Pharmacists’ Patient Care Process
• Collect
– Subjective and objective information
• Assessment
– Analyze for context of therapy goals
• Plan development
– Individual evidence-based and effective
• Implementation
– Interdisciplinary collaboration with patient/care-giver
• Follow-up – Monitor and Evaluate
– Re-assess and collaborate to modify plan as needed
A Change in Mindset
Complex Problem Solving
• Therapeutics is not about accessing factoids or knowledge per se
– There are too many facts to teach you and more than you can
memorize
• Therapeutics is about:
– Critical Analysis
– Synthesis of problem statement(s) & generating essential
question(s)
– Integration of relevant facts & ignore irrelevant facts
– Researching evidence-based option(s) that may solve problem(s)
– Integrate competing or conflicting concepts and then reason
– Clinical Reasoning – choose best and optimal option
– Being able to cite why this is the best option
• If you can not decide get more facts to help guide a decision – it is OK
to say: “I don’t know but will find out”. Never Guess!!!
• If no data, then you may actually have discovered a research question
(a Newtonian “aha” moment!) and a hypothesis – so do a study (yea!)
Gather Relevant Information and
Define Problem
• Patient Assessment
– Pain assessment - Class and nature of pain (see lecture
slides)
• Background information
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Demographics and HPI
Medical history and co-morbidities
Risk factors
Medication history
Outcomes of prior treatment(s)
• Patient statement about goals, expectations
Selecting Medications in a Treatment
Plan – Options and a Decision
• Evidence-based considerations for your patient:
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Indications
Effectiveness
Risk factors
Pharmacokinetic properties
Interactions
Safety
Compliance
Cost
• What are credible sources of evidence?
• Many choices can be correct/acceptable!
• Which choices might not be appropriate because they operate at the
margins in the context of the present patient?
• How will you determine a preference and make a specific prescription
recommendation for the patient?
• In the end it is about variability – patients, drugs, delivery systems, etc.
The Wheel of Factors –
Each Patient is Different
Uncertainty
Factors
Body
Habitus
Other
Diseases
Organ
Dysfxn
Compliance
Evidencebased
Guidelines
Cost and
Insurance
Demographics
Life is like a box of chocolates – You never know what
you are going to get – Forrest Gump, Philosopher
Other
Meds
Spin Here
Multi-Dimensional Critical Thinking in Therapeutics and Pharmacy Practice
Consider Lipitor and High Cholesterol
Person
Behavior&
Mentality
Individual
Health
Outcome
Economics &
Health Care
Finance
Organs
Tissue
Cellular
Expression
Receptor, Enzyme,
Antibody, Antigen
Disease
Manifestation
Populationbased Health
Outcomes
How Will a Medication Effect Be
Expressed at Each Level?
As Applied to a Patient’s Medical
Problem with a Potential
Pharmaceutical Treatment
Law
Society &
Health
Policy
Foundational Basic Sciences
Chemistry, Mathematics, Biology, Physics, Logic, Statistics, Anatomy, Physiology,
Pathophysiology, Pharmacology, Pharmaceutics, Medicinal Chemistry, Genetics
Monitoring – Managing Variability
and Unknowns
• Effectiveness
– What will you monitor to determine effectiveness? Are goals of
therapy being met?
• Safety
– Adverse Effects, Drug Interactions, etc
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Compliance
Changes in other medical problems
Changes in other medications
Re-assessment and adjust as necessary
– Through appropriate follow-up
– Repeat
• Why? – because circumstances and people always change
But Arriving at a Decision is Just One
Element: How Will You Communicate?
• To get to a decision you were a critical reader
and thinker
• You will be called upon to communicate
recommendations
– Effectively and concisely verbalize your
recommendation and reasoning
– Effectively and concisely write your
recommendation and reasoning
– To various audiences (doctors, nurses, other
pharmacists, students and residents, and patients
Much of Therapeutics is Gray
But You Can Responsibly and
Professionally Determine What is Best
for Each Patient
Acceptable
Outcome
Optimal
Outcome
Acceptable
Outcome
Safety and Efficacy Margins
Stay in the Safe Zones
Another Way to Look at Gray!!
What is a Therapeutic Dilemma????
Acceptable
Outcome
Optimal
Outcome
Acceptable
Outcome
Safety and Efficacy Margins
Case
• A 70 year old woman appears in the pharmacy today
regarding her diabetes. The patient tells you that in addition
to taking ER Hydromorphone 16 mg a day, she is taking
approximately 12 ibuprofen 200 mg tablets daily to help ease
her burning foot pain and arthritis pain; still has moderate
pain.
• What is the essential question posed by this
case?
• What else do you need to know?
• Follow the pharmacists’ patient care process!
What is the proper pharmacologic
treatment of diabetic neuropathy and
age-related osteoarthritis?
Concluding Remarks
• I use everything I ever learned in prepharmacy (except physics maybe) and in
pharmacy school to practice pharmacy today.
• I hope you will be able to say the same.
• A professional is a life-long learner