Advanced Pharmacotherapy I PPS 946 Daniel Wermeling Pharm

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Advanced Pharmacotherapy I PPS 946 Daniel Wermeling, Pharm. D. , Professor and Course Coordinator

Advanced Pharmacotherapy I PPS 946 Daniel Wermeling, Pharm. D. , Professor and Course Coordinator

Syllabus Administration Section Review

Syllabus Administration Section Review

The Philosophy of Learning by Alexandre’ Dumas in the Comte de Monte Cristo •

The Philosophy of Learning by Alexandre’ Dumas in the Comte de Monte Cristo • • • 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

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:

Critical Reading What is the essential question? • After reading a document/report/problem, can you: – Concisely state thesis of the work in your own words in one sentence – Elaborate on thesis with additional explanation – Give one or more example – Illustrate 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

Linear and Simplistic Problem Solving Mechanics Elder and Paul

What Kinds of Questions Are There? Simple NSAID analgesic example

What Kinds of Questions Are There? Simple NSAID analgesic example

Clinical Questions Some Are “Simple” and Some Are Not What you will need to

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 Complex • Question at hand is basic

Questioning Concepts – Simple Versus Complex Simple Complex • 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 • 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

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

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

Pharmacists’ Patient Care Process • Collect – Subjective and objective information • Assessment –

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

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

Gather Relevant Information and Define Problem • Patient Assessment – Pain assessment - Class and nature of pain (see lecture slides) • Background information – 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

Selecting Medications in a Treatment Plan – Options and a Decision • Evidence-based considerations for your patient: – – – – 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

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

Multi-Dimensional Critical Thinking in Therapeutics and Pharmacy Practice Consider Lipitor and High Cholesterol Person Behavior& Mentality Organs Tissue Cellular Expression Receptor, Enzyme, Antibody, Antigen Disease Manifestation Individual Health Outcome Population-based Health Outcomes Economics & Health Care Finance 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, Pharmaceutics, Medicinal Chemistry, Genetics

Monitoring – Managing Variability and Unknowns • Effectiveness – What will you monitor to

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 • • 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? •

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

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

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

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?

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)

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