A 34 year old male, Tom enters your

pharmacy with his partner, Phil and asks for a

cough medicine.

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Tutorial Scenario Part 1.• He also presents with the following prescription

Tutorial Scenario Part 1.

• He tells you that he has had a dry cough that he can’t seem to shake off for the past 3-4 weeks

• The doctor said that it was probably viral but to take the antibiotics if it got worse.

• He also tells you that he has had a fever and often feels short of breath when exercising and is feeling very tired.

Lectures to support this case

• Antivirals I and II A/Prof M Collins• Drug Therapy for HIV I and II Dr H Fedorow• Ethics and Privacy Issues Dr B Chaar• Review of Respiratory Drugs Prof P Seale• Review of autacoids Dr B McParland

References to support this case• Second year lectures on antibiotics• Foye's Principles of Medicinal Chemistry; Thomas L Lemke,

David A Williams, Victoria F Roche & S. William Zito, 6th Edition, 2007.

• On Blackboard:– HIV Management in Australasia guidelines 2009– Anti-HIV drugs: 25 compounds approved within 25 years after the

discovery of HIV - Erik De Clercq– Link to WHO report on global AIDS epidemic http://

www.who.int/hiv/pub/global_report2010/en/index.html– HIV drug table (table for completion)

• Respiratory and antimicrobial guidelines• AMH

General learning objectives for PHAR3812

By the end of this tutorial students should be able to: Predict the activity of a drug based on its structure and

physicochemical properties Demonstrate an understanding of how the physical and

chemical properties of a drug determine its pharmacology, toxicology, bioavailability and behaviour in formulations

Identify typical examples of drugs which are used to restore physiological functions in the respiratory system

Describe the mechanism of therapeutic action of a selected drug at the molecular, cellular, organ system and whole body levels

General learning objectives for PHAR3812

By the end of this tutorial students should be able to:• Describe the common adverse effects of a selected drug

and their mechanism of production • Demonstrate an understanding of basic metabolism in

relation to drugs and efficacy and safety in relation to the treatment of disease and/or maintenance of health

• Apply an understanding of the basic and applied sciences to pharmaceutical care in order to optimise health outcomes

• Respond to direct product and symptom based requests (in relevant therapeutic areas)

Learning outcomes specific for Case 3

By the end of this tutorial students should be able to:• Have an awareness of the risk factors and prevalence of chronic

lung disease so as to identify and refer presentations at the pharmacy appropriately

• Understand the pathophysiological mechanisms of disease development and progression in HIV

• Understand the differences between the classes of antiretrovials used in the management of HIV

• Demonstrate an understanding of the clinical and therapeutic principles of treatment and management in HIV

• Be aware of co-morbid conditions in HIV

Information Gathering for Part 1 Prior to Tutorial

• WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED?

• Before your tutorial you should have a list of questions that you would like to ask Mr. Bingham

Information Gathering for part 1 Prior to Tutorial

• WHAT ARE THE POSSIBLE CAUSES OF COUGH?

• Before your tutorial you should have a list of possible causes of cough, identify the ones that could be causing these symptoms for Mr Bingham

Information Gathering for part 1 Prior to Tutorial.

• WHAT IS THE DOCTOR’S RATIONALE IN PRESCRIBING AUGMENTIN?

• Before your tutorial you should review the indications for Augmentin and outline its role in therapy. Comment on its role in upper respiratory tract infections.

Tutorial Scenario Part 2.

• It is now a week later and you are working at St Elsewhere’s hospital and you have a new patient on your ward, Mr. Tom Bingham.

Tutorial Scenario Part 2.

• You are on the rounds with the respiratory and infectious diseases team and they are reviewing the following chest X-Ray.

Tutorial Scenario Part 2.

• The medical notes say the following: • temperature is 39.3°C, • diffuse crackles in both lung fields. • room air oxygen saturation at rest is 88• WBC count is 5500 with 62% PMNs• chest X-ray shows bilateral interstitial infiltrates • induced sputum is positive for P jiroveci (carinii) • Viral load 60,000 copies/mL• CD4 210

Tutorial Scenario Part 2.

• He has been charted for the following medications

• Kaletra • Truvada• Bactrim

Tutorial Scenario Part 2.

• On leaving Tom’s room to go back to pharmacy to dispense his medications, his partner Phil bumps into you and asks you what is going on? What is wrong with Tom?

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Information Gathering for Part 2 Prior to Tutorial.

• WHAT DO THE MEDICAL NOTES AND CHEST X-RAY MEAN?

• Before your tutorial you should research the patient’s documented issues and be able to explain what is going on.

• Read pages 133-136 of HIV management in Australasia – a guide for clinical care (WebCT)

Information Processing for Part 2 Prior to Tutorial.

• HOW DO YOU RESPOND TO PHIL’S REQUEST TO FIND OUT WHAT IS GOING ON?

• Before your tutorial think about the words you would use to explain what is going on.

• Review your Ethics lecture notes

Information Gathering for Part 2 Prior to Tutorial.

• WHAT MEDICATIONS HAVE BEEN PRESCRIBED? WHAT ARE THEY FOR?

• Before your tutorial look up the medications. What doses would you expect? What are they for?

• Read pages 59-72 of HIV management in Australasia (WebCT)

Information Gathering/Processing for Part 2 Prior to Tutorial.

• HOW DOES EACH OF THE ANTIRETROVIRALS WORK?

• Before your tutorial complete the HIV drug table on Blackboard. Comment on how each class differs, specific charge properties which may enhance action, cross resistance, binding sites etc.

• Read LeClerq Paper on WebCT and review lectures

Information Gathering/Processing/Delivery for

Part 2 Prior to Tutorial.• WHAT INFORMATION DO YOU NEED TO GIVE

TOM AT DISCHARGE?

• Before your tutorial read the AIDs epidemic update on WebCT.

• In particular, Tom wants to know how common it is? and how to take his medications and what to do if he misses a dose? (complete a medication list for Tom)

During tutorial – Part 1

• You may be asked to present interesting insights from your placement

• The tutor will ask for answers to the pre-work questions part 1

• A role play with the patient will occur

• Discussion and a recommendation will be made for Mr Bingham at this stage

Information Gathering In Tutorial

• WHO IS THE PATIENT?

• In your tutorial students should role-play with the patient

• (10mins)

Information ProcessingIn Tutorial

• WHAT ARE THE KEY ISSUES APPARENT?

• Discuss issues that need attention for Mr Bingham.

During tutorial – Part 2

• The tutor will ask for answers to the pre-work questions part 2

• A role play with the patient’s partner will occur

• A role play with the patient at discharge will occur using the medication list you created

Information ProcessingIn Tutorial part 2

• HOW DO THE ANTIRETROVIRALS WORK?

• A discussion of how the different classes work and questions related to SAR will be asked:

– What are the features that make a nucleoside analogue a chain terminator and why is this important?

– Various NRTIs are more effective in treating HIV when used in combination even though their mechanism is the same – why?

– Why are second generation NNRTIs less prone to resistance: eg. Efavirenz compared to nevirapine?

– HIV resistance develops quickly to nevirapine. Why does it develop more quickly than resistance to nucleoside analogues (NRTIs)?Why is it still therapeutically useful?

Information DeliveryIn Tutorial Part two

• HOW DO YOU RESPOND TO PHIL’S REQUEST?

• How is privacy maintained?

Information Delivary in Tutorial Part 2

• WHAT DOES TOM NEED TO KNOW

• Provide discharge counselling to Tom. He is particularly interested in how common this is and also how to use his medicines

Global summary of the AIDS epidemic- Dec 2009

• Number of people living with HIV in 2009– Total 33.3 million [31.4 million–35.3 million]– Adults 30.8 million [29.2 million–32.6 million]– Women 15.9 million [14.8 million–17.2 million]– Children under 15 years 2.5 million [1.6 million–

3.4 million]

Global summary of the AIDS epidemic- Dec 2009

• People newly infected with HIV in 2009– Total 2.6 million [2.3 million–2.8 million]– Adults 2.2 million [2.0 million–2.4 million]– Children under 15 years 370 000 [230 000–510

000]

Global summary of the AIDS epidemic- Dec 2009

• AIDS-related deaths in 2009– Total 1.8 million [1.6 million–2.1 million]– Adults 1.6 million [1.4 million–1.8 million]– Children under 15 years 260 000 [150 000–360

000]

• The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information.