A 42 year old mother of two, Mrs Jan Jones comes into the pharmacy to fill

a repeat prescription for

a Ventolin Inhaler..

http://www.topnews.in/files/Christine.jpg

Tutorial Scenario.

• The directions on the prescription specify it is to be used 2 puffs QID PRN.

• On handing over the prescription she adds that she is surprised to need a puffer, as she is not asthmatic but does seem to be short of breath lately and having trouble keeping her puff

• She tells you that even walking causes her to be puffed out

Tutorial Scenario.• She tells you that the puffer before was being used 4

times a day but she still feels a wheeze when walking uphill or walking too fast

• She lets you know that it is starting to get her down because she feels incapable.

• She is also not sleeping well and her husband says she snores.

Tutorial Scenario.

• The Medication history on your dispensing computer shows Mrs. Jones has suffered from two URTIs in the last years, which were treated with antibiotics.

• She has no known allergies

Lectures to support this case• Asthma Devices Dr B Saini• Asthma Therapy Dr B Saini• Inhaler Technique Dr S Bosnic-Anticevich• Controlled Release Dr D Traini• COPD I and II Dr S Bosnic-Anticevich• Sleep Apnoea Dr B Saini• Development of inhaled mannitol as a respiratory product

Prof H-K Chan• Adrenergic Receptors (relevant to Cardiovascular and

Respiratory) Prof B Roufogalis• Review of respiratory drugs Prof P Seale• Review of autacoids Dr B McParland

References to support this case• Foye's Principles of Medicinal Chemistry; Thomas L Lemke,

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

• Respiratory Guidelines• AMH• Global Initiative for Chronic Obstructive Lung Disease (GOLD)

guidelines http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=1116

• On Blackboard:– TORCH study – UPLIFT trial– COPD and OSA study– NSW Domiciliary Oxygen Guide

General learning objectives for PHAR3812

By the end of this tutorial students should be able to:• Predict the activity of a drug based on a 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 this caseBy 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 COPD

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

• Be aware of the pharmacological and non-pharmacological aspects of managing COPD

• Be aware of co-morbid conditions in COPD

Information Gathering Prior to Tutorial 1

• 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 Mrs. Jones

Information Gathering Prior to Tutorial 1

• WHAT ARE THE POSSIBLE CAUSES OF BREATHLESSNESS?

• Before your tutorial you should have a list of possible causes of breathlessness

Information Gathering Prior to Tutorial 1.

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

• Before your tutorial you should review the indications for Ventolin and outline its role in therapy and understand its mechanism of action

Information Gathering Prior to Tutorial 1.

• HOW IS VENTOLIN USED?

• Before your tutorial you should review the Ventolin CMI and be prepared to counsel and show technique

Information Gathering Prior to Tutorial 1

• HOW WOULD YOU DIFFERENTIATE BETWEEN ASTHMA AND COPD? COULD A PATIENT HAVE BOTH?

• Before your tutorial you should research the factors that confirm a diagnosis of these disease states

Information Gathering Prior to Tutorial 1

• WHAT IS COPD? WHAT ARE ITS CAUSES? HOW PREVALENT IS COPD IN AUSTRALIA? HOW WOULD YOU DIFFERENTIATE BETWEEN ASTHMA AND COPD?

• Before your tutorial you should research the causes and prevalence of COPD and factors that confirm a diagnosis of these disease states

Information Gathering Prior to Tutorial 1

• HOW IS COPD DIAGNOSED? WHAT IS THE GOLD CLASSIFICATION FOR COPD? WHAT IS SPIROMETRY, (FEV1)?

• Before your tutorial you should research these questions and understand the GOLD guidelines about the diagnosis, prevention, and management of COPD.

Information Gathering Prior to Tutorial 1

• WHAT DID THE UPLIFT AND TORCH TRIALS CONCLUDE ABOUT THE MANAGEMENT OF COPD

• Before your tutorial you should review the two trial papers on WebCT and summarise your main learning.

During tutorial 1.

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

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

• A role play with the patient will occur

• Discussion and debate will occur in order to recommend an appropriate plan for Mrs Jones

• Demonstration of appropriate device technique will be practiced

Information Gathering In Tutorial 1

• WHO IS THE PATIENT?

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

• (20mins)

Information ProcessingIn Tutorial 1

• WHAT ARE THE KEY ISSUES APPARENT?

• Discuss issues that need attention for Mrs Jones.

Information ProcessingIn Tutorial 1

• WHAT COULD BE CAUSING HER BREATHLESSNESS?

• After questioning make a differential diagnosis

Information ProcessingIn Tutorial 1

• WHAT IS VENTOLIN AND HOW DOES IT RELIEVE BREATHLESSNESS?

• Discuss how ventolin works at the molecular level (including SAR, receptor and cell signalling)

Information Delivary in Tutorial 1

• HOW SHOULD SHE USE THE VENTOLIN

• Discuss the pros and cons of Ventolin and review and refine inhaler technique

Information Delivery in Tutorial 1.

• WHAT IS THE BEST WAY TO MANAGE MRS JONES IMMEDIATELY

• During the tutorial devise an appropriate plan

Mrs Jones sees you again a few days later. With

a new prescription for

Spirivahttp://www.topnews.in/files/Christine.jpg

Tutorial Scenario.

• She tells you that she followed your recommendation and went to see the doctor

• Her GP sent her to a respiratory clinic

• She had lung function and spirometry tests performed

• The doctor has told her that Spiriva only needs to be used once a day

• END OF TUTORIAL 1.

Information Delivery before Tutorial 2

• COMPLETE A MEDICATION PROFILE/CHART FOR MRS JONES

• Before tutorial 2. fill in a medication chart (example on webCT) for Mrs Jones including her Spiriva and any other medicine you think she should be using.

Information Gathering before Tutorial 2

• WHAT IS THE RATIONALE FOR SPIRIVA FOR MRS JONES?

• Before tutorial 2. review the UPLIFT trial again and the guidelines for the management of COPD.

Information Gathering before Tutorial 2

• WHAT DOES AN ANALYSIS OF THE STRUCTURES AND MOA OF BETA AGONISTS AND ANTICHOLINERGIC BRONCHODILATORS TELL YOU ABOUT THEIR ACTIVITY?

• Before tutorial 2. review the chemical structures, thinking about their interactions with target receptors. Be prepared to discuss how these medicines works at the molecular level (including SAR, receptor and cell signalling)

Formoterol

Salbutamol

Terbutaline

Salmeterol

Information Gathering before Tutorial 2

• WHAT IS PULMONARY REHAB AND ITS ROLE IN COPD MANAGEMENT?

• Before tutorial 2. research pulmonary rehab. What is it? And what are the benefits?

Information Gathering before Tutorial 2

• AT WHAT STAGE DO COPD PATIENTS REQUIRE OXYGEN SUPPORT? WHAT ARE THE PRACTICAL ISSUES IN USING DOMICILIARY OXYGEN?

• Before Tutorial 2 Research Supplemental Oxygen Therapy? Are their State by state guidelines? What do the Respiratory therapeutic guidelines suggest?

Information Gathering before Tutorial 2

• WHAT IS SLEEP APNOEA?• How is it diagnosed and treated?• What is the overlap between sleep apnoea

and COPD? • Before Tutorial 2 Research COPD and Sleep

Apnoea. Read the references provided.

Information Processing before tutorial 2

• PREPARE TO COUNSEL MRS JONES ON COPD MANAGEMENT

• Before the tutorial think about the way you might approach Mrs Jones: What will you say and in what order?

During tutorial 2.

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

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

• Review of students medication profiles/charts will be done

• role play with the patient will occur

Information Delivery in Tutorial 2

• MEDICATION PROFILES/CHARTS

• During the tutorial you will swap your profiles with a colleague to review.

Information Delivery duringTutorial 2

• WHAT IS THE INFORMATION THE PATIENT NEEDS

• During tutorial 2. role plays with the patient outlining how to use the Spiriva and Ventolin as well as non-pharmacological management will occur

Information Processing duringTutorial 2

• WHAT IS NEXT?

• During tutorial 2. think about Mrs Jones long term management and the types of medicines she might need to take in the future