September 2017 by PQ PlusTwo

PQ PLUS 2

ISSUE

1 AMONTHLY MAGAZINE FOR PHARMACY STUDENTS

S P O N S O R E D BY P H A R M AC A R E

SEPTEMBER 2017

September Issue -Table of Contents 02

Table of Contents Publications Director and Co-Editor Introductions

Welcome Back - President’s Address A message to new and returning students from the APSA President

First Year Pharmacy Orientation Welcoming the class of 2021 to the pharmily!

Welcome Reception A recap of the welcome reception for the Class of 2021.

Freedom of Choice in America A look at over-the-counter products and the pharmacy environment from our neighbors in the south. Written by Frank Huang, Class of 2019.

Soak up the Sun— While in Class! A taste of pharmacy in Italy. Written by Winnie Lo, Class of 2018.

Edmonton PDW 2018 Why you should go to Canada’s largest annual pharmacy student conference—taking place in Edmonton 2018!

Pharmacy in Spain Daryl Mah (Class of 2019) writes about his experiences this summer with a student exchange trip to Spain Federation.

Therapeutic Tent Talk A discussion of common therapeutic topics with Co-editor David Poon.

The Unique Practice of Palliative Care Pharmacy Co-Editor Ethos Ho interviews an Intensive Palliative Care Unit (IPCU) pharmacist and writes about his institutional placement in IPCU at the Foothills Medical Centre.

Meet The PQ Plus 2 Team Publications Director Welcome back everyone and welcome to the pharmily Class of 2021! My name is Jasmine, your Publication Director for 2017/18 year. I am very excited to work with my PQ+2 editors and yearbook editors. I hope to meet the everyone’s expectation this year and constantly work on improving various student productions. Have a great semester! Co-Editor Hello, my name is Ethos and I am one of your co-editors for the 2017/2018 year. Welcome class of 2021 to the faculty of pharmacy! I wish you best of luck on your journey with this evolving profession. I am looking forward to meeting everyone and hope to write some engaging pharmacy-related content! Co-Editor Greetings! My name is David and I am a co-editor for PQ Plus 2. First of all, I would like to welcome the Class of 2021 to our growing Pharmily! I hope everyone had a fantastic summer. This year, PQ Plus 2 has some amazing content that I think everyone will enjoy! | 2 |

President’s Address By Aliaksandr Savin

Welcome back everybody and welcome to the Class of 2021! I want to congratulate each and every one of you on reaching this milestone in your young and blossoming professional careers. As my time in this program is coming to an end, I think of myself and being where you are today. I can still remember being the third person to show up for the orientation sign up (#keeneralert #workhardplayhard). Those initial nervous moments quickly transformed into amazing memories with friendships that I gained throughout my time here. As my class of 2018 is about to begin their clinical rotations or their final term in classes, the thought of being a graduate is truly bittersweet. While the stress of midterms and finals may no longer be a thought, I am already missing seeing all the beautiful faces that I have grown accustomed to over the past 3 years. As I write this, I start to think about what I would have wanted to hear coming into this unknown territory. You all have gotten into Pharmacy based on your work ethic and dedication, exemplifying your capabilities as individuals. But where do you go now? I can safely say that I do not remember every word of every lecture of Pharmaceutics or Radiopharmacy. I don’t remember the mechanism of action of every drug I learnt. But what I do remember is all the memories and friendships that I have made. All the TGIFs, competitions, and APSA involvement will always have a special place in my heart. Although everyone has different interests and hobbies, my biggest suggestion to you is to get involved in whatever it is that interests you. You may be the next APSA president or you may be the Messi/Ronaldo/Sinclair of our intramurals soccer team. Whatever it is, do not be afraid to push yourself beyond your comfort zone. Take new risks and challenges and use this program as the opportunity to grow and better yourself as a person. I know I am forever grateful for all of the opportunities that I have had along the way and to all of the people that I have met. This program will not be easy. You will encounter many challenges and at times, you may doubt yourself and whether you belong here. As someone once told me: “failure is fun”. You are a student and you will make mistakes along the way. That is to be expected because this is what learning is all about. However, it is not about the mistakes we make, but about our response to them. Whether it was losing in an election my first time around or making clinical mistakes on my rotations, I have experienced my fair share of “failure”. But I am grateful for those experiences because not only did they help me to learn but most importantly, they have pushed me to grow beyond anything I could have imagined. As you are about to begin your journey, make sure to carve your own path. Take risks, push yourself and most importantly, have fun. These next four years will pass you by before you know it, so make the most of it. All the best, Aliaksandr (Aliaks) Savin, APSA President

First Year Orientation Welcome Class of 2021 to the Pharmily! Welcome and congratulations to the class of 2021 to the pharmacy program! You are now all part of this hectic journey that is pharmacy school. You are all in this together. These four years will fly by, and before you know it, youâ&#x20AC;&#x2122;re paying back student loans. A picture is worth a thousand wordsâ&#x20AC;Ś here are some highlights from orientation!

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Welcome Reception 2017 #Welcome #2021 By Jasmine Han Thanks to the Investors Group who generously sponsored us this year, we had another year of successful welcome reception. It was amazing to see a great turn out from the faculty as well as all classes of pharmacy students to welcome the Class of 2021.

Importance of support and involvement The night began with a welcome wish from the representative of the Investors Group who gave a wonderful speech that touched us all deeply. As her speech reflected, it is important for everyone to realize that there will always be support from peers and to be supportive of those around them to ensure the best working environment for everyone. I believe that we are very lucky to be in a faculty where everyone is welcoming, caring and supportive throughout the rocky pharmacy journey. Bright future President Aliaksandr Savin followed up next with his own personal speech emphasizing the s upportive environment that the faculty has to offer. He also expressed the importance and benefits of getting involved not just in APSA but in various ways outside classes. He further highlighted the expansion of our scope of practice which makes it very exciting for many of us to enter this profession. These key messages were again emphasized by President-elect Sean Hanson who gave a little more context by sharing his own personal journey over the last 2 years in pharmacy. Big responsibilities Dean Davies made yet another remarkable speech that we will recall in years to come. In

his opening words, the Dean made a strong impression on all pharmacy students as he reminded us all that we had to â&#x20AC;&#x153;work, work, work, work, workâ&#x20AC;?. The key highlight of Dean Davies speech was how he encouraged students to embrace cultural diversity and take on the responsibility welcoming students from all background moving forward. My thoughts This is my 3rd time attending welcome reception and I feel as though each year, the entering pharmacy students seem to be more and more passionate about the profession which gives me hope as we need to advocate for our own profession. I believe that this faculty has so much to offer for everyone as those before me have re-iterated. I hope that the Class of 2021 can share the passion that we all share in this faculty.

Welcome Reception 2017 #Welcome #2021

PICTURES: Main— Harry Thomson, master thatcher. Inset— Henrick Jansen makes new rush stakes for the roof of Harriet’s Barn, in his forge at OutTown. Photographer credits: both Jane Bamett. | 6 |

Freedom of choice in America By frank huang

Pharmacy in the U.S. is a busy world. The pay is higher than in Canada, but the amount of work done is higher as well. Visiting CVS (equivalent to Shoppers Drug Mart, except WAY bigger), Walgreens, and Costco, the pharmacy staff was always busy filling and re-filing scripts, and counselling patients on their medications. Most notably at a CVS I visited, all I heard was the pharmacist calling and answering calls on their headsets about filling and refilling scripts. Itâ&#x20AC;&#x2122;s fast-paced and thereâ&#x20AC;&#x2122;s no doubt the environment justifies higher wages. What interested me the most in my short visits was the amount of freedom patients had for self-choice of medications. The U.S. is commonly referred to as the Land of the Free; that title cannot be more apt for the freedom of choice for OTC products that one can find in a pharmacy. The number of OTC medications in pharmacies was overwhelming! On one hand,

the vast variety of medications can be useful for treating a wide variety of

ailments, but on the other hand it stresses the importance of OTC counselling and guiding patients to suitable medications. Cold and Allergy Medications Cold medications and antihistamines are very common medications that every pharmacy stocks on their OTC shelves. For cold

medications, most were a combination of an analgesic, decongestant (phenylephrine), cough suppressant (dextromethorphan (DM)), expectorant and sometimes an antihistamine. I did note that there were more single medication products in the U.S., which is nice. Newer single medication products in Canada, such as Mucinex (guaifenesin) are widespread and has been on the market longer in the U.S.. Another example would be the sale of a single ingredient DM cough syrup in the U.S; a pet peeve of mine is the existence of a cough suppressant/ expectorant combo product because what’s the point with thinning up mucous and phlegm to cough out while you’re suppressing your cough reflex?! DM only cough syrups aren’t common in Canada (at least I have never run into it), and the existence of such a product in the U.S not only emphasizes the freedom of choice in OTCs, but also potentially better medication choices that pharmacists can guide patients to select and treat their dry cough. Antihistamine choices also caught my interest in U.S. pharmacies. A common panel of OTC antihistamines, both first generation (diphenhydramine as Benadryl) and second generation (cetirizine as Zyrtec, loratadine as Claritin, fexofenadine as Allegra) are offered. To my surprise, desloratadine (Aerius, in the | 8 |

U.S known as Clarinex) is a prescription only medication. But, what interested me even more was the product levocetirizine (Xyzal) which comes in a 5 mg strength and is dosed daily. Levocetirizine is branded as a third generation antihistamine; it is the active, R-enantiomer of cetirizine. The manufacturer claims the medication is more effective and has less side effects than cetirizine (e.g. decreased drowsiness), despite few published articles to support such claims. A search on Health Canada’s Drug Product Database did not yield any results, suggesting the product will not be coming to Canada

soon. For me, it’s interesting to see and gain knowledge of these differences in pharmacy products between countries because perhaps one day this product will make it to Canadian shelves. Nasal sprays wise, while OTC fluticasone (Flonase) only came to Canadian shelves this year, the product has been on American shelves for a couple of years longer. To my interest, American pharmacies also have a

newer drug delivery device for the medication – a mist type spray. The product aims to improve comfort, ease of use, and minimize dripping from normal nasal spray actuations. Now that’s a product I look forward to seeing for on Canadian shelves!

PPIs Galore Gastroesophageal reflux disease (GERD) is no small issue. According to the Gastrointestinal Society of Canada, approximately 13% of Canadians suffer from GERD symptoms weekly, and almost one quarter of the population (24%) experiences heartburn daily or more frequently. It is an even greater in the U.S, with 20-30% of the adult population experiencing weekly GERD symptoms as reported by the U.S Healthcare Cost and Utilization Project. I have heard stories from others that PPIs are very easy to get in the U.S and a lot of them are OTC. And oh boy that cannot be truer. The first time I stepped into an American pharmacy, the number of PPIs you can

self-select and get easy access to astonished me. Many of the familiar PPIs we see so much in the dispensary, such as lansoprazole (Prevacid), omeprazole (Prilosec), and esomeprazole (Nexium) are found on the OTC shelves. They don’t come in paltry

amounts either. In comparison, Histamine-2 Receptor Antagonists, such as Zantac are still sold, but there are less OTC options and they don’t seem to be as popular compared to PPIs. Bulk-Sizing It Up Another astonishing thing for me was the amount of bulk medications you can purchase from your local Costco pharmacy. Here you can see for yourself! Honestly… who needs a 6pack of enema?

Medical Device Choices There’s also freedom of choice when it comes to medical devices. Blood pressure monitors, glucose monitors and medical supplies are readily available OTC. What caught my interest was the availability of other medical devices… or more like tests. DNA test kits ready to pick up OTC from pharmacies? That’s doable! You’re just purchasing a test collection kit that includes instructions on how to collect samples, and how to pay the applicable lab fees. Genetic testing kits are commonplace in the U.S., but pharmacies in Canada do not stock them. In fact, the

very premise of having these commercial genetic test kits is very controversial. As of right now it’s possible to access these kind of test kits in Canada through testing centres or online, but I don’t think a local pharmacy advertises them like they do in the U.S., however that would probably require some fact checking.

Conclusions At the time of writing this article I haven’t had a chance to talk to a pharmacist here in the U.S., but just by seeing what was offered in the OTC aisle offered a lot of material to write on! A great amount of OTC choices allows patients to select better medications to treat various symptoms and conditions. If the selection of medication is indicated, effective, and safe then this may reduce the need to visit a physician. This ease of access and convenience is excellent. However, as pharmacists we must ensure, and guide patients to indicated, effective, safe OTC medications. An overwhelming choice of OTC medications stresses the importance of OTC counselling. As pharmacists, we need to explain to patients what to choose and how the medication will work. Does the current pharmacy environment, in the U.S., and back home permit that? My visit down south was too short to evaluate that, but this topic is good food for thought.

“Travel is more than the seeing of sights; it is a change that goes on, deep and permanent, in the ideas of living.” I feel that Miriam Beard hit the nail on the head when I searched for some way to explain my ‘study abroad’ in Italy this past summer. In many ways, learning and travelling was a much richer experience than any other traveling I have done before – I could immerse myself in the Italian lifestyle and soak in the culture (as well as the food and sun!). Rather, I would say that I normally experience travel at a lightning pace to fit in all my sightseeing and this was an opportunity for me “walk a mile” in some fancy Italian leather shoes. But I’m getting a bit ahead of myself. “What Italy Trip?”, you might ask. PHARM 453, or the “Intercultural Exploration of Pharmacy and Health” is a credit-course offered as one of your option courses before fourth year. A total of 18 pharmacy students traveled with nursing and | 10 |

nutrition students to Ischia, a small island just south of Naples. This, my fellow peers, is the pinnacle of the island dream life. Gelato stands at every corner, deliciously fresh (and cheap!) pizza on each block, multiple beaches within walking distance, and my personal favourite – friendly Italian cats to ensure your all your snaps are purrfect! We stayed at the Ring Hostel in Forio and had our first taste of Italian hospitality from the Colella family. Giuseppe, Lorenzo, and Amarigo, 3 brothers who more or less ran the island, helped to coordinate everything for us. This included not only our accommodations, but the class room, meals (mmmmm… La Casereccia), and day trips (pro tip: if the poster advertises “Walk in the Woods”, you have now been warned that it involves an 8-hour hike!)! Mama Tina certainly deserves a huge shout-out for the

incredible meals we ate each day – our meals included some outstanding seafood pasta, stuffed zucchini flowers, Ischian-style rabbit, ricotta-pear cheesecake, tiramisu… and I could probably write an entire article on the food alone, so I’ll cut myself off there. Needless to say, do not worry about the food you will get. If anything, worry about bringing clothes a size up. During the week, our classes took place in La Rotunda sul Mare, a pretty Mediterranean “café” by the ocean. The most unique part of our lessons was how each topic we covered was supplemented by hands-on lessons. For example, we spent some time covering the cardiovascular benefits of the Mediterranean diet. This was followed up by a trip to see local agriculture and wineries, then supplemented by a cooking lesson each week. Of course, the cherry on top was getting to eat Mediterranean dishes each day! One of our more interesting projects involved the creation of a lab simulation. We traveled to the University of Naples Frederico II to meet with their pharmacy students and facilitate a lab of our own. After we walked them through one of our labs, the Napoli students took us on a tour of their research labs – which is a stronger focus for the Faculty of Pharmacy in Italy. Many of the people I spoke to aspired to have a career in the pharmaceutical research industry! Rather than a clinically-focused approach like Alberta, Italy’s focus is on research and compounding. Many prescriptions require compounding with natural remedies, tailored specifically to the patient. We took a quick trip to a community pharmacy to see how things were done. Walking in, you’re greeted with rows and rows of lotions, sunscreens, and skin care products. The next thing is a very interesting touch screen. Apparently, Italian patients can specify what concern they are in the pharmacy for and which pharmacist they would like to speak to. Then a small slip is printed with their queue number, so they are free to shop

around until the pharmacist is free. The prescriptions, like some other places in Europe, are pre-packaged into set quantities. What is interesting is that each patient, doctor, and medication have separate identification barcodes printed on the prescription. In addition, Italian healthcare cards also had a similar barcode. Processing a script is so efficient and high-tech! We also visited the Negombo Thermal Gardens to experience the healing waters of Ischia. Each of the 12 pools vary in temperature and design, from 24° to 36° Celsius. The baths are said to help reduce inflammation, improve circulation, and recover from osteoarticulatory disease. The spa is treatment that doctors recommended to for patients’ health. Based on speaking with locals and health care professionals in Italy, their medicine trends towards non-pharmacological remedies and holistic healing. I wouldn’t mind a prescription to enjoy this more often! The concern I heard most before attending this trip was that most people would rather travel on their own time, rather than balance class and travel. I’d have to disagree though! Personally, the best part of going was that I could spend so much time on a beautiful island and take in the lifestyle, without feeling as though I had to rush and see as much as possible. Being just on Ischia meant that I could visit my favourite gelato stands over and over, wander all the tiny back streets, and simply wander down to the beach and sit on the pier for an afternoon. PHARM 453 allowed me to learn more about the other side of medicine that we often neglect in pharmacy – that lifestyle factors are the foundation of health. Visiting Italy this summer expanded my worldview on a cultural and educational level that I will carry with me throughout my life. I’m grateful that I could have this opportunity with close friends! Now… I just need to visit all the countries I couldn’t stop by!

January 10-13, 2018 • •

Shaw Conference Centre Accommodations at the Westin Hotel

For more information visit:

Professional Development Week (PDW) is an annual conference for pharmacy students across Canada. In 2018, the University of Alberta has the privilege to host PDW in Edmonton. PDW is an exciting four-day conference that allows students to attend talks from keynote speakers, network with pharmacists and compete against other universities in various competitions. It is also a great place to meet and get to know other pharmacy students from different provinces. | 12 |

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www.pdw2018.ca

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www.capsi.ca/pdw

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Twitter: @PDW2018

At PDW, you will also have the opportunity to play a role in CAPSI National General Council policy making and elections. Join us from January 10-13, 2018 and take the next step in your professional development. More information regarding the registration process will become clear in the coming weeks. If you have any questions or concerns, please contact CAPSI Sr. Hannah Kaliel (kaliel@ualberta.ca) or CAPSI Jr. Mark Contreras (mcontrer@ualberta.ca).

SOCIAL EVENTS Dance the night away— Hawaiian style during the tropical soiree opening gala. Next evening, experience a Western bar at the heart of downtown, followed by a mini fair on day three. See talented pharmacy students across Canada, compete to be your next Canada’s Next Stop Pharmacist. Lastly, the conference will close with a magical Northern Lights themed gala!

PROFESSIONAL DEVELOPMENT PDW is an excellent opportunity to meet pharmacists who are practicing to their full scope of practice. Network with pharmacists and other pharmacy students across Canada. Who knows, maybe you will meet your future boss at PDW.

HEALTH FAIR See a different side of pharmacy. Meet some of the largest pharmaceutical drug manufacturers — Galenova, Pfizer, Teva, Trudell Medical, RxFiles and many more. Witness the latest innovations in pharmaceutics and novel medical devices. Speak with professionals in industrial pharmacy. There is also tons of free samples and other goodies!

REGISTRATION 1. PDW Information Session (Sep 20 or 25 from 12-1 PM) 2. Educational policy, letter of intent and cheque (Due Oct 6 at 12 PM). Documents given to Hannah or Mark. 3. Students will be entered into a lottery and it will select 150 students at random 4. Selected delegates will be emailed further instructions 5. Additional rounds TBD

COMPETITIONS Represent your university at nationals. Compete against the best pharmacy students in Canada. Competitions includes compounding prescriptions, patient interviews and over the counter interviews. Rally behind the U of A at the PharmaFacts bowl. Support your Canada’s Next Top Pharmacist contestant in a night of entertainment and laughter.

COSTS • Registration $180 - PDW speakers and social events - Select meals

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Hotel $201 (quad occupancy, 4 nights) Cheque for $381 to be made out to the Alberta Pharmacy Students’ Association (due Oct 6 at 12 PM)

Farmacia en España By: Darryl Mah On July 3rd of 2017, I packed up as much as I could into a single backpack and got onto a plane to Albacete, Spain, a small town in the middle nowhere. There, I spent the next two and a half weeks doing an exchange trip through the International Pharmaceutical Student’s Federation (IPSF). I was slated to do research in organic chemistry at the faculty of pharmacy there. The only thing I found new about this town was the saying “Albacete, caga y vete” (please put this into google translate, it’s hilarious). To say I wasn’t expecting much would have been an understatement, but I am glad that I decided to go since I learned a lot on this trip. The first thing I want to talk about briefly is pharmacy. Everyone knows that Alberta’s scope of practice is amazing, so I won’t bore you with another rant about how lucky we are. You already know that. Instead I want to tell you what I learned about pharmacy students in Spain. I had the good fortune of meeting many pharmacy students in all different years of study, some of which I can confidently say I am good friends with. What I found fascinating was not the differences between us, but rather the similarities. Almost all of them had the same reason for getting into the pharmacy - the passion for helping people. Despite the differences in learning material and practice, we are all here for the same one reason. We are all here to help people, that is the tenant of pharmacy more than anything else. Whether you are in Canada, Spain or anywhere else in the world, this idea still stands. One of the things I learned right away was that the Spanish are very laid back. They have a “siesta” (a rest) in the middle of the day from about 2 to 4pm where all the stores close. Moreover, people understand when you | 14 |

need to take a break for family or because you are sick. Even their language seems to roll off the tongue in a sort of laid back drawl. The music they play in the clubs is slower and more akin to a salsa than an EDM rave. I believe that they really value taking things slowly and enjoying their time. In a society where everything is go,-go,-go, I hope to slow things down from time to time and enjoy myself. Their laid-back traits were followed by welcoming spirits. In Spain, everyone is welcoming in every corner of the street. When you walk down the streets, complete strangers would smile and say hello. The owners of shops would always do their best to help me despite the language barrier. When you meet people, they would shake your hands and if it was a woman, you would exchange a kiss on each cheek. In the lab, everyone would talk about language and explore Spanish cuisine during my time off. Nobody treated me differently because I was a foreigner. In fact, many of them actively tried to learn something about my culture. Considering all the recent events, I believe it is important for everyone to try and embody these traits more now than ever.

Continued... During my trip, I was also able to visit the come each other with open arms even if you wonderful city of Barcelona. Shortly after I might be different. left, a van full of terrorist drove full speed through a busy street there, killing 13 people and injuring hundreds. It was the same street where, previously, I had sat down and had a sangria. This attack was done by violent people with hateful intents, plain and simple. It makes me so sick to think that such horrific event would happen in a country where I met some of the most welcoming and accepting people. However, filling my own head with malicious thoughts would only be of benefits to those who did this. In fact, just like the people of Spain, it is more important to echo the spirit of acceptance and condemn actions of hatred. So, I implore all of you reading this now: if you take anything away from this article it is to say hello to each other as you walk down the halls, to put an effort to talk to your neighbour wherever you might be and to wel-

Therapeutic Tent Talk Whether you are camping in the

great outdoors or having lunch with friends, it is never a bad opportunity to discuss therapeutics. This year, PQ Plus 2 is proud to present Therapeutic Tent Talk, which is a series dedicated to discussing common therapeutic topics encountered in a community pharmacy. Topics will primarily come from therapeutic courses from first-year and second-year pharmacy. DISCALIMER! Although topics discussed will be targeted to pharmacy students of all years, practice to your competence level. This article is not intended to be a replacement for a therapeutics course. The purpose of this article is to supplement knowledge and provide basic background information to the selected therapeutic topic. | 16 |

â&#x20AC;&#x153;The capacity to learn is a gift; the ability to learn is a skill; the willingness to learn is a choiceâ&#x20AC;?

â&#x20AC;&#x201D; Brian Herbert

Diarrhea is considered an abnormal increase in bowel movements (≥3 per day) or >200g of stools per day, which causes a decreased quality of life. Diarrhea can be classified as acute (<14 days), persistent (>14 days) or chronic (>30 days or reoccurrence of symptoms). Dehydration, flatulence and changes in electrolytes are the most common complications of diarrhea. However more severe complications include fever, abdominal pain, weight loss, mucus or blood found in stools. Let’s face it, this has happened to us some point in our lives. The patient may be embarrassed discussing his or her bowel movements, therefore it is important to act professional and use empathy to open up the discussion with the patient. Taking an accurate and complete patient assessment is key to identifying possible pharmacological or nonpharmacological treatment options. Preform your patient assessment by identifying the patient’s symptoms, characteristics, history, onset, location, aggravating factors and remitting factors (S.C.H.O.L.A.R.). S— frequency of bowel movements, nausea, vomiting, dehydration, lethargy, changes in mental state. C— consistency of stools, blood or mucus in the stools(see Bristol Stool Chart)

H— has it happened in the past? What was tried? Did it help? Side effects? O— timing of events. Eating questionable foods/drinks, travel, changes in drug therapy (new medication, use of laxatives, etc.) L— head-to-toe assessment. Abdominal pain? Altered mental state due to severe dehydration (tenting of the skin)? A— what makes it worse? Medication(s) such as certain antibiotics? Caffeine? Dairy? Fruit juices? Carbonated drinks? R— what makes it better? Medications? If so, at what dose and was there any side effects? Red flags require further investigation includes: • diarrhea with pharmaceutical intervention (children, elderly >24 hrs and adults >48 hours) • blood or mucus in stools • immunocompromised patients (cancer, HIV, infectious diseases) • Fever, severe abdominal pain, pregnancy • Antibiotics causing pseudomembraneous colitis (cephalosporins, clindamycin, fluoroquinolones, penicillin) Non-pharmacological treatments include discontinuing the offending agent (if possible), and to stop ingesting poorly absorbed

carbohydrates (foods containing sorbitol, fructose and lactose). The B.R.A.T. diet consisting of bananas, rice, applesauce and toast helps maintain electrolyte balance in the body. Adequate hydration should also be recommended. In paediatric populations, use of oral rehydration therapy, such as Pedialyte is effective when dehydration is present.

Pharmacological options for ACUTE diarrhea can be broken up based on severity. Mild-moderate: Psyllium (Metamucil) 1 teaspoon (5-6g) po q12h. • Absorbs liquids to create firmer stools that pass slowly through the GI tract Moderate: Bismuth subsalicylate (Pepto—Bismol) Liquid: 30 mL (17.6 mg BBS/ mL) po q30 mins (max 8 doses/day) Tablet: 2 tabs (262 mg BBS/ tab) po q30 mins (max 8 doses/day) • Decreases bacteria adhering to GI epithelium and antiinflammatory/antisecretory • May cause black tongue and stools at toxic levels, avoid in children ≤ 2 years and caution in children due to risk of Reye’s syndrome • Reduces absorption of fluoroquinolones, doxycycline, tetracycline Severe: Loperamide (Imodium) 2 mg after each bowel movement (max 16mg/ day) for 2 days. • May cause nausea, drowsiness, abdominal

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cramping Avoid use in children <3 years and caution in children <12 Avoid in patients with liver failure, bloody stools, fever

Constipation is loosely defined as a stool frequency of <3 stools per week, however everyone’s bowel movements are different. There are 3 types of constipation, normal transit (most common and will be discussed here), slow transit, and dyssynergic constipation. Many drugs, such as opioids, NSAIDs, antihistamines, anticholinergics, antidepressants may cause constipation. Medical conditions, for example cancer, metabolic/endocrine disorders and GI motor disorders are associated with constipation. Elderly age and pregnancy may also increase the risk of constipation. Ignoring the symptoms of constipation can lead to complications of hemorrhoids, fissures of the anus, fecal impaction and megacolon. S— determine the patient’s bowel frequency and when their last bowels were. See if bloating, abdominal pain, general discomfort, weight loss, rectal bleeding is occurring. C— consistency of stools (hard/ lumpy stools) (see Bristol Stool Chart) H— history of constipation? Laxatives? What helped? Side effects? O— what brought on the | 18 |

change in bowel routine? New diet? Change in water intake? New medication(s)? L— affecting other parts of the body? Abdominal pain, bloating, nausea, vomiting, weight loss? A— sedentary lifestyle, eating foods low in diet, decreased water intake, certain medication(s)? R— increase water intake, eating more fibre rich foods, laxatives? Red flags require further investigation includes: • Constipation lasting > 2 weeks • No bowel movements >1 week, with use of laxatives • Blood/mucus in stool and rectal bleeding • Nausea/vomiting, severe abdominal pain, fatigue, weight loss >5% • Cycles of constipation and diarrhea • Family history of colon cancer Non-pharmacological treatments include increasing fibre intake to 25-38g daily. Beans, chickpeas, peas, avocados, blackberries, prunes, whole-wheat bread and nuts are foods rich in fibre (≥5g fibre/100g). Increasing water intake to >1.5L daily and exercising is also important in being regular. Pharmacological options for NORMAL TRANSIT constipation

Mild Docusate sodium, also known as Colace (stool softener, given at 100mg po once daily to bid • Onset: 12-72 hrs Mild-moderate: Psyllium (Metamucil) is a bulk forming laxative, given at 3.4g mixed with 250mL of liquid po once daily to tid • Onset: 12-72 hrs and is safe for long-term use • May cause flatulence, bloating and abdominal discomfort Moderate PEG 3350 (Lax-A-Day or Restorlax) is an osmotic laxative, which works by drawing water into the lumen of the GI tract, to soften stools. This medication is taken as 17g dissolved in 250mL of liquid po once daily • Onset: Requires daily treatment for 2-4 days to cause a bowel movement • May cause nausea, diarrhea, abdominal cramping Moderate-Severe Bisacodyl (Dulcolax) is a stimulant laxative, which increases peristalsis in the colon. Used if osmotic laxatives fail. It is taken as 5-10mg po once daily or prn. • Onset: 6-12 hours • May cause abdominal pain/ cramps and cathartic colon from chronic use The use of suppositories and enemas may be used for severe constipation for patients requiring immediate relief. For more information see: Diarrhea and Constipation CTC via RxTx (Online)

The Unique Practice of Palliative Care Pharmacy By Ethos Ho As future healthcare professionals, we have (or will be) taught that our duty to our patients is to provide care that benefits their health. Much of the care that we are accustomed to is curing a disease or condition, whether it be taking antibiotics to fight infection, insulin to normalize blood-glucose levels, or anti-epileptic drugs to control and prevent seizures. Indeed, medicine has triumphed in increasing quality of life and in giving everyone a fighting chance against disease. It is our goal for patients to be cured. We want our patients to return home, reunite with families, live long and fulfilling lives, and to be able to find meaning and purpose in this world. However, the reality is that there are still diseases out there without a cure. Certain medications can slow disease progression and increase lifespan, but if a disease reaches a terminal endstage and becomes unresponsive to therapy, then goals of care would refocus to symptom and/or pain management, or palliative care. This summer, I had the opportunity to complete my second-year institutional rotation in the Intensive Palliative Care Unit (IPCU) at the Foothills Medical Centre. It was an incredible learning and emotional experience, where the traditional curative goals of medicine shift comfort care. During my rotation, there were various complex cases with palliative patients. Palliative medicine emphasizes the importance of multidisciplinary teams in tackling interlaced

psychological, spiritual, social, and medical problems associated with end-of-life care. These various dimensions play a crucial role in patient -care, and is linked to psychological and physical well-being. The goal is not to cure the illness but to provide adequate symptom control, acceptance of death, and relief of psychological and physical suffering to enable a peaceful passing. As a pharmacy student, much of my work involved attending rounds, updating patient charts, conducting medication reviews, answering drug information questions, discharge counseling, and coordinating discharge prescriptions with community pharmacies. Most of the patients on the unit are discharged either home or to a hospice once their symptoms are under control. I was able to follow-up with some patients from admission to their discharge from the hospital, or until their passing. The placement allowed me to reinforce my learning of opioid analgesics, nausea/vomiting, and constipation therapeutics in the classroom and apply them to real-life settings. I was also able to practice essential communication skills, such as showing empathy and compassion when meeting with patients and their families.

This article is dedicated to my sister, Sharon Ho, who was admitted to the Intensive Palliative Care Unit in Foothills Medical Centre on February 20, 2016. Sharon passed away in Agape Hospice on May 19, 2016 after a 4-year battle with brain cancer. Please help donate and raise awareness for brain tumour research at https://www.braintumour.ca/

Interview with a Palliative Care Pharmacist Jodi Delday is a clinical pharmacist in the IPCU at Foothills Medical Centre. She was also my preceptor this summer, where she provided an excellent learning environment and mentorship for institutional practice. I encourage all pharmacy students to consider palliative care for their next rotation!

1. To begin, could you share with us your education history and career-path in becoming a palliative care pharmacist?

I graduated from U of A Pharmacy School in 2008 and took a job with London Drugs. I worked there for four years before taking a year off after having my first child. When it came time to return to work, I began applying for hospital positions as I was quite unhappy working in community. I was lucky to get a position with the Foothills Hospital. I started out working solely in the dispensary for about six months then was offered a position covering a maternity leave on Psychiatry. I was there for about 9 months when that pharmacist returned to her position and I was offered the position on the Intensive Palliative Care Unit (IPCU). I have been in this position for about two years now. 2. What do you think distinguishes palliative care from other specialties? Palliative Care requires a certain type of person. It can be a difficult and emotional place to work. The focus of care is quite different from elsewhere in the hospital as we are helping patients to refocus their care on symptom control and comfort rather than life-saving measures. We are often dealing with complex care needs as well as psychosocial issues with the patient and his or her family. 3. What is the criteria for a patient to be admitted to the palliative care unit? To be admitted as an IPCU patient, the patient is usually suffering from symptoms (pain, dyspnea, delirium, etc) related to a palliative (i.e. not curative) diagnosis. That does not necessarily mean a cancer diagnosis however I’d say about 99% of our patients have a cancer diagnosis. We are also working hard to change the view of “palliative” not to mean in the last days to weeks of life but at any time when a patient is having difficult-to-control symptoms. 4. What is a typical work day like for you? I often start my day by creating care plans for any new patients who’ve come in from the previous day. I’ll then go to rounds where we discuss each patient and any concerns the nurses may have. On Wednesday, we have more thorough rounds where we also discuss each patient’s discharge plan in more detail. After rounds, I’ll go see the new patients to introduce myself and do a medication review with them. If we have anyone going home, I’ll then prepare their discharge prescriptions and a medication chart for them. I’ll review everything with them and their family, counsel on the medications and fax off the prescriptions. About once a week or so, I’ll round with one of the physicians on their patients to do medication reviews. I’ll spend the rest of my day charting on each patient and updating their care plans as well as answering any questions I get from physicians, residents or nurses when required.

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Interview Continued... 5. Which medications do you usually encounter for palliative patients? The main medications we deal with are for pain, so opioid medications and neuropathic agents. We also deal with a lot of constipation on the unit so we are very familiar with bowel routine medications. Other medications we tend to deal with a lot are antipsychotics and certain benzodiazepines to deal with delirium. 6. Any interesting cases that you could share with us?

We have many interesting cases, it’s difficult to describe just one. We do have one patient who has come in to us a few times who has a breast cancer that has caused subcutaneous lesions on her chest wall. This causes her extreme pain. Despite these lesions, she has quite a long prognosis which makes it even more important for us to keep her pain under control. We had tried her on multiple

opioid regimens trying to control her pain. We eventually had to turn to an intrathecal catheter implanted in her spine that gives her a constant infusion of hydromorphone and bupivacaine. This has controlled her pain quite nicely. We were able to send her home with this and she can look after her intrathecal at home with the help of Palliative Home Care. She will likely have this intrathecal for the rest of her life. 7. How has the expanded scope of pharmacists in Alberta helped you with your daily work? I have just recently received my APA and have been able to use it a few times—mainly to continue patient’s home medications or to adjust bowel routines. We work so closely with the physicians on this unit that it is not as integral to our practice as it would be in other pharmacy settings. Also, because much of our practice focus is on pain management using opioids, we do not have the ability to prescribe those and therefore work with the physician when managing a patient’s pain. 8. How does a pharmacist impact patient care in this field?

I would consider us integral within the IPCU team. We are very focused on a multidisciplinary approach with everyone (physiotherapy, occupational therapy, psychology, recreation therapy, spiritual care, etc) taking a role in the patient’s care. My two main roles are medication management while the patient is admitted and then discharge. I organize the patient’s prescriptions, provide counselling and education to the patient and their caregivers and ensure continuity of care in to the community. This is incredibly important for our patients as they are often going home with high dose and sometimes multiple opioids. They need to have a good understanding of how to treat their symptoms at home and what to do if they do get into trouble to avoid having to be readmitted. Just as important is for us to stress the safety concerns with the medications we send them home on and we review this thoroughly with the patient and their caregivers.

Interview Continued... 9. Providing care to end-of-life patients can be both mentally and emotionally challenging. As a pharmacist, how do you deal with these challenges? Are there supports and resources available for healthcare professionals in these settings? It can most certainly be very draining. We are very lucky to have a very supportive and close -knit team. We are most often able to support each other through the difficult cases. As a hospital pharmacist, I am also required to work in the dispensary screening orders. I try to view this time as a bit of a mental break from the IPCU and can also keep up my clinical knowledge of the other areas in the hospital. 10. Any tips for students who wish to pursue a future-career in palliative care or related specialties? In this clinical area, social skills and empathy are just as important as clinical knowledge. As I mentioned earlier, it takes a certain type of person to work with this population. A good knowledge of oncology can certainly be an asset and a thorough understanding of the physiology of pain and treatments for the different types of pain. If you are unsure of whether you would be able to work in this area, I would highly recommend volunteering on a palliative care unit or at a hospice to get an understanding of what our patient population is like.

Pharmacist Work Area Patient Rooms (Unit is currently undergoing construction)

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Agenda September 11, 13, 15

Breast Fundraiser Ever

Grad Committee T-Shirt Sale

9 PM

12 PM—1 PM

The Pint Downtown

Outside of MSB Monday September 25 Monday September 11

PDW Information Session #2

Perogy Run for the Cure Fundraiser

12 PM—1 PM

MSB 2-31

Outside of MSB Friday September 29 Wednesday September 13

Welcome Back BBQ and Dodgeball

First Year CAPSI Lunch & Learn

Challenge

12 PM—1 PM

3 PM—7 PM

MSB 2-31

Saville Community Sports Centre

Monday September 18

Deadline for Lockers, Textbooks and

AMP Mentor Training

Mentor Program Sign Up

12 PM—1 PM MSB 2-31

Sunday October 1 CIBC Run for the Cure

Tuesday September 19

9 AM

Bake Sale

Alberta Legislature Building

9 AM—2 PM Tory/Business Atrium

Wednesday October 4 AMP Meet and Greet

Wednesday September 20

Time TBD

PDW 2018 Information Session #1

Location TBD

12 PM—1 PM MSB 2-31

Friday October 6 PDW 2018 Round 1 Registration

Saturday September 23 CAPSI Saving Second Base Slo-Pitch Tournament

Deadline

9 AM—3 PM

Yearbook Photos

Confederation Park

12 PM

1. Take a silly photo of yourself doing something Pharmacy related. 2. Send it to PQ Plus 2 on Facebook. 3. Be automatically entered for a chance to win the mystery box. Bonus points for being creative and finding something related to Run for the Cure. Good luck! Do you have a secret talent writing poetry or short stories? Whether its pharmacy related or not, and everything in between, please send your articles our way at pqplus.2@gmail.com or over Facebook Messenger.

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