Last Day at NTUH

           Today is my last day of rotations at National Taiwan University Hospital. It's amazing how fast 6 weeks fly by. I was a bit apprehensive at first because even though I can speak Mandarin, I can't really read Chinese characters. This proved to be a little difficult in the beginning because you need to be able to read Chinese characters in order to navigate through the EMR. However, after around a week, I was able to navigate through the system more effectively and find the relevant information that I needed.

               For my first 3 weeks, I was in the pediatric ICU in the Children's Hospital. The learning curve was definitely steeper at this time because it was my first pediatrics and ICU rotation. This made it more difficult to compare how the two countries differed in terms of medication therapy mainly because everything was new to me. In addition to rounding with the medical team in the morning, I also attended morning meetings and prepared patient case presentations. I also had the opportunity to spend one afternoon in the compounding room turning ursodiol tablets into a powder formulation for the pediatrics population! Finally, for my end of my rotation I did a 30 minute presentation on Extracorporeal Membrane Oxygenation (ECMO) Dosing Adjustments. 

               For the next 3 weeks, I was in family medicine. This is somewhat similar to our general medicine rotations in the US. However in NTUH, there are many different subspeciality departments so the population of patients that we saw was not as broad as in a general medicine ward. In the family medicine ward, most of the patients I saw had a UTI or cellulitis. I also had the opportunity to go on rounds with the Emergency ICU team and to see how warfarin clinics are run in Taiwan.  One of the interesting things that I  learned on this rotation was that the hospital has no specific guidelines for antimicrobial dosing in obese patients. It just so happened that during my rotation, I had two patients that were obese (BMI ~40) and were being treated for cellulitis. Not many people are obese in Taiwan, so often times the doctors end up contacting the pharnacy to ask how to adjust for this specific patient population. Overall, this rotation was a nice change from PICU and I was able to see how medication therapy differs between Taiwan and the US in the adult population.

            Aside of the differences in medication therapy, I found the cultural differences and how the Taiwanese population viewmedications to be very interesting. Ony of my preceptors mentioned that patient compliance is definitely an area that needs improvement. She was saying that from the patient's perspective, they think that the doctor will always prescribe more medication than is necessary so they might consider taking less. However, from the doctor's perspective, they think that the patient will likely take less medication so they might consider prescribing more. In a way it's a catch 22. I think this situation can be bypassed if there was more of an emphasis on patient education. My preceptor did mention that this was an area that they are actively trying to improve. 

           Overall I had an amazing 6 weeks at NTUH. It was definitely an eye opening experience and I able to see how pharmacy is practiced in a different country. 

Group picture with the current and incoming NTU masters of pharmacy students 

*If you're interested in reading another perspective, check out my classmate Johnny's blog! Click Here!

Warfarin Clinic

         Earlier this week I went with the anticoagulation pharmacist to see how their warfarin clinic is run. This anticoagulation pharmacist happens to be the same ICU pharmacist that I went on rounds with earlier this week. There are currently 4 pharmacists that rotate through the warfarin clinic. Two of the pharmacists have studied abroad in the US and have seen how warfarin clinics are run in the US. The other two pharmacists are the stroke ICU and CV ICU pharmacists. Generallly most of the anticoagulation pharmacists have a masters in clinical pharmacy so only a special subset of pharmacists can work in the clinics. 

           The warfarin clinic receives their patients from referrals. Currently the anticoagulation pharmacists only work with the neuro and cardiovascular departments. Most of the patients that are referred to the clinic are either new start patients or are patients that have uncontrolled INRs. 

            As a intern pharmacist, I worked in Kaiser's Anticoagulation Clinic so I was really excited to be able to see the differences in anticoagulation therapy between Taiwan and the US. Unlike in US where we have multiple doses of warfarin (1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg, and 10 mg), at NTUH, they only have the 1 mg tablet and the 5 mg tablet. According to the pharmacist, Asians are often smaller and have a higher risk of bleeds in comparison to other ethnicities so often times higher doses are not necessary. When I asked the inpatient pharmacy supervisor about this, she mentioned that from the inpatient pharmacy's perspective, having less doses available will decrease the chances of medication errors. Because of this, most drugs are only available in two different doses because of the high prescription load and since the pharmacists are doing all of the filling. 

            Another interesting aspect is how the pharmacists approach dietary questions. As you may know, warfarin has many drug drug interactions and drug food interactions. While the green leafy vegetables are generally similar from country to country, there are certain foods that Taiwanese people eat that we do not eat as often in the US. A great example of this are animal organs (intestines, liver, heart, etc) and blood products (pig's blood), which contains a lot of vitamin K. We don't eat these items too often in the US, but in Taiwan it is a commonly found food, especially in the night markets! Also, people in Taiwan drink a lot of green tea, which contains vitamin K as well. Patients are told that if it's just the brewed green tea, then it is okay to drink it if you are on warfarin. However, the tea leaves itself are a different story and INR should be monitored closely.

         Finally, because of the increased risk of bleeds in Asians, they have different therapeutic INR ranges for certain indications as well. Please see the chart below to see the differences in INR goals between Taiwan and the United States.

Targeted  INR Goals	United States	Taiwan
Atrial Fibrillation	2-3	1.5-2.5
Atrial Flutter	2-3	1.5-2.5
Ischemic Stroke or TIA due to Afib	2-3	1.6-2.6
Venous Thromboembolism	2-3	1.8-2.4
Mechanical Aortic Valve	2-3	2-3
Mechanical Mitral Valve	2.5-3.5	2.5-3.5
Bioprosthetic Mitral Valve	2-3	2-3

Warfarin Clinic

the 2 tablet strengths available 

Case Presentation

One of our final assignments was to give a case presentation at the informal meeting. This was a patient that I had on my family medicine rotation who was admitted for an acute exacerbation of COPD. During his hospital stay, he was diagnosed with esophageal cancer and also has oropharyngeal/esophageal candidiasis. Below is the SOAP that I presented to my family medicine preceptor, NTUH School of pharmacy students, and faculty.

Bed: 6A-03-01

Admission Date: 9/8/2012

Chief Complaint: Progressive dyspnea x 1 week

Patient Profile

Age/Sex: 52 year old male

Height: 167 cm (5’6)

Weight: 55 kg (121 lbs), IBW: 63.8 kg

Renal: Cr: 0.6 mg/dl (9/10), ClCr: 85 ml/min (using a Cr of 0.8 mg/dl)

Hepatic: ALT: 20 (9/12)

History of Present Illness

             This patient has a history of suspected COPD with several episodes of an acute exacerbation the last 4-5 years. In the last three months he has reported a productive cough with whitish sputum and intermittent dyspnea. Patient visited various hospitals in China and was diagnoses with bronchitis refractory to treatment.He is now at NTUH in hopes of receiving a second opinion.

8/23: Chest Xray: upper mediastinal widening

Last week: Progressive worsening in symptoms

-Dyspnea, especially when lying down on his right side, Coughing induced by swallowing, Easily choking à poor oral intake, General malaise, Chilliness in the afternoon x 3 months, Bilateral ankle edema x 1 month, Arthralgia of the elbows, knee and ankle for 10 days, 3 kg weight loss this past week

9/6/12: Arrived at NTUH ER

             -Low grade fever: 37.3 degrees C, Tachycardia at 131 bpm

             -Lab: leukocytosis with left shift(WBC 15020, seg 85%)

-Chest xray: (1)consolidation at retrodiaphragmatic right lower lung, (2)normal heart size, (3)widening of upper mediastinum

-Started on empiric Unasyn & Zithromax

9/8/12: Admitted to family medicine

 Past History
1. Systemic disease: suspected history of COPD; HBV: denied
2. Hospitalization and surgical history: denied
3. Allergy history: nil; Medication ADR: nil

4. TOCC

Travel history:China. Often visits saunas

Occupation: merchant in China

Contact and cluster history: denied

6. Family history: no known major systemic disease
7. Alcohol(+): Whiskey 100~200ml per day for 10~20 years; Betal nut: denied; Cigarette(+): 1PPD for 20~30 years

8. No medications prior to admission

Current Medications

-         Ipratroprium (Atrovent) Neb 1 amp IH q 6 hrs

-         Terbutaline (Bricanyl) Neb 1 amp IH q 6 hrs

-         Methylprednisolone(Solu-Medrol) 40 mg IV q8 hrs& 20 mg IV q 12 hrs PRN 

-         Metoclopramide (Primperan) 10 mg IV q 8 hrs

-         NaCl 0.9% 500 ml QD (167 ml/hour)

-         NaCl 0.9% 1000 ml QD (250 ml/hour)

-         Bisacodyl (Dulcolax) 10 mg: 1 tab PR daily PRN

-         3.3% AA, 7.5% glucose, electrolytes (250 ml/hr)

-         Piperacillin/Tazobactam (2000/250mg) Tazocin STAT and then 4000 mg q 6 hrs

-         Nystatin (Mycostatin) susp 4 ml GA q 6 hrs

1)       Suspected Acute Exacerbation of COPD (likely induced by pneumonia)

Subjective: progressive dyspnea x 1 week (especially when lying on right side, productive cough with whitish sputum, general malaise, chilliness for the last 3 months

Objective

Vitals	9/6	9/8	9/9	9/10	9/11	9/12	9/13	9/14
Temp (highest)	37.3	36.9	36.4	36.5	36.8	36.3	36.8	36.7
BP (highest)	121/87	124/48	142/71	137/75	121/69	108/63	123/67	128/74
Pulse (highest)	131	122	101	109	124	92	88	85
RR (highest)	22	18	18	24	26	20	20	21
SaO2 (lowest)	94%		97%	95%	87%	98%	96%	98%
Pain		1	0	0	0	1	0	0
POC	251	294	141	134	141	178	147	158

Physical Examination (Upon admission)

Consciousness: clear and oriented, E4M6V5
HEENT: grossly normal, conjunctiva: pink, sclera: anicteric
Pupil: isocoric, 3mm/3mm; Light reflex: L/R: +/+, EOM: full and free
Neck: supple, LAP (-) Goiter(-) Carotid bruit(-)
Chest: symmetric expansion,
Breath sounds: loud rhonchi over right lower lung, compatible with CxR findings
Heart: RHB, no murmur
Abdomen: soft and flat, bowel sound: normoactive
Tenderness(-), Rebound tenderness(-), Liver/ spleen: impalpable.
Back: No flank knocking tenderness
Extremities: Freely movable, Pitting edema(-); Cyanosis(-)
Skin: Skin rash(-)
Peripheral pulsation: intact

Review of Symptoms

chills(+, for 3 months), weight loss (+, 3kg in 1 week), easy-fatigability (+, for 3 months), change of appetite (+, in recent 1 week), dyspnea (+, for 3 months, exacerbated in 1 week), cough (+, for 3 months), joint pain(+, arthralgia at bilateral elbow, knee, ankle joints)

Laboratory Report

Common electrolytes: Na (135-148): 135 mmol/L (9/12/12)

                                        K (3.5-5.3): 4.5 mmol/L (9/12/12)

Inflammatory Markers	9/6	9/10	9/12
White Blood Cells (3.59-9.64)	15.02	13.3	17.47
Segs (41.2-74.7)	85.0	73.8	90.4
CRP (0-0.8)			16.64

Gram Stains & Cultures

-SPUTUM: (9/6/12) Gram’s (GS) #1 Few PMNs (<10/LPF)

                              Gram’s (GS) #2 Few epithelial cells (<10/LPF)

                              Gram’s (GS) #3 Gram (+) cocci 2+

                              Gram’s (GS) #4 Gram (-) bacilli 3+

-SPUTUM: (9/7/12) Gram’s (GS) #1 Moderate PMNs  (10-25/LPF)

                              Gram’s (GS) #2 Few epithelial cells (<10/LPF)

                              Gram’s (GS) #3 Gram (-) rods 2+

                              Gram’s (GS) #4 Gram (+) cocci in chains 2+

-SPUTUM: (9/7/12) ID+DS Sputum Culture #1: mixed flora

-BLOOD PERIPHERAL SITE (9/7/12) No aerobic and anaerobic pathogens

-NASAL SWAB (9/8/12) Influenza A+B Rapid Screen Test: negative

-SPUTUM (9/8/12) AFS + Culture #1: acid fast bacilli - negative

-SPUTUM: (9/9/12) Chlamydiae antigen: negative

-BLOOD: (9/10/12) Mycoplasma pneumoniaIgM and IgG: negative

-SPUTUM: (9/13/12) – PENDING

-BLOOD PERIPHERAL SITE (9/13/12) – PENDING

Assessment

             Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 Guidelines:

-The diagnosis of exacerbation relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms (baseline dyspnea, cough, and/or sputum production) that is beyond day-to-day variation.

             Common Causes for acute exacerbations of COPD

                           -Respiratory Tract Infections (bacterial or viral)

                                        -Most common pathogens: H. Influenzae, S. Pneumoniae, M. Catarrhalis, Pseudomonas(for GOLD 3 and 4 pts)                            

-Air pollution

                           -Idiopathic causes

             Treatment Options

Supplemental Oxygen: Target saturation of 88-92%.

Bronchodilators: Preferred therapy is a short acting beta agonist +/- a short acting anticholinergic. This patient is currently on terbutaline (SABA) and ipratropium (anticholinergic). Patient’s respiratory status has been relatively stable on this regimen.

-Monitor: Terbutaline: Serum K+, glucose, HR, BP, RR, chest pain, dyspnea, pulmonary function tests 

               Ipratropium: abnormal taste in mouth, dry mouth ,urinary retention, increased HR

Systemic Corticosteroids: Have been shown to shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the length of hospital stay and treatment failure (evidence A). Recommended therapy (D) is prednisolone 30-40 mg/day x 10-14 days. Upon admission to family medicine, the patient was switched from IV methylprednisolone to PO prednisolone. However, on 9/11 his vitals started to worsen (increase in RR, decrease in SaO2 to 87%) so the patient’s PO systemic corticosteroids were switched back to IV. Patient’s vitals are currently stable. His POC sugar readings and blood pressure have been relatively stable given high dose steroid treatment. If patient’s respiratory function improves, consider tapering down methylprednisolone 20 mg IV q 8 hrs and then transitioning to PO therapy.

             -Monitor: Blood pressure, blood glucose, electrolytes, mood changes 

Antibiotics: Should only be given to patients with three cardinal symptoms: increase in dyspnea, sputum volume, and sputum purulence (evidence B); have 2 of the cardinal symptoms, if increased purulence of sputum is one of the 2 symptoms (evidence C); or require mechanical ventilation (invasive or noninvasive) (evidence B). The recommended duration of treatment is 5-10 days (evidence D). The initial empirical therapy is an aminopenicillin with or without clavulanic acid, macrolide, or tetracycline.This patient has been exhibiting the three cardinal symptoms these past 3 months, but only had increasing dyspnea this past week. Since this patient is likely to be some sort of infection such as pneumonia(due to an increase in inflammatory markers such as WBC and segs), unasyn was started anyway. Sputum culture results from 9/6 and 9/7 did not identify a specific pathogen. All 3 acid fast stains were negative. Also, blood in the peripheral site on 9/7 did not grown any aerobic or anaerobic pathogens. Influenza A+B test was negative. At first it seemed like therapy was working since WBC count was dropping but on 9/12, WBC came back higher that it has ever been and unasyn was switched to tazosin, which is an even broader spectrum antibiotic. This makes it more likely that the pneumonia is possibly nosocomial (possibly because patient has been visiting many hospitals in China) or atypical, since it did not respond to unasyn.

-Monitoring: Tazocin: creatinine, BUN, CBC with differential, PT, PTT, serum electrolytes, LFTs, urinalysis, signs of bleeding

                           Adjunct Therapy (diuretics, anticoagulants, treatment of comorbidities, nutritional aspects)

Plan

-Continue current antibiotic therapy and monitor for clinical improvement (lowering of WBC, segs, CRP, etc)

-Consider tapering methylprednisolone dose when respiratory symptoms have improved. Taper slowly to prevent steroid withdrawal.

-Follow up with pending blood cultures. De-escalate antibiotic therapy if possible and drug sensitivities are available.

-Stress the importance of nonpharmacologic modifications such as smoking cessation. 

-Upon safe discharge from family medicine, patient should follow up with OPD to assess baseline COPD control.

2)       Newly Diagnosed Esophageal Cancer

Subjective: Coughing induced by swallowing, easily choking à poor oral intake, 3 kg weight loss this past week, general malaise

Objective

             -8/23: Chest Xray: upper mediastinal widening

-9/10: CT Imaging

TECHNIQUE: Multidetector row CT of the chest was performed without and with intravenous contrast administration. FINDINGS: - Lungs: Unremarkable. - Pleura: No pleural effusion. - Thoracic lymph nodes: Subcarinal and upper right paratracheal and bilateral supraclavicular adenopathy. - Esophagus: Irregular wall thickening at upper esophagus. - Great vessels: Unremarkable. - Heart and pericardium: Unremarkable. - Adrenal glands: Unremarkable. - Bones/Soft tissues: Spondylosis with degenerative marginal spurs. - Other: Multiple small hypodense lesions at liver.
Impression
Suspect esophageal cancer with mediastinal LAPs.

-9/13/12: GED endoscopic diagnosis: esophageal cancer, upper esophagus, with lumen obstruction, s/p biopsy; candidiasis (oropharynx and esophagus)  

Assessment

Risk Factors: Whiskey 100~200ml per day for 10~20 years; smoked 1PPD for 20~30 years

             The results from the esophagogastroduodenoscopy (GED) confirm that this patient has esophageal cancer.  The patient is almost unable to swallow anything due to a mass in his esophagus. The medical team has consulted for a fibroscope assisted NG insertion in hopes of alleviating this issue for the time being, but the NG tube placement failed. Additional departments will be consulted to decide the next course of action.

Plan

-Continue with all current medication formulations. Until a future plan has been established about the mass, oral medications may not be a feasible option for this patient and if needed to be used, should be assessed closely.

3)       Oropharynx/Esophageal Candidiasis

Subjective/Objective

             -GED: white patchy spots in the throat and esophagus

Assessment

             -This patient is currently being treated with nystatin 4 mL gargling q 6 hours. While this is not the best therapy of choice for this condition, it is likely being used since the patient is unable to swallow pills. Nystatin may be efficacious in treating oropharygeal candidiasis but it has not been shown to be effective in the treatment of esophageal candidiasis. According to the 2004 IDSA guidelines for the treatment of candidiasis, topical therapy is ineffective and should be avoided. If a patient is unable to swallow, parenteral therapy should be used with an azole, capsofungin, or amphotericin B. If this patient is able to swallow a pill, then the drug of choice is fluconazole 400 mg PO loading dose, followed by 100 mg/day for 14-21 days. However, if the patient is unable to swallow pills, then IV fluconazole should be considered at the same dose.

             -Monitoring: nystatin: GI side effects such as nausea, vomiting, stomach pain, and diarrhea.

Plan

             -Consider switching nystatin to fluconazole to better treat patient’s oropharyngeal and esophageal candidiasis.