C3.5 R2: Prepare and deliver educational seminar to pharmacists

For my presentation during my psychiatry rotation, I presented on “Evaluating the neuropsychiatric risks of varenicline in patients with psychiatric disorders”.

Areas of improvement for future presentations are:

  • Speak louder and at a slower pace
    • take time to highlight key important points and to tie things back to the patient case
  • Explaining why I picked the literature to answer my PICO, and providing more background into the reasons for picking my literature if the trial does not fit my PICO:
    • One of the primary literature I looked at was the EAGLES trial, which was the post-marketing trial required by FDA in order for the drug companies. Although the patient population did not match my case, I felt it was an important trial to look at as the FDA had recommended to take off varenicline’s black box warning for neuropsychiatric side effects primarily because of this trial. However, I didn’t explain my rationale for choosing this study when I went over my search strategy and I think it definitely generated confusion as to the importance of going over the trial and likely disrupted the flow of my presentation
  • Making my slides less text/graphics-heavy and busy
    • One way I tried to make it easier to follow text-heavy slides was to put a simple summary which I think was helpful, but I think the slides still looked quite busy overall. It might have been better to try to divide text-heavy slides to multiple slides

Overall, I really enjoyed preparing and doing this case presentation. Everybody was very supportive and there were definitely great discussion and questions! 🙂

Presentation: case-presentation_final

C3.1 R4(e): Perform & document a pharmacokinetic interpretation (OTHER drug)

ID: 72 yo female with bipolar type II disorder and mild Alzheimer’s


  • Taking divalproex EC 1000mg po daily at 800hr since Sept 28, 2016 (no compliance issue in hospital)
    • As per P’net, patient was also on divalproex EC 1000mg po daily PTA (but likely non-compliant as valproic acid level on admission (Sept 26) was 36 umol/L)
  • Valproic acid level: 513 umol/L (350-835 umol/L)
    • Taken on Oct 5, 2016 (12 hours post 800 hr dose)
      SPH lab bases on 12 hr-post dose trough concentration, regardless of dosing frequency as studies have shown that its best for interpretation
  • Oct 5, 2016 Labs:
    Alb: 30g/L, AST = 20, ALT = 12, GGT = 8, ALP = 57, total bilirubin = 5 umol/L
  • As of Oct 6, 2016 – patient denies any concerns or side effects with divalproex (e.g. no tremors, weakness, dizziness, stomach upset). Patient feels that her mood is stable (denies low or elevated mood, issues with sleep and energy)


  1. Level is drawn appropriately and at steady state
  2. Level is within therapeutic range. However, albumin is slightly low and also considering her age the protein binding to valproic acid might be lower and total valproic acid level might noe be reflective that free valproic acid level is within therapeutic range. Her free valproic acid level is likely higher than someone who is younger and have normal albumin levels.
  3. Patient denies any issues with her mood and there are no significant safety concerns with divalproex


  1. Continue current dose of divalproex 1000mg EC po daily
  2. Monitor for adverse reactions of divalproex (e.g. tremors, dizziness, insomnia, stomach upset)

C3.1 R4(h): Provide continuity of care from in-hospital to outpatient setting #3

Discharge counselling for a 29 yo male admitted with psychosis

  • Counselled about medications, indications, regimens, drug interactions and side effects
    • In hospital, patient was on phenytoin 100mg po TID
      → Counselled that being discharged on 200mg AM and 100mg HS to ease compliance
    • Patient stated that when he was started on paliperidone, he started to feel tired in the morning but awake at night (typically sleeps at 2am for 12 hours)
      → Discussed other factors that could be affecting sleep
      → Discussed non-drug measures for sleep
      → Discussed shortening sleeping time, in order to make it easier to sleep at an earlier time and the importance of having a regular sleeping schedule
      → Discussed that if this was an ongoing and intolerable issue, despite adequate attempts at managing sleep – to discuss with his physician
  • Confirmed the community pharmacy that the discharge prescription was faxed to is correct
    • Patient does not remember the community pharmacy he usually goes to
    • Worked with patient to figure out what his regular community pharmacy is
    • Called and confirmed community pharmacy that he is a patient there and have been recently filling medications there PTA. Notified community pharmacy that patient is being discharged today
    • Contacted community pharmacy that the discharge prescription was originally faxed to and cancelled prescription
    • Faxed discharge prescription to patient’s regular community pharmacy and documented changes
  • Patient did not want any patient information handouts. Aware that his community pharmacy and physician is a good resource for any information/questions

C3.1 R4(h): Provide continuity of care from in-hospital to outpatient setting #2

Discharge counselling for a 47 yo male admitted with psychosis

  • Counselled on medications, indications, regimens and side effects
    • In hospital, patient was on olanzapine 5mg daily and 10mg HS
      → Counselled that regimen has been changed to 15mg HS
      (Same daily dose, but changed to a once daily dosing for compliance)
    • In hospital, patient was on divalproex EC 250mg daily and 500mg HS
      → Counselled that regimen has been changed to 750mg HS
      (Same daily dose, but changed to a once daily dosing for compliance)
    • In hospital, patient was on phenytoin 200mg twice daily
      → Checked with patient that he has not had any seizures while on phenytoin
      (Patient stated on medication for 15-20 years and when he was compliant to the medication, he did not have any seizures)
      → Checked with patient if there were any difficulties in compliance and discussed importance of medication (had been previously non-compliant to medication)
      → Phenytoin concentration in hospital was sub-therapeutic (see for reference: https://shermainengorx.wordpress.com/2016/09/29/c3-1-r4e-perform-document-a-phenytoin-pharmacokinetic-interpretation/)

      • Next phenytoin blood work was due today, but postponed and to be done in the community
      • Counselled on importance of getting blood work  with AOT to ensure that his steady-state concentration is within therapeutic range
    • In hospital, received paliperidone 100mg IM q 4 weeks.
      • Counselled that next dose is due on Oct 14, 2016 (AOT team goes to his residential area and administers medication)
    • In hospital, patient was on nicotine replacement therapy – 21mg patches and 4mg gums PRNs (Able to decrease smoking from 3 packs per day to 1-2 cigarettes per daily)
      • Counselled about pharmacare’s coverage for NRTs
      • Patient had already used coverage for this year; however, was not successful in quitting
      • Counselled about other measures for smoking cessation
      • Discussed other drug measures for smoking cessation and advised patient to see GP to further discuss appropriate options
  • Discharge prescription was written for daily dispense in community; however, patient fell and hurt his leg. Unit clerk coordinated with AOT team so that medications were temporarily delivered to the AOT team and the AOT would deliver medications daily to patient.
  • Patient did not want any patient information handouts

C3.2 R5: Submit an Incident Report to appropriate authority

I submitted an incident report through the Providence Health Care Intranet to BC PSLS. The following are the details of the event:

  • Date event was made: Sept 25, 2016
    • Place: Emergency
  • Date event was discovered: Sept 26, 2016
    • Place: 2N Ward
  • Event:Patient with schizoaffective disorder brought himself to emergency on Sept 25 due to recurrence of auditory hallucinations, voices suggesting to kill himself. Pharmanet shows that patient was taking clozapine 175mg po qam and 200mg po qhs. Clozapine PPO was completed by a medical resident.

    Medical resident documented that patient missed last night and this morning’s clozapine, but otherwise compliant. As advised by a psychiatrist (the attending), they ordered a continuation of clozapine but to start the bedtime dose at 100mg (instead of 200mg) and for the regular doctor and pharmacy to decide and assess the next day’s dose. Dose was written to be given at HS and for vitals to not be done as patient will be sleeping (Dose should preferably given at 2000hr and vital signs to be done 2 hours post dose).

    On Sept 26, patient’s CRP is elevated (101.2), Troponin T (7), NT-proBNP (198). Patient was tachycardic (112-140 bpm). It was found out later that patient had 2 weeks of auditory hallucinations due to medication non-compliance

  • Harm: 3-Moderate Harm
    Symptoms require intervention (such as additional operative
    procedure or therapeutic treatment) or an increased length of stay, or
    cause minor permanent or long-term harm or loss of function.
  • Description of Harm:
    CRP was elevated, trop T were mildly elevated (but within range) and patient became tachycardic; therefore, medication was held for one dose and restarted at a lower dose (25mg)
  • Description of potential severe harm:
    Initiation of high doses of clozapine, when the patient has not been compliant for >48 hours can increase the risk of clozapine-induced myocarditis, cardiomyopathy, heart failure and agranulocytosis.
  • After the event, was any intervention attempted to prevent, minimize or reduce harm? Yes
  • At what stage did the event occur? Prescribing
  • Med rec was done:
    • On admission – Yes
    • On internal transfer – No
  • Medical problem: Incorrect dose or concentration
  • Additional Information:
    Given patient’s non-compliance to clozapine for more than 48 hours, the dose of clozapine should have been re-started on a lower initial dose.
    The medical resident had documented that patient only missed his last two doses. However, given the context of his admission (recurrent auditory hallucinations for 2 weeks), the patient’s report of his compliance may be questionable.

    After patient was initiated at a lower dose of clozapine, CRP decreased and normalized within a few days. Patient’s heart rate went from ~140 (elevated) to 100 (“normal baseline”).

  • Ideas for prevention or improvement:
    Thorough medication history and judgment of patient’s adherence. If patient is presenting with psychosis, their adherence to medication should be questioned and initiation of a lower dose like 12.5-25mg should be considered.Although sometimes ordered, clozapine levels may take up to 5 days to be resulted.

Event has been saved. The reference number is PSLS894050

Reflections – Psychiatry

Psychiatry is definitely a very different and complex field, and I am very fortunate to have such an experienced and knowledgeable preceptor to help guide me through psychiatry! 🙂 During this rotation, I had the opportunity to care for patients with various psychiatric disorders such as eating disorders, bipolar, and many more. Before this rotation, I had found psychiatry very daunting…and it’s definitely more of an art than a science as evidence in psychiatry often has various limitations. But, with the help of Gillian, I was able to develop a systematic approach to working up patients and identifying and comparing different therapeutic alternatives. Additionally, through our therapeutic discussions, I also gained a stronger understanding of common psychiatric disorders and was able to garner a lot of clinical pearls from Gillian. In my future rotations, I will continue to develop my knowledge and ability to perform therapeutic drug monitoring for common psychiatric medications (e.g. lithium).


C3.1 R4(e): Perform & document a pharmacokinetic interpretation (OTHER drug) #2

ID: 47 yo male admitted on July 6, 2016 with unspecified psychosis

Medical conditions:

  • Schizoaffective disorder vs. Bipolar I manic disorder
  • (Previous?) Cluster B personality disorder
  • Methamphetamine use disorder
  • Opioid use disorder (on methadone for 20 years ago, started heroin at 15 yo)
  • Tobacco use disorder

Global Assessment Functining (GAF) = 20-25


  • Nicotine patch 21mg/24hr apply 1 patch daily
  • Ferrous fumarate 300mg PO daily
  • ascorbic acid (vitamin C) 500mg PO daily
  • Vitamin D 1000 units PO daily
  • Multi-vitamins – 1 tab PO daily
  • Divalproex EC 500mg tab PO daily (800) and 2000mg PO hs (2200)
    ?Start date in hospital (as chart thinned), but has been on it at this dose at least since the end of Aug
  • Lithium carbonate 900mg PO hs (2200)
    Aug 23: started on 300mg PO hs, 24: ↑ 600mg hs, 29: ↑ 1050mg hs
    Sept 6: ↓ 900mg hs (RN noticed mild tremor, and ++ akathisia – marked restlessness, unable to sit, asking if he can pace, speech – N volume/speed, good eye contact) 

    • Last lithium levels:
      Sept 10: 0.7, Sept 4: 0.9, Aug 29: 0.5
  • Methadone 100mg po daily
  • Trazodone 250mg po hs
  • Quetiapine 800mg po hs
  • Mirtazapine 7.5mg po hs
  • Zuclopenthixol 20mg po hs


Levels drawn on Sept 28:

  • VPA level (drawn at 1000 hr, hold dose until drawn): 563
    • 12-hour post dose
    • AM dose was given at 1030 instead of 800
    • Therapeutic range: 350 – 835 umol/L
  • Lithium level (drawn at 1000hr): 0.70
    • 12-hour post dose
    • Maintenance therapeutic range: 0.6-0.8 mmol/L

LFTs, Sept 5:
AST: 49, ALT: 40, GGT: <5, ALP: 46, Total bilirubin: 4

Renal function:
Sept 5 (1007): eGFR: 84 mL/min, sCr: 93 umol/L
Sept 5 (2040): eGFR: 69 mL/min, sCr: 109 umol/L
Sept 10 (955): eGFR: 85 mL/min, sCr: 92 umol/L

Patient interview:

  • Feels restless, kept pacing during interview and unable to sit in the chair
  • Feels mood is “low” for ?some period of time
  • Showed affect during interview and was pleasant throughout interview
  • Feels that his tremor is resolving since medication change
  • Writer not able to see any tremors when patient raised his arms outwards
  • Denies N/V and any concerns/side effects with medications


  1. Levels drawn appropriately and at steady state
    (>5 days since starting on current dose)
  2. Level is within therapeutic range (0.6-0.8 mmol/L for maintenance)
  3. No significant safety concerns with current doses of valproic acid and lithium
    – No renal impairment
    – No liver impairment
    – Patient has minimal side effects and concerns with medication (no hand tremors)
  4. As per psychiatrist and nurse’s notes, patient is clinically improving and exhibits less aggression.


  1. Continue current doses of valproic acid and lithium
  2. Monitor AEs of valproic acid: ataxia, tremors, visual changes, N/V/D, anorexia
  3. Monitor hepatic function (LFTs, albumin, bilirubin, INR) every 6 months or earlier if patient exhibits symptoms of hepatotoxicity (e.g. malaise, confusion, jaundice, vomiting, anorexia, abdominal distension/bloating, asterixis, spider veins)
  4. Monitor AEs of lithium: headache, tremor, N/V, polydipsia, polyuria, weight gain
  5. Monitor lithium levels and renal function monthly (may decrease frequency to every 3 months when dose is determined to be efficacious, safe and patient is stable)
  6. Monitor for efficacy:
    mood (+affect), thoughts, sleep, appetite, energy, auditory/visual hallucinations

FYI: Previous Pharmacist’s Clinical Note on Lithium on Sept 1, 2016

Baseline TSH 1.77, Cr 78

  • Lithium therapy started Aug 23 at 300mg HS, Aug 24 at 600mg HS
  • On Li 750 HS Aug 25-28, 2016
  • Li level = 0.5 on Aug 29, 2016 morning at 1000 hr
    • subtherapeutic as still titrating upwards
    • may be slightly early to consider this steady state level
    • dose increase to 1050mg HS
  • Met pt in dining room. denies headache. denies N/V. reports good appetite. No slurred speech. vision ✓, able to see clock on wall and tell me time accordingly
  • However, displaying fine tremor in hand bilaterally. per pt, been trembling for about a week (temporally, coincide with lithium start)
  • Drug interaction = Zuclopenthixol, Lithium, Methadone, Olanzapine, Trazodone can all prolong QT interval
    • pt July 28 ECG = 475ms
  • As pt likely experiencing minor hand tremor, secondary to Li
  • Suggest:
    1. Continue clinically monitoring with focus on tremor as escalating Li dose
    2. Repeat ECG x1 once reach a stable Li dose