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By L. Cobryn. Westwood College of Technology.

Notes: Oral Oncology Medication Therapy Management Flowsheet When prescribing therapy with an oral oncology medication purchase norvasc 2.5mg fast delivery blood pressure monitor chart printable, the processes and flow of patient care is different compared to when prescribing therapy with intravenous oncology medication discount norvasc 5 mg with visa heart attack high blood pressure. While the structure and dynamics of each organization is different, this resource reviews sample considerations related to navigating a core set of key components for managing patient therapy with oral oncology medications. Operations, as a core component of oral oncology management, involves: • Managing flow patterns and operational processes specific to treating a patient who is prescribed oral oncology medications throughout the care continuum, from treatment planning and financial review through medication acquisition and educational training Operations Assessment, as a core component of oral oncology management, involves: • Conducting baseline patient readiness assessments to evaluate if patients are appropriate candidates for therapy with oral oncology medications Assessment Access, as a core component of oral oncology management, involves: • Conducting financial review of patient access to insurance or other assistance programs, including identifying support resources • Understanding the methods of acquiring oral oncology medications, most commonly through an in-house dispensing pharmacy or specialty pharmacy, including the specific considerations for each route of access Access Treatment plan, as a core component of oral oncology management, involves: • Conducting comprehensive review of the patient’s medical care with oral oncology medications, including informed consent, obtaining clinical history, performing clinical evaluations and review, and developing an adherence plan, among other considerations Treatment Plan Communication, as a core component of oral oncology management, involves: • At a practice level, ensuring effective and coordinated communication among all providers who are part of a patient’s health care team • At a patient level, understanding when and how to communicate with the health care team, including issues related to correctly administering the oral oncology medication, monitoring adherence, and managing side effects, among other considerations Communication Education, as a core component of oral oncology management, involves: • At a practice level, establishing an educational program and developing a curriculum as needed • At a patient level, receiving educational training related to therapy with oral oncology medications EducationEducation Operations Questions for the organization to review internally 1. Who in the organization will discuss access considerations with the patient, including financial review and medication acquisition? Who in the organization will develop the treatment plan and review on an ongoing basis as needed? Who in the organization will manage communication with other providers in the health care team as needed, as well as communicate with the patient and caregiver? Who in the organization will provide educational training to the patient and caregiver? Assessment Questions for the health care team to review with the patient Physical Ability 1. Do you feel you may have any difficulty understanding how and when to take your medication as well as keeping track of any side effects? Do you feel anxious, upset, tired, or experience sleepiness that may affect taking your medication as prescribed? Is anyone assisting and providing support during your treatment, such as family members, friends, partners, caregiver, or any other contact? Do you feel you will be able to take your medication based on a regular schedule, as prescribed? What do you think your role is during your treatment and what do you expect of me? Will you be able to come here regularly to fill your prescription (if dispensed through in-house pharmacy)? Can you drive in or arrange for transportation to come here regularly for routine follow-up appointments? Has your insurance ever prevented you from being able to obtain or fill your medication? Other Considerations Do you have any other concerns that I should be aware of which may affect your ability to take oral medications? Access Considerations for the health care team to review and involve the patient as needed Patient Financial Review 1. If yes, what is the name of the insurance company, name of the health plan, and if applicable, name of the pharmacy benefit manager? Is the oral oncology medication covered under the patient’s health plan medical benefit or pharmacy benefit? Does the patient’s health plan require prior authorization for the oral oncology medication before therapy initiation? If the maximum out-of-pocket requirement has not yet been met in full, how much is remaining? Does the patient have any other secondary or supplemental insurance benefits that would require coordination? Does the patient’s health plan have any specific coding or claims submission guidelines for reporting the oral oncology medication? What assistance programs and/or foundations may be available to support the patient’s therapy? Does the patient’s insurance mandate specific acquisition requirements for the oral oncology medication? Treatment Plan Considerations for the health care team to review and involve the patient as needed Informed Consent q Yes, my patient has provided signed, informed consent to receive treatment with oral oncology medication q No, my patient has not provided signed, informed consent to receive treatment with oral oncology medication Medical & Treatment History 1. Social considerations, such as drugs/alcohol/tobacco use, religion, sexual history, and employment status Clinical Evaluations Imaging studies/laboratory work/scans/tests Clinical Review 1. Schedule for routine, follow-up visits Progress Notes Communication Considerations for the health care team to review and involve the patient as needed Health Care Team Communication: Coordinating Therapy Management 1. Communication to primary care physician advising of patient’s current therapy, including details on date and method of communication 2. Communication to other specialist advising of patient’s current therapy, including details on date and method of communication 3.

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In other words norvasc 2.5mg line blood pressure medication insomnia, a person will lose at least 50% of the dopamine in his or her brain before noticing that something is wrong with his or her body buy norvasc 5mg otc exforge blood pressure medication. In 2011, a computerized brain scan utilizing a radio-isotope that labels the molecule transporting dopamine into the cell (DaTscan™) first became available in the United States. Since these symptoms are largely due to the diminishing supply of dopamine in the brain, most symptomatic medications are designed to replenish, mimic or enhance the effect of this chemical. Regular exercise, physical therapy, occupational therapy, speech therapy, holistic practices, nutritional consultation, support groups, education, psychological counseling, intelligent use of assistive devices and caregiver relief are all important aspects of the best treatment plan. Pronunciation Key (accented syllable in bold) Levodopa Lee-voe-doe-pa Carbidopa Car-bee-doe-pa Ropinirole Row-pin-er-ole Pramipexole Pram-i-pex-ole Rotigotine Row-tig-oh-teen Apomorphine Ae-poe-more-feen Selegiline Sell-edge-ah-leen Rasagiline Rah-saj-ah-leen 8 Parkinson’s Disease: Medications Table 2. As they continued to explore ways to translate these observations to the human condition, their efforts led ultimately to the successful development of levodopa in the late 1960s. Levodopa was the first medication proven effective for treating a chronic degenerative neurologic disease. Levodopa in pill form is absorbed into the blood stream from the small intestine and travels through the blood to the brain, where it is converted into the active neurotransmitter dopamine. Levodopa Stopped Started 1% The Parkinson’s Outcomes Project is the largest 2% clinical study of Parkinson’s in the world. As of May Not Used 2015, more than 19,000 evaluations had taken place 9% on almost 8,000 people with Parkinson’s. This chart shows the percentage of people using and not using levodopa at each of those 19,000+ visits. In the early days of levodopa therapy, large doses were required to relieve symptoms. The solution to this inefficient delivery of the drug was the development of carbidopa, a levodopa enhancer. When added to levodopa, carbidopa enables an 80% reduction in the dose of levodopa for the same benefit and a marked reduction in the frequency of side effects. In fact, the name says it all: “sin” “emet” roughly translates from “without” “vomiting” in Latin. This is a vast improvement upon levodopa alone, though nausea can be one of the more common side effects of carbidopa/levodopa. The generic product is intended to be chemically identical to the name brand and, for most people, is just as effective. The bioavailability of generic medication in the body may vary by 20% (20% more or 20% less available) compared to the original branded drug. If you observe a difference in your response to medication immediately after switching from name brand to generic, or between two different generics, speak with your physician about ways to optimize your medication. Levodopa’s half-life — a measure of how long a drug stays in the bloodstream before being metabolized by the body’s tissues — is relatively short, about 60-90 minutes. Advantages may be seen for some patients needing longer responses or overnight dosing. But, for other patients, this may be less desirable as there may be a delay in effect and only about 70% of the effective levodopa is usually absorbed before the pills pass through the intestinal tract. These plasma levodopa concentrations are maintained for 4-5 hours before declining. Interestingly, high fat meals delay absorption and reduce the amount absorbed, but can potentially lengthen the duration of benefit. People who have difficulty swallowing intact capsules can carefully open the Rytary capsule and sprinkle the entire contents on a small amount of applesauce (1 to 2 tablespoons), and consume it immediately. Another formulation, the orally-disintegrating carbidopa/levodopa, Parcopa®, is also useful for people who have difficulty swallowing or who don’t have a liquid handy to wash down a dose of medication. The most common side effects of carbidopa/levodopa are: • Nausea • Lightheadedness • Vomiting • Lowered blood pressure • Loss of appetite • Confusion Such side effects can be minimized with a low starting dose when initiating treatment with any antiparkinson drug and increasing the dose slowly to a satisfactory level. Taking drugs with meals can also reduce the frequency and intensity of gastrointestinal side effects. For those patients who have persistent problems, adding extra carbidopa (Lodosyn®) to each dose of carbidopa/levodopa can help. As a result, some patients experience less benefit if they take their carbidopa/levodopa with a stomach full of protein like meats, cheeses and other dairy products. For improved medication absorption, one can take carbidopa/levodopa one hour before a protein-rich meal or two hours afterwards.

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In conscious patients order norvasc 5 mg free shipping heart attack mp3, hypoglycaemia may present with classical symptoms of anxiety discount norvasc 10mg visa pulse pressure sites, sweating, dilatation of the pupils, breathlessness, oliguria, a feeling of coldness, tachycardia, and light-headedness. This clinical picture may develop into deteriorating consciousness, generalized convulsions, extensor posturing, shock, and coma. The diagnosis is easily overlooked because all these clinical features also occur in severe malaria itself. If possible, confirm by biochemical testing, especially in the high-risk groups mentioned above. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 66 • Monitoring of the clinical condition and blood sugar must continue even if hypoglycaemia is initially controlled and the patient is receiving injectable glucose. For children • All children with severe malaria should be assumed to have hypoglycaemia and receive treatment as above even where a test cannot be done. For children who are unable to take food orally, a naso-gastral tube should be inserted and feeds initiated. Where dextrose is not available, mix 20 g of sugar (about 4 level teaspoons) with 200 ml of clean water; give 50 ml of this solution orally. A systolic blood pressure below 50 mm Hg (in children) and below 80 mm Hg in the supine position (in adults) indicates a state of shock. Correct any reversible cause of acidosis (in particular, dehydration in severe anaemia). Convulsions may contribute to lactic acidosis; therefore, Guidelines for the Diagnosis and Treatment of Malaria in Zambia 67 prevention of further seizures may be beneficial. If haemoglobin is above 5 g/dl, give 20 ml/kg of isotonic saline by intravenous infusion over 30 minutes. If the Hb is less than 5 g/dl, give a blood transfusion (whole blood 10 ml/kg over 30 minutes and a further 10 ml/kg over 1 to 2 hours without diuretics). Monitor response by continuous clinical observation supported by repeated measurement of acid/base status, Hb, blood sugar, and urea and electrolyte levels. Guidelines for the Diagnosis and Treatment of Malaria in Zambia 68 Chapter 8: Malaria in Pregnancy 8. Pregnant women are particularly at risk due to the lowered acquired partial immunity during pregnancy. Malaria in pregnancy may present as acute symptomatic disease or as chronic anaemia. In these areas, the risk for pregnant women to get severe malaria is higher than in non-pregnant women, and the mother or her fetus might die from hypoglycaemia, cerebral malaria, or severe anaemia. Adverse pregnancy outcomes include spontaneous abortion, stillbirth, severe maternal anaemia, and low birth weight (weight <2500grams). Low birth weight is as a result of prematurity and/or intrauterine growth retardation. Low birth weight is the single most important risk factor for neonatal and infant death. This means that malaria in pregnancy will often be asymptomatic, with anaemia being the main maternal manifestation of the infection in stable malaria areas, with quite severe anaemia in areas of low transmission. Other effects may include: preterm delivery, intrauterine growth retardation, perinatal death, low Apgar scores, and intrauterine fetal death. A negative slide is therefore not a definitive confirmation of the absence of malaria parasites in pregnancy. Quinine is effective and can be used in all trimesters of pregnancy including the first trimester. In reality, women often do not declare their pregnancies in the first trimester, so early pregnancies will often be exposed inadvertently to the available first-line treatment. There is increasing experience with artemisinin derivatives in the second and third trimesters. Severe malaria Pregnant women, particularly in the second and third trimesters, are more likely to develop severe malaria than other adults, often complicated by pulmonary oedema and hypoglycaemia.

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Patients should be encouraged to fill the prescription/s in advance and to have the pain medications on hand to be taken as needed discount 5 mg norvasc otc heart attack fever. An information sheet with instructions about how to call or page the provider should be given to each patient discount norvasc 10mg with amex heart attack i was made for loving you, and the information should be reviewed to be sure they understand. The patient should be instructed to call their provider if they do not bleed within 24 hours of using the misoprostol, if bleeding exceeds two maxi-pads per hour for two consecutive hours, or if they begin to feel very ill at any time during the medication abortion process. Office- administration may still be easier to limit the number of steps that need to be done at home. Review plans for post-abortion contraception: Patients who choose combination hormonal contraceptives (oral, patch, ring) may begin the method as immediately as the next day or on the most convenient day after taking misoprostol – even if they are still bleeding. The implant may be provided at the first visit, same day of mifepristone administration. Patients who choose tubal ligation should be referred as appropriate to avoid delays. Follow-up Assessment – Office or alternative – Day 7-14 Follow-up to assess completeness of abortion 1. Rivaroxaban, Apixaban: Factor Xa Inhibitors - Reversal Treatment for Bleeding iii. Patient choice and clinician judgment must remain central to the selection of diagnostic tests and therapy. No part of this document may be reproduced, displayed, modified, or distributed in any form without the express written permission of The Ohio State University Wexner Medical Center. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery Circulation, 100 (1999), pp. Therefore, perioperative medication management is largely based on estimating the risks and benefits of either continuing or discontinuing the medication and the urgency of the surgery or procedure being performed. Management must be tailored to the specific patient and procedure and should be based upon:  The patient’s medication allergies and prior adverse reactions  The patient’s medical problems/comorbidities  The specific procedure being performed including anesthesia/analgesia management (e. Anticoagulant/Antithrombotics Consider the procedure and need for neuraxial anesthesia when planning perioperative medication management. Oral Anticoagulant/Antithrombotic Medications  Restart time depends on the procedure and risk for bleeding Prior to Procedure Minimum Minimum recommended Class Examples Recommended time between last dose of Additional Considerations Holding Time antithrombotic and neuraxial catheter placement Patient- and procedure- 1 specific decision should Before holding any of these aspirin Do not hold* be made with patient and medications see care team. Antidepressants Class Examples Benefits of Risks of Continuation Usual Additional Considerations Continuation Management Can cause hypertensive Clearly document to avoid ® crisis when used with both drug and food Monoamine phenelzine (Nardil ) Maintain control of sympathomimetics. Monitor fluid nephrogenic diabetes balance and check Avoid withdrawal insipidus and thyroid syndrome electrolytes frequently. Inhibitors pazopanib (Votrient ) 7 days ® Hold ibrutinib 3 - 7 days after ponatinib (Iclusig ) the procedure depending on ® 7 days the risk of bleeding with the sorafenib (Nexavar ) procedure ® 6 days sunitinib (Sutent ) 2 - 3 weeks Fibrinogen should be checked preoperatively if Asparaginase  given within 4 weeks of the derivative pegaspargase (Oncaspar ) procedure. Non- dihydropyridine: diltiazem Blood pressure Hypotension (Cardizem®) Heart rate control Bradycardia verapamil (Calan®, Isoptin®) Consider obtaining digoxin Lower heart rate Induce arrhythmia level prior to surgical digoxin (Lanoxin®) Continue procedure. Digoxin Consider obtaining potassium Less heart failure Toxicity and magnesium prior to surgical procedure. Ivabradine ivabradine ® Lower heart rate Induce arrhythmia Continue (Corlanor ) chlorthalidone (Thalitone®) furosemide (Lasix®) torsemide (Demadex®) Hypotension bumetanide Continue diuretics in diuretic- (Bumex®) dependent heart failure Hypokalemia patients. If a thiazide diuretic Avoid fluid Do not take on is combined with a beta- Diuretics hydrochlorothiazide Hyperkalemia day of (Mircozide®) overload blocker, e. Hypernatremia spironolactone (Aldactone®) triamterene/hydroc hlorothiazide (Dyazide®, Maxzide®) isosorbide dinitrate (Isordil®) Continue Consider risks of hypotension isosorbide mononitrate Blood pressure versus hypertension when Nitric Oxide ® Hypotension making decisions to either Vasodilators (Imdur ) Angina control give or hold anti- hydralazine Do not take on hypertensives (Apresoline®) day of minoxidil (Loniten®) procedure Hyperkalemia Do not take on If the patient will be receiving Potassium potassium chloride Avoid day of a diuretic, then continue (K-Dur®, Klor-con®) hypokalemia Irritation of esophagus or stomach procedure potassium. For patients with endogenous adrenal failure consult the patient’s endocrinologist for steroid management. Most If patient has not received stress dose patients will not need “stress dose” corticosteroids and develops corticosteroids and should continue usual hypotension unresponsive to Dose equivalent to 5 - 20 May or may not be doses of corticosteroids on the morning of the intravenous fluid boluses treat with mg/day prednisone for adequate reserve cortisol procedure and afterwards. Provides study name and #, location of investigational medication, and protocol link. Procedures include drug preparation, dose, storage/stability parameters, randomization process, and more.

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