Doing What You Love

lifeThere is this paradox of thought that creeps in most days (if I allow it) and most of the time I will even ask a fellow coworker, "Do you love what you do?"  or "If you could go back in time, would you choose pharmacy again?" This article by Paul Graham found its way to my feed this morning through another reading, and though it took me all morning to read and digest the whole thing, I feel validated.  There are moments when I look at myself from another's point-of-view and think, "Is she happy?"  Happiness is the thing that I tend to search for... you see I couldn't tell you exactly how much money I make to the penny.  I have no idea to the hour how much PTO I have built up.  I can tell you I have been a drug expert since 1999 and only recently so feel I can use that term and MEAN it.

Would I do my job without pay?  That, according to the article, seems to be one of the qualifiers of finding and doing what you love.  Would I do right now for money for free?  Maybe.  I mean, I would definitely change the job.  First, I wouldn't sit in a room and just enter orders all day.  I would probably do more of a clinical job but not clinical that is defined in my current job today.

What would that look like?  More patient contact.  More ER contact.  More of a presence where knowledge is valued and needed in a moment's notice.  I have that to offer.  It would make me happy, even if momentarily in that the Sallie Mae bill I continue to pay monthly would see more worthy.

But, if I was really honest with myself I would stop and say I may find something else someday.  Even if it is something on the side.  Being in-demand was a lovely time when district managers valued your license (not so much your credentials) and would throw new cars, sign-on bonuses and time off your way.  They would appear like vultures outside the retail pharmacy with a suit on and ready to beg.

Today?  The students are graduating and learning the art of begging.

The creative life doesn't seem to coincide with making money.

"The most important thing a creative per­son can learn professionally is where to draw the red line that separates what you are willing to do, and what you are not.

Art suffers the moment other people start paying for it. The more you need the money, the more people will tell you what to do. The less control you will have. The more bullshit you will have to swallow. The less joy it will bring. Know this and plan accordingly.” - Hugh McLeod

And this one by him:

"The best way to get approval is not to need it.

This is equally true in art and business. And love. And sex. And just about everything else worth having.”

What about approval from myself because I am so excited to face the day and go to work because it is not work but my passion?  Is that possible?

Steve Jobs:

Your work is going to fill a large part of your life, and the only way to be truly satisfied is to do what you believe is great work. And the only way to do great work is to love what you do. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when you find it. And, like any great relationship, it just gets better and better as the years roll on. So keep looking until you find it. Don’t settle.

What if that looking takes more than 20 years because quite honestly I am THERE.  20 years and able to say apologetically I am still seeking.

The bottom line is start doing the things you love.  What do I love?  Well, I do love medicine.  I would be lying if I didn't admit that.  I do like how convoluted and complicated it can get.  Throw in another disease state and another medication and a genetic tendency to metabolize differently and weight changes.  Throw in some food or no food or grapefruit juice (though in some medications you would have to drink about a quart a day maybe?) and complicate the black and white definition.

Then give it some time because years ago hormone replacement therapy was all the rage and now it's not.  Thank you Women's Health Initiative for that one.

Back to the question at hand...

The realization:  A 21-year-old chose this career path for me.  She, in her silver spoon mentality felt it was prestigious but not to a fault.  She could forsee perhaps having a family and not being on call.  Oh, and Todd Gean's house was close to the biggest house in Adamsville, TN.  He owned and still owns his own drugstore.  Guess what?  I never spent ONE SINGLE DAY in his pharmacy prior to going to pharmacy school.  I am not even sure I was aware what went on except he put pills in a bottle all day.

“If one wanted to crush and destroy a man entirely, to mete out to him the most terrible punishment,”wrote Dostoevsky“all one would have to do would be to make him do work that was completely and utterly devoid of usefulness and meaning.”

Yes, I am searching.

 

Genesis: Wintersong Theme

So basically, I use Genesis to power wordpress on my blog.  Within Genesis you can change out child themes (Genesis considered the "adult" theme).  I have tinkered with different designs, but I am more of a minimalist at heart and while I like the theme I'm running now, Brian Gardner has a theme he made that I love.  In fact, when I chose the one I have now, I thought I was getting the one I want, Wintersong theme. I was wrong, but it's close.

Hoping since I am taking the time to tout this theme on my blog, perhaps I will have a grand chance of winning one of the 10 that he is giving away.

 

 

No Jobs | Pharmacy Keeps On Changing

I read this post by a young pharmacist.

That being said, I would like to talk a little more about pharmacy.  Where I live, the job market is getting saturated.  People are graduating without jobs.

Let me rephrase that.  People are graduating with $150,000+ in debt, without a job.... debt that never goes away... ever.

Really eye-opening right?  I remember the good ole days in 1999 prior to the turn of the century (had to make myself sound a little wiser and aged) when working at a retail counter to pay off my $85,000 student loan debt retail district managers would personally stroll in or call and try to steal you from the competition.  They would throw sign-on bonuses and jobs were a dime-a-dozen.  With that sort of market and shortage, a pharmacist had the power.  I didn't realize at the time what power it was.  There was a lot more negotiation for sure.  Today, not so much.  The good thing about a saturated market that it can weed out those that don't work hard.  Performance is more important.

In Tennessee alone in 1999, there was one pharmacy school.  University of Tennessee at Memphis (my alma mater ;)).  Today, I think I counted five or six?

Another wonderful article... and also think you should spend the time to read the comments.  Work hard, folks.  Work hard.  Jobs are scarce.

Another article...  Tennessee specific as well.

23andMe: Knowledge is Power

In 2008, Time magazine called 23andme the invention of the year!

imagesCall me a skeptic. I would have been that prior to the results I received in the mail from 23andme. You see several weeks prior to my results, I received this ambiguous kit in the mail where I had to submit a copious amount of saliva in a cup provided and return back to 23andme. Needless to say, I was ready for my results.

Not only do you obtain insight into your own ancestral history but also medical history. Given the recent decision by many women to have a mastectomy after finding out they are testing positive for one of the breast cancer genes, I wanted to see if I had any increased risks compared to others.

The information received was and is (still combing through all the material) overwhelming. I found out there is a particular enzyme I am deficient in that could pose a problem with a certain class of medications. I am a fast metabolizer of caffeine!

An example of some of the medical conditions seen (compared risk to average):

Name Confidence Your Risk Avg. Risk Compared to Average
Coronary Heart Disease
Established Research: Multiple studies with 750+ participants
29.3% 24.4% 1.20x
Age-related Macular Degeneration
Established Research: Multiple studies with 750+ participants
22.2% 7.0% 3.16x
Atrial Fibrillation
Established Research: Multiple studies with 750+ participants
20.5% 15.9% 1.29x
Venous Thromboembolism
Established Research: Multiple studies with 750+ participants
14.3% 9.7% 1.47x
Restless Legs Syndrome
Established Research: Multiple studies with 750+ participants
5.2% 4.2% 1.24x
Ulcerative Colitis
Established Research: Multiple studies with 750+ participants
0.66% 0.51% 1.30x
Celiac Disease
Established Research: Multiple studies with 750+ participants
0.42% 0.24% 1.77x
Lupus (Systemic Lupus Erythematosus)
Established Research: Multiple studies with 750+ participants
0.31% 0.25% 1.26x
Bipolar Disorder
Established Research: Multiple studies with 750+ participants
0.20% 0.14% 1.44x
Esophageal Squamous Cell Carcinoma (ESCC)
Established Research: Multiple studies with 750+ participants
0.09% 0.07% 1.21x
Stomach Cancer (Gastric Cardia Adenocarcinoma)
Established Research: Multiple studies with 750+ participants
0.08% 0.07% 1.22x
Abdominal Aortic Aneurysm
Preliminary Research: A single study with 750+ participants
Elevated risk
Alcohol Dependence
Preliminary Research: A single study with 750+ participants
Elevated risk
Alopecia Areata
Preliminary Research: A single study with 750+ participants
Elevated risk
Dupuytren's Disease
Preliminary Research: A single study with 750+ participants
Elevated risk
Hay Fever (Allergic Rhinitis)
Preliminary Research: A single study with 750+ participants
Elevated risk
Hodgkin Lymphoma
Preliminary Research: A single study with 750+ participants
Elevated risk
High Blood Pressure (Hypertension)
Preliminary Research: A single study with 750+ participants
Elevated risk
Hypothyroidism
Preliminary Research: A single study with 750+ participants
Elevated risk
Keloid
Preliminary Research: A single study with 750+ participants
Elevated risk
Narcolepsy
Preliminary Research: A single study with 750+ participants
Elevated risk
Primary Biliary Cirrhosis: Preliminary Research
Preliminary Research: A single study with 750+ participants
Elevated risk
Progressive Supranuclear Palsy
Preliminary Research: A single study with 750+ participants
Elevated risk
Restless Legs Syndrome: Preliminary Research
Preliminary Research: A single study with 750+ participants
Elevated risk
Sarcoidosis
Preliminary Research: A single study with 750+ participants
Elevated risk
Sarcoma
Preliminary Research: A single study with 750+ participants
Elevated risk
Stomach Cancer: Preliminary Research
Preliminary Research: A single study with 750+ participants
Elevated risk
Cleft Lip and Cleft Palate
Preliminary Research: Fewer than 750 people studied
Elevated risk
Hypertriglyceridemia
Preliminary Research: Fewer than 750 people studied
Elevated risk
Tourette's Syndrome

Very insightful! And there are many more diseases covered.

You can also connect with others who share DNA and are possible relatives. So far I see that I am matched with several 3rd-5th cousins.

There are a few videos you can investigate to obtain more information about this valuable service:

23andMe provides over 240 health reports

With over a quarter million members, 23andMe is the largest DNA-based ancestry service worldwide.

When 23andMe was founded, the price of the personal genetic service was $1,000 and over time they have been able to reduce it to $99, making it a widely available information tool

I cannot wait to see where these results take me. I have already been in touch with some potential relatives. I will update as to what knowledge is gained.

I was selected for this opportunity as a member of Clever Girls Collective and the content and opinions expressed here are all my own.

GERD: BCPS 2013 Review

GI Notes Just For You! GERD

  1.  Lifestyle modification
  2. Antacids
  3. Acid suppression (prn/scheduled)
    1.  PPI
    2. H2RA
    3.  Promotility agents

 

AGA Guideline Recommendations

  • Empiric drug therapy is appropriate for patients with uncomplicated heartburn
  • Use of antisecretory drugs for pts with esophageal GERD symptoms (with or without esophagitis) is strongly recommended (grade A).
  • Data are weak to support using PPIs or H2RAs above standard doses.  However, BID dosing of PPIs is appropriate in patients who continue to have symptoms on once-daily PPI therapy (grade B)
  • Antacids are the fastest acting drugs and should be used for those patients that wants to take medications for symptoms.  Safe to take with H2RA or PPIs.
  • On-demand therapy is not recommended for erosive esophagitis.
  • No evidence of improved efficacy by adding a bedtime dose of H2RA to twice-daily PPI therapy
  • Data weak to support the use of PPIs in patients with extraesophageal symptoms

 

AGA Guildeline – Extraesophageal symptoms (chronic cough, laryngitis, and asthma)

  • The presence of extraesophageal symptoms in the absence of esophageal GERD is rare.
  • Evidence is fair for the use of once-or twice-daily PPI therapy in patients with an extraesophageal syndrome and a concomitant esophageal GERD syndrome (grade B).  A two month trail of twice-daily PPI therapy would be an appropriate therapy for these patients.
  • Evidence is for the use of once-or twice-daily PPI therapy in patients with an extraesophageal symdrome in the absence of an esophageal GERD syndrome (grade D).
  • Evidence is insufficient to recommend once-or twice-daily PPI therapy for patients with suspected reflux cough syndrome.

The Drugs

  1. ANTACIDS – calcium, aluminum, magnesium OTC.  Neutralizes acid and raises intragastric pH resulting in decreased activation of pepsinogen and increased LES pressure; rapid onsent of action but short duration, necessitating frequent dosing.  FIRST LINE for intermittent (< 2 times/week) symptoms or as breakthrough therapy for those on PPI/H2RA therapy; not appropriate for healing established esophageal erosions
    1.  Adverse effects

i.      Constipation (aluminum)

ii.      Diarrhea (magnesium)

iii.      Accumulation of aluminum/magnesium in renal disease with repeated dosing.

  1. Drug interactions

i.      Chelation (fluoroquinolones, tetracyclines),

ii.      Reduced absorption because of increases in pH (ketoconazole, itraconazole, iron, atazanavir, delavirdine, indinavir, nelfinavir)

iii.      Increases in absorption leading to potential toxicity (raltegravir, saquinavir)

 

  1.  HISTAMINE-2 RECEPTOR ANTAGNOSITS – Reversibly inhibit histamine-2 receptors on the parietal cell.  All available OTC.
    1. Adverse effects

i.      CNS effects like dizziness, h/a, fatigue, somnolence, and confusion mostly with elderly and compromised renal function.

ii.      Prolonged cimetidine – rare development of gynecomastia

  1.  Drug interactions

i.      Drugs dependent on lower pH for absorption:  ketoconazole, itraconazole, iron, atazanavir, delavirdine, indinavir, nelfinavir

ii.      Increases in absorption leading to potential toxicity:  raltegravir, squinavir

iii.      Cimetidine inhibits cytochrome P450 (CYP) enzymes 1A2, 2C9, 2D6, and 3A4 – Warfarin, theophylline, and other agents may be affected.  Cimetidine also competes for tubular secretion in the kidney.

 

 

  1.  PROTON PUMP INHIBITORS – Irreversibly inhibit the final step in gastric acid secretion
    1. Most effective before meals; for divided dosing, give evening dose before evening meal instead of at bedtime
    2. Adverse effects – h/a, dizziness, nausea, diarrhea, and constipation.  Long-term use is not associated with significant increases in endocrine neoplasia or symptomatic vitamin B12 deficiency.

i.      Cohort study – ELEVATED risk of CAP with these agents (H2RA and PPI) – immunocompromised, the elderly, children, and those with asthma or COPD

ii.      Prospective cohort study – increased risk of HAP in nonventilated patients who were prescribed PPIs

iii.      Increased risk of fractures – not recommend bone density screening or calcium supplementation.

iv.      C diff infection – increased risk

v.      Hypomagnesiumia

  1.  Drug interactions

i.      Inhibition of CYP45 – inhibits the metabolism of substrates such as diazepam through CYP2C19 inhibition

ii.      Reduced effect of clopidogrel (CYP2C19) – omeprazole most implicated

iii.      High dose IV MTX – higher risk of MTX toxicity.  Either switch to ranitidine or hold PPI dose for 2 days before and after MTX admin may help

iv.      pH-dependent absorption (ketoconazole, itraconazole, protease inhibitors)

 

  1.  PROMOTILITY AGENTS – guidelines recommend against the use of metoclopramide as adjunctive therapy or monotherapy in patients with both esophageal and extraesophageal symptoms because the risk of adverse effects (EPS/tardive dyskinesia) outweighs the benefit (grade E).  Metoclopramide has a black box warning for Tardive Dyskinesia.
    1. Works through cholinergic mechanisms to facilitate increased gastric emptying.

i.      Metoclopramide – dopamine antagonist; needs to be dosed several times a day; associated with dizziness, fatigue, somnolence, drowsiness, EPS, and hyperprolactinemia.  New 5- and 10-mg ODT formulations.  Indicated for GERD and diabetic gastroparesis

ii.      Bethanechol – Cholinergic agonist; poorly tolerated because of adverse effects such as diarrhea, blurred vision, and abd cramping; may also increase gastric acid production

iii.      Cisapride – Restricted.  Removed from market for torsades when used in combination w/drugs inhibiting CYP3A4.

A Chart of Anticoags, Antithrombins, etc...

You like this chart?  Why or why not?

  Aspirin (cardio-protective dose only) Clopidagril (Plavix) Dabagatrin (Pradaxa) Dalteparin (Fragmin) Enoxaparin (Lovenox) Fondaparinux (Arixtra) Heparin Rivaroxaban (Xarelto) Ticlopidine (Ticlid) Ticagrelor (Brilinta) Prasugrel (Effient) Warfarin (Coumadin)
Aspirin   M M M M M M M M M M M
Clopidagril (Plavix) M   M M M M M M X X X M
Dabagatrin (Pradaxa) M M   X X X X X M M M M**
Dalteparin (Fragmin) M M X   X X X X M M M M*
Enoxaparin (Lovenox) M M X X   X X X M M M M*
Fondaparinux (Arixtra) M M X X X   X X M M M M*
Heparin  M M X X X X   X M M M M*
Rivaroxaban (Xarelto) M M X X X X X   M M M M**
Ticlopidine (Ticlid) M X M M M M M M   X X M
Ticagrelor (Brilinta) M X M M M M M M X   X M
Prasugrel (Effient) M X M M M M M M X X   M
Warfarin (Coumadin) M M M** M* M* M* M* M** M M M  
                         
                         
Key:                        
M = Monitor                        
M* = Monitor and only give together if INR is NOT therapeutic                        
M**= Monitor and only give together if INR is NOT therapeutic.  Should only be given together when switching from one agent to the other ***Brilinta (Ticagrelor) cannot be given with Apirin doses > 100mg                      
X = Never give together without first checking with a physician                        
                         

Cephalosporins Are Not Created Equal

Cephalosporins Are Not Created Equal Just the other day I found where a pharmacist had discontinued cefepime off a patient's profile because a post-op order had included starting cefazolin post-op for three doses.  This particular patient had pseudomonas positive cultures, and I scratched my head trying to figure out why the cefepime was stopped.

Well...

Our computer system flags cephalosporins as duplicates regardless of what generation and what is being treated.  It is much too easy as a pharmacist to just allow the computer system to do all the thinking, but if you have an archaic computer system as many hospitals I have seen, well...

So here's a cephalosporin refresher.  Maybe some tips to help you remember things about each generation and why cefepime is not the same as cefazolin.  NEVER ever.

Some hints to just memorize I use:  (I did not create these)

How to remember the names of the MC used drugs third generation Cephalosporins? Easy. Third Generation–>cef-Tazidime,cefo-Taxime, and cef-Triaxone. All of them start with CEF (they are Cephalosporins) and have the letter T in their name, right after CEF. There is an exception of that rule. Cef-oTeTan is a second generation Cephalosporin, starts with CEF and has the letter T in its name. It can’t be easier than that. Second generation=IInd. generation–>double T in the name of Cef-oTeTan.

1st: zolin, lexin are dying.

cefazolin, cephalexin, cephradine

2nd: actor fox, u rocks (most don't enter CNS)

actor: cefaclor, fox: cefoxitin, u rocks: cefuroxime

A Fox has a Furry Face ie ceFOXitin, ceFURoxime ceFAClor

3rd: tazi tri taxi enter CNS, opera no CNS

tazi: ceftazidime, tri: ceftriaxone, taxi: cefotaxime

oper: cefoperazone (doesn't enter CNS, from kaplan)

4th:  cefepime

From the fpnotebook.com:

  1. General
    1. Spectrum changes from first to third generation
      1. First Generation: Better Gram Positive Cocci coverage
      2. Third Generation: Better Gram Negative Rod coverage
  2. Contraindications
    1. Drug allergy to other Cephalosporin
    2. Type I Hypersensitivity Reaction to a Penicillin
      1. Less than 10% of those who report Penicillin Allergy actually have a Penicillin Allergy
      2. Penicillin Allergy has only a 1% risk of cross-reactivity with Cephalosporins (previously thought to be 10%)
        1. Herbert (2000) West J Med 172(5): 341
      3. Penicillin Anaphylaxis confers a 0.001% risk of Anaphylaxis to Cephalosporins
        1. Apter (2006) Am J Med 119(4):354.e11-9
      4. Cross reactivity appears limited to First Generation Cephalosporins and Penicillins
        1. Second and Third Generation Cephalosporins have minimal to no allergy cross reactivity
        2. Campagna (2012) J Emerg Med 42(5): 612-20
  3. Class: First Generation Cephalosporins
    1. Oral Agents
      1. Cephalexin (Keflex)
      2. Cephradine (Velosef)
      3. Cefadroxil (Duricef)
    2. Parenteral Agents
      1. Cefazolin (Ancef)
    3. Organisms covered
      1. Gram Positive Cocci
      2. EKP Gram Negative Bacteria
  4. Class: Second Generation Cephalosporins
    1. Second Generation Broad-spectrum Cephalosporins
      1. Oral Agents
        1. Loracarbef (Lorabid)
        2. Cefprozil (Cefzil)
        3. Cefuroxime (Ceftin, Zinacef)
        4. Cefaclor (Ceclor)
      2. Organisms Covered
        1. Gram Positive Cocci
        2. EKP Gram Negative Bacteria
        3. Gram Negative Coccobacilli
    2. Second Generation Anti-anaerobe Cephalosporins
      1. Parenteral Agents
        1. Cefoxitin
        2. Cefotetan
        3. Cefamandole
      2. Organisms Covered
        1. Bacteroides fragilis
  5. Class: Third Generation Cephalosporins
    1. Third Generation Broad-Spectrum Cephalosporins
      1. Oral agents
        1. Cefixime (Suprax)
          1. Only indication is for Gonorrhea
        2. Cefpodoxime (Vantin)
          1. Does not cover Enterobacter or pseudomonas
      2. Parenteral agents
        1. Cefotaxime (Claforan)
        2. Ceftizoxime (Cefizox)
        3. Ceftriaxone (Rocephin)
      3. Organisms Covered
        1. Gram Positive Cocci
        2. EKP Gram Negative Bacteria
        3. ESP Gram Negative Bacteria
        4. No Pseudomonas activity
    2. Third Generation Anti-Pseudomonal Cephalosporins
      1. Agents
        1. Ceftazidime (Fortaz)
      2. Organisms Covered
        1. Pseudomonas
        2. EKP Gram Negative Bacteria
        3. ESP Gram Negative Bacteria
        4. Poor Gram Positive Cocci coverage
        5. No Coccobacilli coverage
    3. Fourth Generation Cephalosporins --Cefepime -  is a fourth-generation cephalosporin antibiotic developed in 1994. Cefepime has an extended spectrum of activity against Gram-positive and Gram-negative bacteria, with greater activity against both Gram-negative and Gram-positive organisms than third-generation agents.Cefepime is usually reserved to treat moderate-severe nosocomial pneumonia, infections caused by multi-resistant microorganisms (e.g.Pseudomonas aeruginosa) and empirical treatment of febrile neutropenia.[3]

      Cefepime has good activity against important pathogens including Pseudomonas aeruginosaStaphylococcus aureus, and multiple drug resistant Streptococcus pneumoniae. A particular strength is its activity against Enterobacteriaceae. Whereas other cephalosporins are degraded by many plasmid- and chromosome-mediated beta-lactamases, cefepime is stable and is a front line agent when infection with Enterobacteriaceae is known or suspected.

So there you go.

 

Don't go discontinuing a broad spectrum cephalosporin used to treat a multi-resistant microorganism like Pseudomonas for a puny mostly gram positive post surgical cefazolin for they are not equal.

And that would be an awesome song lyric!