Pharmacy Technicians Course. LaGuardia Community College
Inventory ManagementPurchasing SystemsIndependent Purchasing: a
single pharmacy entity establishes a contractual agreement with a
pharmaceutical manufacturer or wholesaler.Group Purchasing:
contractual agreement between a manufacturer or a wholesaler and a
group of pharmaciesI.e.. CVS , Walgreens and other chains as well
as a health system pharmacies like the medisys system which
includes Jamaica, Flushing and other hospitals in the NY
areaCompetitive pricing and better termsPurchasing MethodsDirect
PurchasingInvolves buying directly from drug companiesNot commonly
done, only for restricted itemsWholesalers and primary vendors are
not direct purchasing venues but rather are firms whose business is
to provide a warehouse of drugs where pharmacies can order multiple
drugs, both brand and generic from a single source. Examples
include Cardinal Health, McKesson and Anda Generics.They offer next
day service (sometimes same day). Higher cost than direct
purchasing but more convenientOrder ProcessGenerating the order can
be done manually by a technician surveying the inventory and
creating the order. Automated methods involve drugs that a pulled
from selves which are scanned and the quantity deducted from
inventory. When the inventory falls below a certain level the drug
is ordered.Confirmation of an order requires an inspection of the
order before it is transmittedSubmit the order (usually by
computer)Processing the order by wholesalerOrder Delivery by
courierOrder Verification: matching the invoice with the original
order to determine if any items are missing that should have been
sentInventory Adjustment: computerized adjustment of
inventoryStocking of medicationsReturns and RecallsSometimes drugs
can be returned to the wholesaler because its damaged, ordered in
error, or simply not neededExpired drugs are either destroyed or
returned to the manufacturer. Companies like, Stericycle and
Pharmacologistics handle these issues for hospitals.Recalls are FDA
or manufacturer initiated and involve the voluntary or mandatory
surrender of drugs by pharmacies and consumers. It may involve
pharmacies contacting customers and retrieve drugs. Often only
certain lots are required to be surrendered.This is why state laws
requires the NDC to be recorded on the Rx label when dispensing.
Manufacturer will list NDC and affected lotsClass 1 recalls are
serious and can cause deathClass 2 recalls are not as serious Class
3 recalls usually involve misbranding and other regulatory
issuesInsurance Health Maintenance Organizations or HMOs are
organizations that contract with healthcare providers to provide
services to their clients. Insurance clients select a primary care
physician who acts as a gatekeeper for other services. Often the
most competitively priced insurance but with the most
restrictionsPreferred Provider Organizations or PPOs are similar to
HMO with the exception that clients can see out of network
providers but pay a higher copay for this privilege.
Government run Health InsuranceMedicaid and Medicare were formed
by title 18 and title 19 amendments to the social security act of
1935 passed in 1965.Medicaid serves people of limited income and
disabilities.Medicaid is funded by the state and federal government
jointly.Medicare is a coverage program that is offered to elderly
people (over 65) and certain young people with disabilities to
include end stage renal disease.Plan A covers hospital costs. Plan
B medical expenses. Plan D is the prescription drug coverage plan
established in 2003.Plan D is administer through private plans
across the country.Plan C or Medicare advantage offers coverage to
patients via Medicare contracts through private insurance
companies.Paid for through payroll taxes (FICA) on all working
Americans (2.9% total)Insurance Billing and TermsCopay. The portion
of the bill that the patient paysDeductible. The amount that an
insured pays before coverage kicks in. Deductibles are satisfied
all at once or a portion at a time.Pharmacy Benefits Manager (PBM):
a processor contracted by the primary insurance to handle Rx
benefits.Preferred formulary drug: the drug in a class that is paid
for by the insurance. It can be called a tier one drugNon preferred
formulary drug: a drug in a class that is not covered or covered at
a higher copay. Tier 2 drugNon Coverage Drug is a drug that can not
be covered unless the provider ,usually the doctor, calls the
insurance and receives a prior authorizationIntroduction to
CompoundingCompounding in Pharmacy refers to the special
preparation of drug products that are uniquely tailored to a
patients needs medically and otherwise.Extemporaneous is often an
adjective that describes this unique characteristic of
compounding.Today relatively few prescriptions are compounded but
in 1938 when the FDCA was passed about 50% of Rx were compounded.
Pharmacy is an art as well as a medical profession. The Pharmacist
could add favorants and other excipients to make a drug more
aesthetic and/or more palpable to children or animalsCompounded
items can be: creams, ointment, solutions, suspensions, intravenous
solutions, capsules, suppository, etc.Solutions are homogenized
mixtures of drug in aqueous medium.Suspensions are heterogeneous
mixtures of a drug in aqueous medium. These mixtures often require
the shaking of the drug before the suspension can be
given.Intravenous solutions are aqueous drug mediums that are free
of particles; they are sterile and pyrogen freeCapsules are oral
dosage forms that are enclosed in a gelatin casing that dissolves
in the stomach and small intestine Suppositories are dosage forms
that are applied rectally. They are usually made of material like
glycerin which melts at slightly below body temperature. Used for
patients that cant swallow due to neurological disorders
(dysphagia)Special Compounded Dosage FormsEmulsions are mixture of
two non mixable liquids in a stabilized medium. Normally, oil in
water do not mix; however, a compound can be made (an emulsion)
where the two liquids can be mixed with each other.Examples in
pharmacy are creams and lotions.Examples in food are mayonnaise and
milk (fat mixed in water)Two types of emulsion are oil in water
(o/w) or (w/o)When a surfactant or an emulsifier in added to the
mixture the mixture solubilizes. Examples of emulsifiers are
Lecithin, gum Arabic, Polysorbate 80 and stearly alcoholReferences
for CompoundingRemingtons Pharmaceutical SciencesTrissels Stability
of Compounded FormulationsDrug Facts and ComparisonsUnited States
PharmacopeiaThe International Journal of Compounding
Pharmacists
Compounding Equipment A more complete list is mention in the
textThe more important ones are followingBalance, class A, required
in every pharmacy by the state boardBeakersFilter papersGraduated
cylindersHotplatesMoldsMortar and pestleOintment
slabSpatulasWeighing paperMortar and PestleVery important in
compoundingrepresents a symbol of the pharmacy profession. Shown
as
Used to comminutate or triturate a substance to smaller particle
sizes. Smaller particle sizes are a key to make certain compounds
more appealing to the touch and taste.Glass mortar is used to
triturate gritty liquids and porcelain is used for granular
powders
Suspensions Some drugs are in tablet form and are perhaps needed
to be given in very small quantities. (i.e. neonates who need a
fraction of the dose an adult would need)A required number of
tablets are crushed and triturated in a mortar and pestle.An agent
called a suspending agent is added. A very common one is Ora Plus.
Others are carboxymethylcellulose, etc. Used to make the particles
repel each other to homogenize a suspension when its shaken.A
sweetening agent can be added like simple syrup or Ora Sweet After
this the suspension is brought to final volume with water.Strength
of a suspension is measured in usually mass per volume like mg/ml,
g/l , or percentage %v/v. When used without qualification , %
strength usually means grams per 100 ml.For example in IV
terminology an IV solution of normal saline is 0.9% sodium chloride
USP. Its strength is 0.9 grams of sodium chloride per 100 ml of
solution. Question: one liter of saline has how grams of NaCL?Other
question: How much volume is needed to deliver 27 grams of
saline?Other Compounded Dosage FormsPLO gel. A transdermal gel
enhances absorption of drug through the skin. A gel is a suspension
basically that congeals in contact with skin or at a certain
temperature. Contains a suspending agent and surfactant called
Pluronic Lecithin Organogel.Ophthalmic Preparations are usually
solutions but can be suspensions or even ointments, which are
semisolid mixtures of drug in a semisolid base. They are usually pH
balanced and sterile.Otic Preparations are used for the ear. Can be
solutions but are mostly suspensions that are thick enough to be
held in the ear canal for the drug to act.Nasal Preparation are
used for the nose and are mostly sterile and prepared with isotonic
fluids like 0.9% sodium chloride USPOintmentsSemisolid dosage forms
where solid drugs are incorporated in a solid oily base substance,
or just called a base.Normally the drug is triturated in a mortar
and pestle to reduce its particle size and to prevent grittiness in
the final ointment dosage form.Commonly used bases:Vaselin or
simple white petrolatum USP. Its is a high hydrocarbon base
obtained from crude oil processing.Forms an occlusive layer on the
skin to prevent drynessUsed for drugs that are unstable in
waterCommonly Used BasesLanolin, Anhydrous. A base that contains
fatty acid esters that when treated is a water absorbable base.
Comes from the wool of sheep and other animals and is sometimes
called wool fat.Used for water stable drugs Typically has Ok drug
skin penetrating ability
Hydrophilic PetrolatumHydrophilic Petrolatum USPIts a water
Loving base that is a chemical modified form of white petrolatum
USPUSP listing requires the following ingredients86 grams white
petrolatum8 grams white wax3 grams cholesterol3 grams stearyl
alcohol in 1,000 grams total preparation
Water in oil baseEmulsion baseHas good drug skin penetrationHas
good washabliltyExamples are Hydrous Lanolin, Cetaphil and
EucerinTypically called lotions or creamsPEG bases are made from
polyethylene glycol bases and are excellent for drug penetration
and are able to be washed off easily.Introduction to Sterile
ProductsA sterile product is a product that is free of
contamination, microorganism free, and pyrogen freeExamples of
sterile products are intravenous products (IV), ophthalmic products
(for the eye), and nasal products (for the nose), Intramuscular
(into the muscle) and subcutaneous (under the skin)Aseptic
technique refers to the procedure of properly performing the
preparation of sterile products.Includes the environment,
equipment, and personnel garbProvides guidelines for the
procedureNormally any agent that bypasses the skin or the
gastrointestinal tract must be both sterile and pyrogen free. This
is because the skin and the GI tract have a protective role in
filtering out damaging foreign substances or microorganisms.The
blood is a sterile body fluid that requires sterile drug products.
Blood is filtered by the spleen and then by the lymph nodes as its
becomes lymph; however, when a drug is introduced directly into the
blood it must be sterile.Consequences of contaminated IV products
can be seriousMost IV drug products are contaminated by touch
contamination.Bacteria, fungus, and other microorganism colonize
the skinCommon skin microorganisms are: Candida, Dermatophytes, and
Staphylococcus bacteria. Others are common as well. Contaminated
products can colonize the blood and produce bacteremia and
fungemia. Infections can evolve into septic shock and death.Watch :
http://www.youtube.com/watch?v=KC8qgxNB2FAEnvironment for Sterile
Products PreparationClass 100 environment is an environment that
has air that contains no more than 100 particles (0.5 microns) or
larger in one cubic foot of air.Laminar flow hoods provide this
environment.Horizontal flow hoods filter air and pass it through a
HEPA filter and outward out of the hood.Vertical flow hoods blow
filtered air down towards the surface of the hood.Biological Safety
Cabinets are vertical flow hoods that pulls air through vents in
the front and back of the hood to prevent the preparer from
receiving this air. It is used to make chemotherapy drugs.USP
797Introduced in 2004 by the US Pharmacopeia.Consists of standards
for the environment to be considered in the preparation of sterile
productsEndorsed by JCAHO and other regulatory agenciesFollowed in
most hospitals with others moving towards compliance.Standards
include wall/ceiling, wall/wall and wall/floor junction
specifications, etc
In general, sterile products are prepared in laminar flow hoods
in similarly compliance air quality roomsSuch rooms are called
clean roomsUsually have partitions that separate areas of the room
for storage of IV products, gloves, and needle and syringesRooms
are usually positively pressurized to push contaminates out and to
keep other particles from being pulled in.Other Sterile Product
EquipmentNeedle are sterile puncturing devices meant to access drug
solutions in vials and to administer drugs to patients.Normally are
3/8 of an inches to 3.5 inches in lengthThe diameter, or bore, of
the needle is determined by its gauge.The larger the gauge the
smaller the bore of the needleIn general, 25 or 27 gauge needles
are under for subcutaneous injections, 22 gauge for IM injections
with 18 gauge and 16 gauge meant for pharmacy compounding of IV
products. 13 gauge is typically the larger bore needle you will
find.Syringes are the containers that hold the drug solution after
its been drawn from a vial.Consists of a tube with graduations
marks, a piston, a plunger with grip collar and at the other end a
luer lok tip (most syringes).This luer lok tip is designed to be a
twist on to attached to a needle or to a injection port on a
catheter to administer an injection
Author: William Rafti of the William Rafti Institute from
Wikipedia
Source: wikimedia commons pageIntravenous SolutionsNormal saline
(0.9%) is one of the most common because its isotonic with plasma.
Isotonic means equal to it in terms of tonicity. i.e. plasma has a
tonicity valve of about 290 mOsm. Normal saline or NS is about 300
mOsm. Tonicity of a solution determines if bodily fluid shifts will
occurDextrose 5% in water (D5W) is the second most common type.
Consists of glucose or dextrose in water to make it 285 mOsm
(isotonic)D5WNS is a combination of the two and is used when some
calories in the form of glucose is needed. Hypertonic (580 mOsm
about) but it is Ok to use.3 % Saline (NaCL) is only used to treat
certain brain conditions. Very hypertonic and can cause death if
used improperly23.4% saline (NaCL) used only in certain rare
conditions and in small volumes. Will cause death if used
improperly (remember Emily Jerry?)Type of IV therapyIV primary
infusion consists of a drug that is given continuously through a
large volume parenteral solutionIV Piggyback is a IV administration
of a drug that is normally piggybacked to another primary IV via a
Y site connection on the primary IV tubing.IV Piggyback sets are
designed to be small in volume usually 50 ml to 100 ml and are hung
above the primary bag on the IV pole. (see next page)Rate of
infusion can be controlled by gravity and a roller clamps or by an
electronic pump
Picture of IV Piggyback set up
A word about filtersAt times a filter is needed to filter IV
solutionsi.e. when breaking an ampule you need to use a filter
needle to draw the solution to prevent glass particles from
entering the IV.A 0.22 micron filter is a special filter that is
called a sterilizing filter that can sterilize a fluid as it is
passed through the filter.