EO 004.02 Compound a Prescription (Dari)

1. EO 004.02 Compound a Prescription(Dari) 01/09/2013

2. Importance of Lesson(Dari) • Insert Dari • In the prior lectures you learned how to: • interpret a prescription for a compounded medication; • find recipes for compounded medication; • Check compounded medications. • The next lesson will teach you to: • become familiar with non-sterile compounding equipment; • describe commonly used compounding techniques; • calculate ingredient quantities; and • Calculate beyond use dating. AFAMS

3. Overview EO 004.01(Dari) • Common equipment • Compounding techniques • Compounding environments • Calculations • Beyond-use-dating • Record keeping/ documentation • Review • Scenarios (not graded) • Insert Dari AFAMS

4. Sterile CompoundingDari • We will NOT be learning about sterile compounding due to requirements for advanced: • Training • Equipment • Standards • Supplies • Staffing levels • This will require additional training in the future as a need is developed in the pharmacy. • Insert Dari AFAMS

5. Non-Sterile CompoundingDari Common Equipment: • depends on both the product and the quantity of product being compounded. • surfaces of equipment that come into contact with ingredients or finished product must be non-reactive, non-additive, and non-adsorptive. • Prescription balances • Spatulas • Pill tiles and Ointment papers • Graduates • Mortar and Pestle • Insert Dari AFAMS

6. Non-Sterile CompoundingDari Prescription balances • Either a class A torsion balance or an electronic balance can be used to weigh materials for compounding. • brass weights are required for use with a torsion balance, and for testing an electronic balance. Weights should be handled with forceps, not fingers, to avoid scratching or soiling. • Regardless of the type of balance used, materials to be weighed should be placed on weighing papers or in plastic weigh boats, and never directly on the balance. • Should be placed on a flat surface and protected from drafts. • The performance of balances should be checked at least monthly, with documentation of this activity. • Guidelines for checking balances can be found in the manufacturer's instructions. • The minimum weighable quantity for a balance depends on the sensitivity requirement of the balance. If the sensitivity is +/- 1 mg for example, a minimum of 100 mg must be weighed to ensure an error of no more than 1%. • Insert Dari Pharmacist’s Letter AFAMS

7. Torsion BalanceDari • Insert Dari AFAMS

8. Eshelman School of Pharmacy AFAMS

9. PrecautionsDari • Insert Dari Precautions: • Always use weigh boats on both pans to protect the pans from abrasions, eliminate the need for repeated washing, and reduce loss to porous surfaces • The boats should be of reasonable size, giving a maximum weighing area without touching any part of the balance except the pan. • A clean boat should be used for each new ingredient to prevent contamination of components. • Always arrest the balance (i.e. lock the pans in place) before adding or removing weight from either pan.. • Always clean the balance, close the lid, and arrest the pans before storing Eshelman School of Pharmacy AFAMS

10. SpatulasDari • Insert Dari A variety of sizes of stainless steel and plastic spatulas should be on hand in the compounding area. • Small spatulas: handling dry chemicals, • Larger spatulas: preparing large amounts of ointments or creams. Pharmacist’s Letter AFAMS

11. Pill Tiles and Ointment PapersDari • Pill tiles are handy for mixing ointments, when used with a stainless steel spatula. • Pill tiles can be preferable to ointment papers, which can tear when they become moist. • Creams should never be prepared on ointment papers for this reason. • Insert Dari Pharmacist’s Letter AFAMS

12. GraduatesDari • Insert Dari • Use the size of graduate with a capacity equal to or just over the volume to be measured. • No less than 20% of the capacity of a graduate should be measured. This will keep the error in measurement to a minimum.For example, if you measure 10 mL of OraSweet using a 100 mL graduated cylinder, the measurement is likely to be less accurate than if you use a 50 mL graduated cylinder. • Conical graduates with a capacity of less than 25 mL should not be used for prescription compounding. • When measuring a liquid in a graduate, read the measurement at eye level, and at the bottom of the meniscus for the best accuracy. Pharmacist’s Letter AFAMS

13. Measuring Liquid Volumes 1. Choose a graduate with a capacity that equals or very slightly exceeds the total volume of the liquid to be measured. Doing so reduces the percentage of error in the measurement. In no case should the volume to be measured be less than 20% of the total capacity of the graduate. For example, 10 mL of liquid should not be measured in a graduate exceeding 50 mL in capacity. Again, the closer the total capacity of the graduate to the volume to be measured, the more accurate the measurement will be.

14. Measuring Liquid Volumes 2. Bear in mind that the more narrow the column of liquid in the graduate, the less substantial any reading error will be. Thus for very small volume measurements a cylindrical graduate is preferable to a conical graduate.

15. Measuring Liquid Volumes 3. Pour the liquid to be measured slowly into the graduate, watching the level of the liquid in the graduate as you do so. If the liquid is viscous, or thick, then you should attempt to pour it toward the center of the graduate to avoid having some of the liquid cling to the sides.

16. Measuring Liquid Volumes 4. Wait for liquid clinging to the sides of the graduate to settle before taking a measurement.

17. Measuring Liquid Volumes 5. Measure the level of the liquid at eye level and read the liquid at the bottom of the meniscus.

18. Measuring Liquid Volumes 6. When pouring the liquid out of the graduate, allow ample time for all of the liquid to drain. Bear in mind that depending on the viscosity of the liquid, more or less will cling to the sides of the graduate. For a particularly viscous liquid, some compensation or adjustment for this clinging may have to be made.

19. GraduatesDari AFAMS

20. Reading a Meniscus • How many milliliters are read? AFAMS

21. Reading a Meniscus • How many milliliters are read? 20 mls AFAMS

22. Mortar and Pestle • Mortars and pestles come in a variety of sizes, and can be made from a variety of materials (e.g., glass, porcelain, Wedgewood, etc). • A glass mortar and pestle is best for liquid preparations and for chemicals that are oily or will stain. • A Wedgewood mortar and pestle is best for reducing the size of dry crystals and hard powder particles and for preparing emulsions. • Porcelain is smoother than Wedgewood and is best for blending powders and for pulverizing soft materials or crystals. • Insert Dari Pharmacist’s Letter AFAMS

23. Mortar and Pestle • Glass mortar and pestle: • Wedgewood mortar and pestle: • Porcelain: AFAMS

24. Review Prior SlidesDari

25. Compounding TechniquesDari AFAMS

26. Compounding TechniquesDari • Insert Dari • Geometric dilution: A method to help ensure that small quantities of ingredients are uniformly distributed throughout a mixture. • Levigation: The process of reducing the particle size of a solid by triturating it in a mortar or spatulating it on an ointment slab or pad with a small amount of liquid in which the solid is not soluble. • Spatulation: Mixing on an ointment slab or pad using a spatula. • Trituration: Reducing substances to fine particles by rubbing them in a mortar with a pestle or the production of a homogeneous material through mixing AFAMS

27. Geometric Dilution DemonstrationDari AFAMS

28. Levigation/ Dari

29. Levigation DemonstrationDari AFAMS

30. Spatulation DemonstrationDari AFAMS

31. Trituration DemonstrationDari AFAMS

32. Levigating AgentsDari • Levigating agents help reduce particle size. Decreasing particle size helps the ingredient be evenly mixed throughout the base. • Mineral oil works well with oleaginous ointment bases. • Depending on the formulation, water, glycerin, alcohol, propylene glycol, or mineral oil can be used as levigating agents with absorption bases. • Polyethylene glycol and propylene glycol are good for incorporating insoluble powders into water-soluble bases. • Water or glycerin can also be used with water-soluble bases. • Insert Dari Pharmacist’s Letter AFAMS

33. Wetting AgentsDari • Insert Dari • Wetting agent: aids in attaining intimate contact between solid particles and liquids. • Small amounts of wetting agent should initially be added to the dry ingredients to form a thick paste. Then, the vehicle can be added, a portion at a time, with constant stirring, to form the suspension. • The wetting agent required to make a suspension varies depending on the qualities of the dry ingredients (the active drug). • Hydrophilic drugs a water-miscible liquid (water, for example) can be used. • Hydrophobic drugs, a non-polar liquid or surfactant (glycerin) will be needed. • Sometimes, the wetting agent and the suspension vehicle are the same thing. Pharmacist’s Letter AFAMS

34. Compounding EnvironmentDari • Insert Dari Determine whether you have a suitable compounding environment, for example: • Are you too close to the sink (splashing)? • Are you too close to a window or door (breeze)? • Are you close to other employees who aren't compounding (walking-by causes air disturbance)? • Do you have the proper equipment? • Some questions to ask yourself:Are the ingredients cytotoxic (e.g. chemotherapeutic agents, etc) • Are the ingredients flammable? • Are the ingredients teratogenic? Pharmacist’s Letter AFAMS

35. Compounding EnvironmentDari • Insert Dari AFAMS

36. Receipt of a PrescriptionDari Remember: Steps to follow when a prescription for a compounded drug product is received: • Check to see if there's a commercially available product. • If there is a commercially available product, check to see if: • All the ingredients are appropriate for the condition being treated • The concentrations of the ingredients in the prescription are reasonable • The physical, chemical, and therapeutic properties of the individual ingredients are consistent with the expected properties of the drug product that was prescribed. • Insert Dari Pharmacist’s Letter AFAMS

37. Receipt of a PrescriptionDari • If the answers to all of the previous questions are POSITIVE, the Pharmacist should contact the prescriber to suggest a switch to the commercially available product. • Insert Dari Pharmacist’s Letter AFAMS

38. Receipt of a PrescriptionDari • If the answers to all of the above are NOT POSITIVE, the Pharmacist should consider asking the prescriber the following questions: • What is the purpose of the order? (Ready-form product available?) • If a formula is provided by the prescriber, ask where the formula originated. If possible, obtain a copy of the original formula. • How will the compounded product be used? • For how long will the compounded product need to be used? • Does the patient have other conditions that must be considered? • Insert Dari • If no reference for the compound is given then you must review it with the Pharmacist. Pharmacist’s Letter AFAMS

39. Receipt of a PrescriptionDari • If the answers to all of the above are NOT POSITIVE, the Pharmacist should consider asking the prescriber the following questions: • What is the purpose of the order? (Ready-form product available?) • If a formula is provided by the prescriber, ask where the formula originated. If possible, obtain a copy of the original formula. • How will the compounded product be used? • For how long will the compounded product need to be used? • Does the patient have other conditions that must be considered? • Insert Dari • Important to determine if stability of compound is long enough Pharmacist’s Letter AFAMS

40. Steps to Minimize ErrorsDari • Judge the suitability of the prescription to be compounded in terms of its safety and intended use. Determine what legal limitations, if any, are applicable. • Perform necessary calculations for the amounts of ingredients needed. • Identify equipment needed. • Don the proper attire and wash hands. • Clean the compounding area and needed equipment. • Only one prescription should be compounded at one time. • Assemble all necessary materials to compound the prescription. • Compound the preparation following the formulation record or prescription.

41. Steps to Minimize ErrorsDari • Assess weight variation, adequacy of mixing, clarity, odor, color, consistency, and pH as appropriate. • Label the prescription containers. (Including Beyond-use date) • Sign and date the prescription affirming that all procedures were carried out to ensure uniformity, identity, strength, quantity, and purity. • Thoroughly and promptly clean all equipment, and store properly.

42. Compounding ReferencesDari Remember: Two excellent references for compounding recipes are: • Isaac Walton Kilam (IWK) Hospital http://www.iwk.nshealth.ca/page/iwk-compounding-formulas • Hospital for Sick Children http://www.sickkids.ca/Pharmacy/Compounding-Service/ • Insert Dari AFAMS

43. Review Prior SlidesDari

44. Compounding CalculationsDari AFAMS

45. Pharmaceutical CalculationDari • application of basic mathematical calculations to ensure safe and effective pharmaceutical and medication preparation. • Accurate calculation of formulas and conversions are vital.

46. Application of Pharm Calc Dari • Dose calculation • Temperature conversion • Flow Rates • Measurement conversion

47. Application of Pharm Calc Dari • Dilution • Solution concentration • Ingredient calculation for compounds • Prescription quantity calculation

48. Importance of Calculation SkillsDari • Ensure accuracy • Ensure patient safety by providing correct dose • May cause harm to patient if not done properly • To avoid under-dosing • To avoid overdosing

49. Practice ProblemsDari • Mr. Haddad gave you a prescription for Metoprolol 50mg two times daily. Compute the total amount of Metoprolol (in mg) he will consume in 7 days.

50. AnswerDari Metoprolol 50mg x 2 ( times per day) 100mg per day total Then 100 mg per day x 7 days Answer: 700 mg per week of Metoprolol total