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Hey group,
I read a lot of high powered notes on this list. Sorry to say I
dwell in a calmer, low tech environment.
My consults are as follows:
Robert: Sally Anne's Gentamicin Peak and Trough are...blah blah
blah. Dr.
Smith wants you to fix them. (we still do PK/TR levels here on occassion)
My questions to nurses: What are we treating? (look at labs, ID,
Suspected
local focus etc.) Is she peeing? How much? What's her weight and length.
(we are talking peds here). What were her labs this morning? (Chem-7 is
sufficient). What times were the levels drawn? What dose were they
around? How much was the dose? How often? What's her temp? Has she
spiked lately? When did she come in and for what?
The above sceniaro takes 10 to 15 minutes. It helps to tell them
to get
the chart before you start.
***REASON FOR NOTE*** Does anyone have a computer program that can handle
this type of patient. I would like something to keep me from breaking out
the calculator and pencil. I can do the calculations, write up the note
and recommendation then fax it to the unit. They pull the fax, put it in
the chart and make the changes.
The next morning, I take a peek at the little tyke and see what
they LOOK
LIKE. I'll even listen if they have pneumonia, look at the film.
(physical assessment... freaks the nurses and doctors out the first few
times then they get used it and ask YOU how they sound/look.)
OK I'm lazy and don't want to drive to the hospital for a routine
consult.
I drive in for train wrecks not bad UTIs. I am not interested in FDA
submission programs, Bayesian numbers, AUC, 17th
quad-multiphaisic-bipolar-degradation schemes. We are talking Plain Jane
Kinetics here.
Any suggestions??
Thanks................... Robert
Robert G. Aucoin, R.Ph. tel: 1-888-765-PICU (7428) (new toll free #)
Pediatric Clinical Pharmacist fax: 504-765-7917
The Children's Center e-mail: mraucoin.-a-.linknet.net (home)
Our Lady of The Lake RMC or RAUCOIN.aaa.ololrmc.com (work)
Baton Rouge, LA
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Date: Mon, 11 May 1998 14:51:43 -0700 (PDT)
From: Leslie Carstensen Floren
To: PharmPK.at.pharm.cpb.uokhsc.edu
cc: Multiple recipients of PharmPK - Sent by
Subject: Re: PharmPK Home based kinetics
MIME-Version: 1.0
Dear All,I would like to applaud Dr. Aucoin's dedication to his patients.
I'm sorry that I don't have a good suggestion for a computer program for
his clinical kinetics question, but I must comment that it is refreshing
to hear of a clinical pharmacist that is practicing physical assessment
before making dosage adjustments and recommendations.
LEslie C. Floren, Pharm.D.
---
X-Sender: mraucoin.aaa.popalex1.linknet.net
Date: Mon, 11 May 1998 21:05:30 -0500
To: Leslie Carstensen Floren
From: Robert Aucoin
Subject: Re: PharmPK Home based kinetics
Cc: PharmPK.aaa.pharm.cpb.uokhsc.edu
Mime-Version: 1.0
Point of order.
I am not a doctor. When I graduated from pharmacy school there were no
Pharm.D. programs within 3 states distance. I've been at this game for
more than 20 years. Spent at least six of those years being trained by
first: a pair of family practice docs and then: half a dozen sub-specialist
(all MDs.) They tell me its different being trained by pharmacist. I
wouldn't know.
I enjoy what I do and on days like today, come home tired and
happy. We
had 4 kids sicker than stink, three that were just plain sick. Three were
getting central lines at one time. In the middle of this, one decided he
wanted to leave us. We pulled out all the stops and when the smoke cleared
he was still here and doing much better. Physical assessment...I would be
drawn and quartered if I did not look at the patient before writing orders.
Its just not done.
We are a small unit, 10 beds in PICU and 50 on the floor. Some days it
feels like I have consults on about half these little folks. It makes for
a long day.
In any case, to all on this list that think pharmacy is dull, come
on down
and visit. I'll show you how to put on sterile gloves and assist in a CVL
placement. Keep the bevel up and watch for the pulsing red blood.
Leslie, thank you for the kind words. I'll save them for the dark
days.
stay casual.............. Robert
---
Date: Mon, 11 May 1998 22:26:08 -0700
From: Brennan
MIME-Version: 1.0
To: "PharmPK.-a-.pharm.cpb.uokhsc.edu"
Subject: Plain Jane Kinetics
I have to agree with Robert that we can never get away from the need to
take a good hard look at the patient. For practical purposes, the
majority of patients can be monitored by "seat of the pants" dosage
adjustments. After all, we've been doing just that for years.
I would like to offer a couple of observations from my own
experience
1. Adequete monitoring is not optimal monitoring. Pk & Tr levels do
well in the NORMAL patient but do not necessarily give rich information
for those patients who fall outside the norm.
2. Patient comfort is an important factor. If I have the opportunity to
reduce the number of time I have to stick a patient without compromising
their care you be I'll do it. Baysian modeling allows me to do that
better than anything else I've used so far.
3. The major importance of PK Modeling is not treating the normal
patient, but rather identifying the abnormal patient. I have several
cases where seat of the pants monitoring was way off the mark simply
because the patients were on the edges of the curves.
4. I shudder when I read reports of aminoglycoside toxicity reduced to
below 5%. Even decent linear regression software produces better
results. In the past 15 yrs I've been involved in this, I seen less
than 5 aminoglycoside toxicity patients total.
No tool is a substitute for common sense, but the tools sure can help do
the job.
Bob Brennan
---
[Maybe a database program such as FileMaker could be used to develop a
template for patient notes and some 'simple' PK calculations. Or a
spreadsheet program - db]
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Robert:
My suggestion is to write your own program. In this way you will be more
aware of what your assumptions are. I could send you an Excel spreadsheet
that I have used for undergraduate kinetics, but I strongly suggest you
make your own without outside help. This will put you in command of the
very simple calculations and not the "black box"
Art Straughn
UT Memphis
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[A few replies - db]
X-Sender: dfarrier.aaa.mail.bright.net
Date: Tue, 12 May 1998 13:16:02 -0700
To: PharmPK.aaa.pharm.cpb.uokhsc.edu
From: "David S. Farrier"
Subject: Re: PharmPK Home based kinetics
Mime-Version: 1.0
Dear Robert,
When it comes to "Plain Jane Kinetics", if you don't mind sleek, easy,
pretty and powerful Plain Jane, then take a look at PK Solutions. She runs
in Excel and half her suitors are pharmaceutical research labs and the
other half are professors of pharmaceutics and pharmacokinetics. She also
caters to clinicians. See URL below for demo and a date.
Dave
David S. Farrier, Ph.D.
Summit Research Services
Pharmacokinetics and Metabolism Software
1374 Hillcrest Drive
Ashland, OH 44805 USA
Tel: (419) 289-9207
Email: dfarrier.-a-.bright.net
Web Site: http://www.bright.net/~dfarrier
---
From: "Ronald A. Herman"
To:
Subject: RE: PharmPK Re: Simple Kinetics
Date: Wed, 13 May 1998 10:20:36 -0500
MIME-Version: 1.0
X-Priority: 3 (Normal)
Importance: Normal
Robert & Discussion Group Members:
I would like to agree with Art Straughn of Memphis. The very best thing you
can do is write your own little program to use. The same equations that you
use on your hand-held calculator can be put in an Excel or Lotus
Spreadsheet. If you want to keep track of your consults for documentation
or research purposes, you can use Access or Paradox to do the same
calculations in a way that files all the data and recommendations in a data
base. If you know how to program, or at least enter the equations in your
calculator, then you know how to write the equations in spreadsheet cell.
If you have written your own, then you will know what assumptions you have
made, i.e. population estimates of Vd or Ke in prospective dosing
calculations. If you use someone else's program, you often won't know, or
remember what the assumptions were that went into the program.
Ron Herman
*****************************************
Ronald A. Herman, Ph.D.
E-mail: Ronald-A-Herman.-a-.uiowa.edu
http://rherman.pharmacy.uiowa.edu
University of Iowa
S525 College of Pharmacy
Iowa City, IA 52242
Phone: 319-335-8765
Pager: 319-356-7000 #5085
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Dear Robert:
I don't think you can have it both ways. You can have it simple, with
eyeballing and/or linear regression. This approach works in the steady
state for stable patients. Or, for more complex problems, and train wrecks,
you will probably (worse luck) need Bayesian software to model the behavior
of drugs in patients even if their renal function is changing, etc, and you
can develop dosage regimens which are individualized to your patient's
individualized Bayesian model to achieve target goals which you,
thoughtfully, select for each patient according to his/her need for the
drug. You enter the past doses and when they were given, and the levels and
when they were drawn, and put the whole thing together.
The USC*PACK programs are one collection of several that are
designed to
do the job you describe. They also model the diffusion of drug into
endocardial vegetations, and model the growth and kill of organisms by
antibiotics. They also have parametric and nonparametric population
modeling software.
However, what is needed, and I am sure the nurses have the same
question
for you, is for you, or someone with the appropriate clinical and PK
background, to ecaluate the plot of the patient's Bayesian fitted PK model,
based on his serum levels, and then to select the peak and trough goals
which, in your best clinical judgment, are most appropriate for that
patient. You are responsible for the goals you select. Good for you that
you look at the lab, the xrays, and especially, the patient!
Having selected your target goals, one wants to achieve them most
precisely. Tools are there if you should choose to understand and use them.
Plain Jane kinetics won't do very much, especially when you are dealing
with a train wreck. Really, seriously consider getting Bayesian, and
consider software that is specifically designed to be as useful as possible
for your train wrecks. We have worked very hard to have the USC*PACK
software be maximally useful, especially for such train wrecks.
Sincerely,
Roger Jelliffe
************************************************
Roger W. Jelliffe, M.D.
USC Lab of Applied Pharmacokinetics
CSC 134-B, 2250 Alcazar St, Los Angeles CA 90033
Phone (213)342-1300, Fax (213)342-1302
email=jelliffe.aaa.hsc.usc.edu
************************************************
Take a look at our Web page for announcements of
new software and upcoming workshops and events!!
It is http://www.usc.edu/hsc/lab_apk/
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I would like to agree with Art Straughn of Memphis. A good trial is to
write your own PKS program to use. That is why I wrote my "Practical
Pharmacokinetics", You are welcome to try it for free. It at
http://www.PharmaPhone.com
Gamal
========================
Gamal Hussein, Pharm.D. at http://www.ClinPharmInt.com/Hussein.htm
Associate Professor of Pharmacy
Northeast Louisiana University-Pharmacy School
Associate Professor of Neurology
Louisiana State University-Medical School
Clinical Coordinator of Clinical Pharmacy/Pharmacology Program
The Medical Center of Louisiana at New Orleans
http://www.ClinPharmInt.com/Orleans.htm
email=PYHussein.aaa.Alpha.NLU.edu
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Excellent suggestion to get a better understanding about computer
applications.
Have used the computational algorithms the following simple basic routines
and written a program around it.
Yamaoka K, & others. A nonlinear Multiple Regression Program, Multi2
(Bayes), Based on Bayesian Algorithm for microcomputers.
J.Pharmacobio-Dyn., *, 246-256 (1985)
It has all of the optimization routines including a simplex (Nelder-Meade)
If you are interested, this group also has published a series of these
programs including a simple differential equation program.
There is a complete listing of the BASIC program that can be typed in or
scanned in and run under basic. It's great fun for a while but now I use
WinNonlin because of the ease of cut&paste under windows.
This program (Multi2) has all the power of the most sophisticated
calculation programs but without the user friendly goodies.
WW
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We have put up a free equation plotting and AUC, AUMC, MRT calculation tool
that illustrates what you can do with home based kinetics. You can get to
it by hitting "Free Tools" at http://www.bright.net/~dfarrier
Also, follow obvious links to the equations page and download a list of 75
noncompartmental equations all in one place. These can serve as a starting
point for building your home based kinetics program.
David
David S. Farrier, Ph.D.
Summit Research Services
Pharmacokinetics and Metabolism Software
1374 Hillcrest Drive
Ashland, OH 44805 USA
Tel: (419) 289-9207
Email: dfarrier.-a-.bright.net
Web Site: http://www.bright.net/~dfarrier
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Seem to me that we need both the analytical software and the down home
clinical judgement. Numbers are tools, not answers. There is no
substitute for a well informed person saying "Change the dose to this"
and putting themselves at risk for the response.
Bob
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Dear Bob:
This is about clinical judgment. Yes, we need both analytical
software and
"down home" clinical judgment. You are right that there is no substitute
for a "well informed" person saying "change the dose to this". However, the
question is by what means the person becomes well informed. The would is
filled with well intentioned but not so well informed persons changing
doses without a concent of what the target goal is and what dose is needed
to achieve that target. The "down home" judgment is based best then it is
made on the basis of a good model of the behavior of the drug in that
patient, combined with a thoughtful appraisal of the patient's clinical
behavior. It is only in this way that the patiet's individual sensitivity
to the drug can be established, and only thus can the target goal be
thoughtfully chosen, and only thus that the dosage regimen be developed to
best achieve the target goal. Then, one can say "let's change the dose to
this" and have it really become optimal, and one can feel satisfied that
the goal and the regomen were chosen most responsibly. The important things
here are to have the clinician be as well informed as possible, for the
clinician to evaluate everything, and to take the responsibility for the
regimen to achieve it.
Sincerely,
Roger Jelliffe
************************************************
Roger W. Jelliffe, M.D.
USC Lab of Applied Pharmacokinetics
CSC 134-B, 2250 Alcazar St, Los Angeles CA 90033
Phone (213)342-1300, Fax (213)342-1302
email=jelliffe.aaa.hsc.usc.edu
************************************************
Take a look at our Web page for announcements of
new software and upcoming workshops and events!!
It is http://www.usc.edu/hsc/lab_apk/
************************************************
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Roger,
The professional arms him(her)self with as many tools as practical.
That includes everything from "gut" feelings to state of the art modeling. I
have some interesting case studies that show how "reasonable" results can be
very wrong. There are steps that have to be followed.
Obtain data (the best you can get)
Analyise the data (with the best tools you have)
Evaluate the data (look at the patient as well as the numbers)
Act on the data (and be prepared to repeat the process)
Both clinical evaluation and patient modeling are means to an end - A
healthy, well treated patient. After all, that's what we do isn't it?
Bob B
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