1. 1 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Chapter 5 Dosage Forms, Abbreviations, Routes of Administration, Drug Abbreviations, and Medical Terminology

2. 2 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Introduction  For a technician to become proficient, it is necessary to interpret orders correctly.  Many doctors’ handwriting is referred to as “chicken scratch,” and it is the responsibility of the pharmacy to interpret and clarify orders if necessary.  Many abbreviations used in prescribing medication look very much alike.

3. 3 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Where Did Pharmacy Abbreviations Originate?  Terminology in pharmacy and medicine comes from the Latin and Greek languages.  Because pharmacy began in Europe, most of the abbreviations have their origins in a foreign language.  Latin and Greek serve as the universal language that all medical personnel can understand.

4. 4 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Interpreting Doctors’ Orders  It is very important for the pharmacy staff to interpret doctors’ orders correctly.  When writing out the various abbreviations, be sure to write as neatly as possible because other technicians and pharmacists will be reading your handwriting.  Technicians must learn all of the dosage forms and abbreviations to decipher doctors’ orders.

5. 5 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Do Not Use List  Drug errors that have occurred from the misinterpretation of medication orders led to the creation of the do not use list.  The list outlines the most common misread abbreviations.  These abbreviations should be avoided.  See Box 5-1.

6. 6 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Dosing Instructions  Dosing times are abbreviated on prescriptions.  Many pharmacy computers are programmed to accept these abbreviations.  See Table 5-1.  Computerized Doctor Order Entry Computerized Doctor Order Entry Computerized Doctor Order Entry

7. 7 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Classification of Medications  Each drug can be broken down into groupings based on:  Pharmacology  Intent of use  Route of use  How the drug affects the body-by-body system

8. 8 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Dosage Forms  A dosage form refers to the package or container of which the drug has taken the shape.  For example, it might be a tablet or a capsule.  There is more than one type of tablet or capsule.  Tablets come in a wide variety of shapes and sizes.

9. 9 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Dosage Forms (cont’d)  Much of what determines the dosage form of a medication is determined by the drug’s effectiveness.  Manufacturers prepare certain medications with the ability to release the active ingredient over an extended period.

10. 10 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Three major categories of dosage forms:  Solids- tablets, chewable tabs, enteric-coated tab, capsules  Liquids- syrups, elixirs, sprays, suspensions  Semisolids- creams, lotions, gels, ointments, powders, suppositories Dosage Forms (cont’d)

11. 11 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Solid agents can be contained in various packages and administered by almost all routes except parenterally (IV).  Most tablets contain fillers (inert substances that have no active ingredient), sugar coatings, and certain additives. Solids

12. 12 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Tablets are made to be administered sublingually (SL) or vaginally.  Chewable tablets are convenient for persons who have difficulty swallowing and for children.  Tablets can be scored or unscored and coated or uncoated. Solids(cont)

13. 13 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Solids (cont’d) Unscored tablet Scored tablet

14. 14 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Solids (cont’d)  Tablets can be enteric coated (EC) to protect the drug through the acidic environment of the stomach or to delay release of the drug.  Extended-release types are made to control the amount of drug distributed over a set time.

15. 15 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Solids (cont’d) Plain tablets Scored tablets Enteric-coated tablets

16. 16 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.Tablets/Caplets  Most common type of tablet contains some type of filler.  Fillers are composed of inert substances (no active ingredient) that serve to fill space or cover the tablet (sugar coatings).  Coating improves taste and covers unpleasant odors.  Chewable tablets are also made.

17. 17 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Tablets/Caplets (cont’d)  Caplets are smooth sided and easier to swallow.  Many medications have extended-release forms and regular forms.

18. 18 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Capsules  Capsules can have either a hard or soft outer shell.  Hard capsules are composed of sugar, gelatin, and water.  Pulvule: This is a type of capsule that is shaped differently for identification purposes.

19. 19 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Capsules (cont’d)  Spansules are capsules that can be pulled apart to sprinkle the medication onto food for children  Soft-gelatin capsules (gel-caps) cannot be pulled apart, and often hold medications in liquid form

20. 20 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Types of Capsules Capsules Extended-release capsules

21. 21 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Capsule Sizes  Capsules come in different sizes: see Figure 5-5.  Capsuls vary in color, transparency, identifying marks.  Larger half is called body; shorter half is called cap.  Not all capsules are meant to be swallowed; content can be sprinkled on food.

22. 22 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Lozenges/Troches  These are other forms of tablets that are not meant to be swallowed but to dissolve in the mouth, which releases the medication more slowly; similar to hard candy.  Cough drops  Troches are larger than normal-sized tablets and are flat; chalky consistency.

23. 23 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Biomaterials  Biomaterials are polymers that combine with or encapsulate a drug.  Can be capsules, tablets, or implants  Activity of the drug can be activated due to pH or solubility and released over a period of anywhere from 12 hours to several years.  Also known as excipients.

24. 24 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Implants  A special type of capsule can be implanted under the skin and left in place for up to 5 years.  Contraceptives containing progestin are implanted.  Medication is released in a stair-step method.

25. 25 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Transdermal Patches  Transdermal patches are solid pieces of material that hold a specific amount of medication to be released into the skin over time.  They are easily administered and eliminate a possible upset stomach.  Uses:  For angina, nitroglycerin  For chronic pain, Duragesic  For motion sickness, scopolamine  Patch overload Patch overload Patch overload

26. 26 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Liquids  They are composed of various solutions.  They can be administered by all routes.  Syrups are sugar-based solutions that have medications dissolved in them, which improves the taste of the drug. They tend to be thicker than water.

27. 27 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Liquids (cont’d)  Elixirs are agents that contain dissolved medication in either an alcohol base or water and alcohol (hydroalcoholic) base.  Alcohol usually covers up the bad taste of the drug.  Elixirs have the same consistency as water.

28. 28 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sprays  Sprays are composed of various bases such as alcohol or water in a pump-type dispenser.  Nasal decongestants or sunscreens  Nitroglycerin translingual spray that is used under the tongue for relief of anginal pain

29. 29 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Inhalants and Aerosols  Inhaler agents come in a variety of forms but all must be easily inhaled into the lungs.  Common devices available OTC are vaporizers and humidifiers.  Respiratory therapists use nebulizers to give breathing treatments to hospital patients.  Patients can also be trained to use nebulizers at home.

30. 30 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Inhalants and Aerosols (cont’d)  Anesthetics are inhaled solutions that are administered by an anesthesiologist during surgery.  Prescribed inhalants contain drugs that treat asthma and allergies.  Metered dose inhalers (MDIs) dispense a specific amount of drug with each puff or inhalation.

31. 31 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Emulsions  The mixture of water and oil when used with an emulsifier binds the two together.  Many different types of emulsifiers are used.

32. 32 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Suspensions  These are liquids that have very small, solid particles suspended in the base solution.  They can be used orally by children and seniors.  Suspensions have a “Shake well” sticker and a date of expiration.  Reconstituted medication will need to be shaken and refrigerated.

33. 33 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Enemas  Enemas might be administered for two different reasons: retention or evacuation.  They can be used to deliver medication to the body, bypassing the stomach while being absorbed.  Most common use is to evacuate the lower intestine to prepare for surgeries or for women in labor.

34. 34 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Semisolids  Semisolids contain both liquids and solids.  They are meant for topical application.  Creams have medications in a base that is part oil and part water and for topical use.  Lotions are thinner than creams because their base contains more water.

35. 35 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Semisolids (cont’d)  Ointments contain medication in a glycol or oil base; they cover the skin surface and keep out moisture.  Gels contain medication in a very viscous (thick) liquid that easily penetrates the skin.  Pastes contain a smaller amount of liquid base than solids. They are able to absorb skin secretions, unlike other topical agents.

36. 36 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Suppositories  They can be used both rectally and vaginally.  Rectal suppositories bypass the stomach, which is important if the patient has nausea and vomiting.  Vaginal suppositories are used mainly to treat vaginal infections.

37. 37 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Powders  Powders are solids, yet they can be packaged in some forms that allow them to be sprayed, similar to liquid dosage forms.  One of the main uses is to decrease the amount of wetness of an area.  Antifungal foot agents  They can also be spread over a wide area.

38. 38 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Injectables  Normally used for rapid response.  Storage temperatures are important.  Available in many types of containers:  Ampules  Glass bottles  Glass and plastic vials  Bags  Add-O-vials

39. 39 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Routes of Administration  By mouth or oral medications are very convenient, do not need to be measured, less expensive, systemic, and safe.  The downside is that they do not work as quickly as parenterals(IV’s).  Some drugs cannot be taken orally because they are not as effective.

40. 40 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Sublingual and Buccal Agents  Nitroglycerin, which treats anginal attacks, is the most commonly used sublingual tablet.  Buccal agents are placed between the gum and cheek, where the medication penetrates the mouth lining and then enters the bloodstream.  See Figure 5-11.

41. 41 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Rectal  Rectal (R) agents are used for a person who is vomiting and cannot take oral medications.  To reduce inflammation, either ointments or creams can be used in addition to suppositories.  They work on a specific site and not systemically(through the body system).  Downside: they are uncomfortable and the actual amount of drug absorbed is hard to predict.

42. 42 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Topical  Topical (TOP) preparations effects range from systemic to localized for rashes.  There are agents to fight skin infections, inflammation, and UV rays of the sun.  They work at the site of action and systemically.  An advantage is easy application.  A downside is that they might cause a reaction.

43. 43 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Parenteral comes from the Greek and means “side of intestine” or “outside of intestine.”  The most common parenteral medications are given IV, IM, or SC.  Very-small–gauge needles are used, and the length depends on the site being injected.  A benefit is speed of action. Parenteral: Intravenous, Intravenous Piggyback, Intramuscular, Subcutaneous

44. 44 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Parenteral: Intravenous, Intravenous Piggyback, Intramuscular, Subcutaneous (cont’d)  Parenteral drugs work within a few minutes.  This is important for emergency situations, for those who are combative, or for those who are unable to swallow.  A disadvantage is the increased risk of infection.  Narcan Narcan

45. 45 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Parenteral: Intravenous, Intravenous Piggyback, Intramuscular, Subcutaneous (cont’d)  Injections are more expensive and require preparation and administration by trained personnel.  Another downside is that once a drug is injected, there is little time to alter its course if an allergic reaction takes place or too much drug is given.

46. 46 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.  All eye agents are sterile and are to be kept sterile during use.  Doctors often use eye solutions to treat ear conditions, but ear solutions cannot be used to treat eye conditions because the eye is sterile.  Eye treatments are for infections, inflammation, and glaucoma.  A main disadvantage of solutions for the eye, if not kept sterile, is that they can introduce bacteria into the area being treated. Eye, Ear, Nose

47. 47 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Eye, Ear, Nose (cont’d)  Ophthalmics do not last as long as other treatments because of the blinking of the eye and tearing.  Ointments make it hard to see clearly.  For the eye, ear, and nose, there are different types of agents, including ointments, solutions, and suspensions.

48. 48 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Eye, Ear, Nose (cont’d)  Otic preparations are not necessarily sterile because they treat the ear canal and do not penetrate a sterile environment.  Most ear treatments are for clearing up infections or cleaning out ear wax buildup.  Most nasal sprays are used to treat colds and allergies.  These dosage forms work on the specific site rather than the whole body.  Nasal Spray Addiction Nasal Spray Addiction Nasal Spray Addiction

49. 49 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.  Represent many different components concerning the actions of a drug  Considerations such as:  Levels of the drug throughout the blood and tissues  Absorption or movement of the drug throughout the body  Overall distribution Pharmacokinetics vs. Pharmacodynamics

50. 50 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Pharmacokinetics vs. Pharmacodynamics (cont’d)  Metabolism  Excretion of the drug  Reaction of the drugs with other drugs  Patient compliance  Life of the drug that includes bioavailability, half-life, bioequivalence, and excretion

51. 51 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved.Absorption  Medications are made to get through natural body barriers, such as the skin, stomach, intestines, blood-brain barrier, and other membranous tissues.  How well the drug passes through these barriers is the one factor that determines its ultimate effectiveness.

52. 52 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Distribution  After the absorption of a medication, it is distributed throughout the body from the bloodstream into tissues, membranes, and, ultimately, organs of the body.  The distribution of a drug is not necessarily equal throughout the whole body.

53. 53 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Metabolism  Most metabolism takes place in the liver.  Metabolism changes the chemical structure of the original drug.  There are different influences that can alter metabolism such as age, gender, genetics, diet, and other chemicals digested.

54. 54 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Excretion/Elimination  Excretion is the last phase of a drug’s life in the body.  There are many ways a drug can be excreted from the body: via the kidneys, feces, exhalation, sweat glands, breast milk.  Urination and bowel movements are the most common methods of excretion.

55. 55 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Bioavailability  This is the rate at which the drug makes it to its destination and is available to the site of action for which it was intended.  Many drugs travel into the liver before they have a chance to be absorbed into the whole system.  This is known as the “first-pass effect.”

56. 56 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Half-Life  Half-life refers to the measurement of the time it takes the body to break down and excrete one half of the drug.  This is an important factor in the creation of drugs because it tells the manufacturer how long it takes the body to rid itself of the drug.

57. 57 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Bioequivalence  This is the comparison between drugs either from different manufacturers or in the same company but from different batches of a drug.  Generic drug manufacturers strive to achieve the same equivalence to compete with brand name manufacturers.

58. 58 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Packaging and Storage Requirements  Medications are packaged according to manufacturers’ specifications to ensure effectiveness and shelf life of the drug  All medications have a package insert that describes the storage and stability of the drug.  All dosage forms are approved through the FDA.

59. 59 Copyright © 2012, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. Medical Terminology  Medical terms have their origins in Greek and Latin.  There are four segments of word parts:  Prefix  Suffix  Root word  Combining form  See Box 5-3 and Table 5-9.