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In this way order tamoxifen 20 mg, the choice of biological specimen may influence the outcome of a particular test tamoxifen 20mg free shipping. The length of time that a drug or its metabolite is present in a given bio- logical sample is often called its detection time buy generic tamoxifen 20mg online. This may vary depending on the dose (amount) discount tamoxifen 20 mg without prescription, route of administration (injected, inhaled etc. The presence of a drug metabolite in a biological fluid may or may not reflect consumption of the drug recently enough to impair driving per- formance. For example, the presence of a marijuana metabolite in urine may not be, by itself, a reliable indicator of either driving impairment or of recent exposure to the drug. In addition to the analytical test results, supplemental information (including driving, performance on psychophysical tests, values obtained in physio- logical assessments, and unusual behaviors, statements or observations) often is necessary for an appropriate forensic toxicological interpretation of driving impairment. These similar effects provide the basis for most general drug classification schemes. Drug classes may include depressants, stimulants, opioids (narcotics) or hallucinogens. The classes themselves can be further subdivided, based upon the intended use of the drug (Table 1). The effects (signs and symptoms) of some commonly encountered drug classes are summarized in Table 2. Although many drugs within a class produce predictable effects, such as ataxia (inability to coordinate voluntary muscular movements), slow movements or slurred words fol- lowing a sufficient dose of depressant drug, others are more complicated. Some substances are not easily classified because they have multiple char- acteristics. Although drug signs are determined to a large extent by the pharmacology (properties and reactions) of the drug, other factors such as dose, drug use history, mood, environment or setting, as well as the use of other sub- stances, also help to determine the overall effect. Drugs with high abuse-potential may produce chemical or psy- chological dependence that may also result in characteristic withdrawal effects (Table 3). These withdrawal effects may manifest as the exact opposite of the desired or expected effect of a particular class of drug. For example, during withdrawal or the “crash” phase following binge use of methamphetamine (a potent stimulant), an individual may experience profound lethargy, exhaustion and hypersomnolence. Drug Withdrawal Symptoms Stimulants Muscular aches, abdominal pain, tremors, anxiety, hypersomnolence (extreme fatigue), lack of energy, depression, suicidal thoughts, exhaustion Opioids Dilated pupils, watery eyes, rapid pulse, piloerection (erection/bristling of hairs), abdominal cramps, muscle spasms, vomiting, diarrhea, tremulousness, yawning, anxiety, rhinorrhea (runny nose), sweating, restlessness Depressants Trembling, insomnia, sweating, fever, anxiety, cardio- vascular collapse, agitation, delirium, hallucinations, disorientation, convulsions, shock Marijuana Anorexia, nausea, insomnia, restlessness, irritability, anxiety, depression To provide expert testimony, toxicologists look at the characteristic appearance, behavior or observable effects of the drug on the individual. Again, the presence of a drug or drugs in a biological sample provides valuable insight, but more often than not, other factors will also be con- sidered. Pharmacology of a drug can be divided into two disciplines: pharmacoki- netics and pharmacodynamics. When exposed, the body attempts to break down and eliminate these foreign substances. Pharmacokinetics involves absorption (getting the drug into the body), distribution (movement throughout the body), metabolism (breaking it down into other chemical components) and elimination (get- ting it out of the body). These processes largely determine the efficacy (the ability of the drug to produce a result) or effectiveness of the drug, its con- centration at the active site (specific brain receptors), and the duration of the drug effect. Pharmacokinetic properties are used by pharmacologists, clinical researchers and toxicologists to develop new therapeutics, under- stand the factors that govern abuse, determine how drugs can be detected over time and interpret drug effects on human performance. The onset of action, duration of effects, intensity and quality of the drug experience may vary depending upon the route of administration (Table 4). Intravenous drug administration provides maximum drug delivery and rapid onset of effects. However, this bypasses many of the body’s natural safeguards and may result in complications of intravenous drug use. When a drug is smoked, it is rapidly absorbed in the lungs and transported to the brain via the arterial blood supply. Smoking is a preferred route of crack cocaine administration due to rapid onset, intensity and euphoria, even though pipes and smoking apparatus become hot and may burn the lips. In general, the efficiency and speed of drug delivery (the faster it is deliv- ered to the brain) increases the potential for abuse and dependency. This process is largely determined by the physical and chemical properties of the drug. Most drugs can be characterized as acidic, basic or neutral, and unlike alcohol, which is highly water-soluble, many drugs are also soluble in fat or lipids. The degree to which a particular drug is water-soluble or fat-soluble influences how it is distributed throughout the body. Distribution As soon as the drug is absorbed into the bloodstream, it is circulated to surrounding tissues and organs, and the distribution phase begins. Drugs that are lipid (fat) soluble are distributed more readily into the tissues, such as the heart, liver, kidney, brain and fat. The extent to which a drug is distributed in the body is given by its volume of distribution (Vd). Conversely, drugs with large volumes of distribution, like heroin (Vd = 25 L/kg), are widely distributed throughout the body, including the tissues (Table 5). Alternatively, some drug metabolites may be pharmacologically active, therefore contributing to the overall effect, such as: • Metabolism of diazepam to nordiazepam (an active metabolite of many benzodiazepines) • Carisoprodol to meprobamate • Codeine to morphine There are a great many variables that can affect drug metabolism, includ- ing age, sex, genetic polymorphisms (common genetic mutations that may relate to specific genetic predispositions), health, disease and nutrition. Elimination Elimination is the pharmacokinetic process of getting the drug out of the body. Drugs are eliminated in two major ways—referred to as zero order and first order kinetics or elimination. Ethanol is eliminated at a fixed or linear rate which means that the body eliminates it at a relatively constant amount per unit of time (zero order kinetics). However, most drugs are eliminated using first order kinetics, which means that elimination is non- linear. When a drug is metabolized in a non-linear fashion, it is generally not possible to extrapolate backwards from some known drug concentration to some earlier time and concen- tration. Figure 1 illustrates both zero and first order kinetics on a graph that plots drug concentration over time. The zero order line is straight, while the first order line curves over time, depending upon a drug’s specific half-life. It is important to understand the overall dynamic nature of drug phar- macokinetics. The processes of absorption, distribution, metabolism and elimi- nation do not occur in a discrete chronological fashion, one simply fol- lowing completion of the other, but rather, they occur in combination with each other. Initially following drug administration, absorption will likely prevail; later, absorption wanes and elimination becomes the dominant process in the body. Corresponding drug and metabolite concentrations therefore represent the overall net effect of the pharmacokinetic processes at the time of sampling. Similarly, corresponding drug effects are also related to drug pharmacokinetics, or the timeline of drug use. For exam- ple, initial effects of methamphetamine may include intense euphoria, talkativeness and excitement, followed by dysphoria (unpleasant feelings), lethargy and anxiety several hours later. In addition to the relatively complex way in which many drugs are eliminated, the additional pres- ence of active metabolites creates yet another level of consideration or complexity to the interpretation. A simpler way to consider elimination is this analogy: a baseball dropped by a 10-year-old child sitting in a tree house, high above the ground, will fall straight down (alcohol zero order elimination). If that same 10-year-old then drops a maple leaf attached to an acorn, it should hit the ground at about the same time as the baseball (other drugs with zero order elimination). It will drop much more slowly—as it is tossed and turned in the breeze—than the baseball or the leaf and acorn. The leaf’s size also changes during its descent as pieces break off in the wind (changing drug half-life); this also causes its rate of descent to slow. Eventually the leaf gets to the ground, but not in a straight line nor in a necessarily highly predictable time frame (drug first order elimination). The effect of a drug is a result of the drug’s interaction at a given receptor site. Drugs that affect the central nervous system must reach and bind to specific receptors for their effects to be exhibited.

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It is limited to medical necessity order tamoxifen 20mg with amex, which restricts its actual or poten- tial use to the problematic/chronic dependent end of the drug use 9 spectrum buy cheapest tamoxifen. Most commonly purchase tamoxifen 20 mg line, it supports maintenance prescribing as part of a treatment regimen or harm reduction programme order tamoxifen 20 mg fast delivery. As such it will only ever involve a small fraction of the total drug using population, although it should be noted that this user group is disproportionately associated with the greatest personal and 10 societal harms (especially under prohibition ). Prescribed injectable heroin (diamorphine) also has a long history, and established evidence 11 base. Less common, although not unknown, is the prescription of stimulants, including amphetamines and cocaine. They provide a useful, if limited, demonstration of how legal regulation of drugs can help people become prescribed, rather than street, users; a clear example of the benefts of decriminalisation of drug use and regularisation of their supply route. It is hard to know how such services would develop if managed with the latitude afforded to other, less controversial areas of patient care such as, for example, diabetes or mental health. Witton, ‘Thematic review—heroin prescribing’, Drug and Alcohol Findings, 2003, issue 9, page 16. These include requirements for consumption to be supervised in a specifc venue, for very specifc qualifying criteria to be met, or for the prescribing doctor to obtain a special licence. Prescribing is often time limited, administered in progressively reduced dosage, or made conditional on the patient meeting specifc rehabilitation milestones. It raises some diffcult questions for practitioners, as it exposes the grey areas between medical, quasi-medical and non-medical use. There are ongoing controversies and conficts between the clear need to reduce harms associated with problematic illicit drug use and a reluctance to dispense drugs that are being used in any way non-medically. From a medical point of view, these are particularly helpful to those injecting, who are at high risk of contracting blood borne diseases. These benefts are sometimes undermined if practitioners are accused of supporting drug use for pleasure or recreation, while simultaneously ‘failing to treat’—or even ‘endorsing’—dependence. Specialist training, a specifc qualifcation/licence, or a new specialist prescribing-practitioner professional niche could be put in place. These would be supported 22 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices by a strictly ethical code of conduct, and clearly defned general guidance. They would potentially be overseen by a new regulatory agency, or equivalent sub-group. Users were registered and managed in Iran until 1953, and then again in the early 1970s (similar programmes are now being cautiously re-introduced); comparable systems also existed in Pakistan and India—where remnants still function—and in Bangladesh, Indonesia, Thailand and elsewhere. Pharmacists are trained and licensed to dispense prescriptions, although they cannot write them. They can also sell certain generally lower risk medical drugs from behind the counter. These include restrictions according to buyer age, level of intoxication, quantity requested, or case-specifc concerns relating to potential misuse. In addition, pharmacists are trained to offer basic medical advice, support and information. However, it could easily be adapted and developed into an effective way of managing the avail- ability of currently illicit drugs for such purposes. Licensed and trained professionals could serve as gatekeepers for a range of such drugs. They would be legally required to restrict sales according to the kind of strict criteria defned above, and would also act as a source of realistic, well informed and practical advice and support. This new role would be subject to a similar code of practice to that of more conventional pharmacists, but with additional access control criteria. These specialist pharmacists would also be required to offer advice about harm reduction, safer use, and treatment services and referrals to help users quit, where appropriate. Such advice would be supported by necessary addi- tional training or experience in drug counselling. They could either operate alongside existing pharmacies (subject to appropriate licensing conditions) or from separate licensed outlets. Such a system would put various combi- nations of regulatory controls in place to manage the vendor, the 24 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices supply outlet, the product and the purchaser, as appropriate. This would be over- seen and enforced by municipal, regional or national authorities, according to local legal and cultural norms. These authorities would act as the licensing body, and would be able to tailor the regulatory framework to local needs and policy priorities. They would be supported by police, customs, trading standards, and health and safety infrastructure, as appropriate. They might also be required to undergo necessary additional training in drug counselling, or to have pre-existing drug counselling experience. Under this long established system, various controls exist over the venue and (in particular) the licensee. He or she is responsible for restricting sales on the basis of age, intoxication and hours of opening. A clearly defned hierarchy of sanctions for licence infringements includes a sliding scale of fnes, loss of licence, and even criminal penalties. Licensees can also be held partially or wholly liable for how their customers behave—punishable examples include anti- social behaviour, noise, littering and drink driving. Through these coffee shops, the Dutch authorities have gone some way towards legally licensing the sale and consumption of cannabis. However, it should be noted that, even here, the cannabis trade is not subject to full legal regu- lation; supply to the coffee shops remains illicit, even though low level supply and consumption within them is tolerated. The coffee shops themselves operate under a range of strict—and strictly policed—conditions. They are subject to strict licensing, regular external scru- tiny and frm enforcement, although they only provide drugs on a prescription basis. Given this, it could combine elements of existing licensed premises, licensed sales, and specialist pharmacy models, to ensure that moderate drug use took place in a safer, more supportive environment. Reuter, ‘Drug War Heresies: Learning from Other Vices, Times, & Places’, 26 Cambridge University Press, 2001. Where appropriate, food and beverage legislation (dealing with packaging, sell by dates, ingredients etc. These substances are effectively freely available, although they may in some cases be subject to certain localised restrictions or voluntary codes. Regulated Market Model There has been much recent discussion responding to the historic public health failings of tobacco policy (see: 5. This has generated proposals for a new regulatory model that could also be applied to other drugs. Even when used as directed, tobacco is both highly addictive and signifcantly harmful to personal health. It follows that any commercial marketing, which aims to increase tobacco consumption and thus proftability, will inevitability lead to unacceptable increases in health harms. Responding to this, the proposed model would maintain legal access to adults but remove incentives for proft motivated efforts to increase consumption by creating even more addictive products, by increasing usage of existing products, or by encouraging new consumers to begin smoking. Competitive commercial interaction would still occur at point of production, and point of supply. Borland, ‘A strategy for controlling the marketing of tobacco products: a regulated market model’, Tobacco Control, 2003, Vol. There are already a large number of well established businesses engaged in the produc- tion of plant-based and synthetic psychoactive drugs. They are doing so entirely within existing regional, national, and global legal frameworks. Given this, drug production for non-medical use will mostly require expansion of existing frameworks, rather than development of new ones. We demonstrate this with the following summary of existing legal and regulated production of opium/heroin, coca/cocaine, and cannabis. For a more detailed discussion of current legal drug produc- tion summarised below; see: Appendix 2, page 193. It should also be noted that establishing a legal regime permitting the sale and consumption of drugs for non-medical use would allow these legally regulated companies to compete directly with current, illegal non-medical drug providers. The relative quality and legality of their 31 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation products, over and above any price advantage they would have, would no doubt allow them to take very substantial market share from their criminal competitors as their market presence grows. There are economic and social issues to be addressed in any transi- tion from criminal to legally regulated system; for example, it would raise important development issues in previous illicit drug producing areas (see: 4.

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Reaching out for help is an integral piece of our program buy 20 mg tamoxifen with amex, and especially important when walking through difficult times buy tamoxifen 20 mg on-line. Our experience may become a valuable tool for another addict who faces a similar situation generic tamoxifen 20 mg line, and sharing our experience with others strengthens our recovery order tamoxifen canada. Communicate honestly with your sponsor to avoid self-will and get suggestions from someone who has your best interests at heart. Prayer, meditation, and sharing can help us get outside ourselves to focus on something beyond our own discomfort. Identifying yourself as a recovering addict to healthcare professionals may be helpful. Talk to your healthcare provider and sponsor before taking prescription or nonprescription medication. When supporting a member living with illness, remember that they need our unconditional love, not our pity or judgment. Continue on your path of recovery in Narcotics Anonymous by applying spiritual principles. Ideal for reading on a daily basis, these thoughts provide addicts with the perspective of clean living to face each new day. This introductory pamphlet helps provide an understanding of sponsorship, especially for new members. This book includes a section in Chapter Four that highlights how a sponsor can be a valuable source of guidance and support when facing an illness in recovery. The second half of the pamphlet, “The Twelve Steps Are the Solution,” outlines the process that allows recovering addicts to apply the Twelve Steps in every area of their lives in order to gain acceptance of themselves and others. More Will Be Revealed (Basic Text, Chapter 10) This chapter contains a variety of recovery related topics. Oral Oncology Medication Toolkit Overview for Health Care Providers When prescribing oral oncology medications, the framework and continuum of patient care may be considerably different from other forms of oncology treatment options. In this toolkit, various educational pieces as well as support resources are provided both in the form of provider-facing and patient-facing materials, as listed below. Specifically, the types of support resources provided throughout the toolkit include: fact sheets, checklists, question guides, flowsheet, and treatment calendar. While each organization’s setup and patient populations may be different, note that this toolkit is only intended to provide general considerations in navigating patient care with oral oncology medications. Table of Contents Health Care Provider Education This resource provides a general framework of review Considerations to Conduct Organizational AssessmentComponents of an Oral Oncology Program Question Guide Given the estimated growth of oral oncology treatments, establishing the necessary infrastructure to support a comprehensiveQuestion Guide questions that are in line with a core set of key a general framework of review questions that are in line with a core set of components that are key to managing patienttherapy with oral oncology medications. Specifically, this resource may be helpful to organizations that will need to conductoral oncology program is important towards maintaining a clear course of patient care. To assist, this resource provides Components of an Oral processes of an existing oral oncology program. It may be helpful either to • Conducting baseline patient readiness assessments to evaluate if patients are appropriate candidatesAssessment, as a core component of oral oncology management, involves:for therapy with oral oncology medications Considerations to Conduct Assessment organizations that will need to conduct a readiness • Conducting financial review of patient access to insurance or other assistance programs, includingAccess, as a core component of oral oncology management, involves:identifying support resources Organizational Assessment • Understanding the methods of acquiring oral oncology medications, most commonly through anin-house dispensing pharmacy or specialty pharmacy, including the specific considerations for eachroute of access Access Treatment plan, as a core component of oral oncology management, involves: assessment toward developing a new oral oncology • Conducting comprehensive review of the patient’s medical care with oral oncology medications,including informed consent, obtaining clinical history, performing clinical evaluations and review,and developing a monitoring adherence plan, among other considerations Treatment Plan Communication, as a core component of oral oncology management, involves: program, or to organizations that are looking to refine the • At a practice level, ensuring effective and coordinated communication among all providers who arepart of a patient’s health care team Communication • At a patient level, understanding when and how to communicate with the health care team, includingmanaging side effects, among other considerationsissues related to correctly administering the oral oncology medication, monitoring adherence, and processes of an existing oral oncology program. While the structure and dynamics of each organization isdifferent, in this resource, sample considerations related to navigating a core set of components that are key to managingWhen prescribing therapy with an oral oncology medication, the processes and flow of patient care is different compared to navigating a core set of key components for managing patient therapy with oral oncology medications are reviewed. Operations, as a core component of oral oncology management, involves: Process Flowsheet Care Plan • Managing flow patterns and operational processes specific to treating a patient who is prescribedwith oral oncology medications throughout the care continuum, from treatment planning and financialreview through medication acquisition and educational training patient therapy with oral oncology medications. Operations Oral Oncology Medication • Conducting baseline patient readiness assessments to evaluate if patients are appropriate candidatesAssessment, as a core component of oral oncology management, involves:for therapy with oral oncology medications Assessment Therapy Management • Conducting financial review of patient access to insurance or other assistance programs, includingAccess, as a core component of oral oncology management, involves:identifying support resources Access • Understanding the methods of acquiring oral oncology medications, most commonly through anroute of accessin-house dispensing pharmacy or specialty pharmacy, including the specific considerations for each • Conducting comprehensive review of the patient’s medical care with oral oncology medications,Treatment plan, as a core component of oral oncology management, involves:including informed consent, obtaining clinical history, performing clinical evaluations and review, and developing a monitoring adherence plan, among other considerations Treatment Plan • At a practice level, ensuring effective and coordinated communication among all providers who areCommunication, as a core component of oral oncology management, involves:part of a patient’s health care team Communication • At a patient level, understanding when and how to communicate with the health care team, includingmanaging side effects, among other considerationsissues related to correctly administering the oral oncology medication, monitoring adherence, and Education, as a core component of oral oncology management, involves:• At a practice level, establishing an educational program and developing a curriculum as needed • At a patient level, receiving educational training related to therapy with oral oncology medications EducationEducation This resource provides an overview of the benefits and Medication Acquisition:& Specialty Pharmacy In-House Dispensing Pharmacy Know the Facts When prescribing oral oncology medications, acquisition methods for patients typically involve obtaining the treatmentKnow the Facts challenges of in-house dispensing pharmacies and challenges as well as considerations for each method are reviewed. Support point-of-care dispensing and be willing to discuss with each patient the opportunity to obtain his or herprescribed medicationsIn-House Dispensing Pharmacy Medication Acquisition: specialty pharmacies, as well as considerations for each for Health CareConsiderationsProviders & 3. Dispense oral oncology medications in an area of the office that is mindful of patient flow and individual2. Plan for point-of-care dispensing and devote the necessary time to successfully train all personnelstate requirements Staff 5. Collect prescription drug benefit information on all patients as a routine part of patient check-in4. Stock all medications generally required by patients as well as be mindful of volumes and averages • Is convenient and is housed inside of oncology officesBenefits1 • Varying levels of physician supervision may Challenges1 In-House Dispensing Pharmacy method of distribution. Case managers know when patients receive their medications and can educate patients at the outsetabout the course of therapy, side effects, and dosing scheduleSpecialty Pharmacy Stafffor Health CareProviders & 3. Physicians receive regular e-mails and phone calls from case managers regarding their patients taking oral2. Medication therapy management service informs case managers when to be on the lookout for specific toxicitiesand other issues that clinical trials and other patient experiences have made apparent oncology medicationsBenefits1 Challenges1 Specialty • Delivers medication to patient at no additional costs• Likely able to custom pack doses • Provides additional patient education by phone or mailto avoid multiple • Potential challenge with communication about patient care between the specialty pharmacy and oncologypractice Pharmacy • Works closely with various insurance plans• Has access to patient assistance programscopayments • Specialty pharmacy may not be local• Patients may have concerns about working with a pharmacy by phone References:1. Adherence to oral therapies for cancer: helping your patients stay on course toolkit. Behind Closed Network Doors: Oral Cancer Drugs and the Rise of Specialty Pharmacy. To assist, this resource provides a general framework of review questions that are in line with a core set of key components for managing patient therapy with oral oncology medications. Specifically, this resource may be helpful to organizations that will need to conduct a readiness assessment toward developing a new oral oncology program, or to organizations that are looking to refine the processes of an existing program. Operations, as a core component of oral oncology management, involves: • Managing flow patterns and operational processes specific to treating a patient who is prescribed oral oncology medications throughout the care continuum, from treatment planning and financial review through medication acquisition and educational training Operations Assessment, as a core component of oral oncology management, involves: • Conducting baseline patient readiness assessments to evaluate if patients are appropriate candidates for therapy with oral oncology medications Assessment Access, as a core component of oral oncology management, involves: • Conducting financial review of patient access to insurance or other assistance programs, including identifying support resources • Understanding the methods of acquiring oral oncology medications, most commonly through an in-house dispensing pharmacy or specialty pharmacy, including the specific considerations for each Access route of access Treatment plan, as a core component of oral oncology management, involves: • Conducting comprehensive review of the patient’s medical care with oral oncology medications, including informed consent, obtaining clinical history, performing clinical evaluations and review, and developing an adherence plan, among other considerations Treatment Plan Communication, as a core component of oral oncology management, involves: • At a practice level, ensuring effective and coordinated communication among all providers who are part of a patient’s health care team • At a patient level, understanding when and how to communicate with the health care team, including issues related to correctly administering the oral oncology medication, monitoring adherence, and Communication managing side effects, among other considerations Education, as a core component of oral oncology management, involves: • At a practice level, establishing an educational program and developing a curriculum as needed • At a patient level, receiving educational training related to therapy with oral oncology medications EducationEducation Operations Questions for the organization to review internally 1. What are your current patterns of patient-flow with intravenous oncology treatments and how do you think the integration of orals will impact these patterns? Where and when along the patient flow of care do you think issues may arise with patients taking oral oncology medications? Specifically, what do you anticipate these issues will be and how will you plan to address them? Who within the organization will be responsible for leading the overall effort to develop new or refine existing processes related to the oral oncology program? How do you anticipate staff roles changing with the implementation of an oral oncology program? Who within the organization will be responsible for leading financial assessments and counseling for patients who are prescribed oral oncology medications? How will patients be able to obtain their oral oncology medications (eg, through specialty pharmacy or in-house dispensing)? If considering dispensing through in-house pharmacy, what will your organization need to review in terms of requirements (eg, stocking specialized items, credentialing with insurers, assessing if payers allow refills, complying with state regulations) and who will be responsible for leading this effort? If considering routing through specialty pharmacy, what coordination of care and communication processes will your organization and specialty pharmacy establish (eg, monitoring and communicating patient adherence, tracking patient refills, notifying dose changes) and who will be responsible for leading this effort? Who within the organization will be responsible for developing the treatment plan specific to oral oncology medications? What type of information will be included in a patient’s oral oncology treatment plan and how may this be different from an intravenous oncology treatment plan? What plans will your organization have in place to update current policies and procedures to integrate oral oncology medications; who will be responsible for leading this effort, and how will this be communicated within your practice? How will patients be able to communicate with your organization and report issues with taking their oral oncology medications should they arise (eg, adherence, side effects, toxicity/safety concerns) 3. How does your organization anticipate that physician communication will change with the patients who are prescribed therapy with oral oncology medications and what type of training can your practice offer to address communication changes? How will your organization communicate with other providers who are part of your patient’s health care team (eg, primary care physicians, specialists, specialty pharmacy)? How will your organization support caregivers during a patient’s course of treatment with oral oncology medications? How will your organization manage patient adherence and monitoring with oral oncology medications and what level of support will be offered? In general, what is the current level of staff education and knowledge base on treatment with oral oncology medications? What competency training will be provided to your organization’s staff to review the integration of oral oncology medications (eg, documentation processes, patient education support)? How will your practice develop a patient-education plan for those who are prescribed treatment with oral oncology medications and who will be responsible for leading this effort? Will your practice be able to attend off-site presentations related to oral oncology management? What are your organization’s main areas of strengths and how can these strengths be leveraged? What are your organization’s main areas of weakness and how can these weaknesses be addressed? Notes: Oral Oncology Medication Therapy Management Flowsheet When prescribing therapy with an oral oncology medication, the processes and flow of patient care is different compared to when prescribing therapy with intravenous oncology medication. While the structure and dynamics of each organization is different, this resource reviews sample considerations related to navigating a core set of key components for managing patient therapy with oral oncology medications.

Voriconazole ↑ Chloroquine expected Co-administration should be avoided 20mg tamoxifen, if possible discount 20mg tamoxifen. Clarithromycin Artemether/ ↑ Lumefantrine expected Co-administration should be avoided if possible buy tamoxifen canada. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections (page 4 of 15) Effect on Primary and/ Interacting Drug or Concomitant Drug Recommendations Agent Concentrations Chloroquine ↑ Chloroquine expected Co-administration should be avoided buy cheap tamoxifen 20mg on-line, if possible. Ombitasvir paritaprevir expected; ↑ Consider azithromycin in place of clarithromycin. Paritaprevir ombitasvir and dasabuvir Ritonavir possible Elbasvir/ ↑ Elbasvir and grazoprevir Co-administration should be avoided, if possible. If co-administered, monitor for toxicities of both itraconazole and clarithromycin (e. Posaconazole ↑ Clarithromycin expected Co-administration should be avoided, if possible. If co-administered, monitor for rifapentine-associated toxicities, consider monitoring clarithromycin and rifapentine concentrations and adjusting doses accordingly. Voriconazole ↑ Clarithromycin expected Co-administration should be avoided, if possible. Daclatasvir Clarithromycin ↑ Daclatasvir expected Reduce daclatasvir dose to 30 mg once daily. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections (page 5 of 15) Effect on Primary and/ Interacting Drug or Concomitant Drug Recommendations Agent Concentrations Rifabutina ↓ Daclatasvir expected Dose not established. Consider increasing daclatasvir dose to 90 mg once daily and monitor for therapeutic efficacy. Monitor for artemether- and Ombitasvir Lumefantrine possible lumefantrine-associated toxicities. Paritaprevir Atovaquone ↔ Atovaquone (based on data No dosage adjustment necessary. Ritonavir from atovaquone and ritonavir/ atazanavir interaction) Bedaquiline ↑ Bedaquiline expected Co-administration should be avoided, if possible. Clarithromycin ↑ Clarithromycin and paritaprevir Co-administration should be avoided, if possible. With ↓ paritaprevir possible co-administration, decrease rifabutin dose to 150 mg/ day and monitor rifabutin conc. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections (page 6 of 15) Effect on Primary and/ Interacting Drug or Concomitant Drug Recommendations Agent Concentrations Doxycycline Atovaquone Atovaquone concentration ↓ Dose adjustment not established; if co-administered, by approximately 40% with take atovaquone with fatty meal and monitor for tetracycline. Elbasvir/ Clarithromycin ↑ Elbasvir and grazoprevir Co-administration should be avoided, if possible. Itraconazole ↑ Elbasvir and grazoprevir Co-administration should be avoided, if possible. Posaconazole ↑ Elbasvir and grazoprevir Co-administration should be avoided, if possible. Rifabutina ↓ Elbasvir and grazoprevir Co-administration should be avoided if possible. Dasabuvir ↑ Erythromycin and paritaprevir Co-administration should be avoided, if possible. Ombitasvir expected; ↑ ombitasvir and Consider azithromycin in place of erythromycin. Paritaprevir dasabuvir possible Ritonavir Fluconazole ↑ Erythromycin possible Do not co-administer. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections (page 7 of 15) Effect on Primary and/ Interacting Drug or Concomitant Drug Recommendations Agent Concentrations Quinine ↑ Quinine expected; ↑ Do not co-administer. Rifapentinea ↓ Erythromycin expected Consider azithromycin in place of erythromycin. Fluconazole Artemether/ ↑ Lumefantrine possible Co-administration should be avoided, if possible. Bedaquiline ↑ Bedaquiline possible Co-administration should be avoided, if possible. Chloroquine ↑ Chloroquine possible Co-administration should be avoided, if possible. Mefloquine ↑ Mefloquine possible Co-administration should be avoided, if possible. Quinine ↑ Quinine expected; ↑ fluconazole Co-administration should be avoided, if possible. Rifapentinea ↓ Fluconazole expected Monitor for antifungal efficacy; may need to raise fluconazole dose. Itraconazole Artemether/ ↑ Lumefantrine expected Co-administration should be avoided, if possible. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections (page 8 of 15) Effect on Primary and/ Interacting Drug or Concomitant Drug Recommendations Agent Concentrations Bedaquiline ↑ Bedaquiline expected Co-administration should be avoided, if possible. Chloroquine ↑ Chloroquine expected Co-administration should be avoided, if possible. Clarithromycin ↑ Itraconazole and clarithromycin Co-administration should be avoided, if possible. If co- administered, monitor for toxicities of both itraconazole and clarithromycin (e. Dasabuvir ↑ Itraconazole and paritaprevir Itraconazole doses >200 mg/day are not recommended Ombitasvir expected; ↑ ombitasvir and unless dosing is guided by itraconazole levels. Ritonavir Elbasvir/ ↑ Elbasvir and grazoprevir Co-administration should be avoided, if possible. Mefloquine ↑ Mefloquine expected Co-administration should be avoided, if possible. Quinine ↑ Quinine expected; ↑ itraconazole Co-administration should be avoided, if possible. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections (page 9 of 15) Effect on Primary and/ Interacting Drug or Concomitant Drug Recommendations Agent Concentrations Linezolid Rifabutina No data. Fluconazole ↑ Mefloquine possible Co-administration should be avoided, if possible. Itraconazole ↑ Mefloquine expected Co-administration should be avoided, if possible. Posaconazole ↑ Mefloquine expected Co-administration should be avoided, if possible. Voriconazole ↑ Mefloquine expected Co-administration should be avoided, if possible. Posaconazole Artemether/ ↑ Lumefantrine expected Co-administration should be avoided, if possible. Clarithromycin ↑ Clarithromycin expected Co-administration should be avoided, if possible. Ritonavir Elbasvir/grazoprevir ↑ Elbasvir and grazoprevir Co-administration should be avoided, if possible. Rifampina ↓ Posaconazole expected Co-administration should be avoided, if possible. Rifapentinea ↓ Posaconazole expected Co-administration should be avoided, if possible, or monitor posaconazole conc. Fluconazole ↑ Quinine expected; ↑ fluconazole Co-administration should be avoided, if possible. Itraconazole ↑ Quinine expected; ↑ itraconazole Co-administration should be avoided, if possible. Posaconazole ↑ Quinine expected; ↑ Co-administration should be avoided, if possible. Significant Pharmacokinetic Interactions for Drugs Used to Treat or Prevent Opportunistic Infections (page 11 of 15) Effect on Primary and/ Interacting Drug or Concomitant Drug Recommendations Agent Concentrations Atovaquone Atovaquone Css ↓ 34%; Dose adjustment not established; if co-administered, take rifabutin Css ↓ 19% atovaquone with fatty meal and monitor for decreased atovaquone efficacy. Bedaquiline ↓ Bedaquiline possible If co-administered, monitor for bedaquiline efficacy. Consider increase daclatasvir dose to 90 mg once daily and monitoring for therapeutic efficacy.

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