Recommended Clinical Pharmacology Case-Based Learning
Mandatory National Prescribing Curriculum modules for Transitions to Clerkship
To access the Australian National Prescribing Curriculum modules, you must first create a free account here (only limited modules will allow guest access).
Our team has rated the quality and relevance of the Australian National Prescribing e-curriculum the highest and created Canadian ‘translation’ preambles for key modules, which can be accessed here.
Type 2 Diabetes: Initiating Treatment
Preamble: The case description and details about symptoms, vitals, history etc. are reasonable and should be understood by the Canadian learners.
Differences in terms used:
- Haemoglobin vs hemoglobin
- Capillary Blood Glucose Level (BGL) vs Blood Glucose (BG) (*they also use mmol/L as the unit of measurement)
- Anaemia vs anemia
- TDS vs TID
Laboratory Values:
| Parameter | Module | 2018 Diabetes Canada Clinical Practice Guidelines | Hamilton Regional Laboratory |
| Triglycerides (TG) | < 2 mmol/L | <1.5 mmol/L | |
| Albumin to Creatinine Ratio (ACR) | > 2.5 mg/mmol in men and > 3.5 mg/mmol in women is indicative of microalbuminuria | 2 – 20 mg/mmol is the range considered for microalbuminuria. uACR>20 mg/mmol is considered overt nephropathy | |
| Potassium | 3.2 – 4.3 | N/A | 3.5 – 5.2 mmol/L |
| Serum Creatinine | 60 – 120 | N/A | 60 – 110 umol/L |
| ALT | N/A | ||
| AST | N/A | ||
| ALP | N/A | ||
| GGT | N/A | ||
| Albumin | 34 – 48 g/L | N/A | 42 – 50 g/L |
| Target Blood Glucose Ranges | “Generally, the HbA1c target for most people with type 2 diabetes is ≤ 53 mmol/mol (7%) and the fasting blood glucose level is between 6 and 8 mmol/L.” | FBG: 4 – 7 mmol/L (or 4 – 5.5 mmol/L if diabetes is not well controlled)
2-hour post-prandial: 5 – 10 mmol/L (or 5 – 8 if diabetes is not well-controlled) |
N/A |
Therapeutics:
- Metformin: Module states, “Metformin is available in a fixed dose combination with glibenclamide. Due to risk of hypoglycaemia with glibenclamide, blood glucose levels should be monitored when switching a patient to the fixed dose combination.” Glibenclamide is known as glyburide in Canada.
- Long term safety and outcome data DPP-4 inhibitors have on diabetes related complications are lacking – not necessarily true; we have CV outcome data from SAVOR-TIMI, CARMELINA, etc.
- Metformin: Dose: 500 mg once daily PO increasing to maximum 1 g tds PO [“TDS” = “TID”]; According to the 2018 Diabetes Canada guidelines, the maximum dose of metformin is 2.55 grams per day (i.e. 1000 mg QAM + 500 mg at lunch + 1000 mg QPM)
- Vildagliptin: Vildagliptin is not available in Canada
- Semaglutide is missing from the list of GLP1-RA drugs (the list only includes exenatide, liraglutide, and dulaglutide)
- Acarbose: Module states that the maximum dose is “maximum 600 mg daily”. The maximum dose is 100 mg TID, i.e. 300 mg daily (total)
- Glipizide is not available in Canada
- Canagliflozin is missing from the list of SGLT2 inhibitor drugs (the list only includes dapagliflozin, empagliflozin, and ertugliflozin)
- Dapagliflozin also comes in 5 mg tablets (not just 10 mg tablets) in Canada
- Fiasp (faster insulin aspart) is missing from the list of ultra-short acting insulins
- For the insulins, there should be a table that outlines the onset, peak, and duration of action for each group/type of insulin
- There should be a note that ultra-short acting insulins (i.e. rapid-acting insulins) can also be used in CSII (insulin pump) regimens
- Short-acting insulin is also referred to as “Insulin Regular” in Canada (not “Insulin Neutral” as in the module). Canadian Brand Names for short-acting insulin/insulin regular include: “Humulin R”, “Novolin GE Toronto”, “Novolin R”, “Entuzity”
- Insulin degludec (Tresiba) is not missing from the list of long-acting insulins
- In Section “15. More prescription feedback”, there are a number of statements pertaining to the preference for Sulfonylureas as add-on therapy after metformin:
- In Sub-Section 1, it says: “If metformin cannot be tolerated or is contraindicated, a sulfonylurea would be an alternative first-line medication. Sulfonylureas are associated with weight gain and hypoglycaemia, which is why metformin is the preferred first-line treatment wherever possible. As Richard has no previous intolerance to metformin and no contraindications, metformin is the best choice for initial treatment.” → Sulfonylureas have fallen out of favour and are no longer the preferred alternative to metformin for second-line therapy. Either an agent with proven CV benefit (if the patient has CV risk factors or has CVD) is preferred and if not, then another class of antihyperglycemics like SGLT2 inhibitors, DPP4 inhibitors are preferred.
- In Sub-Section 3, it says, “Sulfonylureas are considered add-on therapy to metformin when glycaemic targets are not met on monotherapy. Before intensifying treatment by adding a sulfonylurea, make an assessment of compliance to the metformin dosing regimen, and specifically ask about the presence of troubling gastrointestinal adverse effects. Sulfonylureas are considered a reasonable alternative for first-line treatment if there are contraindications to using metformin.”
- In subsection 4, it says, “It would be unusual to initiate treatment of type 2 diabetes with a DPP-4 inhibitor. Sulfonylureas are the usual initial add-on medicine if monotherapy with metformin is not effective at achieving blood glucose targets. DPP-4 inhibitors (or SGLT2 inhibitors) are an alternative to sulfonylureas as add-on therapy, after considering patient preference, the presence of problematic hypoglycaemia, weight gain or other adverse effects.”
- Sulfonylureas are considered a reasonable alternative for first-line treatment if there are contraindications to using metformin.
Resources:
Other Problems:
- “Glycated haemoglobin (HbA1C) is reimbursable through Medicare for the diagnosis of type 2 diabetes in asymptomatic patients determined to be at high risk (e.g. ethnic background, score of 12 or greater using the Australian type 2 diabetes risk assessment tool [AUSDRISK]).
Urinary Tract Infection
Preamble:
Differences in terms used:
- Loin pain vs flank pain
- Bacteraemia vs Bacteremia
- Amenorrhea vs Amenorrhea
- Systemic Inflammatory Response Syndrome (SIRS) – ?? Canadian equivalent
- Leucocytes vs Leukocytes
- Consumer Medicine Information (CMI) vs. Patient Information Leaflet
Therapeutics:
- For uncomplicated UTI – we usually recommend Nitrofurantoin 100mg po bid x 5 days OR SMX/TMP DS 1-tab po bid x 3 days (Note that the NPS module recommended Trimethoprim 300mg po daily x 3 days)
Resources:
- Module has a resource for asking your patients about sexual history in a sensitive way – need to identify something Canadian (Sexually Transmitted Diseases)
- IDSA instead of Australasian Society of Infectious Diseases
- Urinary Tract Infections – IDSA guidelines
Postoperative Pain and Vomiting
Chronic obstructive pulmonary disease (COPD) exacerbation
Preamble: Important clarifications for Canadian medical students:
Differences in medical terms used, for example:
- oedema vs. edema
- registrar vs. senior resident (“You make a diagnosis of acute exacerbation of COPD. You discuss this with your registrar, who agrees and states that Mary should receive bronchodilators…”). The term “Registrar”, in Canada, would be equivalent to a senior resident.
Potential differences in normal reference ranges for certain laboratory values:
- Note there may be slight differences in the normal ranges of certain laboratory parameters contained within this module and the standard reference values used in Canada. Reference lab values are often institution- or site-specific; for example, the Hamilton Health Sciences and St. Joseph’s Healthcare Hamilton follow the references ranges set by the Hamilton Regional Laboratory Medicine Program (HRLMP), which is one of the largest integrated laboratory service programs in Canada. Please see: Laboratory Test Information Guide and Hamilton Regional Laboratory Medicine Program for more information.
Potential differences in therapeutics:
- Choice of Antibiotic for acute COPD exacerbation: The Australian module recommends Amoxicillin or Doxycycline. Canadian recommendations vary depending on risk for Pseudomonas infection, inpatient vs outpatient setting, etc. Outpatient setting and low risk for Pseudomonas antibiotic choices are typically amoxycillin-clavulanate or a respiratory quinolone. Patients with multiple (more than 2) exacerbations per year are occasionally treated with azithromycin.
- The module talks about recommending COPD patients for influenza and pneumococcal vaccine and then provides a link to The Australian Immunisation Handbook. Canadian physicians would follow NACI guidance: Immunization of persons with chronic diseases: Canadian Immunization Guide – Canada.ca
- There is a link to Australian VTE prophylaxis resource (in the scenario that patient will have limited mobility and admitted) – we refer to Thrombosis Canada: thrombo-prophylaxis in the hospitalized medical patient
- The GOLD (Global Initiative for Chronic Obstructive Lung Disease) Guidelines have published a Pocket Guide to COPD Diagnosis, Management, and Prevention for Healthcare Professionals (updated as of 2020).
Canadian-Specific Resources:
- Two Canadian organizations for respiratory health that provide exceptional resources are outlined below, along with specific and relevant resources from each:
- The Ontario Lung Association (also known as “The Lung Health Foundation”)
- The Canadian Lung Association (also known as “Breathe: The Lung Association”)
- Some of the newer inhalation devices may be prone to errors in usage and technique, which may pose potential efficacy and safety risks. The Institute for Safe Medication Practices Canada (ISMP Canada) produced a 1-page document outlining pertinent counselling points when training and educating patients about the appropriate use of these devices: InhalationDevices-ReferencePoster (ismp-canada.org)
- The Canadian Thoracic Society (CTS) has a library of guidelines, updates/notices, and position statements pertaining not just to asthma and COPD but other relevant topics such as COVID-19, spirometry, home mechanical ventilation, pulmonary vascular disease, sleep disorders, etc.
Prevention of Venous Thromboembolism
Strongly suggested but not mandatory NPC Modules
- Antimicrobials: bacteremia (online course)
- Antimicrobials: surgical prophylaxis (online course)
- Antimicrobials: catheter-associated urinary tract infections (online course)
- Antimicrobials: community-acquired pneumonia (online course)
- Acute pulmonary edema (NPC module)
- Chronic heart failure (NPC module)Alcohol withdrawal delirium (NPC module)
- Lipid and CVD risk management (NPC)
- Delirium in an older person (NPC)
- Insomnia (NPC)
- H. pylori infection (NPC)
- Iron deficiency (NPC)
- Anticoagulation in atrial fibrillation (NPC)
- Management of acute coronary syndrome (NPC)
- Depression in adolescents (NPC)
- Acute mania in bipolar disorder (NPC)
- Preventing fractures: where to start with osteoporosis (NPC)
It is important to read Katzung’s Basic & Clinical Pharmacology, 16th Edition. Student should be able to access this resource through their institutional library, and/or online here.