1. Pharmacotherapy and the High Risk Foot Laeticia Douglas

3. Podiatrists – what you can do with drugs in QLD Obtain, administer and possess –WITHOUT ADRENALINE –Bupivacaine 0.5% or less –Levobupivacaine 0.5% or less –Lignociane 2% or less –Prilocaine 2% or less Administer –S2 poisons –Adrenaline 0.1% or less in a preloaded device for anaphylaxis

4. Scheduling UnscheduledAspirin, paracetamol, some topical antifungals S2Antihistamines, antifungals S3Hydrocortisone cream, S4Antibiotics, oral antifungals, local anaesthetic, corticosteroids, strong pain relief, benzodiazepams S8codeine

6. Endorsed Podiatrists Obtain, administer and prescribe from the drugs listed in the QLD Regulation Possess –WITHOUT ADRENALINE –Bupivacaine 0.5% or less –Levobupivacaine 0.5% or less –Lignociane 2% or less –Prilocaine 2% or less

7. Podiatrists and EPs – know your poison Subscribe to the databases Refer patients to pharmacists for supply of their S2 poisons NPS Medicine Wise –Consumer Medicine Information

8. The Basics Medication history including CAMs Allergies and hypersensitivities Medical conditions Test results Foot Ax and Dx

9. eTG – Diabetic foot infection

10. What to consider Clinical signs of infection History of infection and cultures Has the patient taken it before Allergies or adverse effects Drug interactions Dose adjustment in renal impairment Non-pharmacological treatment

11. eTG – Tinea pedis Application Previous use Allergy or adverse effect itch, sting, redness Tinea elsewhere? Groin? Counselling – dry between toes, use regularly

12. Candidasis

13. Consider History of infection Has the patient taken it before Allergies or adverse effects Azoles and pregnancy Non-pharmacological treatment

14. Case - Diabetic foot infection 64 yo female Nil known allergies Lives with adult son and grandson Non-smoker Uses a 4 wheeled walker Attends social activities with Bluecare

15. Medical history Type 2 Diabetes mellitus Chronic kidney disease Ischaemic heart disease Hypertension Peripheral neuropathy Urinary incontinence Asthma Osteoarthritis Bilateral Charcot foot deformity

16. Medications Aspirin, 1 x day, (NSAID, prevent heart attacks, strokes and blood clotting) Cholecalciferol 25mcg, 2 x day, (vitamin D supplement) Clopidogrel 75mg, 1 x day, (thienopyridine, prevent heart attacks, strokes and blood clotting) Docusate-Senna 50/8mg, 2 tablets 1 x day, (laxative, treat/prevent constipation) Esomeprazole 40mg, 1 x day, (proton-pump inhibitor, prevent gastric ulcers) Ferrous sulphate-folic acid 250mg-0.3mg, 1 x day, (iron and folic acid supplement) Fluticasone-salmeterol 500/50mcg, (inhaled corticosteroid + beta2 agonist, improve control of airways disease) Frusemide 40mg, 1 x day, (loop diuretic, remove fluid) Insulin aspart, 12 Units mane, 12 Units midday, 10 Units nocte, (ultra short acting insulin, diabetes) Insulin glargine, 24 Units mane, 20 Units nocte, (long acting insulin, diabetes) Metoprolol 50mg, ½ tablet, 2 x day, (beta blocker, treat hypertension)Oxybutynin 5mg, 2 x day, (anti-cholinergic, improve bladder control) Oxycodone 5mg, 1-2 tablets every 3 hours, (opioid analgesic, severe pain) Perindopril erbumine 2mg, 1 x day, (ACE inhibitor, hypertension) Pizotifen 500mcg, 1 x day, (5HT2 antagonist with antihistaminic and weak anticholinergic properties, treat migraine) Pravastatin 80mg, 1 x day, (statin, treat hypercholesterolemia)

17. Test results C-Reactive Protein - 32mg/L eGFR – 41ml/min/1.73^2 BGL - 14.1mmol/L BP - 140/74 Wound swab – strep Group c

18. Consider Kidney function Swab results Offloading Instructions for patient and son Drug interactions

19. Prescription

20. Fungal infection 64 yo female Allergy to codeine Lives alone Smokes 40 /day

21. Medical history Hypertension Type two diabetes mellitus Dyslipidaemia

22. Medications Paracetamol 1g QID, (non-opioid analgesic, mild pain) Insulin - ultra-short acting, 10 units mane – 16 units midday – 16 units nocte (insulin, diabetes) Insulin – glargine, 18 units nocte (insulin, diabetes) Metformin 1g BD (biguauide, diabetes) Ezetimibe / Simvastatin 10mg/8mg nocte, (statin, dyslipidaemia) Trandolapril 4mg mane (ACE Inhibitor, hypertension) Aspirin 100mg mane, (NSAID, cardiovascular disease) Amoxycillin + Clavulanic acid 875/125mg BD, (penicillin, infection) Clindamycin 450mg TDS, (lincosamide, infection)

23. Assessment Acute dermophyte infection to the skin where VAC dressing is applied. Likely due to long term occlusion from wound dressing.

24. Prescription Antifungal medication: Miconazole 2% applied to surrounding skin before placement of VAC dressing. Antibacterial medication: Amoxycillin + clavulanic acid 875 +125mg orally every 12 hours Clindamycin 450mg orally every 8 hours

25. Consider Triple whammy – just add a diuretic Formulation Adverse effects and allergies

26. Diabetic foot infection, hypersensitivity 76 yo male patient Lives in mobile home T2 Diabetes mellitus Peripheral neuropathy Atrial fibrillation Glaucoma hyperlipidaemia

27. Medications Amoxicillin + clavulanic acid 875mg+125mg 1 tab BD (broad spectrum antibiotic, foot infection) Warfarin 8mg nocte (vitamin K antagonist, prevent stroke – atrial fibrillation) Perindopril arginine 2.5mg 1 tab mane (ACE inhibitor, improve heart function and reduce protein in urine) Glicazide 60mg 2 tab mane (sulfonylurea, diabetes) Metformin 500mg 4 tab nocte (biguanide, diabetes) Rosuvastatin 10mg 1 tab mane (statin, reduce cholesterol) Latanoprost 50mcg/mL, 2.5mL 1 drop nocte both eyes (prostaglandin analogue, glaucoma)

28. Assessment BGL - 7.6mmol/L eGFR – 59 ml/min/1.73m^2 White Cell Count - 9.2 x 10^9/L C-Reactive Protein – 78mg/L Lower leg Arterial ultrasound – normal tri- biphasic Doppler waveforms. No focal stenosis or occlusion. X-ray right foot – no evidence of osteomyelitis. Discussion with patient about oral amoxicillin prescribed by GP. Patient has not been taking as it causes a stomach upset.

29. Prescription Antihistamine Loratadine 10mg orally Antibacterial *Ciprofloxacin 500mg orally 12 hourly 5 days Clindamycin 450mg orally 8 hourly 5 days

30. Considerations Hypersensitivity v anaphylaxis Dose adjustment in CKD Drug interactions

31. Reading List AMH, eTG, MIMs etc AHPRA – various policies, codes and guidelines –Podiatry guidelines for endorsement for scheduled medicines Qld Drug Regulations