1. Mrs Kearns (78 y.o) asks for an antihistamine. She tells you that she used to use Teldane® when she last had this problem.

2. Tutorial Scenario. Mrs Kearns, a healthy 78 year old female is visiting Sydney to attend her grandson’s wedding. She is 5 days in to a 14-day course of erythromycin therapy. Yesterday she had an upset stomach and diarrhoea, so she is also taking diphenoxylate (Lomotil), which contains a sub-therapeutic amount of atropine sulfate to discourage abuse. She is feeling a little tired and she also as a dry mouth and slightly blurred vision.

3. Tutorial Scenario. She has woken up with red itchy, watery eyes and is sneezing frequently. She used to suffer from hayfever when she lived in Sydney and her doctor had treated her with Teldane (10 years ago). The antihistamines you have available are Claratyne (loratadine), Phenergan (promethazine), Telfast (fexofenadine) and Polaramine (dexchlorpheniramine).

4. Tutorial Scenario. She also asks you for a Ventolin inhaler and presents an asthma card She woke up coughing last night and needed her Ventolin

5. Lectures to support this case Histamine and Antihistamines A/Prof J Hanrahan Clinical Interventions Dr T Chen Adrenergic Receptors (relevant to Cardiovascular and Respiratory) Prof B Roufogalis Allergic Rhinitis Dr L Smith Asthma Therapy Dr B Saini Asthma Devices Dr B Saini Inhaler Technique Dr S Bosnic-Anticevich

6. References to support this case Second year lectures on antibiotics Foye's Principles of Medicinal Chemistry; Thomas L Lemke, David A Williams, Victoria F Roche & S. William Zito, 6 th Edition, 2007. NAC Asthma management handbook NAC health professional guide Allergic rhinitis and the patient with Asthma Respiratory Guidelines AMH

7. General learning objectives for PHAR3812 By the end of this tutorial students should be able to:  Predict the activity of a drug based on its structure and physicochemical properties  Demonstrate an understanding of how the physical and chemical properties of a drug determine its pharmacology, toxicology, bioavailability and behaviour in formulations  Identify typical examples of drugs which are used to restore physiological functions in the respiratory system  Describe the mechanism of therapeutic action of a selected drug at the molecular, cellular, organ system and whole body levels

8. General learning objectives for PHAR3812 By the end of this tutorial students should be able to: Describe the common adverse effects of a selected drug and their mechanism of production Demonstrate an understanding of basic metabolism in relation to drugs and efficacy and safety in relation to the treatment of disease and/or maintenance of health Apply an understanding of the basic and applied sciences to pharmaceutical care in order to optimise health outcomes Respond to direct product and symptom based requests (in relevant therapeutic areas)

9. Learning outcomes specific for Case 1 By the end of this tutorial students should be able to: Have an understanding of the link between Asthma and Allergic Rhinitis Identify the different structure of antihistamines Understand the structural features likely to cause adverse effects with antihistamines Demonstrate an ability to develop appropriate allergic rhinitis and asthma management plans.

10. Information Gathering Prior to Tutorial 1 WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED? Before your tutorial you should have a list of questions that you would like to ask Mrs. Kearns

11. Information Gathering Prior to Tutorial 1 WHAT ARE THE POSSIBLE CAUSES OF COUGH? Before your tutorial you should have a list of possible causes of cough and differentiating features.

12. Information Gathering Prior to Tutorial 1. WHAT IS THE LINK BETWEEN ASTHMA AND ALLERGIC RHINITIS? Before your tutorial you should have read the NAC health professionals guide on WebCT

13. Information Gathering Prior to Tutorial 1 WHAT DO THE STRUCTURES OF THE AVAILABLE ANTIHISTAMINES TELL YOU ABOUT THEIR ACTIVITY AND SIDE EFFECTS Before your tutorial you should review the structures, think about solubility of functional groups, size, drug interactions and adverse effects

14. Information Gathering Prior to Tutorial 1 HOW IS ERYTHROMYCIN METABOLISED BY THE LIVER? Before your tutorial you should review the metabolism pathways of erythromycin and her other medicines.

15. Information Processing Prior to Tutorial 1.

16. During tutorial 1. You may be asked to present interesting insights from your placement The tutor will ask for answers to the pre-work questions A role play with the patient will occur Discussion and debate will occur in order to choose appropriate management for Mrs Kearns

17. Information Gathering In Tutorial 1 WHO IS THE PATIENT? In your tutorial students should role- play with the patient (20mins)

18. Information Processing In Tutorial 1 WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED? Identify key issues that need to be addressed and discuss in your table groups

19. Information Processing In Tutorial 1 WHAT COULD BE CAUSING HER COUGH? After questioning make a differential diagnosis

20. Information Processing in Tutorial 1 WHAT DO THE STRUCTURES OF THE AVAILABLE ANTIHISTAMINES TELL YOU ABOUT THEIR ACTIVITY AND SIDE EFFECTS Discuss the pros and cons of each medicine and choose an appropriate agent

21. Information Processing in Tutorial 1 WHAT ISSUES MAY LOMOTIL AND ERYTHROMYCIN POSE? Discuss the pros and cons of each medicine and choose an appropriate agent

22. Information Processing in Tutorial 1. WHAT IS THE BEST WAY TO MANAGE MRS KEARNS’ SYMPTOMS During the tutorial devise an appropriate allergy and asthma action plan

23. Information Processing in Tutorial 1 WHAT ASTHMA THERAPY WOULD YOU RECOMMEND IF SHE WAS: – A. BACK AT HOME – B. PLANNING ON STAYING IN SYDNEY FOR A WHILE? During the tutorial devise an appropriate allergy and asthma action plan

24. END OF TUTORIAL 1.

25. Information Processing before Tutorial 2 WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED TO ACHIEVE THE DESIRED THERAPEUTIC OUTCOME? Before tutorial 2. identify and prioritise the issues on hand

26. Information Delivery before Tutorial 2 WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED TO ACHIEVE THE DESIRED THERAPEUTIC OUTCOME? Before tutorial 2. document your findings and recommendations for this case. (Be ready to discuss these with the doctor and patient)

27. During tutorial 2. You may be asked to present interesting insights from your placement The tutor will ask for answers to the pre-work questions role play with the doctor will occur role play with the patient will occur

28. Information Delivery during Tutorial 2 WHAT ARE THE PATIENT SPECIFIC FACTS THAT NEED TO BE IDENTIFIED AND PRIORITISED TO ACHIEVE THE DESIRED THERAPEUTIC OUTCOME? During tutorial 2. present your findings and recommendations in powerpoint

29. Information Delivery during Tutorial 2 DISCUSS ANY ISSUES YOU HAVE WITH THE DOCTOR During tutorial 2. articulate your clinical intervention(s) to the patient’s doctor

30. Information Delivery during Tutorial 2 COUNSEL THE PATIENT ON THE CORRECT USE OF THE APPROPRIATE ANTIHISTAMINE During tutorial 2. explain to the patient why you have chosen the particular agent and counsel her on its use

31. Information Delivery during Tutorial 2 COUNSEL THE PATIENT ON HER OVERALL PLAN During tutorial 2. tell Mrs Kearns about her asthma and allergy management