The Blonde Pharmacist

[theblondepharmacist]

The Pharmacist's Manifesto

The Pharmacist’s Manifesto

Pharmacists do not become pharmacists to just dispense medications.

They do not do it just to make a lot of money.

They do not go through 6-8 years of study to feel important or to walk around being patted on the back.

They do it (at least I hope they do it) because they want to help a person, a patient, who needs help.

I remember the day the Pharmacist’s Oath was read aloud to my newly graduated pharmacy class. The feeling of accomplishment filled my being, and I felt proud and nervous to begin the career I had spent the last many years preparing and studying.

This is the updated version in 2009 by the American Pharmacists Association:

"I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:

• I will consider the welfare of humanity and relief of suffering my primary concerns.

• I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.

• I will respect and protect all personal and health information entrusted to me.

• I will accept the lifelong obligation to improve my professional knowledge and competence.

• I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.

• I will embrace and advocate changes that improve patient care.

• I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.”

These points should be important to all pharmacists, and many of them embrace the reasoning we chose pharmacy in the first place. We care, continue to learn, respect, remain ethical and work toward change and preparation for the future of our profession.

These points sound well and good. It wraps up neatly the ideas and beliefs we should hold dear; however, is it applicable in the day-to-day grind of pharmacy work and life?

The retail pharmacist that dispenses with minimal staff has something to add to the conversation.

The pharmacist overseeing warehouse fulfillment operation on a reduced staffing budget would probably worry about the optimal outcomes for patients.

The hospital pharmacist held tightly under a metric goal of so many orders per hour would probably worry as well.

There is a balance between profit margins and production regardless of what field discussed. Physicians and nurses are under tight restrictions as well and at the end of the day, the patient is the one who may suffer.

What does it mean to consider the welfare of humanity and relief of suffering to be our primary concern? It could mean that when a nurse phones down for an immediate dose of a pain medication for a patient, we should do all we can to make the time from phone call to patient receiving the medication as small of a time as we can. It could mean that when someone is out of medication refills in a retail setting, we attempt to help if we can. It could mean that we do all we can to make sure in the warehouse setting that medications are checked and double checked for accuracy and advocate for standards of certification for technicians. The examples go on.

Go above and beyond for the patient. If a pharmacist keeps the ultimate customer in mind, the patient, how could it be argued? Providing care for the patient should be the pharmacist’s manifesto.

[theblondepharmacist]

[theblondepharmacist]

Acute Gout: Topic of the Day

From the Rheumatology Guidelines 2012:

Patient education on diet, lifestyle, treatment objectives, and management of comorbidities is a recommended core therapeutic measure in gout. Foods to avoid are organ meats, foods containing high-fructose corn syrup, and excessive alcohol use; foods to limit are large portions or concentrations of meat and seafood, naturally sweet fruit juices, sugar, desserts, and salt; and foods that are encouraged include low-fat or nonfat dairy and vegetables.  Of course also maintaining a healthy weight, exercising and smoking cessation are important in the management of gout.

Urate-lowering therapy (ULT) should be considered in patients with 1 or more tophi, ≥2 attacks per year, chronic kidney disease (CKD; stage 2 or worse) and urolithiasis:

First line: Xanthine oxidase inhibitor (XOI) therapy with either allopurinol or febuxostat is recommended as the first-line pharmacologic urate-lowering therapy (ULT) approach in gout).

Alternative: probenacid

Serum urate level should be lowered sufficiently to durably improve signs and symptoms of gout, with the target 6 mg/dl at a minimum, and often 5 mg/dl.

 Allopurinol:

Starting allopurinol dose should not exceed 100 mg/day, and patients with CKD of stage 4 or higher should be started at 50 mg/day. Dosages should be titrated up every 2-5 weeks to achieve target serum uric acid and can go above 300 mg/day as long as the patient is educated and monitored for adverse events. 

Caveat: Prior to initiation of allopurinol, rapid polymerase chain reaction– based HLA–B*5801 screening should be considered as a risk management component in subpopulations where both the HLA– B*5801 allele frequency is elevated and the HLA– B*5801–positive subjects have a very high hazard ratio (“high risk”) for severe allopurinol hypersensitivity reaction (e.g., Koreans with stage 3 or worse CKD and all those of Han Chinese and Thai descent).

Combination oral ULT with 1 XOI agent and 1 uricosuric agent is appropriate when the serum urate target has not been met by appropriate dosing of an XOI.

Pegloticase is appropriate for patients with severe gout disease burden and refractoriness to, or intolerance of, appropriately dosed oral ULT options. 

[theblondepharmacist]

Osteoarthritis: Topic of the Day

The American College of Rheumatology has guidelines for patients with Osteoarthritis (OA) of the hand, hip and knee. 

Hand Osteoarthritis

Oral and topical NSAIDs - (in patients 75 and older topical NSAIDs are preferred)

Topical Capsaicin

Tramadol

**Opioids and intra-articular therapies are not recommended. 

Knee Osteoarthritis

Aerobic or resistance land-based exercise, aquatic exercise and weight loss

For moderate to severe pain in patients who don't elect joint replacement, acupuncture and TENS recommended.

Pharmacological: Oral and topical NSAIDs, tramadol, and intra-articular corticosteroid injections

**Glucosamine, chondroitin sulfate, and topical capsaicin were conditionally not recommended

Hip Osteoarthritis

Treat similar to those with knee osteoarthritis

Tramadol and intra-articular corticosteroid injections have been upgraded to initial OA treatment, while previous guidelines listed only APAP as first-line.

 NOTES:

COX-2 inhibitor celecoxib (Celebrex) or a traditional NSAID along with a stomach-protective drug, such as esomeprazole (Nexium) or omeprazole (Prilosec) for younger people at high risk of gastrointestinal side effects

Opioids such as hydrocodone for people who don’t respond to other treatments and aren’t candidates for joint replacement; (The panel cautioned that doctors who prescribe them should follow guidelines established by the American Pain Society and the American Academy of Pain Medicine.

Tai chi, acupuncture, TENS (transcutaneous electrical nerve stimulation) or intra-articular hyaluronate injections for knee OA, but not hip OA. 

Special Populations

For persons age ≥75 years, the Technical Expert Panel (TEP) strongly recommends the use of topical rather than oral nonsteroidal anti-inflammatory drugs (NSAIDs).

In the clinical scenario where the patient with osteoarthritis (OA) is taking low-dose aspirin (≤325 mg per day) for cardioprotection and the practitioner chooses to use an oral NSAID, the TEP strongly recommends using a nonselective NSAID other than ibuprofen or COX-2 inhibitor** in combination with a proton-pump inhibitor. This recommendation is based, in part, on the Food and Drug Administration (FDA) warning that the concomitant use of ibuprofen and low-dose aspirin may render aspirin less effective when used for cardioprotection and stroke prevention because of a recognized pharmacodynamic interaction. **Studies have not demonstrated this same type of pharmacodynamic interaction with diclofenac or celecoxib; nonetheless, the TEP strongly recommends that a cyclooxygenase 2 (COX-2) selective inhibitor should not be used in the above situation as well.

The decision to use an oral NSAID in patients with chronic kidney disease stage III (estimated glomerular filtration rate between 30 and 59 cc/minute) should be made by the practitioner on an individual basis after consideration of the benefits and risks. 

Contraindications

Based on good clinical practice, oral nonsteroidal antiinflammatory drugs (NSAIDs) should not be used in patients with chronic kidney disease stage IV or V (estimated glomerular filtration rate below 30 cc/minute).

ACR elevates NSAIDs to a first-line option 2012 updates: Recommendations for knee and hip OA now include NSAIDs as first-line pharmacological options, with the consideration of adding PPIs to reduce potential GI toxicity in cases of chronic NSAID use.

ACR continues to caution against exceeding a daily 4-g dose of acetaminophen. (FDA cautions against >3 grams/APAP per day). 

[theblondepharmacist]

Fibromyalgia: System and Patient Topic of the Day

I have decided to start a new series to educate and help you in studying for the BCPS coming up this Fall 2015. My goal is to find a topic every single day to cover and hopefully help prepare you! If you have any comments you want to add on topics you want covered, feel free to leave a comment. 

Fibromyalgia

What is fibromyalgia? Pain all over the body and other symptoms

Chronic. Tenderness to touch or pressure to joints and muscles. Fatigue. Sleep problems. Problems with memory or thinking clearly. Some have depression or anxiety. Migraines. Tension headaches. IBS, GERD. Irritable or overactive bladder. Pelvic pain, TMJ.

How do doctors diagnose?

·         Patient’s relevant symptoms (what they feel)

·         NO test to detect but based on ruling out everything else

·         NO cure but meds may help alleviate

Sometimes runs in families. Causes unclear. Sometimes maybe physical or emotional stress triggers this illness.

Some think that the volume control is turned up too high in the brain’s pain processing centers.

 TREATMENT

 FDA Approved:      

1.    Cymbalta (duloxetine): (serotonin and norepinephrine) that help control pain levels

2.    Savella (milnacipran): (serotonin and norepinephrine)

3.    Lyrica (pregabalin): blocks the overactivity of nerve cells involved in pain transmission

Non FDA Approved:

1.    Amitriptyline (Elavil)

2.    Cyclobenzaprine (Flexeril)

3.    Venlafaxine (Effexor)

Other Non FDA Approved (not first line):

1.    Tramadol (Ultram): opioid narcotic

**Note:  Doctors don’t suggest using other opioids for treating this disease not due to dependence but due to evidence that shows that these drugs may actually increase pain sensitivity or make pain persist.

Treatment of Sleep Problems

Cyclobenzaprine (Flexeril)

Amitriptyline (Elavil)

Gabapentin (Neurontin)

Pregabalin (Lyrica)

**Note: Ambien and benzodiazepines are NOT recommended for insomnia in fibromyalgia

 Treatment of Pain

APAP

NSAIDs like ibuprofen/naproxen

[theblondepharmacist]

Drug Overdose Surpasses Traffic Related Deaths in Leading Cause of Death

The BMJ (formerly the British Medical Journal) reported that drug overdose has become the leading cause of death from injury in the US based on a report by the Trust for America’s Health. As prescriptions for opioids have increased the number of deaths from drug overdose has risen and has surpassed traffic related deaths as the leading cause of death from injury in this country. Half of these overdose deaths are due to prescription medications.

The report states that all injury related deaths in the US have remained stable in about half of the states, increased significantly in 17 states and stable in the rest. Injuries are the leading cause of death for Americans ages 1 to 44 leading to about 193,000 deaths per year.

[theblondepharmacist]

Why Hospital Pharmacy Struggles

It is no surprise to hospital pharmacists that there is an internal battle going on. I cannot outline the struggle without first describing how hospitals get paid and businesses cannot continue to function without money to pay its employees and generate profit.

Hospitals are paid by different methods depending on who is paying the bill.

Medicare: the federal program for the elderly usually pays the hospital a flat fee per case depending on the case. There are around 750 different diagnostic related cases (D.R.G.'s) that can be billed and each command a flat rate regardless of what happens in the hospital. These flat rates are changed due to lobbying and advice from commissions and other methods. Many times hospitals claim the payments received are below cost which causes the hospital to lose money.

Medicaid: the federal-state program for the poor, blind and disabled hospitals receive the same D.R.G's or a set amount of dollars per day (per-diem) or fee-for-service (F.F.S.) payments. These are set by state governments. Again, many times hospitals claim the payments received from Medicaid are below cost which causes profit loss.

Private insurers: purchased by consumers and pay hospitals on the basis of per-diems or fee-for-service. These usually exceed hospitals' costs and help override the losses from Medicare and Medicaid. Private insurers also help with net profits for the hospital and are negotiated yearly.

Breaking down the particular fees agreed upon, it's fairly evident that the pharmacist's role in billable services is on the distribution aspect: the medication provided and the rest is dollars saved but not billed. For example, if I dispense 2 bags of IV vancomycin, the hospital can bill $XX for the medication. If I recommend changing vancomycin to an oral antibiotic, the savings are due to medication costing less and I am not billing the other aspects of the IV to PO change. The patient has less chance of infection with an antibiotic given by mouth than IV, easier to administer and is an ideal choice over IV. There are cost savings for the drug (still distribution in nature) and costs in drug delivery, but the consult itself to change a medication has no billable service to the pharmacy department but indirect savings to the hospital as a whole. There are also cost savings with preventable adverse drug errors in regards to length of hospital stay billed, but nothing billed on catching anything amiss on a patient's profile.

In other words, pharmacists command high salaries but do not have a way to bill for the same amount in return. Pharmacists and pharmacies cost the hospital a lot of money.

Hospitals are starting to learn that using pharmacists to cut medication errors cuts down on readmission (financial penalties with reimbursement) and that there are costs tied to a patient experiencing an adverse drug reaction and other indirect cost savings, but we need a return on investment. Perhaps that is where provider status for pharmacists will fill in the gap?

Not only do we struggle with what we bill and what we cannot bill, we also struggle with being segmented within our own pharmacies. Distributive pharmacists (order entry pharmacists) are looked upon as aging dinosaurs out-of-touch with the clinical aspect of rounding with physicians and making real-time recommendations at bedside and new graduates I hear state, "I don't want an order entry job. I want to be a clinical pharmacist." There is a division that seems to be encouraged with residency programs, fellowships, and board certification leading to "clinical" jobs and none required for order entry jobs, unless you are in a more progressive hospital that tries hard to incorporate both models into staff pharmacist decentralized on the hospital floors interacting "clinically" with nursing, physicians and patients.

Another struggle is that clinical pharmacists do not want to be bothered by pharmacy operational problems or regulatory issues. Operational problems affect patient care as well and translates into a cost for the department and hospital and presently are tied directly to a pharmacy's budget.

The last struggle that I have observed over the last fifteen years is the lack of excellence in leadership. I do not have many peers who strive for leadership roles in pharmacy but are fine to sit back and just work as a pharmacist rather than a manager. There are not a lot of strong leaders teaching and mentoring others on how to lead within the pharmacy, because of that pharmacists don't have a lot of power or clout to make change happen.

What is the answer? I am hopeful that provider status will open the door to pharmacists becoming more of a return on investment for hospitals, but I also believe that there should be more meshing with understanding the business side of hospital pharmacy with clinical pharmacy because the two together would benefit what should be the ultimate goal of a hospital: patient care and minimizing costs.

[theblondepharmacist]

Leaving the Anti-Vaccine Movement

The anti-vaccine movement had me in its grips after the early birth of my first child In 2008. My son's lungs were not fully developed, and he needed the NICU. My husband and I had signed up for a "natural" childbirth class where epidurals were evil and rupture of membranes did not mean go to the hospital. We were also told to forgo the hepatitis B vaccine for our newborns because "babies don't have sex or do illicit drugs by injection." I am a hospital pharmacist and was falling for it all.

Jenny McCarthy and Dr. Andrew Wakefield were regularly in the news for the connection between vaccines and autism, and I was fearful for my son. After all, Dr Wakefield was a physician with a research paper in support of the connection between vaccines and autism. Also it was a little bit popular to be anti-vax.

Herd immunity is a form of immunity that results when the vaccination of a significant portion of the population provides a measure of protection for those who have not developed immunity. Herd immunity disrupts normal transmission of diseases covered by vaccination. The anti-vax movement directly compromises this immunity resulting in less people becoming vaccinated and increases in diseases that were virtually eradicated.

Measles is on the rise. Dr. Mark Grabowsky, a health official with the United Nations, wrote last year in the Journal of the American Medical Association-Pediatrics. “Many measles outbreaks can be traced to people refusing to be vaccinated; a recent large measles outbreak was attributable to a church advocating the refusal of measles vaccination.” Measles was once considered eradicated. For every 1,000 children who get the measles, one or two will die from it, and one will get brain swelling so severe it can lead to convulsions and leave the child deaf or mentally impaired, the U.S. Centers for Disease Control and Prevention said. In contrast the fears parents have to vaccinate in relation to autism and MMR according to the Wakefield study continues to rise even though the study was proven false. Wakefield was stripped of his license to practice medicine, and numerous conflicts of interest surrounding the study were discovered. Once upon a time before vaccinations, nearly everyone in the U.S. got measles before there was a vaccine, and hundreds died from it each year. Today, most doctors have never seen a case of measles, but cases keep popping up, the latest starting in Disneyland.

Still the anti-vax movement continues. 

Mumps have also made a comeback. Before widespread vaccination, there were about 200,000 cases of mumps and 20 to 30 deaths reported each year in the USA. Mumps can in some cases lead to encephalitis and deafness. Herd immunity is important because the mumps vaccine is just 88% effective, explaining why someone can easily contract the disease even if they have been vaccinated as I did back in 9th grade from a foreign exchange student. I was vaccinated, but for whatever reason was infected from someone overseas. The CDC reports that the number of mumps cases doubled in the past year - affecting more than 1,000 people nationwide.

Pertussis or whooping cough was a universal disease in the pre-vaccination era was almost always seen in children. Between 1940 and 1945, before widespread vaccination, as many as 147,000 cases of pertussis were reported in the USA each year, with approximately 8,000 deaths caused by the disease. It is estimated that at the beginning of the 20th century as many as 5 of every 1000 children born in the USA died from pertussis.

Why don't parents vaccinate today? Parents today did not grow up with these diseases and see the thousands of children die. We are not afraid of these diseases because they have not been a part of our lives and take for granted how these diseases can cause death or severe consequences. Parents hear celebrities like Jenny McCarthy, Alicia Silverstone and Kristin Cavallari cite fear as a reason not to vaccinate. But what many don't realize is that those against vaccines and not vaccinating their children depend on the rest of us to vaccinate to stay safe. The more people that join in the crusade that vaccines are evil, the higher the risk their own children will succumb to diseases that were virtually gone just a few years ago. 

Side effects of vaccines are mild according to the CDC. And while there are very rare cases of vaccine-related issues, the benefit far outweighs the risk if you compare the numbers pre-vaccination era vs. after vaccinations were introduced.

Why should parents vaccinate? Parents should vaccinate because vaccines are preventing complications from preventable childhood illnesses that can cause deafness, blindness, hospitalization, other life altering effects and death. Parents should become informed and become critical thinkers about the decisions made to increase the risk of these diseases to their children and others who are unable to fight infection (elderly, immunodeficiencies, and the very young). Parents should not, as I did, make decisions by fear and paranoia and look at the facts. We should also as a society consider public health and realize that vaccines are safe and very effective and not vaccinating is irresponsible.

Fortunately, I woke up from the "anti-vax movement" before endangering my son further. Although his vaccines were spaced out individually and further apart, he ended up receiving them all. My daugther, on the other hand, received them all on time as outlined by the CDC. I do have much greater peace of mind knowing the numbers don't lie, vaccines save lives and have since they were first introduced years ago. I am glad I did not let the fear of the unknown and debunked guide my choices to put them in harm's way.

[theblondepharmacist]

Creative Ways Drug Companies are Changing Drugs of Abuse

The FDA has taken a stance on decreasing drug abuse and pushing for drug companies to find ways to deter people from abusing prescribed medications (crushing, snorting or injecting tablets) or using medications the way they were not intended to be used. Some of the novel drugs that have been created include: * Hysingla is a harder to abuse hydrocodone that deters crushing, dissolving and injection because the contents turn into a thick gel when attempting to dissolve. * Targiniq, when crushed and snorted or crushed, dissolved, and injected, the naloxone blocks the euporic effects of oxycodone making it less liked by abusers than oxycodone alone. * Embeda is an agonist/antagonist combination of an extended release morphine with naltrexone. Naltrexone is not an active component unless the tablet is chewed, crushed, or dissolved. Unfortunately, the most common route of abuse of these types of medications is the oral route. This cannot be addressed through the physical component of the tablets on the market but has been combated with changes such as state databases showing trends of prescription opioid fills and refills and also changing hydrocodone from a CIII to a CII causing more regulation and different rules for the pharmacist and prescriber to follow.  

[theblondepharmacist]

A.S.P.E.N.'s Parenteral Nutrition Handbook, 2nd Edition

            As a pharmacist and a clinician at my local hospital, there have been times where I am starting a new PN (total parenteral nutrition) and needed help beyond the usual formula or write-up that we use. In the information age, we have a diverse amount of information online at our fingertips; however sometimes this information can be from sources that are not legitimate. I can google PN and a disease state and hope for something relevant, or I can seek out material that is tried, true and tested.

            The A.S.P.E.N. Parenteral Nutrition Handbook, 2nd Edition is a pocket-sized handbook or quick reference that covers many parenteral nutrition topics with students in dietetics, nursing, medicine and pharmacy in mind. There are 10 fully revised chapters from the 2009 1st edition including: 

1.  Chapter 1: Nutrition Screening, Assessment, and Plan of Care

2.   Chapter 2:  Overview of Parenteral Nutrition

3.   Chapter 3:  Parenteral Nutrition Access Devices

4.   Chapter 4:  Parenteral Nutrition Formulations and Managing Component Shortages

5.   Chapter 5:  How to Prescribe Parenteral Nutrition Therapy

6.   Chapter 6:  Review and Verification of Parenteral Nutrition Orders, Preparing Parenteral Formulations, and Ordering

7.   Chapter 7:  Parenteral Nutrition Administration and Monitoring

8.  Chapter 8:  Complications of Parenteral Nutrition

9.  Chapter 9:  Medication-Related Interactions

10.  Chapter 10:  Home Parenteral Nutrition Support

These chapters cover many of the relevant topics for the patient receiving parenteral nutrition (PN) including some newer topics on order review, compounding, and drug shortage management. Also this handbook contains evidence-based guidelines from the A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations (JPEN, March 2014) and A.S.P.E.N. Clinical Guidelines: Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing (JPEN, March 2014).

I have taken the time to utilize this handbook while dosing PNs in the past few weeks and have found this reference accurate while covering many of the topics I needed.  I especially enjoyed the chapter on parenteral nutrition complications.  I found the topics succinct and spot-on for finding quick information on a couple of questions I had on a patient’s PN.

If you are looking for a guide with a broad range of topics related to PN that will help your student, resident or even new pharmacist managing PN, this guide will help you tremendously.

[theblondepharmacist]

Pharmacists and Provider Status

Pharmacists and Provider Status

What is provider status?  Why is it important to the profession to gain?

Pharmacists and pharmacists’ patient care services are not included in key sections of the Social Security Act (SSA), which determines eligibility for health care programs such as Medicare Part B. In the case of Medicare Part B, the omission of pharmacists as listed providers limits Medicare beneficiaries’ access to…

View On WordPress

[theblondepharmacist]

Meded101

I really wanted to use Beth’s 2014 resolution post to put some pressure on all of the pharmacists that follow this blog.  I really think as pharmacists we need to focus on changing our mindset to help convince others in the healthcare field realize how valuable we are.  I’ve been doing quite of bit of reading and investigating of various healthcare providers blogs and I see many of them talk…

View On WordPress

[theblondepharmacist]

World Report on Cancer

The past few months I have seen too many reports of friends being affected by cancer.  Cases roll in daily at the hospital, and though I can handle the workload, there are days when I see a folder and a name and wonder what they are dealing with…

View Post

[theblondepharmacist]

10 Rules of Email Etiquette at Work

One of the most frustrating things about pharmacy jobs today, for me at least, is the lack of email etiquette at work.  I know it sounds crazy to even bring this up, but I have been pondering this post for years.  You see, I have been guilty of not being…

View Post

[theblondepharmacist]

Ativan Drips and Precipitation

If you happen to run short of the lorazepam 2 mg/mL vials to compound your ativan drips, be mindful…

View Post

[theblondepharmacist]

New Year's Resolutions for the Pharmacist

Most of the time, the New Year ushers in thoughts of dropping 15-20 lbs and signing up for a few…

View Post

[theblondepharmacist]

The Study Schedule I Used in 2013

I have received many requests about how I studied for the exam, and I wanted to share what I did.  I utilized the same sort of format that Ted Williams’ website mentions.  His website, though dated material, still has the outline I’d focus on (with ACCP)…

View Post