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    April 2023

    Micro-Learning CE Associated - Click Here For Details

    Overview of Hepatitis

    HEPATITIS
    • Acute liver injury - Most patients will recover completely once the offending medication is stopped. In the setting of cholestatic injury, jaundice can take weeks to months to resolve.
    • Chronic liver injury - Resolution usually occurs when offending drug is stopped, but this pattern of liver injury may progress to cirrhosis and liver failure.
    COMMONLY IMPLICATED MEDICATIONS IN HEPATITIS:
    • Acetaminophen: Educate patients about not exceeding maximum doses of 3000 mg and measuring pediatric doses accurately. The injury to the liver is due to a direct, toxic effect of high doses of acetaminophen. Hepatotoxicity most commonly arises after a suicide attempt using more than 7.5 grams (generally more than 15 grams) as a single overdose. Hepatic injury generally starts 24 to 72 hours after ingestion.
    • Methotrexate: prevent liver injury with folic acid as well as frequent liver function tests. Methotrexate is well known to cause serum aminotransferase elevations. Long term therapy has been linked to development of fatty liver disease, fibrosis and even cirrhosis. Administration of folic acid (1 mg daily) has been shown to decrease the rate of liver test abnormalities on therapy without affecting the efficacy of methotrexate.
    • Duloxetine (Cymbalta®): should not be administered to patients with substantial alcohol use or any hepatic insufficiency. Duloxetine can induce liver damage in patients with a medical history of chronic liver disease or alcohol consumption, as well as patients with major depressive disorder.
    • Isoniazid: Blacks and Hispanics are more susceptible to toxicity by this drug. Even with monitoring, isoniazid remains a major cause of acute liver failure due to idiosyncratic reactions and is associated with several instances of acute liver failure and death, or emergency liver transplantation in the United States each year.
    • Kava kava: an herb used for anxiety, and has an FDA warning for hepatotoxicity, was withdrawn from the German market.
    • Hepatitis C meds: (Epclusa, Harvoni, Zepatier) may cause liver damage especially in patients who also have hepatitis B. These meds now require a black box warning.
    • Alcohol: Persons who abuse alcohol are susceptible to drug toxicity because alcohol induces liver injury and cirrhotic changes that alter drug metabolism. Alcohol causes depletion of glutathione (hepatoprotective) stores that make the person more susceptible to toxicity by drugs (especially acetaminophen).
    • Amiodarone: Liver injury can be severe and lead to liver failure and death. The acute injury with intravenous infusions can cause an acute liver failure but is usually transient and reverses rapidly. Amiodarone causes liver damage ranging from asymptomatic serum aminotransferase elevation to hepatic failure requiring liver transplantation.


    Hepatitis-A—the basics: Hepatitis-A is typically acquired through ingestion (through fecal-oral transmission) and replicates in the liver. The virus that causes Hepatitis-A is a Picornavirus (RNA) which is stable at low pH and is inactivated by temperature of 185°F or higher, formalin, chlorine.

    After ten to twelve days virus is present in blood and is excreted via the biliary system into the feces. Incubation period ranges from fifteen to fifty days with about a 28-day average. Viruses are present in blood and feces 10 to 12 days after infection. Virus excretion may continue for up to 3 weeks after onset of symptoms. Patients are most infectious 1 to 2 weeks before onset of illness.

    Symptoms of Hepatitis-A : Abrupt onset of fever, malaise, anorexia, nausea, abdominal discomfort, dark urine, jaundice. Most children are asymptomatic. Older kids and adults are symptomatic. Clinical illness I usually limited to two months.

    Humans are the only sources of Hepatitis-A. There are no insect or animal reservoirs. Spread is oral-fecal with contaminated food or water. Although it is spread throughout the world, it is highly endemic in some areas, particularly Central and South America, Africa, the Middle East, Asia, and the Western Pacific. Most vaccinations are given as “travel vaccines”.

    In the United States the rate of Hepatitis-A declined 95.5% since vaccination initiation in 1996 to 2011. From 2016-2021, over 37,000 outbreak-associated cases were reported from 35 states. Before vaccination most cases occurred in the western states.

    Hepatitis A vaccine - Havrix® & Vaqta®:
    • Who gets it?
      • Initially it was recommended for men having sex with men, injection drug users and children living in states with a high disease rate.
      • In 2020, ACIP recommended vaccination of all children and adolescents aged 2 through 18 years who have not previously received Hepatitis-A vaccine and routine vaccination of all persons with HIV age 1 year or older.
      • My daughter, Dr. Gretchen Garofoli tells all her students to get the Hepatitis-A vaccine if they eat out frequently in restaurants.
    • Havrix: available as:
      • 360EL.U/0.5ml (pediatric)
      • 720EL.U/0.5ml (pediatric)
      • 1440 EL.U/1ml (adult formulation)
    • Vaqta available as:
      • 25u/ 0.5ml (pediatric, adolescent)
      • 50u/ 1ml (adult)


    Children 1-18VaccineDose# of DosesSchedule in Months
    Havrix720elu20, 6-12 months later
    Vaqta25u20, 6-18 months later
    Adults Over 19VaccineDose# of DosesSchedule in Months
    Havrix1440elu20, 6-12 months later
    Vaqta50u20, 6-18 months later
    • Generally given between 1st and 2nd birthdays.
    • Both formulations are available in pediatric and adult formulations.
    • Both vaccines use different potency measurements. Both volume and scheduled doses are the same.
    • Hepatitis A is an inactivated vaccine.
    • Give IM in the deltoid, not ID, IV, or SQ.
    Vaccine Efficacy:
    • Highly immunogenic
    • More than 95% of adults develop protective antibody within 4 weeks of a single dose.
    • More than 97% of children and adolescents will be seropositive within 1 month of the first dose.


    Reference: LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Available from: https://www.ncbi.nlm.Snih.gov/books/NBK547852/

    I can’t think of Hepatitis-A without thinking of my childhood. My oldest brother was in 6th grade and was extremely ill. The rest of the Kreckel kids were in 5th, 3rd and 2nd grade. He was diagnosed with hepatitis the day before Christmas in 1967. He spent a week in the hospital in isolation. I remember going to the hospital on Christmas day with my family and waving to him through the glass window. Any toys he got that Christmas given to him while he was in the hospital had to be destroyed!

    On Christmas Eve we had to go to our family doctor’s office to get a shot of gamma globulin. We were joined by our three cousins and 6 family friends at his office, all of us getting the gamma globulin. My Mom was a wonderful baker, and she frequently shared her homemade bread. Because of her generosity, 12 little kids from the ages of 2 to 14 got shots that day.

    Of course, I was the problem patient. I didn’t want a shot in the buttocks and squeezed my gluteal muscles as tight as possible. The doctor told me to relax, and I refused. He smacked my rear end, and I yelled, causing my muscles to relax and he injected me. How things have changed in healthcare!

    Have a Great Day on the Bench!!

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    Vaccination Overview: Diphtheria & Pertussis

    Diphtheria
    Diphtheria is another communicable disease that has been virtually eliminated, thanks to vaccination. It was first described by Hippocrates in the 5th century BC. December 2022: 154 cases of diphtheria have been reported by eight EU/EEA countries: Germany (64), Austria (42), Belgium (18), France (14), Norway (7), the Netherlands (5), Italy (3), and Spain (1). Most of these cases were brought in by refugees. From 1996 to 2018, the United States averaged less than one case per year, due to consistently high vaccination (over 93%),

    The causative agent for diphtheria is Corynebacterium diphtheriae or C. diphtheriae which is a Gram-positive aerobic bacillus. The primary mechanism of transmission consists of close contact with respiratory secretions (direct or via airborne droplets) or skin lesions. Diphtheria can also be spread from human to human by fomites such as towels, handkerchiefs, and used tissues. Humans are believed to be the only known reservoir for C. Diphtheriae. Diphtheria has an R-naught value of 2.6 and is highly contagious.

    TYPICAL COURSE: The normal incubation period is 2-5 days. C. diphtheriae has four biotypes: gravis, intermedius, mitis, and belfanti but all biotypes can become toxigenic and cause severe disease. Toxigenic diphtheria bacilli acquired in the nasopharynx produce an exotoxin that inhibits cellular protein synthesis, destroys local tissue, and forms a pseudo membrane. There are four major complications including myocarditis, polyneuropathies, nephritis, and thrombocytopenia. Non-toxin-producing C. diphtheriae strains cause mild to severe exudative pharyngitis and sometimes lesions, endocarditis, bacteremia, and septic arthritis.

    Before we had vaccines, diphtheria was a major cause of morbidity and mortality worldwide, primarily affecting children under the age of 15. Until the beginning of the 20th century, as many as 10 percent of American children developed diphtheria, and 5-10% died from its complications. By adolescence so many kids were exposed to diphtheria, 70 to 80 percent of the urban population was immune from natural infection. 100,000-200,000 cases and 13,000-15,000 deaths were reported annually in the 1920s before vaccines were available.

    There are four major types of diphtheria:
    • Pharyngeal and Tonsillar Diphtheria: The most common sites of diphtheria are the pharynx and the tonsils. A thick gray membrane covers the throat and tonsils. Infection at these sites is usually associated with substantial systemic absorption of the toxin.
    • Anterior Nasal Diphtheria: This looks much like the common cold, due to low absorption of the toxin.
    • Cutaneous Diphtheria: This may be manifested by a scaling rash or by ulcers with clearly demarcated edges. This type of diphtheria is most seen in the tropics.
    • Other sites: mucous membranes of the conjunctiva and vulvovaginal area, as well as the external auditory canal
    TREATMENT:

    Antitoxin: Diphtheria antitoxin is a hyperimmune antiserum produced in horses that binds to and inactivates the diphtheria toxin. In 1898 a trial showed that the antitoxin reduced mortality from 7 to 2.5 percent. It must be administered early because it is only effective when the toxin has not entered the cells yet. The antitoxin is only available through CDC and it is only used for respiratory and cutaneous diphtheria.

    Antibiotics: erythromycin (Ery-Tab®), procaine penicillin-G (Wycillin®), and oral penicillin VK (Veetids®)are effective treatments for diphtheria and must be administered for 14 days. By killing off the bacteria, toxin release is attenuated.

    VACCINATION: Diphtheria toxoid was developed in the early 1920s but was not widely used until the early 1930s. It was incorporated with the tetanus toxoid and pertussis vaccine and became routinely used in the 1940s. Vaccination does not prevent colonization, but reduces transmission by 60%, likely through reduced symptomatic shedding.

    Diphtheria toxoid is produced by growing toxigenic C. diphtheriae in a liquid medium. Diphtheria toxoid is combined with tetanus toxoid as diphtheria and tetanus toxoid (DT) vaccine or tetanus and diphtheria toxoid: Td (Tenivac®) and (Tdvax®) vaccine. Diphtheria toxoid is also combined with both tetanus toxoid and acellular pertussis vaccine as DTaP (Infanrix®) and (Daptacel®) or Tdap (Boostrix®) and (Adacel®) vaccines. Td contains reduced amounts of diphtheria toxoid compared with DT. More than 95% of recipients develop protective antibody levels after 3 doses and booster for infants or 3 doses for adults.

    I have had quite a few older patients come into the pharmacy, and said “Hey doc, what vaccine am I supposed to get now that my daughter is going to have a baby next month.” First off, I congratulate them on the new bundle of joy, followed by the information about TDaP. EVERYONE who gets to have direct contact with a newborn SHOULD (OK, MUST) have an up-to-date Tdap!

    PERTUSSIS
    Bordetella pertussis is a small, aerobic gram-negative rod. A toxin produced by the bacteria causes most of the pathogenesis of the disease. The bacteria attached to the cilia of the respiratory epithelial cells produce toxins that paralyze the cilia and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary secretions.

    The incubation period is quite long, ranging from 4-21 days, and starts with symptoms similar to the common cold. Once the disease enters the paroxysmal stage it becomes evident that the patient is infected with pertussis. Characteristically, the patient might have bursts of numerous, rapid coughs due to difficulty expelling thick mucus from the tracheobronchial tree. At the end of the paroxysms, a long inspiratory effort is usually accompanied by a characteristic high-pitched whoop or barking sound.

    Between these attacks, the patient usually does not appear to be very ill. When an attack occurs, the patient becomes very distressed and can turn cyanotic and possibly vomit. These attacks are more frequent at night, with up to fifteen attacks in 24 hours. Seizures and encephalopathy, which are more commonly seen in infants, may occur as a result of hypoxia from coughing, or possibly from pertussis toxin.

    TREATMENT:
    • Pediatrics
      • azithromycin (Z-pak®),
      • clarithromycin (Biaxin®) or
      • trimethoprim-sulfamethoxazole (Bactrim®)
    • Adults:
      • azithromycin (Z-pak®):
        • Day-1: 500mg
        • Days 2-5: 250mg
      • trimethoprim-sulfamethoxazole DS (Bactrim DS®): twice daily
      • clarithromycin (Biaxin®) 500mg twice daily
    VACCINATION: Whole-cell pertussis vaccines were first licensed in the United States in 1914 and were available as a combined vaccine with diphtheria and tetanus toxoids (as DTP) in 1948. In the 20th century, pertussis was one of the most common childhood diseases and a major cause of childhood mortality in the United States, primarily due to secondary bacterial pneumonia. Before the availability of the pertussis vaccine in the 1940s, more than 200,000 cases of pertussis were reported annually. Since the widespread use of the vaccine began, the incidence has decreased by more than 75% compared with the pre-vaccine era.

    DTwP versus DTaP: “What is acellular” pertussis?

    The acellular pertussis vaccine (aP) has three or more antigens which provided around 85% efficacy. Its efficacy is similar to the whole-cell pertussis vaccine; however, it declines faster compared to the whole-cell pertussis vaccine. The value of acellular vaccines is in their fewer side effects compared to whole-cell vaccines.

    Pertussis is still a problem in that between 2000 and 2017. There were 307 deaths from pertussis reported to the CDC with which children younger than age 2 months accounted for 84.0% of these deaths. Tdap products
    • Boostrix®:
      • This was approved in 2005.
      • Indications: one dose in adults then use Td for subsequent doses; may be used if over age 65
    • Adacel®:
      • Its safety and efficacy have not been established for geriatrics (65+), however, do not hesitate to use it if only Adacel® is available.
    Tdap
    • Recommended once after the age of 19 and then Td is recommended every 10 years
    Tdap vaccine can protect adolescents and adults from tetanus, diphtheria, and pertussis. One dose of Tdap is routinely given at age 11 or 12. People who did not get Tdap at that age should get it as soon as possible.

    Tdap is especially important for healthcare professionals and anyone having close contact with a baby younger than 12 months. Pregnant women should get a dose of Tdap during every pregnancy, during the third trimester, to protect the newborn from pertussis. Infants are most at risk for severe, life-threatening complications from pertussis.

    One of the most significant demonstrations of the importance of diphtheria antitoxin was its use in the 1925 diphtheria epidemic in Nome, Alaska. Coordinated emergency delivery of this life-saving antitoxin by the dog-sled relay in the harshest of conditions has left a profound legacy in the annals of vaccinology and public health.

    This adventure crossed 674 miles, using 20 mushers and 150 sled dogs, and ran from January 27th to February 1st. Airplanes were not reliable at that time, and the nearest port to Nome was frozen shut. Lead dogs Balto and Togo, and the dog-led antitoxin run of 1925 represents a dynamic illustration of the contribution made by non-human species towards mass immunization in the history of vaccinology. This unique example of cooperative interspecies fellowship and collaboration highlights the importance of the human-animal bond in the one-health initiative. [The 1925 Diphtheria Antitoxin Run to Nome - Alaska: A Public Health Illustration of Human-Animal Collaboration - PubMed (nih.gov)]

    You can meet the mushers and sled dogs on Wikipedia. Look up “1925 Serum Run to Nome.” Better yet, there are some short YouTube videos that are enlightening… especially for you dog lovers!

    Have a Great Day on the Bench!!

    March 2023

    Micro-Learning CE Associated - Click Here For Details

    A Broad Look at Childhood Immunizations: Haemophilus Influenzae Type-B & Tetanus



    Haemophilus influenzae type-b

    H. influenzae type b was the leading cause of invasive bacterial disease among children in the United States prior to licensing of Haemophilus b conjugate vaccines in 1987. The bacterium also causes pneumonia, meningitis, epiglottitis arthritis, cellulitis, and blood infections. Centers for Disease Control and Prevention (CDC) now estimate that H influenzae type b disease in children under the age of 5 years has been reduced by 95%.

    The organism was given the name Haemophilus by Charles-Edward Winslow, et al. in 1920. It was not until 1933 that it was established that influenza was caused by a virus and that H. influenzae was a cause of secondary infection. Haemophilus influenzae is an aerobic gram-negative bacteria with a polysaccharide capsule with six different serotypes (a-f) of polysaccharide capsule.

    H. influenzae enters the body through the nasopharynx. Organisms colonize the nasopharynx and may remain only transiently or for several months in the absence of symptoms (asymptomatic carrier). This bacterium does not survive on inanimate surfaces. Hib could be isolated from the nasopharynx of 0.5% to 3% of healthy infants and children but was uncommon in adults.

    Before effective vaccines were introduced, it was estimated that one in 200 children developed invasive H influenzae type b disease by the age of 5 years. In children less than 5 years of age, the mortality rate for invasive H influenzae type b disease ranged between 3% and 6%.

    Meningitis: In more than 60% of these children, meningitis was the clinical syndrome and permanent sequelae ranging from mild hearing loss to mental retardation affecting 20% to 30% of all survivors.

    Epiglottitis (a swelling of the cartilage covering the windpipe, which can block the flow of air into the lungs): The demographics, causative organisms, and natural history of epiglottitis have changed substantially in the Hib vaccination era. Routine Hib vaccination for infants has made epiglottitis rare in children. It's now more common in adults. Truly an example of “herd immunity”

    Vaccine history:
    • A pure polysaccharide vaccine was licensed for use in the United States in 1985 and was used until 1988. The vaccine had low efficacy and is no longer available in the United States.
    • The first Hib conjugate vaccine was licensed in 1987. Conjugation is the process of chemically bonding a polysaccharide to a more effective protein carrier. This process changes the polysaccharide from a T-independent to a T-dependent antigen and greatly improves immunogenicity, particularly in young children.
    Dosage of available vaccines:
    • MONOVALENT VACCINES:
      • ActHIB®:4-dose series (3 dose primary series at age 2, 4, and 6 months, followed by a booster dose* at age 12–15 months)
      • Hiberix®:4-dose series (3 dose primary series at age 2, 4, and 6 months, followed by a booster dose* at age 12–15 months)
      • PedvaxHIB®: 3-dose series (2-dose primary series at age 2 and 4 months, followed by a booster dose at age 12–15 months
    • COMBINATION VACCINES:
      • Pentacel® (DTaP-IPV/Hib) 4-dose series (3 dose primary series at age 2, 4, and 6 months, followed by a booster dose* at age 12–15 months)
      • Vaxelis® (DTaP-IPV-Hib-HepB): 4-dose series (3 dose primary series at age 2, 4, and 6 months, followed by a booster dose* at age 12–15 months)
      • *Vaxelis® ((DTaP-IPV-Hib-HepB): is not recommended for use as a booster dose. A different Hib-containing vaccine should be used for the booster dose.
    • Vaccines are interchangeable and should follow a 3-dose schedule if more than 1 brand is used
    • Hib vaccines should be given at the same visit as other recommended vaccines.
    Rates of vaccination: Among children born during 2016–2017, 92.2% had received the Hib vaccine primary series (at least 2 or 3 doses, depending on product) and 79.9% had received the full series (primary series and booster; at least 3 or 4 doses, depending on product type) by age 24 months.

    Are the vaccines working? You betcha!!
    Hib Secular Trends in the United States
    • About 20,000 cases of Hib annually before vaccine
    • Incidence of Hib has declined 99% since the pre-vaccine era.
    • Clinical efficacy has been estimated at 95% to 100%. Invasive Hib disease is uncommon in children who are fully vaccinated.
    • From 2009-2018, 36 reported cases of Hib in patients younger than age 5 years
    • Secondary cases of Hib are rare (illness occurring 1-60 days following contact with an ill person)
    TETANUS

    Tetanus is caused by bacteria known as Clostridium tetani, which is an anaerobic bacteria found in the soil. Clostridium tetani resides in the gut of mammals. C. tetani spores can survive autoclaving at 249.8°F (121°C) for 10 to 15 minutes. When the bacteria invade the body, they produce a toxin called tetanospasmin, that causes painful muscle contractions and stiffness, usually all over the body. This occurs by the tetanus toxin entering adjacent inhibitory interneurons, where it blocks neurotransmission by its cleaving action on the membrane proteins involved in exocytosis of the nerve cell. One of the cardinal features of tetanus: intense, painful spasms of the masseter muscles, and an inability to open the mouth, known as trismus or more commonly, “lockjaw”.

    It can lead to tightening of muscles in the head and neck, so you can’t open your mouth, swallow, or sometimes even breathe. Patients have facial paralysis called “Risus Sardonicus” known as “the smile of the devil.” Tetanus kills about 1 out of 10 people who are infected even after receiving the best medical care. Is rare in the US, thanks to our vaccine efforts.

    “Help I stepped on a rusty nail” A clean nail will cause tetanus just as efficiently as a rusty nail. Other opportunities for entry of tetanus includes gunshot wounds, compound fractures, burns, and unsterile intramuscular or subcutaneous injections (that often occur in injection drug users). What needs to happen for tetanus to occur is:
    • Any injury that penetrates the skin, that results in the inoculation of C. tetani spores. Any foreign body increases the risk.
    • Other bacteria present creating a mixed wound infection
    • Tissue breakdown
    • Localized ischemia
    • The incubation period is usually about 8 days, with a usual range of 1 to 3 weeks.
    Other opportunities for tetanus infection includes:
    • Infection of the umbilical stump in neonates
    • Obstetric patients (after septic abortions)
    • Bowel flora growth in post op patients
    • Animal or insect bites
    • Dental abscesses
    • Diabetics with mixed wound infections on the extremities
    • Injection drug users. C. tetani spores can be found in contaminated heroin.
    Clostridium family reunion:

    Clostridium are gram positive anaerobic bacilli. The grow best when there is no oxygen. We health care practitioners are very familiar with the “star” of the clostridium family, C. difficile. However, there are other members of this family we need to avoid as well:
    • Clostridium botulinum: can produce botulinum toxin in food or wounds and can cause botulism. Can cause muscle paralysis. Clostridium botulinum can form spores that are very, very heat resistant. Even hours in the boiling water canner will not kill it. (source: www.foodsafety. gov)
    • Clostridiodes difficile can flourish when other gut flora bacteria are killed during antibiotic therapy, leading to superinfection and potentially fatal pseudomembranous colitis (a severe necrotizing disease of the large intestine).
    • Clostridium perfringens causes a wide range of symptoms, from food poisoning to cellulitis, fasciitis, and gas gangrene.
    • Clostridium sordellii can cause a fatal infection in exceptionally rare cases after medical abortions. no oxygen.
    TREATMENT: Tetanus immune globulin (TIG) is recommended for persons with tetanus to remove unbound tetanus toxin. Toxin bound to nerve endings is unaffected by TIG. A single intramuscular dose of 500 units is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified. Intravenous immune globulin (IVIG) contains tetanus antitoxin and may be used if TIG is not available. Antibiotic therapy is of little value, unless debridement is done in an aggressive manner.

    VACCINATION: The development of tetanus toxoid occurred in 1924. It was first widely used during World War II. After the 1940s, tetanus declined steadily. Since the mid-1970s, about 50 to 100 cases have been reported annually in the United States. More recently, from 2009–2018, an average of 29 cases were reported per year, thanks to our vaccination efforts.

    WaTcH YoUr ShIfT KeY !!!
    When discussing Tetanus vaccines
    • Td contains reduced amounts of diphtheria toxoid compared with DT.
    • DTaP and Tdap contain the same acellular pertussis components, but Tdap contains a reduced quantity of some pertussis antigens and diphtheria toxoid. Boostrix® contains a reduced quantity of tetanus toxoid compared to Infanrix®.
    • Children younger than age 7 years should receive DTaP vaccine or DT vaccine (if not covering pertussis)
    • Persons age 7 years or older should receive Td vaccine or Tdap vaccine, even if they have not completed a series of DTaP or DT (Tdap would be off-label for children age 7 through 9 years, but is still recommended by ACIP).
    • Tdap (Boostrix® by GSK) is approved for persons age 10 years or older to any age
    • Tdap (Adacel® by Sanofi-Pasteur) is approved for persons age 10 through 64 years.
      • Note: Either vaccine administered to a person age 65 years or older is immunogenic and would provide protection. A dose of either vaccine would be considered valid.
    • For complete immunization schedule consult CDC
    • Tetanus antitoxin levels decrease with time, so boosters are recommended every 10 years
    • Small percentage of individuals are unprotected before 10 years, so booster for wound needed if more than 5 years have elapsed since last dose.

    Further reading:https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html#epi

    My sister Mary Kreckel Fritz is a registered nurse who graduated from Philipsburg State Hospital School of Nursing in 1980 has vast experience in the area of pediatrics. In regard to this topic, she had this to offer:

    “We had several kids with epiglottitis, they were either intubated or had a tracheotomy. They were one-on-one nursing care because if they pulled out their tubes you lost their airway. The endo tube and trach tube stayed for a few days until the swelling in the epiglottis went down.

    These kids were easily diagnosed because they would lean forward with constant drooling with respiratory distress. I would have to comfort them by hugging them while they were restrained from pulling out their tubes. When parents in the pediatrician’s office were reluctant to give vaccines, I always told them how epiglottitis has been eradicated because of the vaccines.”

    Have a Great Day on the Bench!!

    Micro-Learning CE Associated - Click Here For Details

    Overview of Polio

    Polio – The History of the Vaccine

    Polio is another vaccine preventable disease that many in my parents’ generation grew to fear. Polio was probably the first disease where science and research, and not just serendipity (like smallpox), brought a dreaded disease under control.

    Jonas Salk\: Jonas Edward Salk was born October 28, 1914 in New York City, the eldest of three sons to Russian-Jewish immigrants. In 1942, Salk went to the University of Michigan on a research fellowship to develop an influenza vaccine. In 1947, Salk was appointed director of the Virus Research Laboratory at the University of Pittsburgh School of Medicine. In 1963, he founded the Salk Institute for Biological Studies in La Jolla, California, thanks to support from the March of Dimes. Salk spent his last years searching for a vaccine against AIDS. He died at the age of 80 on June 23, 1995 in La Jolla, California.
    • Salk created his inactivated polio vaccine (IPV) during 1952–1953 while a researcher at the University of Pittsburgh.
    • The vaccine contained wild polioviruses of all 3 serotypes that had been killed by means of formaldehyde; when injected intramuscularly, the vaccine elicited the production of antibodies, rendering recipients immune to the disease.
    • In 1954, Dr. Salk began a placebo-controlled study on 1.3 million children. By 1955, Dr. Salk announced that the vaccine was safe and effective, and a nationwide campaign began to inoculate our nation. On April 12, 1955, it was proclaimed that the battle against poliomyelitis had potentially been won thanks to Salk’s vaccine.
    • When asked about the patent for his vaccine Dr Salk responded: "Who owns this patent? Well, the people, I would say. There is no patent. Could you patent the sun?"
    Albert Sabin: Dr. Sabin was born Abram Saperstejn on August 26, 1906, in Bialystok, Poland. He imigrated to the United States with his parents in 1921 to avoid the persecutions directed against people of Jewish lineage. He received his M.D. from New York University in 1931 and immediately began research on polio. After World War II broke out, he joined the U.S. Army Epidemiological Board’s Virus Committee and accepted assignments in Europe, Africa, the Middle East, and the Pacific. During this phase of his career, Dr. Sabin developed vaccines for encephalitis (sleeping sickness), sand-fly fever, and dengue fever. Dr Sabin died March 3, 1993, and is buried in Arlington National Cemetery.
    • In the middle of the 1930s, Sabin was studying poliovirus at the University of Cincinnati. In 1939, he realized that it was not a respiratory virus but an enteric virus that lived and multiplied in the intestine.
    • Sabin was able to demonstrate that contagion occurred through both the respiratory route from coughing and sneezing and the enteric route from fecal contamination.
    • In the late 1950’s, the mass vaccination campaign in the Soviet Union demonstrated high vaccine effectiveness and resulted in licensure of the oral polio vaccine (OPV) in the United States in 1961. Subsequently, OPV rapidly replaced IPV as the vaccine of choice in the US. OPV was preferred over IPV because it induced both systemic and intestinal immunity, was easier to administer, and was less expensive than IPV.
    • The main drawback of OPV is that, very rarely (in 1 case out of ≈750,000), Sabin viruses can mutate back to a more neurovirulent form and cause vaccine-associated paralytic polio.
    • Dr. Sabin did not patent his vaccine because he wanted it to be used as broadly as possible. “It’s my gift to all the world’s children”, he said.
    Cutter Incident
    A defective polio vaccine that was manufactured by Cutter Labs in Berkley California was used in the Western and Mid-Western states. Over 200,000 kids were injected. Because of this defective vaccine, thousands of cases were reported, 192 kids were left severely paralyzed, and 11 kids died.

    The government temporarily suspended the vaccination program until it was determined that Cutter vaccine should be permanently withdrawn and IPV from other manufacturers could be reinitiated safely. The jury found that Cutter was not negligent in producing the vaccine but had breached an implied warranty that their product was safe.

    Dr. Paul A. Offit, MD, is the Director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at Children's Hospital of Philadelphia. He wrote a book that outlines a series of events that contributed to the vaccine that contained live virus to be released from Cutter Laboratories. These included the use of a highly virulent strain (Mahoney), deficiencies in the inactivation of vaccine virus, inadequate safety tests, and poor communication with other scientists and the government (Carapetis J, 2006).

    The Cutter Incident still impacts vaccine administration 60 years later, according to Dr. Offit’s book “The Cutter Incident: How America’s First Polio Vaccine Led to Today’s Growing Vaccine Crisis” (Yale University Press, 2005).

    SV-40
    Some of the polio vaccine administered from 1955–1963 was contaminated with a virus, called simian virus 40 (SV40). The virus came from the monkey kidney cell cultures used to produce the vaccine. Most, but not all, of the contamination was in the inactivated polio vaccine (IPV). SV40 has biological properties consistent with a cancer-causing virus, however there was no increase in cancers when this age group was studied that received the IPV between 1955-63.

    The Virus
    Poliovirus, a human enterovirus that belongs to the family Picornaviridae in the genus Enterovirus, is the causative agent of poliomyelitis. It is a single stranded RNA virus. Humans are the only natural hosts of poliovirus. The virus, however, can be transferred to monkeys when it is directly inoculated into the central nervous system (CNS). Polio is usually contracted via the fecal-oral route.

    Signs and Symptoms
    90% of individuals who contract the poliovirus are entirely asymptomatic. In fewer than 1% of cases, however, the virus enters the central nervous system, where it preferentially infects and destroys motor neurons, leading to muscle weakness and acute flaccid paralysis

    Transmission
    Transmission can occur through direct person-to-person contact – either through the fecal-oral route or via respiratory droplet. Polio has an R naught of 5 to 7, meaning that 80-86% of the population would need to be vaccinated before viral spread would stop, according to Infection Control today.

    The Vaccine
    Inactivated polio vaccine (IPV) is the only polio vaccine that has been given in the United States since 2000. It is given by injection in the arm or leg, d

    epending on the person’s age. Children get four doses of IPV, with one dose at 2, 4, 6-18 months, and 4-6 years

    A single-antigen vaccine called IPOL is licensed in the U.S. for active immunization of infants (as young as 6 weeks of age), children, and adults for the prevention of poliomyelitis caused by poliovirus types 1, 2, and 3.

    In unvaccinated adults, two doses of IPV should be administered at intervals of four to eight weeks and the third dose should be administered within six to 12 months of the second dose.

    Eradication
    Cases due to wild poliovirus have decreased by over 99% since 1988, from an estimated 350,000 cases then, to just 6 reported cases in 2021 (World Health Organization).

    Recent Outbreaks
    An unvaccinated adult suffered paralysis from polio in June of 2022, the first case in New York since 1990. Wastewater surveillance later found the virus had been spreading silently in the New York City area for months. The origin of the virus is still under investigation, but samples in New York are genetically linked to polioviruses found in London and Jerusalem wastewater. Poliovirus was first detected in Rockland County, then in neighboring Orange County, New York City, Sullivan County, and later in Nassau County on Long Island. In some areas of Rockland, only 37% of kids in this age group are up to date on their vaccine.

    London Outbreak
    In London, children ages 1-9 were made eligible for booster doses of a polio vaccine after British health authorities reported finding evidence of the virus spreading in multiple areas but found no cases in people.

    Britain’s Health Security Agency said it detected viruses derived from the oral polio vaccine in the sewage water of eight London boroughs. The agency’s analysis of the virus samples suggested “transmission has gone beyond a close network of a few individuals.” 116 isolates have been identified in 19 sewage samples in London between Feb 8 and July 5, 2022.

    Franklin D. Roosevelt
    We are all aware of the most famous polio victim, Franklin Delano Roosevelt. He began having symptoms of paralytic illness in 1921 at the age of 39. He was president of the United States from 1933 to 1945. In 1938, he founded the National Foundation for Infantile Paralysis, to push for the development of a polio vaccine. This organization later became known as the March of Dimes.

    The big question is… Did Franklin Delano Roosevelt really have polio, or was it Guillain-Barré Syndrome? Most evidence points to GBS, rather than poliomyelitis. Read the entire article here: https://pubmed.ncbi.nlm.nih.gov/26508622/. The author of this article also published a book called “Prisoners of Time”. This book is a case study of how doctors can only diagnose what they know, how millions of people can accept myth as fact, and how new research can correct the historical record.

    Interesting Points about FDR’s Diagnosis
    • The diagnosis of FDR's neurological disease still depends upon documented clinical abnormalities.
    • His age, prolonged symmetric ascending paralysis, transient numbness, protracted dysesthesia (pain on slight touch), facial paralysis, bladder and bowel dysfunction, and absence of meningismus are typical of Guillain-Barré syndrome and are inconsistent with paralytic poliomyelitis.
    • FDR's prolonged fever was atypical for both diseases.
    • Finally, permanent paralysis, though more common in paralytic poliomyelitis, is also frequent in Guillain-Barré syndrome. Thus, the clinical findings indicate the most likely diagnosis in FDR's case remains Guillain-Barré syndrome.
    • Other evidence shows FDR never had a lumbar puncture.
    • GBS was only mentioned in European literature and physicians at the time considered he might have either a blood clot, a “heavy cold”, or polio.
    For a 9 page dissertation about FDR’s diagnosis, check out HERE

    Polio Trivia
    • The first disposable syringes were a result of Salk’s polio vaccine. Becton, Dickinson, and Company (BD) developed the HYPAK syringe originally made of glass to administer the polio vaccine. The following year, Roehr Products introduced a plastic disposable hypodermic syringe called the Monoject. Because of their low cost, plastic became the standard for disposable syringes.
    • Mary Poppins’ “…just a spoonful of sugar helps the medicine go down!” was a reference to the administration of Sabin’s OPV.
    • March of Dimes was founded by President Franklin D. Roosevelt in 1938, as the National Foundation for Infantile Paralysis, to combat polio.
    • In 1946, the dime was changed to have Roosevelt’s image as his connection to the “March of Dimes.”


    I wonder what will be written about COVID, vaccines, and masking in the next 50 to 100 years! All of us students of history remember learning that Franklin Delano Roosevelt was a polio victim. His efforts with the March of Dimes provided much needed research dollars to fund Dr. Salk’s work in developing a polio vaccine.

    Have a Great Day on the Bench!!

    February 2023

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    Overview of Mumps & Rubella

    Causative agent: Mumps is a caused by a paramyxovirus, a member of the rubulavirus family. It has a single-stranded viral genome. The average incubation period for mumps is 16 to 18 days. The peak incidence for mumps is late winter to early spring but can occur any time of the year.

    It was first described by Hippocrates in the fifth century BC. 95% of adults had tested positive to prior exposure to mumps, indicating that nearly all people are eventually infected in unvaccinated populations. The R naught value for mumps is between 10-12, which is 10 times greater than influenza.

    Symptoms: Mumps typically starts with generalized symptoms such as fever, headache, muscle aches, tiredness, and loss of appetite for a few days. Patients progress to parotitis (inflammation of the parotid glands) which are salivary glands located in the front, below the ears. This lasts for about 5 days and resolves by day 10.

    Complications: Usually occur in the adult population
    • Meningitis or encephalitis: Before the vaccine was available 10% of viral meningitis cases were caused by mumps
    • Orchitis (inflammation of one or both testicles)
      • Happens in about 10% of post pubertal males
    • Mastitis (inflammation of breast tissue)
    • Parotitis (inflammation of one or both parotid glands)
      • Parotitis occurs only in 31% to 65% of individuals infected with mumps. From 15% to 27% of people with mumps have no signs or symptoms of illness.
    • Oophoritis (inflammation of one or both ovaries)
    • Pancreatitis (inflammation of the pancreas)
    • Deafness
      • occurs in 1:20,000 cases, and once was a major cause of deafness in children.
    Prevalence: United States Mumps cases: As of October 28, 2022, a total of 215 mumps cases were reported in the USA. Texas had the highest number of mumps cases with 21. In the past 20 years, there's years that had over 6000 cases:
    • 2006: 6584 cases
    • 2016: 6369 cases
    • 2017: 6109 cases
    During World War I, only influenza and gonorrhea were more common than mumps as causes of hospitalization among soldiers.

    RUBELLA (GERMAN MEASLES)

    In 2004 Rubella, more commonly known as German measles, was eliminated from the United States. Despite our success in the United States, the World Health Organization (WHO) reports that over 100,000 children worldwide have congenital rubella syndrome (CRS).

    Rubella which translated means “little red” was first lumped in with scarlet fever or measles. It first appeared in German literature as its separate disease and was given the vernacular name “German measles.” Rubella virus is the only member of the genus rubivirus, in the family matonaviridae. It is an enveloped virus with a single-stranded RNA and having a single antigenic type. There are no animal reservoirs, and humans serve as the only host for rubella.

    Symptoms

    The average incubation period is about two weeks. Symptoms are usually mild with up to 50% of the patients being asymptomatic. In small children the rash is usually the first sign of infection. In older children and adults, there may be a 1- to 5-day period with low-grade fever, malaise, lymphadenopathy, and upper respiratory symptoms preceding the rash. Lymphadenopathy may occur a week before the rash and last several weeks.

    RASH: Rubella rash typically begins on the face and spreads downward to involve the trunk and extremities over the next 24 hours; it typically vanishes by the end of day three. Rubella can be differentiated from measles as the rash is fainter than a measles rash, does not coalesce, and is often more visible after a hot shower or bath. Diagnosis of rubella can be confirmed by polymerase chain reaction (PCR) testing or measuring specific rubella IgM antibodies.

    This virus, like so many other common childhood diseases, is spread through respiratory droplets and direct contact. The R naught value of rubella is believed to be 6-7, compared with mumps (10-12) and measles (18). Rubella does its damage to humans by infecting babies through placental transfer. In pregnant women the infected mother gets viremia, and placental transfer occurs. Cell division is interrupted, and cells can be destroyed. This disruption manifests itself in the child with impaired hearing, vision abnormalities and cardiovascular complications. Intellectual disabilities are also a manifestation of CRS.

    Of all the recently reported cases of CRS, the mother of the child was born outside the United States. Although titers to rubella wane in the years after vaccination, there is no evidence that this leads to significant susceptibility to clinical rubella or CRS. Clinical rubella and CRS-affected pregnancies are extremely rare in vaccinated persons the United States.

    Vaccination:

    MMR (Mumps, Measles and Rubella)

    MMR®-II (mumps, measles and rubella) is given to immunize against three different diseases. They contain live, attenuated viruses. Single antigen rubella vaccine is not available in the US. The first rubella vaccination was available in 1969; since then, cases have plummeted by 99%. In 1971, rubella vaccine was licensed in the United States as a combined measles, mumps, and rubella (MMR) vaccine.

    Proquad® a combination measles, mumps, rubella, and varicella (MMRV) vaccine was licensed in 2005. Like MMR-II, this product is manufactured by Merck.

    PRIORIX® is a combination measles, mumps, and rubella (MMR) vaccine manufactured by GlaxoSmithKline Biologicals (GSK).

    At least 95% of vaccinated persons age 12 months or older develop serologic evidence of rubella immunity after a single dose, and more than 90% have protection against clinical rubella for at least 15 years

    Routine vaccination:
    • 2-dose series at age 12–15 months, age 4–6 years
    • Third dose may be considered if in a high-risk population. Pregnancy should be avoided for 4 weeks after vaccination.
    • MMR or MMRV may be administered. Do not administer MMRV if over age 13.
    (consult CDC website for special cases such as travelling.)
    https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-mmr

    Precautions:
    • MMR and MMRV vaccines both contain minute amounts of neomycin and gelatin. Persons with alpha-gal allergy may wish to consult their physician before receiving a vaccine that contains gelatin.
    • MMR or MMRV should not be administered for at least 1 month after cessation of systemic high-dose corticosteroid therapy
    Travelling: As with measles, the CDC recommends adults and teens with no evidence of immunity — such as written documentation of receiving the vaccine or having been born before 1957 — receive the MMR vaccine at least two weeks before traveling. The first dose occurs as soon as possible, with the second dose following 28 days after.

    Interestingly enough, rubella is a disease where vaccination is done not for the protection of the individual getting the vaccine. Symptoms in the patient are usually self -limited, and the patient recovers without incident. Rubella does its damage in the unborn child. Everyone (boys and girls alike) is vaccinated for the protection of unborn children, to eliminate congenital rubella syndrome (CRS). CRS is manifested by deafness, eye abnormalities (cataracts, glaucoma, retinopathy, microphthalmia), and congenital heart disease, and possibly intellectual disabilities.d


    Mumps and rubella are diseases that have been virtually eliminated by vaccines. All of the vaccines we pharmacists administer provide direct benefit to the patient who receives them.

    Rubella vaccine shows direct benefit to the unborn child. All of society gets vaccinated against rubella, but the benefit is for the unborn. An estimated 212,000 cases of mumps occurred in 1964, and I would have been one of them, as a kid in kindergarten. I remember the swollen glands, but best of all I remember being out of school for a couple of weeks! It was amazing how mumps, measles, chickenpox and colds spread through our families.

    Have a Great Day on the Bench!!

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    Childhood Vaccines: An Overview of Chicken Pox & Measles

    Chicken Pox Background: Chicken pox is a highly contagious disease caused by the varicella-zoster virus (VZV). This virus is a double stranded linear DNA virus and a member of the herpesvirus group. It is one of eight known herpes viruses. It can cause an itchy, blister-like rash. The rash appears first on the chest, back, and face, and then spreads over the entire body. Chickenpox can lead to severe disease and cause life threatening illness such as encephalitis and Reyes syndrome. The R-naught (R0) value is believed to be between 10-12.

    Varicella (Chicken Pox)
    • Is the primary infection for herpes zoster
    • Onset within 14-21 days of exposure
    • Spreads by respiratory droplet infection and direct contact with lesions
    • Fever & malaise just before eruption
    • Starts as a rash, pruritic and centrifugal then changing to papular and pustular then finally crusting.
    Varivax® (chickenpox vaccination)
    • Live attenuated virus vaccine
    • Recommended for all children 12-15 months old who have not had chickenpox.
      • Do not give to impaired immune patients as it is a live vaccine
    • Up to 90% of people who receive the vaccine will not get chickenpox.
    • People who get chickenpox after having the vaccine have a milder form of the disease.
    • Children (12 months to 12 years of age):
      • The first dose is administered between 12 and 15 months of age.
      • The second dose is administered between 4 to 6 years of age.
      • There should be a minimum interval of 3 months between doses.
    • Adolescents (age 13 and over) and Adults:
      • Two doses are administered with a minimum interval of 4 weeks between doses.
    Chickenpox treatment:
    • Treatment is usually not needed; antihistamines might be of benefit to relieve itching.
    • Clip fingernails to prevent scabbing when itching occurs.
    • Acetaminophen (Tylenol®) is recommended to relieve fever. Avoid ibuprofen because of the potential for necrotizing fasciitis, a life threatening bacterial skin infection. Avoid aspirin due to potential for Reyes syndrome.
    • Keep your child at home until no new blisters appear and scabs have formed over the blisters.
    Herpes Zoster (Shingles): Roughly 1 million cases in the US each year. There is a 1 in 4 chance of developing shingles in one’s lifetime, increasing risk with age. After age 50, 20% of patients with shingles develop post-herpetic neuralgia (PHN), a form of chronic neuropathic pain.
    • This is considered to be the “recurrent” infection, where Chickenpox (varicella) is the primary infection.
    • Pain follows a sensory nerve tract followed by painful grouped vesicles
    • Involvement is unilateral (some lesions occur outside the dermatome)
    • Lesions occur on trunk and face.
    • Caused by VZV (varicella zoster virus): the same virus that causes chickenpox, which remains dormant in the sensory nerve tracts.
    • Occurs in adults.
    • With rare exceptions, patients suffer only one attack.
    Pain: occurs 48 hours or more before lesions erupt and pain will persist, and even increase after lesions have resolved. About 10 to 18% of people who get shingles will experience PHN. The risk of PHN also increases with age.

    ZOSTAVAX® (ZVL)(varicella zoster vaccine) by Merck, was first introduced back in 2006. It was the first vaccine that pharmacists were administering but, was discontinued by Merck on November 18, 2020. SHINGRIX® Zoster Vaccine Recombinant, Adjuvanted (RZV)
    • Released on October 2017
    • Delivers >90% efficacy in patients 50 years and older.
    • Recommended for the prevention of herpes zoster and related complications for immunocompetent adults aged ≥50 years.
    • HIV patients can get SHINGRIX® after age 18.
    • Recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received zoster vaccine live (ZVL)
    • Preferred over ZVL for the prevention of herpes zoster and related complications
    • A first dose at Month 0 followed by a second dose administered anytime between 2 and 6 months later.
    • Given IM (deltoid)
    • Solicited local adverse reactions in subjects aged 50 years and older were pain (78.0%), redness (38.1%), and swelling (25.9%)
    • Solicited general adverse reactions in subjects aged 50 years and older were myalgia (44.7%), fatigue (44.5%), headache (37.7%), shivering (26.8%), fever (20.5%), and gastrointestinal symptoms (17.3%)
    Herpes Zoster (Shingles)- Antiviral treatment: Early (within 72 hours after onset) and aggressive antiviral treatment reduces the severity and duration of post herpetic neuralgia.

    BRANDGENERICDOSAGE (PO)
    Zovirax®Acyclovir800 mg 5 times daily x 7-10 days
    Famvir®Famciclovir500 mg TID x 7 days
    Valtrex®Valacyclovir1 GM TID x 7days
    Measles: According to the CDC, “Adults born in 1957 or later should receive at least 1 dose of MMR vaccine unless they have documentation of vaccination with at least 1 dose of measles, mumps, and rubella-containing vaccine or other acceptable presumptive evidence of immunity to these three diseases.” https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/meas.pdf

    I was born in May of 1958, so I am right on the edge of this recommendation! The CDC site also mentions “Except for health care personnel who should have documented immunity, birth before 1957 generally can be considered acceptable evidence of immunity to measles, mumps, and rubella.” I find it very interesting that I have never been asked about my MMR status, even though I’ve been a health care professional for 41 years!

    Don’t worry though I do remember getting the mumps in kindergarten, and remember my mom telling me about the measles when I was a very young child. Thank heavens our kids and grandkids are so well protected against these dangerous childhood diseases.

    Measles Background: Measles also known as rubeola, was a common childhood disease back in my youth until vaccines became routinely available. The measles is a paramyxovirus, of the genus Morbillivirus. In 1912, measles became a nationally notifiable disease in the United States, requiring U.S. healthcare providers and laboratories to report all diagnosed cases. In the first decade of reporting, an average of 6,000 measles-related deaths were reported each year.

    Most of the time we hear measles, is when its R-naught value is compared to other viruses. We are aware that Influenza has a R-naught value of 1 to 1.3, meaning that for each person that gets the virus they can spread it on average to 1 to 1.3 people. Measles is the most contagious disease known to spread between humans with an R-naught value of 18, meaning that one person getting the virus can spread to 18 people. If exposed, 90% of susceptible people WILL get the disease.

    Measles lives in the nose and throat mucus of an infected person. It can spread to others through coughing and sneezing. It can also be spread through contaminated air, and by touching infected surfaces. Measles virus can live for up to two hours in an airspace after an infected person leaves an area. After the surface is touched and a person touches their mucus membranes (eyes, nose, or mouth) they can become infected.

    Infected people can spread measles to others from four days before through four days after the rash appears. It can be expected that 1 in 5 children will require hospitalization if infected. Mortality is usually due to complicating bacterial infections. Case fatality is 1–3 per 1000 cases and highest in those younger than five years of age and among immunocompromised individuals. Pneumonia accounts for 6 out of 10 measles associated deaths

    Symptoms of measles:
    • high fever (may spike to more than 104° F)
    • cough
    • runny nose
    • conjunctivitis
    • Tiny white spots (Koplik spots) may appear inside the mouth two to three days after symptoms begin.
    Rash begins 14 days after virus exposure, and three to five days after symptoms begin. It usually begins as flat red spots that appear on the face at the hairline and spread downward to the neck, trunk, arms, legs, and feet.
    • Small, raised bumps may also appear on top of the flat red spots.
    • The spots may become joined together as they spread from the head to the rest of the body.
    • When the rash appears, a person’s fever may spike to more than 104° Fahrenheit.
    • The rash then turns to a brownish hue, and “blanch on pressure” meaning they become white or pale with fingertip pressure
    MMR® Vaccine: MMR® (mumps, measles and rubella) is given to immunize against three different diseases. Sometimes varicella is included for MMRV. They contain live, attenuated viruses. Single antigen measles vaccine is not available in the US.

    Vaccine Schedule:
    • 2-dose series at age 12–15 months, age 4–6 years
    • MMR or MMRV may be administered. Do not administer MMRV if over age 13.
    • (Consult CDC website for special cases such as travelling.) https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-mmr
    By 1981, the number of reported measles cases was 80% less compared with the previous year. Thanks to widespread vaccine use, in the year 2000, measles was declared eliminated by the CDC. The CDC defines eliminated as absence of continuous disease transmission for greater than 12 months. To keep this level of protection, herd immunity must be kept between 85% and 95%

    There are still occasional outbreaks of measles. In 2019, we had the highest reported number of cases (1274 patients) since the early 1990’s. As of November 24, 2022, a total of 55 measles cases were reported nationwide. Most measles cases are due to international travel, or in populations where there is a high concentration of unvaccinated people.

    Vitamin-A therapy: Vitamin A deficiency is a recognized risk factor for severe measles. The World Health Organization (WHO) recommends administration of an oral dose of 200,000 IU (or 100,000 IU in infants) of vitamin A per day for two days to children with measles in areas where vitamin A deficiency may be present. Vitamin A deficiency affects the severity of measles; delays recovery; can lead to measles-related complications, including blindness; and is associated with a higher rate of death. People mostly get vitamin A from foods such as milk, eggs, cheese, fortified cereals, leafy green vegetables, orange vegetables, fish, and meat (in particular, liver). Cod liver oil is high in Vitamin-A if you can get anyone to take it! A well-balanced diet provides the nutritional intake necessary to maintain health. However low- and middle-income people might not consume enough of these Vitamin-A rich foods, which may lead to deficiency. Vitamin-A deficiency leads to poor outcomes for measles patients.?.,mn.


    We give a LOT of SHINGRIX® vaccinations in the community pharmacy. Each time I give one of these shots I think of my wife Denise and her role in pharmacy-based immunizations. Back in 2007, she took a new job with Geisinger Health Systems, and developed the Zostavax® protocol for their community pharmacists to give Zostavax®. She worked closely with the physicians and developed a very robust Zostavax® immunization program.

    About 5 years ago on a Thursday I had a stinging pain on my left hip. There were no lesions, but a sharp burning pain. I remember commenting to Denise “I hope I’m not getting shingles.” As luck would have it, on Sunday morning two small blisters appeared on that left hip. I texted my family physician, Dr Zane Gates, and he gave me a prescription for oral valacyclovir 1GM three times daily.

    Within 2 hours of the blisters breaking out, I started my Valacyclovir prescription. Unless you are a pharmacist with store keys and direct access to your family doctor, you won’t be so fortunate! I continued to break out with an itchy and painful rash for a couple of days. Resolution of the lesions took about 2 weeks, however thanks to the Valacyclovir, I never developed any post herpetic neuralgia.

    As soon as I was eligible, I got both doses of SHINGRIX®!! Your patients need to do the same!!

    Have a Great Day on the Bench!!

    January 2023

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    Overview of RSV

    Background: RSV (does it stand for REALLY SCARY VIRUS??). In our corner of the world respiratory syncytial virus RSV rears its ugly head from October through April, with the peak occurring in January and February. RSV seems to have gotten an early start this year as many of the pediatric hospitals are loaded with kids burdened with this disease. It is believed that this large resurgence is due to previous COVID precautions decreasing its spread. The number of cases in 2022 are DOUBLE of those in 2021.

    Epidemiology: RSV is a single-stranded, large enveloped negative-sense ribonucleic acid (RNA) virus and a member of the Pneumoviridae family. These viruses are seen in mammalian species and are spread by respiratory droplets (coughing, sneezing, talking). The virus can survive on hard surfaces like crib rails, doorknobs, and tables for many hours. Nearly all kids contract RSV by the time they reach the age of 5, with most kids having the disease before their second birthday. RSV is the most common cause of bronchiolitis (inflammation of the small airways in the lungs) and pneumonia (inflammation of the lungs) in kids under one in the US. RSV can also infect adults, but the cases are usually milder. According to the CDC, each year in the United States, RSV leads to approximately:
    • 2.1 million outpatient (non-hospitalization) visits among children younger than 5 years old.
    • 58,000-80,000 hospitalizations among children younger than 5 years old.
    • 58,000-80,000 hospitalizations among children younger than 5 years old.
    • 6,000-10,000 deaths among adults 65 years and older.
    • 100–300 deaths in children younger than 5 years old.
    Symptoms occur rapidly after infection occurs usually within 4-6 days of exposure. Symptoms of RSV infection may include:
    • Runny nose
    • Decrease in appetite
    • Coughing
    • Sneezing
    • Fever
    • Wheezing
    Treatment Pharmacological: Management of pain and fever with over-the-counter pain and fever reducers, such as acetaminophen or ibuprofen. Never give aspirin or naproxen to children, due to potential of developing Reyes syndrome.
    • Ibuprofen:
      • Do not use ibuprofen in children less than 6 months of age.
      • Dose is 4-10mg/kg every six hours. Some sources say use 5mg/kg for mild fever and 10mg/kg for high fever.
    • Acetaminophen
      • Acetaminophen is usually dosed at 10-15mg/kg every 4-6 hours with a maximum of 5 doses per day. Some clinicians use the shortcut of 5mg per pound.
    Hydration: Drink lots of water to prevent dehydration. Pedialyte is also a good option to replace electrolytes. Consult your doctor or pharmacist to select appropriate over the counter medications for management of symptoms.

    Vaccines: The RSV vaccine has been slow to come to market because of its history. In 1966, infants and toddlers immunized with a formalin-inactivated vaccine against respiratory syncytial virus (RSV) experienced an enhanced form of RSV disease characterized by high fever, bronchopneumonia, and wheezing when they became infected with wild-type virus in the community. 80% of the kids were hospitalized, and two immunized toddlers died upon infection with wild-type RSV. Now that we have a better understanding of the immune system, this tragedy should not be repeated

    CodaVax-RSV (by Codagenix)
    • CodaVax™-RSV, an intranasal, live-attenuated vaccine candidate, for the prevention of RSV.
    • On November 7, 2022, the FDA announced the beginning of Phase-1 trials for an RSV vaccine by Codagenix. The trial will begin in 2023 after the RSV season. After Phase-1 trial, the Phase 2 dose confirming study will explore efficacy during the RSV season in 2023-2024.
    • The age group to be tested is age 6 months through 5 years.
    RSVpreF® (by Pfizer)
    • Administered to a pregnant woman to protect the newborn and can synthesize antibodies and passively transfer them to the fetus via placenta. Pfizer’s RSV vaccine candidate could be the first maternal vaccine available to help prevent this common and potentially life-threatening respiratory illness in young infants.
    • Vaccine efficacy of 81.8% was observed against severe medically attended lower respiratory tract illness due to RSV in infants from birth through the first 90 days of life with high efficacy of 69.4% demonstrated through the first six months of life.
    • The RSVpreF investigational vaccine was well-tolerated with no safety concerns for both vaccinated individuals and their newborns.
    • On March 2, 2022, Pfizer announced that its vaccine candidate received Breakthrough Therapy Designation from the FDA for the prevention of RSV-associated lower respiratory tract disease in infants up to six months of age by active immunization of pregnant women.
    • Read the press release at HERE
    RSV Prevention:
    • Do not share cups or utensils (especially if they have mild cold symptoms)
    • Do not touch your face (eyes nose and mouth) after touching potentially infected surfaces.
    • Wash hands often with antibacterial soap for at least 30 seconds.
    • Frequently disinfect “high touch” surfaces like door knobs, table surfaces and toys.
    The understanding we will have, thanks to Dr. Kendsersky, is most appreciated by the readers of this column.

    Synagis for RSV prevention:
    RSV was discovered in 1956, but took until 1998 to get a monoclonal antibody to prevent the disease. Last week we discussed two vaccines that are being studied, one that will be given intranasally (Coda-VAX-RSV®) and RSVpreF® (by Pfizer) which is given to the mother while pregnant.
    Palivizumab (SYNAGIS ® ) injection:
    • Approved in 1997 and available in 50 mg and 100 mg for intramuscular injection.
    • Designed to help prevent a serious lung disease caused by respiratory syncytial virus (RSV) in children who:
      • are born prematurely (at or before 35 weeks) and who are 6 months of age or less at the beginning of RSV season.
      • have a chronic lung condition, called bronchopulmonary dysplasia (BPD), that needed medical treatment within the last 6 months, and who are 24 months of age or less at the beginning of RSV season.
      • are born with certain types of heart disease and who are 24 months of age or less at the beginning of RSV season.
    • Dose:
      • Administered 15mg/kg at first visit, and given monthly thereafter.
      • The first dose should be given prior to the commencement of RSV season and given monthly throughout.
    Non-pharmacological Prevention Strategies
    • Hand washing in all settings, particularly when high-risk infants are at risk for exposure to respiratory infections from older siblings
    • Practicing cough hygiene – cover mouth, cough into elbow, dispose of tissues immediately
    • Avoid exposure to combustible tobacco
    • If possible, avoid daycare during RSV season
    Elderly Patients: Adults who get infected with RSV may be asymptomatic or have mild symptoms. Symptoms include rhinorrhea, pharyngitis, cough, headache, fatigue, and fever. Disease usually lasts less than five days.

    Some adults, however, may have more severe symptoms consistent with a lower respiratory tract infection, such as pneumonia. High Risk elderly include:
    • Age 65 years and older
    • Adults with chronic lung or heart disease
    • Adults with weakened immune systems
    RSV in elderly may exacerbate:
    • Asthma
    • Chronic obstructive pulmonary disease (COPD)
    • Congestive heart failure
    Although these symptoms sound rather generalized, there are tests that can help with the diagnosis with RSV:
    • Reverse transcriptase-polymerase chain reaction (rRT-PCR), which is more sensitive than culture and antigen testing. This is the best option for older patients.
    • Antigen testing is 80-90% accurate in children due to sensitivity, but not is sensitive in adults.
    There is a lot of information on-line about this drug, but I am most fortunate to be able to consult a pediatric hospital pharmacist. After last week’s column on RSV, Dr. Rebecca Wytiaz Kendsersky, PharmD reached out to me and offered to help me discuss Synagis® which as a community pharmacist, I have had no experience with. “Becca” did a residency in pediatric pharmacy and currently works at Children’s Hospital of Philadelphia. Here are her comments:

    Ah yes, Synagis definitely has a special pocket in the pediatrics world :) Happy to share more info!
    • Typical RSV/palivizumab season is November to March, however the past two years have thrown us for a loop so we've started seeing RSV cases as early as August . Because palivizumab is a bit expensive (see below), we limit dispensing in the hospital to only during " palivizumab season". This year, we deemed to begin in September and will likely go through (at least) March pending on the RSV trends in the area and nation.
      • Of note, patients are eligible to receive up to 5 doses of monthly palivizumab per year as it is thought to provide coverage through the entire season. I'm curious if this recommendation will change as the season is showing to start earlier and earlier.
      • If patients contract RSV during palivizumab Synagis season", then they are no longer eligible to receive Synagis for the remainder of the season since the chance that they'll be reinfected with RSV in the same season is highly unlikely.
    • Cost: CHOP carries the 100 mg/mL vials, which is a ripe $3,947.86! While not the most expensive drug in the world, certainly not a small cost. Although the cost of treatment is definitely cheaper than a hospital admission!
    • Administration: CHOP (and the other hospitals I've worked at) administer Synagis via intramuscular route for qualifying patients within 72H of discharge - a cost-savings and risk/benefit to not administer while still admitted to the hospital. CHOP limits administration to MWF so we can batch the doses prepared and also reduce costs in that way. After patients receive their doses on their way out the door from an inpatient admission, they'll follow up with their outpatient physicians to receive subsequent IM doses during the season.
      • One last point is that Synagis is not a vaccine (a common misnomer by many of our resident physicians) but rather a prophylactic IM injection. I like to avoid the "vaccine" classification just in case qualifying patients have anti-vaccine parents who may automatically reject this therapy without knowing more about it.


    My sister Mary, is a top flight pediatric nurse with over 40 years of practice. She has staffed pediatric wards, pediatrician’s offices and served as a school nurse. Her entire career has been devoted to the care of the little ones. I spoke with her on the phone and she was telling me that she has never seen so many RSV cases so early on.

    She spent the last week helping family members deal with RSV cases. Good nursing care kept the little ones out of the hospital. She also noticed that the kids that had it all reacted differently, with the youngest having the most respiratory distress. Since not everyone has access to a private duty pediatric nurse like Mary, the hospital pediatric wards and ER’s are busting at the seams. Like me, Mary cannot wait for the RSV vaccines to become widely available.

    Have a Great Day on the Bench!!

    December 2022

    Micro-Learning CE Associated - Click Here For Details

    Overview of Ear Infections

    EAR INFECTIONS

    OTITIS EXTERNA:Characterized by erythema (redness) and edema of the external auditory ear canal. Symptoms frequently include otalgia (ear pain), pruritis (itching), purulent discharge, and impaired hearing. Recent exposure to water or mechanical trauma (Q-tips, scratching etc.) can precipitate the condition. The ear canal may become blocked by hair follicles or wax providing a protective barrier and adequate environment for bacteria and fungi to grow. Edema commonly associated with external ear infections occurs from a change in normal pH, triggering an inflammatory response. Manipulation of auricle often causes pain response. Frequently referred to as “swimmers’ ear”. Infection is usually unilateral only affecting one ear at one time. Usually caused by gram negative rods (Pseudomonas aeruginosa and Staphylococcus aureus) or fungi (Candida and Aspergillus) which grow well warm, dark, moist environment.

    Treatment of Otitis Externa:
    • Protection of ear from further moisture and/or mechanical injury are key to treatment
    • Avoid placing cotton swabs in the ear
    • Oral acetaminophen and nonsteroidal anti-inflammatories
      • Adequate for mild to moderate pain
    • Short course of oral opioids may be prescribed for severe pain associated with uncomplicated otitis externa
      • Should resolve within 48 to 72 hours of initiating antibiotic therapy
    Primary Treatment:
    • Neomycin/Polymyxin/Hydrocortisone (Cortisporin® otic) ear drops
      • Dose: 4 drops three to four times daily
      • MAX duration of 10 days
    • Ciprofloxacin 0.3%/dexamethasone 0.1% (CiproDex Otic®)
      • Dose: 4 drops into the affected ear(s) twice daily for 7 days
    • Ofloxacin otic (Floxin otic®)
      • Dose: 10 drops into affected ear(s) once daily for 7 days
    • Ciprofloxacin + hydrocortisone (Cipro-HC®)
      • Dose: 3 drops into affected ear twice daily for 7 days
      • This preparation is not sterile
      • Cannot be used when a patient has a perforated ear drum
    • Swim Ear®:
    • Contains 95% isopropyl alcohol as a drying agent for “clogged ears”
    Fungal infection for Otitis Externa:
    • Nonperforated tympanic membrane: hydrocortisone/acetic acid otic (1%/2%)
    • Perforated: Tolnaftate topical drops (1%) (usually found in the foot section)
    • Fluconazole 200mg x1 dose then 100mg daily for 3-5 days
    OTITUS MEDIA: Inflammatory process of the middle ear. Inflammation of area behind the eardrum. It is accompanied by the presence of fluid, in the middle ear and a rapid onset of signs and symptom of ear infection.

    Signs/Symptoms:
    • Fever, otalgia, otorrhea, changes in balance or hearing, irritability, lethargy, vomiting or diarrhea.
    • Patients commonly experience upper respiratory infection symptoms as well consisting of rhinorrhea, cough, congestion.
    Types of Otitis Media
    • Myringitis: inflammation of tympanic membrane
    • Otitis media with effusion
    • Acute otitis media
    • Chronic suppurative otitis media
    Microbial Pathogens: Overall Detection in Middle Ear Fluid
    • VIRAL: up to 70% of all otitis media cases are of viral etiology.
    • Bacterial and viral is 66% of cases
    • Bacteria 92%
    • No pathogen= 4%
        • Streptococcus pneumoniae:
        Contributed to 49% of bacterial otitis media. Resistance is becoming more of a problem. Up to 50% of strains are resistant to macrolides
        • Haemophilus influenzae:
        Contributed to 29% of the cases. Bacterial resistance is due to beta-lactamase production
        • Moraxella catarrhalis:
        Contributed to 28% of cases. Almost all strains are beta-lactamase producing.
    Benefits and Risks of Pharmacological Therapy: A study conducted from 1966 to 1992 concluded that the overall rate of spontaneous resolution of acute otitis media was 81%. (https://www.aafp.org)

    According to the new guidelines, watchful waiting is considered an appropriate option for:
    • Children six months to 23 months with unilateral infection and non-severe symptoms (presence of mild ear pain for less than 48 hours and a temperature less than 39°C or 102.2°F)
    • Children two years or older with unilateral or bilateral infection and non-severe symptoms (presence of mild ear pain for less than 48 hours and a temperature less than 39°C or 102.2°F)
    • Regardless of the use of an antibiotic, an analgesic should be considered within the first 24 hours to relieve (AAP guidelines 2013)
    Conversely, antibiotic therapy should be prescribed for:
    • All children less than six months
    • Children six months of age or older with severe symptoms (presence of moderate to severe ear pain for at least 48 hours or a temperature of 39°C or 102.2°F or higher)
    • Children six months to 23 months with bilateral infection and nonsevere symptoms (presence of mild ear pain for less than 48 hours and a temperature less than 39°C or 102.2°F for less than 48 hours)
    • All children with acute otitis media with otorrhea
    Treat ear pain with ibuprofen or acetaminophen. In most patients, symptoms begin improving within 24-72 hours of initiation of therapy. As a result less than 50% of the children complete the prescribed course of antibiotics. Adherence to antibiotic regimens may be improved by selecting agents that require less frequent dosing (once or twice daily) and by prescribing shorter (five days or less) treatment courses. Advise parents to bring children with suspected otitis media to the clinic for evaluation however, they should not always expect an antibiotic.

    NON-PHARMACOLOGICAL TREATMENT MEASURES

    Otitis Media:
    • Local heat can help comfort the child
    • American Academy of Otolaryngology recommends tubes being placed in patients who have had 4 episodes of AOM in past 6 months or 6 episodes in past year
    • Myringotomy and insertion of tympanostomy tubes:
      • Incision is made in tympanic membrane; middle ear effusion is aspirated
      • Biflanged tympanostomy (ventilator tube) tube is inserted
    • These tubes decrease episodes by 50%.
      • They usually last 6-12 months
      • After extrusion there is no evidence of ongoing benefit
    Risk Factors for Otitis Media:
    • Age:peaks between 6 and 12 months of age
    • Family History: especially if siblings are prone to ear infections
    • Day Care: risk ratio is 2.8 to 5 times greater
    • Tobacco Exposure: risk ratio is 1.66 times greater
    • Pacifier Use: slight risk increase, with risk ratio of 1.24
    OTITIS MEDIA TREATMENT AND PREVENTION
    FIRST-LINE VS SECOND-LINE VS THIRD-LINE THERAPY

    NO ANTIBIOTICS IN THE LAST 30 DAYSANTIBIOTICS IN THE LAST 30 DAYS
    First line (initial empiric) therapyAmoxicillin HD (high risk patients)Amoxicillin HD or Amoxicillin/Clavulanate HD or cefuroxime, or cefdinir, or cefpodoxime or cefprozil
    (Adults--moxifloxacin or levofloxacin)
    Failure after 3 days RXAmoxicillin/clavulanate HD *or*cefprozil or cefpodoxime or cefuroxime OR ceftriaxoneCeftriaxone-IM in 3 daily doses. Clindamycin, tympanocentesis
    Failure at days 10-28Same as above, choose different regimenAmoxicillin/clavulanate HD, cefuroxime, ceftriaxone-IM x3 , tympanocentesis.


    Prescribing Rules:
    • Amoxicillin HD (high dose) (80-90 mg/kg/day)
      • First line therapy for otitis media
      • Divided into 2 or 3 doses (every 8 or every 12 hours)
    • Amoxicillin/Clavulanate high dose
      • Treatment of choice for first line failure (amoxicillin high dose)
    • Amoxicillin-UD (usual dose)
      • Not recommended for first line use in otitis media
      • 40 mg/kg in 2 or 3 divided doses
    • Amoxicillin HD
      • 80-90 mg/kg/day in 2 or 3 divided doses (q8h or q12h)
    Shortcut for Amoxicillin prescribing at 80 mg/kg (HD):
    • High Dose =80-90mg/kg.
    • Using 400 mg/5 mL concentration think of it as (80 mg/mL)
      • 80mg/1 mL equals 80mg/kg therefore every 1 kg a child weighs he/she gets 1 mL of amoxicillin 400 mg/5 mL per day.
    • EXAMPLE: Child weights 44lb. 44lb divided by 2.2lb/kg= 20kg
      • The child gets 20 mL/ day may give 10 mL twice daily (1600mg/day)

    Now here is the problem when prescribing Amoxicillin/Clavulanate (Augmentin®), which is dosed based on the component.
    vr
    DrugTo get 1500mg amoxicillinYou get this much clavulanate daily
    Augmentin 125 mg/31.25 mL12 teaspoon375 mg
    Augmentin 250 mg/62.5 mL6 teaspoon375 mg
    Augmentin 400 mg/57 mL3.75 teaspoon213.75 mg
    Augmentin-ES 600 mg/42.9 mL2.5 teaspoon107.25 mg
    Augmentin 250 mg/125 mL6 tablets750 mg
    Augmentin 500 mg/125 mL3 tablets375 mg
    Augmentin 875 mg/125 mL2 tablets250 mg


    As you can see from the above chart for a child getting Amoxicillin 1500mg per day (37lb child) would get 107.25mg of clavulanate should the prescriber use Augmentin ES 600, versus 375mg of clavulanate should the prescriber use Augmentin 250/5.

    Whenever you are prescribing Augmentin therapy HD (high dose) as is recommended for otitis media, it is critical to use Augmentin ES 600mg/42.9 to minimize clavulanate exposure and decrease incidence of severe GI upset and diarrhea. Maintain daily clavulanate dose < 10 mg/kg/day. Amoxicillin/Clavulanate can cause diarrhea in 3- 34% of patients, and this percentage varies upon dose and regimen.

    Clinical Pearls:
    The younger a child is when they develop otitis media, the more likely they are to have a recurrence.
    High dose amoxicillin is first line, do not use if child has had antibiotics the previous 30 days, or receiving prophylaxis with amoxicillin.
    Standard treatment duration is 10 days, with short course being 1-7 days.
    • Use 10 days for all children under 2 years of age, and ALL children with severe disease
    • For children age 2 and older, with mild to moderate acute otitis media a 5-7 day course is appropriate
    • A Cochrane review showed that in otherwise healthy children a 5 day course is as effective as the 10 day course supported in AAP/AAFP guidelines.
    • Clinical improvement should be evident in 48-72 hours
    • Antihistamines and decongestants are of NO value in the treatment of acute otitis media
    Maximum Amoxicillin dose: The recommended dose of amoxicillin is 80 to 90 mg/kg per day for otitis or respiratory infections due to resistant S. pneumoniae. The manufacturer recommended dose (per package insert is 1.75g/day. This is exceeded when a kid weighs over 20kg. When amoxicillin was approved in 1974, pneumococcal resistance was not a problem. Today feel comfortable dispensing 3g per day and sometimes up to 4g per day if necessary.


    PREVENTATIVE MEASURES AGAINST OTITIS EXTERNA & OTITIS MEDIA
    Prevention of otitis externa:
    • Turn head to drain water after swimming or showering
    • Utilizing earplugs may help prevent water from getting inside the ear but if water is already present it may trap water. There have been mixed results when looking at use of earplugs
    PREVENTION of OTITIS MEDIA HIGHLIGHTS:
    Be sure to emphasize the importance of prevention to all parents of small children
    • Pneumococcal vaccine Use of the according to the childhood immunizations schedule has been shown to be effective in reducing the incidence of acute otitis media.
    • Influenza vaccine: many cases of acute otitis media follow a viral upper respiratory tract infection. Reducing viral infections will reduce otitis media.
    • Breastfeeding: Breastfeeding for 4-6 months reduces episodes of acute otitis media. American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life and to continue for at least the first year or longer, based on the abilities of the mother and child.
    • Day care: Family provided day care or small group day care helps prevent otitis media.
    • Tobacco smoke: Avoid exposure of household tobacco smoke.
    • Pacifiers: Avoid giving your infant a pacifier
    • Viral infections: Viral infections like the common cold increase the likelihood of otitis media. Wash hands frequently, do not share toys etc.
    • Allergies: Inflammation and mucus caused by allergies can block the eustachian tube and make ear infections more likely
    Prophylaxis: Antibiotic therapy for Otitis Media: Use of antibiotics to prevent otitis media is a MAJOR contributor to the emergence of antibiotic resistant S. pneumoniae.
    • Antibiotic prophylaxis for otitis media is NO longer recommended
    • Pneumococcal conjugate vaccine (Prevnar-13) decreases frequency of otitis media in children


    When my wife Denise worked in State College at a clinic pharmacy, one of the pediatricians was insistent on using only the Amoxicillin/Clavulanate (Augmentin) 600 mg/5 mL concentration. She would not tolerate prescribing any Augmentin 250 mg/5 mL or Augmentin 400 mg/5 mL for her patients. If she read the emergency room reports, or listened to any other physician writing for the 250 mg/5 mL or the 400 mg/5 mL, she would instruct the parents to dump out the product dispensed, and come the pharmacy to get the 600mg/5cc product to decrease nausea, vomiting and of course, diarrhea.

    One of my former PA students did the same. She sent me an email begging me to reinforce this concept as well. For otitis media the best option is the 600 mg/ 5mL to decrease clavulanate exposure and its side effects.

    All of the amoxicillin/clavulanate products taste horrible and cannot be made palatable with any flavoring agent. I recommend the parent use an oral syringe, and have a teaspoon ready with Hershey chocolate syrup ready. Once the child swallows, stick the spoon of chocolate syrup in their mouth to clear the nasty taste.

    Have a Great Day on the Bench!!

    Micro-Learning CE Associated - Click Here For Details

    Overview of Glaucoma Therapies

    Glaucoma Medications that Decrease Production of Aqueous Humor

    BETA-ADRENORECEPTOR ANTAGONISTS [YELLOW or BLUE CAPS]

    Mechanism:
    • Decrease production of aqueous humor by the ciliary body without producing substantial effects on aqueous humor outflow
    • Beta activity decreases during the night, so these drugs might not be effective while patients are asleep
    • NO EFFECT on pupil size or accommodation
    Indications for Use:
    • Open angle glaucoma
    • May be used alone, or in combination with mitotics
    Warnings/Precautions/Adverse Effects:
    • Stinging upon application
    • Dry eyes
    • Only betaxolol is beta selective: Caution if using other beta blockers in cardio & pulmonary (specifically asthma) patients
      • May cause increased risk for bronchospasm, or bradycardia
    • Caution in patients with decreased cardiac function
    • Other side effects: depression, lethargy, dizziness, vertigo headaches etc.
    • If combining therapy with epinephrine: administer epinephrine 4 hours after using beta blocker
    Drug Interactions:
    • Oral beta blockers: may potentiate systemic effect of decreased heart rate
    • Digoxin and non-dihydro calcium channel blockers: may prolong atrioventricular conduction time and increase risk of hypotension or bradycardia
    Patient Education:
    • Bradycardia and bronchospasm are common signs of overdose
    • Do not touch dropper directly to the eye
    Representative products:
    • Betaxolol (Betoptic®-S) 0.25% suspension
      • Dose: 1 drop twice daily
      • Beta-1 selective: affects cardiovascular parameters
    • Timolol (Timoptic®-XE) 0.25% and 0.5% gel forming solution
      • Dose: 1 drop once daily
    • Timolol (Timoptic®) 0.25% and 0.5% solution
      • Dose: 1 drop twice daily
      • Timolol is non-selective: affects cardio and pulmonary parameters
    • Levobunolol (Betagan®) 0.25% and 0.5% solution
      • Dose: 1 to 2 drops once daily; may increase to 1 drop twice daily
      • Levobunolol is non-selective: affects cardio and pulmonary parameters
    • Carteolol (Ocupress®) 1% solution
      • 1 drop twice daily
      • Carteolol is non-selective: affects cardio & pulmonary parameters


    ALPHA-ADRENORECEPTOR AGONISTS (SYMPATHOMIMETICS) [PURPLE CAPS]

    Mechanism:
    • The alpha agonists: Brimonidine, dipivefrin, & epinephrine decrease formation of aqueous humor AND increase outflow of aqueous humor
    • Apraclonidine (Iopidine): decreases aqueous production with NO effect on outflow
    Indications for Use:
    • Apraclonidine, brimonidine, dipivefrin and epinephrine
    • Open-angle glaucoma
    Warnings/Precautions/Adverse Effects:
    • Minimal effects on blood pressure
    • Caution with severe cardiovascular disease
    • Caution in depression & Raynaud’s phenomenon
    • May cause fatigue/drowsiness in some patients
    Patient Education: May cause fatigue or drowsiness

    Representative products:
    • Brimonidine 0.15% (Alphagan-P®) solution
      • CAUTION: new additional strength 0.1% (brand only)
      • Dosage: 1 drop three times daily (preferably Q8H)
      • Brimonidine 0.025% (Lumify®) is OTC for correction of red eyes not glaucoma


    CARBONIC ANHYDRASE INHIBITORS [ORANGE CAPS]

    Mechanism: Inhibits carbonic anhydrase (CA) in the ciliary process of the eye reducing the production of bicarbonate ions leading to a decrease in aqueous humor production

    Indications for Use: Reduction of intraocular pressure in patients with open-angle glaucoma

    Warnings/Precautions/Adverse Effects:
    • Sulfonamide derivatives that are absorbed systemically may cause allergic reaction: caution for hypersensitivity reactions or Stevens-Johnson syndrome (SJS) like reactions
    • Temporary blurring of vision: use caution while driving
    Patient Education:
    • These are sulfa drugs. Watch for signs of allergy!
    • Horrible taste can be mediated by using punctal occlusion (blockage of tear duct)
      • Pinch bridge of nose for 30 seconds after administration
    Representative products:
    • Dorzolamide (Trusopt®) 2% solution
      • Dosage: 1 drop three times daily
    • Brinzolamide (Azopt®) 1% suspension
      • Dosage: 1 drop three times daily
    • Acetazolamide (Diamox®) oral
      • Dose: 250 to 1000 mg daily
        • Available as 250 mg tablets or 500 mg SR capsules
      • Very useful as adjunct therapy
      • Watch for hypokalemia: consider supplementation with K+


    Although we rarely dispense pilocarpine, it reminds me of my grandfather. As a little kid growing up, my Grandpa lived only one block away, and I spent a lot of time at his house. He was a blacksmith, tall and thin and had the most gorgeous blue eyes, none of these characteristics he shared with me!

    As he got older, he struggled more with his eyesight. He used pilocarpine eye drops several times a day to manage his glaucoma. Grandpa would sit on the front porch to read his large edition of the Reader’s Digest or the newspaper. He always said the hardest part of growing was twofold, the loss of his friends and his eyesight. At age 77 he gave up his driver’s license and sold his 1952 Chevy truck.

    One day he was telling me he was sitting by the window watching the birds at his bird feeder. He described a bright red cardinal, taking a sunflower seed in his beak and breaking it open and eating the kernel inside. What amazed me is how this guy who complained of failing eyesight could see such detail with such clarity.

    As a pharmacist it all makes sense. Grandpa had pinpoint pupils from the pilocarpine drops that made him struggle to see if there was not sufficient light. As long it was a bright and sunny day Grandpa could see such minor details as the birds eating at his feeder.

    Glaucoma Medications that Facilitate Drainage of Aqueous Humor MIOTICS [GREEN CAPS]

    Mechanism:
    • Parasympathomimetic drug which duplicates the muscarinic effects of acetylcholine
    • Produces pupillary constriction, stimulates ciliary muscles, increases aqueous humor outflow
    • It causes increased tension on the scleral spur and opening of the trabecular meshwork spaces to facilitate outflow of aqueous humor
    Indications for Use:
    • Decrease intraocular pressure due to glaucoma
      • May be combined with beta blockers, carbonic anhydrase inhibitors, sympathomimetics, or hyperosmotic agents
      • May be acceptable alternative for patients that cannot tolerate cardiovascular side effects of beta blockers
    Warnings/Precautions/Adverse Effects:
    • Miotics can induce vision changes or myopia (near-sightedness) in younger patients
    • Miotics causes pupillary constriction that compromises vision in patients especially with cataracts
    • Stinging and burning on application
    • Decreased visual acuity
    • Headache
    • Decreased night vision
    Patient Education: Caution driving at night; vision may be affected

    Representative products:
    • Pilocarpine (Vuity®) 0.25%, 0.5%, 1%, 2%, 3%, 4%, 5%, 6%, 8%, 10%
      • Dosage: 1 drop up to four times daily; initiate on 1% and increase strength and dose based on intraocular pressure
    • Pilocarpine hydrochloride(Pilopine HS®) 4% ophthalmic gel
      • Apply ½ inch ribbon in conjunctival sac once daily at bedtime (HS)
    • Pilocarpine (Ocusert Pilo) intraocular system
      • Ocular system placed in eye
      • Changed weekly
      • Releases 20 mcg/hr for 1 week


    PROSTANOIDS [TURQUOISE CAPS]
    (considered first line by most ophthalmologists)

    Mechanism: Reduces intraocular pressure by increasing outflow of aqueous humor

    Indications for Use: Open angle glaucoma

    Warnings/Precautions/Adverse Effects:
    • May discolor iris blue eyes to brown. Color change may be permanent
    • Increases length, thickness and pigmentation of eyelashes
    • Eyelid skin darkening
    Patient Education:
    • Color changes to iris
    • Eyelash and eye lid changes
    Representative products:
    • Latanoprost (Xalatan®) 0.005%
      • Dosage: 1 drop once daily in the evening
    • Travoprost (Travatan-Z®) 0.004% solution
      • Dosage: 1 drop once daily in the evening
      • Keep at room temperature for up to 6 weeks; keep refrigerated in the pharmacy before dispensing
    • Bimatroprost (Lumigan®) 0.01% solution
      • Dosage: 1 drop once daily in the evening
    • Tafluprost (Zioptan ®) solution
      • Dosage: 1 drop once daily in the evening
      • Preservative free
      • Available in single use containers
    • Bimatoprost (Latisse®) solution
      • The first drug approved for increasing eyelash growth
      • Patients using these prostaglandin eye drops noticed thicker and longer eyelashes
      • Takes about 8 weeks to work
      • Eyelashes return to "normal" a few weeks or months after stopping treatment
      • Darkens the iris and skin around the eyes
      • The skin darkening may be reversible while the iris darkening usually is not
      • Wait 15 minutes before re-inserting contact lens
    • Latanoprostene bunod (Vyzulta®) 0.024% solution
      • Metabolized into latanoprost and nitric oxide increasing fluid outflow by two pathways
      • Not much more effective than latanoprost
      • Cost is $180 for 2.5ml vs $12 for latanoprost 2.5ml.

    RHO KINASE INHIBITORS [WHITE CAPS]

    Mechanism:
    • Rho kinase inhibitors increase fluid outflow through the trabecular meshwork
    • Considered to be an add on to therapy, as it modestly decreases IOP
    Indications for Use: Reduction of elevated intraocular pressure in patients with open-angle glaucoma

    Warnings/Precautions/Adverse Effects: The most common side effects are conjunctival (eye) redness, golden brown deposits in the cornea (covering of the colored portion of the eye), pain with drug application, conjunctival (eye) bleeding, blurred or decreased vision, increased tearing and redness of the eyelid.

    Patient Education: Remove contacts before administration and wait 15 minutes before reinserting

    Representative products:
    • Netarsudil (Rhophressa®) 0.02% solution
      • Dose: 1 drop once daily in the evening
      • Rhopressa modestly lowers intraocular pressure
      • Expensive product at $230.00 per 2.5ml bottle
      • Refrigerate until opening then may be stored at room temperature up to 6 weeks
    • Netarsudil 0.2% combined with latanoprost 0.005% (Rocklatan®) solution
      • Dose: 1 drop once daily in the evening
      • MAX dose: 1 drop daily


    Color Codes for Topical Ocular Medications
    ClassColorExamples
    Anti-infectivesTanMoxifloxacin, ofloxacin
    Anti-inflammatories/steroidsPinkPrednisolone
    Mydriatics and cycloplegicsRedAtropine, tropicamide
    Nonsteroidal anti-inflammatoriesGrayBromfenac, ketorlac
    MioticsDark GreenPilocarpine
    Beta-blockersYellowTimolol
    Beta-blocker combinationsDark BlueBrimonidine and timolol
    Adrenergic agonistsPurpleBrimonidine
    Carbonic anhydrase inhibitorsOrangeDorzolamide, brinzolamide
    Prostaglandin analoguesTurquoiseLatanoprost, travoprost


    When I am explaining glaucoma drugs to my student pharmacists or student PA’s I use the analogy of a bathtub filling up with water, and a washcloth plugging the drain. As the tub is about to overflow, what corrective action would you take?

    Step one is to shut the water off; step two is to unplug the drain. These two simple steps sum up how we treat glaucoma. We can shut the water off (decrease formation of the aqueous humor) or we can unclog the drain (facilitate drainage through the canal of Schlemm.

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    Overview of Glaucoma

    IOP: intra ocular pressure : - Is physiologically determined by the relative production and elimination of the aqueous humor, the clear liquid fills the anterior and posterior chambers of the eye. The relatively constant flow (2 to 3 microlitres/minute) maintains the physiological IOP.

    Aqueous humor in the anterior chamber leaves the eye by two routes.
    • filtration through the trabecular network to Schlemm’s canal (80-85%)
    • traversal to the anterior face of the iris and absorption the iris blood vessel
    Increased IOP may result from obstruction of resistance to outflow at the angle of the anterior chamber, but it may also result from pupillary block as a result of lens dislocation or drugs (beta adrenergic agents).

    The normal range of IOP is 10-21 mmHg. Except for acute cases the diagnosis of glaucoma is not made on the basis of a single tonometric measurement. IOP over 40 is an emergency referral.

    Glaucoma presents as first loss of peripheral vision followed by progress of loss of central vision.

    Risk factors for Glaucoma:
    • Hypertension: observational studies show an association between elevated blood pressure and elevated IOP
    • Diabetes: observational studies also showed a risk for glaucoma in patients with diabetes. The risk increased 5 percent each year after the diagnosis of diabetes.
    • Age: prevalence of open-angle glaucoma is less than 1% in individuals under 55 years of age, approaches 2% at age 65, and reaches 4% by the 80th birthday.
    • Race: White and black population is more affected by open angle population, while the Asian population is more at risk for closed angle glaucoma.
    • Family history: relative risk of open-angle glaucoma increased 3.7- fold if a sibling is affected and 2.2-fold for a parent
    Closed Angle Glaucoma: primary closed angle glaucoma accounts for 5 % or less of primary glaucomas. In chronic closed angle glaucoma flow of aqueous into the anterior chamber angle is obstructed. When CAG occurs, it MUST be treated as an ophthalmologic emergency to avoid visual loss.

    Symptoms include:
    • Rapid onset in older age groups, particularly hyperopes and Asians.
    • Severe pain and profound visual loss with “halos around lights”.
    • Hazy edematous cornea. Red eye and dilated pupil.
    • May see nausea, vomiting, abdominal pain and diaphoresis.
    • In prolonged attacks vision loss may occur if IOP is high enough. Tonometry reveals IOP as high as 40-70 mmHg.
    Treatment: goal is rapid reduction of IOP to preserve vision loss.
    A single dose of Acetazolamide 500mg IV followed by 250mg by mouth four times daily.
    Treatments consists of mannitol, urea or glycerol.
    Once the IOP has started to fall administer topical Pilocarpine 4% one drop every 15 minutes for 1 hour, then four times daily.
    Definitive treatment is laser peripheral iridotomy. This procedure should be prophylactically on the other eye.

    ROLE OF MANNITOL AND GLYCEROL & UREA

    Mechanism: are hyperosmotic drugs that are administered systemically in the pre-operative management of primary acute angle closure glaucoma.

    Indications: closed angle glaucoma

    Warnings/precautions/ adverse effects: All 3 will cause headache, nausea, diarrhea, excessive thirst and electrolyte imbalance

    Representative products:
    • Mannitol: is administered IV in adults in a 20% solution rapidly in 20 minutes. Its effect is produced in 1 hour and lasts approximately 6 hours. Since mannitol enters the eye more slowly, it produces a greater osmotic gradient, which is beneficial when inflammatory processes are active.
    • Urea: is administered IV in a 30% solution effects are produced within 45 minutes. Since it enters the eye easier than mannitol, its effects are usually not as good.
    • Glycerol: is administered ORALLY in a 50 to 75% solution. Ocular penetration is poor, which results in substantial osmotic gradient between plasma and aqueous humor. This method appears to be as effective as IV routes. (can use chronically)

    Open Angle Glaucoma: Chronic disease primarily treated with topical drugs. Primary defect is reduced drainage of the aqueous humor into the canal of Schlemm. Cause is not clearly understood, although genetic mutations have been identified in a small number of the cases.

    BENEFITS AND RISKS OF PHARMACOLOGICAL THERAPY
    Benefits: decrease of IOP, will preserve vision in patients. Glaucoma is often called the silent thief of sight, because of an insidious onset and vague symptoms of discomfort. Will also preserve field of vision. Untreated glaucoma can lead to damage to the optic nerve and blindness.

    PHARMACOLOGICAL MANAGEMENT
    Pharmacological management consists of:
    • Decreasing the production of Aqueous Humor
    • Facilitating the drainage of the aqueous humor from the chamber.
    • Therapy is started as a single agent in one eye, to evaluate drug efficacy and tolerance. Monitoring of therapy is individualized. IOP should be measured, and the optic disc visualized initially every 2-4 weeks. Then every 1-6 months when stabilized. The visual field should be measured every 3-12 months, more frequently after any change in drug therapy.
    Drugs that Decrease production of Aqueous Humor:
    • Beta blockers (topical) (timolol, betaxolol, carteolol, levobunolol)
    • Alpha agonists (topical) Epinephrine, dipivefrin, apraclonidine, brimonidine
    • Carbonic anhydrase inhibitors: acetazolomide (po), dichlorphenamide, dorzolamide, brinzolamide
    Drugs that Increase the drainage of Aqueous humor.
    • Miotics: carbachol, pilocarpine
    • Prostaglandins: Latanoprost, Travoprost, Bimatoprost
    • Some sympathomimetics: Epinephrine, dipivefrin, brimonidine
    • Rho Kinase inhibitors: netarsudil
    Risk factors for Glaucoma: Prevention: All persons over age 40 should have tonometric and ophthalmoscopic exams every 2 years. In diabetics and individuals with a family history of glaucoma, annual exam is indicated.

    Drugs that may induce or potentiate increased IOP:

    Open Angle Glaucoma
    • Ophthalmic corticosteroids (highest risk) affect the drainage through trabecular network)
    • Systemic corticosteroids and topical steroids
    • Nasal or inhaled corticosteroids
    Closed angle glaucoma
    • Topical anticholinergics
    • Topical sympathomimetics
    • Oral sympathomimetics
    • Systemic anticholinergics
    • Low potency phenothiazines
    • Antihistamines
    • Ipratropium
    • Low risk: benzodiazepines, Theophylline, CNS stimulants, tetracyclines, MAOI, topical anti cholinergics.

    Lasers in Glaucoma YAG (yttrium –aluminum-garnet) laser is used to form a hole in the iris (iridectomy) to increase the flow of aqueous humor. Used for closed angle glaucoma.
    ALT/ SLT: (argon laser trabeculoplasty is an adjunct to topical therapy, helps clear paths in the trabecula to facilitate drainage. Helps decrease IOP in open angle glaucoma patients, where drug has not produced optimal results. It can be used as a primary measure in Open angle glaucoma
    Diode: Used as an adjuvant to control IOP


    I have only seen only one patient in my career with closed angle glaucoma, and he was suffering! He had a massive headache and had bloodshot eyes and tears streamed down his cheeks.

    Dr. Mark Dsousa enlightened me about the use of lasers in his practice. I recommend that you "google" iridotomy and see how the holes are lasered into the iris. I was also educated on the fact that brown irises are harder to treat because of the pigment, and the "power" has to be turned up. Of course, in India where Dr. Mark practiced, everyone had dark brown eyes!

    People of Chinese ancestry are also more at risk for closed angle glaucoma. We are a product of our genetics!

    Have a Great Day on the Bench!!

    November 2022

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    Overview of NSAID Eye Drops

    Non-Steroidal anti inflammatory Eye drops:
    May cause “cornea melting” should not be used for more than one month.


    Acular® (ketorolac) 0.5% eye drops: Rx only
    • Indication: Relief of ocular itching caused by seasonal allergic conjunctivitis. Also treatment of post-op inflammation following cataract extraction.
    • Dosage: one drop four times daily (allergic conjunctivitis)
    Acular LS® (ketorolac) 0.4%: for ocular pain/stinging/burning after corneal refractive

    Voltaren® ophth soln (diclofenac) 0.1% Rx only
    • Indication: post op inflammation after corneal extraction. Photophobia and pain after corneal refractive surgery. (Worst for corneal melting may occur in 2 days)
    • Adult dose: 1 drop QID beginning 24 hours post op., for 2 weeks.
    Nevanac® ophth soln (Nepafenac 0.1%) Rx Only
    • Indication: Post op pain and inflammation following cataract surgery
    • Adults : 1 drop TID 1 day before surgery and for 2 weeks post-op
    Bromday® (bromfenac ophthalmic solution) 0.09% Rx only
    • Indiation: indicated for the treatment of postoperative inflammation and reduction of ocular pain in patients who have undergone cataract extraction
    • Adults: Instill one drop once daily beginning 1 day prior to surgery, 14 days post-op
    ILEVRO® Suspension (nepafenac 0.3%) is dosed once daily post-op compared with 3x daily for NEVANAC® (nepafenac ophthalmic suspension) 0.1%- has increased viscosity, smaller particle size and more concentrated. (Use beyond 14 days is increased risk for corneal melting)
    • Indication: treatment of pain and inflammation associated with cataract surgery.


    OPHTHALMIC CORTICOSTEROIDS

    Indications for use: to decrease inflammation and pain. For acne rosacea in the eye. Allergic conjunctivitis. Ocular surgery. Corneal injury due to radiation or chemical burns. Endogenous anterior uveitis

    Warnings/precautions/ adverse effects
    • Contraindicated in fungal and caution with viral infections
    • May elevate IOP
    • Watch for sulfite or benzalkonium allergy.
    • Caution with contact lens.
    Patient Education: If there is no improvement of condition within 2 days, report to clinician.

    Representative products:
    • Prednisolone acetate 1% (Pred forte®) : depending on severity may begin with drop every 1 hour during day & every 2 hours during night. When favorable response is observed use 1 drop 3-4 times daily.
    • Fluorometholone (FML® 0.1%) or (FML forte 0.25%)
      • During first 1-2 days: 2 drops every 2 hours. Then 1 drop 2-4 times daily
    • Difluprednate (Durezol®) dosed QID for 2 weeks then taper
    • Loteprednol (Lotemax®) 0.5% : Initally may use 1 drop every hours then when satisfactory response: 1 drop QID Less effect on IOP
    • Loteprednol + tobramycin (Zylet®) 1-2 drops every 4-6 hours.
      • (Best to avoid steroids +antibiotic combo—Dr Mark)


    TREATMENT OF DRY EYES
    Prevalence of dry eye: 17.9 percent in women and 10.5 percent in men

    Mechanism: serve as lubricants and emollients

    Indications: for dry eyes or irritation

    Warnings/precautions/ adverse effects: Benzalkonium (preservative) may cause hypersensitivity reactions in select patients.

    Patient Education: Differences are between preservative systems.


    Can be divided into two causes:
    1. Decrease in tear production
    2. Decrease in lipid production: oil (meibum) secreted from Meibomian glands should be oily in appearance and composition. If it thickens then it cannot exit glands appropriately. Glands become clogged and no oil is released into tears.
    Associated systemic conditions causing dry eyes
    • Connective tissue and autoimmune diseases
    • Sjogren syndrome
    • Rheumatoid Arthritis
    • Wegener granulomatosis,
    • Systemic lupus erythematosus
    • Vitamin A deficiency
    Medications causing Dry Eyes
    • Medications
    • Oral contraceptives
    • Anti’s: Anticholinergics, Antihistamines, Antiarrhythmics, Antipsychotics, Antispasmotics
    • Tricyclic antidepressants, SSRIs
    • Beta blockers
    • Diuretics
    • Chemotherapy
    Lubricating eye drops- Over the Counter
    Recommend four times daily dosing to start then taper as needed
    Side effects: Slight blur and burn upon instillation
    Different formulations to treat different categories of dry eye


    Artificial Tears for aqueous deficiency:
    • Refresh®
    • Blink®
    Lipid based Artificial Tears
    Replenishes the complete tear film and provides a protective lipid barrier:
    • Systane® Balance
    • Refresh Optive® Advance
    • Soothe® XP
    • Retaine®MGD

    CYCLOSPORINE EYE DROPS (Rx only) Mechanism: immunomodulator. Decreases inflammation in patients with keratoconjunctivitis , which causes a decrease in tear production.

    Indications for use: to increase tear production.

    Warnings/precautions/ adverse effects: Caution with herpes keratitis.

    Patient Education:
    • Single dose vials. Discard immediately after each use.
    • Contact lens may be inserted 15 minutes after eye drops (patients with dry eyes are not ideal candidates for contact lens)
    Restasis® (cyclosporin) available in boxes of 30 and 60 vials.
    • Dosage: 1 drop in each eye twice daily. May take 3 months for some patients to begin noticing an increase in tear production, with significant increase in tear production at 6 months.
    • Very expensive about $660/month (60 vials)
    • 2022: generic available around $300/month (60 vials)

    IMMUNOMODULATOR for DRY EYES
    XIIDRA™ (lifitegrast ophthalmic solution) 5% 2016

    Dose: Instill (1) drop twice a day in each eye, using one sterile container. Remove contact lens, instill drops and wait 15 minutes before re-insertion.

    Mechanism: dual leukocyte function-associated antigen-1 (LFA-1)/intracellular adhesion molecule-1(ICAM-1) inhibitor. LFA-1 antagonists mediate both migration and adhesion of the white blood cells to sites of inflammation. ICAM-1 may be overexpressed in corneal and conjunctival tissues in dry eye disease. LFA-1/ICAM-1 interaction can contribute to the formation of an immunological synapse resulting in T-cell activation and migration to target tissues. Also, lifitegrast may inhibit mononuclear cells from secreting inflammatory cytokines

    Adverse effects: instillation site irritation, dysgeusia (nasty taste), decreased visual acuity.

    Cost: $660.00/month

    We pharmacists are quite undertrained in the area of eye care. Back 10 or 12 years ago I got a prescription for Lotemax® (loteprednol) for a patient. The copay was $45.00. I did a test claim for Prednisolone 1% eye drops and the copay was $5.00. I called the optometrist and explained the situation.

    He said in a friendly voice “Pete, if we do that the patient has to come to my office every 2 hours to have his intra-ocular pressure measured.” He went on to say “Lotemax® does not raise the IOP like prednisolone does, so let the patient pay the $45.00."

    Whether it is Dr. Mark Dsousa, Dr. Rachel Fritz or that optometrist that educated me on loteprednol I’m always open to learning. And your commitment to continuing education shows that you are too!

    Have a Great Day on the Bench!!

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    Overview of Eye Infections

    Conjunctivitis

    The membranes covering the sclera (the white part of the eye) and the inside lining of the eyelid, may be sensitive to chemical irritants, allergens, bacteria, and viruses. Conjunctivitis, also known as “pink eye”, may be a sign of systemic disease or infection, or may occur after an upper respiratory infection.

    Clinical presentation: one or both eyes may be itchy and feel as if they are burning. A clear, white, or yellow-greenish discharge may occur.

    Infectious conjunctivitis: bacterial conjunctivitis may start in one eye and spread to the other. Signs are redness, swelling, itchy painful eye, with thick discharge often yellow or green. Discharge is crusty and dried upon wakening in the morning, causing eye to stick shut. Although this condition is self-limiting, it should be treated by a clinician to decrease length of disease, decrease spread to others, and decrease possible complications. Pathogens most frequently responsible for bacterial conjunctivitis are Streptococcus pneumoniae, Haemophilus influenza, and Staphylococcus aureus Contact lens wearers should wear glasses until all signs of infection are gone.

    Treatment: consists of antibiotic eye drops or ointment given several times per day. Warm wet compresses are soothing for patients and helps to soften up the morning crust around the eye.

    SULFISOXAZOLE// SODIUM SULFACETAMIDE
    Is a potent sensitizer. Many allergic reactions are confused with therapeutic failures. Not an ideal choice for conjunctivitis.

    Representative products:

    Bleph-10® or Sulamyd 10%®: Sodium sulfacetamide comes in 15cc dropper bottle.
    Dose: 1 drop in the affected eye every 2-3 hours for initial dose.

    ERYTHROMYCIN ophthalmic ointment:
    Indications: may be used for prophylaxis of aophthalmia neonatorum due to N. gonorrhoeae or Chlamydia. Excellent coverage of GM positive organisms
    Erythromycin ophthalmic ointment: dosed ½ inch four times daily for 5-7 days

    AMINOGLYCOSIDES (GENTAMYCIN & TOBRAMYCIN):
    Indications: coverage for both Gram negative & gram-positive organisms. Most strep are resistant. Are not ideal choices since they are toxic to the corneal epithelium and can cause a reactive keratoconjunctivitis after long term use.

    Typical dose (drops): (it varies from clinician to clinician)
    Conjunctivitis: 1-2 drops every 2 hours while awake for 2 days, then 1-2 drops every 4 hours while awake for five days.
    • Gentamycin (Garamycin®) ophthalmic solution
    • Tobramycin (Tobrex®) ophthalmic soln
    • Tobramycin plus dexamethasone (Tobradex®) suspension
      • (Clinicians should avoid this combo, due to chance of herpes infection)
      • Ophthalmic corticosteroids can cause sight-threatening complications such as corneal scarring, melting, and perforation when used inappropriately. Chronic ophthalmic corticosteroid treatments may lead to cataracts and glaucoma
    Typical dose (ointment)
    Conjunctivitis: ½" of ointment every 3-4 hours, two to four times daily.
    • Gentamycin (Gentak®) ophthalmic ointment
    • Tobramycin (Tobrex ®) ophthalmic ointment
    • Tobramycin/dexamethasone (TobraDex®) ophthalmic ointment
      • (Clinicians should avoid this combo, due to chance of herpes infection)
    BACITRACIN Good Gram-positive coverage
    Minimal gram-negative coverage.
    Representative products
    Bacitracin® ophthalmic ointment –1/2 inch every 3-4 hours for 7-10 days.

    FLUOROQUINOLONES Indications for use: Good coverage for Gram positive and Gram negative. Good for most bacteria associated with conjunctivitis. Fluoroquinolones are the best choice to treat bacterial conjunctivitis in contact lens wearers due to the high incidence of Pseudomonas infection

    Dosage is similar: 1 drop every 2 hours while awake the first 2 days. Then 1 drop four times daily while awake.

    Representative products:
    Ciloxan® drops & ointCiprofloxacin (generic available)1st gen
    Ocuflox® dropsOfloxacin (generic available)2nd gen
    Quixin® dropsLevofloxacin3rd gen
    Vigamox® drops
    Moxeza ®
    Moxifloxacin (may dose TID)
    Moxifloxacin (dosed BID)
    4th generation
    Zymar® dropsGatifloxacin 0.3%4th generation
    Zymaxid®Gatifloxacin 0.5%4th generation
    Besivance®dropsBesifloxacin (may dose TID)4th generation

    AZITHROMYCIN:
    Azithromycin (Azasite®) cost about 240.00/bottle
    Think of it as Z-pack for the eyes. Great for mid-day dosing problems (schools, etc). effective for gram (+) microbes and also against H. influenzae

    Dosage: 1 drop every 12 hours for two days; then just once daily for the next 5 days.

    Storage: refrigerate before dispensing, can be left at room temp for 14 days after it is opened.

    Flip, whip, and drip method for administering: The solution is viscous and hard to get out of the bottle. Tell patients to flip the bottle upside down before opening it; give it a whip or shake to force the solution down into the tip; then remove the cap and drip it into the eye. Is thicker when removed from pharmacy refrigerator. Keep at room temp to decrease viscosity.

    TRIMETHOPRIM/POLYMYXIN B
    Trimethoprim has broad spectrum activity often including methicillin resistant staph. Polymyxin B has only gram (-) spectrum, and is relatively ineffective.

    VIRAL CONJUNCTIVITIS
    Etiology: usually adenoviruses, herpes simplex or herpes zoster (shingles). Herpes simplex virus is a major cause of worldwide blindness. The herpes virus lies dormant in the trigeminal ganglia, where it remains for the life of the patient. When activated infectious viral particles travel to the ends of the neurons, where the virus is shed.

    Trifluridine (Viroptic®) available as 1% solution ($225/bottle)
    Dosage: 1 drop every 2 hours while awake. Maximum dosage of 9 drops/day. Use until corneal ulcer is healed. Following healing treat for an additional 7 days, one drop every 4 hours while awake (Minimum daily dose of 5 drops). Avoid use for more than 21 days.

    Patient information:
    • Drops MUST be refrigerated
    • Wash hands thoroughly after each use.
    • Transient stinging may occur.
    Ganciclovir
    (ZIRGAN®) ophthalmic gel) 0.15% ($400/tube) is a topical ophthalmic antiviral that is indicated for the treatment of acute herpetic keratitis (dendritic ulcers).

    Dose: 1 drop in the affected eye 5 times per day (approximately every 3 hours while awake) until the corneal ulcer heals, and then 1 drop 3 times per day for 7 days
    *Patients should not wear contact lenses if they have signs or symptoms of herpetic keratitis or during therapy with ZIRGAN.

    Epithelial Keratitis dosing for oral antiviral agents
    ttp://www.aao.org/clinical-statement/herpes-simplex-virus-keratitis-treatment-guideline
    • Acyclovir (Zovirax®): 400mg 3-5 times daily for 7-10 days OR
    • Valacyclovir (Valtrex®): 500mg twice daily for 7-10 days OR
    • Famcyclovir (Famvir®) 250mg BID for 7-10 days
    CAUTION: most common dispensing error for route of administration in a pharmacy is ofloxacin ear drops for the eye. BE SURE to specify route.
    1. Remember: Antibiotics usually are not needed to clear up conjunctivitis. Most cases are viral, and even bacterial infections often resolve without antibiotics.
    2. Recommend symptomatic treatment such as cold or warm compresses, ocular lubricants, and decongestants. Emphasize hand washing to prevent spreading the infection. Use paper towels in “community bathrooms”
    3. Save antibiotics for patients who don't improve in 5 to 7 days, or earlier if daycare requires treatment before a child can return.
    4. Bacterial infections are contagious until antibiotics have been on board for 24 to 48 hours.
    5. Viral infections are usually contagious until the eye clears.
    6. Bacterial conjunctivitis is less common than viral conjunctivitis. In adults, infective conjunctivitis is viral about 85% of the time and bacterial in about 15% of cases.
    7. For children, the incidence is about evenly split between viral and bacterial.
    Differentiation between bacterial and viral conjunctivitis:
    • Bacterial conjunctivitis will usually present with a purulent discharge.
      • The most common causative organisms for acute bacterial conjunctivitis are Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae.
      • Conjunctival cultures are not routinely recommended for patients with acute conjunctivitis
    • Viral conjunctivitis will present with a watery, mucous, discharge.

    Differentiating Bacterial, Viral, and Allergic Conjunctivitis
    Type of conjunctivitisBacterialViralAllergic
    Redness+++
    Swelling+++
    Clear, watery discharge+
    Stringy, white mucus discharge+
    Purulent discharge+
    Burning+++
    Lash matting++
    Grittiness+++
    Itching+
    Pain++
    Photophobia++


    TREATMENT OF CORNEAL EDEMA - all are OTC
    Treatment of corneal edema, or swelling of the cornea, is based on the underlying cause of the condition. Most commonly, the endothelial cells responsible for pumping fluid out of the cornea are damaged. In glaucoma, the intraocular pressure needs to be reduced. In inflammatory conditions, the inflammation needs to be treated. Hypertonic saline drops or ointment can temporarily help reduce swelling of the cornea
    • Muro-128 2% and 5% solution for daytime
    • Muro-128 5% ointment for overnight use
    • Corneal swelling causes the lens to stretch, causing loss of visual acuity
    • May be caused by:
      • ocular surgery, trauma, infection, inflammation, and secondary causes like glaucoma.
      • over-wear of certain types of contact lenses
    • Is OTC but use only if recommended by an eye care professional


    Have a Great Day on the Bench!!

    October 2022

    Micro-Learning CE Associated - Click Here For Details

    Overview of Eye Care Considerations in the Pharmacy

    General principals of eye care:

    Drugs must cross the cornea to act within the eye.

    • Must be lipophilic or uncharged
    • Adjust pH so weak bases or acids can produce larger portion of uncharged molecules.
    • Most eye drops are sterile products.
    Action of some drugs is related to eye color. Black & brown irises contain more pigment than green, gray or blue. The more pigment, the more drug that can bind to it resulting in a slower onset and longer duration of action.

    Eye drops basics

    There no FDA approved anti-infective products available OTC. Avoid “homemade” products – boric acid solution, chamomile tea compresses, etc.

    Patients must wash hands before application of ophthalmic agents.
    Remind patient to throw out any unused eye drops at end of treatment course.
    Best not to write refills for antibiotic eye drops

    Administration techniques for Eye drops:
    • If suspension, shake well.
    • Do not touch tip to the eye
    • Pull down on lower eyelid to expose conjunctival sac
    • Multiple drops: the eye can only handle 1 drop at a time. Wait 5 minutes between drops. No script should read 2 drops TID (1 drop will wash out the other)
    • Replace cap immediately and tighten.
    • Preferable to drop in the middle of the conjunctival sac and not inner canthus.
    • May be beneficial to hold lower lid for a minute after instillation and then press finger against inner corner of eye for 1 minute to prevent rapid drainage into tear duct
    • Use tissue only to remove excess liquid form the eyelid.


    PPPP EYE CARE


    Appropriate use of eye ointments:
    • Use a mirror or have someone else apply the ointment.
    • Tilt head back
    • Hold the ointment tube between the thumb & forefinger of your other hand and brace the remaining fingers of this hand against cheek or nose.
    • Place about ½ inch ribbon of ointment in the pouch formed.
    • Do NOT touch the eye or eyelid with the tip of the ointment tube.
    • Blink eye gently. Vision may be blurred for a few minutes.
    • Replace cap tightly
    • Use a tissue to remove excess ointment from the eyelid.
    General clinical pearls for eye products
    • Worsening symptoms during topical treatment with any antibiotic (particularly Polysporin® or a Sulfonamide (Sulamyd, Bleph-10®) may represent a contact allergic reaction.
    • Some locally applied drugs can cause systemic adverse effects. (a single drop of timolol for glaucoma may affect asthma, COPD, Bradycardia, Heart block, Heart failure).
    • If the patient is concerned that they won't be able to tell if the drops make it inside their eye, keep the bottle in the fridge so the medicine is cold, giving a better sensation when the drop lands.
    • If the patient concerned that the medicine will bounce out of the eye or roll down the cheek, know that each drop contains about 10 times more medicine than can fit in the tear film. What a patient feels is excess that runs down the cheek.

    https://www.aao.org/eye-health/tips-prevention/tips-eyedrop-anxiety-scared-kids-adults

    Treatment of Hordeolum (Styes):
    One of the more common questions I get is for a recommendation for treatment of a stye. Styes can be internal, appearing underneath the eyelid, infecting the meibomian glands. These glands, found along the edge of the eyelids produce the oil that makes the surface of the eye “slick” and keep the tears from drying. Styes can also be external, infecting the follicle of eyelashes.

    Staphylococcus aureus is the bacteria usually implicated in styes. When we think of a walled-off staph infection we think of MRSA. MRSA is not treated with glucocorticoids, fluoroquinolones (ciprofloxacin/ofloxacin), or aminoglycosides, so treatment of styes with these products does not make sense either.

    Styes usually resolve on their own within two weeks if untreated. Most eye practitioners agree that warm compresses 5-6 times a day is the most effective treatment for styes.

    Patients with rosacea and seborrheic dermatitis near the eyes are prone to having frequent episodes of hordeolum. Doxycycline oral tablets are frequently prescribed for treatment in these patients with frequent styes.

    Eye makeup that is contaminated by bacteria, can cause styes (hordeola) by clogging and inflaming gland pores. Women should avoid using any eye makeup if they are prone to styes.

    What about the Stye® medication in our eye care section? This product only contains white petrolatum (think Vaseline®) and is of no use treating a staph infection.


    Medications that May Cause Ocular Concerns:

    Drugs causing Intraoperative Floppy Iris Syndrome:
    Alpha-1 Blockers: tamsulosin (Flomax®), doxazosin (Cardura®), (alfuzosin (Urozatral®); any of the alpha-1 blockers, that are generally used for BPH (benign prostatic hyperplasia) and hypertension.
    • The iris becomes flaccid and billows in response to intraoperative irrigation currents, causing the potential prolapse of the iris toward phacoemulsification incisions.
    • Ophthalmologists can modify their surgical techniques including using iris hooks, iris dilation rings, viscoelastic devices.
    • Ophthalmologists MUST know before surgery that patient has been on alpha blocker therapy. Usual protocol is to stop the medication 7-10 days pre-op
    Drugs causing corneal and conjunctival disturbances:
    • Chlorpromazine
    • Thioridazine
    • Chloroquine
    • Hydroxychloroquine
    • Lovastatin (progression of cataracts)
    Drugs causing retinopathy
    • Disease state: diabetes mellitus
    • Methanol (moonshine)
    • Chloroquine
    • Indomethacin
    • Amiodarone
    • Tamoxifen
    • Phenothiazines
    • Ibuprofen, naproxen, indomethacin at high doses.
    Drugs causing optic neuropathy
    • Ethambutol
    • Chloroquine
    • Quinine
    • Quinidine
    • Ethylene glycol methanol
    • Tobacco
    Drugs causing color visual disturbances
    • Digoxin
    • Oral contraceptives
    • Viagra® (sildenafil) and other 5-PDE
    • Ethambutol
    • Metronidazole

    OTC TREATMENT OF CONJUNCTIVITIS

    Exclusions to self-care: If someone comes to the pharmacy and has one of the following complaints, seek professional help from an eye care specialist:
    • Blunt trauma
    • Foreign particles trapped or embedded in the eye
    • Ocular abrasions
    • Infections of the eyelid/eye surface
    • Eye exposure to chemical splash, solid chemical, or chemical fumes. “Super glue” damage
    • Thermal injury to eye
    • Bacterial conjunctivitis
    • Chlamydial conjunctivitis
    Blepharitis: Can be detected by redness of the lids, burning, itching, and scaly skin. The underlying problem such as seborrheic dermatitis, or staph aureus should be treated. Staph infection often requires antibiotic therapy. Bacitracin ophthalmic ointment may be beneficial. For seborrheic blepharitis washing with baby shampoo, applying warm compresses, and using artificial tears if the eyes are dry. Pharmacies also have disposable eye scrub kits, with disposable pads.

    Conjunctivitis (“Pink Eye”): The membranes covering the sclera (the white part of the eye) and the inside lining of the eyelid, may be sensitive to chemical irritants, allergens, bacteria and viruses. Conjunctivitis also known as “pink eye” may be a sign of systemic disease or infection or may occur after an upper respiratory infection.

    Clinical presentation: one or both eyes may be itchy and feel as if they are burning. A clear, white, or yellow-greenish discharge may occur.

    Allergic conjunctivitis: Conjunctivitis may also be caused by allergic reaction. It is often seasonal and appears in both eyes at the same time. Itchy watery eyes and swelling of the eyelids accompany this condition. May see other allergy symptoms: runny nose, sneezing or scratchy throat.

    Treatment: if using antihistamine/decongestant eye drops do not use for more than 2 weeks. May also use oral antihistamines. May also use non-steroidal anti-inflammatory eye drops. Cold wet compresses will help decrease the itchy feeling.

    Treatment Goals: Remove or avoid allergen
    • Provide symptomatic relief-limit allergy reaction
    • Protect the ocular surface


    OVER THE COUNTER Pharmacologic Therapy:
    1st line: Artificial tears
    If symptoms persist: Ophthalmic antihistamine/mast cell stabilizer. If no resolution in 72 hours. Contact eye care practitioner.

    Nonpharmacologic Therapy
    • Do not wear contact lenses until resolved
    • Apply cold compresses 3-4 times a day
    • Causes: Pollen, Animal dander, topical eye preps
    Symptoms: Red eye with watery discharge, itching

    Ophthalmic Decongestants: Constrict conjunctival vessels reducing redness-Works on alpha-adrenergic receptors of ophthalmic vasculature
    • Phenylephrine
    • Oxymetazoline
    • Naphazoline
    • Tetrahydrozoline
    Ocular decongestant side effects:
    • Generally, do not have ocular or systemic side effects
    • Long-term use leads to potential for:
      • Rebound conjunctival hyperemia
      • Allergic blepharitis
      • Abnormal dryness
    Ophthalmic Antihistamines

    Mechanism: histamine1- receptor antagonists
    • Pheniramine maleate
    • Antazoline Phosphate
    • Available in combination with decongestants
      • Pheniramine/naphazoline
      • Pheniramine/naphazoline
    • More effective than using either agent alone
    Ophthalmic Antihistamines/mast cell stabilizers

    Ketotifen fumarate (Zaditor®) OTC
    • Potent H1-receptor antagonist
    • Mast cell degranulation inhibited; release of inflammatory mediators inhibited
    • Relief in minutes, lasting for 12 hours
    • Can use in children 3 years of age and older
    Olopatadine (Pataday®) (OTC) available in 2020. Previously Rx only

    Stabilizes the mast cells, blocking histamine release. Also blocks histamines that have already been released from attaching to the histamine (H1) receptors in the eye, breaking the chain of allergic reaction.
    • Olopatadine (Pataday®) Once Daily Relief 0.2% soln
      • Dosage: 1 drop in each eye every 24 hours.
    • Olopatadine (Pataday®) Twice Daily Relief 0.1% soln
      • Dosage: 1 drop in each eye every 12 hours.

    OTC alpha agonist Brimonidine: (Lumify 0.025%®) (Alphagan is Rx)
    • the first over-the-counter low-dose brimonidine tartrate ophthalmic solution for the treatment of ocular redness.
    • Adults and children 5 years of age and over: instill 1 drop in the affected eye(s) every 6-8 hours. do not use more than 4 times daily. Remove contact lenses before use.


    Eye care is one facet of pharmacy I really push with my student pharmacists, as most of us get minimal education on eye care. When I think how many pharmacy schools are attached to a top flight hospital offering ophthalmology residencies, I find it unfathomable that more focus is not spent on eye care. We had no lectures on eye care when I graduated 40 years, and many schools of pharmacy still do no extensive teaching of eye care.

    Have a Great Day on the Bench!!

    Micro-Learning CE Associated - Click Here For Details

    verview of Dual Orexin Receptor Antagonists (DORAs): A New Agent Comes to Market!

    I have always been a good sleeper and early in my pharmacy career found the complaint of insomnia personally unrelatable, but I recognized that people who experienced it really seemed to suffer a terrible degree of unhappiness and great health consequences as they continued a never-ending search for the holy grail of restful sleep. Fast forward to now when I have joined the unfortunate membership of intermittent, but extreme, insomniacs. I can fall asleep just fine, but a random wake up around 1:00 am without escape back to sleep seems to be my new normal and I am not a happy camper! Some may blame disrupted sleep patterns with the shared altered human experience as a COVID consequence, but many factors play into insomnia and restoring sleep. There is a ton of information on non-pharmacologic interventions which can help without the need for further drug therapy, but many people in need of sleep relief seek what they consider to be the fastest solution in obtaining a magic pill to cure the downstream sleepless cycling stop.

    Sleep guidelines recommendations are intended to guide prescribers in choosing a specific pharmacological agent for treatment of insomnia in adults, when treatment is indicated. Insomnia disorder is as a complaint of either trouble initiating (delayed sleep onset) or maintaining sleep (or both) when given the opportunity to sleep, which is not otherwise attributable to environmental conditions and is associated with daytime consequences. When the symptoms have persisted for less than three months, it is considered short-term insomnia but is identified as chronic when it has persisted for at least three months at a frequency of at least three times per week1.

    Short-term insomnia is more common and affects 30% to 50% of the population compared to chronic insomnia disorder, which is estimated to be at least 5% to 10% but can occur more often in patients with co-occurring medical and psychiatric diagnoses. Insomnia is associated with numerous adverse effects on function, health, and quality of life, often with significant impairment in functional status as evidenced by increased rates of work absenteeism, occupational and motor vehicle accidents, development of psychiatric disorders, increased risk of relapse for depression and alcoholism, and increased risk for cardiovascular disease and development of hypertension (1). Insomnia is not a one size fits all diagnosis. It has a high degree of variability and consequences of which some people are more resilient and others more susceptible. Medications approved for sleep onset only are not appropriate or effective for enhancing sleep maintenance and thus must be clarified prior to making an appropriate recommendation for pharmacologic intervention. For example, if someone is only experiencing trouble falling asleep but can stay asleep, taking a medication for both deficits are unnecessary and in some cases, may result in a spillover effect with feelings of next day grogginess. One example of this is zolpidem immediate release versus controlled release. Only the controlled release is approved for both onset and maintenance whereas the immediate release is just to get you to fall asleep faster. Tis the story for the DORAs then…. these agents are approved for both, which likely meets most of the insomnia needs in our current population.

    Recommendations intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults are presented below (Table 1.). The authors of the guidelines report that although there were weak “grades” of evidence supporting them, guidelines disclosing a weak “grade” of evidence should not be construed as an indication of ineffectiveness. It is also important to consider age specific cautions when referring to guidelines, as the Beers list may add additional information when considering benefits versus risks to older adults who may be prescribed medications for insomnia2.

    Table 1. American Academy of Sleep Medicine Clinical Practice Guidelines1

    InterventionAASM (2017)
    1ST lineCognitive Behavioral Therapy (CBT)
    2ND lineFor sleep onset:
    ramelteon, triazolam, zaleplon
    For sleep maintenance:
    doxepin, suvorexant
    For both sleep onset and maintenance:
    eszopiclone, temazepam, zolpidem
    Other considerationsNot recommended for use:
    Diphenhydramine, L-tryptophan, melatonin, tiagabine, trazodone, valerian


    One of the newest agents arriving on scene are the dual orexin receptor antagonists (DORAs). The mechanism of action is considered novel in that it uses the orexin pathway to induce their sleep promoting effects by competitively binding with both orexin receptors in the lateral hypothalamus and reversibly blocking the action of orexin. Remember that orexin is a wake-promoting neurotransmitter so antagonism at that site makes a lot of sense, pharmacologically speaking of course. DORAs have been around a while now, with suvorexant (Belsomra®) being the first in class approved by the FDA in 2014 and now, the US Food and Drug Administration (FDA) has approved the DORA daridorexant (Quviviq®) for the treatment of insomnia in adults(3). Although daridorexant is too new to have made it specifically on the recommendation list, suvorexant represents the DORAs as a treatment only for sleep maintenance insomnia (versus no treatment) in adults, despite its FDA indication that includes sleep onset as well. The phase 3 trial for daridorexant measured daytime functioning using a new patient-reported outcome instrument called the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ). And because previous trials of other DORAs did not use the IDSIQ as an outcome, it is not possible to compare daridorexant with the other agents within the class on that same specific outcome (3,4).

    What if you are recommending a DORA? Remember the most common side effects include drowsiness and headache, there are also more serious, less common concerns3,4:

    Worsening depression and suicidal thoughts. Patients should be advised to contact their healthcare provider immediately if they experience thoughts of suicide or dying or if there is a worsening of depression.

    Patients should be also advised to stop taking their DORA and contact their healthcare provider right away if they experience a complex sleep behavior.

    Complex sleep behaviors such as sleep-walking, sleep-driving, preparing, and eating food, making phone calls, having sex, or doing other activities while not fully awake that you may not remember the next morning.

    Sleep paralysis which is described as temporary inability to move or talk for up to several minutes and may include hallucinations when falling asleep or when waking up.


    So, let’s look at our case for consideration

    Sherry is a 45-year-old who was seen by primary care today for a routine annual physical exam. She reported that she has been feeling exhausted during the day, not exercising like she used to and is gaining weight. She works remotely from home since the pandemic started, but she finds she falls asleep while working on the computer. When she can stay awake, she has trouble concentrating on her work. She also reports that she has been trying to overcome this sleep problem by having a few glasses of wine in her hot tub at night daily during the workweek.

    So, what about Sherry?

    1. What should we consider before making a sleep recommendation for her?
      • a.What type of sleep complaint she is experiencing?
      • b.Whether beer provides the same relief as wine does
      • c.What type of computer she is using for her remote work at home?
      • d.If she has completed the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ)
    2. If Sherry asks for a DORA, what side effects would you warn her about?
      • a.She may develop hypertension
      • b.She should report any thoughts of suicide
      • c.She may experience caffeine-like wakefulness
      • d.She will likely have significant memory loss


    By understanding the options available and knowing the appropriate questions to ask, we are better poised to help the patient!

    References
    (1) Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349.
    (2) 2019 American Geriatrics Society Beers Criteria® Update Expert Panel, Fick, D. M., Semla, T. P., Steinman, M., Beizer, J., Brandt, N., ... & Sandhu, S. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674-694.
    (3) https://www.drugs.com/history/belsomra.html
    (4) https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/214985s000lbl.pdf

    Welcome to my micro-CE mini-blog based on TLD’s BEST in the classroom series! If you haven’t already participated in these, please refer to my earlier submission if you want to catch up on what you may have missed!

    Tammy Lee Demler

    September 2022

    Micro-Learning CE Associated - Click Here For Details

    Drugs used to treat CENTRAL ACTING SPASTICITY:

    TIZANIDINE [Zanaflex® 2mg and? 4mg tablets; 2mg.4mg 6mg extended release capsules]????????? approved:1996

    Dosage: start with 4mg, increase gradually in 2 to?4mg steps.? May repeat every 6-8 hours. Maximum of 36mg per day. The effect peaks at 1-2 hours and dissipates in 3 to 6 hours

    Mechanism of action: Tizanidine is an alpha-2 receptor agonist. It reduces spasticity by increasing presynaptic inhibition of motor neurons and inhibiting pre-synaptic release of nor-epinephrine. It has no direct effect on skeletal muscle fibers. Reduces facilitation of spinal motor neurons. Tizanidine is a structural analog of clonidine.

    Indications for use: short term drug indicated for the management of spasticity. Because of the short duration of effect, treatment should be reserved for those daily activities when relief of spasticity is most important.

    Warnings/precautions/adverse effects:
    • Pregnancy category: C
    • Use with caution if renally impaired. Avoid if hepatic impaired.
    • Drug interactions: interacts with oral contraceptives, because tizanidine clearance is reduced by 50%.? Avoid use with other CYP1A2 inhibitors (e.g., cimetidine, oral contraceptives)
    • Hypotension (20% decrease in blood pressure)
    • Hepatotoxicity (usually reversible, rarely fatal)
    • Ciprofloxacin and fluvoxamine (Luvox®) contraindicated due to increased tizanidine levels.? This is a major drug interaction that should not be recklessly overridden.? Ciprofloxacin can increase tizanidine levels from 7-10 fold.
    • Withdrawal syndrome: hypertension, tachycardia, hypertonia
    Drug monitoring: Taper slowly for patients on high doses for long periods. May cause withdrawal and rebound hypertension, tachycardia, and hypertonia.

    Comments:
    • Effect is short-lived (3 to 6 hours); reserve for time relief most important
    • Food affects absorption, and affects tablets and capsules differently
    • Monitor liver function at baseline, 3 months, and 6 months, then periodically or as clinically indicated
    • Avoid in hepatic disease
    • Dose cautiously if creatinine clearance?<25 mL/min


    BACLOFEN [Lioresal®] 10mg and 20 mg tablets??? approved 1981

    Indications for use:
    • for signs and symptoms of spasticity resulting from multiple sclerosis 
    • for spasticity of cerebral origin and spinal cord origin
    Mechanism of action: Inhibits spinal reflexes; structural analog of gamma-aminobutyric acid (GABA)

    Dosage: 10mg three times daily, may be titrated upward until desired response. Dose range 40-80mg per day.? Some patients may require over 80mg/day. Drug is also given intrathecally.

    Adverse effects: do not discontinue abruptly to reduce risk of seizures
    • Drowsiness, dizziness and fatigue, hypotension.
    • Drowsiness, dizziness and fatigue, hypotension.
    Pregnancy category: C

    Precautions:
    • Use caution in patients with epilepsy
    • May cause constipation, nausea and headache
    • Frequent urge to urinate or painful urination
    Patient Educations: discontinue very slowly. Avoid alcohol. Watch for drowsiness


    DANTROLENE (Dantrium®)? available as 25mg, 50mg and 100mg caps (1974)

    Indications for use:
    • Spasticity due to upper motor neuron disorders (spinal cord injury, cerebral palsy, multiple sclerosis)
    • Malignant hyperthermia prevention or management (from general anesthesia)
    Mechanism: ?Blocks ryanodine channel, which inhibits calcium release, thus reducing muscle contraction. Does NOT interfere with calcium entry at the cell surface as with Calcium Channel Blockers.

    Dose: titrate slowly from 25mg daily for 1 week, to a maximum of 100mg four times a day

    Adverse effects: hepatotoxicity- most common in women over 35 years of age. Dose dependent diarrhe


    BENZODIAZEPINES/DIAZEPAM

    Mechanism of action: potentiates the effects of GABA and other inhibitory transmitters

    Indications for use: useful adjunct for the relief of skeletal muscle pain due to reflex spasm due to local pathology; spasticity due to upper neuron disorders: (cerebral palsy, and paraplegia)

    NET EFFECT on the GABA receptor
    • Barbiturates increase the duration of chloride ion channel opening at the GABA receptor, to increase the efficacy of GABA.
    • Benzodiazepines increase the frequency of the chloride ion channel opening at the GABA receptor to increases the potency of GABA.
    Adverse Reactions: (General adverse reactions of Benzodiazepines)

    Central Nervous System: sedation and sleepiness, depression, lethargy, apathy, fatigue, hypoactivity, lightheadedness, memory impairment, disorientation, amnesia, restlessness, confusion, delirium, headache, slurred speech, stupor, coma, syncope, euphoria, irritability, difficulty in concentration, agitation, incoordination, vivid dreams, psychomotor retardation
    Dermatological: urticaria, hair loss, ankle, and facial edema
    GI:constipation, dry mouth, coated tongue, sore gums, change in appetite
    GUchange in libido, urinary retention? EYESnystagmus, diplopia
    PSYCHbehavioral problems, hysteria, suicidal tendencies
    MISCdiaphoresis, gynecomastia, may elevate liver enzymes, hepatic dysfunction, blood dyscrasias


    METABOLISM by P450: Lorazepam, Temazepam and Oxazepam are not metabolized by P450.? They are conjugated only.? Diazepam is metabolized by the CYP 450-3A4 enzyme system.? The metabolism of diazepam is intricate. Diazepam is first demethylated by CYP3A4 and CYP2C19 in the liver to nordiazepam, and hydroxylated by CYP3A4 to form the active metabolite temazepam. Increased benzodiazepine serum concentrations due to inhibition of Cytochrome P450 3A enzymes is a major problem with azole antifungals (may be a better choice for elderly)

    Patient information:
    • May cause drowsiness: avoid driving or other tasks requiring alertness
    • Avoid alcohol or other CNS depressants
    • May take with food or water if stomach upset occurs.
    Withdrawal concerns:
    • Relapse or rebound of condition being treated
    • Withdrawal symptoms: sweating, tachycardia, tremor, insomnia, anxiety, agitation, nausea, vomiting, hallucinations, and seizures.



    We community pharmacists dispense a lot of baclofen and tizanidine frequently with opioids, prescribed by pain clinics.? As we will discuss, central muscle relaxants, although not as problematic as the opioids, are not innocuous. The tizanidine and ciprofloxacin interaction scares me.? To have a ten-fold increase in the blood levels of tizanidine could cause a lot of serious adverse effects, especially dizziness and drowsiness.? When I think of tizanidine, I think of its big brother, clonidine.?The drowsiness, hypotension, and withdrawal hypertension are a concern with both drugs.? Also, in the tizanidine/clonidine family is (lofexedine (Lucemyra®) which is used for symptomatic management of opioid withdrawal.

    Have a Great Day on the Bench!!

    Micro-Learning CE Associated - Click Here For Details

    Overview of Peripheral Muscle Relaxers

    PERIPHERAL MUSCLE RELAXERS
    SPASTICITYSPASMS
    DEFINITIONabnormal increase in muscle tone caused by the increased excitability of the muscle stretch reflex. Interferes with movement or causes pain.Involuntary muscle contractions
    ETIOLOGYCentral disorder of upper motor neuronsPeripheral muscle sprain or nerve compression
    SYMPTOMSSTIFFNESSTWITCHING
    CAUSESMS, Cerebral Palsy, Spinal Cord or Brain Injury, Motor Neuron Disease, or Post-Stroke SyndromeMusculoskeletal, Fibromyalgia, Herniated Disk, Mechanical Lower Back Pain, Spinal Stenosis, Sciatica, or Myofascial Pain
    FDA APPROVED MEDSbotulinum toxin baclofen (Lioresal®) dantrolene (Dantrium®) diazepam (Valium®) tizanidine (Zanaflex®) Carisoprodol (Soma®) Chlorzoxazone (Parafon®) Cyclobenzaprine (Flexeril®) Metaxalone (Skelaxin®) Methocarbamol (Robaxin®) Orphenadrine (Norflex®)


    CHLORZOXAZONE [Parafon Forte DSC® 500mg] (approved 1958)

    Dosage: 500mg three or four times daily

    Mechanism of action: acts at the level of the spinal cord and subcortical areas of the brain, where it inhibits multisynaptic reflex arcs involved in producing and maintaining skeletal muscle spasm of varied etiology.

    Indications for use: as an adjunct to rest, physical therapy and other measures.

    Warnings/precautions/adverse effects:
    • May cause drowsiness
    • Pregnancy Category-C
    Patient education:
    • Caution driving
    • Avoid alcohol
    • May cause reddish- purple urine!

    CYCLOBENZAPRINE (Flexeril®) (approved 1977)
    Dosage: 5mg to 10 mg three times daily. Use longer than 2 to 3 weeks is NOT recommended.

    Elderly: initiate dose of 5mg TID

    Mechanism of action: relieves skeletal muscle spasm of local origin without interfering with muscle function. Does not work with muscle spasm due to CNS disease. Acts principally in the CNS at the brainstem, and in the spinal cord.

    Indications for use: adjunct to rest and PT, for relief of muscle spasms with acute painful musculoskeletal conditions

    Warnings/precautions/adverse effects:
    • Pregnancy Category: B
    • Caution if patient has urinary retention or closed angle glaucoma (atropine like effects)
    Drug interactions:
    • life threatening with MAOI
    • Enhanced effects with alcohol, barbiturates and CNS depressants
    • Anticholinergic side effects: Use may be limited by anticholinergic side effects.
    Patient education: may cause drowsiness, dry mouth and dizziness.

    Comments:
    • Long half-life—caution in elderly.
    • Structurally related to amitriptyline
    • Has the most evidence for efficacy
    • Dose of 5 mg three times daily seems as effective as higher doses, with less side effects
    • Is approved for use in Canada for treatment of fibromyalgia

    ORPHENADRINE (Norflex® 100mg) (approved 1959

    Dosage: Norflex 100mg: 1 tablet twice daily every 12 hours

    Mechanism of action: has anticholinergic properties. Therapeutic benefits are due to analgesic properties. Is a structural analog of diphenhydramine (Benadryl), a first-generation antihistamine.

    Indications for use: adjunct to rest and physical therapy, for relief of muscle spasms with acute painful musculoskeletal conditions. Does not directly relax tense muscles.

    Warnings/precautions/adverse effects:
    • Pregnancy Category: C
    • Dizziness & lightheadedness
    • Anticholinergic effects
    Patient education: watch for drowsiness. Avoid alcohol. It is over the counter in Canada under the trade name Orfenace®


    CARISOPRODOL (Soma®) approved 1959
    250mg and 350mg tablets (Controlled Substance, Schedule-4)

    Dosage: 350mg four times daily. There is also a 250mg strength available, seldom used due to expense.

    Mechanism of action: produces muscle relaxation by blocking intraneuronal activity in the descending reticular formation and spinal cord. Onset of action is rapid and lasts 4 to 6 hours

    Indications for use: djunct to rest and PT, for relief of muscle spasms with acute painful musculoskeletal conditions. Mode of action may be due to sedative properties. Does not directly relax tense muscles.

    Warnings/precautions/adverse effects:
    • Additive effects with alcohol
    • Careful in hepatic or renal impairment
    • Tachycardia
    • Facial flushing
    • Can cause hiccoughs or hiccups
    Patient education: Watch for drowsiness, Caution driving. Take with food or meals.

    Comments:
    • Avoid alcohol.
    • Use drug with caution in addiction prone individuals. Metabolized to meprobamate. May see withdrawal symptoms on discontinuation.
    • Used to enhance opiate or tramadol effects, or lessen cocaine's stimulant effects
    • Dose cautiously in renal or liver impairment
    • European Medicines Agency withdrew from market, also withdrawn from market in Canada and Indonesia.

    METAXALONE [Skelaxin®] 800mg tablets approved 1962

    Dosage: 400mg to 800mg three to four times daily

    Mechanism of action: unknown, may be due to general CNS depression. No direct action on the muscle

    Indications for use: adjunct to rest and PT, for relief of muscle spasms with acute painful musculoskeletal conditions

    Warnings/precautions/adverse effects:
    • Caution if hepatic impairment
    • Alcohol enhances CNS depressant effects
    • Pregnancy Category-C
    Patient education: Watch for drowsiness. Caution Driving. Avoid alcohol

    Comments:
    • May cause less drowsiness than cyclobenzaprine.
    • Requires four times daily dosing and costs twenty times more.

    METHOCARBAMOL [Robaxin® 500mg and 750mg] (approved 1957)

    Dosage: initial dosage 1500mg four times daily—then 1000mg four times daily or 750 every 4 hours

    Mechanism of action: unknown, may be due to general CNS depression. No direct action on the muscle

    Indications for use: adjunct to rest and PT, for relief of muscle spasms with acute painful musculoskeletal conditions

    Warnings/precautions/adverse effects:
    • Avoid alcohol CNS depressants
    • Pregnancy Category: C have been reports of fetal abnormalities
    Patient education:
    • Watch for drowsiness, avoid alcohol, caution driving
    • May discolor urine brown- to dark green

    Most of the drugs in this class have been around as long as me…not since I started my professional career, but since I started breathing!! Many of these drugs are over 60 years old, and they have yet to elucidate the mechanism of action!

    For the most part, these drugs cause significant drowsiness, and should be administered with caution, especially if given with alcohol or opioids. All of these drugs, because of their anticholinergic effects, sedation, cognitive impairment, weakness, urine retention, and questionable efficacy at lower doses are on the Beers list, and should be avoided in the elderly.

    Have a Great Day on the Bench!!

    August 2022

    Micro-Learning CE Associated - Click Here For Details

    Rheumatoid Arthritis: Benefits and Risks of Pharmacological Therapy

    Objectives of Pharmacological Therapy:
    • To prevent or control joint damage
    • To prevent loss of function
    • To decrease pain
    • To control synovitis
    • To maintain patients’ quality of life
    • Avoid or minimize adverse effects of treatment

    Traditional Prescribing Sequence of Medications:

    Current treatment philosophy is an “inverted pyramid”, which refers to using aggressive therapy with DMARDS (disease modifying anti rheumatic drugs). Some patients immediately start out with DMARDS with or without NSAIDS (non-steroidal anti-inflammatory drugs). Others start out with NSAIDS, then starting DMARDS 3 months later. NSAIDS basically control symptoms until DMARDs take effect.

    DMARDS fall into two classes:
    • csDMARDS: “conventional synthetic” DMARDS (hydroxychloroquine, sulfasalazine, methotrexate)
    • bDMARDS: “biologic” DMARDS (adalimumab (Humira®), etanercept (Enbrel®), baricitnib (Olumiant®)
    Treatment in a Stepwise Fashion:
    • Step-1: Establish diagnosis of RA early. Document baseline disease activity. Estimate prognosis.
    • Step-2: Initiate therapy. Start DMARDS OR NSAIDS for 3 months then DMARDS. Consider local or low-dose steroids. Start PT and OT
    • Step-3: Reassess therapy and disease activity. Refer to rheumatologist if needed.
    • Step-4: Change DMARD if needed.
    • Step-5: Methotrexate consideration (1st if Rheumatologist)
    • Step-6: Add biologics (i.e., adalimumab, etanercept)
    • Treatment failure: Patients who fail to achieve remission within three to six months of initiating therapy or who require more than 5 mg/day of prednisone to maintain a state of remission should generally escalate to a more potent disease-modifying antirheumatic drug (possibly a biologic) or combination of DMARDs.
    BRIDGE THERAPY: Bridge therapy refers to the use of NSAIDS and corticosteroids while a patient is starting on DMARD. The onset of action for the DMARDS is prolonged thus anti-inflammatory drugs are given concurrently as a bridge until the therapeutic effect occurs. Includes corticosteroids, salicylates, Cox-2, and NSAIDS INDICATIONS FOR USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
    DMARDS or Biologic agents should be used in all patients EXCEPT:
    • Those with limited disease
    • -class IV disease where little reversibility of the disease is expected
    • DMARD Toxicity:
      • Acute hepatitis B or C is a contraindication to all DMARDs except hydroxychloroquine and sulfasalazine. American College of Rheumatology guidelines recommend testing for hepatitis B and C before starting leflunomide or methotrexate in patients at risk
      • Recommend checking for HIV in at-risk patients prior to methotrexate or biologic initiation.
      • Patients being considered for biologics, methotrexate, or leflunomide should be screened and treated for tuberculosis.
      • DMARDs should be held in the case of a serious bacterial or fungal infection, or herpes zoster infection.
      • Watch for endemic fungal infections such as histoplasmosis in patients receiving biologics.
      ANALGESIC VS ANTIINFLAMMATORY MEDICATIONS IN RELATION TO PATHOPHYSIOLOGY OF RA.
      • • NSAIDS do not prevent joint erosions in RA perhaps due to limited role of prostaglandins play in the inflammatory cascade. This approach should be used only in patients with milder disease for no more than 3 months as monotherapy. May stay on NSAIDS if demonstrated satisfactory response.
      • Analgesic (opioids and others) do manage the pain, but do not modify disease progression. They are not to be used as monotherapy.
      NON-PHARMACOLOGICAL TREATMENT MEASURES
      • Occupational Therapy
      • Rest (relieves stress on inflamed joints. Prevents destruction.)
      • Physical Therapy
      • Assistive devices
      • Weight reduction
      • Surgery
      IMMUNOSUPPRESSIVE THERAPY
      • (Azathioprine (Imuran®): used for refractory RA. Very toxic bone marrow suppression, stomatitis, alopecia, diarrhea, liver failure. Azathioprine causes bone marrow suppression and lowering of blood cell counts (white blood cells, red blood cells, and platelets) particularly in patients with renal insufficiency or when used concomitantly with allopurinol or ACE inhibitors. Azathioprine:allopurinol is a level-1 drug interaction and can cause fatal blood dyscrasias. Allopurinol blocks xanthine oxidase, one of the three enzymes that metabolizes azathioprine.
      • (Cyclosporine (Neoral®): blocks T-cell activation, powerful immunosuppressive effects. Cyclosporine also inhibits Interleuken-2 and therefore has some DMARD activity. Cyclosporine is typically used to prevent kidney and liver transplant rejection. Nephrotoxicity, glucose intolerance, hepatotoxicity and hypertension that might need to be treated.
      JANUS KINASE INHIBITORS (JAK):
      • Tofacitinib (Xeljanz®) cost $5071.63/60 tablets
        • Dose: 5mg tablet twice daily or ER-11mg once daily
      • Upadacitinib (Rinvoq®) cost $5529.78/ for 15 & 30mg tablets
        • Dose: 15mg once a day
      • Baricitinib (Olumiant®) cost=specialty pharmacy drug
      Mechanism: Janus kinases are enzymes linked to inflammation in joints and other tissues.

      Clinkcal use:JAK inhibitors are not a first line agent. Tried and failed on methotrexate. May ADD to methotrexate Works as well as TNF inhibitors but can NOT be used along with TNF inhibitors.

      Warnings/Precautions for JAK inhibitors:
      • MUST screen for tuberculosis.
      • Increases cholesterol, and liver enzymes. Check CBC, LFT, and lipids 1-2 months after initiating therapy
      • Sept 1,2021: FDA warning- There is an increased risk of serious heart-related events such as heart attack or stroke, cancer, blood clots, and death with JAK inhibitors.
      Efficiency: : patient response is variable. Monitor therapy accordingly. Some patients who don’t respond to one JAK inhibitor might get adequate response from another. Most JAK inhibitor patients have “been through the mill” having tried bio-DMARDS and other DMARDs.

      COMPLIANCE ISSUES of all Bio-DMARDS:
      • Costs of these medications can be a real compliance issue.
      • Because these therapies can cost over $30,000 per year, insurance companies require prior authorization to ensure that the correct diagnosis is made, and the patient has failed on methotrexate.
      • The TNF require refrigeration and special storage. Proper injection technique is a must.
      ORAL GLUCOCORTICOIDS: Low dose corticosteroids (less than 10mg/day of prednisone –or equivalent) and local injections of glucocorticoids are highly effective in maintenance therapy for rheumatoid arthritis. Due to their inability to alter the course of RA, these agents are generally considered last line therapy. They may be useful for acute flare ups and in patients with significant systemic manifestations of RA. RA is associated with an increased risk of osteoporosis; INDEPENDENT of corticosteroid therapy and the addition of corticosteroids dramatically increase the risk.
      • Patients on glucocorticoids should receive 1500mg elemental Calcium per day, and 400-800iu Vitamin D per day.
      • Many of these patients are taking acid suppressing drugs like histamine-2 blockers or proton pump inhibitors, calcium citrate is a better option as it does not require acid for absorption.
      INTRA-ARTICULAR CORTICOSTEROIDS Depending on joint size, typical doses are 5 to 40mg of triamcinolone acetonide (or equivalent). Are effective in controlling local joint inflammation without changing the treatment regimen.
      • Minimize the frequency of local steroid injections whenever possible. Repeated injections may cause a painless joint destruction.
      • It is recommended that intraarticular joint injections be performed with intervals of at least 3 months to minimize these complications.
      • Rheumatologists recommend joint rest for 24 hours after injection, to decrease leakage, and systemic absorption.
      ASSESSMENT OF THE PATIENT’S THERAPEUTIC OUTCOMES
      • Based on clinical signs and symptoms of improvement
      • Reduced joint swelling
      • Decreased warmth over actively involved joints
      • Decreased tenderness to joint palpitation
      • Decrease in perceived joint pain and morning stiffness
      • Longer time to onset of afternoon fatigue
      • Improvement of ability to perform ADL’s
      • Joint radiographs to assess progression of disease.
      • Show little or no evidence of progression if treatment is effective.
      • Lab monitoring is necessary to show the drugs are SAFE but are of little value to show response to therapy


      Several of my former physician assistant students have settled into practice in rheumatology. Rheumatology is a perfect discipline for a physician’s assistant. PA’s are skilled with following patients with slow progressive diseases, such as neurology and rheumatology

      One of the biggest challenges for a community pharmacist is that so many of the biologic DMARDS are available only after prior authorizations. More times than not, the insurance companies contract with, or have their own specialty pharmacies.

      Have a Great Day on the Bench!!

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    Overview of Treatment and Preventative Options for Osteoporosis

    Treatment and prevention with SERMs and PTH analogs
    The World Health Organization (WHO) defines osteoporosis as being present when BMD (bone mineral density) is 2.5 SD or more below the average value for young healthy women (a T-score of 2.5 SD). A second, higher threshold describes “low bone mass” or osteopenia as a T-score that lies between −1 and −2.5 SD. “Severe” or “established” osteoporosis denotes osteoporosis that has been defined in the presence of one or more documented fragility fractures. “Normal” is defined as being within 1 SD of the mean level for a young adult reference population, or a T-score of -1 or above.

    All osteoporosis drugs referred to as antiresorptive agents increase bone mass, but only alendronate, risedronate, zoledronic acid, estrogen + progesterone, denosumab (Prolia®) and romosozumab (Evenity®) are shown to decrease both vertebral and hip fractures. However, the efficacy of the remaining is only for vertebral fractures. Hip fractures cause increased morbidity, mortality, and healthcare costs as compared to vertebral fractures.

    By far and away, we dispense alendronate for the most used osteoporosis drug.? There are times when other osteoporosis drugs may be a better choice.? There are at least 6 different mechanisms of action for osteoporosis treatment/prevention.

    Raloxifene (Evista®)
    Available as tablets: 60mg??? available as a generic

    Dosage: 60mg once daily

    Mechanism: binds to estrogen receptors.? Binding results in activating some and blocking other pathways. Effects on bone similar to estrogen therapy.? However, it acts as an antagonist on receptors in the breast and endometrium. I refer to this drug as “estrogen light” as it mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen.

    Indications for use: Postmenopausal osteoporosis (prevention & treatment). A 36-month study showed that 30% reduction in vertebral fractures.? However, there was not a significant difference in reduction of non-vertebral fractures versus placebo. Bisphosphonates are a better choice if hip fracture reduction is paramount.

    Warnings/Precautions:
    • Pregnancy: Category X
    • Contraindicated in history of venous thromboembolic events
    Adverse effects:
    • Venous thromboembolic potential (PE and DVT & stroke)
    • May cause hot flashes, leg cramps, joint/muscle pain
    Drug interactions?? (raloxifene): May decrease prothrombin time

    Patient education:
    • Discontinue raloxifene 72 hours prior to prolonged immobilization (including travel)
    • Not effective in reducing hot flashes.
    • Take with calcium and Vitamin D
    The STAR Trial: (Study of tamoxifen and raloxifene)
    • Raloxifene has been shown to be as effective as tamoxifen (Nolvadex®) in preventing invasive breast cancer, with fewer side effects.?
    • Both raloxifene and tamoxifen were equivalent in reducing the incidence of invasive breast cancer in post-menopausal women at increased risk for the disease by about 50% compared with expected incidence.? (There was no control arm in the STAR trial)
    • These drugs are given for a 5-year period, there the side effect profile becomes very important
    • Tamoxifen side effects include endometrial & uterine cancers, blood clots, strokes and cataracts.
    • Tamoxifen also increases menopausal symptoms (hot flashes) and minor gynecologic problems (vaginal dryness)
    Raloxifene was not as effective as tamoxifen in controlling the incidence of non-invasive breast cancers.? Tamoxifen is approved in both POST and PRE menopausal women.

    Teriparatide (Forteo®)? (PTH-134)
    ($4,200.00/month Aug-2017)???? approved 1987

    Subcutaneous injection once daily given in periumbilical region.

    Mechanism: while the usual role of PTH in calcium homeostasis is bone resorption, when given in daily subcutaneous injections, it actually exerts an anabolic effect, stimulating the activity of osteoblasts.

    Indications for use: Women with a history of osteoporotic fracture, multiple risk factors for fracture, have failed or intolerant of osteoporotic therapy. Reduces risk of vertebral and non-vertebral fractures in postmenopausal women. Increases vertebral and femoral neck BMD.? Does?not?prevent hip fractures.

    Warnings/Precautions: Osteosarcoma: don’t use in high-risk patients: Paget’s, skeletal radiation, unexplained elevations of alkaline phosphatase, and open epiphyses. Do not use in patients with bone metastases Watch renal function

    Adverse effects:
    • Metallic taste
    • Nausea, diarrhea, abdominal cramping
    • Paresthesias
    • Muscle pain
    • Drug interactions: using in combination with bisphosphonates impairs the ability of teriparatide to stimulate new bone formation.? Don’t use together.
    Patient education:
    • Must be?refrigerated?at all times.? Return to refrigerator promptly after each use.
      • If left out, you must contact Eli Lilly: 1-800-545-5979.? On a case-by-case basis they will help you determine if product left out of refrigeration can be used.? Must be clear, colorless and no particulates.
    • Subcutaneous injection once daily give in periumbilical region.
    • Contact provider if symptoms of hypercalcemia arise: Nausea, Vomiting, Constipation.
    • Use calcium, Vitamin-D and weight bearing exercise.
    • Be sure to prescribe pen-needles for administration
    • No risk for osteonecrosis of the jaw.



    Abaloparatide (Tymlos®)?80mcg once daily.? (2017)
    Mechanism, warnings, precautions are the same as teriparatide:
    Avoid in patients with pre-existing hypercalcemia or an underlying hypercalcemic disorder, (e.g., primary hyperparathyroidism)
    Warn patients that abaloparatide may cause orthostatic hypotension.
    • monitor urine calcium in patients with previous hypercalciuria or if kidney stones are suspected
    • Use for a maximum of 2 years due to dose-dependent risk of osteosarcoma in rats
    • 2-yr treatment course may be followed by bisphosphonate to maintain BMD.
    Patient education:
    • Must be refrigerated until first use, then may be kept at room temperature.
    • Subcutaneous injection once daily, given in the periumbilical region.
    • Contact provider if symptoms of hypercalcemia: Nausea, Vomiting, Constipation
    • Use calcium, Vitamin-D and weight bearing exercise.
    • Be sure to prescribe pen-needles for administration
    • No risk for osteonecrosis of the jaw.



    CALCITONIN?
    • Calcitonin salmon (Miacalcin®? nasal spray)??????????? (approved 1978)?
    • Fortical® nasal spray (recombinant) doesn’t have benzalkonium chloride?
    • One spray daily in alternating nostrils.???
    Mechanism: inhibits bone resorption by binding to osteoclasts.?

    Indications for use:?
    • Postmenopausal osteoporosis: (nasal spray and injection)?
    • Paget’s disease of the bone: injection only?
    • Hypercalcemia: injection only.?
    • Most feel this drug should be used in patients who cannot use a bisphosphonate, raloxifene, estrogen, denosumab, abaloparatide, or teriparatide.?
    • *Provides pain relief from compression fractures.?
    PROOF study? (Prevent Reoccurrence Of Osteoporotic Fracture)
    A significant reduction (33%) in vertebral fractures was observed, however there was no significant reduction in hip fractures.??
    Calcitonin may provide pain relief in acute fractures.? Because it is less effective than other osteoporotic medications it is used most often in patients with fracture pain, or for whom other therapy is unsuitable.? Calcitonin shows significant increases in BMD when combined with Vitamin-D

    Warnings/Precautions: Pregnancy Category-C?

    Adverse effects:
    • Rhinitis, epistaxis, nasal irritation & sinusitis
    • Salty taste?
    • Facial & hand flushing
    Drug interactions: Non-significant (may affect lithium levels)? Drug monitoring: Normal osteoporosis follow up? Patient education:
    • Store unit in refrigerator until needed.? Do not freeze.?
    • Assemble and prime, once at room temperature.?
    • After opening the bottle store at room temperature for 30 days. (Each bottle holds 30 doses)?
    New FDA Safety Evaluation: A meta-analysis of 21 random controlled trials with calcitonin-salmon (nasal spray and investigational oral forms) suggests an increased risk of malignancies in calcitonin-salmon treated patients compared to placebo-treated patients (4.1% vs 2.9%). The FDA found this non-significant and believes there is no conclusive evidence of a causal relationship between the use of these products and cancer and has chosen to keep calcitonin-salmon products on the market to provide options for those patients who cannot or do not want to use other treatments for osteoporosis. Health care professionals are urged to weigh the risks and benefits of all available treatments.???


    RANKL inhibitor:?

    Denosumab (Prolia®)????? ($1420.00/6months)?????????? approved 2010
    Injectable monoclonal antibody osteoporosis treatment?

    Mechanism: slows bone loss by inhibiting?rank ligand?which is a protein in the tumor necrosis factor family that's involved in bone breakdown.?Is as effective as bisphosphonates.?

    Adverse effects: higher risk of serious infections such as cellulitis, diverticulitis, and UTIs. May exacerbate pre-existing hypocalcemia.? Watch for increased infection.

    Dosage: 60 mg administered subcutaneously by a healthcare professional once every 6 months.

    Storage: REFRIGERATE.? Remove from refrigerator and let stand in room temperature for 15 to 30 minutes. Should be at room temperature (up to 25°C or 77°F) prior to injection.?


    Omosozumab-aqqg (Evenity; Amgen)?????? approved 2019
    Sclerostin inhibitor:?

    Indication: injection for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapies.?

    Mechanism: inhibits the action of sclerostin, a regulatory factor in bone metabolism. This allows the drug to rapidly increase?bone formation?and, to a lesser extent, decrease bone resorption.?

    Dose: once a month. As the anabolic effect wanes after 12 monthly doses of therapy, duration of therapy should be limited to 12 monthly doses; treatment with an antiresorptive drug (bisphosphonate) should be considered if continued osteoporosis therapy is needed.?

    Warnings/Precautions:
    • Do NOT use if patient has had myocardial infarction or stroke.?
    • Avoid in patients susceptible to osteonecrosis of the jaw.?

    ESTROGEN REPLACEMENT THERAPY? HERS TRIAL does NOT RECOMMEND ESTROGEN FOR TREATMENT of OSTEOPOROSIS, even though it is FDA approved for that indication
    Suggested daily doses for Osteoporosis:?
    • Conjugated Estrogens (Premarin®) 0.625?
    • Ethinyl Estradiol? 0.02mg?
    • Estropipate: 0.625mg?
    • Micronized Estradiol: 1mg?
    • Transdermal estradiol: 0.05mg/day?
    Remember, estrogen therapy should be used ONLY for relief of vasomotor symptoms, at the LOWEST possible dose for the SHORTEST period of time!

    CALCIUM SUPPLEMENTATION WITH AND WITHOUT VITAMIN D
    Vitamin D is required for absorption of Calcium from gut.?
    Normal dosage 400-800iu per day. Experts are recommending 1000iu-2000iu, especially necessary in the nursing home environment.?

    Remember that calcium citrate is the best option for elderly with poor stomach acid secretion, or any patient on H2RA or Proton pump inhibitors.? Also, calcium citrate is the best option for gastric bypass patients.

    About 16?years ago I had two patients, a husband and wife who attended our church.? He was a bright man, read the Wall Street Journal every morning and took care of his wife.? She had COPD and was on oxygen therapy. He cooked, shopped, cleaned the house did all the family finances and was one of the most personable guys you would ever want to meet.? He was meticulous about her care, making sure her oxygen was set just right, there were no obstacles on the floor, and did everything to keep her safe.

    One morning while getting her breakfast he tripped over her oxygen hose and crashed to the ground.? He called his son to come over and help him up, stating it was a “bad bruise”.? His son called for an ambulance, and he was taken to the hospital where he was diagnosed with a fractured hip.?

    He had surgery and moved to a nursing home, where he died six months later.? His sickly wife that he so meticulously cared for outlived him by 3 years. Safety in the home is as important as drug therapy; a broken hip can lead to a nursing home stay, decreased quality of life and early death.

    Have a Great Day on the Bench!!

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    Overview of Osteoporosis
    According to the American Family Physician, one fourth of elderly persons who sustain a hip fracture will die within six months of the injury, more than 50 percent of older adults who survive a hip fracture are discharged to nursing homes, and nearly half of that population will still reside in a nursing home a year later. Deaths can be due to pulmonary embolism, infection and heart failure.
    https://www.hospiceotp.org/news/why-falls-and-fractures-in-the-elderly-can-be-a-trigger-for-hospice-care/#:~:text=According%20to%20the%20American%20Family,a%20nursing%20home%20a%20year

    Prevention is key in keeping our baby boomers out of the hospital. Strengthening and fall prevention must be stressed.?

    Environmental adjustments to reduce fall risk:
    • Floor coverings
    • Grab bars in bathroom
    • Showers are safer than tubs
    • Increased lighting
    • Handrails on steps—both sides.
    • Use of a cane/ walker rollator for stability
    Exercise:? in 2 studies, one hour of walking and running 2 or 3 times a week significantly increased the lumbar spine bone mass.

    Weight-bearing, aerobic, and strength training all help to strengthen bone and increase bone mineral density (BMD). Remember, Wolff’s Law!!

    DEFINITIONS
    • Osteoporosis: a disorder of compromised bone strength causing an increased risk of fragility fractures
    • Osteopenia: reduced bone mass due to a decrease in the rate of osteoid synthesis to a level insufficient to compensate normal bone lysis
    • Osteomalacia: a condition marked by softening of the bones due to impaired mineralization, usually resulting from deficiency of Vitamin-D and calcium
    • Osteoblast:?a cell which arises from a fibroblast, and as it matures is associated with the production of bone. Osteoblasts?build bones.
    • Osteoclasts: a large multinuclear cell associated with the absorption and removal of bone. Osteoclasts?chip bones.
    Pharmacological Prevention of Osteoporosis- BISPHOSPHONATES Mechanism: inhibits osteoclast activity.? Must be continuously administered to suppress the osteoclasts on newly formed resorption surfaces.? It reduces bone turnover, causing bone formation to exceed bone resorption at the remodeling sites. Thus, there is progressive gain in bone mass. Indications for use:
    • Osteoporosis in post-menopausal women
    • Increase bone mass in men
    • Glucocorticoid induced osteoporosis
    • Paget’s disease of the bone
    Warnings/Precautions:
    • Severe erosive esophagitis Pregnancy Category-C
    • AVOID: Renal insufficiency—do not use if CrCl is less than 35mL/minute
    • Inability for patient to sit erect for 30 minutes
    Drug interactions for oral bisphosphonates: NSAIDS and Aspirin may increase potential for GI bleeding
    Patient education (bisphosphonates)
    • Take with at least 8oz of water, 30 minutes prior to the first meal of the day.
    • Remain upright for at least 30 minutes after ingestion; 60 minutes for ibandronate.
    • Calcium supplementation: is required for maximal benefit.
    Alendronate (Fosamax®)?approved Sept 1995 Available as:? ????
    • 5mg, 10mg, and 40mg tablets?? ? (daily dosing)
    • 35mg & 70mg in a 4-tablet pack (weekly dosing)
    • available with Vitamin D (Fosamax + D)
    Treatment:
    **Male or Female Osteoporosis: ?70mg weekly?? (rarely: 10 mg/day)

    Prevention:
    **Osteoporosis-Post menopausal women:? 35mg/week (rarely: 5 mg/day) Paget’s disease of the bone: 40mg/day for 6 months Glucocorticoid induced osteoporosis: 5mg/day?? (10mg/day post-menopausal women without estrogen)

    Risedronate (Actonel®)??????(approved March 1998)??generically available
    Available as: (most common dosing)
    • 35mg in a 4-tablet blister pack for weekly dosing.
    • Actonel 150mg one tablet once a month


    How long to use bisphosphonates?
    FLEX study: Many women when therapy of alendronate for was stopped for up to?five years?does not appear to significantly increase nonvertebral fracture risk. Women at very high risk of clinical vertebral fractures may benefit from continuing alendronate beyond five years.

    Osteonecrois of the jaw (ONJ) due to bisphosphonates: 94% of cases are in cancer patients getting prolonged therapy with IV zoledronic acid (Zometa®) or pamidronic acid (Aredia®)
    (IV bisphosphonates used for hypercalcemia of malignancy)
    • Most cases occur after dental work that traumatizes the jaw (extractions, etc.)
    • Incidence is less than 1/100,000 if taking oral bisphosphonates
    Prevention: recommend dental exam and any necessary procedures 3 months before beginning bisphosphonate therapy
    • Good dental hygiene
    • Inform dentist you are taking bisphosphonates
    • Avoiding any elective jaw procedure
    • Baseline and routine dental exams including panoramic jaw radiography
    • Delaying bisphosphonate therapy, if risk factors allow, to complete dental procedures for teeth or dental structures with poor prognosis
    • Educating patients about the importance of good oral hygiene, symptom reporting, and regularly scheduled dental assessments1
    Patients already receiving bisphosphonates should:
    • Maintain excellent oral hygiene and have routine dental examinations
    • Obtain routine dental cleanings (require careful attention to avoid soft-tissue injury)
    • Have aggressive nonsurgical management of any dental infection
    • Have root canal treatment if needed rather than dental extraction when possible


    I remember all of the fanfare when alendronate (Fosamax®) hit the market in the 1990’s.? Alendronate has been a game changer indeed, keeping bones strong and patients out of the nursing home. ?Physical therapists are extremely valuable in getting patients to exercise within their abilities.

    I always talk about Wolff’s Law, when discussing osteoporosis. In the late 19th century, German surgeon Julius Wolff described bone remodeling and how it relates to the stress placed on bones. According to Wolff, bones will adapt according to the demands placed on them.? Bones will grow in the direction to oppose the force put on them.? Exercise accelerates bone healing and strengthening. As our Baby Boomers continue to age, we will be seeing an increased need to offer preventative strategies to prevent nursing home admissions.?

    Have a Great Day on the Bench!!

    July 2022

    Micro-Learning CE Associated - Click Here For Details


    Overview of Prolactin and Adrenal Hormones

    The Hypothalamus
    The hypothalamus is the “governor” of the pituitary gland. It precisely releases stimulating hormones that cause hormone release from the pituitary. These hormones influence the endocrine glands in our body.
    • Feedback Mechanism – end product inhibition tightly controls hypothalamic and pituitary gland hormone release
    • Negative feedback – in homeostasis where the first hormone in a pathway is shut off by the last hormone or product in a pathway
    Prolactin
    • The usual normal range for serum prolactin is approximately 5 to 20 ng/mL
    • Release of prolactin is caused by serotonin, acetylcholine, opiates, and estrogens
    • Inhibition of prolactin release is caused by dopamine. Any drugs that block dopamine are expected to cause hyperprolactinemia.

    Drugs that block dopamine:
    • Metoclopramide (Reglan®)
    • First generation antipsychotics
    • Risperidone (Risperdal) and Paliperidone (Invega®): can elevate prolactin levels up to 300 or even 400 ng/mL
    • Remember too, that these dopamine blockers may cause/exacerbate Parkinson’s symptoms
    Drugs that stimulate prolactin:
    • SSRIs (selective serotonin reuptake inhibitors): fluoxetine, sertraline, fluvoxamine, citalopram (slight)
    • Estrogens (increasing levels of estrogen in late pregnancy appears to be responsible for elevated prolactin levels that prepare the mammary gland for lactation at end of gestation)
    • Cimetidine (Tagamet®) – antiulcer medication
    • Opioids (narcotics – codeine, hydrocodone, etc.)

    In men, elevated prolactin levels are associated with decreased libido, infertility, erectile dysfunction, gynecomastia, and, rarely, galactorrhea.

    In post-menopausal women, because they are already hypogonadal, a prolactinproducing adenoma needs to become large enough to cause headaches or impair vision for most to be detected. In premenopausal women, excess prolactin can lead to menstrual cycle irregularities and infertility. Hyperprolactinemia accounts for 10-20% of the cases of amenorrhea.

    Prolactinomas: Prolactinomas account for 40% of all pituitary adenomas but, with an incidence of only 60-100 cases per million, they are considered a rare disease. Treatment is usually essential when the tumor is large enough to cause neurologic symptoms, such as visual impairment or headache. Dopamine agonists decrease the size of the prolactinoma, as well as decreasing prolactin secretion.

    Prolactin function:
    • During pregnancy, prolactin levels rise to above normal levels
    • Prolactin induces lobuloalveolar growth of the mammary gland
    • Prolactin stimulates lactogenesis after giving birth
    • All other conditions where prolactin levels are in excess (hyperprolactinemia), are considered to be pathologic
    Prolactin as a Diagnostic Test: elevated serum prolactin may be helpful in differentiating generalized tonic-clonic and focal seizures from psychogenic nonepileptic seizures in adults and older children. A low serum prolactin does not exclude epileptic seizure, although it lowers the likelihood of an epileptic seizure if the event appeared to be a generalized tonic-clonic seizure.

    Pharmacotherapy with dopamine agonists is VERY effective in normalizing serum prolactin levels, in restoring menstruation and reducing tumor size in 70-100% of the affected patients within 3-6 months of therapy.
    • Bromocriptine (Parlodel®) – ergot alkaloid
      • Dosed twice a day (2.5mg and 5mg twice daily)
      • First drug used for the treatment of hyperprolactinemia
      • Causes more nausea and is usually considered second-line
      • Because it is an ergot alkaloid, cardiac valvular disease can occur and should be monitored
    • Cabergoline (Dostinex®) – ergot derived
      • Dosed once a week
      • Less nausea
      • Long acting and has become the agent of choice for hyperprolactinemia
      • Cardiovascular evaluation should be performed, and echocardiography should be considered to assess for valvular disease, especially if over 2mg per week. (May be attributed to cabergoline’s affinity for serotonin receptors on cardiac valves.)
    • Ropinirole (Requip®) and pramipexole (Mirapex®) – non-ergot dopamine agonists
      • Commonly used for the treatment of restless legs syndrome and Parkinson’s disease

    The Adrenal Gland
    The adrenal cortex can be divided into 3 distinct layers of tissue based on their organization:
    NameLayerPrimary Product
    Zona glomerulosaMost superficial cortical layerMineralocorticoids (aldosterone)
    Zona fasiculataMiddle cortical layerGlucocorticoids (cortisol)
    Zona reticularisDeepest cortical layerWeak androgens


    Conditions treated with systemic glucocorticosteroids:
    • Allergic diseases
    • Collagen diseases
    • Dermatologic diseases
    • Edematous states
    • Endocrine disorders: primary or secondary adrenal cortical insufficiency
    • GI diseases
    • Hematologic disorders
    • Neoplastic diseases
    • Nervous system
    • Ophthalmic
    • Respiratory
    • Rheumatic disorders
    Action: Natural occurring adrenocortical steroids have both anti-inflammatory (glucocorticoid) and salt retaining (mineralocorticoid) activities. They modify the body’s response to diverse stimuli.

    Natural:
    • Hydrocortisone (cortisol) and cortisone used for replacement therapy
    Synthetic:
    • Prednisone, primarily used for glucocorticoid effect (has mineral effect too)
    • Fludrocortisone (Florinef®) primarily used for mineralocorticoid effect
    • Triamcinolone, dexamethasone, methylprednisolone, betamethasone: marked glucocorticoid activity. Potent anti-inflammatory drugs.
    Warnings:
  • Prolonged therapy of pharmacologic doses may lead to hypothalamicpituitary- adrenal suppression
    • Abrupt discontinuation may lead to a withdrawal syndrome without evidence of adrenal insufficiency. To minimize morbidity associated with adrenal insufficiency, gradually taper dose.
    Symptoms of adrenal insufficiency:
    • Nausea, fatigue, anorexia, dyspnea, HYPOtension, hypoglycemia, myalgia, fever, malaise, arthralgia dizziness, desquamation of the skin, fainting

    Trivia fact: Oral prednisolone is usually used in horses and cats since they can't convert the prednisone as easily as dogs can. Prednisone gets activated to prednisolone in the liver in humans.

    Most Common Adverse Effects of Corticosteroids
    Side effects:
    • Infection: mask signs of infections
    • Ocular effects
    • Osteoporosis (inhibits calcium absorption)
    • Weight increase
    • Edema
    • Elevates blood sugars (monitor diabetics)
    • Thin fragile skin, impaired healing, hirsutism
    • Suppression of growth in children (long term)
    • Sodium and fluid retention
    • GI upset, increased appetite, weight gain
    • Muscle weakness (steroid mypoathy)
    • Eyes: increase IOP (intra ocular pressure), cataracts
    • Stomach ulcers
    • Hypokalemia
    • Emotional labiality
    Contraindications:
    • Systemic fungal infection
    • Live virus vaccines
    • Caution with immunosuppressed patients
    • Active TB cases can reactivate disease

    Preventing and Decreasing Adverse Effects of Glucocorticosteroids
    • Take with food or snack
    • Watch for signs of adrenal insufficiency.
    • Taper dose
      • Adults who get up to 60 mg/day of prednisone for 10 days or less don't need tapering
      • Adrenal suppression usually doesn't occur until patients take prednisone 40 mg/day for more than 2 weeks. Taper patients taking more than 20 mg/day of prednisone for longer than 3 weeks to prevent adrenal problems.
      • Tapering is necessary for patients who have been on chronic oral corticosteroids
    • Use glucocorticoids for shortest amount of time. Use intermediate acting glucocorticoids to minimize the risk of adrenal suppression. Prednisone every OTHER day if long term.
    • Use only if absolutely necessary.
    • Nasal and inhaled corticosteroids cause minimal adrenal suppression. (Betamethasone is worst)
    Glucocorticoid Equivalencies
    Short ActingEquivalent potencyAnti-inflammatory potencySodium retaining
    Cortisone (Cortone®)25mg0.82
    Hydrocortisone or Cortisol (Cortef®)20mg12
    Intermediate acting
    Prednisone (Deltasone®)5mg41
    Prednisolone (Prelone®)5mg41
    Triamcinolone (Aristocort® or Kenalog®)4mg50
    Methylprednisolone (Medrol®)4mg50
    Long acting
    Dexamethasone (Decadron®).75mg20-300
    Betamethasone (Celestone®).6mg20-30o


    Key points about mineralocorticoid activity:
    • When given at regular doses, triamcinolone, dexamethasone, and betamethasone have no clinically important mineralocorticoid activity. They would never be used for Addison’s Disease.
    • 20mg hydrocortisone and 25mg of cortisone acetate each provide a mineralocorticoid effect that is approximately equivalent to 0.1 mg fludrocortisone. Hydrocortisone (Cortef®) is most commonly used for Addison’s Disease.
    • Prednisone or prednisolone given at anti-inflammatory doses ≥50 mg per day provides a mineralocorticoid effect that is approximately equivalent to 0.1 mg of fludrocortisone
    Pharmacological Treatment of Poison Ivy with Oral Corticosteroids:
    • Oral prednisone: 0.5 to 2mg/kg/day tapered over 14- to 21-day period
    • Medrol dosepak (6-day therapy) is not long enough of duration
      • “rebound dermatitis”
    • Sterapred DS® – 10mg begins with a 60mg dose and is tapered over 12 days is acceptable


    There are other pituitary hormones, such as oxytocin, thyroid stimulating, luteinizing hormone, follicle stimulating hormones, etc. Not many medications in the community pharmacy arena apply to these hormones. Prolactin, however, warrants closer examination, because so many drugs we dispense on a daily basis affect prolactin.

    I once had a lactation nurse at the hospital call in a prescription for metoclopramide for a nursing mother, to assist with her milk “letdown.” I also remember a while ago when bromocriptine was used to help “dry up” mothers who would be formula feeding their newborn. Once we understand the mechanisms of action of these drugs, it makes sense how we can use them for other than their common indications.

    Have a Great Day on the Bench!!

    June 2022

    Micro-Learning CE Associated - Click Here For Details

    Seasonal Allergies are coming At-Choo Soon

    Key Terms
    • Anticholinergics: act locally on nasal mucosa to inhibit serous and seromucous gland secretions
    • Antihistamines: selectively block peripheral histamine-1 receptors, to minimize response to triggers
    • IgE: immunoglobulin E, antibodies produced by the immune system as part of the body’s defense against specific triggers
    • Leukotriene receptor antagonists: inhibits activation of receptors that are correlated with pathophysiology of asthma, airway edema, smooth muscle contraction, and inflammatory responses
    • Mast cell stabilizers:act locally to reduce histamine degranulation from mast cells
    • Rhinitis medicamentosa: chronic nasal congestion associated with overuse of vasoconstrictor nasal medications, sometimes referred to as “rebound” nasal congestion
    Shifting Trends
    Springtime brings with it warmer weather, baseball games, and budding trees. In the Fall, we enjoy Friday night football games and pumpkin-flavored everything. For many, these seasonal changes also bring unrelenting watery eyes, runny noses, and scratchy throats. And it is only getting worse.

    In 2010, the Asthma and Allergy Foundation of America (jointly with the National Wildlife Federation) released a report on the effect of a warming climate on allergies and asthma.1 Ragweed is the chief Fall trigger for many patients’ allergies. According to the report, it grows faster and produces more pollen in an environment with more carbon dioxide. Longer growing seasons as a result of warmer weather allow ragweed plants to grow larger, releasing more pollen. In the Spring, budding trees and flowers are the primary pollen producers. A warmer climate means their habitat will expand to previously inhospitable areas. Fungal allergens, too, could be more problematic as the planet warms.

    Review of Allergic Pathophysiology
    Allergic rhinitis is characterized by sneezing, runny nose, nasal obstruction, and often accompanied by itchy, watery eyes. The physiological response to seasonal allergens is an IgE antibody-mediated inflammatory response.2 The severity of this response can be mild to severe and varies with trigger type, the extent of exposure, and patient-specific factors.

    The Pharmacist’s Role in Treating Seasonal Allergies
    Allergic rhinitis is likely a condition that affects many of your patients. Indeed, surveys indicate physician-diagnosed allergic rhinitis affects upwards of 20% of adults and 13% of children in the United States. The functional and economic toll of seasonal allergies is immense. Impaired physical and social functioning and daytime somnolence can lead to lost days of work and lower quality of life.

    As patients reach for over-the-counter allergy medications, the incidence of potentially harmful drug interactions increases as well. It is in this capacity that pharmacists can play a key role in alleviating patients’ symptoms while helping them minimize the effects of medications.

    Cornerstones of Treatment for Seasonal Allergies
    The most common medications used to treat allergic conditions are antihistamines, decongestants, and glucocorticoids. Leukotriene inhibitors, mast cell stabilizers, and anticholinergics can be useful in some cases, too. In recommending a medication to a patient, we should maximize symptom reduction and improve patient productivity while minimizing adverse effects and drug-drug interactions. The latest treatment guidelines were published in 2020 by the American Academy of Allergy, Asthma, and Immunology (AAAAI).3

    Antihistamines
    Oral antihistamines have long been the standard for seasonal allergies. They can be used proactively to minimize symptoms prior to trigger exposure, or reactively post-exposure. First-generation agents tend to be more sedating and require multiple daily doses. Second-generation agents, conversely, tend to cause less sedation and are taken once daily. These second-generation agents are sometimes called “non-sedating” antihistamines, but a more accurate label is “less-sedating.” Medications in both generations are available without a prescription.

    Oral AntihistaminesGenerationRecommended Adult Dose
    (≥12 years)
    Recommended Pediatric Dose
    (6≥11 years)
    Chlorpheniramine14mg every 4-6 hours2mg every 4-6 hours
    Clemastine fumarate11.34mg BID, or 2.68mg daily0.67mg BID, or 1.34mg daily
    Diphenhydramine125mg every 4-6 hoursNot recommended3
    Hydroxyzine110-25mg at bedtime12.5-25mg at bedtime
    Triprolidine12.5mg every 4-6 hours1.25mg every 4-6 hours
    Cetirizine (Zyrtec®)210mg daily5-10mg daily
    Desloratadine (Clarinex®)25mg daily2.5mg daily
    Fexofenadine (Allegra®)260mg BID, or 180mg daily30mg BID, or 60mg daily
    Levocetirizine (Xyzal®)25mg daily2.5mg daily
    Loratadine (Claritin®)25mg BID, or 10mg daily5-10mg daily


    Many of the agents listed above (and several other medications) are also available in ophthalmic and nasal dosage forms. The topical formulations generally cause little to no sedation. With all antihistamines, it is important that the patient use caution when drug-induced sedation would interfere with activities.

    Glucocorticoids
    Nasal steroids are now the gold standard for allergic rhinitis. They are the single most effective maintenance therapy and cause very few adverse effects. They can successfully treat both nasal and ophthalmic symptoms of seasonal allergies. Antihistamines often do little to relieve allergic nasal congestion; nasal steroids are particularly effective in these cases. Many of nasal steroids are available over the counter. The choice of agent is generally patient preference. Dose and frequency of these agents is product specific. Generally, though, the recommended dose for most products is 1 or 2 inhalations in both nostrils once or twice daily.

    It is important that patients be counseled on correct dosing technique with nasal steroids. Proper positioning of the head will ensure the medication is distributed to the nasal tissues rather than draining down the throat. The patient should tilt the head slightly downward, while pointing the spray upward, away from the septum.

    Older, first-generation agents are associated with higher systemic bioavailability. Second-generation agents are typically undetectable at the systemic level, which is preferable especially for children and when using year-round. The maximum effect of nasal steroids usually arrives after one to two weeks of daily use. In the interim, oral antihistamines can be used concurrently to treat allergy symptoms.

    Nasal SteroidGenerationOTC/Rx
    Beclomethasone (Beconase®, Qnasl®)1Rx
    Budesonide (Rhinocort®)1OTC
    Flunisolide (Nasarel®)1Rx
    Triamcinolone (Nasacort®)1Rx and OTC
    Ciclesonide (Omnaris®, Zetonna®)2Rx
    Fluticasone furoate (Flonase Sensimist®)2OTC
    Fluticasone propionate (Flonase®)2Rx and OTC
    Mometasone (Nasonex®)2Rx


    Two of the above products – beclomethasone and ciclesonide – are delivered via dry aerosol. This delivery form may be preferable for patients put off by the scent or taste effects of the other aqueous solutions.

    Anticholinergics and Mast Cell Stabilizers
    The anticholinergic ipratropium bromide, in nasal spray form, can be useful for treating rhinorrhea (runny nose), but it is still less effective than the nasal glucocorticoids for sneezing, itching, and nasal obstruction.4 If runny nose is still not well controlled on nasal steroids, it can be used concurrently. Ipratropium requires frequent dosing. Because of its inferiority to nasal steroids, ipratropium is not considered first-line treatment for seasonal allergies.

    Cromolyn sodium, a mast cell stabilizer, is particularly useful for people who have episodic symptoms that can be anticipated. For example, a patient who is allergic to cats can use cromolyn nasal spray about 30 minutes prior to visiting a friend who has a cat to minimize nasal allergen triggering. In the same way, cromolyn can be initiated 1-2 weeks prior to environmental pollen peaks as a prophylactic measure. This agent does require frequent daily dosing when used for seasonal allergies. Cromolyn is also considered second-line treatment to nasal steroids but can be useful when other agents are not- well tolerated.5

    Second-Line AgentsOTC/RxTypical Dose and Frequency
    Ipratropium (Atrovent Nasal®)Rx2 sprays in each nostril 2-3 times daily
    Cromolyn (NasalCrom®)OTC1 spray in each nostril 3-4 times daily


    Nasal Decongestants
    Nasal decongestants work by causing local vasoconstriction. Phenylephrine, oxymetazoline, xylometazoline, and naphazoline are the agents in this class. While they are very effective for nasal congestion, they are not recommended for allergic rhinitis monotherapy. Chronic use of nasal decongestants can give rise to rhinitis medicamentosa or “rebound” congestion. Downregulation of alpha-adrenergic receptors in the nasal tissues can occur in as little as 3 days of use. Patients who use nasal decongestants frequently often find themselves in a cycle of nasal congestion both caused by and relieved by the medication. Therefore, patients should be warned against using any of these singly agents for more than 72 hours.

    Patients with congestion-dominant seasonal nasal symptoms may find benefit from a combination of once-daily nasal steroid plus the long-acting nasal decongestant agent oxymetazoline. A study that evaluated this combination found that nasal symptoms were less than in the placebo group, and even less in the group using a steroid alone.6 Moreover, the study found that the once-daily dosing with the steroid did not bring on rhinitis medicamentosa. Still, it is still advisable to discontinue use of a nasal decongestant once symptoms are well-controlled.

    Leukotriene Receptor Antagonists
    One medication in this class, montelukast (Singulair®), was used for patients who could not tolerate nasal sprays. However, recent trials revealed troubling neuropsychiatric changes associated with the drug. As a result, the FDA issued a boxed warning for montelukast, citing its link to insomnia, anxiety, depression, and suicidal ideation.7, 8 With this new information, the risk/benefit ratio of montelukast increased significantly. Given the number of other safer alternatives for treating seasonal allergies, montelukast (and other agents in its class) should be avoided.

    When to Refer at Patient to a Specialist
    If a patient fails multiple courses of the recommended agents, an evaluation for non-allergic etiologies is advisable. A specialist should rule out other conditions before initiating allergen immunotherapy. Adult and pediatric patients who have prolonged, severe symptoms, co-existing asthma or nasal polyps should also be referred for further evaluation.

    Summary
    Seasonal allergy symptoms and allergic rhinitis are very common conditions, affecting 10-30 percent of adults and children in industrialized countries. Prevalence is increasing. Medications to treat allergic nasal symptoms are numerous, many available without a prescription. As such, pharmacists play a key role in advising patients on safe use of these medications.

    The treatment of choice for most patients is a nasal glucocorticoid. These agents offer safety, minimal systemic absorption, convenient once-daily dosing, and over-the-counter availability. Nasal steroids can also be combined with oral antihistamines when symptoms are most severe. For some patients, targeted therapy with ipratropium or cromolyn may be beneficial. Nasal decongestants offer some short-term relief but should be used very cautiously – and briefly – to avoid “rebound” vasoconstriction. Recent warnings about serious neuropsychiatric adverse effects of leukotriene receptor antagonists have taken montelukast off the recommended list of allergy treatments. If patients have other pulmonary conditions, or fail multiple trials of the standard agents, an immunologist or otolaryngologist consult is warranted.

    References
    • National Wildlife Federation. Extreme Allergies and Global Warming.; 2010. Accessed March 22, 2022. https://www.aafa.org/media/1634/extreme-allergies-global-warming-report-2010.pdf
    • Dykewicz MS, Wallace DV, Baroody F, et al. Treatment of seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 2017;119(6):489-511.e41. doi:10.1016/j.anai.2017.08.012
    • Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020;146(4):721-767. doi:10.1016/j.jaci.2020.07.007
    • Milgrom H, Biondi R, Georgitis JW, et al. Comparison of ipratropium bromide 0.03% with beclomethasone dipropionate in the treatment of perennial rhinitis in children. Ann Allergy Asthma Immunol Off Publ Am Coll Allergy Asthma Immunol. 1999;83(2):105-111. doi:10.1016/S1081- 1206(10)62620-8
    • Pitsios C, Papadopoulos D, Kompoti E, et al. Efficacy and safety of mometasone furoate vs nedocromil sodium as prophylactic treatment for moderate/severe seasonal allergic rhinitis. Ann Allergy Asthma Immunol Off Publ Am Coll Allergy Asthma Immunol. 2006;96(5):673-678. doi:10.1016/S1081-1206(10)61064-2
    • Baroody FM, Brown D, Gavanescu L, DeTineo M, Naclerio RM. Oxymetazoline adds to the effectiveness of fluticasone furoate in the treatment of perennial allergic rhinitis. J Allergy Clin Immunol. 2011;127(4):927-934. doi:10.1016/j.jaci.2011.01.037
    • Druss B, Pincus H. Suicidal ideation and suicide attempts in general medical illnesses. Arch Intern Med. 2000;160(10):1522-1526. doi:10.1001/archinte.160.10.1522
    • Federal Drug Administration. FDA requires Boxed Warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. Drug Safety and Availability. Published March 4, 2020. Accessed April 10, 2022. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-boxed-warning-about-serious- mental-health-side-effects-asthma-and-allergy-drug


    May 2022

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    New Updates to Asthma Treatment

    Key Terms
    DPI: dry powder inhaler
    ICS: inhaled corticosteroid
    LABA: long-acting beta-2 adrenergic agonist
    MART: maintenance and reliever therapy
    MDI: metered-dose inhaler
    OCS: oral corticosteroids
    SABA: short-acting beta-2 adrenergic agonist


    Have you met GINA?
    The Global Initiative for Asthma (GINA) guidelines were established in 1993 and are now considered the gold standard for best practices in treating patients with asthma. The GINA report is updated every year, with cumulative reviews of new evidence twice yearly. The newest update was issued in 2021. It expounds on a significant change in the standard of care for most patients that was first suggested in 2019. The 2021 update also addresses many aspects of asthma treatment relative to COVID-19 risk and management. A free download of the GINA reports is available for personal use at http://ginasthma.org.

    Review of Asthma Step Treatment The standard of care for treating adults and adolescents with asthma follows a stepwise approach, based on symptom severity.
    • Step 1: symptoms less than twice per month
    • Step 2: symptoms twice a month or more
    • Step 3: symptoms most days, or waking at night once or more per week
    • Step 4: daily symptoms, waking at night once or more per week, and low lung function
    • Step 5: persistent exacerbations and worsening symptoms despite aggressive treatment
    In the 2021 GINA report, treatment recommendations for each step were updated to reflect the most recent studies. Of all patients with asthma, almost one-quarter will require high-intensity treatment (high-dose ICS-LABA or medium-dose ICS-LABA plus OCS). Of those, about 17% have multiple treatment failures on high-intensity regimens. And, furthermore, about 4% of patients with difficult-to-treat asthma will be classified as having severe-refractory disease, with poor symptom control despite good inhaler technique and medication adherence.1 These patients fall in Step 5, and should always be managed by a pulmonologist and/or immunologist.

    A Sea-Change in Asthma Treatment
    In 2019, the GINA guidelines changed the recommendation for medication therapy in Step 1 asthma patients.2 Until then, patients who had infrequent symptoms (less than two exacerbations per month) and no risk factors for exacerbations were given a single medication – a SABA (e.g., albuterol or levalbuterol) for as-needed use. At that time, the GINA report recommended treatment with either symptom-driven (as needed) or daily low-dose ICS inhaler regimens. Monotherapy with a SABA had been first-line for fifty years. However, the GINA report clearly stated a SABA-only regimen was no longer recommended for adults and adolescents.

    In making this fundamental change, the report cited safety evidence that SABA-only treatment increased the risk of severe exacerbations, and that adding any ICS significantly reduced that risk. A study in 2007 found of patients with infrequent asthma symptoms (less than weekly), up to 20% of those were at risk of dying during an acute exacerbation.3 More recent studies demonstrated higher uses of SABA inhalers were associated with adverse clinical outcomes like severe exacerbations and death.4, 5

    At that time, GINA did not alter its recommendations for more severe asthma (Step 2 and above). Patients with more frequent asthma symptoms, or who have more risk factors for exacerbations, were to continue the standard combination LABA-ICS inhaler on a scheduled-dose basis, along with a SABA as a “rescue” inhaler.

    The GINA 2021 update built upon the 2019 guidelines.6 This report states the new preferred mild asthma treatment strategy is a low-dose ICS, specifically combined with inhaled formoterol. Formoterol is classified as a LABA, but it has a similar onset of action to SABAs (5-15 minutes).

    GINA 2021 also established two “tracks,” based on evidence gleaned since the 2019 change. Track 1 (the preferred approach) is a low-dose ICS-formoterol combination inhaler, either as-needed or scheduled based on the patient’s disease severity. Track 2 is the use of a single-drug SABA plus a separate ICS inhaler used immediately after SABA. This sequential inhaler use can be as-needed for symptom control for milder-severity asthma patients. Patients with more severe and frequent symptoms should use the ICS on a schedule and the SABA as needed. Track 1 is preferred because using low-dose ICS as a symptom reliever has been shown to reduce the risk of severe exacerbations compared to the use of a SABA as the reliever. The latest GINA report named this type of therapy “maintenance and rescue therapy” (MART).

    For patients requiring high-intensity treatment (Steps 3-5), GINA acknowledged that MART would require modification. A medium dose ICS, oral corticosteroids, or biologic therapy should be considered to reduce the risk of exacerbations.

    Classification of Medication Intensity
    The following tables classify the recommended total daily dose ranges into low, medium, and high-intensity treatment options. These tables do not represent drug-dose equivalence.

    Adults and Adolescents
    ICSDaily ICS Dose in Micrograms
    LowMediumHigh
    Beclomethasone diprop. DPI100-200>200-400>400
    Budesonide MDI or DPI200-400>400-800>800
    Ciclesonide MDI80-160>160-320>320
    Fluticasone fur. DPI100100200
    Fluticasone prop. MDI or DPI100-250>250-500>500
    Mometasone fur. MDI200-400200-400>400
    **Adapted from GINA 2021, Box 3-6A6

    Children Ages 6-11 Years
    ICSDaily ICS Dose in Micrograms
    LowMediumHigh
    Beclomethasone diprop. DPI50-100>100-200>200
    Budesonide MDI or DPI100-200>200-400>400
    Budesonide nebules250-500>500-1000>1000
    Ciclesonide MDI80>80-160>160
    Fluticasone fur. DPI5050n/a
    Fluticasone prop. MDI or DPI40-100>100-200>200
    Mometasone fur. MDI100100200
    *Adapted from GINA 2021, Box 6-66

    GINA Recommendations for Children
    The 2021 GINA update saw similar treatment recommendations for children under age 12. As always, adherence and inhaler technique should be closely assessed in children before increasing asthma medication doses. For young patients in Steps 1-2, the use of an ICS whenever the SABA is used is the standard. Step 3 patients should follow MART using a very low-dose ICS-formoterol combination inhaler. Those in Steps 4-5 should use a medium-dose or high-dose ICS-LABA (or low-dose ICS-formoterol MART) and be referred to a pediatric pulmonologist.6

    COVID-19 Implications on Asthma Treatment
    We now have two years of data on the risk and complications of coronavirus infection on asthma sufferers. First, people with asthma are not at higher risk for acquiring COVID-19, nor are those with well-controlled asthma more likely to die if infected.7 However, studies have shown asthma patients who recently required oral glucocorticoids8 or hospitalization9 to treat an exacerbation were more likely to die after acquiring COVID-19. For these reasons, it is critical to select asthma medications that maximize symptom control to prevent fatal COVID-19 complications. There is one caveat to this recommendation: nebulized medications should be avoided to minimize COVID virus transmission.

    Vaccination Recommendations
    The COVID-19 vaccines available in the U.S. have been successfully tested on patients with asthma. Generally, adverse events related to the various COVID-19 vaccine products are very rare. With current data in this population, GINA recommends COVID-19 vaccination for all patients with asthma who do not have contraindications.6 The vaccines should be given in a healthcare setting where severe reactions can be addressed quickly if they occur. Any patient who has a history of a severe allergy to polyethylene glycol, or any other vaccine ingredient, should not receive a product with these ingredients. The other standard vaccine precautions apply to patients with asthma.

    The CDC’s Advisory Committee on Immunization Practices (ACIP) also recommends patients with asthma receive an annual influenza vaccine, along with appropriately-timed Tdap, pneumococcal, and zoster immunizations.10

    Summary
    • Asthma guidelines for adults, adolescents, and children were updated in 2021 based on safety data that showed adding an ICS for even mild asthma reduced the risk of death, hospitalization, and exacerbations.
    • Low-dose ICS treatment provides the most clinical benefit for most patients with asthma.
    • Two treatment “tracks” were established by GINA in 2021. Track 1 involves the use of a low-dose ICS-formoterol combination inhaler, either as-needed or scheduled. Track 2 is comprised of a single-drug SABA plus a separate ICS inhaler used immediately after the SABA. This new recommendation is called “maintenance and reliever therapy,” or MART.
    • A scheduled ICS-formoterol regimen is preferred for patients with more frequent symptoms, or risk factors for exacerbations. The ICS strength should be titrated to adequate symptom control.
    • Regimens that offer optimal symptom control are crucial to reducing the complications of and hospitalizations for COVID-19.
    • Asthma patients should receive COVID-19, influenza, Tdap, and pneumococcal vaccinations on schedule unless they have contraindications to these products
    References
    1. Hekking PPW, Wener RR, Amelink M, Zwinderman AH, Bouvy ML, Bel EH. The prevalence of severe refractory asthma. J Allergy Clin Immunol. 2015;135(4):896-902. doi:10.1016/j.jaci.2014.08.042
    2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2019. Published online 2019. http://www.ginasthma.org
    3. Dusser D, Montani D, Chanez P, et. al. Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations. Eur J Allergy Clin Immunol. 2007;62(6):591-604.
    4. Nwaru B, Ekström M, Hasvold P, et. al. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020;55(5):1901872. doi:10.1183/13993003.01872-2019
    5. Stanford RH, Shah MB, D’Souza AO, Dhamane AD, Schatz M. Short-acting β-agonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol Off Publ Am Coll Allergy Asthma Immunol. 2012;109(6):403-407. doi:10.1016/j.anai.2012.08.014
    6. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2021. Published online 2021. http://www.ginasthma.org
    7. Wu T, Yu P, Li Y, et al. Asthma does not influence the severity of COVID-19: a meta-analysis. J Asthma. Published online April 23, 2021:1-7. doi:10.1080/02770903.2021.1917603
    8. Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020;584(7821):430-436. doi:10.1038/s41586-020-2521-4
    9. Bloom CI, Drake TM, Docherty AB, et al. Risk of adverse outcomes in patients with underlying respiratory conditions admitted to hospital with COVID-19: a national, multicentre prospective cohort study using the ISARIC WHO Clinical Characterisation Protocol UK. Lancet Respir Med. 2021;9(7):699-711. doi:10.1016/S2213-2600(21)00013-8
    10. Centers for Disease Control and Prevention. Lung Disease Including Asthma and Adult Vaccination. Accessed March 21, 2022. https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/lung-disease.html

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    Overview of Lithium: What to know when you didn’t remember what you needed to know!

    The use of lithium in psychiatry goes back to the mid 1800s, however more scientific rigor in examining its role in mania began in the mid 20th century.1 Fast forward ahead to today where lithium is FDA approved for the treatment of bipolar disorder (i.e., Bipolar I Disorder), including acute mania and maintenance therapy.

    Although the FDA has approved lithium for this condition, different guidelines recommend the use of lithium in different ways. Therefore, pharmacists should not expect a rigid “cookie cutter approach” to its use. For example CANMAT (Canadian Network for Mood and Anxiety Treatments) and BAP (British Association for Psychopharmacology) recommend lithium as a 1st line intervention for acute mania and mixed episodes whereas NICE (National Institute for Health and Care Excellence) and WFSBP (World Federation of Societies of Biological Psychiatry) suggest the use of other agents such as second generation antipsychotics (SGA) with what might be perceived as less adverse effects when compared to lithium, first.

    Our case for consideration
    TS is a 32-year-old patient who returns monthly to your community pharmacy for refills on lithium along with a few other medications. According to his most recent lab report, his lithium levels are appropriate and no other monitoring parameter are out of range. Here is TS’s complete medication list:
    • Lithium 600mg twice daily for bipolar disorder x 10 years
    • Metformin 1000mg twice daily for T2DM x 2 years
    • Lisinopril 20mg daily for hypertension x 5 years
    • Melatonin 3mg daily at bedtime for sleep
    • Multivitamin daily for nutritional supplementation
    TS expresses concern over a recent emergence of acne that has caused distress and embarrassment.

    What is Bipolar Disorder (BP)? Although there is a specific criteria list of symptoms and duration of illness for formal diagnosis, typical symptoms include a rotation and range of extreme moods including elevated (mania) and depression. Both the duration and severity of the mood episodes are different based on the type of BP the individual is diagnosed with, however the presence of mania and whether or not hospitalization is required generally leads clinician’s towards making the more severe BP I diagnosis. Typical symptoms of mania include hyperactivity, decreased need for sleep, poor judgement, flight of ideas, grandiosity (exuding unrealistic pompous superiority) and possible aggression. Sometimes individuals can experience a “mixed state” and have both depression and mania occurring at the same time.

    Clinical pearls for safe and effective Lithium use

    Dosing is just one part of the program! Lithium is generally dosed to a target serum concentration range somewhere between 0.6mEQ/L to 1.2mEQ/L. In some severe cases, targets can be as high as 1.5mEq/L but anything over this threshold is considered potentially toxic and should be avoided. Because there is a very narrow range between therapeutic and toxic, lithium is a narrow therapeutic range medication and is often considered a “high alert” medication in medication safety organizations and communities. Also, it should be noted that some prescribers may opt for lower dosing thresholds purposefully. Routine ongoing therapeutic drug concentration monitoring, in addition to other regular tests to prevent adverse outcomes, is a necessary part of lithium therapy.

    A good starting dose for most healthy adults is 300 mg by mouth 3 times per day with serum lithium concentrations measured after 3 days with labs drawn 12 hours after the last oral dose and regularly until the patient is stabilized which takes about 5 days after given a steady scheduled dose. Dose changes are best if implemented by 300 mg doses every 3 days until the desired outcome is achieved. There has also been a liquid formulation available with 8mEq lithium citrate = 300mg lithium carbonate, however the recent supply chain disruption has been associated with raw ingredient shortage and lack of availability and uncertain future access of the lithium liquid.

    Basic pharmacokinetics:
    • No hepatic metabolism and no CYP450 drug interactions
    • Renal excretion; avoid using in patients with pre-existing renal compromise as evidenced with CrCl less than 30ml/min but cautious dosing is permitted for patients with CrCl above 30mL/min
    • Susceptible to drug interactions that result from impact on kidney function
    • Linear and predictable. Double the oral dose and expect that serum concentration to double too. Pregnant women may require higher doses during pregnancy but dose decreases prior to delivery to accommodate for normalization of volume of distribution that occurs late in 3rd term.
    Drug interactions
    Let’s review an illustrative summary to refresh your memory. Refer to the package label for a complete list of drug interactions! There are times when drug interactions may be present, but when combined use is medically necessary, can be managed with appropriate monitoring and vigilance.

    Blood pressure:
    • Ace inhibitors/ARBs: decreased sodium reabsorption, sodium loss and reduced GFR leading to a compensatory reabsorption of lithium and increased lithium concentrations
    • Diuretics: thiazide diuretics are the main problem-can result in 50% increase in lithium concentration and thus should be avoided; loop diuretics when used judiciously, generally result in less clinically significant consequences if over-diuresis can be avoided. Other diuretics should be considered on a case-by case basis.
    • Non-dihydropyridine Calcium channel blockers (such as diltiazem, and verapamil): increased risk of neurotoxicity when combined with lithium
    NSAIDS: thought to be result of inhibited prostaglandin synthesis, decreased renal blood flow and increased lithium concentrations

    Other: although rare, reported increased risk of neuroleptic malignant syndrome when combined with antipsychotics. Reports of serotonin syndrome are even more rare.

    What about the adverse effects we should expect with lithium treatment?
    Let’s review an illustrative summary to refresh your memory but always remember to refer to the package label for a complete list of adverse effects reported and recommendations to mitigate these risks!

    Genitourinary-can occur in up to 33% of patients but mitigated with once daily dosing and targeting the lowest effective serum concentration.
    • Polyuria
    • Acute more common versus chronic kidney disease
    Endocrine/metabolic- monitor thyroid panels-exogenous thyroid supplementation generally preferred over lithium discontinuation when clinically appropriate. Monitor bone density based on prescribers’ clinical judgement and patient specific clinical risks
    • Hypothyroidism
    • Hyperparathyroidism
    • Weight gain
    Cardiovascular
    • QT prolongation, ECG changes and arrhythmias-avoid in patients with underlying cardiac conditions (avoid entirely in patients with 3rd degree block and if family history of sudden death in young adults).
    Gastrointestinal- tends to be transient early in treatment; emergence of later episodes could be suggestive of lithium toxicity (evaluation needed)
    • Nausea
    • Thirst/dry mouth
    Neurologic
    • Muscle weakness and lethargy, tremor
    Hematologic
    • Leukocytosis reported (generally benign)
    Dermatologic
    Acne, psoriasis and alopecia-both newly emergent or exacerbated preexisting condition (may resolve with lower doses; addressing the dermatologic side effect is the preferred mitigation versus discontinuing lithium whenever clinically appropriate and possible). These seemingly “cosmetic” problems can be personally distressing and may result in non-adherence therefore addressing these adverse effects with appropriate concern and subsequent pharmacologic recommendations is essential.

    Patients are best positioned to “see something and to say something” when it comes to adverse effects. Please give lithium a fair shake and keep my tip sheet for future use when you encounter new prescriptions and opportunities to educate prescribers and patients on safe, effective and appropriate use of this oldie but goodie medication!

    So what about TS?
    1. What pharmacologic intervention should be recommended when a patient reports a new emergence or worsening of a dermatologic condition such as acne?
      1. Acne usually occurs due to a drug interaction with lithium so discontinue other drugs that can interact with lithium
      2. Acne is usually a sign of a bigger problem and lithium should be discontinued immediately
      3. Acne can be personally distressing and should not be ignored; initiate a topical acne product as a first line intervention
      4. Acne is not a big deal; explain that the patient should be more worried about the mental health condition and just continue lithium
    2. You are concerned that TS is on an ACE inhibitor for blood pressure along with lithium since this can represent a significant drug interaction. Looking in TS’s history, he has had intolerable adverse reactions to almost all other blood pressure medications and his lisinopril is resulting in improved blood pressure control without complaints of side effects. What action do you take when advising pharmacotherapeutic recommendations?
      1. TS should not be on lisinopril; it is contraindicated with lithium therapy
      2. TS can remain on lisinopril provided TS’s renal function remains acceptable and lithium levels are appropriate
      3. TS can only remain on lisinopril at half dose to prevent complications resulting from hepatic metabolism
      4. TS should not be on lithium if he needs lisinopril


    I have had the privilege of developing and presenting programs that have covered a wide range of mental health topics. And, while I love this part of the CE experience, it is really the Q & A with you that I treasure the most. After each Q & A session I reflect back on the questions asked and felt compelled to circle back to these and use them in future updates._Viola! Perfect for the new launch of the micro CE mini-blog based on Tammie Lee Demler’s BEST in the classroom series..

    During my psychiatric updates, I am often asked how lithium fits in. I have become an increasing fan of lithium and I observe that many prescribers are hesitant to use this very effective medication because of fear of side effects. Here I share some basics and clinical pearls to refresh you in your advocacy for the safe use of lithium!

    Have a Great Day on the Bench!!

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    Overview of Drugs Requiring Renal Monitoring

    Drugs contraindicated in renal failure: Mnemonic

    Students often find the following amusing and memorable mnemonic helpful in recalling the major drugs that fall into this category:
    • Many (Metformin)
    • People (Potassium sparing diuretics)
    • Like (Lithium)
    • Napping (Nitrofurantoin)
    • Naked (N-SAIDS)
    In no particular order, then, let’s tackle some of the ‘big ones’:

    NSAID/COX-2 Inhibitors

    No difference in the safety profile of these two classes for drugs in renal insufficiency. Both can lead to edema, hypertension, acute and chronic renal failure.

    Acetaminophen is by far the safest analgesic in patients in renal failure. Use colchicine, renal adjusted dose joint injection or brief course of corticosteroids for episodic gout in renal failure.

    Lithium

    Withdrawal of lithium therapy can be associated with disastrous consequences and should only be done under the supervision of a physician experienced in the management of bipolar affective disorder. Because lithium is almost entirely renally excreted, monitor BUN, creatinine and TSH before and while a patient is on therapy. Use caution if the patient is sodium depleted or taking diuretic therapy. Maintenance lithium level is 0.6-1mEq/liter to minimize side effects.
    • Draw blood levels 12 hours after last dose.
    • Check blood levels: 5-7 days after initiation & any change in dosage.
    • Maintenance: every 1-2 months. In stable patients, every 6-12 months.
    • Monitor more frequently if volume depletion, or diuretic use, diarrhea or vomiting.
    • Check thyroid and renal function before starting lithium and every 6-12 months.
    • Hypothyroidism can occur and contribute to bipolar exacerbations
    IV contrast dye

    At least 5 percent of patients who undergo cardiac catheterization experience a transient rise in the plasma creatinine concentration of more than 1.0 mg/dL due to contrast-induced renal dysfunction. This risk is greater in patients who have diabetes. The plasma creatinine concentration usually returns to baseline within seven days, and less than 1 percent of patients, usually patients who have diabetes with underlying severe chronic kidney disease, go on to require chronic hemodialysis.

    High molecular weight/ ionic contrast dye can cause severe vasospasm in the afferent arteriole and acute renal failure. Risk factors include: diabetes, myeloma, chronic renal failure, dehydration, diuretic therapy and CHF. Less common with newer lower molecular weight/ nonionic contrast dyes. Best to avoid all together by utilizing MRI, ultrasound, CT scans.

    Acetylcysteine (Mucomyst®) can also be given orally to prevent nephrotoxicity caused by radio contrast dye. Usually administered orally the day before and the day of the procedure.

    Statin have also been shown to be protective of kidneys during cath procedures. At some institutions, it is now standard of care to put acute coronary syndrome (ACS) patients who are a candidate for percutaneous coronary intervention (PCI) on statins to prevent contrasted-induced acute kidney injury. High-dose rosuvastatin given on admission to statin-naïve patients with ACS who are scheduled for an early invasive procedure can prevent CI-AKI (contrast induced acute kidney injury) and improve short-term clinical outcome. (Statin Contrast Induced Nephropathy Prevention [PRATO-ACS]. Rosuvastatin (Crestor®) was given to statin naïve patients at a dose of 40mg for the first dose, then 20mg daily. https://www.jacc.org/doi/abs/10.1016/j.jacc.2013.04.105

    Antibiotics that do NOT require Dosage adjustment in Renal impaired:
    • Azithromycin (Zithromax®)
    • Cephtriaxone (Rocephin®)
    • Ciprofloxacin XL (Cipro-XL)
    • Clindamycin (Cleocin®)
    • Doxycycline Vibramycin®)
    • Linezolid (Zyvox®)
    • Minocycline (Minocin®)
    • Moxifloxin (Avelox®)
    For an excellent reference, consult the latest edition of the Sanford Guide. It features 23 pages of renally adjusted antibiotic/antiviral medications.

    Factor Xa inhibitors
    Pay attention to CrCl when dosing these anticoagulants. Even though they don’t require INR monitoring, renal function needs to be checked before prescribing.

    Rivaroxaban (Xarelto®): Nonvalvular Atrial Fibrillation (NVAF):
    • For patients with CrCl >50 mL/min: 20 mg orally, once daily with the evening meal
    • For patients with CrCl 15 - 50 mL/min: 15 mg orally, once daily with the evening meal
    Apixaban (Eliquis®)
    • Reduction of risk of stroke and systemic embolism in nonvalvular atrial fibrillation:
      • The recommended dose is 5 mg orally twice daily.
      • In patients with at least 2 of the following characteristics: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, the recommended dose is 2.5 mg orally twice daily.
    Edoxaban (Savaysa®)
    Treatment of NVAF: Assess CrCL before initiating therapy. The recommended dose is 60 mg once daily in patients with CrCL >50 to ≤ 95 mL/min.
    • Do not use edoxaban in patients with CrCL > 95 mL/min (sorry, your kidneys are “too” good for this drug!)
    • Reduce dose to 30 mg once daily in patients with creatinine clearance 15 to 50 mL/min
    Metformin (Glucophage®)
    • Metformin medications should be stopped at the time of or prior to CT studies with IV Contrast and withheld for 48 hours after the procedure.
    • Most experts prefer using creatinine clearance because it's adjusted for the patient's age, weight, and gender. (Cockcroft-Gault equation). When using creatinine clearance, avoid in patients with clearance less than 30 mL/minute.
    Allopurinol (Zyloprim®):
    Requires renal dosage adjustments: Titrate to dosage to lower uric acid to 6mg/dL. Decrease dose if renal impaired for maintenance.
    • If Creatinine clearance: 20mL/min= 200mg daily.
    • If Creatinine clearance: 10mL/min = 100mg daily
    STATINS: All statins require renal dosing adjustments except for Atorvastatin (Lipitor®)

    BETA-BLOCKERS:
    • The lipophilic beta blockers labetalol (Normodyne®), metoprolol (Toprol-XL®, Lopressor®) and Carvedilol (Coreg®) are the best options.
    • Most references recommend Carvedilol as the best choice due to its renal protective effect. Carvedilol with its alpha blocking ability blocks the unopposed alpha vasoconstriction.
    BISPHOSPHONATES: Should be avoided in CKD. AVOID: Renal insufficiency—do not use if CrCl is less than 35ml/minute


    When we look at the laundry list of medications in this piece, these drugs are most frequently used in patients at risk for renal impairment. Patients with metabolic syndrome, Type-2 diabetes, heart failure and hypertension are most likely to take these medications.

    Lithium is not a favorite among most family practitioners for bipolar disorder. Most family practice clinicians leave monitoring of this drug to the psychiatrists. At the clinic I helped staff two days a week we had a 20-year-old patient come in with his caregiver.

    It was in the summer and as I do with all of my lithium patients, reminded them of the need for adequate hydration. His caregiver alerted me that the kid was drinking a 2-liter bottle of water about every half hour. My ears perked up. When I see any lithium patient, I think thyroid and kidneys. I alerted our very astute PA, and the patient was diagnosed with lithium induced nephrogenic diabetes insipidus.

    This condition is rather common, occurring between 20-40% of all lithium patients. Especially during summer months, it is important for all pharmacists to caution lithium patients. While you are at it, remind your topiramate and zonisamide patients to drink up as well!

    Have a Great Day on the Bench!!

    April 2022

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    Overview of ACEs and ARBs

    The TRIPLE WHAMMY! ACE/ARB + DIURETIC + NSAID = TROUBLE

    ACE inhibitors are not nephrotoxic per se, or at least not in the manner that cyclosporine or aminoglycosides are. By inhibition of ACE (angiotensin converting enzyme) they alter the hemodynamics within the glomerulus. ACEI prevents the conversion of Angiotensin-I to Angiotensin II thus releasing the vasoconstriction of the efferent glomerular arterioles, with a subsequent decrease in the glomerular hydrostatic pressure. With less glomerular hydrostatic pressure, there is less glomerular filtration.

    How ACEI has beneficial renal effects: they decrease proteinuria possibly by selectively decreasing the permeability of the glomerular membrane to protein by stabilization of basement membrane of glomerulus. There is a risk of renal impairment in patients taking an ACE inhibitor (or ARB), diuretic, and NSAID. Combining any two of these drugs can lead to acute renal failure (Acute Kidney Injury) in susceptible patients. Combining all three is a "triple whammy."

    Mechanism: In the normal kidney, glomerular filtration is related to glomerular blood flow. In school we learned that the glomerulus is like a coffee filter. However, I would propose that the glomerulus is more like an espresso machine. An espresso machine is dependent on PRESSURE. If we INCREASE the flow into the vessel, and INHIBIT the outflow, pressure builds and filtration occurs.

    Endogenous prostaglandins are responsible for vasodilatation of the afferent arterioles, which allows increased blood flow to the glomerulus. When these prostaglandins are blocked, perfusion is reduced and filtration is inhibited.

    Angiotensin II is responsible for the vasoconstriction in the efferent arterioles, which is necessary to drive up pressure. We think of Angiotensin-II as a “bad guy” since it is responsible for elevating blood pressure. HOWEVER, this vasoconstriction in the efferent arterioles facilitates filtration, by essentially blocking the outflow.
    • NSAIDS: block prostaglandin mediated afferent arteriolar VASODILATION. (Allows blood to perfuse into the glomerulus)
    • ACE/ARB: blocks Angiotensin-2 mediated efferent arteriolar VASOCONSTRICTION (increases pressure for filtration)
    • DIURETICS: decrease plasma volume

    WHO’s AT RISK?
    Is a problem in patients who already have impaired renal function or at risk due to:
    • older age
    • heart failure
    • dehydration
    It is best to avoid chronic NSAIDs or aspirin for pain, including COX-2 inhibitors like celecoxib (Celebrex®).

    DON'T stop low-dose aspirin (doses of 325 mg/day or less aren't likely to cause renal problems)

    What to do:
    Monitor susceptible patients for worsening renal function:
    • increased blood pressure
    • elevated potassium (hyperkalemia)
    • edema
      • Don't reduce the dose or stop an ACE /ARB unless serum creatinine increases more than 30% within 2 months of starting the drug.
      • Stop (or reduce) ACE/ARB if serum potassium exceeds 5.5 mEq/L.
    ACE’s /ARB ‘s for diabetes
    Treatment with ACE inhibitors (or Angiotensin Receptor Blockers) results in kidney protection due to reduction of systemic blood pressure, intraglomerular pressure, an antiproliferative effect, reduction of proteinuria and a lipid-lowering effect in proteinuric patients (secondary due to reduction of protein excretion). Elderly patients with diabetes mellitus, coronary heart disease or peripheral vascular occlusion are at risk for deterioration of kidney function due to a high frequency of renal artery stenosis in these patients.
    Source: https://pubmed.ncbi.nlm.nih.gov/9036682/#:~:text=Treatment%20with%20ACE%20inhibitors%20results,to%20reduction%20of%20protein%20excretion

    Between 33% and 50% of patients with renal artery stenosis will usually have a mild decline in GFR, occurring within a few days after the administration of an ACE/ARB. A large decline in kidney function occurs in less than 5 to 10 percent of cases. The ACE inhibitor-induced reduction in GFR in renovascular disease almost always resolves after cessation of therapy. For renal protection in diabetics, it is always best to “start low and go slow.” If a patient has an elevated serum creatinine of more than 30% within one week of initiation of ACE/ARB therapy, bilateral renovascular disease should be strongly suspected.

    One of the toughest questions I answer from students is this: “Why do we give a drug like an ACE inhibitor or ARB to diabetics for renal protection when, in fact, they can be nephrotoxic?” My students love the analogy of the espresso machine, which is dependent on PRESSURE. If we INCREASE the flow into the vessel, and INHIBIT the outflow, pressure builds, and filtration occurs.

    Except for one student. One of my students was a family practice physician who just came to the United States. All throughout this segment he would shake his head. At the end of class he said, I understand everything you said, I just don’t believe it!

    Some find it hard to believe, since ACE inhibitors are revered for their effects on the kidneys and STAR ratings for Medicare. STAR ratings are based on patients with diabetes taking “RAS” drugs, including ACE inhibitors or ARBs. Physicians and pharmacists get “dinged” if their patients are not taking an ACEi or an ARB… regardless of the reason.

    That is unfortunate too, because we always need to be looking at the entire patient. Medicare plans look at numbers, while we look at patients!!!

    Have a Great Day on the Bench!!

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    Overview of Nephrotoxicity

    NEPHROTOXICITY

    Acute kidney injury (formerly known as acute renal failure) occurs in the hospital setting at a rate of 22% worldwide. Half of all the acute kidney injury cases occur in critically ill patients.
    https://pubmed.ncbi.nlm.nih.gov/30388976/

    Drugs Causing Tubular Epithelial Cell Damage:
    • Aminoglycoside antibiotics
    • Radiographic contrast media
    • Cisplatin & Carboplatin
    • Amphotericin-B: both tubular injury and renal vasoconstriction contribute to this drug’s nephrotoxicity
    • Tacrolimus and cyclosporine
    Hemodynamically mediated Renal Failure:
    • ACE inhibitors & ARBS
    • NSAIDS
    Obstructive Nephropathy: Drugs can cause renal stone formation either by raising excretion rates of naturally occurring stone components or by directly precipitating within the urinary tract. Seen in patients with volume depletion and renal insufficiency.
    • Acyclovir
    • Sulfadiazine
    • Indinavir & Foscarnet
    • Tricyclic Antidepressants
    • Triamterene (Potassium sparing diuretic)
    • Ciprofloxacin
    Glomerular disease:
    • NSAIDS
    • Hydralazine
    • Avoid potassium sparing diuretics if CrCl is less than 30
    Tubulointerstitial disease:
    • Methicillin
    • NSAIDS
    • Cyclosporine
    • Lithium
    • Methotrexate
    Pseudo-renal failure:
    • Corticosteroids
    • Trimethoprim
    • Cimetidine


    Selected antimicrobial agents causing nephrotoxicity:

    Aminoglycosides - examples:
    • neomycin –most nephrotoxic
    • Tobramycin and Gentamycin are about the same nephrotoxicity
    • Streptomycin is the least nephrotoxic.
    • Tetracyclines are nephrotoxic—(Doxycycline is safe, as it is fecally excreted)
    Mechanism: they accumulate in the proximal tubule, causing acute tubular necrosis.

    Cephalosporins: Keflex ® (cephalexin) may be nephrotoxic, use with caution in patients with CrCl less than 50mL/min.


    Selected antineoplastic agents causing nephrotoxicity:

    Cisplatin & Carboplatin: Proximal tubular damage occurs acutely after administration as a result of impairment of cell energy and production, possibly by binding to proximal tubular cellular proteins and sulfhydryl groups. Nephrotoxicity was 50-100% in the 1980’s but has been decreased to 6-13% by limiting total drug dose, and reducing the rate of administration. Contributes to acute renal failure if used with other nephrotoxins.

    Selected immunosuppressant drugs causing nephrotoxicity

    Cyclosporine (Neoral®) and Tacrolimus (Prograf®): Toxicity is usually dose dependent. It causes distal tubular dysfunction from severe vasoconstriction. Causes reversible vasoconstriction and injury to glomerular afferent arterioles, possibly because of increased activity of vasoconstrictors. Regular blood monitoring is necessary to prevent nephrotoxicity. Kidney biopsy is necessary in transplant patients to distinguish rejection from toxicity. Calcium channel blockers are useful, blocking the vasoconstrictive effects of cyclosporine.

    Tacrolimus and cyclosporine: calcineurin inhibitors with a high risk of developing kidney injury either as acute kidney injury, which is largely reversible after reducing the dose, or as chronic progressive kidney disease, which is usually irreversible.

    Managed with dose reduction and/or discontinuing interacting drugs.

    Renal failure is insidious, and frequently slips by prescribers. Many drugs that are in our fast-moving section require a lot of respect. Drugs like ibuprofen, lisinopril, hydrochlorothiazide, metformin, cephalexin, and allopurinol are purchased in bottles of 500 or 1000, and we dispense them frequently. All of them can cause problems with kidney function.

    A “triple whammy” is sometimes observed, featuring ACE’s/ ARBS when given with a diuretic and an NSAID. Numerous drugs we frequently dispense require renal dosing from antibiotics to gabapentin and the Factor Xa inhibitors for anticoagulation.

    These fast movers deserve our respect.

    Have a Great Day on the Bench!!

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    Overview of Beta-3 Receptor Agonists for Overactive Bladder & Agents for Female Sexual Function Disorder

    Mechanism of Action: By stimulating beta-3 receptors, these drugs relax the detrusor muscle during the storage phase of the urinary bladder fill-void cycle thereby increasing bladder capacity.

    Mirabegron (Myrbetriq®) $420/month (FDA approved:2013)
    • Available as extended-release tablets: 25mg or 50mg
    • Available as extended release suspension 8mg/mL 100mL bottles (28 day expiration)
    Advantages: does NOT cause anticholinergic side effects. Less likely to cause prolongation of QT on EKG. Disadvantages:
    • Moderate blocker of CYP2D6 pathway (increases metoprolol and digoxin levels)
    • May cause increases in blood pressure (8-10% incidence).
    • Allow 8 weeks to see full benefit.
    • Don’t exceed 25mg/day if patient has renal impairment
    Vibegron (Gemtesa®) $480/month April-2021
    • Available as 75mg tablets
    Advantages:
    • Being a Beta-3 agonist, it does not cause anticholinergic side effects.
    • Less increases in blood pressure than seen with mirabegron
    • Does not block CYP-2D6
    • Less discontinuation- significantly less side effects
    Female Sexual Dysfunction:

    Women have very limited treatment options in the realm of sexual dysfunction, with the available options (flibanserin (Addyi®) and bremelanotide (Vyleesi®) being grossly cost prohibitive. A year’s worth of flibanserin would be $6,600 for six sexual encounters per year, while the same $6,600 would buy approximately a months’ worth of bremelanotide.

    The Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-V) defines Female Sexual Disorders (FSD) as disturbances in the female sexual response cycle, resulting in marked distress and interpersonal difficulties. In particular, female sexual arousal disorder (FSAD) belongs to the subcategory “female sexual interest/arousal disorder” and is one of the most prevalent subcategories of FSDs.

    - Includes lack of sexual desire, impaired arousal, inability to achieve orgasm, anxiety about sexual performance, not finding sex pleasurable or pain with sexual activity - Approximately 40% of women in the U.S. have sexual concerns - Sexual response cycle: Desire (libido) → Arousal (excitement) → Orgasm → Resolution

    Risk Factors: depression, anxiety, psychotic disorders, benzodiazepines, SSRIs

    Treatment: treat underlying cause, lifestyle modifications (weight loss, diet, sleep), lubrication, therapy

    Female Hypoactive Sexual Desire Disorder (HSDD):
    • Estrogen - (alone or in combination with progestin) for peri/postmenopausal atrophic vaginitis
      • May improve vaginal environment - less dryness, improved mucosa, reduced pH
    • Testosterone - NOT FDA approved, often prescribed off label w/ or w/o estrogen
      • May be effective for short-term treatment but limited evidence for treatment >6 months
      • Increases # sexually satisfying events by around 1.2 events/month
      • Formulations: tablet, transdermal spray, patch
      • Contraindications: presence/high risk of breast/endometrial cancer, VTE, CV disease
      • Adverse events: hirsutism/virilization, acne, CV complications, breast cancer
    • Bupropion - norepinephrine-dopamine reuptake inhibitor
      • May increase sexual arousal and orgasm (may or may not improve desire) in HSDD
    Flibanserin (Addyi®)- serotonin receptor 1A agonist/serotonin receptor 2A antagonist, 2015
    • Cost for 30 tablets is ~$550.00
    • 100 mg tablet, once daily at bedtime (NOT PRN) in premenopausal women
    • Increases number of sexually satisfying events by approximately 0.5 events/month
    • Can cause dizziness, somnolence, nausea, fatigue, insomnia, dry mouth
    • Interacts with CYP3A4 inhibitors, alcohol CONTRAINDICATED with use (can cause severe hypotension/syncope), must enroll in REMS program to prescribe
    • Not for those with HSDD due to medical/psych conditions, medications or other drug substance, or relationship problems
    Female Orgasmic Disorder: mainstay of treatment is psychotherapy

    Sexual Pain Disorder: conduct pelvic exam, consider hormonal treatments (estrogen, ospemifene)

    Bremelanotide (Vyleesi®) (approved June 21,2019)

    Cost: ~$6,667.00 per month (9 autoinjectors)

    Mechanism: Activates melanocortin receptors, but the mechanism by which it improves sexual desire and related distress is unknown.
    • The First FDA-Approved As-Needed Treatment for premenopausal women experiencing distress or interpersonal difficulty due to low sexual desire
    • 1 in 10 Premenopausal Women in the U.S. (Approximately 6 Million Women) suffer From HSDD
    EFFICACY: There was no difference between treatment groups in the change from the start of the study to end of the study in the number of satisfying sexual events. Bremelanotide does not enhance sexual performance. (source: FDA)
    • 25% of patients treated with bremelanotide had an increase of 1.2 or more in their sexual desire score (scored on a range of 1.2 to 6.0, with higher scores indicating greater sexual desire) compared to about 17% of those who took placebo
    DOSING: Inject SQ at least 45 minutes prior to sex
    • Only one dose per 24 hours
    • Maximum of 8 doses per month
    • Only for use in pre-menopausal women
    • Available as an auto-injector 1.75mg dose (per 0.3mL)
    • STOP: treatment after eight weeks if they do not report an improvement in sexual desire and associated distress.
    SIDE EFFECTS:
    • nausea (40%) and vomiting, (13% needed meds to control nausea and vomiting)
    • flushing
    • injection site reactions
    • headache
    • hypertension- usually resolves in 12 hours, not recommended for uncontrolled hypertension or cardiac patients
    MAJOR DRUG INTERACTION: Naltrexone (Revia®) if taken by mouth, bremelanotide may significantly decrease the levels of naltrexone in the blood. Patients who take a naltrexone-containing medication by mouth to treat alcohol or opioid dependence should not use bremelanotide because it could lead to naltrexone treatment failure.

    CHECK THE MED LIST!
    Watch for female sexual dysfunction caused by meds - review medication list for SSRIs/benzodiazepines
    • Highest risk antidepressants (>30%): fluoxetine, fluvoxamine, paroxetine, sertraline
    • Medium risk (10-30%): citalopram, duloxetine, escitalopram, venlafaxine
    • Lowest risk: bupropion, mirtazapine, desvenlafaxine, vilazodone, vortioxetine
    NOTE: In one study, the incidence of individuals who spontaneously reported sexual side effects was 14% compared with 58% of individuals who reported sexual side effects when asked directly by their physicians. It is fair to say, it is an issue worth bringing up. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007725/

    Management strategies for SSRI-induced sexual dysfunction:
    1. Consider decreasing dose of offending medication.
    2. Switching to another SSRI or antidepressant, augmenting therapy with bupropion.
    Remember to taper, cross-taper, or leave wash-out periods when switching between SSRIs/antidepressants as appropriate!

    The distinct side effect profiles of anticholinergics and beta-3 receptor agonists, is a “no-brainer.” All of the peripheral side effects of the anticholinergics, along with the increase chance for dementia, make them no competition for the beta-3 agonists. Beta-3 agonists are as efficacious, albeit more expensive.

    Beta-3 receptor agonists appear to be at least effective as the anticholinergic medications, without the side effects of dry mouth, constipation, cardiac issues and possibly dementia. Reduced discontinuance rates may favor these products, however due to their expense, might require prior authorizations from insurance companies.

    Have a Great Day on the Bench!!

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    Overview of Anticholinergics for the Pharmacological Management of Overactive Bladder

    Mechanism: Drugs with anticholinergic activity are often the first drug used for Urge Urinary Incontinence (UUI). Drugs with anticholinergic activity act by antagonizing muscarinic cholinergic receptors, through which efferent parasympathetic nerve impulses evoke detrusor contraction. The detrusor muscle is responsible for urine flow. The net effect of cholinergic blockade is increased bladder capacity and decreased urgency. In addition, women with mixed Urinary Incontinence (UI) or UUI plus urethritis or vaginitis may benefit from topical or systemic estrogen (alone or in combination with an anticholinergic.)

    General Distribution of Muscarinic Receptor Subtypes

    M1Brain (cortex, hippocampus), glands, sympathetic ganglia
    M2Heart, smooth muscle (including detrusor), hindbrain
    M3Smooth muscle (detrusor), salivary and excretory glands
    M4Brain (cerebral cortex, striatum), lung
    M5Brain (substantia nigra) eye
    COMPARISON of ANTICHOLINERGICS

    Brand NameGenericM3 selectivityDosage
    Ditropan 5mgOxybutynin+(5mg) 2 to 4 times daily
    Ditropan XL 5mg, 10mg , 15mg tabsOxybutynin+(5 to 30mg) once daily
    Detrol 1mg,2mgTolterodine+(1mg –2mg) BID
    Detrol LA 2mg, 4mgTolterodine+(2mg-4mg) once daily
    Sanctura 20mgTrospiumleast(20-40mg) BID
    Sanctura XR 60mg capsTrospiumleast60mg once daily in am
    Enabelex 7.5 & 15mgDarifenicin+++(30mg) daily
    Vesicare 5mg & 10mgSolifenacin++(5mg-10mg) once daily
    Toviaz® 4mg & 8mgFesoterodine++4-8mg daily (use 4mg if on CYP450 blocker)


    Differences in the available products:

    Sanctura ® (trospium), although is the least M3 selective is most commonly used in Europe. It is a quaternary amine/anticholinergic. Not as lipid soluble and minimal blood brain barrier penetration, and less sedation. Improves OAB symptoms in 3 days. Negligible amount metabolized by P450, therefore minimal drug interactions. Give on empty stomach.

    Detrol (oxybutnin) and Detrol LA (oxybutynin ER) are the most commonly used anticholinergics at this time.

    Toviaz ® (fesoterodine) is a prodrug, with the same active metabolite as tolterodine (Detrol). Cost is over $400/month. Topical anticholinergic for bladder control. Avoids first metabolism and less anticholinergic side effects.

    Oxytrol® Oxybutynin patch (3.9 mg/24 hr patch) dose 3.9mg twice a WEEK Available Rx cost approximately $740.00 per box of 8 patches. Over the Counter (retail $29.99) per box of 8 patches.

    Gelnique® available in one gram foil packets. Apply 1 gel-packet once daily. Cost is around $450.00/month

    Oral oxybutynin is available as a generic, and is dosed 3 times daily. This is often the first choice of the insurance companies due to costs. Sanctura® (trospium) is also generically available. Many insurance companies require a patient to “try and fail” on generic oxybutynin before approving the more expensive ($120-$430/month) brand name products.

    Anticholinergics: Even a single anticholinergic medication can increase the risk of cognitive impairment by up to 50%...even more in patients who've had a stroke or have a family history of dementia. Anticholinergics are also linked to higher hospitalization rates. Anticholinergics are sometimes added for incontinence that's caused or exacerbated by a cholinesterase inhibitor, used for Alzheimer’s. These cholinesterase inhibitors increase cholinergic activity and may lead to OAB symptoms.

    The more potent the anticholinergic, the more likely it will cause memory loss. The potent anticholinergics were most often associated with poorer memory and executive function, brain hypometabolism, brain atrophy, and increased risk of clinical conversion to cognitive impairment. Source: JAMA Neurol. 2016;73(6):721-732. doi:10.1001/jamaneurol.2016.0580


    Other anticholinergics: Drugs with significant anticholinergic adverse effects decrease urinary bladder detrusor muscle contractility, resulting in urinary retention (examples: antihistamines, tricyclic antidepressants, phenothiazines).

    Drugs like Detrol® (tolterodine) poses little risk of urinary retention, IF there is good flow. Antimuscarinics work during storage, rather than voiding.

    This category of drugs is frustrating as a community pharmacist. Third party payers sometimes demand that patients try and fail anticholinergics, potentially causing a whole boatload of problems. We give drugs for Alzheimer’s that increase cholinergic activity (donepezil) and others. Then, a prescriber must prescribe an ANTI-cholinergic if the patient has overactive bladder. These payers sometimes insist that prescribers give cholinergics and ANTI-cholinergics to the same patient!

    I was also amazed to see that our warehouse (McKesson) still has oxybutynin (Oxytrol®) over the counter. The cost difference is nearly $700!

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    March 2022

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    OVERACTIVE BLADDER- THE BASICS

    Overactive Bladder (OAB) is characterized by the presence of involuntary bladder contractions that occur during bladder filling, despite the patients attempt to suppress them. An individual presenting with OAB is likely to present with several of the following symptoms:
    • Increased daytime frequency: individual believes that he or she voids too often during the day.
    • Urgency: the sudden compelling desire to pass urine, which is difficult to defer.
    • Urinary incontinence: any involuntary leakage of urine. Should be described further by specifying other relevant factors, such as type, frequency and severity.
    Additional symptoms of OAB may include:
    • Urge Urinary Incontinence (UUI): involuntary leakage accompanied by or immediately preceded by urgency. Can present in different symptomatic forms, for example small losses between micturition or complete bladder emptying. UUI is most commonly found in older women and believed to be from detrusor muscle overactivity.
    • Stress Urinary Incontinence (SUI): involuntary leakage on effort or exertion or sneezing or coughing or anything that builds up abdominal pressure. Believed to be due to the lack of mechanical support of the urethra which leads to insufficient resistance to outflow of urine during increased abdominal pressures. Seen most commonly in women ages 45 to 49 years.
    • Mixed Urinary Incontinence (MUI): involuntary leakage associated with urgency, and also with exertion, effort sneezing or coughing.
    • Overflow Urinary Incontinence: can be due to detrusor muscle underactivity and is characterized by a loss of urine with no warning or triggers. The volume leaked may be small or large and can occur with a change of position or activity.
    • Nocturia: waking to void at night 2 or more times.
    Drugs that can affect bladder contractility:
    • Anticholinergics
      • Tricyclic antidepressants such as amitriptyline (Elavil®)
      • First generation antihistamines such as diphenhydramine (Benadryl®), chlorpheniramine (Chlor-trimeton®)
      • GI spasmolytics: dicyclomine (Bentyl®), hyoscyamine (Levsin®), glycopyrrolate (Robinul®)
      • Anticholinergics for Parkinson’s: trihexyphenidyl (Artane®) and benztropine (Cogentin®)
    • ACE inhibitors: (lisinopril etc.) decreases contractility, as well as potentially causing an increased frequency of cough.
    • Benzodiazepines: (diazepam, lorazepam etc) their muscle relaxation effect may impair bladder emptying.
    • Alpha blockers like Tamsulosin (Flomax®) terazosin (Hytrin®) and all members in this class decrease urethral sphincter tone.
    • Any antipsychotic, antidepressant or muscle relaxants with anticholinergic effects will decrease bladder contractility
    • Alcohol: decreases contractility
    • Caffeine: increases contractility and rate of emptying. Diuretic effect increases urine volume.


    Non-Pharmacological Management: There is no cure for OAB, so management techniques are essential. Keep a bladder diary. Keep a record of ins & outs.
    • Education about lifestyle interventions
    • Regulate fluid intake
    • Eliminate bladder irritants (alcohol & caffeine, carbonated beverages, artificial sweeteners, citrus juices, tomato-based products, chocolate)
    • Maintain bowel regularity
    • Kegel exercises- Pelvic muscle rehab. Strengthens muscles in pelvic floor which support the bladder neck & urethra. Method:
      • Find the right muscles: imagine you are trying to stop yourself from passing gas. Squeeze the muscles you would use, if you sense a “pulling feeling” those are the right muscles.
      • It is important not to squeeze other muscles, at the same time, and NOT to hold your breath. Be careful not to tighten your stomach, leg, or buttock muscles. Squeezing the wrong muscles can put undue pressure on bladder control muscles.
      • Pull in muscles, hold for count of 3. Relax for a count of 3. Work up to 3 sets of 10 repeats.
      • Start doing these exercises lying down, this is easiest because muscles do not need to work against gravity. When muscles get stronger, do them sitting or standing. Working against gravity is like adding more weight.
      • Repeat but don’t overdo it
    • Bladder training-void regularly every hour on the hour. Then increase duration between voids by 15 minutes each week, until comfortable with urinary frequency. This helps with control by suppressing involuntary detrusor contractions. Check out: https://medlineplus.gov/ency/patientinstructions/000141.htm


    According to the Agency for Healthcare Research and Quality, approximately 15.1 % of US women report overactive bladder (OAB) and 11.0 % report OAB with urge urinary incontinence.

    When we see the selection of incontinence products in our over-the-counter space and the number of OAB meds on our shelves, we can make a definite difference in this population.

    Most of the treatment options for OAB, with the exception of two, are taking advantage of the “side effects” caused by anticholinergic therapy. This represents a huge market where patient consultation is a must.

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    Overview of Treatment Options for Interstitial Cystitis (Bladder Pain Syndrome)

    Pentosan polysulfate sodium (Elmiron®) 100mg caps
    Recommended dose: 300 mg/day taken as one 100 mg capsule orally three times daily. The capsules should be taken with water at least 1 hour before meals or 2 hours after meals.
    Patients should be reassessed after 3 months. May take 3-6 months for improvement.



    WARNINGS
    Weak anticoagulant effect: This drug is a heparin-like compound, with approximately 1/15th the effect of heparin. It is in the low-molecular weight heparin family. Mechanism of action for IC is unknown. Pregnancy Category-B (inform clinician if pregnant) FDA WARNING 2020: Retinal pigmentary changes
    • A detailed ophthalmologic history before starting therapy.
    • For patients with preexisting ophthalmologic conditions, get a baseline before starting therapy for future comparison.
    • A retinal examination is suggested for all patients within six months of initiating treatment and periodically while continuing treatment. If pigmentary changes in the retina develop, access risk versus benefits.
    • May be a cumulative effect.
    ADVERSE EFFECTS:
    The most common side effects are hair loss (almost always limited to a single area of the scalp), diarrhea, nausea, blood in the stool, headache, rash, upset stomach, abnormal liver function tests, dizziness, and bruising.

    DIETARY APPROACH:
    Some foods are well known for causing interstitial cystitis (IC): Start by eliminating the top offenders: citrus (Vitamin-C), spicy hot foods, Mono Sodium Glutamate (MSG), soy, caffeine, coffee, tea, sodas, alcohol, tomatoes, cranberry juice, and chocolate.

    There are lists of: “Most bothersome”, “IC friendly” and “Foods worth trying”. Each individual should maintain a food diary. A useful website that I recommend is:
    http://www.ichelp.org/living-with-ic/interstitial-cystitis-and-diet/elimination-diet/least-and-most-bothersome-foods/

    WORTH CONSIDERATION:
    • Bladder training with “urge suppression" may be helpful.
    • Patients might also get relief from OTC therapy such as ibuprofen, acetaminophen, or naproxen.
    • Tricyclic Antidepressants, such as amitriptyline might be helpful to relieve the neurogenic pain component as well as help manage the depressant symptoms of the disease state.



    Phenazopyridine (Pyridium®) 100mg & 200mg tablets
    available OTC: Azo-standard® 95mg and 97.5mg
    • Mechanism: Phenazopyridine is an “azo” excreted in the urine, where it exerts a direct topical analgesic effect, on urinary tract mucosa. 65% remains unchanged in the urine.
    • Phenazopyridine has been marketed since 1925 and since 1951 has had a dual status of prescription and over-the-counter
    • status of prescription and over-the-counter Indication: symptomatic relief of discomfort and pain
    OTC Dosage:
    • 97.5mg (maximum strength) three times daily with meals.
    • 95mg (regular strength) three times daily with meals
    • Do not administer for more than 2 days with antibacterial agents (no benefit if longer). May mask symptoms of inappropriate antibiotic choice.
    Indication: symptomatic relief of discomfort and pain, before antibacterial therapy becomes effective.

    Prescription dosage: Phenazopyridine (Pyridium®) 100-200mg three times daily with meals. Do not administer for more than 2 days with antibacterial agents. (no benefit if longer). May mask symptoms of inappropriate antibiotic choice.

    Warnings, precautions, adverse effects:
    • Headache/ rash /pruritis
    • Staining of contact lens
    • Discoloration of urine – reddish-orange in color
    • Patient information
    • Avoid if glucose-6-phosphate dehydrogenase deficient
    • Avoid if kidney function is less than 50mL/minute.
    Patient education:
    • This medicine will change the color of your urine to red or orange. This is temporary and harmless, but it can stain clothing and towels. Other body fluids may be discolored as well. Recommend mini-pads to minimize staining.
    • Don't wear soft contact lenses while taking this medicine. It can permanently stain your lenses.
    • Take with food
    • May mask symptoms of active infections


    I met a patient a few years back, a 30-year-old female with interstitial cystitis (IC), or what is commonly known as ‘bladder pain syndrome’. She kept track of her IC triggers, which included smoked foods, soda, especially “citrus based soda”, iced tea, and sports drinks.

    It is also advisable that the patient maintain a bladder diary, as patients truly suffer with this disease state. Many patients seem to get the most benefit from dietary restriction. This incurable inflammatory bladder condition affects up to half a million people, primarily women (10:1 females:males) . It causes severe pain and urinary frequency, similar to the symptoms caused by a severe bladder infection. Unlike infections, however, bacteria are not usually found.

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    Prophylaxis of Urinary Tract Infections

    Prophylaxis is indicated for:
    Women with 3 or more episodes per year (or 2 or more in 6 months). Be sure to exclude abnormalities: stones, reflux, fistula etc.
    Agents must eliminate pathogenic bacteria from the fecal or introital reservoirs, and not cause bacterial resistance. Prophylaxis is appropriate if recurrent cystitis episodes have no association to coitus.

    ANTIBIOTIC PROPHYLAXIS:
    ANTIBIOTIC PROPHYLAXIS: Once daily dosing-usually at bedtime
    • Trimeth/Sulfa SS (400/80): ½ tablet daily at bedtime
    • Trimethoprim 100mg daily
    • Cephalexin (Keflex®)? 250mg daily
    • Nitrofurantoin (Macrodantin®)? 50mg or 100mg daily
    Note : this product is?NOT?MacroBID®.? It is an immediate release product. Take with food or milk to prevent GI upset.

    Post coital dosing for prophylaxis:
    • Trimeth/Sulfa SS (400/80) one tablet once
    • Trimethoprim 100mg one tablet once
    • Cephalexin 250mg one capsule once
    • Nitrofurantoin: 50mg or 100mg one capsule once
    Self-administered antibiotic therapy:
    • Self-administered single dose of Trimeth/Sulfa DS two tablets at onset of symptoms
    UTI prevention tips that actually work:
    • Urinate immediately after having sexual intercourse. Urinating flushes out bacteria that may have entered the urethra during intercourse.
    • Use proper hygiene. Wipe front to back.?
    • Rinse the vulva after sex.
    • Keep well hydrated with water and avoid “holding it” throughout the day
    • Wear regular cotton underwear. Thong underwear can lead to UTI’s by tracking bacteria from the rectal area into the urethra via the vagina.
    • Don’t smoke; it lowers immunity.
    • Avoid condoms coated with nonoxynol-9
    • In post-menopausal women, topically administer estrogen cream.? It decreases the colonization of the E.coli.
      • Nitrofurantoin is more effective; however, clinicians worry about pulmonary fibrosis with long term nitrofurantoin use.
    URINARY TRACT ANTISEPTICS:
    • Methenamine Hippurate (Hiprex®) FDA approved 1967: 1,000 mg twice daily
    • Methenamine Mandelate (Mandelamine®): 1,000 mg 4 times daily
    Urinary tract infection, prophylaxis/suppression. Prophylaxis or suppression of recurrent urinary tract infections when long-term therapy is indicated, and infection has been eradicated by appropriate antimicrobial treatment.? Needs acidic urine for maximum efficacy. Restrict alkalinizing foods and medications to maintain urine pH ≤5.5.

    Mechanism: methenamine component is hydrolyzed to formaldehyde in acidic urine. Hippuric or mandelic acid, has some antibacterial activity and also acts to keep the urine acidic.

    Note: should only be used?after?eradication of the infection by other appropriate antimicrobial agents.

    CRANBERRY SUPPLEMENTS:
    Cranberry appears to work by inhibiting the adhesion of type I and P-fimbriated uropathogens (e.g. uropathogenic E. coli) to the uroepithelium, thus impairing colonization and subsequent infection.? It seems to work in the lab, but there is no compelling data to “push” these products.

    Because of clinical study designs and the lack of consensus regarding the dosage regimen and formulation to use, cranberry products cannot be recommended for the prophylaxis of recurrent UTIs at this time.

    Cranberry tablets- (AZO Cranberry®) no data to support its use, and causes significant GI upset and heartburn.

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    Overview of Treatment Options for Urinary Tract Infections in Pregnancy

    DRUGS to AVOID:
    Tetracyclines, Sulfonamides (1st and late 3rd trimester), fluoroquinolones.

    OPTIONS FOR CONSIDERATION:

    Cephalosporins: Cephalexin (Keflex®) 250-500mg every 6 hours for 7 days.
    Cefpodoxime (Vantin®) 100mg BID for 5-7 days (third-generation cephalosporin)
    Penicillins: Amox/clav (Augmentin®) 500mg every 8 hours OR Amox/clav 875/125 twice daily for 7 days.
    Nitrofurantoin: MacroBID® 100mg twice daily for 7-10 days (avoid if G-6-PD & at term).
    • Historically marked as ‘Pregnancy Category B’. Recommended that nitrofurantoin be AVOIDED during the first trimester and late last trimester of pregnancy due to potential for hemolytic anemia in newborns.
    Trimeth/Sulfa (Bactrim DS®): 1 tablet BID x 7days.
    • Avoid Trimeth/Sulfa during 1st trimester and 3rd trimester near term. Avoid if G-6-PD.
    • Remember, trimethoprim is a folic acid antagonist, and should be avoided during the first trimester.
    • Avoid all sulfonamides in the last days before delivery because they can displace bilirubin from plasma binding sites in the newborn, which may possibly increase risk for kernicterus.
    Fosfomycin (Monurol®) only indicated for UTI

    Mechanism: broad spectrum bactericidal antibiotic, that interrupts cell wall synthesis. It also reduces bacterial adherence to the uroepithelial cells.

    Dosage: 1 packet (3gm of granules) mixed with 3-4 oz. cool water and dissolve. Drink at once.
    May see diarrhea (9%) and Headache (4%) and nausea (4%)
    Pregnancy category-B

    Patient information:
    • May take with or without food.
    • Symptoms should improve in 2 or 3 days. If not, call clinician. Do not repeat dose.
    • Always mix with water. Do not ingest in dry form.
    • Clinician note: this drug is seldom used, so call the pharmacy to see if it is in stock.
    • Good choice if the patient is pregnant.
    • Good choice if the patient is sulfa allergic, or if local E.coli are over 20% resistant.
    • Approximate cost: $75.00 for 1 packet (1 dose)
    Fluconazole: For yeast infections, high dose fluconazole (400mg-800mg/day) is teratogenic. However, the 150mg dose for vaginal yeast infections has data that is not so clear. Best to avoid since topical azole antifungals such as clotrimazole and miconazole are so safe and effective.

    I would have to think that the toughest job for any OB/GYN would be prescribing any medication in pregnancy. I remember when Bendectin® was pulled from the market in 1983, due to lawsuits. Bendectin® was a combination of doxylamine and pyridoxine, both which were Pregnancy Category A drugs at the time. Today, we have Diclegis® and Bonjesta®, which contain the same ingredients for nausea of pregnancy.

    One day when my wife Denise was working the bench, the OB/Gyn department called with a question. They had a patient with a UTI and were not sure what to give. The patient was pregnant (so, no fluoroquinolones/tetracyclines). The culture showed resistance to penicillins (so, no cephalexin/penicillins), and the patient was from the Middle East and had Glucose-6 Phosphate deficiency (so, no nitrofurantoin or Trimeth/sulfa)! Of course, my wife knew the only answer...Fosfomycin (Monurol®), which the practitioners had never heard of!

    Denise ordered in the drug for the patient, who recovered without incident. As I always tell my student pharmacists, yes those patients are REAL and many times come to our pharmacies. We have to be the drug experts!

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    February 2022

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    Treatment of Uncomplicated Cystitis

    MICROBIOLOGY

    UTI’s are the most common bacterial infection in women. The most common bacteria found in acute uncomplicated cystitis is E.coli, which is responsible for 75% to 95% of all cases. The remainder of the cases are caused by Proteus mirabilis, Klebsiella pneumoniae, and Staphylococcus saprophyticus. Most cases can be treated with short course therapy.

    I highly recommend that pharmacists call the inpatient pharmacies at their local hospitals, as resistance rates may vary significantly by region. Hospital pharmacists are the keepers of the antibiograms.

    THE ‘GO TO’ DRUGS FOR UNCOMPLICATED UTI:

    TRIMETHOPRIM/SULFAMETHOXAZOLE DOUBLE STRENGTH
    Sanford Guide recommends use only if local E.coli resistance is less than 20%, and patient has no allergy.
    Watch for drug interactions, especially with warfarin.
    Pregnancy Category D
    • TRIMETH/SULFA (Bactrim DS®) (1) TABLET TWICE DAILY FOR 3 DAYS
    Complicated: Trimeth/Sulfa DS: Give BID for 7-10 days

    FLUOROQUINOLONES
    Sanford Guide recommends use of fluoroquinolones if local resistance patterns for E. coli are 10% or less and patients can’t take SMX/TMP.

    Watch for drug interactions.
    Absorption can be blocked with di and trivalent cations such as calcium, iron, magnesium etc.
    May cause fluctuations in blood sugars.
    Is an alternative choice for patients with sulfa allergy or contraindications (G6P-dehydrogenase).
    (Note: moxifloxacin does not achieve high enough levels in the kidney/bladder for treatment of UTI’s)

    • CIPROFLOXACIN (Cipro® 250mg) (1) TABLET TWICE DAILY FOR 3 DAYS
    Complicated: Ciprofloxacin 250-500mg BID for 7 to 10 days.
    • LEVOFLOXACIN (Levaquin 250mg) (1) TABLET DAILY FOR 3 DAYS
    Complicated: Levofloxacin 250mg daily for 7 to 10 days

    NITROFURANTOINS

    NITROFURANTOIN MACROCRYSTALS MONOHYDRATE
    Recommended writing for “MacroBID” do not confuse for “Macrodantin”.
    Avoid if G6P-dehydrogenase. Pregnancy Category B
    • NITROFURANTOIN MAC/MONO: (MacroBID 100mg) (1) CAP TWICE DAILY FOR 5 DAYS
    Prescribing tips:
    • AVOID nitrofurantoin in patients with creatinine clearance less than 60mL/minute. However, there is a bit of a controversy, with some references saying 30-40mL per minute. The newest Beers list allows for nitrofurantoin use down to 30mL/minute.
    • AVOID nitrofurantoin if early pyelonephritis is suspected, because serum concentrations don’t get high enough to treat systemic infections.
    • AVOID last week of pregnancy due to potential for hemolytic anemia in newborns.
    • WATCH for: increased risk for pulmonary toxicity, neuropathy, hepatotoxicity.
    • AVOID in complicated UTI

    Fosfomycin (Monurol®) only indicated for UTI

    Mechanism: broad spectrum bactericidal antibiotic, that interrupts cell wall synthesis. It also reduces bacterial adherence to the uroepithelial cells.

    Dosage: 1 packet (3gm of granules) mixed with 3-4 oz. cool water and dissolved. Drink at once.

    May see diarrhea (9%) and Headache (4%) and nausea (4%) Pregnancy category-B

    Patient information:
    • May take with or without food
    • Symptoms should improve in 2 or 3 days. If not, call the clinician. Do not repeat dose
    • Always mix with water. Do not ingest in dry form.
    • Clinician note: this drug is rarely used, so call the pharmacy to see if it is in stock
    • May be a good choice if patient is pregnant
    • May be a good choice if the patient is sulfa allergic, or if local E.coli resistance rates are over 20%.
    • Approximate cost: $75.00 for 1 packet (1 dose)


    I am always impressed with the bacterial resistance rates in the areas that I practice. It makes sense to me that nitrofurantoin resistance rates are always less than 10% for E.coli.

    Given the fact that trimethoprim/sulfamethoxazole and the fluoroquinolones can be used for a variety of infections, there is more potential for overuse of these medications. Nitrofurantoin has limited use, and therefore, is much less likely to be “overprescribed.”

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    Overview of Acute Pyelonephritis

    ACUTE PYELONEPHRITIS--- OUTPATIENT

    Is an infectious inflammatory disease involving the kidney parenchyma and renal pelvis. Gram negative bacteria (most likely: E.coli) are most common. Infection usually ascends from the lower urinary tract, with the exception of Staph aureus, which is spread hematogenously. Usually occurs in women 18-40 years of age.

    Clinical presentation:
    • Temperature over 102F
    • Definite costovertebral tenderness (flank pain)
    • Voiding symptoms
    • Positive urine culture.
    Mild cases can be treated with oral medication. Severe cases should be hospitalized.
    • ALWAYS perform culture and sensitivity!
    • Monitor for drug interactions if using SMZ-TMP or fluoroquinolones.
    Antibiotics should be dosed for at least 2 weeks. Highly active agents such as fluoroquinolones can be given for 7 days.

    Sanford guide recommends:
    Ceftriaxone 1gm IV, then may transition to:
    fluroquinolones for 5-7 days.
    • Ciprofloxacin (Cipro®) 500mg BID x 7 days OR
    • Levofloxacin (Levaquin®) 750mg Daily for 7 days
    Other Options:
    • SMZ/TMP (Bactrim-DS®) should not be used for initial empiric therapy because of high rates of resistance, SMZ/TMP 160/800 mg (one DS tablet) PO twice daily x 14 days is appropriate treatment of uncomplicated cystitis for pathogens known to be sensitive.
      • Watch for warfarin interactions and hyperkalemia
    • Oral Cephalosporins for 14 days. (Oral beta-lactams are less effective for acute pyelonephritis and frequently relapse.)
    • Amoxicillin/Clavulanic acid (Augmentin®) for 14 days. (Oral beta-lactams are less effective for acute pyelonephritis and frequently relapse.)
    • Nitrofurantoins (MacroBid®) are not recommended for acute pyelonephritis as it does not attain therapeutic levels in renal parenchyma.
    Hopkins Antibiotic Guide recommends: consider an initial dose of a parenteral agent, particularly if fluoroquinolone resistance is >10%. Then complete treatment as guided by antimicrobial sensitivity results.
    • Ceftriaxone 1 gm IM or IV x 1
    • Gentamicin 5 mg/kg IM or IV x 1
    • Ciprofloxacin 400 mg IV x 1
    If hospitalized: treat until patient is afebrile for 24-48 hours, then complete a 2-week course with oral drugs. Follow up with urine culture 2 weeks after course of antibiotic therapy is completed, to ensure response and to prevent relapse.

    Chronic pyelonephritis: recommended treatment is 3 to 6 months of therapy.

    Pharmacists occasionally see patients coming into our practice sites seeking something for bladder burning and head to the phenazopyridine section.

    I make it a point to ask about having any back pain (flank pain) and if they have a fever. Acute pyelonephritis is a condition that phenazopyridine has no role in its treatment.

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    Urinary Tract Infections: The Basics 

    Causative Agents

    Pathogens most likely to cause urinary tract infections include primarily Escherichia coli, but also other Enterobacteriaceae (Klebsiella). Other gram-negative bacilli such as Pseudomonas aeruginosa may be involved. Staphylococci, enterococci, Proteus, and Candida species can also be implicated in urinary tract infections.

    Female Anatomy and the Risk of UTI
    • Short urethra facilitates ascent of organisms from the introitus into the bladder
    • Frequency of UTI increases after puberty due to sexual activity
      • Approximately 50% of women will develop at least one UTI within their lifetime, with 1 in 3 women having a UTI by the age of 24
    • Women with recurrent UTI may have more adhesive receptors on GU mucosa—allowing more binding sites for pathogens
    • Women whose mucosal secretions lack fucosyltransferase activity are more prone to recurrent UTI, as this enzyme keeps bacteria from adhering to the urethra
    • The female urethra is usually colonized with bacteria believed to originate from the fecal flora
      • Bacteria reach the bladder by a “massaging action” during sexual intercourse
    • Use of spermicides and diaphragms increase the risk of UTI
    • Risk factors include pregnancy, mechanical instrumentation, catheterization
    • Lactobacilli which produce lactic acid & decrease E. coli colonization in the vaginal flora help to prevent UTI, as well as circulating estrogen levels. Use of beta-lactam antibiotics (penicillins and cephalosporins) will destroy Lactobacillus, which is protective for UTI
    • In elderly females, poor bladder emptying due to prolapse may increase risk

    Male UTIs
    • Higher incidence in uncircumcised men has been observed
      • Over their lifetime, uncircumcised men are four times more likely to experience a UTI than circumcised men
    • The prostate secretes zinc, a potent antibacterial that stops the ascent of infection
    • Lower zinc levels in prostatic secretions of men with bacterial prostatitis
    • In elderly males, prostatic hypertrophy causes obstruction
    • Therapy is more difficult than in females. Treatment should last 10 to 14 days.
    • Uncomplicated infections are rare. Most infections are complicated, because of structural or functional abnormality which disrupts normal defense mechanisms.

    Age
    • Elderly population (over 65) equal ratio between male and female UTI
    • Most age-related UTI are asymptomatic
    • In patients with dementia, fecal incontinence causes increased incidence if UTI
    • Neuromuscular disease, such as strokes, may cause increased incidence
    • Catheterization is more common in elderly
    • Residual urine volume due to anticholinergic use, prostatic hypertrophy, urethral stricture, calculi, tumors, and bladder diverticula

    Treatment of Elderly Patients
    • Make sure there are symptoms, and that urine is abnormal, not just a positive culture
      • Treatment of asymptomatic UTI in the elderly is not advised. It is said to be a benign disease and treatment is not warranted.
    • Asymptomatic Bacteriuria is dependent on age. Check for obstruction if there are recurrent symptoms. Don’t treat chronic bacteriuria in elderly females; this is often due to diverticuli in the bladder.
    • Males: most common cause of infection is due to bladder outlet obstruction, because of prostatic hypertrophy
      • Obtain culture before treatment... because cause of infection is NOT as predictable in men as they are in women

    Treatment of Pediatric Patients

    If the child is under 5 with a positive urine culture, he/she should be treated even if asymptomatic with conventional courses of therapy used for symptomatic infections. In children, there is a greater risk of developing renal scarring and long-standing renal damage during the first five years of life.

    Urinary tract infections are common depending on the age group. We see most UTIs in young, sexually active females. Back in the day, the condition was referred to “honeymooner’s cystitis.” Urinary tract infections can also be common on the other end of the spectrum, affecting older women who have issues with incomplete bladder emptying.

    When I see my patients reaching for those urinary tract medications, such as phenazopyridine, I make sure they understand this is for symptomatic relief. Appropriate treatment for the UTI is still needed.

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    Overview of Testosterone Replacement Options

    Warnings/Precautions and/ Adverse effects: Traditional oral tablets: may cause GI upset and are of little value because of extensive first pass metabolism. May also cause hepatotoxicity. However, there is a newer formulation which bypasses these traditional issues caused by oral testosterone.
    • Edema, weight gain
    • Hypertension, CHF
    • LABS to be checked: hematocrit (red blood cell levels) (D/C if over 55%), serum testosterone, lipid profile every 6-12 months. PSA yearly and digital rectal exam twice yearly.
    • CANCER: men over 50 years who begin testosterone treatment should be reevaluated for prostate cancer three months and one year after beginning treatment
    • Acne can be exacerbated
    • Exacerbate benign prostatic hyperplasia, or enhanced growth of prostate cancer
    • Avoid testosterone in males with breast cancer, as testosterone can be converted to estradiol by aromatase.
    • Caution in patients with sleep apnea
    Drug Interactions:
    • May increase insulin requirements.
    • Increased clearance of propranolol.
    Chronic drugs that LOWER testosterone levels:
    • Prednisone 5mg/day and greater, or
    • Morphine 100mg/day or greater AND their equivalents.



    Representative Products and Dosages (Testosterone replacement):
    • • Delatestryl® (testosterone enanthate) 200mg/mL & Depo-Testosterone (Testosterone cypionate) 100 & 200mg/mL. Administered intramuscularly (IM) (generics are very inexpensive)
    Dosage: 200mg every 2-4 weeks. Generally, doses of over 400mg/month are not necessary.
    • Androderm® 2.5mg and 5mg patches. Apply to arm, back, abdomen or thighs. Change every 24 hours. Do NOT apply to the scrotum. Cost approx. $600/month
    TESTOSTERONE topical gels:

    Advantages: Provides therapeutic testosterone levels without large fluctuations, easier to use and less skin irritation than patches.

    Disadvantages: Transfer of gel or solution from one person to another --avoid this by washing hands after application and wearing clothing over application site.

    Comments: Do not apply to genitals.

    Testosterone Monitoring: Check testosterone level at least 7 to 14 days after initiation of therapy.
    • Androgel® testosterone gel 1.62% packets and pump ($650/month) generic available Apply once daily to upper arm, shoulders or abdomen. One study showed a 30 percent lower bioavailability when it was applied to the abdomen as opposed to the arms and shoulders.
    • Fortesta®: testosterone gel 2% 10mg per pump ($490/month) generic is available Dosage: Start with 40 mg (4 pump actuations) once daily in the morning applied to thighs to minimize product transfer. Max dose is 70 mg per day.
    • Testim® gel (1%) ($710.00/month) generic is available Start with 5 g (50 mg of testosterone) once daily applied to shoulders or upper arms. Increase to 10 g if needed. Do not apply to abdomen.

    Oral Testosterone: Testosterone undecanoate (Jatenzo®) : 158mg, 198mg and 237mg

    Mechanism: Jatenzo® is lipophilic, absorbed through the intestinal lymphatic system, which then eliminates first pass metabolism. Previous oral testosterone therapies (methyltestosterone) saw first pass metabolism and associated liver issues.

    Dose: 1-2 capsules twice daily with food.

    Dose range: minimum of 158 mg twice daily and a maximum of 396 mg twice daily based on serum testostxerone drawn 6 hours after the morning dose at least 7 days after starting treatment or following dose adjustment and periodically thereafter

    Advantages:
    • No liver function issues
    • No topical transfer
    • Ease of use

    Warnings: May cause hypertension and cardiovascular events such as myocardial infarction and stroke

    Cost: for the two lower strengths around $950/month. Highest strength is $1900/month. Bottles of 120 capsules


    TESTOSTERONE MONITORING
    • Check a morning TOTAL testosterone...and repeat to confirm. FREE testosterone: check if the total is borderline especially if the patient has factors that can alter levels, such as: obesity, diabetes, cirrhosis, hypo- or hyperthyroidism, etc
    • Check serum testosterone 4 to 12 weeks after starting therapy. In older men, aim for the low end of normal, such as 400 to 500 ng/dL.
    • Measure midway between injections for testosterone enanthate and cypionate
    • Also monitor for increased hematocrit and PSA and do a digital rectal exam at baseline, 3 to 6 months, and then yearly.


    Direct to consumer advertising is a real thing when it comes to testosterone replacement. One of the physician assistants I had the privilege to work with directly said he seldom complies with an older male’s request to do testosterone levels. For the most part, they are low! And when the guy finds out they are low he wants a supplement.

    Direct to consumer advertising for testosterone replacement in males really works.

    Between 2009 and 2013 among US men residing in 75 United States direct marketing areas, regional exposure to televised direct to consumer advertising was associated with greater testosterone testing, new initiation, and initiation without recent testing. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471355/

    Testosterone levels are rarely identified as a cause of erectile dysfunction. Must do an endocrine workup, must also exclude prostate cancer by PSA and digital rectal exam. Testosterone should only ever be administered to hypogonadal men, with documented low testosterone levels.

    Testosterone requires conversion to dihydrotestosterone (DHT) for its action on the external genitalia, sexual hair, and of course the prostate gland. Testosterone requires conversion to estradiol to have its effects on bone strength. If a male has aromatase deficiency, osteoporosis occurs.

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    January 2022

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    Treatment of Premature Ejaculation (PE)

    IELT: Intravaginal Ejaculatory Latency Time (time from intromission until ejaculation)
    Prevalence is consistently around 30% in men age 18-59 in the U.S.
    In the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V), PE is defined as a sexual disorder with:
    • consistent ejaculation within 1 minute or less of vaginal penetration
    • duration over a period of at least 6 months
    • experienced 75–100% of the time
    • the condition results in clinically significant distress, sexual frustration, dissatisfaction, or tension between partners
    • this condition is not better accounted for by another non-sexual mental disorder, medication or illicit substance use, or medical condition
    Topical anesthetics
    Mechanism: contain benzocaine or lidocaine, a local anesthetic, causing a decreased sensation. Promoted to decrease premature ejaculation.

    There are desensitizing gels with 7.5% lidocaine, as well as condoms with benzocaine (4-5%) to cause desensitization

    Warnings/Precautions and/ Adverse effects:
    • Sensitivity to this product/ or benzocaine or lidocaine
    • Apply 10-15 minutes before intercourse
    • Use a condom to prevent transfer to partner.
    Dapoxetine
    Is a SSRI and meets many of the ideal treatment criteria, including oral administration, pharmacokinetic profile suitable for PRN administration, and a good side effects profile.'

    Can be taken with a PDE5 inhibitor or alcohol without any significant interactions. Compared to placebo, the 60mg to 100mg produced statistically significant improvement in the men’s IELT generating an approximately 3 fold increase in average IELTs from just under 1 minute at baseline, to 2.91 minutes (60mg) and 3.1 minutes (100mg).

    Nausea is the most common side effect at approximately 9%

    In October of 2005, the FDA sent a non-approvable letter to Johnson & Johnson. The drug “Priligy” by Jaansen Pharmaceuticals is available in Europe.

    SSRI’s
    Paroxetine is far superior to fluoxetine and other SSRIs within this realm, with one study showing an increase of IELT of 9 minutes. For improvement of IELT, it requires chronic daily dosing which patients find inconvenient and laden with unpleasant side effects. SSRIs have a slow onset of action and adverse effects including nausea, drowsiness, cognitive impairment, and sexual side effects. With any SSRI, start with a low dose and gradually increase at monthly intervals. Will take at least 2-3 weeks of therapy to see desired effect.

    Clomipramine
    In one study, off label use of clomipramine was shown to be more effective in prolonging IELT than sertraline and fluoxetine. Side effects were more common than other agents.

    Dose: clomipramine 25mg taken 4 to 6 hours before intercourse.

    Substantially prolonged ejaculation time in about half of the men, although was of little benefit with short initial IELT’s.

    Tramadol
    Considered a third line agent, due to its effects with serotonin and norepinephrine. Because of the potential for opioid abuse, this therapy is not recommended.

    Ejaculatory dysfunction
    Frequently seen with tamsulosin, switching to alfuzosin provides relief from ejaculatory dysfunction from other alpha blockers.

    Getting your patients comfortable to discuss sexual dysfunction does require a lot of trust. When I notice that a guy is not being adherent to his tamsulosin, I will inquire if he is having sexual dysfunction. I have had four male patients admit to me that they were having painful ejaculation while taking tamsulosin. I recommended to their physician to switch to alfuzosin, which the physician made the change. All four patients were quite pleased with the results of the switch.

    On another occasion, a young couple come to the pharmacy and wanted to talk with me. She was complaining that he was "taking too long” and was it the clonazepam or sertraline causing this problem. Of course, it was the sertraline, and I explained to them that any of the SSRI's can cause this problem. He was changed to bupropion for his depression, and the issue resolved.

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    Overview of Nontraditional Options for Erectile Dysfunction

    Alprostadil Intracavernosal injection (FDA approved 1995)

    Mechanism: direct injection of vasoactive prostaglandins onto the corpora cavernosum.

    Warnings/Precautions and/ Adverse effects: First injection should be done in a clinician’s office with trained personnel. Must stay in office until complete detumescence occurs. If there is no response, the next higher dose may be given in 1
    • Generally reserved for patients who have failed other regimens.
    • May be used only twice a week.
    • May cause: Penile fibrosis, priapism, penile pain. hematoma, ecchymosis
    Contraindications: sickle cell anemia, leukemia, (any condition predisposing patient to priapism), penile angulation, Peyronies disease , cavernosal fibrosis & penile implants.

    Representative Products and Dosages:
    • Alprostadil (Caverject®) 5mcg/ml , 10mcg/ml, 20mcg/ml, 40mcg/ml injection
    • Alprostadil (Edex®) 10mcg/ml, 20mcg/ml
    For purely neurogenic dysfunction, start with 1.25mcg. If other etiologies, start with 2.5mcg. Final dose should not exceed 60mcg, should produce an erection adequate for intercourse within 5 to 20 minutes ideally to last no longer than 1 hour. (Mean dose at end of 6 months- 20mcg) (cost about $90.00 per injection)


    Alprostadil urethral suppository (FDA approved 1996)

    Mechanism: alprostadil inserted via suppository into the urethra. Apply post urination, residual urine disperses the medicated pellet permitting alprostadil to be absorbed by the urethral mucosa. Then transported through the erectile bodies by communicating vessels between corpus spongiosum and corpora cavernosa. Induces vasodilatation in the vascular beds.

    Erection occurs in 5 to 10 minutes and lasts 30-60 minutes. Can be used up to twice daily.

    Warnings/Precautions and/ Adverse effects:
    • May cause transient penile pain, and hypotension
    • NOT priapism
    • Headache and dizziness, testicular pain
    • Possible urethral abrasions and bleeding
    • Do NOT use if partner is pregnant, unless using a condom


    Representative Products and Dosages:

    Alprostadil (Muse®): 125mcg, 250mcg, 500mcg, and 1000mcg urethral suppositories. Are small pellets one time use applicator/injector containing the alprostadil dose, about 30mm into the urethra. (cost= about $75/dose)

    Papaverine penile injection
    Mechanism: Smooth muscle relaxer
    Relaxes blood vessels and allows increased blood flow to the penis.
    Possibly inhibits phosphodiesterases and it may have direct actions on calcium channels.
    A natural opiate from the poppy plant.
    • Onset: 10 minutes. Intercourse should be attempted within 2 hours. Maximum 3 times per week.
    • Dose: 30 to 60mg: slowly inject over one or two minutes to completely inject the dose. This minimizes serious adverse effects such as arrhythmias.
    Yohimbine
    Mechanism: blocks presynaptic alpha-2 adrenergic receptors. Increases parasympathetic and decreases sympathetic activity. Erection is linked to cholinergic activity, and alpha-2 blockade, which theoretically results in increased penile blood inflow, decreased outflow or both.

    Widely used as an aphrodisiac to improve sexual drive. Frequently seen in herbal or “natural” remedies for erectile dysfunction.

    Warnings/Precautions and/ Adverse effects/Drug Interactions
    May cause: anxiety, insomnia, tachycardia and hypertension.
    • American Urological Society has cautioned against the use of yohimbine.
    • HAS NO FDA sanctioned indications
    • Contraindicated with antidepressants
    Alprostadil (Prostaglandin E1, PGE1) is used in the management and treatment of erectile dysfunction in males and for temporary patency of ductus arteriosus in newborns with congenital heart diseases before surgical intervention. PGE1 causes smooth muscle relaxation, leading to vasodilation, increasing peripheral blood flow and helping with erectile dysfunction.

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    Overview of 5-PDE Inhibitors for Erectile Dysfunction

    Phosphodiesterase type-5 inhibitors:

    sildenafil (Viagra®)-approved 1998
    vardenafil (Levitra®) approved 2003
    tadalafil (Cialis®) approved 2003

    Mechanism: Works by enhancing the effect of nitric oxide by inhibiting phosphodiesterase type 5 (PDE5). When sexual stimulation causes the local release of nitric oxide, inhibition of PDE5 by Phosphodiesterase-5 inhibitors produces increased levels of cGMP in the corpus cavernosum. This results in smooth muscle relaxation and inflow of blood into the penile tissues, which in turn produces an erection.

    Warnings/Precautions and/ Adverse effects:
    • Color disturbances: (blue/green) important for pilots (PDE-6 found in retina) can be affected at higher doses.
    • Headache (16%), facial flushing, dyspepsia
    • Hypotension: 8-10mm decrease in systolic & 5-6 mm in diastolic.
    • Hearing loss: ISMP-2016: reports a strong association between PDE5 drugs and hearing loss. PDE5 caused hearing loss 21.5 times higher than similar comparators.
    • In 1998, there were 123 sildenafil related deaths, 67% were MI and 36% developed CV symptoms within 5 hours of administration. Interestingly, less than 20% of these patients took nitrates.
    Drug Interactions (5-PDE inhibitors)
    • CONTRAINDICATED with nitrate use.
    • CONTRAINDICATED with alpha blockers due to hypotension.
    • Caution with all blood pressure medications.
    • Metabolized by Cytochrome P450 3A4. Cimetidine increases sildenafil levels by 56%. Also increased with ketoconazole and erythromycin (180% increase)
    • Give lower doses to men who take potent CYP3A4 inhibitors such as erythromycin, ketoconazole, itraconazole, ritonavir, or indinavir.
    Representative Products and Dosages

    BrandGenericDose mgOnset min.Duration
    Viagra®sildenafil25,50,10030 min4 hours
    Levitra ®vardenafil2.5,5,10,2020 min4 to 5 hours
    Cialis®tadalafil5, 10, 2030 min36 hours (weekend)
    Cialis®tadalafil2.5mg or 5mgTaken once daily
    Stendra®avanafil50,100,200mg15 min4 hours


    Dosage: On demand dosing - Taken on an as needed basis, usually ½ to 1 hour before sexual activity

    Cialis® tadalafil continuous dosing The low-dose daily dosing provides an option for men with ED who want a medication that can be taken without regard to timing of sexual activity and who anticipate sexual activity at least twice weekly. Men will take 2.5 or 5 mg tadalafil daily instead of 5 to 20 mg as needed. The long half-life of tadalafil allows for continuous daily dosing, so men do not need to plan ahead.

    Revatio® (sildenafil) 20mg: treatment of pulmonary arterial hypertension. Retails for $.50- 2.00/tablet…
    • Dose: 20mg 3 times daily, spaced 6 hours apart.
    • May improve exercise tolerance
    • May slow down worsening changes in physical condition
    • NOTE: all strengths of sildenafil (25,50 and 100mg) are available as GENERICS. Prices are less than 10% of the cost of the brand name Viagra®


    OTHER POTENTIAL USES FOR 5-PDE INHIBITORS:

    ALZHEIMER's PREVENTION: Cleveland Clinic’s Genomic Medicine Institute examined a database of more than seven million patients, finding that the ED medication performed significantly better at Alzheimer’s prevention than high blood pressure and diabetes drugs like losartan and metformin. Sildenafil, which has been shown to significantly improve cognition and memory in preclinical models, presented as the best drug candidate. Based on retrospective case–control pharmacoepidemiologic analyses of insurance claims data for 7.23 million individuals, it was found that sildenafil usage was significantly associated with a 69% reduced risk of AD.
    https://www.nature.com/articles/s43587-021-00138-z

    High Altitude Pulmonary Edema (HAPE) is the abnormal accumulation of plasma and some red blood cells in the lung air sacs due to a breakdown in the pulmonary blood-gas barrier, triggered by “thin oxygen” seen at higher altitudes. PDE-5 inhibitors sildenafil and tadalafil prevented hypoxic pulmonary hypertension and the development of HAPE.
    • • Sildenafil: single dose of 50 or 100 mg just prior to exposure for acute ascent, or give 50 mg every eight hours if staying 2-6 days.
    • • Tadalafil: 10 mg every 12 hours
    I am amazed with the numerous uses for the 5-PDE inhibitors. Their side effects of hypotension can be so bothersome, that pilots cannot fly, according to FAA regulations, for 8 hours after using sildenafil and vardenafil. For tadalafil on ‘as needed’ basis, pilots have to wait 24 hours!

    https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/pharm/ed/ Have a Great Day on the Bench!!

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    Broad Overview of Erectile Dysfunction

    Erectile dysfunction: (DSM IV- American Psychiatric Association)
    • The consistent inability to achieve and/or maintain an erection adequate for satisfactory sexual intercourse
    • Cause is marked by distress or interpersonal difficulty
    • Cause is not better accounted for by a drug of abuse or medication or direct physical effects of a substance
    It’s complicated---both physical and psychological components are at play. Most men experience spontaneous erections during rapid eye movement sleep and often wake up with an erection during the night. Complete loss of nocturnal erections is present in men with neurologic or vascular disease and may help rule out a psychogenic component. Parasympathetic nerves mediate an erection, while sympathetic nerves are responsible for ejaculation and penile stiffening. Nitrous oxide and other chemicals cause vasodilation, which leads to venous occlusion, rigidity and erection.

    INCIDENCE OF ERECTILE DYSFUNCTION (ED) IN MEN WITH OTHER DISEASES:
    • Cerebrovascular disease 70%
    • Coronary artery disease 60%
    • Coronary artery bypass graft 60%
    • Diabetes mellitus 50%
    • Peripheral vascular disease 70%
    • Untreated hypertension 10%
    Complete erectile dysfunction: About 5 percent of men (1/20) that are 40 years old have complete erectile dysfunction. About 15 percent of men at age 70 have complete ED.

    Mild and moderate erectile dysfunction affects approximately 10 percent of men per decade of life:
    • 50 percent of men in their 50’s
    • 60 percent of men in their 60’s.
    • 70 percent of men in their 70’s
    Classes of Drugs implicated with ED
    • Major antipsychotics (typical)
    • Tricyclic antidepressants
    • SSRI antidepressants
    • Anxiolytics (benzodiazepines)
    • Anticholinergics (as antispasmodics & anti-Parkinson’s drugs)
    • Antihistamines (especially sedating)
    • Muscle relaxants
    • Antiarrhythmic (disopyramide) (amiodarone) (mexiletine)
    • ANTIHYPERTENSIVES
    • Diuretics: thiazides and spironolactone
    • Central sympatholytics: methyldopa and clonidine
    • Beta-Blockers (propranolol & metoprolol)
    OTHERS:
    • Cimetidine
    • Digoxin
    • Indomethacin
    • Lithium
    • Metoclopramide
    • Phenytoin
    • Ketoconazole
    • Anti-androgenic agents (bicalutamide, flutamide, leuprolide)
    DRUGS WITH ABUSE POTENTIAL
    • Amphetamines
    • Barbiturates
    • Cocaine
    • Marijuana
    • Narcotics/Opiates (especially if over 100 MME per day)
    • Nicotine
    Cost:

    MECHANISMS for medications causing ERECTILE DYSFUNCTION

    Medication:Mechanism Proposed:Modified Libido/Sexual Response:
    Antihypertensives, anxiolytics, ethanol, muscle relaxants, narcotics, neuroleptics sedativesSEDATIONDecreased libido
    Cimetidine, Marijuana, Digoxin, excess Ethanol, Ketoconazole, SpironolactoneTestosterone antagonismLibido
    Metoclopramide, Narcotics, AntipsychoticsProlactin elevationLibido
    Anticholinergic Agents, TCAs, antihistamines (1st generation)Parasympathetic dysfunctionPenile tumescence
    Diuretics, methyldopa, beta-blockersDecreased arteriolar flow to corporaPenile tumescence


    DRUG causing sexual dysfunction:Possible alternative:
    AnticonvulsantsValproic acid
    AntidepressantsBupropion
    AntihypertensivesACE inhibitors & Calcium Channel Blockers, ARBS, alpha-blockers
    AntipsychoticsLoxapine
    DiureticsFurosemide
    Anti-ulcer drugsFamotidine
    Nonsteroidal anti-inflammatoryDiclofenac
    Antihistamines (1st generation)Second generation antihistamines




    I remember as a teenager watching an episode of M*A*S*H where “Hawkeye” was out with a nurse and was having “difficulties”. He was talking with BJ, his tentmate and told him the “couldn’t”. BJ responded, “couldn’t what?”. Hawkeye said, “you know, the big couldn’t.” That was the only reference that I ever remember seeing on TV until sildenafil (Viagra®) came out in 1998.

    Now, guys walk into the pharmacy and say, “Hey doc, I need a refill on my Viagra”. Wow how times have changed. Before the three PDE-5 inhibitors became generic, the Super Bowl was overrun with ads for ED drugs. Remember Bears Coach Mike Ditka (Pitt alumnus) promoting ED products? Now that these generics are cheap, more and more men are buying them on a regular basis.

    Have a Great Day on the Bench!!

    December 2021

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    Benign Prostatic Hyperplasia (BPH): Complicating Medications & Related Conditions

    Benign Prostatic Hypertrophy
    • Most common benign neoplasm of American men.
    • Nearly ubiquitous condition among all elderly men. Nearly 80% of men who live to be 80 have BPH. 50% will be symptomatic. 50% of the symptomatic patients require treatment.
    Irritative symptoms:
    • Dysuria (discomfort when urinating)
    • Nocturia (frequent urination at night)
    • Urgency
    • Frequency
    • Burning
    Obstructive:
    • Hesitancy
    • Straining
    • Dribbling
    • Weak stream
    • Incomplete emptying
    MEDICATIONS to Avoid with BHP
    • Testosterone: causes prostate enlargement and growth. Although the television is chocked full of commercials for men with “low T”, care must be exercised in the older population so as not to exacerbate prostate issues
    • Sympathomimetic agents may cause or worsen urinary difficulty in patients with prostate enlargement due to smooth muscle contraction in the bladder neck via stimulation of alpha-1 adrenergic receptors. Therapy with sympathomimetic agents should be administered cautiously in patients with hypertrophy or neoplasm of the prostate. Avoid all amphetamine products as well as pseudoephedrine (Sudafed®) in the older population.
    • Drugs with significant anticholinergic adverse effects: decrease urinary bladder detrusor muscle contractility, resulting in urinary retention.Avoid first generation antihistamines, tricyclic antidepressants, phenothiazines. However, drugs like tolterodine (Detrol®) poses little risk of urinary retention, if there is good flow. Antimuscarinics work during storage, rather than voiding.
    • Anticholinergics: Avoid anticholinergics such as benztropine, hyoscyamine and trihexyphenidyl.
    • Diuretics: polyuria secondary to high dose therapy may present as urinary frequency.

    Be sure to rule out Bacterial Prostatitis:
    Inflammation of prostate gland and surround tissue as a result of infection. Pathogenic bacteria, usually gram-negative organisms, must be present in prostatic secretions and in urine. A urine gram stain is indicated in any patient with suspected bacterial prostatitis.

    Clinical appearance:
    • Sudden onset of fever, chills, myalgia, malaise, cloudy urine
    • Localized pain: perineal and or suprapubic regions.
    • Digital palpitation of the prostate via the rectum may reveal a swollen, tender, warm, tense or indurated gland.


    TREATMENT:
    Prostatitis Usual etiologyTreatment
    Less than age 35 years oldN. gonorrhoeae, C.trachomatisceftriaxone 250mg IM + doxycycline 100 BID x10 days
    Over 35 years of ageEnterobacteriacae (coliforms)Fluoroquinolones OR Trimeth/Sulfa DS BID for 10-14 days
    Chronic bacterialEnterobacteriaceae (80%)
    Enterococci
    Proteus
    Pseudomonas aeruginosa
    Ciproflox 500 BID x 4 weeks or Levoflox 750mg daily x 4 weeks. Trimeth/Sulfa DS BID for 1-3 months.


    Patients frequently inquire about getting something for their cold symptoms that is safe for hypertensive patients. Although pseudoephedrine is safe for most patients with controlled blood pressure (it raises blood pressure by about 3mm Hg), we need to be cautious in patients with prostate issues.

    I always ask any patients with as much gray hair as I have if they have any issues with their prostate. Most of us are aware that first generation antihistamines (such as diphenhydramine) should be avoided, but we also need to avoid pseudoephedrine. Although phenylephrine may be safer, it’s practicality as a decongestant is limited.

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    Overview of 5-Alpha Reductase Inhibitors for Benign Prostatic Hyperplasia (BPH)

    Getting to know the prostate:
    • At birth, it is pea-sized and weighs 1gm. The prostate stays pea sized until puberty, reaching “adult size” by age 25 to 30.
    • The prostate typically remains that size until patient is 40. At that time, a second growth spurt begins and continues until the man is 70 or 80. During this time, the prostate can double or triple in size.
    5-Alpha Reductase Inhibitors

    Mechanism: Inhibits the production of dihydrotestosterone. Most useful in male patients whose prostates are very large. Minimal benefit in patients with normal or moderately enlarged prostate gland, and whose BPH symptoms are caused primarily by muscle cell overgrowth.

    Indications: Patients with large prostates (50-60 gm), who are not good surgical candidates, those who wish to avoid surgery, and those who cannot tolerate the side effects of alpha-adrenergic antagonists.

    Warnings/Precautions/Adverse effects:
    • Pregnancy Category-X
    • Women who are of childbearing age should not handle tablets, crushed or broken.
    • Erectile dysfunction in about 4%
    • Decreased libido, decreased ejaculate volume.
    • Breast tenderness and enlargement
    • Testicular pain
    Dosages:
    • Dutasteride (Avodart®) : 0.5mg capsules : one capsule daily
    • Finasteride (Proscar®) : 5mg tablets : 1 tablet daily.
    • Finasteride (Propecia®): 1mg tablets-------for alopecia, not for BPH
    Prescriber notes: Finasteride and Dutasteride are available generically and decrease the need for surgery by 50% compared to alpha blockers. Dutasteride is three times more potent of an inhibitor of 5-alpha-reductase type 2 and 100 times more potent of an inhibitor of 5-alpha-reductase type 1, when compared to finasteride. Dutasteride 0.5mg reduces serum DHT by 94% compared to Finasteride 5mg at around 70%.

    Drug interactions: Dutasteride is metabolized by CYP450-3A4. According to in vitro data, blood concentrations of dutasteride might increase in the presence of CYP3A4 inhibitors such as ritonavir, ketoconazole, verapamil, diltiazem, cimetidine, and ciprofloxacin. These are considered to be moderate drug-drug interactions.


    Natural remedies—Saw palmetto

    Many previous studies suggest that saw palmetto leads to mild to moderate improvement of urinary symptoms of BPH. Some studies suggest that it's comparable to finasteride, but probably less effective than alpha-blockers. A well-designed NIH trial shows no significant improvement in men with moderate to severe BPH who took saw palmetto for a year.

    The difference might be: patient study group had more severe symptoms, or different formulation of saw palmetto. Typical dose 160mg twice daily. Always expect different results from different formulations. More rigorous studies suggest that saw palmetto isn't better than placebo for BPH symptoms.

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    Overview of Alpha Blockers for Benign Prostatic Hyperplasia (BPH)

    ALPHA BLOCKERS---for BPH

    Mechanism: Relaxes smooth muscles, especially in the urinary tract and prostate. By relaxing muscles around the prostate, they increase urinary flow. Minimal effect on sex drive.

    Alpha blockers are classified according to selectivity and half-life. Alpha-1a receptors are localized to the prostate and bladder neck, and selective blockade results in fewer systemic side effects (orthostatic hypertension, dizziness, tiredness, headache & rhinitis). These agents work quickly and may exhibit symptomatic relief when appropriately dosed, within 2 weeks. Approximately 70% of patients will respond.

    Nonselective alpha blockers: Terazosin (Hytrin®), Doxazosin (Cardura®), Prazosin (Minipress®). Prazosin is not approved for BPH.

    Selective alpha-1a blockers: Tamsulosin (Flomax®) and Alfuzosin (Uroxatral®) Silodosin (Rapaflo®)

    Warnings/precautions (alpha blockers): Orthostatic hypotension may occur with the first few doses. Minimize by slow titration. Watch for syncope. Best to have patient take at bedtime to minimize dizziness.

    Significantly less side effects with the selective alpha-1a blockers. Titration not required for Alfuzosin (Uroxatrol®)

    Adverse effects: (alpha blockers):
    • Orthostatic hypotension
    • Dry mouth
    • Urinary urgency
    • Constipation
    • Priapism, ejaculatory problems
    Intraoperative Floppy Iris Syndrome: ALL Alpha-1 Blockers cause intraoperative floppy iris syndrome (IFIS). The iris becomes flaccid and billows in response to intraoperative irrigation currents, causing the potential prolapse of the iris toward phacoemulsification incisions. Ophthalmologists can modify their surgical techniques including using iris hooks, iris dilation rings, viscoelastic devices. Ophthalmologists MUST know before surgery that patient has been on alpha blocker therapy.

    Drug interactions:
    NSAIDs decrease antihypertensive effects
    Beta Blockers and Diuretics increase the antihypertensive effects of these agents

    Patient Education:
    • Watch for postural hypotension
    • Watch for drowsiness
    • If priapism occurs, seek medical treatment immediately.
    ALPHA BLOCKERS - ALPHA NON-SELECTIVE
    GENERICBRANDINDICATIONSTARTING DAILY DOSEUSUAL DAILY DOSEMAXIMUM DAILY DOSE
    DOXAZOSINCARDURA®BPH1mg at bedtime1-16mg/day16mg=HTN
    8mg=BPH
    PRAZOSINMINIPRESS®1mg at bedtime2-20mg (in 2-3 doses)40mg
    TERAZOSINHYTRIN®BPH1mg at bedtime1-20mg20mg/day


    ALPHA BLOCKERS - ALPHA –1a SELECTIVE
    GENERICBRANDINDICATIONSTARTING DAILY DOSEUSUAL DAILY DOSEMAXIMUM DAILY DOSE
    TAMSULOSINFLOMAX®BPH0.4 mg at bedtime0.4- 0.8mg0.8mg
    ALFUZOSINUROXATRAL®BPH10mg10mg10mg
    SILODOSINRAPAFLO®BPH8mg with food8mg with food (4mg if CrCl=30-50)


    Prescriber notes:
    • Alfuzosin (Uroxatral®) is least likely of alpha blockers to cause ejaculatory problems. Does not require dosage titration.
    • Silodosin (Rapaflo®) : Contraindicated with potent CYP3A4 inhibitors
    • Tamsulosin (Flomax®) is least likely of alpha blockers to cause orthostatic hypotension, and MOST likely to cause ejaculatory problems


    One of my favorite stories I share with students occurred in the family practice office I worked at two days a week. A patient was not being adherent to his terazosin (Flomax®) and, when I questioned him, he was experiencing sexual side effects. We changed his medication to alfuzosin (Uroxatrol®). Three months later when I saw him at a Christmas party, I got the biggest hug! He was so pleased with the change in therapy. The truth is we had at least 4 other gentlemen at the clinic with the same issues and changed with good results.

    At the same office, we had a patient in for a simple physical for cataract surgery. The patient did not understand the ophthalmologist’s instructions and continued to take his tamsulosin and was scheduled for surgery in just two days. I called the eye doctor’s office and informed them, and the nurse said they would inform the surgeon doing the surgery. He simply used iris hooks to stabilize the iris, and the surgery was uneventful. When we get prescriptions for eye drops for a patient preparing for cataract surgery, if it is a male, I always check for alpha blockers on their chart.

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    Prescriptions That May Contribute to Hair Loss

    DRUG CLASSExamplesComments
    ACE inhibitorsCaptopril, Lisinopril, RamiprilUp to 5% of Ramipril patients may experience hair loss
    AndrogensTestosteroneMay cause androgenic alopecia
    Blood ThinnersWarfarin especially high doses HeparinOver 5% of warfarin patients see hair loss; up to 50% if on high doses
    AntifungalsFluconazole, Terbinafine, KetoconazoleUp to 20% with fluconazole / Over 5% for terbinafine
    Anti-ThyroidMethimazole & PropylthiouracilAlso, check thyroid levels for any hair loss
    Aromatase inhibitorsExemestane, Anastrozole, LetrozoleThey block estrogen formation / Frequency: Exemestane-15% ; Anastrozole-5%
    BuspironeBuspar®May cause hair loss 5%
    Calcium Channel BlockersNifedipine (Procardia)May cause hair loss up to 5%
    Chemotherapeutic agentsDepends on drug. Antimitotic agents are the worstCauses anagen effluvium. (Active follicles)
    AntidepressantsbupropionBupropion had highest risk; paroxetine had lowest
    Estrogen blockerTamoxifenCauses androgenic alopecia
    ImmunosuppressantsLeflunomide mycophenolate tacrolimus Leflunomide- 15% ; mycophenolate=15% tacrolimus =28%
    InterferonsFor MS and HepatitisMay cause hair loss 50% of the time
    Mood StabilizersLithium; Divalproex & Carbamazepine can be used for seizuresLithium up to 20% / Divalproex up to 28%- may treat with zinc and selenium / Carbamazepine up to 6%
    Oral ContraceptivesThe more androgenic progestins are most likely to cause TE. Desogestrel, norgestimate, drospirenone are LEAST androgenic progestins
    Vitamin-A analogsAcitretin and isotretinoinIsotretinoin for acne -5% / Acitretin for psoriasis up to 75%
    StatinsAtorvastatin and SimvastatinRosuvastatin does not cause hair loss


    Treatment of Hair Loss

    Finasteride: Although we are accustomed to dispensing Finasteride (Proscar®) at a dose of 5mg per day for treatment of benign prostatic hypertrophy, the dose for treatment of male patterned is finasteride 1mg (Propecia 1mg). 1mg per day inhibits the production of dihydrotestosterone in the scalp by more than 60%. Finasteride does not have any affinity for androgen receptors. Long term treatment is necessary; hair count showed a 9% increase after 1 year and showed a 24% increase after 4 years. Hair regrowth will be lost 9-12 months after drug discontinuation.

    Minoxidil (topical) 2% and 5%: Product works directly on the hair follicles by promoting hair growth by increasing the duration of anagen, shortening telogen, and enlarging miniaturized follicles. The 5% strength shows greater efficacy. Initially, hair shedding may occur at the initiation of treatment possibly due to stimulation of telogen follicles to reenter the anagen phase. Apply to the scalp twice daily, not to the hair. Combination therapy with finasteride plus minoxidil produces better results than either agent alone. These hair loss treatments seem to work best in patients that have shorter duration of baldness and more limited areas of baldness seem to do better with finasteride or minoxidil treatment.

    Biotin: Biotin deficiency is very rare and occurs from drinking raw egg whites. Supplementation for the purposes of hair loss is not beneficial for most patients.


    Last week we discussed the three phases that our hair cycles through. The telogen phase is when the hair is “at rest”. Telogen effluvium (TE) results from changes in follicular cycling that leads to the excessive shedding of telogen hairs. A wide variety of endogenous and exogenous factors have been linked to induction of telogen effluvium. Serious illness, major surgery, childbirth, rapid weight loss, nutritional deficiency, profound emotional stress, and drug exposure have been implicated in causing TE. Always recommend checking the thyroid!

    Telogen hair loss develops within two to three months after the inciting factor, and reverses once the inciting factor is eliminated. The cause of telogen effluvium may be multifactorial in patients who have multiple medical problems or who are taking multiple drugs. In some cases, an inciting factor cannot be identified. But, let’s look at medications implicated in causing hair loss. I’ve included the most common culprits (causing hair loss more than 5% of the time)

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    Hair Loss---The basics

    Our hair growth undergoes three distinct cycles. 90% of our hair follicles are in the “anagen” hair growth phase. In this cycle our hair grows about 0.3mm per day, which translated would be 9mm (1/3 inch) per month. Activation of the androgen receptor in the hair follicles shortens the anagen or growth phase in the normal hair growth cycle.

    The other 10% are in the “transformation” and “resting” phases. We lose about 50-150 hairs per day on average. Infrequent shampooing will show increased losses on days that the patient shampoos, due to manual dislodging, but the average is the same. A common cause of hair breakage is prolonged tension of hair by tight braids & ponytails. Ask the patient when they look at the lost hairs, do they see the follicular “bulb” at the bottom, to rule out hair breakage. If they are seeing the distinct white bulb, this indicates hair loss of the shaft in the resting or “telogen” phase.

    Thanks Mom: It's not ALL Mom’s fault! Baldness is strongly associated with the AR gene found on the “X” chromosome, but other chromosomes are at play too. A large study looking at 12,806 men of European ancestry found that people with the gene had more than twice the risk of developing male patterned baldness than people without it. However, factors from the father’s side, as well as other external factors can be implicated in male pattern baldness. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3364959/)


    Patterned baldness- where genetics and aging meet:

    Male pattern hair loss or androgenetic alopecia in men is characterized by the slow, progressive loss of hair in a characteristic distribution. The condition is mediated by the action of androgens on androgen-sensitive hair follicles in genetically susceptible males. Drugs like low dose finasteride (Propecia®/Proscar®) are used to block the testosterone, which affects the androgen sensitive follicles. Finasteride and dutasteride, commonly used for enlarged prostate, are 5-alpha reductase inhibitors that block the conversion of testosterone to the more potent dihydrotestosterone. Interestingly, no one can find a link between baldness and prostatic hypertrophy.

    Female pattern hair loss most frequently presents as hair thinning on the frontal and vertex areas of the scalp. The frequency of this condition increases with age and is most commonly seen in women that are post-menopausal. It will affect as high as 19% of Caucasian women. Again, testosterone is the villain in our female patients, although most ladies have normal levels. Topical minoxidil (Rogaine®) is the first line treatment. If they poorly respond to minoxidil or have elevated testosterone levels, the anti-androgens like spironolactone (Aldactone®) or finasteride (Proscar®/Propecia®) can be tried. Allow at least a 4–6-month trial of minoxidil, finasteride or spironolactone to see benefits.

    Polycystic ovary syndrome is a common cause of excessive androgen production in women. Common dermatologic manifestations of elevated testosterone include excessive hair growth (hirsutism), acne, brown patches on the neck (acanthosis nigricans), and male patterned baldness (androgenic alopecia). Hirsute women often have increased activity of 5 alpha-reductase. Androgens affect the formation of acne by increasing sebum production from sebaceous glands in the skin. The diagnosis of polycystic ovary syndrome includes a complete history, physical examination with emphasis on evidence of androgen excess, and appropriate laboratory investigation to exclude other causes of hyperandrogenism. Treatments for the dermatologic conditions of hyperandrogenism include: diet and exercise, oral contraceptives, antiandrogens, and insulin-sensitizing medications, such as metformin.

    Vitamins?? Excess vitamin A from supplements (retinoids, isotretinoin, etc.) may cause hair to fall out. Deficiencies of zinc, iron, biotin, or vitamin D can also cause hair to thin. Supplementing these vitamins is only beneficial if there is a deficiency of that vitamin.

    Foods? Green tea, onions, pumpkin seeds, and edamame, among other foods and beverages, contain nutrients that may lower DHT levels and prevent hair loss. Obviously, this needs more study, but these foods are healthy additions to anyone’s diet regardless of their effect on hair loss.

    As this seasoned pharmacist gets older a lot of changes in the hairline have occurred. When my barber cuts my hair, the trimmings are a lot whiter and the pile seems to be smaller. We get questions about hair loss: could some of the drugs we dispense cause hair loss? could biotin or “Hair/Skin/Nails” formula help? Biotin deficiency, after all, is implicated in hair loss. Biotin deficiency, though, is very rare, and supplementation does little to restore hair growth.

    Have a Great Day on the Bench!!

    November 2021

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    Running out of Options: Now What? A Review of Rarely Used Epilepsy Drugs



    Felbamate (Felbatol®) ??(approved 1993)
    Rarely used due to extreme side effect profile. Parent or legal guardian should sign a legal consent form before administration.

    Mechanism: Blockade of NMDA ( n-methyl-d-aspartate)

    Dosage: 1200-3600mg in 3 divided doses. Days to steady state: 4 to 5 days

    Adverse effects: aplastic anemia, hepatotoxicity, blurred vision, diplopia, photosensitivity anorexia

    Contraindications: last resort therapy

    Drug Monitoring:? ?Aplastic anemia: rates of 20 to 30% may be as high as 70%. Liver failure is common; administer liver function tests every 1 – 2 weeks.

    Patient education: Report signs of infection, easy bruising, weakness, or fatigue


    Tiagabine (Gabitril®)?????(approved 1997)
    Available as tablets= 2, 4, 12 & 16mg

    Mechanism: selective GABA reuptake inhibitor (SGRI

    Use: adjunctive treatment for focal seizures in patients 12 years of age and older

    Dosage: Adults: (over 18yrs)= 4mg daily. May increase by 4mg per day at weekly intervals. Take in divided doses 2-4 times per day. Time to steady state is 2 days. Usual adult maintenance: 32-56mg in 2 to 4 divided doses. (max=80mg)

    Adverse effects: dizziness (27%), asthenia, somnolence, nervousness & nausea.

    Patient education: Take with food to minimize GI upset. Exercise caution when driving or operating dangerous machinery.


    Rufinamide (Banzel®)?(approved 2008)
    Available as 200 mg, 400 mg tablets

    Mechanism: modulates activity of sodium channels

    Use: Adjunctive treatment of Lennox-Gastaut syndrome in adults and children 4 years and older

    Adults Dose: Initial: 400-800 mg/day, divided twice daily (Max/day: 3200 mg--divided twice daily)

    Adverse effects: QT interval shortening, multiorgan hypersensitivity reaction, including rash
    • Drug interactions: CYP2E1 inhibitor (weak) andCYP3A4 inducer (weak). Watch for drug interactions with inducers and inhibitors of CYP450.
    • Take with food
    • Serum level monitoring not needed


    Perampanel (Fycompa®)? ??????????(approved 2012)
    Available as: 2mg,4mg,6mg,8mg,10mg,12mg tablets

    Mechanism: first?glutamate?receptor antagonist. Remember that glutamate is the most prevalent?excitatory?neurotransmitter. (GABA is an inhibitory transmitter).

    Use: Approved for the treatment of focal-onset seizures (four years of age and older), and as adjunctive treatment of primary generalized tonic-clonic seizures in patients with epilepsy 12 years of age and older. Maximum dose is 12mg/day.

    Schedule III controlled substance: possible euphoria and abuse.? Watch for mood changes such as anger, hostility.

    Drug interactions:
    • CYP450-3A4;? perampanel? 12 mg/day reduces the efficacy of levonorgestrel contraceptives. Select an additional or alternate contraceptive
    • Perampanel undergoes extensive liver metabolism.? Its effect will be decreased by CYP inducers like phenobarbital, carbamazepine and phenytoin.

    Cannabidiol (Epidiolex®) oral solution? 100mg/mL ?(Schedule-V)? (June-2018)
    Available as: 12.5mg, 25mg, 50mg, 100mg, 150mg and 200mg tablets
    • CBD is a chemical constituent of the cannabis plant
    • CBD does not cause intoxication or the euphoria that comes from tetrahydrocannabinol (THC), the primary psychoactive component of marijuana
    Inication: For the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients 2 years of age and older.

    Dose: Administered orally.
    • The starting dosage is 2.5 mg/kg twice daily (5 mg/kg/day).
    • After one week, the dosage can be increased to a maintenance dosage of 5 mg/kg twice daily.

    Pushing the dose to 20 mg/kg/day dosage resulted in somewhat greater reductions in seizure rates than the recommended maintenance dosage of 10 mg/kg/day, but with an increase in adverse reactions.

    Precautions: be sure to order liver function tests (ALT and AST) before starting therapy.
    • 32% of treated patients experienced drowsiness and sedation.
    • can cause decreases in hemoglobin and hematocrit
    • metabolized by CYP3A4 and CYP2C19
      • Inducers will lower blood levels.
      • Blockers will raise blood levels.

    Cenobamate (Xcopri®)?(approved 2019)
    Available as: 12.5mg, 25mg, 50mg, 100mg, 150mg and 200mg tablets

    Mechanism: inhibits voltage-dependent sodium channels and enhancing gamma-aminobutyric acid (GABA) inhibition through the GABA-A receptor.

    Use: focal (partial-onset) seizures in adults. Should be used in adults with treatment-resistant focal seizures.

    Dosing: Long titration schedule, starting with 12.5mg per day, escalating the dose every 2 weeks until the maintenance dose of 200mg per day is reached.? Maximum daily dose is 400mg.

    Drug interactions: expect lots, due to metabolism by CYP2E1, CYP2A6, CYP2B6, and to a lesser extent by CYP2C19 and CYP3A4/5, and glucuronide conjugation. May increase concentration of clobazam, phenobarbital and phenytoin.?

    Avoid in patients with hepatic or renal impairment.

    Our discussions on seizure medications shows us that our understanding of epilepsy is still in its infancy. Although we don’t see a lot of phenytoin and phenobarbital dispensed, we see even less of the drugs in today’s discussion dispensed. Newer agents are equally effective, and in most cases, better tolerated than older agents.

    Some of the newer drugs are only approved for adjunct therapy, while others may be appropriate for monotherapy. Many older drugs (carbamazepine, phenobarbital, phenytoin, primidone, valproic acid) have significant side effects, requiring serum monitoring, as well as tolerance developing. Also, some are enzyme blockers and inducers, having lots of drug interactions.

    I had a patient on felbamate 30 years ago, when the patient’s doctor ran out of options for seizure treatment. Just recently I dispensed a prescription of cerobamate.? One of the readers of Clinicians Corner has a family member who has benefited immensely with CBD for seizure control.

    We have a long way to go in neurology, as the neurons have yet to be completely understood!

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    Overview of Gabapentinoids

    Gabapentin (Neurontin®) FDA approved in 1993
    capsules 100mg, 300mg, 400mg; tablets 600mg & 800mg (available generically) Mechanism: A GABA analog, with no GABA receptor interaction, or GABA effects. Binds to the voltage-gated calcium channels at the alpha 2-delta subunit in the central nervous system. Seems to block excitatory neurotransmitters, as well as modulating the release of several neurotransmitters including glutamate, noradrenaline, and substance P.

    Indications:
    • Postherpetic neuralgia in adults
    • Adjunctive therapy in the treatment of partial onset seizures, with and without secondary generalization, in adults and pediatric patients 3 years and older with epilepsy
    • ‘Off Label’ Uses: restless leg syndrome, hot flashes, diabetic peripheral neuropathy, back pain, paresthesia, anxiety in bipolar disease, alcohol withdrawal etc.
      • These are NOT FDA approved indications.
    Dosage:
    • ADULT: initial: 300mg at bedtime, increase to 900mg over 3 days.
    • Maintenance 1,800 to 2,400mg/day in divided doses.
    • Most clinicians are using 2,400 to 4,800mg/day for epilepsy
    • For neuropathic pain don’t exceed 3,600mg per day.
    • CHILD: start 10 to 15mg/kg/day in 3 divided doses. Maintenance dose of up to 50mg/kg /day
    Renally impaired patients require dosage adjustment: GABAPENTIN
    Renal clearance CrCl in mL/minTotal Daily dosage range (mg/day)
    Over 60900-3,600mg
    30-59400-1,400
    15-29200-700
    15 and less100-300mg (reduce proportionally)

    Adverse effects: Fatigue, dizziness, headache drowsiness, ataxia, nystagmus, aggressive behavior in children.

    Contraindications: None

    Drug Monitoring: No optimal level given. Titrate to therapeutic effect, takes about one day to reach steady state.

    Drug interactions:
    • Antacids reduce bioavailability by 20%
    • Cimetidine reduces renal excretion of Gabapentin, causing increase in Gabapentin effect.
      • Separate by 2 or 3 hours.
    • Gabapentin does NOT induce or inhibit liver enzymes.
    • Elimination half-life is 5-7 hours; takes 2 days to completely clear the body
    • Takes at least 7 days to taper a patient off of gabapentin
    Patient education:
    • Watch for drowsiness-caution driving.
    • Avoid cimetidine & antacids by 2 hours.
    Abuse potential: especially with alcohol and high doses. Be on the lookout for frequent requests for early refills. Some states now have Gabapentin in Schedule-V
    • States where gabapentin is classified as a controlled substance: Alabama, Kentucky, Michigan, North Dakota, Tennessee, Virginia, and West Virginia.
    • Not controlled but mandated reporting: Connecticut, Washington DC, Indiana, Kansas, Massachusetts, Minnesota, Nebraska, New Jersey, Ohio, Oregon, Utah, and Wyoming.
    • States thinking about mandatory reporting: Delaware, New York, and Wisconsin.


    Pregabalin (Lyrica®) FDA Approved 2004
    available as capsules: 25, 50, 75, 100,150, 200, 225, 300mg
    Lyrica CR® : Extended-release tablets: 82.5 mg, 165 mg, and 330 mg

    Schedule-V controlled substance

    Mechanism: Not well understood. Looks like GABA but has no effect on GABA or BZ receptors. Pregabalin binds to the voltage-gated calcium channels at the alpha 2-delta subunit in the central nervous system, resulting modulation in the release of several neurotransmitters including glutamate, noradrenaline, and substance P.

    Dosage and Administration: May give with or without food. Immediate release is FDA Approved for:
    • Epilepsy: for adjunctive treatment of partial onset seizures.
    • Diabetic peripheral neuropathy
    • Post herpetic neuralgia
    • Fibromyalgia
    • Neuropathic pain associated with spinal cord injury
    • Once-daily dosing (CR) for diabetic peripheral neuropathy and post-herpetic neuralgia, but not for fibromyalgia.
    • When converting from IR twice daily to CR once daily, take the daily dose in the morning. Add 10% to total IR dose to get CR dose. (75mg IR= 82.5CR; 150mgIR=165mgCR; 600mgIR=660mg ER, etc.)
    Warnings/ Precautions/Adverse Effects:
    • Weight gain and edema (especially if given with thiazolidinediones)
    • Visual disturbances (notify clinician if occurs)
    • Report any muscle pain, tenderness, or weakness & fever
    • May see additive effects with CNS depressants (opioids & benzodiazepines).
    • Avoid alcohol
    • Pregnancy Category-C
    • May cause male mediated teratogenicity. (inform clinician if planning to father a child)
    • Dizziness and somnolence
    • MUST taper drug over a 1-week period. Do NOT stop abruptly.
    • In clinical practice, this drug is used for post herpetic neuralgia, and diabetic neuropathy.
    GABAPENTINOID WARNING: Dec-2019
    The U.S. Food and Drug Administration (FDA) is warning that serious breathing difficulties may occur in patients using gabapentin (Neurontin®) or pregabalin (Lyrica®, Lyrica CR®) who have respiratory risk factors. These include the use of opioid pain medicines and other drugs that suppress the central nervous system, and conditions such as chronic obstructive pulmonary disease (COPD) that reduce lung function. The elderly are also at higher risk.

    Gabapentinoids are often being combined with CNS depressants, which increases the risk of respiratory depression. CNS depressants include opioids, anti-anxiety medicines, antidepressants, and antihistamines. There is less evidence supporting the risk of serious breathing difficulties in healthy individuals taking gabapentinoids alone.

    Be aware of the potential additive effects of all these CNS depressants and plan accordingly, by starting with low doses, titrating carefully, and informing patients of the potential for CNS and respiratory depression and their symptoms. The gabapentinoid prescribing information already includes guidance for health care professionals to caution patients about dizziness, somnolence, and the potential for impaired ability to operate a car or complex machinery. https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-breathing-problems-seizure-and-nerve-pain-medicines-gabapentin-neurontin

    Is there a drug in the pharmacy that we dispense more inappropriately than gabapentin? It seems to be part of most pain management doctors regimen, also including tizanidine or cyclobenzaprine, and an opioid.

    I have yet to ask a student pharmacist what the FDA approved indications are for gabapentin and received a correct answer. I most often get “neuropathic pain” or “diabetic peripheral neuropathy” as the answer. The truth is gabapentin is only FDA approved for post herpetic neuralgia and seizure management.

    Many physicians see gabapentin as “not as bad as” opioids, but we as pharmacists still need to warn our patients about the dangers of this drug, especially given the fact it is frequently prescribed in conjunction with opioids, and other CNS suppressants such as tizanidine, tricyclic antidepressants and cyclobenzaprine.

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    Overview of Topiramate and Lacosamide Use in Seizure Disorders

    Topiramate (Topamax®) FDA approved:1996
    tablets: 25mg, 50mg, 100mg, 200mg.
    Sprinkle caps: 15mg,25mg (available generically)
    • Qsymia®: phentermine/ topiramate: 3.75 mg/23 mg; 7.5 mg/46 mg; 11.25 mg/69 mg; 15 mg/92 mg. Approved 2012 for weight loss (BMI over 30 or BMI over 27 with other risk factors.)
      • This drug requires a REMS program that is available on the website at https://qsymiarems.com/information-for-pharmacists.htm
    Mechanism: blocks voltage dependent sodium and calcium channels, augments the activity of the neurotransmitter GABA at some subtypes of the GABA-a receptor and antagonizes the kainate subtype of the glutamate receptor.

    Indications for use:
    • Partial onset seizures
    • Tonic-clonic seizures
    • Unlabeled use: alcohol dependence, binge eating, bulimia nervosa, cluster headache, infantile spasms, migraine prevention, weight loss in obesity.
    Dosage: Recommended dose: 200mg-400mg /day in 2 divided doses. 400mg/day as adjunct for tonic clonic seizures. Start with 25-50mg/ day; then may increase by 25mg-50mg increase per week. Pediatrics: 5-9mg/kg/ day (ages 2-16; Not approved for use under age 2.)

    Adverse effects: 28% of patients taking this drug discontinued therapy because of the following side effects: anorexia (2.7%); ataxia (2.1%); confusion (3.1%; depression (2.6%); difficulty with concentration (2.9%); fatigue, mental difficulty & somnolence (3.2%). Most of the side effects are dose dependent. Impaired cognition.

    Pregnancy Category: D (was changed March 2011 from Cat-C): causes oral clefts and low birth weight.

    Drug interactions:
    • Avoid alcohol (increases drowsiness)
    • Avoid carbonic anhydrase inhibitors (promotes stone formation by reducing urinary citrate excretion, and by increasing urinary pH. Topiramate is a weak carbonic anhydrase inhibitor. Be sure patients are adequately hydrated in summer months.
    • Mild inducer of CYP-450--- caution with oral contraceptives.
    Patient education:
    • Monitor weight, may cause weight loss
    • Maintain adequate fluid intake to minimize renal stone formation
    • Watch for drowsiness- caution driving
    • Reduces effectiveness of oral contraceptives. Decreases plasma concentrations of ethinyl estradiol by 25%. Consider alternate method or increase estrogen dose.


    Lacosamide (Vimpat®) FDA approved: 2008
    Tablets: 50mg, 100mg 150mg & 200mg tabs; solution and injection 200mg/20mL.
    Schedule-V controlled substance

    Indications for Use:
    • An adjunctive therapy in the treatment of partial-onset seizures in patients with epilepsy who are 17 years and older.
    • Injection is indicated as short-term replacement when oral administration is temporarily not feasible in these patients.
    Dosage: Initially, give 50 mg twice daily (100 mg/day). The dose may be increased, based on clinical response and tolerability, at weekly intervals by 100 mg/day given as two divided doses to a daily dose of 200 to 400 mg/day.

    Mechanism: In vitro electrophysiological studies show selectively enhances slow inactivation of voltage-gated sodium channels, resulting in stabilization of hyperexcitable neuronal membranes and inhibition of repetitive neuronal firing.

    Adverse effects:
    • Most common side effects: double vision, headache, nausea, dizziness
    • Suicidal ideation
    • Dizziness and ataxia
    • Schedule V controlled substance; can cause euphoria or "drunk" feeling
    Monitoring:
    • Check EKG at baseline and after dose titration in patients with cardiac conduction problems, heart disease, or heart failure.
    • Serum level monitoring not needed.
    • Minimal interactions with CYP 450 ---is a CYP2C19 substrate and inhibitor (same as omeprazole). Elimination may be decreased by coadministration of divalproex.


    One of my patients that was taken Topiramate and said he stopped taking it because he was feeling lightheaded and fuzzy, he referred to the drug a “Dope-a-max”. We use a fair amount of topiramate for migraine prevention, and I always warn my patients in the summer to be sure they are adequately hydrated because of the risk of oligohidrosis (lack of sweating).

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    Overview of Levetiracetam and Brivaracetam



    Levetiracetam (Keppra 250mg, 500mg, 750mg (available generically) FDA approved in 1999

    Mechanism: has a most unusual mechanism of action described as binding to the synaptic vesicle protein SV2A; binding at this site may modulate synaptic transmission through alteration of vesicle fusion. SV2a does not cause immediate seizures but may contribute to a state of heightened epileptogenicity. SV2A dysfunction is linked to seizure activity.

    Indications: Most neurologists will start new patients on this medication, due to efficacy and low generic cost, and lack of drug interactions. Levetiracetam has a broad spectrum of use.
    • adjunctive therapy in the treatment of partial onset seizures in adults and children 4 years of age and older with epilepsy.
    • adjunctive therapy in the treatment of myoclonic seizures in adults and adolescents 12 years of age and older with juvenile myoclonic epilepsy.
    • adjunctive therapy in the treatment of primary generalized tonic-clonic seizures in adults and children 6 years of age and older with idiopathic generalized epilepsy.
    Dosage: initial dose: 500mg twice daily. Titrate by 1000mg/day increments every 2 weeks. Maximum = 3000mg/day

    Adverse effects: drowsiness, headache & dizziness.

    Drug Monitoring: None necessary. Time to steady state: 2 days.

    Drug interactions: Not extensively metabolized. Not dependent on P450 isoenzymes.

    Patient education:
    • Swallow tablets whole. Do not chew or crush
    • May cause drowsiness. Use caution when driving or operating dangerous machinery.
    • Report any behavioral changes to practitioner, such as: hostility, irritability, hallucinations, thoughts of suicide.
    • Considered to be weight neutral. Some reports show significant weight loss.
    Oct-2021: Study results showed that individuals treated with levetiracetam showed improvement in cognitive function, and those with silent epileptic activity showed a clear benefit from the drug. There’s a subtype of Alzheimer’s disease, consider it an epileptic variant, that’s quite common, occurring in approximately 60% of patients. Patients with this form of Alzheimer's disease show symptomatic improvement with levetiracetam, by improved cognitive function.
    https://jamanetwork.com/journals/jamaneurology/article-abstract/2784539
    Among Alzheimer’s patients, an estimated 10-22% develop seizures, while an additional 22-54% exhibit silent epileptic activity.

    Brivaracetam (BRIVIACT®) FDA approved in 2016 Schedule-V
    Available as Tablets: 10 mg, 25 mg, 50 mg, 75 mg, and 100 mg and oral solution: 10 mg/mL. cost $1,200/ month

    Indications: approved as monotherapy or adjunctive therapy for focal-onset seizures in patients one month of age and older.

    Mechanism: same as Levetiracetam, binding to SV2A protein.

    Dosage: Monotherapy or adjunctive therapy is 50 mg twice daily. Dose can be adjusted dosage may be adjusted down to 25 mg twice daily (50 mg per day) or up to 100 mg twice daily (200 mg per day), based on patient tolerability..

    Drug interactions: Brivaracetam is 60% metabolized by CYP450-2C19 (same isoenzyme that activates clopidogrel) Weak metabolizers of CYP2C19 might experience excess levels of brivaracetam, causing toxicity. Best to avoid inducers of CYP2C19, such as phenytoin, carbamazepine, and phenobarbital as they may increase metabolism of brivaracetam. Adverse effects: Sleepiness, dizziness, fatigue and nausea.

    I’m always amazed with the new information coming out with old established drugs. Such was the case this past week, when I read about levetiracetam being used in Alzheimer’s patients. I was never aware that Alzheimer’s patient exhibited increases in seizure activity.

    As we discussed in a previous column, the cholinesterase inhibitors helped 1/12 Alzheimer’s patients. It shows our very rudimentary knowledge of Alzheimer’s, seizures and function of the CNS.

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    Overview of Lamotrigine for Seizure Disorders

    Lamotrigine (Lamictal®)
    FDA approved 1994
    Available as: chew: 2mg, 5mg & 25mg, tablets: 25, 100, 150 & 200mg

    Mechanism: is unknown but may interfere with sodium channels and stabilize neuronal membranes, modulation presynaptic excitatory amino acid release (glutamate & aspartate). Also, may have a slight effect on calcium channels.

    Lamotrigine is FDA-approved for adjunct therapy for Lennox-Gastaut syndrome, primary generalized tonic-clonic seizures (adjunctive), and focal onset seizures (monotherapy or adjunctive therapy); may be used off-label for other seizure types.

    The investigators at the SANAD (Standard and New Antiepileptic Drugs) trials concluded that lamotrigine should be the first drug of choice for use in focal seizures.

    Although we think of lamotrigine as being a seizure medication, it is more commonly used for bipolar disease. Lamotrigine has better evidence of efficacy than lithium for monotherapy for bipolar depression. Lamotrigine is the best choice for prevention of recurrent depressive episodes. Lamotrigine does not have great efficacy for mania. Dosage:

    Adults: read and follow all package instructions concerning dosing.
    Because of risk for Stevens-Johnson Syndrome, slow titration is a must. The incidence of rash, which has included Stevens-Johnson syndrome, is approximately 0.3% to 0.8% in pediatric patients (2 to 17 years of age) and 0.08% to 0.3% in adults receiving lamotrigine. Rash, if it occurs, is almost always seen in the first 8 weeks of therapy.
    There are different dosage regimens to follow:
    • Adding lamotrigine to AED regimen containing Valproic acid (Depakote®)
      • 25mg every other day, for 2 weeks. Then 25mg every day for 2 weeks.
    • Adding lamotrigine to EIAED (enzyme inducing anti-epileptic drug). CBZ, DPH, PBARB without valproic acid.
      • 50mg daily for 2 weeks. Then 100mg daily in 2 divided doses for 2 weeks.
    • Start lamotrigine without any inducers/ inhibitors:
      • 25mg daily for 2 weeks. Then 50mg daily for 2 weeks.
    Adverse effects: skin rash (discontinue if it appears)-Black box warning. Titrate slowly, especially if taking Valproic acid.


    Lamotrigine Safety Alert April 2021
    The FDA has issued a drug safety communication after a review of study findings showed a potential increased risk of arrhythmias in patients with heart disease who are taking lamotrigine (Lamictal®)

    Drug interactions: many drug interactions between enzyme blockers and inducers. Although lamotrigine does not induce or inhibit other drugs, its metabolism is affected. Adding valproic acid to lamotrigine, will double lamotrigine steady state concentration.

    Half-life for lamotrigine is 6-8 hours.

    Drug Monitoring: optimal blood level: 4 to 20 mcg. Days to steady state: 4 to 5 days

    Patient care points:
    • Be sure to follow titration guidelines.
    • If rash should occur, stop the drug and immediately contact your prescriber.
    • Inhibits dihydrofolate reductase. Folic acid supplementation may be necessary.
    • May also cause nausea, dizziness, tremor, diplopia.
    • Lamotrigine may reduce the effectiveness of combined estrogen-progestin contraceptives
    • Pregnancy may cause an increase in seizures by increasing lamotrigine clearance by 65%. It quickly reverts to pre-pregnancy levels after delivery.


    Lamotrigine dosing is a textbook example of drug interactions. I included this drug as an example in my intro to Pharmacology lectures. If a patient is on a CYP3A4 blocker, you cut the dose in half. If a patient is on a CYP3A4 inducer you double the dose.

    We frequently see lamotrigine used for bipolar, especially in patients that lean to the depressive side. This drug, like carbamazepine, does require that patients be warned of the potential for rash, which could be Stevens Johnson Syndrome, “The Mother of all Rashes.” For lamotrigine, a benign rash may occur in up to 10% of patients; the rate for SJS is 1/1,000 patients.

    Unlike carbamazepine, there is no blood or genetic test to determine who is at risk for SJS. Slow titration and good counseling need to be standard processes with each patient.

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    Overview of Valproic Acid and Divalproex for Seizure Disorders

    Depakene® (approved 1978), Depakote® (approved 1983), Depakote ER® (approved 2000)

    Mechanism:
    • Increases levels of GABA by potentiating post synaptic GABA response by inhibiting the enzymatic response for the catabolism of GABA
    • Valproate is considered the most effective antiseizure medication for idiopathic generalized epilepsy with generalized tonic-clonic seizures
    • Affects potassium channel creating direct membrane stabilizing effect
    Depakene capsules, Depakote tablets, Depakote-ER DOSING: Adults: 1000 to 3000mg daily in divided doses. (Depakote ER as a single dose). Maximum is 60mg/kg/day.
    Child: start with 10-15mg/kg per day. Divided into 2 or 3 doses. Expect dose to escalate. Don’t exceed 60mg/kg/day.
    • Depakote® (divalproex sodium) is an enteric coated valproic acid derivative.
    • Written as “Depakote® 500mg” implies the enteric coated but multiple dosed.
    • Only Depakote ER 500mg should be given as a single dose (Multiple tablets given together)
    • Depakote is available as 125mg enteric coated tablets, 250mg tablets & 500mg tablets. Also available as 125mg sprinkle capsules.
    • Depakote ER® is available as 250mg and 500mg tablet (these are silver colored)
    • Divalproex ER (Depakote-ER) is used for epilepsy, mania, and migraine prophylaxis. Effective in preventing depressive recurrences in mania by 30
    • Divalproex DR (Depakote) is used for epilepsy. Divide doses if over 250mg.
    • Depakene® is valproic acid capsules and is available as a generic. Depakote and Depakote ER are available generically:
      • Depakote= divalproex delayed release
      • Depakote-ER= divalproex extended release
    Adverse effects: Hepatotoxicity, Teratogenicity, Pancreatitis are in the Black Box Warning.

    Stomach upset, alopecia, weight gain, tremor, easy bruising, thrombocytopenia.

    Blocker of P4503A4

    Teratogenicity: Divalproex has the highest risk for teratogenicity of all available anti-epileptic drugs.

    Contraindications: Hepatic disease and known urea cycle disorders

    May cause hyperammonemic encephalopathy which can lead to seizures, coma and death.

    Drug Monitoring:
    • Optimal blood level is 50-125mcg/mL. May take 2- 4 days for steady state blood levels.
    • Liver function tests are necessary: initial therapy: every 1 to 2 weeks, then periodically
    Patient education:
    • Take with food to minimize stomach upset.
    • Swallow tablets whole. Do not chew or crush.
    • Will cause weight gain. Monitor weight.
    • Watch for drug interactions, as this is a blocker of P450 3A4 metabolism


    Primidone (Mysoline®) 50 and 250mg tablets (approved 1954)

    Mechanism: Metabolized to Phenobarbital and PEMA (phenylethylmalonamide)
    Used for focal seizures and generalized tonic-clonic seizures.
    In some refractory patients, the PEMA potentiates the activity of phenobarbital.


    Essential tremor: Low dose primidone (start with 25mg) may also be effective when used intermittently for essential tremor that is exacerbated by situational stress or anxiety. Frequently used with propranolol.

    Dosage:
    • Maintenance: 250mg three to four times daily. Maximum 500mg four times daily (2 grams/day)
    • Children under age 8: days 1-3= 50mg at bedtime; days 4-6 = 50mg twice daily. Days 7-9: 100mg twice daily. Maintenance: 125 to 250mg three times daily
    Adverse effects:
    • CNS: drowsiness, alteration of sleep cycles, sedation, lethargy, behavioral changes, hyperactivity, ataxia, tolerance, dependence
    • Children: hyperactivity
    Drug Monitoring: optimal blood level: 10-40mcg/mL. Days to steady state: 10 days

    Drug interactions: Inducer of CYP-3A4 (similar to phenobarbital, one of the metabolites).

    Patient education:
    • Watch for drowsiness.
    • Report multiple drug therapy to practitioner.


    Both divalproex and primidone, although effective for seizure management, are more commonly used for other conditions. Most of the divalproex I dispense is written by mental health professionals. We also see a good bit of divalproex used for migraine prophylaxis.

    Divalproex is a drug that be challenging to prescribe, given the delineation between ER and DR. It was not such a challenge when we were dispensing brand Depakote versus Depakote-ER.

    Now that it is available generically, the confusion may occur between Divalproex ER versus Divalproex DR. I advise my prescribers to write it by the brand name, and we pharmacists will dispense the generic.

    Although divalproex and primidone have lots of side effects and drug interactions, sometimes divalproex is the best choice for migraine, bipolar and epilepsy.

    Primidone seems, at low dose, to be effective for essential tremor, along with propranolol. Chances are that if you see a prescription for primidone, it probably is for essential tremor.

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    Overview of Carbamazepine

    Carbamazepine (Tegretol®, Carbatrol®)
    Tegretol: FDA approved 1968
    • Tegetol® available as : 100mg chew, 200mg tablets, & XR 100,200 ,400mg. Tegretol suspension=100mg/5mL. Generic equivalents available for susp, chew tabs and 200mg tablets
    • Carbatrol®: extended release capsules 100, 200 & 400mg
    Mechanism: thought to act by reducing polysynaptic responses and blocking post-tetanic potentiation.

    Uses:
    • treatment of focal and generalized seizures
    • affective illnesses such as bipolar disorder
    • chronic pain syndromes such as trigeminal neuralgia.
    Dosage:
    • Adults: initial-200mg twice daily. May increase to 800 to 1600mg daily in divided doses.
      • May increase at weekly intervals of no more than 200mg/day.
      • Maintenance level: 800-1200 per day
    • Child: 10-20mg/kg/day in 2 or 3 divided doses. Max dose 35mg/kg/day.
      • May increase at weekly intervals of no more than 100mg/day
    USE: For newly diagnosed, new onset, and refractory epilepsy

    Adverse effects:
    • Bone marrow suppression –FDA box warning: Aplastic anemia, agranulocytosis, pregnancy category-D, hyponatremia.
    • Men may have higher rates of sexual dysfunction due to lowering of testosterone.
    • May cause aggression! Slow titration minimizes adverse effects.
    Contraindications: Drug interactions - extensively metabolized by the P450 3A4 isoenzyme. The metabolism of carbamazepine is blocked by: cimetidine, erythromycin, clarithromycin, fluoxetine & azole antifungals.

    Is a potent enzyme inducer: it will speed the metabolism of drugs metabolized by the P450 enzyme system. Will decrease the effect of: oral contraceptives (recommend another method), doxycycline, haloperidol, anticoagulants, benzodiazepines, theophylline. It . Carbamazepine induces its own metabolism!
    • Half-life after chronic therapy decreases. Autoinduction occurs 3-4 weeks after starting carbamazepine, resulting in a decrease in carbamazepine levels
    • Phenytoin and phenobarbital may lower carbamazepine levels but increase levels of its active metabolite carbamazepine 10,11-epoxide
    HYPERLIPIDEMIA: Enzyme-inducing antiseizure drugs have been associated with increased hyperlipidemia. Order lipid panels for patients who require long-term therapy with enzyme-inducing drugs.

    Drug Monitoring: target serum concentration: 4 to 12 micromol/mL. Carbamazepine 10,11-epoxide is the metabolite that is measured. Measure at 3, 6 and 9 weeks, then every 60 days until constant levels. Time to steady state: 3-4 days.
    • Perform blood counts and liver function at baseline.
    • Monitor sodium levels
    • Do CBC and LFT (liver function testing) monthly
    • Monitor blood level of drug closely every 2 weeks, for first 2 months
    • After patient titrated, do CBC and LFT every 6-12 months.
    • Check blood levels every 3-6 months and after each dosage change
    Carbamazepine

    Patient education:
    • May cause drowsiness, dizziness and blurred vision.
    • Report any unusual bleeding or bruising, fever, sore throat rash or ulcers
    • Report liver reactions: anorexia, N/V, or jaundice
    -Note: minimal cognitive impairment compared with other antiepileptic drugs.



    Genetic Testing
    It is recommended to genetically test many Asians BEFORE starting carbamazepine to predict risk of a serious drug reaction. This is the first time that genetic testing is recommended before using a rather common drug.

    Carbamazepine carries a FDA box warning recommending that patients of Asian descent be screened for the HLA-B*1502 (HLA=Human Leukocyte antigen) gene before starting carbamazepine.

    HLA-B*1502 is seen almost exclusively in Asian populations (Chinese & South Asian Indian). About 5% of patients who have it will develop Stevens-Johnson syndrome or toxic epidermal necrolysis with carbamazepine.


    Symptoms of Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis:
    Both Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis can start with non-specific symptoms such as: coughing, aching, headache, fever, vomiting, diarrhea. Symptoms usually occur within the first 8 weeks to therapy.

    This is usually followed by a red rash across the face and the trunk of the body, which can continue to spread to other parts of the body. Blisters then form across the body in places such as the nose, mouth, eyes, and genital areas, and the mucous membrane becomes inflamed. With some people, the nails and hair begin to come out as well. In the case of Toxic Epidermal Necrolysis patients, the skin can start to come away in sheets leaving exposed flesh that could be likened to serious burning and is very susceptible to infection.

    Both disease variations are potentially deadly. In drug related cases, the symptoms for both diseases can take one or two weeks to manifest from the first time the patient takes the drug.


    Treatment for Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis
    If the cause is drug related, doctors can stop the drug immediately. In the case of a new infection on top of the condition or a bacterial infection, select a suitable antibiotic. In severe cases, the patient is treated in a burn unit. Patients have to be treated in meticulously hygienic environments to alleviate the risk of further infection, which could result in death. In cases where the patients have lost a lot of fluid through seeping areas where the skin has come away, intravenous fluid replacement may be required. The hospital may also use topical and oral corticosteroids to treat affected areas.
    Reference: http://www.skinassn.org/stevens-johnson-syndrome-symptoms-treatment.html



    Carbamazepine is another 50 plus year old drug. When I taught students in the neurology component of pharmacology, seizure meds seem to be the most challenging. For us older practitioners, we simply divide them into “old drugs” those that we had on the shelves when we started practicing: phenobarbital, phenytoin, primidone, valproic acid, and carbamazepine were the go-to drugs for seizure management until the early 1990’s. Then came a landslide of seizure medications in the 1990’s with more introduced every couple of years.

    These drugs are a hodge-podge of drug interactions and needs for frequent lab monitoring. Neurologists seldom use these five drugs, but psychiatrists frequently use divalproex and carbamazepine for mood stabilization.

    Carbamazepine with its drug interactions and potential drug interactions deserves special attention. Be sure to look at the “entire patient” and if the patient is of Asian descent, genetic testing for HLA-B*1502 antigen is a must. Stevens-Johnson syndrome is frequently referred to as “the Mother of all Skin Rashes.”

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    Overview of Phenobarbital and Phenytoin

    PHENOBARBITAL

    Phenobarbital tablets 15mg,30mg,60mg,90mg, 100mg

    20mg/5cc elixir
    Phenobarbital was first marketed in 1912 by Bayer under the brand name Luminal®.

    Mechanism: binds to GABA receptors and intensifies the effects of GABA.
    INCREASES the duration of the GABA mediated chloride channel opening. Chloride is the major inhibitory ion in the central nervous system.

    Use: partial and generalized seizure

    Dosage:
    Child: 3-6mg/kg/ day in divided doses.
    Adult: 60-100mg/day

    Neonates: is drug of choice for seizures. May cause delayed intellectual development. Adverse effects: drowsiness, depression, and confusion

    Contraindications: drug abusers, alcohol abusers, depressed patients

    Drug interactions: Phenobarbital is a potent p450 enzyme inducer.
    Decreased serum levels of: Warfarin, OC’s, propranolol, lamotrigine, and theophylline (speeds up metabolism)

    HYPERLIPIDEMIA: Enzyme-inducing antiseizure drugs have been associated with an increased incidence of hyperlipidemia. Order lipid panels for patients who require long-term therapy with enzyme-inducing drugs.

    Drug Monitoring: therapeutic blood level 10 to 40mcg/mL, Time to steady state: 14 to 21 days

    Patient education:
    • withdraw slowly from drug, under a practitioner’s advice
    • Schedule IV drug

    • NET EFFECT on the GABA receptor
    • Barbiturates increase the duration of chloride ion channel opening at the GABA receptor, to increase the efficacy of GABA.
    • Benzodiazepines increase the frequency of the chloride ion channel opening at the GABA receptor to increase the potency of GABA.
    Other Uses:
    • To prevent seizures in newborns, who are born to mothers with a history of heroin use during pregnancy
    • To increase breakdown of bilirubin in neonates to prevent jaundice. (Gilberts syndrome)


    Phenytoin, “Diphenylhydantoin, DPH (Dilantin®)

    History: In 1908, phenytoin was first synthesized as a barbiturate derivative in Germany by professor Heinrich Biltz (1865-1943) and subsequently resynthesized by an American chemist of the pharmaceutical company Parke-Davis in 1923 in Detroit. In 1938, it was discovered to be an effective anti-seizure medication.

    Available as capsules: 100mg, chew tabs 50mg, suspension 125mg/5cc and Phenytek® 200mg & 300mg

    Mechanism: stabilizes neuronal membranes and decreases seizure activity by increasing efflux or decreasing influx of sodium ions.

    Use: simple/complex partial, generalized tonic-clonic.

    Dosage: Adult: 300mg-700mg/day

    Adverse effects: nystagmus, ataxia, sedation, confusion, gingival hyperplasia, hirsutism, blood dyscrasia, vitamin K deficiency, osteomalacia, & folate deficiency. Can cause megaloblastic anemia.

    Contrandications: do not use in sinus bradycardia, or cardiomyopathies

    Drug Interactions
    • Drugs increasing the effect of phenytoin - inhibit metabolism: Allopurinol, benzodiazepines, cimetidine, alcohol, fluconazole, metronidazole, omeprazole, sulfonamides, valproic acid, and trimethoprim. Alcohol-acute ingestion
    • Drugs decreasing effect of phenytoin - increase metabolism: Barbiturates, carbamazepine, alcohol- (chronic), theophylline
    • Phenytoin is also an enzyme inducer- it will decrease the effectiveness of oral contraceptives. It also decreases the effectiveness of: Acetaminophen, amiodarone, carbamazepine, quinidine, theophylline & valproic acid.
    Hyperlipidemia: Enzyme-inducing antiseizure drugs have been associated with an increased incidence of hyperlipidemia. Order lipid panels for patients who require long-term therapy with enzyme-inducing drugs.

    Drug Monitoring: optimal blood level 10-20mcg/mL. Time to steady state: 5-10 days

    Patient Education (Phenytoin):
    • Practice good oral hygiene to decrease gingival hyperplasia/li>
    • Take with food to decrease GI upset.
    • Avoid alcohol
    • Watch for drowsiness, dizziness, blurred vision. Exercise caution when driving.
    • Encourage use of another method of birth control


    Both phenytoin and phenobarbital have been available for over 100 years. From the folks who brought us aspirin and heroin, Bayer Pharmaceuticals also brought phenobarbital to market in the early 1900’s, under the brand name Luminal®. Luminal® was used as a sedative and also as an anti-seizure medication.

    Phenobarbital also has a very dark side. In the 1940’s Adolph Hitler used Luminal® as part of his child euthanasia plan to kill mentally and physically handicapped children. Over 5,000 children were killed as part of Nazi Germany’s Kinder-Euthanasie program which led to the extermination of even more children in the concentration camps. It all started with Luminal® being administered to 50 intellectually disabled children in 1940 at a clinic in Ansbach Germany.

    Phenytoin also has a story line, albeit not as tragic as phenobarbital. It was described that Richard Nixon was given phenytoin to stabilize his mood swings when he was in the White House. Jack Dreyfus of the Dreyfus Fund fame, was reported to give Richard Nixon large doses of phenytoin after he was elected in 1968, as Dreyfus felt it helped with mood swings and depression.

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    Overview of Seizure Disorders

    Seizure Basics:: What type of seizure the patient experiences is important to the selection of pharmacotherapy. The purpose of this piece is not to make us amateur neurologists, but to cover the basics:

    Seizures can be divided into two classes: focal or generalized
    • Focal (partial) seizures involve only a portion of the brain and are broken down to their impairment of awareness.
    • Generalized seizures are broken down into motor and non-motor seizures. The most obvious generalized seizure is the tonic-clonic variety.
    Seizures by the numbers: (source: International League Against Epilepsy (ILAE)
    • 90% of people with epilepsy are aware of their diagnosis as a treatable brain disorder
    • 80% of people with epilepsy have available to them safe, effective and affordable medications
    • 70% of patients with epilepsy experience adequate seizure management
    • 10% of the world’s population will experience a seizure in their lifetime
    What meds to choose: Treatment for the first seizure is not immediately recommended if what provoked the seizure can be resolved. Usually, 50% of patients with a new diagnosis of epilepsy will become seizure free with the first antiseizure medication prescribed. Treatment for the first seizure depends on the following:
    • Seizure type
    • Patient preference
    • Risk benefit ratio: side effect profile
    • Patient’s age
    • Potential for pregnancy
    FDA Requires Warnings about Risk of Suicidal Thoughts and Behavior for Antiepileptic Medications. (2008)
    The U.S. Food and Drug Administration announced it will require the manufacturers of antiepileptic drugs to add to these products' prescribing information, or labeling, a warning that their use increases risk of suicidal thoughts and behaviors (suicidality). The action includes all antiepileptic drugs including those used to treat psychiatric disorders, migraine headaches and other conditions, as well as epilepsy.

    The FDA is also requiring the manufacturers to submit for each of these products a Risk Evaluation and Mitigation Strategy, including a Medication Guide for patients. Medication Guides are manufacturer-developed handouts that are given to patients, their families and caregivers when a medicine is dispensed. The guides contain FDA-approved information about the risks of suicidal thoughts and behaviors associated with the class of antiepileptic medications.

    OK, so what about the newer anti-epileptic drugs approved since 2008?
    The August 2, 2021 edition of JAMA Neurology states that “suicidality was evaluated prospectively in trials of 5 antiseizure medications eslicarbazepine (Aptiom®), perampanel (Fycompa®), brivaracetam (Briviact®), cannabidiol (Epidiolex), and cenobamate (Xcopri®), including 17 trials involving 5996 patients, including 4000 patients treated with antiseizure medications and 1996 treated with placebo. There was no evidence of increased risk of suicidality (ideation or behavior) overall or for any individual drug.”

    Basically the study shows: “There is no current evidence that newer antiseizure medications increase suicidality in epilepsy; therefore, a suicidality class warning is not warranted.”
    JAMA Neurol. Published online August 2, 2021. doi:10.1001/jamaneurol.2021.2480

    Background:

    Older agents: Before 1990, we only had 6 drugs to treat all forms of epilepsy: These agents included carbamazepine (Tegretol®), ethosuximide (Zarontin®), phenobarbital, phenytoin (Dilantin®), primidone (Primidone®), and valproic acid (Depakote®/Depakene®). These drugs were used as monotherapy and in combined regimens in newly diagnosed and refractory cases, yet 20% to 30% of epileptic patients are refractory to these drugs.

    All six had in common:
    • Drug interactions (very complex pharmacokinetic parameters)
    • Need for blood level monitoring
    • Teratogenic potential


    I have witnessed four seizures and all four times I was scared to death. I have seen a middle-aged woman have a seizure in church, a 20 something year old female who was waiting for her levetiracetam prescription to be filled, and a 24-year-old who had a seizure as a result of hypoglycemia.

    The lady in the store handed me her empty bottle of levetiracetam and asked “How long is this going to take? I have been out of this for a couple of days.” Within minutes, she was on the floor with a clonic tonic seizure.

    Every time, after every seizure I called 911 to summon help, especially when it happens in the store. Sometimes your most important job is keeping the spectators away from “gawking”, by moving them to the next aisle and allowing the patient some level of dignity.

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    Overview of NMDA Receptor Antagonists in the Management of Alzheimer’s Disease

    NMDA receptor antagonists
    “neuroprotective”

    Memantine (Namenda®): tablets 5mg & 10mg (approved 2003) generic available Namenda-XR®: once daily available as 7mg,14mg, 21mg, 28mg XR capsules (approved 2010) generic available

    Mechanism: Persistent activation of CNS n-methyl-d-aspartate (NMDA) receptors by the excitatory amino acid glutamate has been postulated to contribute to symptoms of Alzheimer’s. The drug memantine (Namenda®) has low to moderate affinity for the NMDA receptor. In the presence of memantine, an open channel antagonist, excessive calcium is prevented from entering, effectively lowering background noise. Memantine binds deep inside the channel, not at the glutamate receptor. This helps memantine discriminately block abnormal glutamate activity.

    Memantine remotely modulates the receptor, preventing excessive flow, BUT allowing normal function. The abnormal glutamate activity that leads to neuronal loss is prevented, but physiological activation that produces learning and memory is preserved. Memantine (Namenda®) blocks neuronal toxicity and has a neuro-protective effect on the glutaminergic and cholinergic neurons.

    Dosage: start 5mg daily, increase to 5mg BID, then 5mg in am and 10mg in PM, then 10mg BID. Wait 1 week between dosage interval increases. For XR capsules, start with 7mg/day titrating to 28mg max. Separate dosage increases by 7 days.

    NOTE: this drug is often used in combination with the cholinesterase inhibitors. Is used for moderate to severe Alzheimer’s disease. This drug is said to improve behavior.

    Adverse Effects: generally, well tolerated.

    Contraindication: drugs that make urine alkaline- sodium bicarbonate, carbonic anhydrase inhibitors or severe UTI’s

    Drug Interactions: Clearance of memantine is reduced by 80% in alkaline urine conditions pH=8. May also interact with drugs secreted by tubular secretion (HCTZ, ranitidine, cimetidine, triamterene, quinidine)

    Memantine and Donepezil Extended Release (Namzaric®) 28/10 and 14/10
    (cost= $507.00/month)
    Treatment of moderate to severe dementia of the Alzheimer's type in patients stabilized on:
    • Memantine (10 mg twice a day or 28 mg ER once a day) and donepezil 10 mg once a day, or
    • Memantine (5 mg twice a day or 14 mg ER once a day) and donepezil 10 mg once a day in patients with severe renal impairment
    Lecithin Lecithin is a major dietary source of choline, so extra consumption may reduce the progression of dementia. After multiple studies it showed no more effect than placebo in the treatment of Alzheimer’s disease. Has no therapeutic effect in early onset Alzheimer’s.

    CROSSWORD PUZZLES — possibly the most efficacious prevention for Alzheimer's https://www.alzinfo.org/articles/crossword-puzzles-alzheimers/
    “We report a direct association between cognitive activity and Pittsburgh compound B uptake, suggesting that lifestyle factors found in individuals with high cognitive engagement may prevent or slow deposition of beta-amyloid, perhaps influencing the onset and progression of Alzheimer’s disease,” the researchers write.”

    Pittsburgh compound B binds to beta-amyloid, a toxic protein that builds up in the brains of those with Alzheimer’s and is the main component of the brain plaques that characterize the disease.

    The researchers found that the more often someone engaged in mentally stimulating activities, the less buildup of beta-amyloid they were likely to have in the brain. Other tips to reduce the risk of cognitive decline or dementia, some evidence (not high-level) supports the following:
    • For adults who smoke, offer interventions to facilitate smoking cessation.
    • Reduce or stop excessive alcohol consumption
    • Mediterranean-like diet may be beneficial
    • Offer cognitive training for mild to moderate impairment.
    • Hypertension, diabetes, dyslipidemia (at mid-life), and weight (at mid-life) management may be offered.


    Alzheimer’s disease affects 1 in 9 older Americans, with 2/3 of them being women. Currently there are 6 million people living with Alzheimer’s disease, and that number is expected to double by the year 2050. Currently, this disease costs the nation $355 billion dollars. Between 2000 and 2019, deaths from heart disease have decreased 7.3% while deaths from Alzheimer’s have increased 145%.

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    An Overview of Cholinesterase Inhibitors in Alzheimer’s Disease

    Cholinesterase Inhibitors

    Donepezil (Aricept®) 5mg and 10 mg tablets; 23mg tablets (approved 1996) Dosage: initial: 5mg at bedtime. May increase to 10mg 4 to 6 weeks later. Take in the evening, just prior to retiring.
    • 5mg: mild to moderate AD
    • 10mg: mild, moderate, severe AD
    • 23mg: moderate and severe AD (only increased score 2 points out of 100)
    Donepezil® (Aricept) 23mg tablet: For moderate to severe dementia. Must be stabilized on 10mg dose for 3 months before instituting the 23mg dose. Causes significant GI distress. Adverse effects: insomnia, dizziness, nausea, diarrhea, headache. (all less than 10%). Much higher incidence of GI upset and weight loss with 23mg dose.

    Contraindications: increases gastric secretions. Watch for GI bleeding especially if on NSAIDS

    Drug interactions: P450 inhibitors could increase blood levels. Anticholinergics (such as those of IBS and Overactive bladder) will decrease effectiveness.

    Patient education: Take right before bedtime. May take with food. Generally, well tolerated.

    Rivastigmine (Exelon®) caps: 1.5, 3,4.5 & 6mg (approved 2000)
    Dosage: initial: 1.5mg BID. May increase to 3.0mg BID after 2 weeks.
    • May increase to 4.5mg BID after two weeks, and to 6mg BID in 2 weeks.
    • Usual maintenance dose is 3 to 6 mg BID.
    • Take with food in divided doses in the morning & evening.
    Adverse effects: nausea (47%), vomiting (31%), diarrhea (31%), headache (17%), dizziness (21%) anorexia (17%)

    Contraindications: cholinergics increase gastric secretions. Watch for GI bleeding especially if on NSAID

    Drug interactions: not metabolized by P450. Anticholinergic drugs will decrease effectiveness.
    Patient education: High incidence of nausea, vomiting and diarrhea
    NOTE: Rivastigmine is the only cholinesterase inhibitor approved for dementia in Parkinson’s Disease

    Rivastigmine (Exelon®) patch:
    Dosage available: 4.6mg and 9.5mg/day patch
    • For patients who have trouble swallowing
    • Once daily dosing instead of the BID oral formulations increases compliance.
    • Less nausea and vomiting because drug levels are lower and steadier than with caps
    • New start: 4.6 mg patch, then increase to 9.5 mg after 4 weeks if tolerated.
    Switching from oral: prescribe the 4.6 mg patch for those taking less than 6 mg/day of oral or the 9.5 mg patch for patients on higher doses.



    Galantamine (Razadyne®) 4, 8, 12mg tabs. ER caps available. (approved 2001)
    {name was originally Reminyl, but was changed due to confusion with Amaryl®}
    An anticholinesterase, but also has activity as a nicotinic receptor agonist

    Dosage: start: 4mg twice daily for 4 weeks. Then 8mg twice for 4 weeks. Then increase to 12mg twice daily for 4 weeks, then 16mg twice daily.

    Maintenance dose: 8 to 16mg BID

    Adverse effects: Pregnancy Category B

    Contraindications: Cholinesterase inhibitors increase gastric secretions. Watch for GI bleeding if on NSAID

    Drug interactions: Anticholinergics will reduce its effect.

    Drug monitoring: dosage adjustments are necessary in hepatic impairment and renal impairment.

    Patient education: if therapy is interrupted for several days, the patient must be re-titrated. Starting on the lowest dose and escalated to maintenance dose.

    Class side effects: donepezil, rivastigmine, galantamine)
    • There is an increased risk of bradycardia and fainting in patients taking cholinesterase inhibitors
    • Remember: cholinergic stimulation can slow heart rate which can to a higher risk of fainting, falls, hip fractures, and pacemaker insertion.
    • Cholinesterase inhibitors increase gastric secretions. Watch for GI bleeding if on NSAID
    Bottom Line: One in 12 patients will experience side effects (mostly GI) with cholinesterase inhibitors. Conversely, only 1 in 12 patients show any improvement. No good evidence that drugs delay nursing home placement. Rate of functional and cognitive decline do not improve with drug therapy.



    Alzheimer's drugs have always been expensive. Back in 2010 the chief financial officer called me for some advice. He was curious as to how the Long-Term Care unit of the business had drastically decreased their monthly wholesaler bill.

    He said, “I know they are good, but they cut over $240,000 off last month’s bill.” I explained that donepezil (Aricept®) went from being $240.00 for thirty tablets per patient per month to the generic being around $6.00 per patient per month.

    Most of us seasoned pharmacists remember the first Alzheimer’s drug tacrine (Cognex®) by Parke Davis. It was dosed four times daily. When I first dispensed it and explained the dosing to the patient’s husband he quipped “If she can remember to take this medicine four times a day, does she really have Alzheimers?!!”

    Efficacy of these drugs is questionable, at best. We indeed are treating the caregiver and not so much the patient.

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    Overview of Alzheimer’s Disease

    Signs and symptoms of Alzheimer’s Disease (AD):

    MILD ADMODERATE ADSEVERE AD
    ForgetfulnessDisorientationAgnosia* (more pronounced)
    Word-finding difficultyIncreased memory lossApraxia*
    ApathyConfusionAggression
    Poor attentionInsomniaAgitation
    Difficulty with complex tasksWanderingIncontinence
    DepressionSpeech difficultyPoor Basic ADL
    Work TroubleRestlessGait disturbance
    Difficulty with IADL


    Definitions:
    • Apraxia: inability to carry out purposeful movements in the absence of paralysis or other motor/sensory impairment
    • Agnosia: loss of the power to recognize the import of sensory stimuli
    • ADL: activities of daily living
    • IADL: instrumental activities of daily living
    RULE OUT:
    • Vitamin B12 deficiency
    • Depression, which is a treatable comorbid condition.
    Incidence:
    • The incidence and prevalence of Alzheimer’s disease increases with age, essentially doubling in prevalence every 5 years after the age of 65 years.
    • Onset of AD before age 60 has been associated with a genetic disposition (less than 1% of patients.)
    • Patients with Down Syndrome can develop signs of AD 10-20 years earlier than their counterparts.


    Cholinesterase inhibitors
    The cholinergic system is the system MOST often associated with the early degeneration of Alzheimer’s Disease (AD). Large numbers of cholinergic neurons in the basal forebrain innervate the cortex and hippocampus and are intricately involved in normal learning and memory. In addition to loss of these neurons, cholinergic impairments observed in patients with AD also include:
    • Decline in choline acetyltransferase activity
    • Depletion of acetylcholine (Ach)
    • Acetylcholine in CNS: COGNITION
    • Acetylcholine in PNS: MUSCLES and AUTONOMIC nervous system
    • Decline in acetylcholinesterase activity
    Site of dysfunction is also important:
    • Cortex: loss of cholinergic output contributes to attention deficits
    • Amygdala: cholinergic loss is associated with emotional changes.
    Cholinesterase inhibitors function by blocking ACh destruction and increasing the lifespan of the neurotransmitter in the synaptic cleft, therefore compensating for the loss of ACh containing neurons. While they may enhance cognitive function, they do not slow the degenerative process that underlies the disease.

    Mechanism: enhances cholinergic function by reversible inhibition of acetycholinesterase.


    Aducanumab (Aduhelm®)
    Since aducanumab has been in the news and has caused a lot of controversy, lets discuss it first. Mechanism: Aducanumab is an amyloid beta-directed antibody indicated for the treatment of Alzheimer’s disease. The accumulation of amyloid beta plaques in the brain is a defining pathophysiological feature of Alzheimer’s disease. Treatment with aducanumab should be initiated in patients with mild cognitive impairment or mild dementia stage of disease, the population in which treatment was initiated in clinical trials

    Dose: given as a one-hour infusion, given every 4 weeks. Must be titrated, starting with 1mg/kg ending at 10mg/kg. MRI’s need to be obtained before the 7th and 12th infusion.

    Cost and controversy: $56,000 per year. If all 6 million Alzheimer’s Disease patients were treated with aducanumab, we could significantly strain Medicare funds, to the tune of $336 BILLION. For comparison, Medicare Part B, the hospital insurance plan for seniors, spent $37 billion total on ALL drugs in 2019! This amounts to a 10-fold increase for just ONE drug. (Don’t forget the cost of infusion, as well as those MRI’s required by the package insert)

    Efficacy: Efficacy: Biogen states it slows the progression of AD, but only showed a reduction in the number of amyloid plaques, but there is not a direct correlation to the severity of Alzheimer’s.

    Alzheimer’s is indeed a devastating disease. The drug therapy we have isn’t very robust at all. The cholinesterase inhibitors seem to cause lots of side effects and have issues with efficacy. The NMDA antagonist memantine does not show much efficacy either. In short, our toolbox is limited.

    I always use the analogy with my patients of jumping out of an airplane when discussing AD drug therapy. If they jump out of an airplane with a parachute, and I jump out without one, what happens? We both will hit the ground, me a lot faster. Even with the parachute you will eventually hit the ground, just a lot longer time. At their very best, therapies we have for AD are parachutes, not cures.

    I truly feel with the lack of efficacy of the AD drugs, we are treating the caregiver… just by showing we do care about their loved one with AD.

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    Overview of Treatment Considerations for Patients with Parkinson’s Disease

    Parkinson's Disease

    Parkinson’s Disease has more surgical and pharmacological treatments than any other disease of the central nervous system. The effect on activities of daily living (ADL) are the primary determining factor for selection of pharmacological treatment options. The current belief is that the choice and timing of initial therapy for PD, regardless of mechanism of action, has little impact on the long-term outcome of PD in terms of motor fluctuations.

    Holding off treatment unnecessarily deprives patients of therapeutic benefit early in the disease, when the potential for sustained improvement is greatest. This needs to be a shared clinical decision with the patient and their family.

    Hoehn & Yahr Scale (used to describe severity of Parkinson’s)
    • Stage 1 : unilateral involvement
    • Stage:2 bilateral involvement, no postural abnormalities
    • Stage 3: Bilateral involvement , mild postural imbalance, patient is independent
    • Stage 4: Bilateral involvement postural instability, patient requires much help
    • Stage 5: Severe, fully developed disease, patient restricted to bed or chair
    Wehn to start levodopa treatment...
    • Delay treatment: evidence suggests long term L-dopa therapy can cause response fluctuations, dementia, and loss of L-dopa efficacy.
    • Dyskinesias are more likely the longer patients are on levodopa. (window keeps getting smaller)
    • Start ASAP: counter-argument that response fluctuations is due to disease progression and not L-dopa therapy. In a 3-year multicenter study, mortality doubled if L-dopa therapy is delayed.
    • Current thinking is to initiate treatment when disease interferes with person’s occupation or activities of daily living. The former belief of holding off levodopa therapy (think rationing levodopa therapy) has been unfounded.
    MOTOR FLUCTUATIONS and POSSIBLE INTERVENTIONS IN PARKINSONS DISEASE

    For end-of dose deterioration (“wearing off”) consider:
    • Increase frequency of carbidopa-levodopa doses.
    • Use controlled release carbidopa-levodopa
    • Add dopamine agonists, selegiline, tolcapone or amantadine.
    • Add apomorphine
    For delayed onset of response consider:
    • Giving on an empty stomach before meals
    • Crushing or chewing with a full glass of water
    • Reducing protein intake and antacids
    • Adding dopamine agonists
    • Using morning standard release carbidopa-levodopa instead of sustained release
    For drug-resistant “off periods” consider:
    • Increasing dose and/or frequency of carbidopa-levodopa
    • Crushing or chewing and take with a full glass of water
    • Adding dopamine agonists, and or apomorphine
    For treatment of random oscillations (“on-off”), consider:
    • Adding dopamine agonists, selegiline, or tolcapone
    • Using ‘drug holidays’
    For treatment of start hesitation (“freezing”), consider:
    • Increasing dose of carbidopa-levodopa
    • Adding dopamine agonists
    Treatment of Parkinson’s Disease Dementia
    • Parkinson's disease dementia: dementia that occurs more than a year after onset of Parkinson's
    • Hallucinations or delusions can occur in as many as 50 percent of patients with Parkinson’s disease at some time during the course of their illness.
    • Lewy body dementia
      • cause: abnormal protein deposits in brain
      • deficient in BOTH acetylcholine (like Alzheimer’s) and dopamine (like Parkinson’s).
      • challenge: Treating one symptom worsens the other. (cholinesterase inhibitors help dementia but makes Parkinson’s worse). L-dopa helps motor movements but makes dementia worse.
    • L-dopa and dopamine agonists may cause psychiatric symptoms including delirium, agitation, paranoia, delusions, or hallucinations.
    Treatment choices for dementia:
    • Pimavancerin (Nuplazid®): first and only medication indicated for treatment of hallucinations and delusions associated with Parkinson’s disease psychosis.
      • What makes it different: doesn’t block dopamine receptors; it is an “inverse agonist” at the 5-HT2a receptor.
      • Dose=34mg/day
      • Reduce dose by ½ if strong CYP450-3A4 inhibitor. Dose= 17mg/day
      • Potential for QT prolongation. Caution with other drugs
    • Clozapine (Clozaril®) at low doses is effective but requires monitoring for neutropenia. (only available at specialized pharmacies)
    • Quetiapine (Seroquel® started at 12.5mg / week and titrated upward by 12.5mg/week is also safe and effective and doesn’t require the monitoring for neutropenia that Clozaril® requires.
    • Rivastigamine (Exelon®) the only cholinesterase inhibitor approved


    Stepwise Approach to Drug-Induced Psychosis in Parkinson’s Disease:
    1. Simplify regimen. Stop medications with highest risk to benefit first.
      1. Stop anticholinergics and antidepressants with anticholinergic activity
      2. Stop Selegiline
      3. Taper and stop dopamine agonists
      4. Taper and stop amantadine (watch for amantadine withdrawal)
      5. Stop COMT inhibitors.
    2. Start quetiapine (Seroquel®) or pimavancerin (Nuplazid®) or rivastigamine (Exelon®) therapy.
    Dextromethorphan=20mg + quinidine=10mg (Nuedexta®):
    Used for treatment of pseudobulbar effect, which is emotional lability manifested by laughter or crying outbursts in neurological conditions such as MS, ALS, neurological conditions. Pseudobulbar effect has been treated by TCA’s, and SSRI. Quinidine (antiarrhythmic) blocks the first pass metabolism of DM and causes an increase of 25 fold in the AUC of DM.

    Drug interactions: stop SSRI, SNRI or TCA or MAOI.

    Parkinson’s Disease is arguably the worst of the neurological diseases. Patients experience their own decline every single week; they are worse this week than they were last week, and next work will be even worse. If the physical manifestations of Parkinson’s Disease are challenging enough, the psychological manifestations of the disease can be equally disabling.

    Have a Great Day on the Bench!!

    August 2021

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    An Overview of Carbidopa/Levodopa Therapy for the Management of Parkinson’s Disease

    Levodopa therapy

    Mechanism: Dopamine does not cross the blood brain barrier (BBB), however Levodopa the metabolic precursor, does cross the BBB. It is decarboxylated into dopamine in the basal ganglia and in the periphery by dopa-decarboxylase. Hence the blood dopamine is increased.
    • Sinemet® (carbidopa/levodopa):10/100, 25/100, 25/250 immediate release.
    Controlled release: 25/100 and CR 50/200
    • Rytary® (carbidopa/levodopa): Extended-release capsules: Carbidopa and levodopa 23.75 mg / 95 mg, 36.25 mg / 145 mg, 48.75 mg / 195 mg, 61.25 mg / 245 mg. Immediate release beads, coupled with extended-release beads. Released at different intervals in the gastrointestinal tract.
    • Stalevo®: (carbidopa/levodopa and entacapone)
      • Stalevo® 50: 12.5mg carbidopa/ 50mg levodopa/ 200mg entacapone
      • Stalevo® 100: 25mg carbidopa/ 100mg levodopa/ 200mg entacapone
      • Stalevo® 150: 37.5 carbidopa/ 150mg levodopa/ 200mg entacapone
    • Inbrija®: Levodopa for inhalation: Is a dry powder for inhalation containing 84mg per dose (2 capsules at 42mg each), for breakthrough freezing episodes. Can be used up to 5 times a day for a maximum of 420mg/day. Works within 10 minutes of inhalation.
    I watched the video, and can’t imagine how a Parkinson’s patient could load this device. It is similar to the Spiriva Handihaler®, where a capsule gets punctured, and the dry powder gets inhaled. Check out the video: https://www.inbrija.com/how-to-use

    Effects of carbidopa:
    • decreases peripheral conversion of levodopa to dopamine by blocking dopa-decarboxylase
    • increases amount of levodopa to cross blood brain barrier
    • carbidopa does NOT cross blood brain barrier.
    • carbidopa has a levodopa sparing effect, decreasing the amount of Levodopa necessary to obtain a clinical response by 75%
    Dosage: must be individualized.
    Start with Sinemet 25/100 three times daily, or 10/100 three or four times daily
    Ideal carbidopa range =70 to 100mg. (over 125mg has no more effect)
    • Adjust carbidopa dose based on side effects. When more carbidopa is required, move up to 25/100.
    • Adjust levodopa dose based on desired effects. If more levodopa is required move up to 25/250. Maximum daily dose of levodopa is 3g.
    May increase by one tablet daily or every other day.
    NOTE: sustained release formulations may cause more erratic absorption.

    Adverse effects: When used alone, L-Dopa effects are common: nausea & vomiting (80%), cardiac arrhythmias (10%) postural hypotension (25%). These all occur secondary to the peripheral conversion of levodopa to dopamine. Therefore, carbidopa is added, based on side effects.

    Challenges with Levodopa therapy
    • Medication dosages taking too long to “kick in” and start working
    • Medication wearing off before the next scheduled medication dose
    • Severe on-off medication fluctuation periods (e.g. rapid cycling during the day ranging from feeling completely on medication to completely off medication)
    • Dyskinesia (too much movement, usually resulting from too high of a blood level of dopamine)
    • Too many pills
    • Too many medication dosage intervals; such as taking medications every 1-2 hours throughout the waking day
    Wearing off: 2/3 of patients will experience loss of efficacy after 5 years.

    ON/OFF: wide fluctuations between hyperkinetic to hypokinetic state, potentially occurring several times a day.

    “ On” period: : is characterized by dyskinesias of face, neck & limbs, augmented by stress or movement at a time of maximal levodopa benefit. They appear as abnormal, choreiform movements, usually involving the neck, trunk and upper extremities.

    Dyskinesias can be thought of as too much movement secondary to the extension of the pharmacologic effect or too much striatal dopamine stimulation. Dyskinesias are more likely to occur with L dopa therapy (D1 and D2 agonism) suggesting that the D1 receptor is involved in producing dyskinesia. Most patients however will tolerate these mild dyskinesias as a trade-off for good mobility.

    “Off” period: characterized by akinesia & dystonia. Can be painful and immobilizing generalized to limb, face & trunk. This can be very debilitating as it can cause a freezing of gait. Rock hard spasms of abdominal musculature may occur.
    Can address this concern of on/off by using Sinemet SR®. May also add COMT or MAO-b inhibitors.

    Other Adverse effects: akathisia, delirium, depression, hallucinations, paranoia & dementia.

    Contraindications: levodopa may activate malignant melanoma. Rule out any suspicious skin lesions before therapy.

    Food interactions: Competes with protein for absorption. Lower protein meals during the day and main protein at dinner.

    Drug interactions: MAOI (antidepressants). Stop for 2 weeks before initiating therapy. Pyridoxine (B-6) decreases Levodopa effect; however, this is seen less often with carbidopa/levodopa combinations. Chelation (Iron, Calcium, multivitamins) can affect absorption.

    Drug Monitoring: Clinical response drives the therapy and dosing. Notify practitioner if uncontrollable movements of face, tongue, limbs, mood or mental changes, irregular heartbeat, difficult urination, or persistent nausea and vomiting.

    Patient Education Levodopa therapy:
    • May take a few weeks for optimal results.
    • Avoid vitamins with B-6 (pyridoxine)
    • Exercise caution when driving.
    • Watch for orthostatic hypotension.
    • Take medication with food.
    • Do not crush SR tablets
    Other Drugs:
    • Levodopa (Larodopa®): is available as 100mg & 500mg tablets
    • Carbidopa (Lodosyn®): is available as 25mg tablets.


    There seems to be a shortage of neurologists in most areas, so primary care physicians, nurse practitioners and physician assistants will become more engaged in the management of Parkinson’s disease and drug therapy. One of my favorite neurologists several years ago was resistant to hiring physician assistants and CRNP’s because neurology patients are such a challenge. After he finally broke down and had to hire two physician assistants, he said it was one of the best decisions he ever made. He said, “I finally get to be a doctor again, and my PA’s help keep the loose ends tied together.” The pharmacist, as the drug expert, will be called upon to guide family practice physicians and their mid-level prescribers to provide advice for their Parkinson's patients.

    Most neurologists at one time held off on Levodopa therapy until after all of the other treatment options were exhausted. Today’s recommendations are to start when the patient needs it. Shared clinical decision making is the best approach for starting any Parkinson’s therapy.

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    An Overview of Adjunctive Therapies for Parkinson’s Disease

    Adjunctive therapies for Parkinson’s Disease

    COMT inhibitors: (catecholamine-o-methyl-transferase)
    • Entacapone (Comtan®) 200mg tablets (approved 1999)
    • Tolcapone (Tasmar®) 100mg & 200mg tablets (approved 1998)
    • Opicapone (Ongentys®) – 2020 available as 25mg and 50mg capsules (approved 2020)
    Mechanism: no effect on Parkinson’s disease as monotherapy. They are used with carbidopa/levodopa to prevent peripheral conversion. Inhibits COMT, increasing dopamine levels. When carbidopa blocks dopa decarboxylase as with carbidopa/levodopa (Sinemet®), COMT is the main metabolizing enzyme for levodopa.

    Significantly decreases off times and decreases levodopa requirements. Prolongs and potentiates the levodopa effect and thereby reduce "off" time when used as add-on therapy with levodopa.

    Increases blood levels (AUC), but does not increase Cmax or Tmax.

    May theoretically be better than CR products because they don’t delay time to maximal effect. Overall help simplify carbidopa/levodopa (Sinemet®) dosing, may reduce Levadopa requirements and decrease time in “off” period.

    Dosage: decrease the dose of levodopa 10 to 30 percent to avoid exacerbating peak-dose dyskinesia and other dopaminergic side effect
    • Entacapone (Comtan®): 200mg with each dose of carbidopa/levodopa max=1600mg/day
    • Opicapone (Ongentys®): The recommended dosage is 50 mg once daily at bedtime
    • Tolcapone (Tasmar®): 100mg three times daily. (May cause severe liver failure, making it a last line choice)
    Adverse effects: dizziness, drowsiness, diarrhea, orange discolored urine (tolcapone, entacapone). Because of increased dopaminergic stimulation, patients might see dyskinesia, psychiatric effects (such as visual hallucinations), nausea, orthostatic hypotension, and somnolence.

    Contraindications: tolcapone (Tasmar®): liver disease

    Drug interactions: COMT also breaks down sympathomimetics. May increase BP & HR, possible arrhythmias

    Drug Monitoring: tolcapone (Tasmar®): liver enzymes. D/C at once if ALT or AST is above ULN.


    Carbidopa/ Levodopa/ Entacapone:
    • Stalevo® 50: 12.5mg carbidopa/ 50mg levodopa/ 200mg entacapone
    • Stalevo® 100: 25mg carbidopa/ 100mg levodopa/ 200mg entacapone
    • Stalevo® 150: 37.5 carbidopa/ 150mg levodopa/ 200mg entacapon
    Istradefylline (Nourianz®) approved 2019

    Mechanism: Istradefylline is an adenosine receptor antagonist indicated as adjunctive treatment to levodopa/carbidopa in adult patients with Parkinson’s disease (PD) experiencing “off” episodes

    Dosage: 20mg daily, up to a maximum of 40mg daily.
    Note: Patients who smoke 20 or more cigarettes per day (or the equivalent of another tobacco product), recommended dosage is 40 mg once daily

    Adverse effects: The most common adverse reactions were dyskinesia, dizziness, constipation, nausea, hallucination, and insomnia. Patient Education: avoid OTC sympathomimetics. Watch for postural hypotension. Exercise caution when driving.

    I love the brand name for entacapone (Comtan®); it’s nice to have a brand name that describes the mechanism of action, like Namenda®, which is an NMDA receptor antagonist for Alzheimer’s.

    Istradefylline intrigues me. It is a methylxanthine like caffeine, theobromine, theophylline and pentoxifylline.

    So, this class of drugs contains a stimulant (caffeine), an ingredient in chocolate (theobromine), an asthma/COPD medication (theophylline), a drug to improve blood flow for intermittent claudication (pentoxifylline) and a Parkinson's drug (istradefylline). Now that is diversity in a family!!

    Lots of mechanisms of action for Parkinson’s treatment, all based on providing sufficient dopamine to the brain. I tell my students to remember the three big enzymes for dopamine metabolism: catecholamine-o-methyl-transferase (COMT), monoamine oxidase (MAO) and dopa-decarboxylase (DDC).

    Have a great day on the bench!!

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    An Overview of Monoamine-B Oxidase Inhibitors

    Monamine Oxidase Inhibitors (MAO-b)

    Monoamine oxidase-B (MAO-b) is an enzyme responsible for the chemical breakdown of dopamine in the brain. MAO-B inhibitors act by inhibiting the activity of this enzyme and therefore slowing the breakdown of dopamine, which allows for increased levels of dopamine in the brain.

    MAO-b inhibitors can be given either as a monotherapy or they can be combined with carbidopa-levodopa therapy. They are considered to be modestly effective as early symptomatic treatment for Parkinson’s disease. Although MAO-b inhibitors have been shown to bring about only a modest decrease in the severity of Parkinson’s symptoms, initiation for MAO-b therapy can delay the reliance on levodopa.

    Selegiline (L-deprenyl) brand: Eldepryl® (1989) or Carbex®/ Zelapar(ODT) 5mg caps (now generic)

    Mechanism: irreversible inhibitor of MAO-b

    Dosage for Selegiline: Parkinsonian patients receiving levodopa/carbidopa therapy who demonstrate a deteriorating response to this treatment:
    Dose: 5mg at breakfast and at lunch (gets metabolized to an “amphetamine like” metabolite). Don’t exceed max daily dose of 10mg, because of non-selective inhibition of MAO over that dose.

    Adverse effects: Dosing over 10mg per day puts patients at risk for dietary reactions with tyramine containing foods, referred to as “cheese reaction”.

    Contraindications: No dietary restrictions are required due to selective MAO-b inhibition

    Drug interactions: Although no interactions with fluoxetine & meperidine have been reported with this medication, it is prudent not to administer these drugs.
    • Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin Norepinephrine Reuptake Inhibitors (SNRI) , Buspirone, and mirtazapine may cause Serotonin Syndrome (excessive levels of serotonin): Confusion, agitation, tremor, seizures & death.
    Drug Monitoring: clinical presentation

    Patient Education: Don’t exceed 10mg. Take at breakfast & lunch. Report severe headache or elevated blood pressure

    Selegiline oral disintegrating tablets (Zelapar®) 1.25mg
    • Designed to minimize first pass metabolism, increase bioavailability, and reduce amphetamine-like metabolites.
    • Start with 1.25mg dissolved in mouth. After 6 weeks, may increase to maximum dose of 2.5mg.
    Rasagiline (Azilect®) Teva Neuroscience ,2006 0.5mg, 1mg (now generic)
    • Approved for initial monotherapy, as well as adjunct therapy in moderate to advanced disease.
    • Is a MAO-B inhibitor that blocks the breakdown of dopamine, primarily in the brain.
    • Adverse effects: hallucinations, headache arthralgia, dyspepsia, depression, falls and flu-like symptoms
    • Dosage:
      • Monotherapy: 1mg daily
      • Combination therapy: initial dose 0.5mg daily. May increase to 1mg if inadequate response. May potentiate adverse effects of L-dopa (hallucinations and dyskinesias)
    Safinamide (Xadago®) 50mg & 100mg ($800/month) new-2017
    • A reversible (new class of drugs) MAO-B inhibitor as an adjunct to carbidopa/levodopa therapy in patients that experience on/off motor fluctuations.
    • Currently not approved as monotherapy.
    • Used in mid-late-stage Parkinson’s and increases ON time without causing dyskinesias.
    • Not known if there are any advantages over the older irreversible MAO-B inhibitors.
    I don’t think anyone waited more anxiously for the introduction of Selegiline (L-deprenyl) than my wife’s family. My mother-in-law as I described in the first unit of this Neurology section, was a robust and brilliant reading supervisor. She had been afflicted with Parkinson’s in her early 50’s. We waited anxiously for Selegiline to become available, as we heard about its success in Europe.

    As I described at the beginning of this letter, MAO-b inhibitors are lightweights. Once the drug became available in the US, I’m sure my mother-in-law was one of the first to have it prescribed for her. Unfortunately, it provided no benefit as her condition was so advanced.

    Have a great day on the bench!!

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    An Overview of Dopamine Receptor Agonists

    Dopamine Receptor Agonists

    Mechanism: Dopamine agonists are ineffective in patients who have shown no therapeutic response to levodopa. Seems to be more efficacious in early Parkinson’s disease.
    • Direct stimulation of dopamine receptors
      • Although they do not “look” like dopamine, they stimulate the dopamine receptor.
    Class effects:
    • Associated with pathologic gambling, compulsive sexual behavior, binge eating or compulsive buying, in up to 50 percent of patients with long-term use.
      • Remember, dopamine is known as the “pleasure hormone”/li>
      • Dopamine agonist withdrawal syndrome (DAWS): If stopped suddenly, anxiety, panic attacks, depression, sweating, nausea, pain, fatigue, dizziness, and drug craving, like cocaine withdrawal may occur.
      • Class adverse effects: watch for dizziness, hallucinations can occur, may all cause drowsiness, may cause nausea, vomiting, headache, dry mouth and fatigue. Vivid dreams are common leading to sleep disturbances.
    Bromocriptine (Parlodel®) tablets: 2.5mg caps: 5mg
    Classification: Ergot Dopamine Receptor Agonist

    Start with 1.25mg BID with meals. May increase dose by 2.5mg /day every 2 to 4 weeks.
    Usual dosage range: 10 to 40mg/day. Don’t exceed 100mg/day. Seldom used for Parkinson’s disease, mostly used as second line therapy for hyperprolactinemia. Patients unresponsive to L-dopa therapy are poor candidates for bromocriptine.

    CAUTION: CAUSES stiffening of heart valves. Causes significant nausea.

    Cycloset® (Bromocriptine) is an add on treatment for Type-2 diabetes. Initial dose is one tablet (0.8 mg) daily increased weekly by one tablet until maximal tolerated daily dose of 1.6 to 4.8 mg is achieved.



    NON-Ergot dopamine receptor agonists: Pramipexole & Ropinirole

    Pramipexole (Mirapex®) (non-ergot) 0.125mg, 0.25mg, 0.5mg 1mg and 1.5mg (available generically)
    MIRAPEX ER® 0.375, 0.75, 1.5mg, 3.0mg, 4.5mg (available generically)
    • tablets are taken once daily, with or without food
    • Is approved as monotherapy
    • Usually dosed three times daily for Parkinson’s disease
    • Maintenance dose: 1.5 to 4.5mg/day
    • If used with Levodopa, may decrease L-dopa dosage. (May see average decrease of 27%)
    Ropinirole (Requip®) (non-ergot) 0.25mg, 0.5mg 1mg,2mg, 4mg (available generically)
    REQUIP XL: once daily : Tablets: 2 mg, 4 mg, 6 mg, 8 mg, and 12 mg
    Approved for monotherapy--(generics are available)
    • Take 3 times daily with or without food.
    • Starting dose is 0.25mg three times daily
    • Increase dose by 0.25mg thee times daily for each week for 4 weeks.
    • When used as an adjunct to levodopa, the levodopa dose can be decreased gradually as tolerated.
    Contraindications: may need to reduce levodopa based on clinical response

    Drug interactions: Ropinirole: CYP1A2 is the major enzyme responsible for the metabolism of ropinirole. Thus inhibitors (ciprofloxacin, fluvoxamine) or inducers (omeprazole or smoking) of CYP1A2 may alter the clearance of ropinirole.

    Drug Monitoring: clinical management of symptoms

    Patient Education:
    • Exercise caution when driving
    • Take with food or milk to reduce GI upset
    • Report mood changes and uncontrolled movements
    USE (Parkinson’s disease): :
    • may be used as monotherapy early on, so as to delay L-dopa therapy.
    • less effective for motor symptoms but do cause less dyskinesias and motor fluctuations.
    • less effective for motor symptoms but do cause less dyskinesias and motor fluctuations. May be effective as add-on treatment to L-dopa therapy induced motor fluctuations.
    USE (restless leg syndrome): :
    • • Requip® (ropinirole) is approved for restless legs syndrome. Begin therapy for RLS: Ropinirole 0.25mg daily 1 to 3 hours before bedtime, with increased doses as needed (by 0.5mg/ week), and as tolerated to a maximum of 4mg/ day. Median dose studied was 2mg.
    • • Mirapex® (pramipexole) is approved for restless legs syndrome as of December. Begin therapy for RLS: Pramipexole 0.125mg once daily 2-3 hours before bedtime. Can be titrated every 4-7 days if needed. 3 strengths available for RLS 0.125mg, 0.25mg and 0.5mg for convenient titration. 75% of patients will have relief at 0.25mg 2-3 hours before bedtime.
    Key diagnostic Criteria for Restless Legs Syndrome (RLS) :
    • Urge to move the legs (usually caused by uncomfortable leg sensations- may be described as aching, burning or painful)
    • Temporary relief with movement – partial or total relief from discomfort by walking or stretching.
    • Onset or worsening of symptoms in the evening or at night.
    • During evaluation, rule out pregnancy, renal failure, or iron deficiency.
    Apomorphine hydrochloride (Apokyn®) injection 10mg/ml (non-ergot)

    Indication: for acute intermittent hypo mobility on “off” or “end of dose wearing off” episodes through stimulation of postsynaptic dopamine D2-type receptors within the caudate-putamen in the brain. Associated with advanced Parkinson’s disease. Helpful for freezing episodes

    Kynmobi® (apomorphine hydrochloride) for the acute, intermittent treatment of off episodes in patients with Parkinson disease (PD)
    • a sublingual film formulation (doses 10mg, 15mg, 20mg, 25mg, and 30mg ) of apomorphine, a non-ergoline dopamine agonist.
    • Adverse reactions: nausea, oral/pharyngeal soft tissue swelling, oral/pharyngeal soft tissue pain and paresthesia, dizziness, and somnolence.
      • Because of the high incidence of nausea and vomiting, an antiemetic starting 3 days prior to the initial dose of Kynmobi is recommended. Avoid ondansetron (Zofran®) for nausea due to hypotension.
    Rotigotine (Neupro®) is a patch. Approved May 2007 (non-ergot).
    Available strengths: 1 mg/24 hr.; 2 mg/24 hr.; 3 mg/24 hr.; 4 mg/24 hr.; 6 mg/24 hr.; 8 mg/24 hr.
    • For early-stage idiopathic Parkinson’s disease and restless legs syndrome. Rotigotine is a dopamine agonist, mimicking the effects of dopamine.


    “Who is the most famous Parkinson’s Disease patient of all?” I would ask my class and the response was usually “Michael J. Foxx”. Wrong! The next answer invariably was “Mohammed Ali”. I would remind the students they are at St. Francis University and this guy’s image could be found anywhere! That’s right “Pope John Paul II” was the answer I would be looking for.

    Exactly 20 years ago we were in Rome Italy, on a pilgrimage with our beloved priest as our tour guide. We went to outdoor Mass at St. Peter’s Square for St Peter and Paul’s Feast Day, which is a holiday in Italy. At the beginning, Pope John Paul walked out with his Cardinals, he read his sermon while he was sitting. By the end of Mass (about 1.5 hours after the start), he was wheeled off in a wheelchair.

    How could he deteriorate so quickly? I later read that before any big event, the Pope’s physician would give him an injection of apomorphine, that would enable him to participate for a while. Unfortunately, it wore off quickly.

    Have a great day on the bench!!

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    An Overview of Drugs Used in the Management of Parkinson’s Disease

    Initial therapy for Parkinson's Disease--manage the symptoms!

    Amantadine:
    • Symmetrel® 100mg capsules, syrup 50mg/5mL
      • Dose is usually 100mg twice daily. Never exceed 400mg.
    • Gocovri® 68.5mg and 137mg ER capsules. /li>
      • The initial daily dosage is 137 mg; after 1 week, increase to the recommended daily dosage of 274 mg .
      • Dosed at bedtime
    • Osmolex ER® Extended-release tablets containing 129 mg, 193 mg, or 258 mg amantadine.
      • Start with 129mg in morning; titrate to a max of 322mg.
    History: Initially developed as an antiviral medication to treat influenza. Was approved in 1968, but later found to be useful as a treatment for Parkinson’s Disease. Because of resistance, amantadine is no longer recommended for prophylaxis or treatment of influenza A, as of 2006.

    Mechanism: Decreases pre-synaptic uptake of dopamine. And enhances dopamine synthesis and release from presynaptic storage granules

    Dosage: 100mg BID max= 300mg/day (dosage adjustment required if renal impaired)
    Response is rapid and is effective in 50% of patients.

    Adverse effects: hyper excitability, tremor, confusion, livedo reticularis (rose colored mottling of skin), slight anticholinergic effects.

    Patient educations:
    • Tolerance develops in 6 to 12 weeks of the initiation of therapy.
    • Take last dose well before bedtime to decrease insomnia.
    Use: To treat early Parkinson’s Disease or as adjunctive treatment in later stages. May be effective in treating tremor which can be resistant to dopamine treatment. Effect may last only a few weeks. Withdraw slowly so as not exacerbate symptoms.



    Anticholinergics:

    Mechanism: Decreases cholinergic function, thereby increasing relative activity of the remaining dopamine. Monotherapy for patients with Parkinson Disease who are less than 65 years of age and have disturbing tremor but do not have significant bradykinesia or gait disturbance. Used for management of symptoms only.

    Drugs and dosage:
    • Benztropine (Cogentin®): tablets = 0.5mg, 1mg & 2mg (generic available)
      • 1 to 2 mg at bedtime, may also divide doses. Up to 6mg/day
    • Trihexyphenidyl (Artane®) : tablets 2mg & 5mg (generic available)
      • Start 1 –2mg first day. May increase by 2mg/day every 3 to 5 days. Max= 15mg
      • Give in divided doses.
    Adverse effects:
    • Minor: you know the big 4 anticholinergic side effects! With apologies for the crudeness here, I will offer a reminder of the popular memory tool here:
      • Can’t see, can’t pee, can’t spit, can’t s**t!
    • Major: delirium, disorientation hallucinations, agitation & anxiety
    • Disease State Interactions: decreased gastric motility, may cause gastric deactivation of L-Dopa
    Patient Educations:
    • if GI upset is a problem, take with food
    • Exercise caution with drowsiness/dizziness, especially during dangerous tasks & driving
    • Hard candy may help relieve symptoms of dry mouth
    • Avoid alcohol
    Use: May be most useful in treatment of tremor and drooling. Withdraw slowly so as not to exacerbate these symptoms.

    Treatment of Parkinson’s Disease can be challenging. Most neurologists usually start with ‘symptom management drugs’ such as amantadine and the anticholinergics. I always found it interesting that benztropine (Cogentin®) was always prescribed by psychiatrists primarily to prevent the adverse effects caused by the first-generation antipsychotics like perphenazine, trifluoperazine, thiothixene etc.

    Neurologists always prescribed trihexyphenidyl (Artane®) for Parkinson’s disease. I asked a neurologist once why trihexyphenidyl was written for by neurologists, and he responded “Gee, I don’t really know; that’s just how we were trained!” Simply explained as “tradition.”

    Most neurologists hold off on treatment with dopamine agonists and levodopa until the patients see impact on their activities of daily living. This is truly when “shared decision making” is a must for treatment of Parkinson’s disease.

    Have a great day on the bench!!

    July 2021

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    An Overview of Idiopathic Parkinson’s Disease

    Idiopathic Parkinson’s Disease (IPD)
    • A progressive and irreversible degeneration of melan-containing dopaminergic neurons within the pars compacta of the substantia nigra.
    • The severity of IPD generally correlates with the degree of cell loss. Neural degeneration also correlates with a decrease in dopaminergic neurotransmission.
    • Loss of dopamine results in a deficiency of dopamine relative to other neurotransmitters, particularly acetylcholine (ACH). Typically, noticeable symptoms for diagnosis do not arise until 80% of neurons are gone.
    Incidence: Parkinson’s impacts over 1 million people in North America. Parkinson’s disease is uncommon in those under age 40, with a rapid increase at age 60. Mean age of diagnosis is 70 years, with men being diagnosed twice as frequently as women.

    Smoking: interestingly enough, smokers have a lower rate of Parkinson’s disease.

    Hoehn & Yahr Scale: (used to describe severity of Parkinson’s)

    Stage 1: unilateral involvement
    Stage 2: bilateral involvement, no postural abnormalities
    Stage 3: Bilateral involvement, mild postural imbalance, patient is independent.
    Stage 4: Bilateral involvement postural instability, patient requires much help
    Stage 5: Severe, fully developed disease, patient restricted to bed or chair.


    Parkinson symptoms
    • Micrographia (small writing)
    • Hypomimia (“Masked faces”)
      • caused by rigid movement of facial muscles, creating an expression that appears to lack emotion
    • Tremor at rest
      • begins unilaterally and are present in 70%
    • Tremors (not during sleep)
      • may worsen with stress
    • Rigidity of limbs trunk and face
    • Bradykinesia (slow movement when walking)
    • Soft or low voice
    • Some people report loss of smell many years before onset of tremor/symptoms
    • Depression is reported in up to 50% of Parkinson’s patients
    • Abulia: loss of the impulse, will, or motivation to think, speak, and act, usually due to presence of a disease


    Secondary Parkinson’s Disease: May be precipitated by trauma, neoplasms or severe ischemic vessel disease, medications. Need MRI to rule out.

    Drug induced Parkinsonism:
    • May be indistinguishable from idiopathic Parkinsonism. /li>
    • Drug-induced symptoms are often symmetrical and occur within weeks to months after starting an offending medication.
    • About 10% of Parkinson-like motor symptoms are caused by mediations.
    • Drug induced is reversible, occurs later in treatment than the preceding extrapyramidal symptoms.
    High potency neuroleptics (antipsychotics), especially first-generation antipsychotics, frequently require anti-Parkinsonism drugs.

    Treatment: decrease dose of antipsychotic. Use anti-Parkinson drugs. After 4 to 6 weeks, these anti-Parkinson drugs may be stopped.

    Common drugs causing Parkinson-like effects:
    • Metoclopramide (Reglan®) (very significant)
    • Prochlorperazine (Compazine®)
    • Haloperidol: Haldol® (block dopamine receptors)
    • Phenothiazine: Chlorpromazine, Trifluperazine etc. (block dopamine receptors)
    • Second generation antipsychotics: risperidone, paliperidone, and olanzapine
      • (quetiapine and clozapine are considered safest in this regard)
    • Cholinesterase inhibitors: donepezil, rivastigmine
    • Amitriptyline
    • Carbamazepine
    • Reserpine
    • Less common: valproate, lithium and SSRI’s
    • Other Agents: Carbon monoxide, Cyanide, Lead, Mercury, Methyl chloride, photographic dyes.
    NOTE: Drug Induced Parkinsonism is most commonly seen in elderly women, who are taking higher doses of the offending drug.

    Of the all the neurological diseases, none hit home for me like Parkinson’s disease. My beautiful mother-in-law, Dolores succumbed to this dreaded disease at age 61. She presented with symptoms in her early fifties, and we saw her gradual decline. She was a vibrant, attractive and brilliant woman who raised 6 kids. She was a reading supervisor and was loved by her students and her colleagues in the elementary schools she visited.

    I once had a nurse at a long-term care facility tell me that she thought Parkinson’s disease was the cruelest of the neurological diseases because the patients were able to see firsthand their own decline. Parkinson patients are very cognizant of the fact that they get a little worse every day.

    I remember seeing Denise’s mom deteriorate every time we saw her. My daughters in elementary school, when asked what their favorite food was didn’t respond “pizza” or “chicken nuggets”. It was chicken gravy over waffles, because we seemed to eat that once a week because it was Grandma’s favorite. It was a staple meal for quite a few years in our home, because it was something she could enjoy, as she had difficulty chewing and swallowing.

    None of Denise’s four sisters have seen any sign of this dreaded disease. I’ve combed through pages of genetic studies with regard to the PARK2 gene, and there doesn’t seem to be a strong genetic generational link. For that, our entire family is thankful

    Have a great day on the bench!!

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    An Overview of Antiarrhythmics

    CLASS I AGENTS: Sodium Channel Blockers

    CLASS Ia AGENTS

    Indications for Use:
    • Treatment of: Supraventricular tachycardia, ventricular tachycardia, prevent ventricular fibrillation, symptomatic ventricular premature beats.
    • Delay the recurrence of occasional atrial fibrillation
    Mechanism of Action: Sodium channel blocker- depresses phase 0 depolarization, slows conduction, prolongs repolarization. Increases QRS interval and increases QT interval.
    Examples: disopyramide (Norpace®) and quinidine (Quinaglute®)

    CLASS Ib AGENTS

    Indications for Use: ventricular tachycardia, prevention of v-fib, symptomatic ventricular beats.
    Mechanism of Action: Sodium channel blocker; modest depression of conduction, shortening of repolarization, decrease in QT interval.
    Examples: Lidocaine®, Mexiletine (Mexitil®), tocainide (Tonocard®)

    CLASS Ic AGENTS
    Indications for Use: life threatening ventricular tachycardia, or v-fib, refractory supraventricular tachycardia Mechanism of Action: Sodium channel blocker. Markedly depress phase 0 repolarization, slows conduction

    Examples: Flecainide (Tambocor®); Morcozine (Ethmozine®), Propafenone (Rythmol®)


    CLASS II AGENTS: BETA BLOCKERS

    Indications for Use: Supraventricular tachycardia, may prevent v-fib, digitalis induced ventricular arrhythmias Mechanism of Action:
    • Beta blockers- suppress phase 4 depolarization. Slows AV conduction. Decreases heart rate.
    • Reduces sympathetic stimulation of the heart (beta-1). Slows sinus rhythm without significantly changing the QT or QRS interval. Decreases HR and myocardial oxygen demand.


    CLASS III AGENTS: Potassium channel blockers

    Amiodarone (Cordarone®, Pacerone®) 100mg, 200mg & 400mg tablets (approved 1985)

    Mechanism of Action: potassium channel blockers. Causes prolonged action potential (QT prolongation). refractory v-tach, suprav-tach, prevention of v-tach, a-fib, v-fib
    Indications for Use: For atrial and ventricular tachycardia. Has been shown to decrease patient arrhythmic deaths in patients after a myocardial infarction.
    • Should only be initiated in the hospital setting.
    • Is the most effective for prevention of a-fib and v-tach or v-fib.
    • More effective than sotalol or drugs in reducing recurrent tachycardia.
    • Most effective drug for atrial fibrillation.
    • The most effective antiarrhythmic drug for maintenance of normal sinus rhythm.
    Dosage: loading dose of 800-1600mg/day for 1 to 3 weeks. When control is achieved dose can be decreased to 600-800mg/day for 1 month. Maintenance dose is usually 400mg/day.

    Warning/Precautions & Adverse Effects
    • Life threatening pulmonary toxicity (especially if over 400mg/day)
    • Most patients develop corneal micro deposits, 1 to 4 months after therapy.
    • Monitor for hypotension and brady arrhythmias
    • Monitor for hepatic dysfunction, thyroid disorders (hypo & hyper), and photosensitivity
    • May cause blue/gray skin discoloration
    • Half-life is 65 days....drug interactions may continue after drug is discontinued (May have adverse reactions for 4 months after therapy has ended!)
    Patient Information:
    • Watch for photosensitivity
    • Take consistently with regard to meals (food affects absorption)
    • Choose amiodarone over dronedarone for patients with paroxysmal or persistent atrial fib who need rhythm control, especially if they have heart failure or severe left ventricular hypertrophy.
    Dronedarone (Multaq®) available as 400mg tabs (approved 2009)
    • Evidence suggests that patients with permanent atrial fibrillation actually have a higher risk of death and cardiovascular events, when on dronedarone.
    • Avoid dronedarone or other antiarrhythmics for permanent atrial fibrillation. None of them improve outcomes.
    Sotalol (Betapace®) approved 1992

    Indications:
    • Treatment of life-threatening, documented ventricular arrhythmias, such as sustained ventricular tachycardia
    • Maintenance of normal sinus rhythm (delay in time to recurrence of AFIB/AFL) in patients with symptomatic AFIB/AFL who are currently in sinus rhythm.
    Mechanism of Action: non-selective beta blocker
    • methanesulfonanilide, is a class III antiarrhythmic drug that is used for the treatment of both atrial and ventricular arrhythmias.
    Dosage: Hospitalized patients initiated or re-initiated on sotalol for at least 3 days or until steady-state drug levels are achieved, in a facility that can provide cardiac resuscitation and continuous electrocardiographic monitoring.
    Typical Dose: 80mg twice daily.
    Adverse Effects:
    • Renal dosing is required. Dosing frequency is determined by renal clearance.
    • Sinus bradycardia (heart rate less than 50 bpm) occurred in 13% of patients receiving sotalol

    Dofetilide (Tikosyn®) approved 1999
    • Use: conversion or prevention of a-fib and a-flutter. Not considered first line. Use only if patient is not a candidate for amiodarone or sotalol
    • Dosage calculated by creatinine clearance and QTc interval
    • Watch patients for Torsades
    • Monitor closely for CYP4503Ar4 drug interactions
    • Patients initiated on this therapy must be placed in a facility that can provide calculations for creatinine clearance, continuous ECG monitoring, and cardiac resuscitation for a minimum of 3 days


    CLASS IV AGENTS---Calcium channel blockers

    Indications for Use:
    • treatment and prevention of supraventricular tachycardia
    • first line agent for prevention of PSVT (paroxysmal supraventricular tachycardia)
    Mechanism of Action: CCB inhibit the influx of calcium through its channels causing slower conduction through the SA and AV nodes. They slow ventricular rates, in atrial flutter, atrial fibrillation, and PSVT. Only diltiazem (Cardizem®) and verapamil (Isoptin®) are indicated for heart dysrhythmias.



    GENERAL PATIENT COUNSELING INFORMATION
    • Inform patients that complete remission is unlikely, notify if you have increase in arrhythmias
    • Patients with a-fib or a-flutter should be educated about importance of antithrombic therapy, as well as signs and symptoms of stroke:
      • Drooping of mouth, sudden onset of slurred speech, muscle weakness. FAST!!!!
    • Monitor drug interactions. Carefully change therapies.
    • Periodic ECG and lab assessments are necessary.
    KEY POINTS:
    • All antiarrhythmics are proarrhythmic
    • Cardiac arrhythmias may range from benign to lethal
    • Use anticoagulation to help prevent strokes...and rate control with a beta-blocker, verapamil, diltiazem, or digoxin.
    • Tell patients that it is often okay to stay in atrial fib especially if they don't have symptoms.
    • Most antiarrhythmics are hepatically eliminated, thus drug interactions are common
    • Non-Pharmacological therapies are necessary for life threatening v-tach & v-fib
    • Treatment of a-fib should include assessment of antithrombic therapy
    • Direct current cardioversion is typically treatment of choice for severe arrhythmias
    • The ICD is the most highly effective method in preventing sudden death due to recurrent ventricular tachycardia or ventricular fibrillation.
    I remember in the early 1980’s we bought procainamide (Procan SR®) and quinidine (Quinaglute Duratabs®) in bottles of 500 and moved them. We were excited when tocainide (Tonocard®) and flecainide (Tambocor®) came out in 1985, as new and improved antiarrhythmics. Then, the bottom fell out of that market. It was discovered that rhythm control was not as important as rate control.

    Today we seldom use antiarrhythmics, maybe an occasional flecainide and mostly amiodarone. Amiodarone is a great drug to discuss with student pharmacists. Most are taught that after 5 half-lives there is minimal drug in the body (actually 3.125%).

    With a half-life of 65 days, it takes amiodarone 1 year (5 x 65 days) to clear out of the patient. I would tell my PA students to make sure they have done every test necessary before initiating amiodarone therapy. I have had a couple of patients have thyroid issues (usually hypothyroid) while on amiodarone therapy. I spell it out amIODarone, and notice the presence of iodine in the compound. Remind your patients to have their physicians to do a yearly TSH.

    Have a Great Day on the Bench!!

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    An Overview of ARNIs in Heart Failure

    ANGIOTENSIN RECEPTOR BLOCKER / NEPRILYSIN INHIBITOR (“ARNI’s”)

    Sacubitril/valsartan (Entresto®):Approved 2015
    Sacubitril= neprilysin inhibitor AND
    Valsartan=angiotensin II receptor blocker (ARB)

    Indications: reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure (NYHA Class II-IV) and reduced ejection fraction.

    Mechanism:
    • Sacubitril blocks neprilysin, which degrades the beneficial compounds in the Renin-Angiotensin Aldosterone system. By increasing the levels of natriuretic peptides, bradykinin and adrenomedullin, sodium is lowered, vasoconstriction is decreased as well as decreases in maladaptive remodeling.
    • Valsartan is an Angiotensin-1 receptor blocker. By blocking the effects of Angiotensin-2, vasoconstriction is decreased, along with decreasing sodium retention.
    Entresto®: available as tablets: (sacubitril/valsartan) 24/26 mg; 49/51 mg; 97/103 mg

    Initial Therapy:
    • Allow a 36 hour “washout” period if switching from a previous ACE or ARB
    • Starting dose: 49/51 mg (sacubitril/valsartan) twice daily
    • Double the dose after 2-4 weeks, to a maintenance dose 97/103 mg (sacubitril/valsartan) twice daily, as tolerated by the patient.
    Precautions:
    • Caution patients about the risk for angioedema, and hypotension. Avoid for severe hepatic impairment.
    • Be aware of hypotension and avoid Entresto® when systolic BP < 100 mmHg. Watch for syncope!
    Bad News for Entresto® (sacubitril/valsartan)
    • In the phase 3 Paradise-MI trial, Entresto® missed its primary endpoint to reduce the risk of cardiovascular death and heart failure after an acute myocardial infarction. Basically, Entresto® (sacubitril/valsartan) lost to an ACE inhibitor. Although Entresto® fared better than ramipril (Altace®), the outcome was not statistically significant.
    • There was a 6% rate of heart failure hospitalizations in the Entresto® arm, versus 6.9% in the ramipril cohort. And 1.4% of Entresto® patients developed outpatient heart failure compared to 2% in subjects who received ramipril.
    • Reference: https://www.acc.org/latest-in-cardiology/clinical-trials/2021/05/14/01/22/paradise-mi
    Cost:
    • Wholesale acquisition cost of Entresto®, is nearly $600/month.
    • Wholesale acquisition cost for Ramipril= $6.00/ month
    • Adherence: Entresto® requires twice daily dosing, while ramipril and most ACE inhibitors/ARBs are dosed once a day.


    HEART FAILURE WRAP-UP:

    MORTALITY REDUCING DRUGS (best options in parentheses)
    • ACEI’s: (ramipril, enalapril)
      • ARB’s (losartan, valsartan, candesartan)
    • Beta-Blockers: (metoprolol-XL, carvedilol, bisoprolol)
    • Aldosterone Antagonists:
    • ARNI’s: (sacubitril/valsartan)
    • Hydralazine/BiDil:
    • SGLT2 inhibitors: Dapagliflozin (Farxiga®) was shown to prolong survival in heart failure. Canagliflozin (Invokana®) Empagliflozin (Jardiance®), were shown to have benefits in cardiovascular disease, to varying degrees.
    MORBIDITY REDUCING DRUGS
    • Diuretics
    • Digoxin
    • Ivabradine
    The pharmacist is critical for the following:
    • Watch for drugs that can worsen heart failure, such as nonsteroidal anti-inflammatory drugs, antiarrhythmic drugs, calcium channel blockers like diltiazem (Cardizem®) and verapamil (Isoptin®), thiazolidinediones like rosiglitazone (Avandia®), pioglitazone (Actos®).
    • Patient Education for self-management
      • Weighing daily and reporting significant weight gain
      • Limiting fluids
      • Watching salt intake and diet
      • Monitoring shortness of breath, especially at night
      • Adherence to prescribed medication
      • Monitoring pulse
      • Caution with dizziness
      • Providing pill boxes, especially for multiple dosing regimens
    References:
    ARBS:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947116/
    ACE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753869/

    “New and improved” ---we see it from automobiles to dishwashing soap. I have to admit for the longest time, I thought Entresto® (sacubitril/valsartan) was in a class by itself. The latest data from May, though, doesn’t seem to support that.

    As Entresto® hones in on the 5-billion-dollar annual sales mark, I have to wonder how many of those patients would have had similar outcomes with an ACE inhibitor, given the information from the latest trials. The average prescription for Entresto® approaches $600.00 per month versus $6.00 for a month supply of ramipril!

    I can easily tell the difference in my original dish soap, versus the ‘new and improved’. I am not so sure we can see significant differences between these two drugs, and certainly when the cost is 100 times more.

    Have a great day on the bench!!

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      An Overview of Heart Failure Drugs Isosorbide dinitrate/hydralazine and Ivabradine


    VASODILATORS

    Isosorbide DN 20mg/Hydralazine 37.5mg (BiDIL®) FDA approved:2005
    • Hydralazine: reduces afterload + dilates arterioles
    • Nitrate: reduces preload + dilates veins
    • Dose: start with 1 tablet three times daily, with a maximum dosage of 2 tablets three times daily
    Use:
    • There are no large-scale studies that support their use as monotherapy
    • Have been used in combination with nitrates
    Effects:
    • Reduces pulmonary congestion
    • Increases CO, by reduction of preload and afterload.
    Indications:
    • Adjunct to standard therapy in self-identified African American patients to improve survival, improve time to hospitalization for heart failure, and to improve patient reported functional status. This is the first “race specific” drug approved by the FDA.
    • Is added on with ACEI/ARBs , diuretics, digoxin
    • The African American Heart Failure trial was terminated early because at 12 months the BiDil® group showed a 43% reduction in overall mortality.
    Warnings/Precautions:
    • May cause lupus like symptoms
    • May cause symptomatic hypotension
    • Hydralazine may cause myocardial ischemia and anginal attacks
    • May cause headache (50%), dizziness (32%)
    • May cause GI upset
    Drug interactions
    • Caution with erectile dysfunction PDE-5 inhibitors (i.e. sildenafil, vardenafil, etc.)
    • Caution with alcohol & MAOI

    HYPEROLARIZATION ACTIVATED CYCLIC NEUCLEOTIDE GATED CHANNEL BLOCKER

    Ivabradine (Corlanor®) FDA approved 2015
    • Available as tablets 5mg, 7.5mg

    Indications:
    • Reduces the risk of hospitalization for worsening heart failure in patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤ 35%, who are in sinus rhythm with resting heart rate ≥ 70 beats per minute and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use
    • No effect on myocardial contractility or ventricular repolarization
    • Beta-blockers are STILL first line treatment in heart failure. Treat to target doses (Carvedilol 25mg twice daily, or Metoprolol succinate 200mg/day or Bisoprolol 10mg/day)
    Dosing Schedule:
    • Starting dose is 5 mg twice daily
    • After 2 weeks of treatment, adjust dose based on heart rate
    • Maximum dose is 7.5 mg twice daily
    • In patients with conduction defects or in whom bradycardia could lead to hemodynamic compromise, initiate dosing at 2.5 mg twice daily
    Effects
    • Prevents 1:25 patients being hospitalized.
    • Lowers heart rate without decreasing blood pressure; elevated plasma norepinephrine concentration is a marker for poor survival in these patients. An elevated heart rate contributes to adverse outcomes in patients with HFrEF
    Mechanism:
    • Inhibits the sinoatrial modulating pacemaker If (“I sub f”) or "funny” current in the heart. This in turn lowers heart rate without decreasing blood pressure. High heart rates reflect adverse effect of heart failure.
    Warnings/Precautions: Avoid ivabradine in patients with:
    • Acute decompensated heart failure
    • Avoid in A-fib or other arrhythmias
    • Blood pressure less than 90/50 mmHg
    • Sick sinus syndrome, sinoatrial block or 3rd degree AV block, unless a functioning demand pacemaker is present
    • Resting heart rate less than 60 bpm prior to treatment
    • Severe hepatic impairment
    • Pacemaker dependence (heart rate maintained exclusively by the pacemaker)


    BiDil® (hydralazine/isosorbide) was the first race specific drug. This points to the fact that we are all different in the ways we metabolize drugs, as well as their efficacy among various populations. A lot of talk has been around for years about “precision medicine”. Hopefully the day will soon get here that we see more and more benefits of precision medicine.

    About 5 years ago Denise and I were at our alma mater, the University of Pittsburgh, where they did some genetic tests. We both found out that we are intermediate metabolizers of CYP 450-2C19. This is the enzyme system that activates clopidogrel to its active metabolite. Denise and I would not see much benefit from clopidogrel if it were prescribed, because of our inability to activate the drug.

    Asian patients should not be started on more than 5mg of rosuvastatin. Chinese patients are more susceptible to Stevens-Johnson-Syndrome caused by carbamazepine. Chinese patients also have a significantly higher incidence of closed angle glaucoma.

    We’re all different and I look forward to the day that our genomic sequence will be part of our charts. That will be precision medicine!

    Have a great day on the bench!!


    June 2021

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    An Overview of Digoxin

    DIGOXIN??

    ?Although digitalis glycosides have been in use for over 250 years, it was not until the 1920s were they clearly demonstrated to have a positive ionotropic effect on the heart. The efficacy of digoxin in heart failure and supraventricular tachyarrhythmias such as a-fib, is well established and widely accepted. The role in heart failure patients with normal sinus rhythm is more controversial.

    Current recommendations are:
    • Patients with LV systolic dysfunction & supraventricular tachyarrhythmias (a-fib)
      • consider early in therapy to control ventricular response rate
    • Patients with normal sinus rhythm
      • digoxin does not improve survival, but its positive ionotropic effects, symptom reduction, and quality of life improvement are evident in patients with mild to severe heart failure
      • should be used with other heart failure therapies (DIUR, ACEI, BB)
    Mechanism:
    • Inhibits the Na/K APTase pump. This results in an increase of intracellular calcium and in turn causes a positive inotropic effect.
    • Recent evidence indicates it decreases sympathetic outflow from the CNS thus blunting excessive sympathetic activation that occurs in heart failure.
    • Recent evidence suggests digoxin acts by furthering the activation of neurohormonal systems; this results in deactivation of renin-angiotensin-aldosterone compensation which promotes diuresis, decreases fluid volume, decreases renal sodium reabsorption and diminishes edema
    • Overall, it increases force of cardiac contraction
    Indications:
    • Heart failure: Mild to moderate heart failure
      • increases left ventricular ejection fraction, and improves heart failure symptoms, as evidenced by exercise capacity, and heart failure related hospitalizations, emergency care.
    • Atrial fibrillation: controls ventricular response rate in patients with chronic a-fib.
      • less effective than beta-blockers or calcium channel blockers
    Warnings/Precautions/Adverse Effects:
    • Cardiac: arrhythmias, bradycardia, heart block
    • GI: anorexia, abdominal pain, nausea and vomiting
    • Neurological: visual disturbances, disorientation, confusion, fatigue
    Toxicity:
    • Current target range: 0.5-1 nanogram/mL
    • Toxicity occurs over 2 nanogram/mL but may occur at lower levels if the patient has hypokalemia, hypomagnesemia, or is elderly.?
      • Be sure to monitor for blood levels of potassium and magnesium, especially if patient takes loop diuretics.
      • Digoxin has a narrow therapeutic range
        • Toxicity can be fatal in a significant percentage of patients experiencing toxicity
    Drug interactions

    INCREASES the Digoxin effect: (increased serum concentrations):
    • Quinidine, Verapamil, Amiodarone: decrease dose of digoxin by 50% if added.
    • Propafenone (Rhythmol®), Flecanide (Tambocor®)
    • Macrolide antibiotics (Erythromycin, Clarithromycin)
    • Itraconazole (Sporanox®)
    • Spironolactone (Aldactone®)
    • Cyclosporine
    DECREASES the effect of Digoxin (decreased serum concentrations):
    • Antacids
    • Cholestyramine (Questran®), Colestipol (Colestid®),
    • Metoclopramide (Reglan®)
    • Bupropion (Wellbutrin®)
    • Inducers of p-glycoprotein, such as rifampin, phenytoin (Dilantin®), carbamazepine (Tegretol®), phenobarbital, St. John’s Wort
    OTHER concerns:
    • Diuretics: increases the risk of digoxin toxicity when hypokalemia and hypomagnesemia are present. (Be sure to keep potassium levels at 4- 5.5mmol/L)
    • Renal insufficiency: Digoxin clearance is reduced, therefore monitor closely for toxicity.
    • Biotin: can interfere with the assay for digoxin by interfering with lab test.? This may appear as an artificial increase in digoxin levels
    Products:
    • Lanoxin® (digoxin) tablets 0.125mg (yellow), 0.25mg (white)
    • Lanoxin® (digoxin) elixir 0.05mg/mL (pediatric)
    • Lanoxin ® (digoxin) injection 0.25mg/mL
    Dosage:
    • Based on clinical response. There are several tables in the literature for rapid digitalizing in the hospital setting based on age, lean body weight, renal function, and concomitant disease state.? Also, there are regimens for slow and fast initiation of therapy.
    Initiation Dose:
    • 0.25mg/day in patients less than age 70 with good renal function?
    • 0.125mg in patients greater than age 70 or with impaired renal function.
    • 0.0625mg in patients with marked renal impairment.?
    Maintenance Dose:
    • 0.125 to 0.5mg daily
    • Doses may be increased every 2 weeks
    • Remember: 0.25mg= 250mcg; 0.125mg= 125mcg
    Patient Education:
    1. Know the SIGNS of Digoxin Toxicity
      • Anorexia: common and early sign
      • Fatigue, headache and malaise
      • Nausea and vomiting
      • Mental confusion, disorientation
      • Alterations in visual perceptions (halos around lights)
      • Cardiac effects: premature ventricular contractions, ventricular tachycardia, SA/AV block, atrial tachycardia with AV block.
    2. Eat small frequent meals (4-6/day) to decrease metabolic demands
    3. Moderate sodium restriction may be helpful as well.
    Treatment of Digitalis Toxicity:
    • DigiFab® (40mg per vial) or DigiBind® (38mg/vial)
    • Each vial binds approximately 0.5mg of digoxin
    Indications:
    • Treatment of life threatening or potentially life-threatening digoxin toxicity or overdose. Not indicated for milder cases of digitalis toxicity.
    • Known suicidal or accidental consumption of more than 10mg of Digoxin in healthy adults or 4mg in previously healthy children or ingestion causing steady state serum concentrations greater than 10 nanograms/mL
    Maechanism:
    • Binds the molecules of digoxin making them unavailable for binding at their site of action. The Fab fragment/digoxin complex accumulates in the blood and is excreted by the kidney.? It shifts the equilibrium away from binding digoxin to its receptors and reverses its effects.
    Dosage/Administration:
    • Infused IV through a 0.22micron filter


    We seasoned pharmacists love digoxin, but don’t dispense it as much as we did in previous years.? I remember as a student pharmacist in the 1980’s working for a small independent pharmacy selling Lanoxin® (digoxin) by Burroughs Wellcome for $1.89 for 30 tablets.?

    Back then, pharmacists charged a 40% mark-up on medications, and actually made money without filling hundreds of prescriptions per day! This was before the Angiotensin Converting Enzyme Inhibitors (ACEI’s) were introduced, and quickly became first line therapy for heart failure.

    This evening, I checked our warehouse site, and the current price is $1,372.61 per 100 tablets, which would be a 400-fold increase from the price paid back in 1981.? The digitalis glycosides were first isolated from the foxglove plant (Digitalis lanata) by William Withering an English Physician in 1785.? Before the United States became a country, digitalis glycosides were being used to treat “dropsy”, so a 400-fold increase in a 40 year seems drastic at best.?

    If automobiles had increased at the same rate, the Datsun 210 that Denise and I bought in 1981, would now cost 1.6 million dollars!

    Have a great day on the bench!!

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    A Broad Overview of Medications Used in Heart Failure

    HEART FAILURE--- the Basics
    Heart Failure: a clinical syndrome resulting from a variety of cardiac disorders that impairs the ability of the ventricle to fill with or eject blood.
    • Heart failure is the only major cardiovascular disease increasing in prevalence.
    • Heart failure is the most common hospital discharge diagnosis for Medicare patients. More Medicare dollars are spent for the diagnosis and treatment of heart failure than any other disorder.
    • Symptom management and reduction of hospitalization are the primary goals of treatment
    DRUG THERAPY FOR HEART FAILURE:

    Improvement in symptoms (improved morbidity) can be achieved with the use of diuretics, beta blockers, ACE inhibitors, ARBs, ARNI, hydralazine plus nitrate, digoxin, and aldosterone antagonists.

    Prolongation of patient survival (improved mortality) has been documented with the use of beta blockers, ACE inhibitors, ARNI, hydralazine plus nitrate, and aldosterone antagonists. More limited evidence of survival benefit is available for diuretic therapy

    MANIFESTATIONS OF HEART FAILURE:
    The primary manifestations of heart failure are dyspnea (shortness of breath) and fatigue, which may limit exercise tolerance and fluid retention, which may lead to pulmonary edema and peripheral edema. Some patients have marked exercise intolerance and little fluid retention, whereas others have prominent edema and few symptoms of fatigue or dyspnea.

    Ejection fraction: Patients with a left ventricular ejection fraction less than 40% are considered to have systolic dysfunction. In general, there is poor correlation between ejection fraction and symptoms. Most patients will present with Heart Failure with Reduced Ejection Fraction (HFReF)

    NON-PHARMACOLOGIC MEASURES
    smoking cessation
    restriction of alcohol consumption
    salt restriction
    weight reduction if obese (BMI >30.0)
    monitor weight every day to detect fluid accumulation before it becomes symptomatic.

    DRUGS that can precipitate or worsen heart failure:
    Antiarrhythmics: disopyramide, flecainide, propafenone
    Beta blockers
    Calcium Channel Blockers: Verapamil & Diltiazem (non-dihydropyridine)

    Role of Calcium Channel Blockers:
    First generation CCB (verapamil & diltiazem) may accelerate progression of CHF
    Amlodipine (Norvasc®) is safe with severe heart failure. (No better than placebo)

    Avoid CCB unless treating angina or hypertension. If needed, use amlodipine.

    Classification Based on Patient Symptoms: NYHA

    Class-1: patients with cardiac disease, but without limitations of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitations. (no limitations)
    • Described as Ejection Fraction <40% with no signs of dyspnea
    • TREATMENT: ACEI; may consider BB
    Class-2: patients with cardiac disease, that results in slight limitations of physical activity. Ordinary physical activity results in fatigue, palpitations, dyspnea, or angina. (can climb 2 flights of stairs)
    • Described as mild dyspnea on exertion.
    • Treatment: Volume Overload: diuretic, ACEI or ARB or ARNI and digoxin. Later, consider Spironolactone.
    • Treatment: No Volume Overload: ACEI or ARB or ARNI and BB
    Class-3: patients with cardiac disease that results in marked limitations of physical activity, although patient is comfortable at rest, less than ordinary activity leads to symptoms. (climbs ½ flight of stairs)
    • Described as moderate dyspnea on exertion
    • Initiate and titrate diuretic, ACEI or ARB or ARNI; Add digoxin then initiate BB (if not already done), consider spironolactone.
    Class-4: patients with cardiac disease that results in an inability to carry on physical activity without discomfort. Symptoms of CHF are present even at rest. With any physical activity increased discomfort is experienced. (won’t even look at a flight of stairs) (Source: American Heart Association)
    • Described as severe dyspnea on exertion
    • Consider hospitalization. Initiate diuretic, ACEI or ARB or ARNI, add digoxin & titrate BB
    • Add spironolactone later. If no improvement, add IV ionotropes.

    HEART FAILURE MEDICATIONS
    MORTALITY REDUCINGMORBIDITY REDUCING
    ACE-inhibitors or ARBSDiuretics (prefer-loop)
    Beta-blockersthiazides are ok
    Aldosterone antagonistsDigoxin
    ARNI’s (Entresto®)vabradine
    Hydralazine/ISDN (BiDil) – if African American
    Dapagliflozin (Farxiga) SGLT2 inhibitor for diabetes.


    When I would teach heart failure to my class I would throw in a little history and use the British term “dropsy”. One of my students from Jamaica came up after class and was pleased that I used the term “dropsy” in class. He said as a boy in Jamaica he would see several old people sitting around with their feet elevated, and he was told that they had “dropsy.” He shared with me that he often wondered about this disease, and what the medical term was.

    Heart failure treatment has come a l-o-n-g way since I graduated in 1981. Ace inhibitors were not available yet, and the standard treatment was digoxin (Lanoxin®), furosemide (Lasix) and potassium because of the furosemide.

    Today, ACE inhibitors or Angiotensin Receptor Blockers (ARB’s) are first line treatment as they do reduce mortality. Community pharmacists have a huge role in treatment of heart failure by making sure patient adherence is optimal, to reduce hospitalizations.

    Next we will discuss drugs specific for the treatment of heart failure. Kind of interesting to see a diabetes drug , dapagaflozin (Farxiga®) being used for heart failure!

    Have a great day on the bench!!

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    Hypertension: A Glance at Special Patient Populations

    Treatment of SPECIFIC PATIENTS

    I. PREGNANCY Methyldopa (Aldomet®) during all trimesters of pregnancy is traditionally the “go to” due to remote chance of fetal harm. Use only if clearly needed.
    • Methyldopa is Category-B; watch for fatigue and dizziness.
    • Nifedipine-ER (a CCB) – is considered safe
    • Labetalol (Normodyne®): appears to be better able to prevent the appearance of fetal growth retardation.
    AVOID: ACEI, ARB, Aliskiren, Eplerenone, Spironolactone

    II. COPD/ASTHMA
    Drug of Choice: Calcium Channel Blockers
    AVOID: BB, especially if non-selective beta-blockers

    III. DIABETES MELLITUS
    Drug of Choice: Angiotensin Converting Enzyme Inhibitors (ACEI’s)/ Angiotensin Receptor Blockers (ARB’s); CCB (2nd choice)
    AVOID: Beta Blockers (BB) & diuretics

    IV. ANGINA
    Drug of Choice: Beta Blockers (non-ISA) and CCB
    AVOID: peripheral vasodilators

    V. HEART FAILURE
    Drug of Choice: ACEI/ARB and diuretic
    Also, non-Dihydropyridine (diltiazem, verapamil) and low dose BB

    VI. AFRICAN AMERICANS Drug of Choice: Diuretic or CCB Monotherapy with BB or ACEI are often ineffective. May add ACEI—40% of blacks have good response to ACEI May add BB: BB plus diuretics are equally efficacious in blacks and whites.

    VII. ELDERLY
    Drug of Choice:
    • Thiazide plus ACEI, (preferred if diabetic or HF)
    • BB if hypertensive with angina
    • Men with BPH: use alpha blockers
    • AVOID: central acting alpha agonist
    VIII. DEPRESSION
    AVOID: central alpha agonists & beta-blockers

    IX. SEXUAL DYSFUNCTION
    Drugs of choice: ACEI, ARBs and CCB
    Avoid BB and alpha agonists, and diuretics


    X. RENAL INSUFFICIENCY
    Drug of Choice: ACE & ARBS; Loop Diuretics
    CAUTION: ACE if bi-renal arterial stenosis.
    AVOID: Thiazides



    TREATMENT of RESISTANT HYPERTENSION- Top 10 Considerations
    1. ALWAYS check with the pharmacy to see if poor adherence is the problem before proceeding with additional hypertensive medications.
    2. Simplify regimens such as using combination products to decrease the number of pills per day, and lower number of copays. (Lisinopril/hctz) (Diovan/HCT) (Amlodipine/benazepril). Will see additive effect and decrease in side effects.
    3. Bedtime dosing may be helpful if early morning hypertension is a problem
    4. Secondary causes of resistance include: obstructive sleep apnea, renal artery stenosis, primary aldosteronism. Screen for these conditions.
    5. Check for drugs that can elevate blood pressure such as NSAIDs and COX-2 inhibitors, sympathomimetics amines (pseudoephedrine)
    6. Many experts feel a diuretic should be used. Chlorthalidone (Hygroton®) and indapamide (Lozol®) two old diuretics, seldom used today are usually more effective than HCTZ for blood pressure reduction.
    7. Use Loop diuretics if impaired renal function
    8. Most patients need an ACE/ARB plus CCB or BB.
    9. Next step is to use an aldosterone blocker (spironolactone, eplerenone), because these patients (20%) have elevated aldosterone levels.
    10. Watch potassium levels, with aldosterone blockers, especially if combined with ACE or ARBs
    COMBINATION therapy:
    Start 2 drug therapy if patients are over 20mmHg(systolic) or 10mmHg(diastolic).
    Pick combos for UNCOMPLICATED hypertension using this summary.
    Preferred Combos
    • ACEI + thiazide
    • ACEI + dihydropyridine CCB
    • ARB + thiazide
    • ARB + dihydropyridine CCB
    • CCB + thiazide
    Acceptable Combo
    • Thiazide + potassium-sparing diuretic
    • Aliskiren + thiazide or CCB
    • B-blocker + diuretic or dihydro CCB
    • B-blocker + ACEI or ARB
    • Dihydropyridine CCB + non-dihydropyridine CCB
    NOT Preferred Combos
    • ACEI + ARB
    • Aliskiren + ACE or ARB
    • B-blocker + Nondihydropyridine CCB
    • B-blocker + Central acting (clonidine, methyldopa, etc)


    Only a gray-haired pharmacist like me and my colleagues would remember SER-AP-ES® which was a combination product for treating high blood pressure (Serpasil-Apresoline-Esidrex). It contained three drugs: reserpine (an adrenergic uptake inhibitor), hydralazine (vasodilator) and hydrochlorothiazide (diuretic).

    After we graduated in 1981, the ACE inhibitors took over. Combination therapy went out the window, as clinicians were told to push the dose of monotherapy, so you knew where the side effects were coming from.

    Now the pendulum has swung in the opposite direction, using low doses of combination therapy to minimize side effects, and to maximize the additive benefit of mechanisms of action. “The more things change, the more they remain the same!”

    Have a great day on the bench!!

    Micro-Learning CE Associated - Click Here For Details

    Hydralazine, Aliskiren, and Minoxidil: The Lesser Known Antihypertensives

    In this session, we cover three drugs that are not frequently used. Of the three, I have dispensed hydralazine the most. It has been years since I’ve dispensed aliskiren (Tekturna®) or minoxidil (Loniten®). I think most clinicians associate minoxidil with hair growth more often than with hypertension!

    Hydralazine remains a relevant player, as we will discuss its use when we cover heart failure. Hydralazine is part of BiDil®, along with isosorbide, for heart failure in self-described African American patients. I was amazed to discover that hydralazine (Apresoline®) was first approved in 1953.

    RENIN INHIBITOR
    Tekturna (aliskiren) --approved 2007
    cost: $290 (Generic now available at around $180/month)
    Mechanism: is the first direct renin inhibitor.
    Available as 150mg or 300 mg and is dosed once a day.
    It works earlier in the renin-angiotensin-aldosterone system than ACE inhibitors or ARBs.

    Indications: is approved only for hypertension.
    • Works as well as: ARBs, ACE inhibitors, and thiazides.
    Do not add to an ACE or an ARB, provides no cardiovascular benefit, and causes an increase in adverse events, such as angioedema and hyperkalemia.

    Adverse effects
    • can cause diarrhea especially at the higher dose. Use a lower dose or a different drug if this is bothersome.
    • may also cause cough and angioedema, but probably less often than ACE inhibitors. Considered to be third- or fourth-line for hypertension, not considered monotherapy.
    Pregnancy: Categories C (first trimester) and D (second and third trimesters)

    RENIN INHIBITOR
    NOTE: Avoid this class of drugs, unless necessary, to treat refractory hypertension unresponsive to all other agents. They should not be used alone, secondary to increases in plasma renin activity, cardiac output & heart rate. Use only with beta-blockers and diuretics (usually Loop diuretics). BB will block the baroreceptor reflex response, and decrease the likelihood or precipitating an angina attack.

    Mechanism: Direct relaxation of peripheral arterial smooth muscle, and therefore significantly decreases peripheral resistance, possibly by inhibition of calcium release from the sarcoplasmic reticulum and inhibition of myosin phosphorylation in arterial smooth muscle cells

    Indications: severe hypertension that has been refractory to other agents.

    Warnings/precautions:
    • Monitor for fluid accumulation
    • Hydralazine: may cause drug induced systemic lupus
    • Caution with pulmonary hypertension
    • Caution with significant renal failure or CHF
    Adverse effects
    • Dizziness, hypotension, fatigue, malaise, joint ache
    • Minoxidil: hirsutism—(Remember Rogaine®?)
    • Peripheral neuropathy
    • Headache
    Patient Education: Notify physician immediately if: HR over 20 bpm over baseline, rapid weight gain (over 5lb) unusual swelling of extremities, face or abdomen, breathing difficulty, new or aggravated angina, severe indigestion, lightheadedness.

    VASODILATORS

    GENERIC
    (Year)
    BRANDSTARTING DAILY DOSEUSUAL DAILY DOSEMAXIMUM DAILY DOSE
    Hydralazine (1953)Apresoline®25mg BID50-300mg (2-4 doses)300mg
    Minoxidil (1979)Loniten®5mg /day5mg /day 5-40mg/day40mg


    Have a great day on the bench!!


    May 2021

    Micro-Learning CE Associated - Click Here For Details

    Overview of Angiotensin Receptor Blockers (ARB's)

    Mechanism: AT1 receptors are normally acted upon by Angiotensin II to produce to produce vasoconstriction & aldosterone release. When the AT1 receptor is blocked, aldosterone secretion is blocked, and vascular smooth muscle is relaxed (vasodilation)

    Indications:
    • Nephropathy in Type II diabetics
    • Heart failure
    • Hypertension
      • Can be used alone but are frequently combined with a diuretic
      • Less cough, and reduced incidence of angioedema than ACEI’s
    Warnings/precautions:
    • May cause hyperkalemia
    • (ARBS) Pregnancy category D; report pregnancy ASAP
    • May be nephrotoxic if combined with HCTZ/NSAIDS
    Drug interactions
    • Watch potassium levels monitor for HYPERkalemia (excessive potassium levels)
    • Caution with drugs that elevate potassium (K+ supplements, spironolactone)
    Patient Education:
    • Report pregnancy as soon as possible. Stop drug.
    • WATCH Potassium Levels! Avoid salt substitutes, K+ sparing diuretics.
    • May be NEPHROTOXIC (especially if combined with HCTZ/NSAID)
    Prescribing information:
    Generic nameBrand nameStarting doseAverage daily doseMaximum daily doseHalf life
    Irbesartan
    **generic**
    1997
    Avapro®
    75,150,300
    150mg/day150-300mg300mg12-20hours
    Losartan
    **generic**
    1995
    Cozaar®
    25, 50, 100mg
    50mg/day25-100mg100mg2hrs. Metabolite=6-9 hrs
    Valsartan
    **generic**
    1998
    Diovan®
    80, 160, 320mg
    80mg/day80-320mg320mg6 hrs
    Telmisartan
    *generic**
    2000
    Micardis
    40, 80mg
    40mg/day20-80mg80mg24 hrs
    Candesartan
    **generic**
    1998
    Atacand®
    4.8.16.32mg
    16mg/day monotherapy2mg-32mg80mg9hrs
    Olmesartan
    **generic**
    2003
    Benicar®
    5, 20, 40mg
    20mg/day20-40mg40mg13hrs
    Azilsartan
    (2011)
    Edarbi®40-80mg80mg80mg, then combo11hr


    Because ACEI’s and ARBS affect different steps in the Renin-Angiotensin-II pathway, what value would they have if used in combination?
    • Heart Failure:
    An ARB (valsartan-Diovan®) or (candesartan- Atacand®) can be added to a HF regimen containing an ACE, and a BB for further symptom relief, and possible reduction in mortality.
    • Acute MI
    Although ACEI’s are first line, if patient is intolerant, valsartan (Diovan®) is a viable alternative. However, combination therapy of ACEI and ARB are NOT recommended.
    • Renal impairment
    Combination therapy of ACEI and ARB has been shown to reduce microalbuminuria, compared with monotherapy, in patients with diabetic and nondiabetic renal disease. The reduction in proteinuria seen in patients in the combination therapy group came at a cost of increased renal impairment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183919/

    ARBs practice points:

    Olmesartan: in 2013 the FDA announced Olmesartan (Benicar®) can produce a "sprue-like enteropathy" characterized by severe chronic diarrhea and weight loss. This may occur months to years after starting drug therapy.
    Irbesartan, Olmesartan and Telmisartan: have the longest half-lives and are available as generics.
    Losartan: has shown a decrease in serum uric acid levels by 1-2mg/dl. It is the only ARB with the ability to significantly lower uric acid levels.

    Stopping the ACEI cough:
    • ARBs have about 1/3 of the incidence of cough versus ACEI’s.
    • May occur with 1 or two weeks of therapy but may take up to 6 months.
    • Women experience the ACEI cough more than men.
    • It usually begins within one to two weeks of instituting therapy, but it can be delayed up to six months.
    • Chinese have the highest ethnic prevalence.
    • May take up to 4 weeks to resolve after discontinuation.


    When I practiced in Altoona, we used a lot of irbesartan (Avapro®) at the clinic because the Physician Assistants were former students. Losartan (Cozaar®) was the first ARB approved, and hence the first generic approved, and the insurance companies jumped on Losartan as the preferred drug.

    Most people take a once-a-day blood pressure medication in the morning. You may recall that after 5 half-lives, there is minimal drug in the body. With a 2-hour half-life, that 7am dose of Losartan is negligible after 5pm! This is concerning, because patients are most likely to have a stroke at 4:00am, when there is virtually no losartan available for the receptors. For this reason, ARBs with a longer half-life, such as irbesartan, are preferred.

    The most in-depth discussion I ever had about ARBs was last February when a local pulmonologist quizzed me about the specificity of the ARBs for the AT-2 receptor. After a bunch of research, I found that none of the ARBS covered the AT2 receptor. As you can guess he was looking to block the AT2 receptor to prevent attachment of the SARS-COV2 virus.

    Have a great day on the bench!!

    Micro-Learning CE Associated - Click Here For Details

    Overview of ACE Inhibitors

    Indications: for specific populations, ACE inhibitors are first line choice for these compelling indications:
    • Diabetes, post MI, high coronary disease risk, chronic kidney disease, recurrent stroke prevention.
    • Decreases or stabilizes microalbuminuria. Are nephroprotective in diabetics and patients with renal disease.
    • Decreases incidence of new onset diabetes.
    Prescribing Notes:
    • Captopril and enalapril are considered to be the shortest acting, all of the other ACE inhibitors are long acting and should be used once a day.
    • ACE inhibitors are less effective in African American patients unless prescribed with a thiazide diuretic or calcium channel blocker
    Warnings/precautions: Pregnancy category C (1st trimester); Category-D (2nd & 3rd trimester): report pregnancy ASAP. Watch for HYPERkalemia (Excessive potassium levels)

    Adverse effects
    • Neutropenia is rare, but serious
    • Proteinuria
    • May be NEPHROTOXIC (especially if combined with hydrochlorothiazide)
    • Dry, non-productive cough. Possibly due to bradykinin formation in the lungs
    • Altered sense of taste (captopril)
    • Angioedema (rare)
    • NO adverse effect on Erectile dysfunction
    Drug interactions
    • NSAIDs may diminish their effectiveness.
    • WATCH potassium levels
    • Use caution with potassium sparing diuretics
    • Use caution potassium supplements (salt substitutes)
    • Yaz® or Yazmin® oral contraceptives have drosperidone (spironolactone relative)
    Patient Education:
    • Watch for signs of angioedema: swelling of lips, tongue, lips, difficulty in swallowing or breathing.
    • May cause rash or impaired taste perception (captopril)
    • Report pregnancy to practitioners ASAP
    SELECTED ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEI’s)
    Generic nameBrand nameOther indications
    (all are indicated for hypertension)
    Starting doseUsual
    hypertensive dose
    Maximum daily dose
    Captopril
    (1981)
    Capoten®
    12.5,25,50,100mg
    HF, post MI, diabetic nephropathy25mg BID50mg-two to four times daily450mg
    Enalapril
    (1985)
    Vasotec®
    2.5, 5. 10.20mg
    HF, asymptomatic LV dysfunction5mg10-40mg daily (divide doses)40mg
    Lisinopril
    (1987)
    Prinivil® or Zestril®
    2.5,5,10,20,30,40
    HF, post MI5-10mg /daily20-40mg daily40mg
    Quinapril
    (1991)
    Accupril®
    5,10,20,40
    HF10mg/day20-80mg/d or BID80mg
    Ramipril
    (1991)
    Altace®
    2.5,5,10mg
    HF, post MI2.5mg/day5-20mg/d or BID20mg


    SMACK DOWN on ACE inhibitors: ACE inhibitors have a worse adverse effect profile than angiotensin receptor blockers (ARBS). We’re all aware of the dry, irritating cough that is the most common adverse effect of ACE inhibitors. I’ve seen percentages range from 5 to 20%. This ACE inhibitor cough is particularly pronounced in Asian patients. Angioedema, a more serious adverse effect that is sometimes fatal, is more common in those using ACE inhibitors than in those using angiotensin receptor blockers.

    With efficacy for cardiac outcomes being similar, the authors find no reason to prescribe ACE inhibitors. The Angiotensin Receptor Blockers (ARBs) are now as cheap as ACE inhibitors and have equal to or better outcomes for stroke, cardiac and diabetic nephropathy. The author feels that ARB's (which we will discuss in the next session) should be first line.

    https://www.healio.com/news/cardiology/20180326/review-no-reason-to-use-ace-inhibitors-for-hypertension


    I share this story with my student pharmacists, especially if they tell me they were told in class not to warn patients of the ACE inhibitor cough. Students at one university were told not to warn patients of the potential for an ACE inhibitor cough, because it “puts ideas in patient’s heads”.

    Some years ago, a patient transferred to my store. I went over to talk to her about her lisinopril prescription. She stated she has taking it for years. Regardless, I went over the side effects such as cough and angioedema. Four weeks later she came in with her husband and pointed to me and said, “He’s the guy who told me about my blood pressure pill, and the cough.”

    Turned out she had this persistent cough that was treated with an Azithromycin pack, promethazine/codeine cough syrup, and prednisone. Previously she saw her PCP and was ultimately referred to an ENT specialist.

    She was scheduled for a throat biopsy, because of the concern for esophageal cancer. She discussed my ACE inhibitor cough concern with her PCP, who changed her to valsartan, and the cough went away! I always discuss ACE inhibitor coughs, especially with any new start.

    Have a great day on the bench!!

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    Review of the Renin-Angiotensin-Aldosterone System (RAAS)

    Most of us, including me, have wondered what the purpose of the Renin-Angiotensin-Aldosterone-System (RAAS) has other than to cause hypertension and heart and kidney failure. I was fascinated to read that the activation of this system was a critical adaptation for survival of mammals that migrated from sea to land. It protected against life-threatening circumstances like salt and water deprivation, diarrhea, or hemorrhage. While we seem to no longer need this protection, activation of the system in many patients leads to disease, most commonly hypertension and heart failure. Sodium retention, coupled with hyperaldosteronism, results in vascular remodeling of the heart and disease progression. When we block this system and its effects, we can prevent or at least manage heart failure, chronic kidney disease, myocardial infarction, and hypertension. This system plays a vital role in cardiac, renal and vascular diseases, primarily causing renal failure, hypertension and heart failure.

    1) ANGIOTENSINOGEN : GETS CONVERTED TO ANGIOTENSIN-1 BY RENIN
    2) ANGIOTENSIN-1 GETS CONVERTED TO ANGIOTENSIN-2 BY ANGIOTENSIN CONVERTING ENZYME
    3) ANGIOTENSIN-2 BINDS TO THE AT-1 RECEPTOR SITE
    • Renin inhibitors block the first step. They inhibit ACTIVATION of the whole system.
    • Angiotensin Converting Enzyme (ACE) inhibitors work further down. They inhibit the PRODUCTION of angiotensin II, but some is still produced by other routes.
    • Angiotensin Receptor Blockers (ARBs) inhibit BINDING of angiotensin II at the receptors; but don't inhibit the cascade at all. Also, keep in mind ARBs block only type 1 receptors; angiotensin II can still bind to other receptors.


    “GOOD GUYS”“BAD GUYS”
    Naturetic peptidesAngiotensin II (vasoconstrictor)
    bradykininAldosterone (sodium retention)
    adrenomedullin“Bad guys” cause sodium retention and vasoconstriction, driving up blood pressure.
    Positive effects of the “good guys”: lowers sodium, decreases vasoconstriction, decreases “maladaptive remodeling”“Bad guys” are made by Angiotensinogen, Renin, Antiotensin-I, Angiotensin-II. Their effects are blocked by ACE-I, ARBS, Renin Blockers.
    DEGRADED by neprilysin, which can be blocked by sacubitril. Blocking neprilysin increases the “good guys”.
    Renin: Is released by the kidneys in response to reduced renal arterial pressure, sympathetic neural stimulation, or reduced sodium delivery to the distal tubule.

    Angiotensin II: Is a potent peripheral vasoconstrictor, and also stimulates aldosterone release from the adrenal glands.
    • Elevated aldosterone causes an increase in sodium reabsorption, which leads to an increased blood volume, thereby increasing blood pressure.
    • Therefore, ACE inhibition results in decreased Angiotensin II production which leads to decreased sodium & water retention, decreased potassium excretion, and arterial vasodilation.
    • Angiotensin Converting enzyme is also responsible for the metabolism of bradykinin, a vasodilator.
    • ACE inhibitors cause bradykinin levels to increase because of decreased breakdown.
    • The vasodilation caused by increased bradykinin levels may contribute to the hypotensive effects of the ACE inhibitors.
    • It has been postulated that elevated levels of bradykinin in the lungs may be responsible for the cough that ACEI’s induce in patients.
    Adrenomedullin: Identified as a potent vasodilator considered by some to be the most potent endogenous vasodilatory peptide found in the body. It is metabolized by neprilysin.

    Bradykinin: also a vasodilator, and also affects vascular permeability. It is metabolized by neprilysin and angiotensin converting enzyme.

    Natriuretic peptides: enhances sodium output in the kidneys, and plays a role in heart remodeling in congestive heart failure. It is metabolized by neprilysin.

    Aldosterone: Aldosterone binds to the mineralocorticoid receptor in various tissues. Its main actions occur in the distal tubule of the kidney where it causes sodium and water reabsorption and potassium secretion. This potassium excretion occurs in the urine, as well as the feces, sweat, and saliva.

    There is probably not another system that points out the need for continuing education more than the Renin-Angiotensin-Aldosterone System (RAAS). I remember in pharmacology back in 1980 our professor mentioning this system and this new drug he was studying called captopril. Captopril was released just as we were graduating in 1981.

    Before we continue our conversation in subsequent sessions about three classes of drugs, the Angiotensin Converting Inhibitors (ACEi), Angiotensin Receptor Blockers (ARBs) and the seldom used Renin Inhibitor, it is important to review the basics of where they work and the enzymes and hormones they affect.

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    Focus on Dihydropyridine Calcium Channel Blockers

    Mechanism: inhibits the influx of calcium through slow channels in vascular smooth muscle, and causes relaxation. In the vascular system, arterioles appear to be more sensitive than veins; therefore, postural hypotension seldom is an adverse effect. Generally, the dihydropyridines have a greater ratio of vascular smooth effects relative to the cardiac effects than do verapamil and diltiazem. From a patient population perspective, black and elderly patients tend to respond well to these drugs.

    Indications:
    • Alternative drugs in patients unable to take beta blockers such as angina patients, bronchospastic patients, and patients with Raynaud’s.
    • CCB differ in degrees of systemic and coronary arterial vasodilation, SA node and AV node depression, and decrease in myocardial contractility.
    Dihydropyridines: [Amlodipine (Norvasc®), Felodipine (Plendil®), Nifedipine (Procardia®) , Isradipine (Dynacirc®), Nisoldipine (Sular®), and Nicardipine (Cardene®)]
    • have greater affinity for vascular, versus myocardial channels (potent vasodilators)
    • watch for vasodilatory side effects: edema, headache, flushing, rarely orthostatic hypotension
    • Minimal effect on heart conduction: not useful for supraventricular tachycardias
    • Can be used with Beta Blockers or in patients with heart block
    • Minimal drug interactions. Caution with amlodipine (weak inhibitor of CYP-450-3A4) and higher doses of amlodipine may see two-fold increase in simvastatin levels.
    • Grapefruit juice may increase levels of dihydropyridines: amlodipine, felodipine and nifedipine
    Patient Education:
    • Notify physician if any of the following occur: irregular heartbeat, shortness of breath, swelling of hands and feet, constipation, dizziness, hypotension.
    • Instruct patient in postural hypotension
    • Avoid grapefruit juice in dihydropyridines
    • Most of the products in this class are sustained release. Do not open capsules, or chew or crush tablets.


    GenericBrandDate of IntroductionComments
    AmlodipineNorvasc® 2.5, 5mg 10mg (Pfizer)1992
    NifedipineNifedipine Procardia-XL® -30, 60, 90mg (Pfizer)1981 (caps)Don’t use capsules for hypertension
    FelodipinePlendil® 2.5, 5, 10mg (Merck)1991
    NisoldipineSular® 20,30, 40mg (Zeneca)1995
    NimodipineNimotop® 30mg (Bayer)1988Used for subarachnoid hemorrhage
    NicardipineCardene® 20, 30mg1988Longer half-life than amlodipine
    IsradipineDynacirc® 2.5, 5mg (SKB)1990


    Other than hypertension, uses for dihydropyridine CCBs include:
    • Nifedipine has some efficacy in treatment of preterm labor.
    • Nimodipine (Nimotop®) has affinity for cerebral blood vessels and appears to reduce morbidity after a subarachnoid hemorrhage.
    • Nicardipine is used IV to prevent cerebral vasospasm associated with stroke. It has higher affinity for vessels in the heart and in the brain.


    The 1990's were filled with "me too" drugs: the benzodiazepines, cephalosporins, ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers came onto the market by the droves!

    Of all of these new classes of drugs, none completely dominated the class like amlodipine dominates the dihydropyridine CCB's. It's been years, actually decades, since I have dispensed isradipine (Dynacirc®), nicardipine (Cardene®), and nisoldipine (Sular®), but interestingly enough I've dispensed nimodipine a few times for patients this past year with subarachnoid hemorrhages, due to accidents

    The physician from the rehab hospital was amazed that a local pharmacy had it in stock. Lately, it is amlodipine being dispensed ... by a landslide.

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    NON-Dihydropyridine Calcium Channel Blockers

    Mechanism:
    CCBs inhibit the influx of calcium through its channels causing slower conduction through the SA and AV nodes. They slow ventricular rates, in atrial flutter, atrial fibrillation, and PSVT.

    Only diltiazem and verapamil are indicated for heart dysrhythmias. Cardiac muscle is highly dependent on the influx of calcium during each action potential for normal function and rhythm. Impulse generation in the sinoatrial node and conduction in the atrioventricular node may be reduced or blocked by calcium channel blockers

    Angina
    • Indicated for reduction in symptoms where beta blockers are contraindicated. The reduction in mechanical function reduces oxygen demand in patients with angina.
    • Combination with beta blockers when a beta blocker therapy is not successful
    • Slow release long acting dihydropyridines & non-dihydropyridines are effective in stable angina
    • Decrease systemic vascular resistance and arterial BP by vasodilation of systemic arteries
    • Decreased contractility and oxygen requirements
    • Verapamil & Diltiazem decrease MV02 (myocardial oxygen demand) by decreasing conduction through the AV node, and decreasing heart rate

    Antiarrhythmic
    Indications for use: treatment and prevention of supraventricular tachycardia. First line agent for prevention of PSVT (paroxysmal supraventricular tachycardia). Also useful for treatment of atrial fibrillation, especially when beta blocker therapy is not tolerated. Diltiazem and Verapamil are more selective for cardiac tissue than are the dihydropyridines. They block tachycardias in the calcium dependent cells especially in the AV node

    Hypertension: In the absence of cardiac disease, there is no compelling reason to consider non-dihydropyridine CCB to be first line therapy. Are useful in patients with obstructive airway disease and in the African American population. They are also useful in patients with angina and atrial fibrillation, with hypertension.

    Diltiazem (Cardizem®, Dilacor®, Tiazac®, Taztia®, Cartia XT®) (tablets approved 1982)
    Available as tablets: 30, 60, 90 and 120mg
    • SR-Capsules: dosed BID : 60-90-120mg
    • CD-capsules: once daily 120,180,240,300,360mg
    • LA –tablets : 120,180,240,300,360,420 mg tablets

    Dosage 120mg- 360mg / day

    Drug Interactions: inhibits cytochrome P-450 enzymes in the liver.
    • Administration with a beta blocker may precipitate heart failure.
    • Quinidine increases the risk of hypotension.
    • May increase digoxin concentration.

    Verapamil (Isoptin®, Calan®, Verelan®, Covera HS®)
    • Immediate release tablets: 40mg, 80mg 120mg tablets dosed 3 times daily.
    • Sustained release tablets: 120,180,240mg
    • Sustained release capsules: 120,180,240,360mg
    • PM capsules: 100, 200, 300mg
    • Dosage:120mg-360mg /day

    Drug Interactions / Special Notes: inhibits cytochrome P-450 enzymes in the liver
    • Administration with a beta blocker may precipitate heart failure
    • Quinidine increases the risk of hypotension
    • May increase digoxin concentration
    • May cause nausea and constipation

    Diltiazem (Cardizem-CD®) & Verapamil (Isoptin® , Calan®, Verelan®)
    • More potent coronary vasodilators (verapamil more than diltiazem)
    • Good choice for supraventricular tachycardias
    • Minimal peripheral vasodilation & side effects
    • May cause bradycardia, and heart block
    • Avoid in patients with LV systolic dysfunction (EF less than 30%), conduction abnormalities or combined with beta blockers.
    • Indicated for angina
    • Indicated for migraine headache prophylaxis
    • Verapamil is indicated for prevention of cluster headache
    • First generation CCB (verapamil & diltiazem) may accelerate progression of heart failure

    Warnings/precautions/ adverse effects (CCB's)
    • May worsen conduction defects, systolic dysfunction
    • Gingival hyperplasia
    • May cause nausea & headache
    • Verapamil: may cause constipation

    Calcium channel blockers and rash:
    • Calcium channel blockers may cause eczema and other skin problems. About 1% of patients get minor skin reactions (rash, itching, photosensitivity) Calcium blockers can cause a delayed eczema rash occurring about 3 months after starting the drug.

    • Patient Education CCB
      • Notify physician if any of the following occur: irregular heartbeat, shortness of breath, swelling of hands and feet, constipation, dizziness, hypotension.
      • Instruct patient in postural hypotension
      • Most of the products in this class are sustained release. Do not open capsules, or chew or crush tablets



      Calcium channel blockers (CCBs) can be divided into two distinct classes, even though they “block calcium”. We have the dihydropyridines and the “non-dihydropyridines”. This session will explore the two non-dihydropyridine calcium channel blockers, diltiazem, and verapamil. These two drugs were very popular in the 1980's when they came out. We had Calan® by Searle and Isoptin® by Knoll that were the verapamil products. On the verapamil front, Marion Merrell Dow had Cardizem®, first as tablets, then SR capsules then CD capsules then LA tablets. Other branded products followed as well, including Taztia®, Dilacor® and Tiazac®.

      Prescribers may be advised to write diltiazem by the brand name to decrease confusion. "Diltiazem 120" can be interpreted as 120mg immediate release tablets (3-4 times daily); SR capsules (twice daily), CD once a day capsules, or LA once a day tablets. This is a potential for medication error with which pharmacists and pharmacy technicians must be keenly aware.

      Have a great day on the bench!!


    April 2021

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    ALPHA BLOCKERS

    Mechanism: blocks peripheral alpha-1 receptors (post-synaptic)- causes vasodilation of arteries and veins. Alpha-1 receptors are also abundant in the smooth muscle of the bladder neck and prostate. Causes less reflex tachycardia than direct vasodilators (like minoxidil & hydralazine).

    Indications: for patients who have not responded to initial hypertensive therapy. Ideal for older men with BPH.

    Warnings/precautions: Orthostatic hypotension may occur after the first few doses. Minimize by slow titration. Watch for syncope. In the ALLHAT study, the doxazosin arm was discontinued prematurely due an increase of 25% in CV disease outcomes. Caused increase in risk of stroke, CHF and CHD. An alpha blocker is not recommended for initial monotherapy, with the possible exception of older men with symptoms of prostatism and if they are not at high cardiovascular risk.

    Adverse effects
    • Orthostatic hypotension
    • Dry mouth
    • Urinary urgency
    • Constipation
    • Priapism
    Drug interactions

    NSAIDs decrease antihypertensive effects
    Beta blockers and Diuretics increase antihypertensive effects of these agents

    Patient Education:
    • Watch for postural hypotension. Start low. Give dose at bedtime.
    • Watch for drowsiness
    • If priapism occurs seek medical treatment immediately.


    ALPHA BLOCKERS
    GENERICBRAND (year)OTHER INDICATIONSSTARTING DAILY DOSEUSUAL DAILY DOSEMAXIMUM DAILY DOSE
    DOXAZOSINCARDURA®
    (1990)
    BPH1mg at bedtime1-16mg/day16=HTN
    8mg=BPH
    PRAZOSINMINIPRESS®
    (1976)
    1mg at bedtime2-20mg
    (in 2-3 doses)
    40mg
    TERAZOSINHYTRIN®
    (1987)
    BPH1mg at bedtime1-20mg20mg/day


    Prescribing information:

    PRAZOSIN: Always a test question for my PA students...which alpha blocker is NOT to be used for BPH. The answer is prazosin (Minipress®), as it has too short of a duration of action. We dispense more prazosin than doxazosin or terazosin!

    Prazosin is used frequently for improving sleep and decreasing nightmares for patients suffering from PTSD (post-traumatic stress disorder). Nearly 20% of veterans who suffer from PTSD are treated with prazosin. There have been studies proving and disproving its efficacy. Although one rigorous study found it no more effective than placebo, it is recommended NOT to change its clinical use, since there is little else for treatment of nightmares.

    Prazosin blocks the alpha1 receptor for norepinephrine, which becomes more sensitive in combat settings (or any trauma). This up-regulation doesn't seem to go away once the stimulus is removed, and nightmares can become problematic.

    Drugs causing Intraoperative Floppy Iris Syndrome:

    Alpha-1 Blockers: both selective and non-selective The iris becomes flaccid and billows in response to intraoperative irrigation currents, causing the potential prolapse of the iris toward phacoemulsification incisions. Ophthalmologists can modify their surgical techniques including using iris hooks, iris dilation rings, viscoelastic devices.

    Ophthalmologists MUST know before surgery that patient has been on alpha blocker therapy. Usual protocol is to stop the medication 7-10 days pre-op. Be sure to check for alpha blocker use with pre-op physicals for cataract surgery!

    Alpha blockers have been mostly reserved for treatment of Benign Prostatic Hypertrophy (BPH), thanks to the ALLHAT study (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial). We use lots of alpha blockers, but mostly for treatment of BPH. The selective alpha blockers (tamsulosin, alfuzosin, silodosin) were purposely excluded from this discussion, as they are not for treatment of hypertension.

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    ALPHA AGONISTS (CENTRALLY ACTING)

    Mechanism: decreases sympathetic outflow to the cardiovascular system.
    • Clonidine: stimulates alpha-adrenoceptors in the brain stem. This action results in reduced sympathetic outflow from the central nervous system and decreases in peripheral resistance, renal vascular resistance, heart rate, and blood pressure.
    • Guanfacine: stimulation of central a2-adrenergic receptors. By stimulating these receptors, guanfacine reduces sympathetic nerve impulses from the vasomotor center to the heart and blood vessels.
    • Methyldopa: conversion into alpha-methylnorepinephrine, which is a potent alpha-2 adrenergic agonist that binds to and stimulates potent central inhibitory alpha-2 adrenergic receptors.
    Indications: use in mild to moderate hypertension has been reduced due to availability of other agents with less side effects.
    • Methyldopa: is primarily used for hypertension during pregnancy.
    Warnings/precautions:
    • Methyldopa: flu like symptoms. Monitor for hepatic dysfunction. Anemia
    Class adverse effects:
    • Drowsiness, dizziness, dry mouth
    • Depression and sleep disturbances
    • Impotence
    • Orthostatic hypotension
    • Bradycardia
    Drug interactions:
    • Caution with other sedating medications
    • Caution with angina, recent myocardial infarction, and cerebrovascular accident.
    Patient Education: Gradually taper dose. Do not suddenly stop. (rebound hypertension)

    CENTRAL ACTIVE ALPHA-2 AGONISTS

    GENERICBRANDYEARSTARTING DAILY DOSEUSUAL DAILY DOSEMAXIMUM DAILY DOSE
    ClonidineCatapres®
    Catapres TTS®
    19740.1mg BID 0.1mg/day patch weekly 0.2-0.6mg (2 divided doses)
    patch 0.1-0.3mg/day
    Tabs=0.8mg
    patch=0.3mg
    GuanfacineTenex®19861mg/day1-3mg/day3mg
    MethyldopaAldomet®1962250mg BID500-2000 in 2 doses2000mg

    Clonidine has been used for the following:
    • Atrial fib
    • alcohol withdrawal
    • ADD
    • Constitutional growth delay in children
    • Cyclosporin associated nephrotoxicity
    • Diabetic diarrhea
    • Hyperhidrosis
    • Hypertensive urgencies
    • Mania
    • Menopausal flushing
    • Methadone/opiate detox
    • Pheochromocytoma diagnosis
    • Post Herpetic neuralgia
    • Psychosis
    • Reduction of allergen induced inflammatory reaction
    • Restless legs syndrome
    • Smoking cessation facilitation
    • Ulcerative colitis


    My son-in-law, Mark Garofoli and I attended PAINWEEK in Las Vegas a couple of years ago, where Mark did several presentations. We went to the exhibit hall and spoke with the pharmaceutical representatives. One was extolling the wonderful benefits of a new medication for opioid withdrawal disorder, and how effective it was when compared to placebo. Both of us being pharmacists and understanding the mechanisms of action asked the reps, “How did it stand up against clonidine?” The silence was deafening! This product costs $20 per tablet; the cost of clonidine is negligible.

    I remember in the 1980’s dispensing alpha-methyl-dopa (Aldomet®) as the “go to” drug for hypertension. We older pharmacists remember buying Aldomet® 250, Aldomet® 500, and Aldoril® 15 and Aldoril® 25 in bottles of 500! Today when we see methyldopa prescribed, it is usually for pregnant women with hypertension.

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    Overview of Potassium Sparing Diuretics

    POTASSIUM SPARING DIURETICS

    Mechanism of action:
    • Amiloride (Midamor®) and triamterene (Dyrenium®) are cations that directly block sodium channels but do not affect the mineralocorticoid receptor, thus preserving potassium.
    • Spironolactone (Aldactone®) and eplerenone (Inspra®) competitively inhibit the mineralocorticoid receptor, with eplerenone being more specific for that receptor. Eplerenone has less endocrine side effects, especially gynecomastia in males.
    Uses: All four potassium sparing diuretics are weak with respect to diuresis. They are frequently combined with loop diuretics to minimize potassium loss. Years ago, they were combined with thiazide diuretics to enhance hypertension control.
    • Spironolactone and eplerenone: by blocking the mineralocorticoid receptor, these drugs may reduce the adverse effects of excess aldosterone on the heart, making them useful for heart failure. Growing evidence shows that they may mediate some major effects of the Renin-Angiotensin-Aldosterone system activation, such as myocardial remodeling and fibrosis as well as sodium retention and potassium loss at the distal tubules. Aldosterone promotes sodium retention, potassium and magnesium loss, sympathetic activation, parasympathetic inhibition, myocardial and vascular fibrosis, baroreceptor dysfunction, and vascular damage and impairs arterial compliance. The RALES study showed a 29% relative risk reduction in heart failure. Should be considered as a “neurohormonal antagonist” rather than a potassium sparing diuretic.
    • Amiloride: useful for treatment of lithium induced diabetic nephrogenic diabetes insipidus
    Adverse effects: Monitor for hyperkalemia, especially if taking potassium supplementation or ACE inhibitors or ARBS. Triamterene is a potential nephrotoxin, possibly leading to crystalluria and cast formation. Causes kidney stones, which can be oxalate or triamterene stones.

    GenericBrandYearStartAverageMaximum
    AmilorideMidamor®Oct 19815mg/day5mg/day20mg
    TriamtereneDyrenium®Aug 196450mg/day50-100mg300mg
    SpironolactoneAldactone®Jan 196012.5-25mg50-100N/A
    EplerenoneInspra®Sep 200212.5-25mg50mg50mg
    Amiloride/HCTZModuretic® 5/50Oct 1981One dailyOne daily2 tabs daily
    Triamterene/HCTZDyazide® 37.5Dec 1965One dailyOne daily2 caps daily
    Spironolactone/HCTZAldactazide 25Jan 1961One dailyTwo daily8 daily


    I remember early on in my career when spironolactone, amiloride, triamterene were the go-to drugs for hypertension. In 1983, we dispensed so much spironolactone (Aldactone®) and spironolactone/HCTZ (Aldactazide®), that we got a free Hoover sweeper!

    We bought potassium sparing diuretics in bottles of 1000 and turned them over in a couple of weeks. We seldom dispense triamterene and amiloride today, and spironolactone is used by cardiologists for heart failure and dermatologists to suppress testosterone in women to help control acne and poly cystic ovary syndrome.

    One of my favorite patients came to the pharmacy a few years back. He was taking spironolactone for heart failure and complained that he was suffering from gynecomastia. He said the pain was so annoying he was ready to try on one of his wife’s bras!

    I wrote the drug name “eplerenone” on a sheet of paper, as he was seeing his endocrinologist the next day. The endocrinologist refused saying it would not help. Being persistent he approached his family doctor, and she made the change to eplerenone. Within a month the gynecomastia resolved, while still maintaining good control of his heart failure.

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    Overview of Loop Diuretics

    LOOP DIURETICS: The “big guns” for edema

    Mechanism:Inhibits the NKCC2 (the luminal Na/K/2Cl co-transporter) in the thick ascending limb of the loop of Henle. This leads to a decrease in total fluid volume through inhibition of sodium and chloride resorption, which causes increased excretion of water, sodium, chloride, magnesium and calcium. Loop diuretics are several times more potent than thiazides, cause less vasodilatation, and are not usually as effective for treating hypertension.

    Indications:
    • When patients are unable to tolerate thiazide diuretics, when they lose effectiveness, and in patients with impaired renal function (less than 30mL/min).
    • Most heart failure patients require more potent Loop diuretics rather than thiazide diuretics.
    • Loops primary agents used to increase excretion of sodium and water
    Dosing:
    • Take daily in the morning.
    • If dosed twice daily, take in AM and afternoon.
    • Ideally, furosemide should be taken on an empty stomach (food decreases absorption), Torsemide (Demadex®) is not affected by food.
    Warnings/precautions/ adverse effects:
    • Same effects as thiazides, additionally:
      • monitor for hypovolemia
      • check BUN and serum creatinine
      • watch for ototoxicity (especially if on an ototoxic drug)
      • may cause postural hypotension
      • may cause photosensitivity
    Drug interactions:
    • NSAIDS: blunt loop diuretics response
    • Antiarrhythmics: depleted K+ may cause Torsade’s de Pointes
    • May cause hyperuricemia, and precipitate gout attacks
    • Lithium: diuresis may spike lithium levels
    Patient Education/Counseling:
    • Report muscle cramps, dizziness, excessive thirst, weakness and confusion as these may be signs of over diuresis.
    • Patients should weigh themselves daily (fluid retention)
    • May be allergic if are allergic to sulfa antibiotics.
    • Caution for photosensitivity—recommend sunscreen
    • Potassium supplements may not be needed if taking an ACE inhibitor (lisinopril, etc.)
    • May need to change to potassium-sparing diuretic if hypokalemia persists
    • Control sodium intake
    • Take in the morning. Take with food
    • Notify practitioner if muscle cramps occur
    • Monitor blood sugar levels in diabetics
    Monitoring:
    • Weight
    • Urine output
    • Blood pressure
    • Blood levels for sodium, potassium, magnesium, creatinine, BUN
    GENERICBRANDSTARTING DOSEUSUAL DOSEMAXIMUM DOSE**SEVERE CKD LESS THAN 30ML/MIN
    BumetanideBumex®0.25mg BID1mg BID-TID10mg8-10mg
    FurosemideLasix®20mg BID40mg 3-4/day320mg200mg
    TorsemideDemadex®2.5mg/day5mg/day15-20mg50-100mg
    Ethacrynic acidEdecrin®50mg/day50mg-200mg/ day (divided dose)400mg400mg


    **MAXIMUM DOSE: dose that when exceeded, does not produce additional diuresis in healthy subjects.

    CHEAT SHEET: bumetanide 1 mg = furosemide 40 mg= torsemide 20 mg = Ethacrynic acid 50 mg

    Hypersensitivity reactions: Furosemide (Lasix®), bumetanide (Bumex®), and torsemide (Demadex®), which are in the sulfonamide class, can cause hypersensitivity reactions, usually manifested as a rash or rarely acute interstitial nephritis, similar to those produced by other sulfonamide drugs. Caution if severely allergic to Sulfa antibiotics, such as Bactrim® or Septra®.
    • Ethacrynic Acid (Edecrin®)- is the “go to” for patients that are refractory to the sulfonamide loop diuretics, or patients that are extremely allergic to the sulfa class (including celecoxib, sulfonylureas, thiazides, etc.). This product is expensive, one tablet of ethacrynic acid costs about as much as 100 tablets of the other loop diuretics!


    In the 1920's while treating syphilis with mercury-based compounds, clinicians noted that they caused excretion of excess fluid. Until the discovery of azetazolamide (a carbonic anhydrase inhibitor) in 1950, the toxic mercury-based compounds were all that was available!

    Chlorothiazide (Diuril®) (1958), yet another sulfa derivative, became the mainstay for heart failure and hypertension. In 1966, the FDA approval of furosemide (Lasix®) took over the treatment of kidney failure and pulmonary edema. Ethacrynic acid (Edecrin®) was approved in 1967 and marketed by Merck.

    In 1983, bumetanide (Bumex®) became the third loop diuretic to be approved. In 1993, torsemide (Demadex®) was FDA approved and marketed by Roche.

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    March 2021

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    Overview of Thiazid Diuretics

    THIAZIDE DIURETICS

    Mechanism:
    • direct arteriole dilation
    • Reduction in total fluid volume, through the inhibition of sodium resorption in the distal tubules of the nephron
    • Prominent diuretic effect fades over time; however, the antihypertensive effect is persistent.
    • Increases effectiveness of other antihypertensive agents by preventing the re-expansion of plasma volume.
    Indications:
    • Currently recommended for initial therapy of hypertension.
      Diuretics are more effective in African Americans and elderly patients because they are more renin dependent than Caucasians. Thiazide diuretics are preferred over “loop” diuretics because of their extended action.
    Warnings/precautions:
    • Thiazides are filtration dependent, and only effective in patients with a creatine clearance (CrCl) greater than 30mL per minute.
    • Take early in the day to avoid nocturia
    • Photosensitivity—use SPF >15
    • May increase blood glucose in diabetics
    • Report muscle cramps, may indicate depleted potassium
    • Caution if allergic to sulfonamide drugs.
    Adverse effects
    • May cause hypokalemia, and hypomagnesemia
    • May cause orthostatic hypotension.
    Drug interactions
    • Steroids: cause salt retention and antagonize the actions of thiazides
    • NSAIDS: blunt thiazides response
    • Calcium: increases calcium levels, is protective for osteoporosis
    • Antiarrhythmias: depleted K+ may cause Torasades de Pointes
    • May cause hyperuricemia, and precipitate gout attacks
    • Lithium: thiazides decrease lithium clearance and increase risk of toxicity
    Patient Education: Thiazide diuretics
    • Be sure to monitor: BUN/ creatinine; cholesterol levels, K+ levels, uric acid levels, weight and BP
    • Take in the morning. Take with food
    • Notify practitioner if muscle cramps occur
    • Use sunscreen due to photosensitivity
    • Monitor blood sugar levels in diabetics
    • Watch alcohol intake for OTC drugs
    • May cause gout attacks, notify physician of sudden joint pain.
    Prescribing information: Thiazide diuretics
    • Flattened dose response curve for hypotensive effect. Blood pressure reduction plateaus at 25mg for HCTZ , while adverse potential increases with increasing doses (50mg, 100mg). Full antihypertensive effect may take up to 4 weeks or longer.
    • Very, very inexpensive therapy. 100 tablets less than $8.00
    • Pregnancy: Category-B: indicated when edema is due to pathological causes. Dependent edema resulting from restriction of venous return by the gravid uterus is NOT properly treated with diuretics.
    • The combination of an Angiotensin Converting Inhibitor (ACEI)/ or Angiotensin Receptor Blocker (ARB) with a thiazide diuretic reduces risk of thiazide-induced hypokalemia. Most common combinations are Lisinopril/HCTZ, Losartan/HCTZ and Irbesartan/HCTZ
    • ACEI/ARB ameliorates diuretic-induced activation of the renin-angiotensin-aldosterone system, caused by a thiazide diuretic. This leads to an additive blood pressure reduction
    • Chlorthalidone and indapamide, both thiazide-like diuretics in the same class as HCTZ, have been shown to provide greater antihypertensive efficacy. Both chlorthalidone and indapamide reduce cardiovascular events and mortality compared with hydrochlorothiazide. So that begs the question why do most pharmacists buy HCTZ in bottles of 1000, and we “blow the dust off” the indapamide and chlorthalidone?
    • Metolazone (Zaroxolyn®) is frequently prescribed by nephrologists because it may be effective in patients with renal impairment. Most often used as a “kicker” two or three times a week to augment the diuretic effects of loop diuretics like furosemide (Lasix®).


    Generic/BrandDosage formsTypical adult doseHalf life
    Chlorthalidone (Hygroton®) 25, 50mg tablets12.5- 25mg once daily.50-60 hours
    Chlorothiazide (Diuril®)500mg tablets 250mg/5ml susp 500mg-1000mg per day or divided BID1-2 hours/td>
    Hydrochlorothiazide (HydroDiuril®, Esidrex®) 12.5mg caps; 12.5mg, 25mg, 50mg tabs12.5-50mg/day5.6-14hrs
    Indapamide (Lozol®) 1.25mg, 2.5mg tabs1.25-2.5mg daily16hrs
    Metolazone (Zaroxolyn®)2.5mg, 5mg 10mg tablets2.5-5mg once daily14 hours



    THIAZIDE DIURETIC TIMELINE:

    GENERICBRANDAPPROVAL DATEMANUFACTURER
    ChlorothiazideDiuril®9/4/1958Merck
    HydrochlorothiazideEsidrix®
    HydroDiuril®
    Oretic®
    2/12/1959
    2/24/1959
    7/6/1959
    Ciba-Geigy
    Merck
    Abbott
    HydroflumethiazideSaluron®7/22/1959Shire LLC
    BendroflumethiazideNaturetin-10®12/7/1959Apothecon
    ChlorthalidoneHygroton®4/7/1960USV
    MethyclothiazideEnduron®10/21/1960Abbott
    PolythiazideRenese®9/26/1961Pfizer
    MetolazoneZaroxolyn®11/27/1973Pennwalt
    IndapamideLozol®7/6/1983USV

    BODY STOP

    Thiazide diuretics are 63 years old and still going strong! These agents are timeless, with only three of them used at all today, namely hydrochlorothiazide (HCTZ), metolazone and chlorthalidone.

    With all of the evidence for indapamide and metolazone being superior to HCTZ, we have the HCTZ 12.5mg and 25mg in our "fast moving" section of the pharmacy.

    I can’t think of more than 2 or 3 current patients taking chlorthalidone or indapamide. I remember 40 years ago, when we would buy Enduron® (methyclothiazide) in bottles of 1000 and move them right off the shelf. I also remember buying bulk bottles of Diuril® 500mg as well as HydroDiuril® 100mg tablets.

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    Hypertension and Beyond: A Glance at the Wide Utility of Beta Blockers

    BETA-ADRENERGIC BLOCKERS (Beta Blockers) for HEART FAILURE

    Mechanism: Interfere with sympathetic nervous system to decreases peripheral vasoconstriction
    • Protect heart from over-stimulation by sympathetic nervous system. Blockade of beta receptors antagonizes the increase in sympathetic nervous system activity responsible for the progression of heart failure
    • Over a period of 3-6 months BB produce substantial rises in ejection fraction (averaging 10% absolute increase) and reducing LV size and mass
    • Current guidelines recommend BB with all patients with stable HF due to LV dysfunction unless unable to tolerate. Patients MUST be stable before treatment is initiated
    Beta blockers most effective for heart failure
    • Carvedilol (Coreg®) target dose: 25mg BID
    • Metoprolol succinate (Toprol-XL) target dose 200mg/day
    • Bisoprolol (Zebeta®) 10mg daily
    Titrate all beta blockers slowly (increase dose every two weeks), but try to get patient to target doses.

    BETA-ADRENERGIC BLOCKERS (Beta Blockers) for HYPERTENSION
    • Unless a patient has Coronary Artery Disease (CAD), atrial fibrillation, angina or heart failure, beta-blockers are considered second line therapy for hypertension, especially in patients over age 60.
    • Atenolol has NOT been shown to improve outcomes in hypertension, heart failure, or after a myocardial infarction.
    • Non vasodilating beta blockers are also associated with impaired glucose tolerance, which may lead to an increase risk of new onset Type-2 diabetes. (Carvedilol, labetalol and nebivolol are VASOdilating beta blockers)
    BETA-ADRENERGIC BLOCKER (Beta Blocker) for HYPERTENSION IN PREGNANCY
    • Labetalol is the preferred antihypertensive in pregnancy. Low concentrations of labetalol appear in breast milk
    BETA-ADRENERGIC BLOCKERS (Beta Blockers) for MIGRAINE PROPHYLAXIS
    • Metoprolol tartrate (Lopressor), propranolol (Inderal) and timolol (Blocadren) penetrate the blood brain barrier, and have proven efficacy for migraine prevention.


    I tell my new heart failure patients that are just starting out on carvedilol (Coreg), that “if I have a miracle drug on my shelf it is carvedilol.”Back in the early 1990’s one of my patients came in with a sheet of paper from his cardiologist. Turns out his cardiologist was Pittsburgh’s most renown heart failure specialist.

    He asked me to review the side effects about carvedilol.The drug was not even on the market yet, and the patient was to be enrolled in a study.He was on the heart transplant list, and this was the last-ditch effort using medication.

    The patient responded well, lived another 20 years, and never needed a heart transplant.The efficacy of that drug is amazing, just getting the patients to have good adherence is the biggest challenge.Every two weeks when the dose is increased, the patient feels wiped out, and many fall short of the 25mg twice daily goal. Keep encouraging their patients to tolerate the initial side effects, because the benefits are amazing!

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    Exploring Differences Between Common Beta Blockers

    Eighteen beta blockers are listed in Up-To-Date's website. I find it beneficial to sort them out into the most common ones on the community pharmacist's shelves.

    I remember early on in my career when propranolol (Inderal®) changed from the round orange, blue, green tablets to hexagonal tablets because the manufacturer's patent expired in July 1985. Now, nebivolol (Bystolic®) is the only branded beta-blocker left on our shelves, and a prior authorization is usually the case if a clinician needs to prescribe it. Over time, beta blockers have proven to be cheap and effective.

    BETA BLOCKERS- The differences...

    Cardioselectivity for Beta-1: All Beta blockers lose their cardio-selectivity at higher doses. Avoid beta blockers in patients with asthma, COPD, and peripheral vascular disease and diabetes unless there are compelling indications, such as ischemic heart disease and prevention of second myocardial infarction (MI).
    • Beta-1 selective drugs include: Acebutalol (Sectral®), Atenolol (Tenormin®), Bisoprolol (Zebeta®), Metoprolol (Lopressor® or Toprol-XL®)
    ISA (intrinsic sympathomimetic activity) in theory may have advantages in beta blockers in patients with borderline CHF, sinus bradycardia or peripheral vascular disease. These agents do not appear to be as protective against cardiovascular events as other beta blockers. They may increase the risk of MI, thus should not be used.
    • Penbutalol (Levatol®) and Pindolol (Visken®) and Acebutalol (Sectral®) have ISA, causing less resting bradycardia and lipid changes
    Lipophilic Beta Blockers: All Beta Blockers cross the Blood Brain Barrier, but the extent to which they enter the brain depends on the lipophilicity. Propranolol (Inderal®) (least cardio selective BB) and Metoprolol (Lopressor®/Toprol-XL®) are relatively lipophilic. More lipophilic BB cause more CNS side effects such as depression.

    Hydrophilic Beta Blockers:
    • Atenolol (Tenormin®) and Nadolol (Corgard®) are more water soluble (weakly lipophilic). Less likely to cause sedation.
    Non-Vasodilating beta blockers:
    • Propranolol (Inderal®), Metoprolol (Lopressor®, Toprol-XL®), Atenolol (Tenormin®), are associated with insulin resistance, and decreased insulin secretion.
    Vasodilating beta-blockers:
    • Carvedilol (Coreg®), Nebivolol (Bystolic®), Labetalol (Normodyne®) do not cause hyperglycemia. Are the best choice for a diabetic patient.

    Mechanism: Beta blockers
    Beta-blockers slow heart rate and reduce myocardial contractility. In hypertensive patients, they reduce total peripheral resistance.

    Proposed mechanisms include:
    • -stimulation of renin secretion is blocked
    • -cardiac contractility is decreased, thus decreasing cardiac output
    • -central sympathetic output is decreased
    • -decrease in heart rate decreases cardiac output
    • -Beta blocker action may combine all the above mechanisms
    Indications for beta blockers:
    • Patients with rapid resting heart rate (a-fib, paroxysmal supraventricular tachycardia)
    • Heart failure, post-MI
    • High coronary disease risk
    • Angina
    • Hypertension
    • Prevention of migraine (propranolol). Documentation of efficacy is less clear for metoprolol, atenolol, and nadolol.
    Warnings/precautions
    • Caution with diabetics: Diabetes (watch for “masking” of hypoglycemic symptoms)
    • Caution in patients with Raynauds or peripheral vascular disease
    • Caution in COPD/ asthma or bronchospastic disease
    • Caution in depressed patients—avoid lipid soluble BB (propranolol & metoprolol)
    • Caution in hyperlipidemia; increases LDL and decreases HDL
    Patient Education
    • Report dizziness or hypotension
    • Sedation with lipid soluble beta blockers (propranolol & metoprolol)
    • Avoid rapid withdrawal: taper dose over 14 days.
    • Sexual dysfunctions (impotence & decreased libido)
    NOTES: Beta Blockers:
    • • All beta blockers lower blood pressure to a similar extent, and can be dosed once or twice daily.
    • • Cardioselectivity is dose dependent
    • • May increase triglycerides
    • Carvedilol (Coreg®), Metoprolol (Toprol-XL®), and Bisoprolol (Zebeta®) are the only beta-blockers with mortality evidence for use in heart failure. (However, the COMET study showed that carvedilol is the most effective)
    BETA BLOCKERS— MOST COMMON Non-Selective Beta Blockers
    (beta-1 and beta-2 activity – are more likely to cause peripheral vasoconstriction, bronchoconstriction, delayed recovery from hypoglycemia in Type-1 diabetes, and impair exercise performance. Not a good choice for patients with asthma/COPD)
    DrugLipophilicityHalf LifeIndicationDoseComments
    Nadolol (Corgard®)LOWLONGAngina, HTN, A-fib10-240mg/day
    Propranolol (Inderal®) HIGHShort, but LA formula availableAngina, HTN, tremor, Migraine PxTabs: 10-40mg QID LA-CAPs: 80-160/day max=320mg High risk of fatigue. Low concentrations in breast milk

    BETA BLOCKERS- MOST COMMON beta-1 selective
    (remember beta selectivity is lost at higher doses)

    DrugLipophilicityHalf LifeIndicationDoseComments
    Atenolol (Tenormin®)LOWLONGA-fib for rate control. HTN: no improvement in mortality 25-100mgRenal elimination
    Metoprolol tartrate Immediate release (Lopressor®) ModerateMediumAngina, hypertension, post MI25-400mg
    Metoprolol Succinate extended release (Toprol-XL®) ModerateLONG (once a day) Heart failure, HTN, angina, a-fib12.5-400mgSuccinate is long acting
    Nebivolol (Bystolic®) LOWLONGHTN,5-40mgNot indicated for HF in USA

    BETA-BLOCKERS MOST COMMON alpha-1 antagonist activity
    (these cause peripheral vasodilation)

    DrugLipophilicityHalf LifeIndicationDoseComments
    Carvedilol (Coreg®) Moderate1st-pass metabolism. Moderate Heart Failure, Hypertension, LVD after MI 3.125mg BID to 25mg BID maximum of 50 mg BIDNOT cardioselective
    Labetalol (Trandate®) (Normodyne®)LOWModerateHypertension100mg-400mg BIDNOT cardioselective. Preferred BB in PREGNANCY. Low concentration in breast milk.


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    Overview of Statins for Hyperlipidemia

    Statins: what would we ever do without them? At one time, diet and exercise and anion exchange resins were all we had to combat hyperlipidemia.

    One of the biggest challenges we all have as community pharmacists is KEEPING patients on statin therapy. We all know that our star ratings are based on diabetics being prescribed statins, as well as adherence to statin therapy. Everyone complains of muscle pain, but a patient along with their doctor should decide based on liver function tests as to whether they should continue therapy.

    STATINS

    Mechanism of Action: HMG-CoA reductase is the rate-controlling enzyme of the mevalonate pathway, the metabolic pathway that produces cholesterol and other isoprenoids.

    Indication: Overwhelmingly the best choice for elevated LDL cholesterol, providing safe and effective LDL lowering by 18- 55%. Also, lower triglycerides, and increase HDL.

    The primary target of lipid-lowering therapy is LDL because there is a strong relationship between elevated LDL and coronary heart disease. Moderate doses of statins, which primarily target LDL, decrease cardiovascular morbidity and mortality by 25% to 35% within five years’ use. Although low HDL and high triglycerides are associated with increased risk for coronary heart disease, evidence of cardiovascular benefit from treating low HDL or high triglycerides is less compelling.

    Warnings/Precautions/Adverse effects:
    • GI adverse effects
    • Headache & dyspepsia
    • Elevated liver enzymes AST and ALT.
      • Do LFT initially, at 12 weeks, then annually.
    • Myopathy: is believed to be low 0.08% (8 per 10,000)
    • Check CK (creatine kinase) before starting therapy. Do not stop statins if less than 3 times upper-limit of normal.
    • Evaluate for increased/excess exercise.
    • 30% of patients on placebo experience muscle pain
    • Evaluate in 6-12 weeks as per the scheme outlined previously
    • May be worse if other drugs are taken concurrently (erythromycin, cyclosporine, niacin, fibrates, antifungals)
    • May lead to rhabdomyolysis: disintegration of dissolution of muscle
    Drug Interactions:
    • Pravastatin (Pravachol®) and Rosuvastatin (Crestor®) are not metabolized by CYP450.
    • Pitavastatin (Livalo®): Not significantly metabolized by CYP450 and may be less likely to be involved in drug interactions.
    • Other statins (simvastatin/lovastatin) have potential for significant drug interactions.
    • Grapefruit juice: co administration with grapefruit juice (8oz or 1 grapefruit)) may increase simvastatin, & lovastatin levels. Separation for food and drug does NOT work. Grapefruit primarily affects intestinal, not hepatic enzymes.
    STATIN COMPARISONS: to get 41% LDL-C lowering:
    Rosuvastatin 5mg= Atorvastatin 20mg= Simvastatin 40mg=Pravastatin 80mg


    Contraindications for statins:
    Itraconazole, Ketoconazole, Posaconazole, Erythromycin, Clarithromycin, Telithromycin, HIV protease inhibitors, Nefazodone, Gemfibrozil, Cyclosporine, Danazol

    Simvastatin dose should not exceed 10 mg with amiodarone, verapamil, or diltiazem. Simvastatin dose should not exceed 20 mg with amlodipine or ranolazine.

    Cholesterol medications are ideally dosed after supper & before bedtime, due to increased cholesterol synthesis during the night. Although rosuvastatin (Crestor®) and atorvastatin (Lipitor®), because of their long half-lives, can be dosed any time, most clinicians advise that all statins be given in the evening for maximum benefit. Pravastatin (Pravachol®), Fluvastatin (Lescol®), Simvastatin (Zocor®) and Lovastatin (Mevacor®) must be dosed in the evening.

    May cause photosensitivity reactions.

    Pregnancy category-X.

    Asian patients may require lower doses of the statins.

    All statins except pitavastatin (Livalo®) are available generically.

    Statins are no longer recommended to be combined with niacin for hyperlipidemia. The FDA pulled approval of this combo to treat hyperlipidemia.

    Statins inhibit CoQ10 formation and many theorize low CoQ10 levels might lead to myopathy. There's no conclusive proof that CoQ10 works for statin induced myopathy but some anecdotal reports suggest it might be helpful. Dosage: If patients want to try CoQ10, suggest starting low and dividing doses over 100 mg. Take two to three times daily to minimize nausea and diarrhea. Interestingly enough, a meta-analysis of 2400 patients showed significant lower levels of Vitamin-D in patients who had statin associated muscle pain.

    Muscle complaints defined:

    Myopathy - a general term related to any muscle complaint

    Myalgia - muscle complaints (i.e., ache, weakness) without elevations in CK. This is the most common myopathy reported with statins

    Myositis - muscle complaints with elevation of CK Rhabdomyolysis - markedly elevated levels of CK, usually greater than ten times the upper limit of normal; usually accompanied by creatinine elevation, brown urine, and urinary myoglobin.

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    February 2021

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    Beyond the Statins: An Overview of PCSK9 Inhibitor Antibodies

    Monoclonal antibodies are notoriously expensive. Whether for the treatment of rheumatoid arthritis or multiple sclerosis, the costs are incredibly high. I smile when I think of these drugs, because they were first introduced at around $1,200 per month.

    Due to poor sales because of formulary coverage, both companies reduced the price of these drugs by 60%. It shows that monoclonal antibody therapy for COMMON diseases needs to be reasonably priced.

    We are seeing more of these drugs being used, thanks to decreased costs. They are highly efficacious, but certainly do not take the place of statin therapy for most patients, with a cost of around $10 per month.

    PCSK9 (Proprotein Convertase Subtilisin Kexin Type 9) Inhibitor Antibodies
    (Both drugs approved in 2015)


    HOW THEY WORK: The PCSK9 protein interferes with the clearance of LDL-C from the blood. LDL receptors on liver cells remove LDL-C from the blood by binding it and then moving it into the cell for elimination. The lipid-free receptors then return to the surface of the cell. When PCSK9 binds to the LDL receptor, however, the receptor is unable to re-emerge on to the cell surface to remove more LDL-C, which then remains in the blood. By inhibiting the PCSK9 protein, PCSK9 inhibitors essentially improve the liver’s ability to recycle LDL receptors, resulting in a greater number of receptors on the cell surface and enabling more LDL-C to be removed from circulation.

    BENEFITS
    • They can lower LDL-C by as much as 60% in patients on statin therapy.
    • Reductions in the rates of stroke or myocardial infarction by 50%.
    • Lowers triglyceride levels by 12 to 31 percent
    • Slight increase in high density lipoprotein cholesterol by 5 to 9 percent
    Alirocumab (Praluent®): (approx. $500/month): Indicated as adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL- C

    Storage: keep in a refrigerator at 36°F to 46°F in the outer carton in order to protect from light. Warm up to room temperature before injection. Don’t exceed 24 hours of time out of refrigerator. May take up to 20 seconds for injection to be complete.

    Dose: 75mg SQ every 2 weeks. This is usually enough to achieve max lowering of LDL-C. Maximum dose is 150mg every 2 weeks. Available as pre-filled single dose pens, 75mg or 150mg.

    Evolocumab (Repatha®): (approx. $500/month) is used along with diet and maximally tolerated statin therapy for adults with heterozygous familial hypercholesterolemia, (an inherited condition that causes high levels of LDL), or atherosclerotic heart or blood vessel problems, who need additional LDL lowering.

    Keep refrigerated. May be stored at room temperature for up to 30 days.

    Dose: Primary hyperlipidemia with established clinical atherosclerotic CVD or heterozygous familial hypercholesterolemia: 140 mg every 2 weeks or 420 mg once monthly in abdomen, thigh, or upper arm.

    For both products “maximally tolerated statin therapy” can be interpreted as no statin at all if patients can’t tolerate statins.

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    Beyond the Statins: Overview of Fibric Acid Derivatives

    For most of our patients elevated triglycerides seem to be directly connected to their poor diet of refined carbohydrates. Pizza, pasta, bread, sugar drinks, cookies, donuts, virtually anything that tastes good can drive up triglycerides. Fibrates are of not much value. Treatment of elevated triglycerides is better left to the dietician, rather than reaching for the fibrates! Diet and exercise are the cornerstone for hyperlipidemia, cardiovascular disease, and diabetes.

    Tricor was first introduced in 1993 (67mg, 134mg, 200mg), and reformulated in 2001 (54mg and 160mg), and again in 2004 (48mg and 145mg), just to protect the patent. To follow up, they introduced Trilipix (fenofibric acid) in 2008, which was their last attempt to breathe life into this product. It bombed.

    Fibrates for High Triglycerides... not so fast

    Triglyceride overview:

    ASCVD: Elevated fasting plasma triglycerides levels are associated with atherosclerotic cardiovascular disease (ASCVD) burden and events such as myocardial infarction and stroke. Triglycerides over 150mg/dl seems to increase the risk of ASCVD. Elevated triglycerides are also associated with insulin resistance, metabolic syndrome, platelet aggregation and low HDL. Lowering TG’s has not been proven to reduce ASCVD events.

    Acute pancreatitis: The risk for acute pancreatitis rises when serum TG levels exceed 500 mg/dL. The risk of developing acute pancreatitis is approximately 5 percent when TG’s exceed 1000mg/dl and up to 20 percent with TGs exceed 2000 mg/dL.

    Medications that can exacerbate hypertriglyceridemia:
    • Oral estrogens
    • Bile-acid sequestrants (Cholestyramine, Colestipol, Colesevelam)
    • Antiretroviral regimens, especially for HIV (especially Protease inhibitors)
    • Second-generation antipsychotic medications such as clozapine (Clozaril) and olanzapine (Zyprexa
    • Nonselective beta blockers (propranolol)
    • Thiazide Diuretics
    • Glucocorticoids
    • Increased consumption of alcohol, sugar-containing beverages and simple carbohydrates


    FIBRIC ACID DERIVITIVES

    Mechanism of Action:
    Bind to and stimulate peroxisome proliferator-activated receptor alpha (PPARα), a transcription factor which increases lipoprotein lipase activity, which hydrolyzes triglycerides from VLDL. Other effects include decreased hepatic cholesterol synthesis, and increased cholesterol secretion in the bile \

    Indication: 20 to 50% reduction in triglycerides

    Warnings/ Precautions/Adverse effects:
    • Caution if combined with statins (watch CK, rhabdomyolysis)
    • Take with food to minimize GI upset
    • May increase gallstones - don’t give if patient has gallbladder disease.

    Drug Interactions: Fibrates will increase warfarin effect- reduce warfarin dose by 30%

    Patient Education: Take with food to minimize GI effects

    Products of this Class (Fibrates)
    • Gemfibrozil (Lopid®)
      • 600mg tablets
      • Dosage: 1 tablet BID
      • Prescriber note: Avoid combining Gemfibrozil with statins CONTRAINDICATED.
    • Fenofibrate (Tricor®)
      • Tablets 48mg and 145mg (new formulations)
      • Dosage: 1 tablet daily
      • Other fenofibrate formulations: 54mg, 67mg, 134mg, 150mg, 160mg, 200mg


    Fibric acid derivatives have fallen out of favor.

    NOTE: Statins typically lower TG levels by 5 to 15 percent; however, high-intensity statin therapy can lower TGs by 25 to 30 percent. Most clinicians will increase the statin dose rather than add a fibrate. Fibrates, when combined with statins did not lower risk of non-fatal MI, non-fatal stroke, or CV death. Gemfibrozil is the only fibrate with demonstrated beneficial effects on cardiovascular outcomes, but its use with statins can increase the risk of myopathy and is not recommended. Fenofibrate is not proven, gemfibrozil with statins causes high risk of myopathy and is not recommended.

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    Beyond the Statins: Overview of Ezetimibe and Bempedoic Acid

    Ezetimibe (Zetia®- approved October-2002)

    >Mechanism: works by blocking NCP1L1 (Niemann-Pick C1-Like 1), which blocks intestinal absorption of cholesterol and phytosterols. It is effective in absence of dietary cholesterol because it blocks absorption of cholesterol in the bile.

    Indication:
    It lowers LDL by 18%, and triglycerides by 8%, and raises HDL by 1-5% by itself. When combined with statins it lowers LDL 25%, triglycerides by 14%, and raises HDL by 3%.

    Prescribers Note:
    Most clinicians will try to get a statin on board even if the patient complains of muscle pain. Even giving Atorvastatin 5mg 3 or 4 times a week greatly improves the lipid profile over that of ezetimibe (Zetia®) alone. Ezetimibe may be helpful for avoiding high doses of statins, and therefore possibly decreasing risk of myopathy in patients who do not meet cholesterol goals on low-dose statin therapy alone.

    Warnings/Precautions/Adverse Effects:
    Well tolerated. May see increase in liver transaminases when combined with statins.

    Pregnancy Category-C


    Bempedoic Acid (Nexletol®-approved 2020)

    Mechanism: the first ATPcitrate lyase (ACL) inhibitor, indicated for use as adjunct to diet and maximally tolerated statin therapy. This enzyme is “upstream” from HMG reductase, the enzyme that statins block. First oral, once daily, non-statin in 20 years since ezetimibe. Lowered LDL-C by 17% on background therapy.

    Dose: 180mg once daily, with or without food.
    • Simvastatin: Avoid concomitant use with simvastatin greater than 20 mg.
    • Pravastatin: Avoid concomitant use with pravastatin greater than 40 mg
      • Practice Point: other statins such as rosuvastatin and atorvastatin do not seem to be affected by bempedoic acid and may be a more rational choice./li>
    Warning: may increase blood uric acid levels. Hyperuricemia may occur early in treatment and persist throughout treatment and may lead to the development of gout.
    • Practice Point: Check the profile for allopurinol, febuxostat or colchicine which indicate potential for gout flares. Be sure to contact the prescriber and patient.
    Tendinopathies: bempedoic acid increases the risk for tendon rupture, especially in the rotator cuff, biceps, and Achilles tendons.
    • Practice point: Check patient profile for the following that can increase the risk of tendon rupture: patients over 60 years of age, in those taking corticosteroid or fluoroquinolone drugs, in patients with renal failure, and in patients with previous tendon disorders..
    Pennsylvania Medicaid Formulary requires: “Is being prescribed the ACL inhibitor by or in consultation with an appropriate specialist (e.g., cardiologist, endocrinologist, or other provider specializing in lipid disorders.”

    Do not consider Bempedoic acid to be as safe as the PCSK-9 inhibitors (alirocumab (Praluent®), evolocumab (Repatha®). The potential for gout as well as tendinopathies makes it necessary for the prescriber and pharmacist to provide a more intense patient counseling effort. This is especially important for patients with commercial insurance or Medicare-D plans where the prescriber might not need to be a specialist as required for the state Medicaid plans, such as Pennsylvania's.

    Nexletol (bempedoic acid) and Nexlizet (bempedoic acid + ezetimibe) are being detailed to family practice offices as well as the specialists.

    Make sure you are monitoring the uric acid levels, as bempedoic acid might precipitate a gout attack. Most recommendations say check uric acid (and get it under control) before prescribing bempedoic acid.

    Have a great day on the bench!!

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    An Overview of Bile Acid Resins

    At the beginning of my career, all we had to lower cholesterol was diet, exercise, and cholestyramine (Questran®). One of my colleagues had a heart attack at the age of 42 years. His wife went to a cooking school in the early 1980’s to learn how to cook heart healthy meals.

    The statins came along about 1987 and for the most part displaced cholestyramine as treatment of hyperlipidemia. Now I see that most of the cholestyramine prescriptions are written by gastroenterologists, and the colesevelam prescriptions are written by endocrinologists!

    BILE ACID-RESINS
    Mechanism of Action: Anion exchange resin that binds bile acids in the intestine. Resins are insoluble and non-absorbable. Bile acids are synthesized from cholesterol, and by their removal more cholesterol is taken up from the bloodstream. Bile acids and resins are excreted in the stool.

    Indication: Usually used as adjuncts to statin therapy requiring further lowering of LDL, reduces LDL by 15-30%.

    Warnings/ Precautions/Adverse effects:
    • Constipation- major side effect (30%)
    • Taken right before meals.
    • ELEVATES Triglycerides (negative feedback with liver)
    • Vitamin deficiencies: Bind fat soluble vitamins (A, D, E, K); be sure to monitor for Vitamin-K deficiency
    Drug interactions:
    • Will bind other drugs and decrease their absorption. Colestipol and cholestyramine bind digoxin, warfarin, statins and other ionic charged drugs can be bound
    • Other drugs should be taken 1 hour before, or 4-6 hours after the resins
    Patient Education:
    • Other drugs should be taken 1 hour before, or 4-6 hours after the resins
    • Increase fluid intake and fiber in order to better cope with constipation
    • Large tablet load, unpalatable taste and side effects will impact adherence to this class of drugs
    Products of this Class:
    • Cholestyramine (Questran®, Prevalite®) available in regular and sugar free. Scoop is included
      • Dose = 4gm 1 –2 times daily
      • Dissolve granules in water or juice
    • Colestipol (Colestid®)
      • Tablets (1gm): 2 to 16 tablets daily
      • Granules: 5gm packets, 5 to 30gm/day
    • Colesevelam (Welchol® 625mg)
      • Also used as add-on therapy for Type-2 diabetes. Used along with Metformin, sulfonylureas, and insulin. Bile acids play a role in cholesterol and glucose metabolism (FXR receptor). Reducing bile acid absorption can improve both. Lowers HbA1c about 0.5%- 0.8%; Lowers LDL up to 20%.
      • CAUTION: in patients with triglycerides over 300 mg/dL. Avoid use if triglycerides exceed 500 mg/dL. May increase triglycerides up to 10% especially when combined with insulin or sulfonylureas.
      • Dose: 3 tablets BID or 6 tablets as a single dose or 3.75gm packets once daily
      • Colesevelam does NOT bind digoxin, warfarin, or statins


    ITCHING:
    Pruritus may develop in patients with cholestasis due to any cause. Elevated bile acids in the skin can cause itching. Cholestyramine (4-16 grams per day) can be considered as first line therapy. Colestipol can also be considered. Best if dosed before and after breakfast in patients with an intact gallbladder to enhance the excretion of the bile pruritogens, which seem to accumulate in the gallbladder during the overnight fast.

    CLOSTRIDIUM DIFFICILE:
    Cholestyramine binds toxins A and B excreted by Clostridium difficile. Cholestyramine does not alter the gut flora but may be helpful as adjunctive therapy. Now that vancomycin is considered first line therapy for C. dif, caution must be exercised when using cholestyramine, as it may bind vancomycin rendering it less effective. If both are given together, be sure to separate by at least 2-3 hours.

    DIAPER RASH:
    Some diaper rash compounds include cholestyramine to bind up bile acids, which can cause direct irritation. Nationwide Children’s Hospital uses a 20% Cholestyramine/Petrolatum preparation, consisting of cholestyramine light (80%) [25grams] combined with petrolatum base [75grams]. Shelf life was 180 days.

    Para Have a great day on the bench!!

    January 2021

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    Role of Niacin in the Management of Hyperlipidemia

    Understanding Niacin therapy always gives me a better appreciation for treating hyperlipidemia. I always tell my students that “Niacin makes the numbers look pretty but does nothing to extend life.”

    Niacin raises HLD, lowers LDL and triglycerides, but doesn’t do anything to decrease CV events. You have to wonder what it is that the statins do that is so “magical”. When statins make the numbers look pretty, patients live longer. I have to wonder if further research will show that statins do more than play the numbers game. Hyperlipidemia is clearly more than a numbers game!

    The goal of treating hyperlipidemia is to decrease the concentration of free LDL in the blood that can cause fatty streaks and plaques and to increase HDL which works to reverse the formation of fatty streaks and plaques.

    LDL: low density lipoprotein –a genetic link exists (bad cholesterol)
    • Oxidized LDL becomes atherogenic
    HDL: high density lipoprotein- no genetic link (“good cholesterol”)
    TG: triglycerides-a genetic link exists.
    • Oxidizes LDL, lowers LDL clearance, causes inflammation—a genetic link exists
    The overall goal is to decrease the risk for a cardiac event or a stroke.
    • For every 1% reduction in total cholesterol, total CV mortality is reduced by 1.5%
    • For each 1% decrease in LDL there is a 2% decrease in risk of CV events
    • For each 1% increase in HDL there is a 3% decrease in risk of CV events
    Major risk factors that modify LDL goals:
    • Cigarette smoking
    • Hypertension (BP >140/90 mmHg or on antihypertensive medications)
    • Low HDL cholesterol
    • Family history of premature CHD
      1. Male first degree relative <55 years old
      2. Female first degree relative <65 years old
    • Age
      1. Men > 55 years old
      2. Women > 55 years old

    NICOTINIC ACID (Niacin) Vitamin B3
    Mechanism of Action for hyperlipidemia
    Decreases the production and release of very low-density lipoprotein (VLDL). Niacin also decreases the release of free fatty acids from adipose tissue into the circulation, which is the primary producer of circulating FFA’s.

    Indication:
    • Niacin (1.5-4.5gm/day) - lowers LDL by 5-25%, increases HDL 15-35%, and decreases triglycerides by 10-50%. Sounds like a winning combination… except…
    • Never monotherapy (low-cholesterol, low-fat diet)
    Warnings/ Precautions/Adverse effects:
    • Although Niacin is arguably the most effective drug for improving the entire lipid profile it is difficult for patients to tolerate.
    • Causes cutaneous flushing
      • Can be overcome by one Aspirin 325mg 30 minutes before niacin (enteric coating 1 hour).
    • Start low and go slow with niacin dosing
    • Take with food
    • GI upset
    • Liver toxicity
    • May cause mild worsening of glucose intolerance.
      • Diabetics may experience a 25% increase in serum glucose levels.
    • May raise uric levels and precipitate gout.
    Patient Education:
    • Major side effect is cutaneous flushing.
    • Take with food to decrease GI upset, right before bed..
    • Swallow whole, with cold water.
    • Avoid sudden changes in posture. May cause dizziness.
    • Avoid alcohol and hot drinks during administration.
    • Increase blood glucose monitoring if diabetic.
    • Watch niacin content in multivitamin.
    Products of this Class:
    • Niaspan® 500, 750 and 1000 (generic available, but still expensive)
    • gen=$60/90 tablets
    • brand= 990.00/90 tablets
    • Adult dose: start at 500mg at bedtime for 1-4 weeks. Then 1000mg at bedtime for 5-8 weeks then titrate to response and tolerance. Doses over 2000mg/day are not recommended
    Other forms of Niacin:
    • Can be either nicotinic acid or nicotinamide
    • Nicotinic acid is the only form proven to lower LDL
    • Immediate Release Niacin
      • Over-the-counter
    • Niaspan ER®
      • Less flushing, but long-term effects unknown
    • “Slow” Niacin- over the counter
      • Not used for the treatment of Dyslipidemia
      • Typically, nicotinamide
      • Hepatotoxicity


    BAD PRESS FOR NIACIN! (September 2014): “Added to a statin Niacin does NOT improve cardiovascular outcomes more than a statin alone when LDL is around 70 mg/dL. Adding niacin to bump up HDL makes number look better but doesn’t improve outcomes.” (AIM-HIGH study)

    SAFETY: For every 1000 patients treated for about 4 years with a statin plus niacin and an anti-flushing agent, about 18 more will develop diabetes and 37 more diabetics will have worse glycemic control...compared to patients on a statin alone.

    RECOMMENDATION: Niacin is associated with dyspepsia, diarrhea, rash, muscle pain, and flushing with possibly more infections and GI bleeding. If they have low LDL and stable CV disease, recommend stopping the Niacin

    URBAN LEGEND: Niacin to flush THC for drug testing? Doesn’t work, high doses lead to liver toxicity. Have a great day on the bench!!

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    Overview of Anticoagulation Management

    A lot of noise was made when the Factor Xa drugs came out and there was no reversal agent. We all feel comfortable with Vitamin-K reversing the effects of warfarin, but that can take a couple of days. Just simply stopping the Factor Xa inhibitors will produce similar results! Now that we have monoclonal antibodies to reverse dabigatran and the Xa inhibitors that worry should be gone.

    A common question, though, in the family practice setting is when someone should stop their anticoagulant or antiplatelet therapy. The chart below provides guidance on that front:

    Drug NameHALF LIFEWhen to STOP BEFORE PROCEDURE
    Asprin7-10 days before
    Prasugrel (Effient®)7-10 days before
    Clopidogrel (Plavix®)5 days before
    Ticagrelor (Brilinta®)5 days before
    Warfarin (Coumadin®)5 days before
    Dabigatran (Pradaxa®)12-17 hours1-2 days before
    3-5 days if CRCl is less than 50
    Rivaroxaban (Xarelto®)5-9 hoursAt least 24 hours (ideal=48hr)High risk= 2 days
    Apixaban (Eliquis®)8-15 hoursAt least 24 hours (ideal-48hr)High risk= 2 days
    Edoxaban (Savaysa®)6-11 hoursAt least 24 hours (ideal-48hr)High risk= 2 days


    WHEN to RESTART: Most experts say to restart therapy 24 hours after a low bleeding risk procedure. Most agree that the anti-platelet drugs cannot be reversed.

    ASPIRIN reversal… sort of
    Intravenous DDAVP may be beneficial in some cardiac surgical patients with intractable microvascular bleeding due to platelet dysfunction that may be caused by aspirin use.

    Vitamin-K: Reversal agent for Warfarin Treatment: Stop drug.
    • If minor bleeding progresses to major bleeding: Administer Vitamin-K at 5 to 25mg parenterally. May cause prolonged resistance to warfarin.
    • If INR is between 5 to 9, a low dose of oral Vitamin K (2.5mg) is given
    • Greater than 9 with no bleeding: give 5 mg orally. Will reduce the INR within 12 to 24 hours.
    Idarucizumab (Praxbind®)- reversal agent for dabigatran
    • Idarucizumab is a humanized monoclonal antibody fragment (Fab) indicated in patients treated with idarucizumab when reversal of the anticoagulant effects of dabigatran is needed:
      • For emergency surgery/urgent procedures
      • In life-threatening or uncontrolled bleeding
    Coagulation factor Xa (recombinant), inactivated-zhzo) (Andexxa®)
    • ANDEXXA® is indicated for patients treated with rivaroxaban and apixaban, when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding.
    • This indication is approved under accelerated approval based on the change from baseline in anti-Factor Xa activity in healthy volunteers. An improvement in hemostasis has not been established. Continued approval for this indication may be contingent upon the results of studies to demonstrate an improvement in hemostasis.
    Limitation of use:
    • ANDEXXA® has not been shown to be effective for, and is not indicated for, the treatment of bleeding related to any Factor Xa inhibitors other than apixaban (Eliquis®) and rivaroxaban (Xarelto®).
    Prothrombin Complex Concentrate (PCC) (Kcentra®)

    Kcentra® is a blood coagulation factor replacement product indicated for the urgent reversal of acquired coagulation factor deficiency induced by Vitamin K antagonist (warfarin) therapy in adult patients with acute major bleeding or the need for urgent surgery or other invasive procedure..

    Administration route: intravenous use only. Online dosing calculator available.
    • Administer Vitamin-K to maintain Vitamin K-dependent clotting factor levels once the effects of Kcentra® have diminished
    Source: human plasma. The risk of transmission of infectious agents, including viruses and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent (mad cow disease), is possible

    FRESH FROZEN PLASMA
    Plasma is frozen within hours after donation in order to preserve the clotting factors. The shelf life of FFP is 12 months, but it can be extended to 7 years if stored at − 65 °C (-85°F). Most often used to treat bleeding disorders when a clotting factor or multiple factors are deficient, and no factor specific concentrate is available.
    A unit of FFP contains near normal levels of all factors, including 400mg of fibrinogen. It increases factor levels by 3%

    Indications for use for FFP
    • Treatment of multiple or specific coagulation factor deficiency, with abnormal PT or APPT. Either congenital or acquired (related to drug treatment)
    • Can be used for prophylaxis for planned surgical procedures.
    • Patients with massive transfusion who have clinically significant coagulation deficiencies.
    Patients on warfarin who are bleeding or need to undergo an invasive procedure before Vitamin-K could reverse the warfarin effect or who need to have anticoagulation therapy after the procedure.

    Have a great day on the bench!!

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    OVERVIEW OF DIRECT ORAL ANTICOAGULANTS (DOACs)

    Virchow’s Triad—risk factors for venous thrombosis
    STASIS OF BLOOD FLOWENDOTHELIAL INJURYHYPERCOAGUABILITY
    Atrial fibrillationSmokingObesity
    Varicose veinsCholesterol plaquesPregnancy
    Prolonged immobilizationChronic high BPCancer/Chemotherapy
    Genetic factors (Factor-V)
    Oral contraceptives


    DOAC-NOAC- TSOAC?
    Direct oral anticoagulants (DOACs) are oral medications that specifically inhibit factors IIa or Xa. They are also known as new (or novel) oral anticoagulants (NOACs) or target-specific oral anticoagulants (TSOACs). DOACs are the preferred name according to the International Society of Thrombosis and Haemostasias

    Where DOAC’s work:
    Prothrombin---- ((Xa))------ Thrombin (Rivaroxaban works here)
    Fibrinogen----((Thrombin))-----Fibrin (Dabigatran works here)
    Fibrin does the cross linking to stabilize the clot that is formed


    DABIGATRAN (PRADAXA®) (released- November 2010)

    Mechanism: Direct Thrombin Inhibitor. Dabigatran was the first ORAL anticoagulant to be introduced in over 50 years!! Referred to as a “univalent direct thrombin inhibitor” that binds directly to the active site on factor IIa (thrombin). Thrombin is a naturally occurring enzyme in our circulatory system that converts fibrinogen into fibrin, which is an important step in clot formation. By tying up thrombin, clots are not so readily formed.

    Dosage: 150mg BID / 75mg BID if CrCl is 15-30mL/min
    Advantages compared to warfarin:
    • Prevents more strokes, including hemorrhagic (5/1000 a/fib patients/year)
    • Extensive monitoring not necessary
    • Fewer food and drug interactions
    • Less intracranial bleeding
    Disadvantages compared to warfarin:
    • COST: $15/day costs more than warfarin + monitoring
    • TWICE DAILY DOSING must have excellent patient compliance
    • GI upset- give with food. Increase GI bleed
    Prescribing info: Make sure INR is below 2 before starting therapy.
    • Some drug interactions with P-glycoprotein inhibitors (Ketoconazole, Clarithromycin, others)
    • Rifampin speeds metabolism.
    • Due to costs, this drug is ideal for patients with uncontrolled INR on warfarin therapy.

    FACTOR Xa INHIBITORS
    Role of Factor Xa: Factor Xa is responsible for the conversion of prothrombin to thrombin. Blocking Xa blocks that conversion to thrombin and clot formation is impeded.

    Rivaroxaban (Xarelto®) available August-2011 (490.00/month)
    The first oral, selective inhibitor of Factor Xa approved by the FDA

    Nonvalvular Atrial Fibrillation:
    • For patients with CrCl >50 mL/min: 20 mg orally, once daily with the evening meal
    • For patients with CrCl 15 - 50 mL/min: 15 mg orally, once daily with the evening meal
    Treatment of DVT, PE, and Reduction in the Risk of Recurrence of DVT and of PE:
    • 15 mg orally twice daily with food for the first 21 days for the initial treatment of acute DVT or PE. After the initial treatment period, 20 mg orally once daily with food for the remaining treatment and the long-term reduction in the risk of recurrence of DVT and of PE. Reduce to 10mg after 1 year.
    • Prophylaxis of DVT Following Hip or Knee Replacement Surgery: 10 mg orally, once daily with or without food
    Indications:
    • to reduce risk of stroke and systemic embolism in nonvalvular atrial fibrillation
    • for treatment of deep vein thrombosis (DVT)
    • for treatment of pulmonary embolism (PE)
    • for reduction in the risk of recurrence of DVT or PE
    • for the prophylaxis of DVT, which may lead to PE in patients undergoing knee or hip replacement surgery (10mg daily)
    • for prophylaxis of venous thromboembolism (VTE) in acutely ill
    • to reduce the risk of major cardiovascular events in patients with chronic coronary artery disease (CAD) or peripheral artery disease
    ADVANTAGES:
    • Convenient once-daily, oral dosing
    • No routine monitoring of INR or other coagulation parameters is required. Fast onset.
    • AVOID use in severe renal impairment (creatinine clearance <30 mL/min).
    • AVOID in patients with hepatic impairment
    • AVOID drugs that Inhibit Cytochrome P450 CYP3A4 Enzymes and Drug Transport Systems such as P-gp and strong CYP3A4 inhibitors, which cause significant increases in rivaroxaban exposure. May double dose if giving concurrently with P4503A4 inducer.
    • for prophylaxis of venous thromboembolism (VTE) in acutely ill
    • to reduce the risk of major cardiovascular events in patients with chronic coronary artery disease (CAD) or peripheral artery disease
    (October 2018) Rivaroxaban XARELTO® is indicated, in combination with aspirin, to reduce the risk of major cardiovascular events (cardiovascular death, myocardial infarction, and stroke) in patients with chronic coronary artery disease (CAD) or peripheral artery disease (PAD).
    • • Dose is 2.5mg BID + 81mg aspirin/day
    Apixaban (Eliquis®) (approved Dec 28, 2012) ($485.00/month)

    Indications
    ELIQUIS® is a factor Xa inhibitor anticoagulant indicated:
    • to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation.
    • for the prophylaxis of deep vein thrombosis (DVT), which may lead to pulmonary embolism (PE), in patients who have undergone hip or knee replacement surgery.
    Apixaban Indications and Dosages: Reduction of risk of stroke and systemic embolism in nonvalvular atrial fibrillation (NVAF): The recommended dose is 5 mg orally twice daily.

    In patients with at least 2 of the following characteristics reduce dose to 2.5mg twice daily:
    • Age: over age 80,
    • body weight less than 60kg (132lbs),
    • serum creatinine ≥1.5 mg/dL
    • Greater than 9: give 5 mg orally.? Will reduce the?INR within 12 to 24 hours
    Indications and dosage:
    • Prophylaxis of DVT following hip or knee replacement surgery: The recommended dose is 2.5 mg orally twice daily.
    • Treatment of DVT and PE: The recommended dose is 10 mg taken orally twice daily for 7 days, followed by 5 mg taken orally twice daily.
    • serum creatinine ≥1.5 mg/dL
    • Reduction in the risk of recurrent DVT and PE following initial therapy: The recommended dose is 2.5 mg taken orally twice daily.

    Drug interactions: Warfarin is metabolized by the P450 enzyme system.? Lots of drug interactions.
    • P450 inhibitors (blockers): Azole-antifungals, some HMG CoA reductase drugs, erythromycins, etc.
    • P450 inducers: carbamazepine, barbiturates, phenytoin
    • Can be displaced from binding sites: loop diuretics, valproate
    • Platelet aggregation: NSAIDS can enhance warfarin’s effect.


    A fib: for every 1000 patients treated per year, apixaban prevents three more strokes, avoids ten major bleeds, and prevents four deaths compared to warfarin


    Edoxaban (Savaysa®) (2015) ($400/month)

    Treatment of NVAF: Assess CrCL before initiating therapy. The recommended dose is 60 mg once daily in patients with CrCL >50 to ≤ 95 mL/min.
    • Do not use SAVAYSA in patients with CrCL over 95 mL/min (sorry, your kidneys are “too” good for this drug!)
    • Reduce dose to 30 mg once daily in patients with creatinine clearance 15 to 50 mL/min
    Treatment of DVT and PE: The recommended dose is 60 mg once daily. The recommended dose is 30 mg once daily for patients with CrCL 15 to 50 mL/min or body weight less than or equal to 60 kg or who use certain P-gp inhibitors.

    With nearly 50% of our warfarin patients having uncontrolled INR's, DOACs have been a Godsend. They do not require extensive monitoring, do not hang around very long in the body, and have excellent efficacy.

    One of the biggest challenges we see, however, is the cost of these medications. Adherence becomes a challenge when patients struggle to pay even a percentage of the costs of these medications.

    Rudolf Virchow (1821-1902) was a German physician who is credited for elucidating the origins of thromboembolism. In fact, he coined the term “thrombosis” which is the process by which a clot forms in a blood vessel as well as the term “embolism”, which is a clot that has moved and blocks off a vessel. Virchow also had a brilliant career in which he clarified how cells divide, as well being a strong social medicine advocate. Considered by many to be the most brilliant physician of the 1800’s and the ‘father of cell pathology’, he even has a lymph node named after him!

    In the next session, we will discuss when to stop these drugs before elective surgical procedures. Have a great day on the bench!!

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    Anticoagulation Overview: Vitamin-K Antagonists (Warfarin)

    Warfarin? (Coumadin®) tablets: (approved by FDA June 8, 1954)
    Mechanism of Action: Vitamin K antagonist: produces its pharmacological effect by interfering with the interconversion of Vitamin-K and its 2,3 epoxide.? Leads to depletion of Factors: II, VII, IX and X (produced in liver)?and anticoagulant proteins C & S.?

    Dosage: at least 4 to 5 days are necessary before a patient is anti-coagulated.
    Initial Dosage: 5mg / day in normal patients.? The INR should be 2 in four to five days.
    • 2.5 to 4mg for elderly or patients with liver disease
    • 7.5 to 10mg for young, healthy or obese patients
    • Most clinicians titrate warfarin doses by trial and error
    • Now the FDA is suggesting lower doses for patients with certain genetic variations.
    Genetic Variations in Warfarin:
    • CYP2C9 activity indicates a slow or fast metabolizer. A slow metabolizer may need a lower maintenance dose and take longer for their INR to get to steady state
    • Vitamin K epoxide reductase activity (VKORC1) tells whether a patient is sensitive or resistant to warfarin’s effects.
    Adverse effects bleeding
    Treatment stop the drug
    • If minor bleeding progresses to major bleeding: Administer Vitamin-K 5 to 25mg parenterally. May cause prolonged resistance to warfarin.
    • 7.5 to 10mg for young, healthy or obese patients
    • MIf INR is between 5 to 9, a low dose of oral Vitamin K (2.5mg) is given
    • Greater than 9: give 5 mg orally.? Will reduce the?INR within 12 to 24 hours
    Contraindications: pregnancy Category X
    Drug interactions: Warfarin is metabolized by the P450 enzyme system.? Lots of drug interactions.
    • P450 inhibitors (blockers): Azole-antifungals, some HMG CoA reductase drugs, erythromycins, etc.
    • P450 inducers: carbamazepine, barbiturates, phenytoin
    • Can be displaced from binding sites: loop diuretics, valproate
    • Platelet aggregation: NSAIDS can enhance warfarin’s effect.
    Drug monitoring: Warfarin is metabolized by the P450 enzyme system.? Lots of drug interactions.
    • Initial: INR should be done daily while in the hospital.
    • Every 2 or 3 days if not hospitalized
    • Once stabilized, monitor every 4 to 6 weeks
    • TARGET INR is between 2 and 3 for most conditions requiring anticoagulation therapy

    TEACHING POINTS FOR Warfarin ) Consult pharmacist or practitioner for recommendations for OTC medications?
    Bleeding:? have lots of Band-Aids; use electric razors
    FOOD–drug interactions:? Be careful with diets and Vitamin K rich foods.?? Patients are often told to avoid foods high in vitamin K because of warfarin antagonism. A diet too low in vitamin K makes it MORE difficult to manage INR, because any change in dietary vitamin K can cause large fluctuations in INR. Encourage patients to eat a well-balanced consistent diet.
    Note: Warfarin patients are at the goal INR only 55% of the time (yikes!)
    –BEFAST: teach your patients signs and symptoms of a stroke, pulmonary embolism, deep vein thrombosis and heart attack:

    Signs and symptoms of a Stroke—BE FAST!
    • B -Balance: sudden loss of balance, headache, or dizziness
    • E -Eyes: trouble seeing out of one or both eyes
    • F -Face: Uneven smile or expression, facial droop or numbness in the face
    • A -Arms: weakness, numbness, one arm drifts down
    • S -Speech: slurred, mute, inappropriate words or strange speech
    • T– Time: seek help immediately. Immediately call 9-1-1.
    Signs and Symptoms of Pulmonary Embolism (PE)
    • Dyspnea: Difficulty breathing or shortness of breath. Usually sudden and severe
    • Hemoptysis: Coughing up blood
    • Diaphoresis: Abnormal?sweating
    • Cyanosis: Nails or lips turning blue
    • Tachycardia: Rapid heartbeat
    • Pain: Unexplained sharp, severe?pain in the chest?and/or back
    • Syncope: Loss of consciousness
    Signs and Symptom of Deep Vein Thrombus (DVT)
    • throbbing or cramping pain in 1 leg (rarely both legs), usually in the calf or thigh
    • swelling in 1 leg (rarely both legs)
    • warm skin around the painful area
    • red or darkened skin around the painful area
    • swollen veins that are hard or sore to the touch

    Signs and symptoms of Heart Attack in WOMEN
    Usually in female patients multiple symptoms may occur:
    • Chest pain: or fullness in the chest (an elephant sitting on my chest!)
    • Nausea or stomach pain: feeling like the need to vomit. More commonly seen in women
    • Anxiety: feeling like something is wrong, but cannot put your finger on it
    • Arm pain: pain in the arm, leg, or jaw. A woman may feel numbness radiating down the left arm, and this pain or sensation can pread elsewhere in the body, especially the shoulders
    • Dyspnea: shortness of breath or difficulty with breathing
    • Cold sweats: resulting in cold clammy skin
    • Dizziness: sudden onset of lightheadedness, room spinning is usually combined with other symptoms on this list
    • Extreme fatigue: unexpected sluggishness or exhaustion
    • Heart palpitations: heart skips a beat or fluttering sensation

    Signs and symptoms of Heart Attack in Men
    Usually in male patients the following symptoms occur:
    • Pain or tingling in back, neck, shoulder, or jaw
    • Chest pain
    • Sweating
    • Shortness of breath

    The history of the discovery and marketing of warfarin (Coumadin®) is a most fascinating story that begins in the pastures of the northeast:

    Numerous cows in the 1920’s died after routine minor surgical procedures such as castration or dehorning. A Canadian veterinarian named Frank Shofield astutely reasoned that this hemorrhaging could be attributed to animals that ate silage that had rotten sweet clover.? This hemorrhaging became known as “sweet clover disease.”

    Dr Karl Paul Link, a chemist from Wisconsin, started his own investigation into the curious problem in 1933. He published an article in Circulation describing the effects of the rotted sweet clover. Dr Link’s work was supported by the Wisconsin Alumni Research Foundation (WARF), which is the root name for warfarin.? Dr Link’s student Harold Campbell isolated the anticoagulant dicoumarol in 1939.?At first this compound was sold as a rat poison, and it wasn’t until the 1950’s that Endo Pharmaceutical began marketing warfarin for human use.

    While on vacation in 1955, President Eisenhower was given warfarin after a heart attack, which vaulted this drug to national prominence.? Warfarin poisoning was also postulated to have caused the cerebral hemorrhage and gastrointestinal bleed that lead to the demise of Russian dictator Josef Stalin.

    My daughter Gretchen gave me a 1959 drug handbook, which listed the available strengths of Coumadin as 1mg, 5mg and 25mg!

    Have a great day on the bench!!

    December 2020

    Micro-Learning CE Associated - Click Here For Details

    A Overview of Heparin and Low Molecular Weight Heparins

    HEPARIN First available 1936
    Mechanism of Action: derived from bovine lung or porcine intestinal mucosa. Heparin binds to Antithrombin III and results in an inactivation of clotting factors IXa, Xa, XIIa and Thrombin (IIa). By inactivating thrombin, it inhibits the thrombin induced factors V and VIII. Not only does Heparin prevent the growth and propagation of the formed thrombus, but it also allows the patient’s own thrombolytic system to degrade the clot. Heparin may also have a direct effect on thrombolysis.

    Dosage: each hospital develops its own nomograms that are specific for the reagent and instrument used to validate that nomogram. Is administered IV or SC.
    Adverse effects & contraindications: bleeding is the primary adverse effect. Watch for nosebleeds, hematuria, or tarry stools. Minimal renal elimination, can be used for renal insufficiency or renal failure.

    HIT: Most common cause of DRUG INDUCED neutropenia. Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of exposure to heparin (ie, unfractionated heparin, low molecular weight [LMW] heparin) that occurs in up to 5 percent of patients exposed, regardless of the dose, schedule, or route of administration. More common with heparin.

    Reversal: Protamine sulfate 1% solution will neutralize heparin. Each mg of protamine neutralizes about 100 USP heparin units. Works in 5 minutes and is active for 2 hours. Should give via slow IV infusion over 10 minutes. Heparin also has a very short half-life of 60-90 minutes.

    Contraindications:
    • Use caution with elderly women; they are twice as likely to experience major bleeding than men.
    • Severe uncontrolled hypertension is a contraindication.
    • Pregnancy category-C

    Drug interactions: interactions do occur with NSAIDS, digitalis etc. Since tight monitoring is required, dosage adjustments are easily made.

    Drug monitoring: most common: APTT (Activated Partial Thromboplastin Time), is widely used, quickly done and reproducible. Do APTT six hour after bolus dose, or after any dosage change then every 6 hours until a therapeutic APTT is reached. Then evaluate every 24 hours. APTT= normal range is 25-35 seconds. Ranges vary from lab to lab. Heparin induced APTT is 1.5 to 2.5 times normal.


    LOW MOLECULAR WEIGHT HEPARINS (LMWH)

    Enoxaparin (Lovenox®) approved 1993
    injection 30mg/0.3ml, 40/0.4ml, 60/0.6ml, 80/0.8ml, 100/1ml, 120/0.8ml, 150/ml & 300mg/3ml

    Mechanism: inhibits factor IIa and to a much greater extent Xa.
    • DVT surgical prophylaxis: (dose dependent on surgical site)
    • DVT treatment with or without PE:
    • Outpatient treatment: patients with acute DVT without PE who can be treated at home. Typical outpatient dose: is 1mg/kg subcutaneously every 12 hours.
    Adverse effects & contraindications: minor bleeding, gingival bleeding, watch for GI or urogenital bleeding.

    Reversal: Protamine: give 1mg for every 1mg of enoxaparin. Protamine neutralizes only 60-75% of antithrombotic activity. Not recommended if LMWH was given more than 12 hours earlier.

    Pregnancy category B. LMW does not cross placenta. Appears to be safe to use during pregnancy. Good alternative to heparin when long term anticoagulation is necessary.

    Caution with NSAIDS, they can increase bleeding.

    Drug Monitoring: because of predictable responses, routine monitoring of APTT is not necessary. Have baseline PT, CBC, Creatinine then periodic monitoring of platelets and fecal occult blood. Patient education: (enoxaparin)
    • Contact practitioner if bleeding, bruising, dizziness itching, rash or fever occurs
    • Injections are given around the navel, upper thigh, or buttocks. Change site daily
    • Inject under skin not into muscle
    • If excessive bruising occurs at injection site it may be lessened by an ice cube massage on the site prior to injection.
    NOTE: other low molecular weight heparins are available, but enoxaparin (Lovenox®) is the most commonly used. Here are the others:
    • Dalteparin (Fragmin®)
    • Tinzaparin (Innohep®)
    • Fondaparinux (Arixtra®)


    Have a great day on the bench!!

    Micro-Learning CE Associated - Click Here For Details

    A Broad Overview of Antiplatelet Therapy

    ASPIRIN (patented: 1899)
    Mechanism: Acetylation of platelet cyclooxygenase prevents synthesis of Thromboxane A2, (a prostaglandin derivative) which is a potent vasoconstrictor, and inducer of platelet aggregation and platelet release reaction. Aspirin inhibits platelet aggregation for the life of the platelet (7 to 10 days).

    Men benefit more: cardiovascular protection
    Women benefit more: stroke prevention

    Dosage: American Heart Assn. Recommends 75mg to 325mg/ day
    Adverse effects & contraindications: GI bleeding. Avoid with asthma.
    Drug interactions: Warfarin (however, this may be beneficial)
    Drug monitoring: check for signs and symptoms of bleeding such as dark stools
    Patient education: Take with food. Use enteric coated tablets. Take low dose


    Thienopyridines
    Mechanism: inhibits platelet aggregation and activation by blocking the P2Y12 adenosine diphosphate (ADP) receptor on the platelet surface. This inhibition is irreversible and lasts throughout the lifespan of the platelet (5-7 days).

    Clopidogrel (Plavix®)
    75mg tablets (FDA approved 1997)
    Dosage: one tablet (75mg) daily, with or without food.
    Clopidogrel is a pro-drug needing activation by the CYP450-2C19 pathway.
    • Indicated for recent MI, or stroke, or established peripheral arterial disease. Reduces the rate of new ischemic stroke, new MI and other vascular deaths.
    • Acute coronary Syndrome (ACS): for patients with acute coronary syndrome (unstable angina, non-Q-wave MI) including patients who are managed medically and those to be managed with percutaneous coronary intervention (with or without stent) or Coronary Artery Bypass Grafting (CABG)
    Mechanism: inhibits platelet aggregation for the life of the platelet (5-7 days)
    Adverse effects: increased bleeding risk
    Contraindications: active bleeding (GI) or intracranial hemorrhage
    Drug interactions: administer with caution for NSAID patients (increased GI bleeding risk)
    • About 30% of Caucasians are poor CYP450- 2C19 metabolizers
    • Omeprazole (Prilosec®) blocks this pathway and may reduce effectiveness of clopidogrel. Pantoprazole (Protonix®) is the least likely in this drug class to interact
    Patient education: Discontinue 7-10 days before surgery if so directed. Most clinicians when combining with aspirin, will use the 81mg (low dose).

    In some cases, there is no benefit to aspirin/clopidogrel than aspirin therapy alone:
    • Cardiovascular risk factors only: aspirin + clopidogrel: combo NOT beneficial
    • Established cardiovascular disease: aspirin + clopidogrel: combo NOT beneficial
    • Acute coronary syndrome: aspirin + clopidogrel: combo is beneficial
    • After a stent: aspirin + clopidogrel: combo is beneficial

    Prasugrel (Effient®)
    FDA approved in 2009. Prasugrel seems to be more effective than clopidogrel for reducing cardiovascular events in some acute coronary syndrome patients undergoing angioplasty. Carries a higher bleeding risk than clopidogrel.

    Compared to clopidogrel:
    • Higher bleeding risk. Avoid in patients with prior TIA or prior stroke.
    • Not affected by 2C19 activation (minimal drug interactions with omeprazole)
    • Combine with aspirin after angioplasty
    • Avoid if over 75, unless high risk
    • More effective than clopidogrel after angioplasty-more bleeding!
    • Discontinue 7 days before surgery
    Dosage: 5mg per day if under 60kg / 10mg if over 60kg


    WHEN A PATIENT RUNS OUT OF REFILLS. MAJOR RISK!!

    What about STOPPING aspirin, clopidogrel, prasugrel, and ticagrelor? The first challenge is no clear evidence determines the most effective duration for dual antiplatelet therapy (DAPT) after drug-eluting stents.

    Risk of stopping aspirin, clopidogrel, or other antiplatelet drugs too soon:
    NOTE: serious consequences can occur for patients on aspirin for secondary prevention, or on aspirin plus clopidogrel for acute coronary syndrome or after a stent, if they stop their drug therapy too soon.

    Platelet rebound effect-Stopping Aspirin therapy:
    • Stopping aspirin even short-term may increase the risk of heart attack and stroke possibly due to a rebound effect.
    • Stopping aspirin seems to stimulate the production of new platelets and increase binding of fibrinogen. This rebound effect lasts at least 8 to 10 days after stopping therapy.
    • More surgeons will continue aspirin if bleeding risk is low especially if the patient's risk of thrombosis is high.
    • Aspirin prevents clotting while it is being taken, but abruptly stopping it triples the risk of stroke and increases the risk of other cardiovascular adverse effects.
    • Stopping aspirin in patients with a prior MI leads to 4 extra MIs per 1000 patients per year.
    • Stopping clopidogrel (Plavix®) within 30 days after a drug-eluting stent results in 25% of patients having a stent thrombosis instead of just 1%.
    • For stents, continue aspirin plus clopidogrel (Plavix®), prasugrel (Effient®), or ticagrelor (Brilinta®):
      • 30 days after a bare metal stentl
      • 1 year after a drug eluting stent
      • Many clinicians will keep patients on dual therapy longer if the bleeding risk is low

    CONTINUE ASPIRIN INDEFINITELY!
    • Surgery: If the drug must be stopped, stop clopidogrel, ticagrelor, or aspirin 5 days prior and prasugrel 7 days before surgery. Continue aspirin for all but the riskiest surgery.

    TALKING POINTS, WE WANT TO SHARE WITH OUR PATIENTS:
    • Adherence is critical for all antiplatelet therapy. Triple risk of heart attack if stopped too soon.
    • Aspirin is serious medicine, do not stop without talking to your doctor


    Aspirin is serious therapy. As such, prescribers are encouraged to actually write prescriptions for aspirin therapy. First, prescribed aspirin therapies are covered on many state Medicaid programs. Secondly, it underscores the importance of this therapy and provides valuable adherence data with respect to refills.

    I often wonder how long it would take to get Aspirin through the FDA approval process today, given its side effect profile. Most pharmacists are aware that Aspirin is really the trade name that Bayer gave acetyl salicylic acid, which had its origins from willow bark. Interestingly enough, aspirin came onto the market one year after heroin was marketed, also by the Bayer company in Germany.

    Have a great day on the bench!!

    Micro-Learning CE Associated - Click Here For Details

    An Overview of Platelets and Coagulation

    Antiplatelet Therapy
    As pharmacists, we provide prescription therapy directed at clot prevention. Many of us older pharmacists remember a 60-Minute “hatchet job” done to our profession in the 1980’s when a staged patient was buying a bottle of aspirin, while the pharmacist dispensed his warfarin prescription.

    I remember an expert saying that this was a big “no-no”. We all learned in pharmacy school that warfarin and aspirin should never be given together… those were the days!! Today, it is rather commonplace to see triple therapy consisting of an anticoagulant, and two antiplatelets (aspirin/clopidogrel). It just depends on the source of the clot.

    TRIPLE THERAPY for ANTI-COAGULATION
    Some older patients are at higher risk for conditions that require two antiplatelet drugs plus anticoagulation.

    An example of such a patient:
    • coronary stent patient (needs Aspirin + clopidogrel (Plaxix®)
    • plus has atrial fibrillation or mechanical valve or Venous thromboembolism (VTE) (needs Warfarin)


    In this case, TRIPLE therapy is warranted because there are 2 different kinds of clots:


    White clot:
    • Mostly platelets
    • Usually forms in the arteries (high pressure)
    • Use antiplatelet therapy such as Aspirin, Clopidogrel, prasugrel, or ticagrelor
    • Protective against MI and stroke
    Red clot:
    • Rich in red blood cells and fibrin
    • Usually forms in the veins or atrium (low pressure)
    • Use Anticoagulant therapy such as warfarin
    • Protects against DVT (deep vein thrombosis) and PE (pulmonary emboli)


    PLATELETS: stop the bleeding!
    Platelets initiate hemostatic mechanisms that repair injured blood vessels. The platelet is a circulating disc-shaped cell that does not contain a nucleus. Many references refer to them as “blood cell fragments.”

    ROLE OF PLATELETS: As pharmacists, we provide prescription therapy directed at clot prevention. Many of us older pharmacists remember a 60-Minute “hatchet job” done to our profession in the 1980’s when a staged patient was buying a bottle of aspirin, while the pharmacist dispensed his warfarin prescription.

    Activated platelets do the following:
    • Adhesion to the site of injury
    • Activation and secretion
    • Aggregation- form clumps to “plug the leaks”
    • Interaction with coagulation factors especially with factor VIIa to promote local coagulation, and ultimately the generation of thrombin, the most potent of the platelet agonists.
    Antiplatelet mechanisms of action… ways to block platelet activity:
    • Blocking the thrombin receptor (PAR-1): think vorapaxar (Zontivity®), which was removed from the US market
    • Blocking ADP binding at the P2Y1 and P2Y12 receptors: think clopidogrel (Plavix®), prasugrel (Effient®) and ticagrelor (Brilinta®)
    • Blocking prostaglandin synthesis: think aspirin and other non-selective COX-1 inhibitors
    • Blocking cyclic AMP: think dipyridamole

    How many?
    A normal platelet count ranges from 150,000 to 450,000 platelets per microliter of blood.
    • Having more than 450,000 platelets is a condition called thrombocytosis or thrombocythemia
    • Having fewer than 150,000 is known as thrombocytopenia.


    Last week my 4-year-old grandson Luke and I were out for a walk. He said, “Let’s take a shortcut over to the other road.” We walked through some brush, and Luke got scratched by a briar. He looked at his scratch and saw the blood and said, “We need to go home and have Mom put a Band-aid on it.”

    I told him, “You’ll be fine; your platelets will take care of it.” He asked me what a platelet was, and I explained that was like your body’s own Band-aid that stops the bleeding. For the next 3 days we watched every platelet video on YouTube! He sustained another scratch, and told me it was so big that he needed “two platelets” to fix it… I guess my Band-aid analogy painted the wrong picture.

    We are beginning to cover Cardiology meds, which would seem appropriate given the sudden interest in platelets in my family!

    Have a great day on the bench!!

    Micro-Learning CE Associated - Click Here For Details

    An Overview of Herpes and Zoster Treatment

    Acyclovir (Zovirax®)
    Available as: capsules 200mg; tablets 400mg & 800mg and 200mg/5ml
    Mechanism: requires 3 phosphorylation steps for activation. Is selectively activated and accumulates only in infected cells. It inactivates DNA polymerase.
    Indication for Use:
    • Initial and recurrent HSV I and II
    • Treatment of herpes Zoster (shingles)
    • Treatment of varicella (chickenpox)
    • IV used for treatment of herpes simplex encephalitis, neonatal HSV and serious HSV or VZV infections
    Dosages:
    • Initial genital: 400mg 5 times daily for 7-10
    • Mucocutaneous oral labial: 400 mg 5 times daily for 5 days
    • Recurrent: 800mg three times daily for 2 days or 400mg three times daily for 5 days
    • Suppression: 400mg twice daily
    • Zoster: 800mg 5 times daily for 7 days. (start within 24 hours of rash)
    • Varicella: 20mg/kg (800mg MAX) four times daily for 5 days. (generally, treatment not recommended)
    Warnings/Precautions:
    • Pregnancy: Category-B
    • Treatment for Zoster is MOST effective when initiated within 48 hours of onset of rash. After 72 hours of onset, minimal benefit.
    • Renal impairment: dosage adjustment required
    Adverse Effects:
    • Photosensitivity may occur
    • Stevens-Johnson syndrome
    • GI: diarrhea and nausea
    Drug Interactions:
    • May elevate theophylline
    • May lower levels of Phenytoin and Valproic acid
    Patient Education:
    • Avoid sexual intercourse when visible herpes lesions are present.
    • Oral Acyclovir does NOT eliminate latent HSV, and is not a cure
    • May cause photosensitivity, wear sunscreens and protective clothing.
    • May take with or without food


    Famvir® (Famciclovir)
    Available as: tablets 125mg, 250mg & 500mg
    Mechanism: Gets bio-transformed to penciclovir which is active against HSV I & II, and VZV. Inhibits viral DNA synthesis.
    Indication for Use:
    • Zoster: 500mg every 8 hours for 7 days
    • Recurrent genital herpes: 1GM twice daily for 1 day
    • Herpes Simplex (oral or genital) 250mg three times daily for 7-10 days
    • Suppression: 250mg twice daily for up to 1 year
    • Mucocutaneous oral labial: 500mg twice daily for 7 days
    • Famciclovir has been approved as the first and only antiviral to shorten duration of cold sore outbreak with a single dose:
    Dosage: Famciclovir 500mg: Three tablets (1500mg) as a single dose at earliest sign or symptom of a cold sore.

    Warnings/Precautions:
    • Pregnancy: Category-B
    • Initiate therapy ASAP
    Adverse Effects:
    • Headache
    • Nausea & vomiting
    Patient Education:
    • Initiate therapy ASAP (within 6 hours of outbreak)
    • May take with or without food

    Epithelial Keratitis dosing for oral antiviral agents.
    Click Here for AAO Treatment Guide
    • Acyclovir (Zovirax®): 400mg 3-5 times daily for 7-10 days OR
    • Valacyclovir (Valtrex®): 500mg twice daily for 7-10 days OR
    • Famciclovir (Famvir®) 250mg BID for 7-10 days


    Viruses are non-living particles that require a host cell in order to replicate. They must be inside a host cell to cause infection, by overtaking that cells ‘machinery’. The virus is surrounded by a protein coat or capsid and contains only a few dozen genes either in the form of RNA or DNA that contain the information necessary for replication.

    Some viruses such as the common cold are self-limiting, resolving in 7 to 10 days. Other viruses such as HIV can cause serious and sometimes fatal disease and require aggressive therapy. Challenges in drug therapy are due to rapid mutation which can quickly render drugs ineffective. Due to the intracellular nature of the viruses, it is difficult for medications to find their “targets” inside normal living cells.

    Depending upon whether the HSV-1 virus attacks the oral mucosa, or HSV-2 attacks the genital mucosa, the doses for the three antivirals are different.

    For Zoster (shingles), caused by a varicella virus, think highest dose for longest duration. Most important with the treatment of these viral infections, start treatment early, ideally within 48 hours of onset of symptoms.

    Didn’t you forget something?? Topical treatment of Herpes infections.
    The short answer is no I didn’t. All of the topical products whether for cold sores, genital herpes or herpes eye infections are expensive and need to be applied frequently, at least 5 times per day.

    With the oral dosage forms being available as generics, there is no need whatsoever to prescribe these less than effective and overpriced products.

    Have a great day on the bench!!



    November 2020

    Micro-Learning CE Associated - Click Here For Details

    An Overview of Influenza Treatment

    TREATMENT OF ACUTE FLU

    ADAMANTANES
    • Amantadine (Symmetrel®) not recommended
    • Rimantadine (Flumadine®) not recommended
    At one time these drugs were recommended for treatment of Influenza-A. Since 2006, the CDC has not recommend using these drugs due to resistance to Type-A flu strains.

    NEURAMINIDASE INHIBITORS

    Zanamavir (Relenza®) approved July 1999 (WAC=$59.00)
    Mechanism:
    inhibits neuraminidase, with the possibility of alteration of virus particle aggregation and release.

    Indications for use:
    Treatment of both Type A and Type-B influenza. Will decrease symptoms by 1.3 days if started within 48 hours of viral symptoms.

    Warnings / Precautions / Adverse effects:
    May see pulmonary effects in asthma and COPD patients. Have albuterol ready for rescue as this drug may induce bronchospasm. Not recommended for this patient group. May see mild gastrointestinal distress such as nausea, vomiting and diarrhea.

    Patient Education:
    • If asthmatic or COPD, have Albuterol inhaler ready.
    • Instruct patient on use of delivery system.
    • Must complete 5-day course even is symptoms disappear
    • Does not reduce the transmission of virus to others.
    • Take 2 doses first day of treatment, if there are 2 hours between doses. Then every 12 hours.

    Representative Products:
    Relenza® (zanamivir) diskhaler: Adults: 2 inhalations twice daily. Age 7 years to adult.

    OSELTAMIVIR (Tamiflu®) approved 1999
    Mechanism:
    Inhibits neuraminidase, with the possibility of alteration of virus particle aggregation and release. Is a prodrug, is pharmacologically similar to zanamivir

    Indications for use:
    Influenza type A and B. Begin within 48 hours of symptoms. May reduce symptoms by 1 day.

    Warnings / Precautions / Adverse effects:
    Nausea, vomiting, vertigo and insomnia

    NOTE: CDC warning: November 13, 2006
    The FDA approved a labeling supplement to include a precaution about neuropsychiatric events for Tamiflu®. Self-injury and delirium have been observed in Japan primarily among pediatric patients. Monitor pediatric patients for signs of unusual behavior.

    Patient Education:
    Start therapy as soon as possible.
    Not a substitute for the vaccine

    Representative Products:
    Tamiflu® 75mg capsules and powder for suspension 12mg/mL (available generically) Adults: 75mg twice daily for 5 days.
    Adults: 75mg twice daily for 5 days.
    Children: based on body weight:
    • If younger than 1 yr old: 3 mg/kg/dose twice daily

    If 1 yr or older, dose varies by child’s weight:
    • 15 kg or less, the dose is 30 mg twice a day
    • >15 to 23 kg, the dose is 45 mg twice a day
    • >23 to 40 kg, the dose is 60 mg twice a day
    • >40 kg, the dose is 75 mg twice a day


    CHEMOPROPHYLAXIS with Tamiflu and Relenza
    FormulationsAdult DosePediatric dose
    Oseltamivir (Tamiflu)30,45,75mg caps and 6mg/ml oral suspProphylaxis: 75mg/day Treatment: 75mg BIDProphylaxis: 30-75mg/day Treatment 30-75mg BID
    Zanamivir (Relenza)5mg/blister inhalerProph: 2 inh once daily Treat: 2 inh BID x5Proph: over 5yrs: 2 inh QD Treat over 7 yo: 2 inh BID

    COST of Tamiflu: $180.00/ 10 capsules 75mg
    Cost of generic (oseltamivir): $40.00/10 caps 75mg


    Baloxavir marboxil tablets (XOFLUZA® ) approved 2018 Cost: $180.00/dose
    Mechanism of action:
    is a polymerase acidic (PA) endonuclease inhibitor, an influenza virus-specific enzyme in the viral RNA polymerase complex required for viral gene transcription, resulting in inhibition of influenza virus replication

    Indications for use:
    for the treatment of acute uncomplicated influenza in patients 12 years of age and older who have been symptomatic for no more than 48 hours. Shortens flu symptoms versus placebo by about one day.

    Dose:
    Take a single dose of XOFLUZA® orally within 48 hours of symptom onset with or without food
    • 80kg and over: take 80mg dose.
    • 40kg-80kg: take 40mg as a single dose.
    • On average, patients recovered from flu symptoms in 2.3 days---(54 hours versus 80 hours) by about one day.
    • Does not reduce the transmission of virus to others.
    • Reduces viral load faster than oseltamivir, but not sure that reduces spread of flu.

    Warnings / Precautions / Adverse effects:
    • No changes at QT interval, even at twice the dose.
    • Avoid co-administration of XOFLUZA® with dairy products, calcium-fortified beverages, polyvalent cation-containing laxatives, antacids, or oral supplements (e.g., calcium, iron, magnesium, selenium, or zinc).
    • The dose of XOFLUZA® depends on weight
    • Avoid if pregnant
    • Reduces viral load faster than oseltamivir, but not sure that reduces spread of flu.


    CANDIDATES for PHARMACOLOGICAL TREATMENT (per 2018 IDSA guidelines)

    HIGH RISK PATIENTS:: Clinicians should start antiviral treatment as soon as possible for adults and children with documented or suspected influenza, vaccinated or not, who meet the following criteria:
    • Persons of any age who are hospitalized with influenza.
    • Outpatients of any age with severe or progressive illness, regardless of illness duration.
    • Outpatients who are at high risk of complications from influenza, including those with chronic medical conditions and immunocompromised patients. Think diabetes, obesity, chronic kidney disease, chronic heart disease, chronic lung disease (asthma, COPD)
    • Children younger than 2 years and adults ≥65 years.
    • Pregnant women and those within 2 weeks postpartum

    LOW RISK PATIENTS:: Outpatients with illness onset ≤2 days before presentation (C-I).
    • Symptomatic outpatients who are household contacts of persons who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III).
    • Symptomatic healthcare providers who care for patients who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised

    NON-PHARMACOLOGICAL TREATMENT MEASURES
    (Of course, PREVENTION is the best approach)
    • Vaccination: best if given in October and November
    • Avoid close contact with sick people
    • Stay home if you are sick
    • Cover mouth and nose when coughing or sneezing
    • Wash your hands---OFTEN! Viruses can survive on surfaces for 2-8 hours.
    • Avoid touching eyes, nose, mouth
    • Looks like we need to add masking and social distancing to this list given the low transmission rate in the Southern Hemisphere in 2020.

    TREATMENT MEASURES
    • Bedrest
    • Fluids
    • Humidification of air

    PHARMACOLOGICAL MANAGEMENT
    • Cough suppressants, analgesic. Symptom management.
    • Absolutely no aspirin in patients under age 18.

    We’ve seen a significant decrease in the influenza spread in the southern hemisphere, most likely due to social distancing, masking, working from home and on-line learning. All of the efforts made to decrease the spread of the COVID-19 virus are greatly impacting the spread of the seasonal influenza virus. Patients seem a lot more interested in getting their flu vaccinations this year. I’ve noticed a huge uptick in patient who were “first timers”.

    Many universities will end their fall term before Thanksgiving, and the students will not return to campus until 2021. This should greatly help decrease the “holiday germ exchange” where students would go home collect their Thanksgiving germs, bring them back to campus, spread them around, and everyone could bring home fresh germs for Christmas.

    All of the efforts made to decrease the spread of the COVID-19 virus are greatly impacting the spread of the seasonal influenza virus. Patients seem a lot more interested in getting their flu vaccinations this year. I’ve noticed a huge uptick in patient who were “first timers”.

    Finally, some good news for 2020! But patients will inevitably be diagnosed with influenza in the coming season. So, what do we do?

    Have a great day on the bench!!

    Micro-Learning CE Associated - Click Here For Details

    Flu shots? Did you get yours?

    Who should get the flu vaccine?
    That’s easy… virtually everyone from age six months and up, regardless of pregnancy status. Patients with laboratory confirmed COVID 19 infection, symptomatic or not, should not get the influenza vaccination until they are no longer acutely and do not require isolation.

    On average, about 45% of the United States citizens get their annual flu shot.
    Healthcare workers: last year 80.6% of all healthcare workers got the vaccine. By occupation, flu vaccination coverage was highest among physicians (98%), nurses (92%), pharmacists (90.6%), and nurse practitioners and physician assistants (88.8%). (source: CDC.gov)

    Efficacy of last year’s vaccine:was estimated to be 45% with 50% accuracy for the Influenza-B and 37% for Influenza-A

    For 2020-2021, trivalent (three-strain) egg-based vaccines are recommended to contain:
  • A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09-like virus (updated)
  • FA/Hong Kong/2671/2019 (H3N2)-like virus (updated)
  • B/Washington/02/2019 (B/Victoria lineage)-like virus (updated)

  • Quadrivalent (four-strain) egg-based vaccines, which protect against a second lineage of B viruses, are recommended to contain:
  • the three recommended viruses above, plus B/Phuket/3073/2013-like (Yamagata lineage) virus. (remains unchanged from 2019-2020 vaccine)


  • US DRUG NAMES (egg based):Afluria Quadrivalent; Fluad Trivalent; Fluad Quadrivalent; Fluarix Quadrivalent; Flucelvax Quadrivalent; FluLaval Quadrivalent; Fluvirin; Fluzone High-Dose; Fluzone Quadrivalent

    For 2020-2021, cell- or recombinant-based vaccines are recommended to contain:
    • A/Hawaii/70/2019 (H1N1)pdm09-like virus (updated)
    • A/Hong Kong/2671/2019 (H3N2)-like virus
    • B/Washington/02/2019 (B/Victoria lineage)-like virus
    • BB/Phuket/3073/2013-like (Yamagata lineage) virus

    There are two egg-free vaccines available in the US. Flublok Quadrivalent is recombinant and Flucelvax Quadrivalent is cell-based.


    Flu vaccines for patients over age 65:
    • Fluzone High-Dose Quadrivalent® contains four times the amount of antigen as the standard-dose inactivated flu vaccine, producing better protection in the elderly population. In a NEJM study Fluzone High Dose was found to be 24% more effective in preventing flu in adults 65 years and older relative to a standard-dose vaccine.
    • FLUAD® Influenza Vaccine, Adjuvanted: For active immunization of persons 65 years of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine. (Source: fda.com) Medicare beneficiaries 65 years and older found that trivalent FLUAD provided greater protection against flu-related hospitalizations than standard-dose, egg-based flu vaccine.

    Adjuvants are ingredients of a vaccine that elicits a more robust immune response. Adjuvants also can reduce the amount of virus needed for production of a vaccine and still give adequate immune response.


    Share the following talking points with your patients:
    • During the preparation of inactivated influenza vaccines, the vaccine viruses are made noninfectious (inactivated or killed). Therefore, it cannot cause influenza.
    • The flu vaccine is administered intramuscularly by injection.
    • The flu vaccine takes two weeks to provide a full immune response.
    • The flu vaccine is licensed for use among persons aged >6 months, including those who are healthy, pregnant, and those with chronic medical conditions.

    What will this year’s flu season look like?
    • Flu season: influenza activity remained at lower levels than expected for this time of the year, though increased detections were reported in some countries. In the temperate zones of the southern hemisphere, the influenza season remained low or below baseline. Despite continued or even increased testing for influenza in some countries in the southern hemisphere, very few influenza detections were reported.
    • In the temperate zone of the northern hemisphere, influenza activity remained below inter-seasonal levels. (Source: World Health Organization)
    • It appears that all of the mitigation efforts to stop the spread of COVID-19 are having a significant impact on influenza spread. Children naturally spread influenza, and with many of them staying at home and attending school virtually, it seems to have impact on the decreased spreading of influenza. Social distancing, wearing face masks, limiting size of gatherings and travel restrictions all have impacted the rates of influenza illness.
    Once again, I relied heavily on my daughter Dr. Gretchen Garofoli to do the proofreading and additions to this column. She does outstanding presentations for her students as well as freeCE.com.

    I was amazed that the physicians and nurses had a higher immunization rate than did the pharmacists. Whenever you call most chain pharmacies, they answer the phone “Hi this is “Big Box Drug store, we are offering flu shots.” Every pharmacy is actively promoting flu shots to their patients, with increased availability and flu shot clinics. Certainly, we as pharmacists know of the availability of flu shots.

    I’m hoping that the very mild flu season is a harbinger of what we have in the Northern Hemisphere this flu season. Most agree we need a break from viruses. Wear your mask, wash your hands, and social distance!

    As Gretchen is doing, I would encourage you to get actively in your community and pharmacies providing flu shots, especially as patients are more concerned than ever with vaccinations. Throw in a Tdap, and a pneumonia shot while you're at it!!

    Have a great day on the bench!!

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    Influenza: The Basics

    FLU SEASON: starts in October and November and greatly increases in December and January with the highest peak occurring in February in the Northern Hemisphere. Here are some flu basics that we clinicians need to become familiar with:
    • Flu is caused by an RNA virus of the orthomyxovirus family.
    • Antigenic drift: Frequent minor changes in antigenic structure of the virus. This can reach epidemic proportions, but not every year. This is what requires minor adjustments in the vaccine formulation.
    • Antigenic shift: Major change in one or both major antigens in Influenza-A resulting in different subtype. This can result in major pandemics in all ages.
    Influenza-A
    • Subtypes based on 2 surface antigens hemagglutinin (H) and neuraminidase (N).
    • Four types of hemagglutinins cause disease in humans and virus attachment to cells (H1, H2, H3, H5). There are 16 known hemagglutinin proteins (Labeled H1- H16).
    • Two types of neuraminidase cause disease in humans and have a role in viral penetration of cells. (N1, N2) There are 9 known variants of the neuraminidase proteins.
    • Causes moderate to severe disease in all ages and can be transmitted in other animals.
    • Most commonly associated with global pandemics
    • Three subtypes of Influenza A have maintained a presence in the human population:
      • H1N1, H1N2, and H3N2
      • *Note: Avian flu is the H5N1 subtype which is infamous for its transmission from infected fowl to humans.
    EGG BASED FLU VACCINE:
    For 2020-2021, trivalent (three-component) egg-based vaccines are recommended to contain:
    • A/Guangdong-Maonan/SWL1536/2019 (H1N1)pdm09-like virus
    • A/Hong Kong/2671/2019 (H3N2)-like virus
    • B/Washington/02/2019 (B/Victoria lineage)-like virus
    Quadrivalent (four-component) egg-based vaccines, which protect against a second lineage of B viruses, are recommended to contain:
    • the three recommended viruses above, plus B/Phuket/3073/2013-like (Yamagata lineage) virus.
    • US DRUG NAMES (egg based): Afluria®; Afluria Quadrivalent®; Fluad®; Fluarix Quadrivalent®; Flucelvax Quadrivalent®; Flucelvax [DSC]®; FluLaval Quadrivalent®; Fluvirin®; Fluzone High-Dose®; Fluzone Intradermal Quadrivalent®; Fluzone Quadrivalent®; Fluzone [DSC]®
    For 2020-2021, cell- or recombinant-based vaccines are recommended to contain:
    • A/Hawaii/70/2019 (H1N1)pdm09-like virus (updated)
    • A/Hong Kong/45/2019 (H3N2)-like virus (updated)
    • B/Washington/02/2019 (B/Victoria lineage)-like virus (updated)
    • B/Phuket/3073/2013-like (Yamagata lineage) virus
    The only product available for this flu season is Flublok Quadrivalent®. There are no egg proteins in this product.

    Medication Guide and/or Vaccine Information Statement (VIS) In the U.S, the appropriate CDC-approved Vaccine Information Statement (VIS) must be provided to the patient prior to administering each dose of this vaccine; VIS is available at http://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html.

    WHO IS THE ACIP?: ACIP comprises medical and public health experts. The ACIP meets three times a year to develop recommendations on how to use vaccines to control disease in the United States. The recommendations include the age(s) when the vaccines should be given, the number of doses needed, and the amount of time between doses.
    • Oseltamivir-resistant influenza A (H1N1) strains have been identified in the United States and some other countries. However, oseltamivir or zanamivir continue to be the recommended antivirals for treatment of influenza because other influenza virus strains remain sensitive to oseltamivir, and resistance levels to other antiviral medications remain high.
    Influenza –B
    No subgroups.
    Only affects humans and causes a milder disease usually in children.

    Influenza-C
    Rarely reported in humans. Does not cause significant infections in humans.

    INFLUENZA:
    • Major complication is pneumonia, Reyes syndrome, worsening of chronic bronchitis and death.
    • One of the leading causes of vaccine-preventable disease. 20-40K deaths during epidemics.
    • Rates of disease highest in elderly (over 65 years old), less than 2 years of age, and people of any age with medical conditions.
    • Penetrates the epithelial cells of the respiratory tract and destroys the host cell.
    • Virus is shed in respiratory secretions for 5 to 10 days, and transmission is through direct person to person droplet contamination or contact.
    • Incubation period is approx. 2 days
    • Clinical features: abrupt onset, fever, myalgia, sore throat, nonproductive cough, headache.
    • Disease peaks between December and March in the Northern Hemisphere.
    Comparison of Symptoms Between Common Cold and Influenza
    Symptom/ParameterCommon ColdInfluenza
    FeverUncommon (low grade)Common 100-104F
    Myalgia, arthralgiaUncommonCommon and severe
    AnorexiaUncommonCommon
    HeadacheUncommon and mildCommon and severe
    Dry coughMild to moderateCommon and severe
    Malaise and weaknessMildSevere
    Fatigue LevelMild, short livedSevere long lasting 2-3 wks
    Nasal congestionCommonOccasional
    Sore throatCommonOccasional
    Vaccine availablenoYes (yearly)
    Incubation period12 hours to 5 days (avg=2d)1-4 days (average=2 days)
    Contagious period1 day before & 5 days after1 day before & 5 days after
    ComplicationsSinus congestionBronchitis, pneumonia

    My daughter Gretchen Garofoli sits as the Coordinator of the American Pharmacists Association Immunizing Pharmacists SIG Community. She is very active at West Virginia University teaching and promoting immunization. She lectures across several platforms, especially FreeCE.com where she is their immunizing expert.

    As Gretchen is doing, I would encourage you to get actively in your community and pharmacies providing flu shots, especially as patients are more concerned than ever with vaccinations. Throw in a Tdap, and a pneumonia shot while you're at it!!

    Have a great day on the bench!!

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    Overview of Antibiotic-Induced Clostridioides difficile Infection

    C. dif infections... what a way to wrap up antibiotics!

    Clostridioides (Clostridium) difficile is an anaerobic gram-positive spore and toxin producing bacillus first discovered in 1935. In the 1970’s, its role was elucidated in antibiotic associated diarrhea. It is one of the most common and problematic nosocomial infections to contain. As “C. diff” multiplies, it produces two toxins (A and B) that cause diarrhea and colitis. 027/NAP1/BI isolates are the most virulent and produce 20 times more A and B toxins in vitro.

    Incidence: Between 2001-2010, the CDC analyzed data from 2.2 million hospital discharges. 700,000 patients were admitted for Clostridioides difficile infection (CDI) and nearly 1.5 million others acquired the infection while hospitalized for other reasons. CDIs increased from 4.5 to 8.2 per 1,000 discharges across the study period. Overall, 7.1% of infected patients died. Additionally, patients who acquired the infection while hospitalized were more than twice as likely to die than patients who were admitted for treatment of principal infection, a trend that increased during the study.

    Risk factors for developing CDAD (Clostridioides difficile associated diarrhea) include:
    • Antacid drugs (especially Proton pump inhibitors—omeprazole, esomeprazole)
    • Previous exposure to antimicrobial agents: Virtually all antibiotics have been associated with CDAD, but historically these drugs have posed the greatest risk. Aminopenicillins, cephalosporins, clindamycin and fluoroquinolones are frequently being implicated as risk factors. Fluoroquinolone administration for as short as 1-3 days whereas most antibiotics associated with CDAD take more than 3 days to occur. Remember this major side effect when counseling patients when dispensing levofloxacin (Levaquin®) ciprofloxacin (Cipro®), and moxifloxacin (Avelox®)
    Treatment of C. difficile (source: Sanford guide 2020)
    • First line: Vancomycin (Vancocin®) 125mg capsules four times daily for 10-14 days
    • Second line: Fidaxomicin (Dificid®) 200mg twice daily for 10 days (cost:$4100)
    • Third line: Metronidazole 500mg three times daily is only to be used if patient is not able to afford vancomycin or fidaxomicin
    • Adjunct therapy: Some clinicians use cholestyramine (Questran) 4gm 3 or 4 times daily to bind the toxins released by C.dif. Be sure to separate from vancomycin therapy by 2-3 hours to avoid binding.
    • Adjunct therapy: Saccharomyces boulardii (Florastar/ Stabile-GI) has the best efficacy of all probiotics for C. dif diarrhea.
    • Fecal transplant can be tried if reoccurrence, where an infusion of stool from a healthy donor is usually given rectally by enema or colonoscope. Some success has occurred when given by NG tube. Has the highest rate of efficacy.
    Zinplava® bezlotoxumab: approved 2016
    • human monoclonal antibody that binds to Clostridioides difficile toxin B, indicated to reduce recurrence of Clostridioides difficile infection (CDI) in patients 18 years of age or older who are receiving antibacterial drug treatment of CDI and are at a high risk for CDI recurrence.
    • Limitation of Use: ZINPLAVA is not indicated for the treatment of CDI because it is not an antibacterial drug. ZINPLAVA should only be used in conjunction with antibacterial drug treatment of CDI
    Prevention of Difficile:
    • Alcohol wipes and gels do not stop the spread. C. difficile is spread by spores, and the spores are relatively resistant to alcohol and other antiseptics. Wash hands with soap and water. Artificial fingernails are impossible to clean adequately, even after vigorous scrubbing or use of an antimicrobial soap. Healthcare workers are advised not to wear artificial nails, if in contact with C. dif patients.
    • Bleach wipes: good bathroom hygiene is effective in controlling C. dif. Patients should wipe down the toilet seat after each use with bleach wipes. Note that commercially available Clorox® wipes (yellow and green can) do not contain bleach. However, Clorox® “HealthCare” wipes contain bleach, and can be used for disinfection in the bathroom. See www.clorox.com for recipes to make your own solution. Don’t use paper towels, as they degrade the solution. https://www.clorox.com/resources/coronavirus/how-to-make-your-own-disinfecting-solution/
    • Antibiotic stewardship is a must! Use antibiotics only when absolutely necessary to avoid potential for C. dif.
    We pharmacists frequently dispense antibiotics, and sometimes we question the rationale. Now that the fluoroquinolones are very cheap, clinicians seem to jump on them. The current resistance rate for Strep pneumo (respiratory infections) for azithromycin (Z-pak) is around 47%. The current resistance rate for E. coli (urinary tract infections) for Trimeth/Sulfa is 21% and for Cipro/Levofloxacin is 27%.
    Besides the huge problem of antibiotic resistance, the development of Clostridioides difficile infection (CDI) is yet another problem that can be created with indiscriminate antibiotic use.

    Have a great day on the bench!!

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    Clindamycin Overview

    CLINDAMYCIN

    Mechanism:
    Binds exclusively to the 50S ribosomal subunit and suppresses protein synthesis. Clindamycin is 90% bioavailable after oral administration.

    Indications for use:
    Treatment of serious infections due to susceptible strains of streptococcus & staphylococcus. Very effective for Gram positive and Anaerobes. Penetrates well into the bone even in absence of inflammation.

    Common use: dental infections, anaerobic intra-abdominal infections, Methicillin resistant staph aureus (CA-MRSA).
    2nd choice for dental prophylaxis: adults 600mg one hour before appointment. Toxic shock syndrome: inhibits production of staphylococcal toxin associated with the toxic shock syndrome, used along with vancomycin.

    Warnings/Precautions:
    PSEUDOMEMBRANOUS COLITIS: fatal colitis characterized by severe persistent diarrhea. Toxins caused by Clostridioides difficile cause antibiotic associated colitis. When significant diarrhea occurs, STOP the drug. Don’t give anti-peristaltic meds. This condition can begin even after the cessation of Clindamycin.
    This condition is treated with Vancomycin, Fidaxomicin or Metronidazole.

    Pregnancy Category: B

    Side effects:
    Colitis & diarrhea

    Drug Monitoring:
    Watch for pseudomembranous colitis.

    Patient Education:
    Do not treat diarrhea without notifying the prescriber
    May take Clindamycin with food and full glass of water

    Most common Drugs & dosage of this class
    Clindamycin (Cleocin®)
    Available as capsules: 150mg, 300mg. Suspension: 75mg/5ml
    Suspension needs to be reconstituted. Do NOT refrigerate. Good for 14 days.
    Dosage: Serious infections: 150mg- 300mg every 6 hours
    More serious: 300mg-450mg every 6 hours.
    Child 8-16mg/kg divided in 3 or 4 equal doses.
    Dental prophylaxis: 600mg 1 hour before appointment

    Clindamycin is also used topically for treatment of acne.
    Available as 1% lotion, cream, gel and solutions. Apply twice daily.
    Also available as: Cleocin® Vaginal cream and suppositories.

    Clindamycin (Cleocin®), we learned in Pharmacy School back in the late 1970’s, was a most welcome addition to the infectious disease clinician’s armamentarium because it penetrated the vasculature of infected bone. It was pretty well elucidated at that time that there was a significant risk of Clostridioides difficile infection, and abundant caution was recommended.

    To quote the American Association of Endodontists (AAE) for patients that cannot take penicillins or cephalosporins, they offer this warning:

    “For patients with a true allergy to penicillin, the primary alternative antibiotic recommendation has changed. It is now azithromycin with a loading dose of 500 mg, and then 250 mg for four additional days.”

    “Clindamycin now has a U.S. Food and Drug Administration black box warning for Clostridioides difficile infection, which can be fatal. Therefore, it is only indicated if the patient cannot take azithromycin.”

    “For all patients on antibiotics, the antibiotic treatment is discontinued as soon as definitive treatment and improvement of the condition occurs (as short as three days), rather than to the full course of the prescription.”

    With the dental warnings from the AAE, I suspect we will be seeing a lot less oral clindamycin.

    Clindamycin, which was derived from lincomycin was approved by the FDA in the late 1960’s. Lincomycin (Lincocin®) is a natural product made by Streptomyces lincolnensis, an actinobacterium. Generic Clindamycin capsules became available in 1989.

    Have a great day on the bench!!


    October 2020

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    Role of Nitroimidazoles in Practice

    NITROIMIDAZOLES

    METRONIDAZOLE (Flagyl®) (1963)

    Mechanism:
    Disrupts structure of RNA and DNA, and cellular proteins of organism.

    Indications for use
    • Highly effective against ANAEROBES (mostly gram negative)
    • 3 types of protozoal infections: giardiasis, amebiasis, trichomoniasis
    • Clostridium difficile (C.dif) infections if cost is a concern, however we are seeing more resistance, and metronidazole is no longer considered first line therapy.
    • used in combination for H. pylori infections
    • bacterial vaginosis
    • used for intra-abdominal infections
    • “They clean-up what the big classes of drugs (FQ, ceph, pen, macrolides) miss!”
    Most common uses:
    • Abdominal infections, vaginosis, trichomoniasis, GI infections such as amebiasis, Giardia duodenalis (also termed G. lamblia) Helicobacter pylori, C.dif
    • Topical therapy can be used for treatment of acne rosacea and bacterial vaginosis
    Warnings/Precautions
    Pregnancy Category B (however, some references say don’t use 1st trimester)
    Disulfram reactions (nausea, flushing, vomiting with alcohol)
    Neurological effects (rare) seizures, peripheral neuropathy
    Headache
    Metallic taste
    Nausea, vomiting & diarrhea

    Side effects:
    Headache
    Metallic taste
    Nausea, vomiting & diarrhea

    Patient Education:
    Avoid alcohol
    Report any neurological effects to prescriber
    Complete course of therapy as prescribed
    May darken urine
    May cause unpleasant metallic taste.

    Most common Drugs & dosage of this class
    Metronidazole (Flagyl®)
    Dosage: Adult 250- 500mg every 6 to 8 hours for 7 to 10 days.
    Trichomoniasis: 1- day treatment: 2GM in one day, as a single or divided dose.
    Child dose: consult literature. Based on type of infection.

    Metrocream® & Metrogel®
    Used topically once or twice daily.
    Used for rosacea

    Metrogel Vaginal®
    Bacterial vaginosis: 1 applicatorful once or twice daily for 5 days. Be sure to specify route of administration when prescribing topical therapy.

    TINIDAZOLE (Tindamax®) 2004
    Is a second generation nitroimidazole
    Indications:
    • Treatment of trichomoniasis caused by Trichomonas vaginalis. (2GM single dose)
    • Treatment of giardiasis caused by Giardia duodenalis (also termed G. lamblia) (2gm single dose)
    • Treatment of intestinal amebiasis and amebic liver abscess caused by Entamoeba histolytica (2gm daily for 3-5 days)
    • Treatment of bacterial vaginosis (Gardnerella vaginitis) (2gm daily for 2 days)
    Side effects: like metronidazole; also avoid first trimester of pregnancy, avoid alcohol.

    SECNIDAZOLE (Solosec®) (2017)
    Indications:
    • Bacterial vaginosis. Dose one single gram packet of granules taken with food.
    Side effects: The most common side effects of secnidazole include yeast infection, headache, nausea, altered taste, vomiting, diarrhea, abdominal pain, and vaginal itching

    Note: does not seem to affect alcohol metabolism like tinidazole and metronidazole. There are no restrictions on alcohol use with secnidazole.

    Nitroimidazoles have been available since 1963. Metronidazole counseling is a must and most of us are well engrained to counsel patients about the absolute need to avoid alcohol. Often, people are bothered by the metallic taste from metronidazole.

    Even though tinidazole is available generically, and costs less than $30 per course of therapy it never got much attention, because metronidazole is so effective and cheap.

    One use of the metronidazole is for giardiasis. Giardiasis is extremely common, with 95% of all fresh surface water being contaminated. I remember as a kid going fishing with my Grandpa and we always drank out of a spring or creek, as long as it “didn’t smell bad”! Today, all fresh water needs to be purified before drinking. Here in Central Pennsylvania you’ll still see people with their plastic water jugs getting “fresh mountain spring water.” Keep the metronidazole handy!!

    Have a great day on the bench!!

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    Role of Nitrofurantoins in the Treatment of Urinary Tract Infections

    NITROFURANTOINS for UTI

    Nitrofurantoin history
    Approved by the FDA in 1953, nitrofurantoin became standard therapy for lower urinary tract infections (UTI) until the late 1970s. Other antibiotics, such as the fluoroquinolones, became available and its use decreased substantially. Since 2011, nitrofurantoin was again recommended as first-line therapy for lower UTI due to increasing resistance to fluoroquinolones.

    Mechanism
    MAY disrupt carbohydrate metabolism. May inhibit cell wall synthesis. Low doses are bacteriostatic; high doses are bactericidal. Therapeutic serum & tissue concentrations are not achieved, except in the urinary tract. Poorly absorbed. 90% is renally eliminated, achieving high urine concentrations.

    Indications for use
    Effective against many Gram (+) and Gram (-) including some strains of E.coli, P.mirab, Klebsiella, S.aureus, Enterobacter. Nitrofurantoin macrocrystals (Macrodantin®) may also be used for prevention of urinary tract infections. Dose is one capsule at bedtime or one capsule after each act of intercourse.

    Prescribing tips or more like “when not to prescribe”:
    • AVOID nitrofurantoin in patients with creatinine clearance less than 60mL/minute due to an increased risk for pulmonary toxicity, neuropathy, hepatotoxicity.
    • AVOID nitrofurantoin if early pyelonephritis is suspected, because serum concentrations doesn’t get high enough to treat systemic infections.
    • AVOID in the first trimester of pregnancy
    • AVOID last week of pregnancy due to potential for hemolytic anemia in newborn. Neonates had a higher rate of neonatal jaundice.
    • AVOID in complicated UTI
    Warnings/Precautions
    Pulmonary reactions: manifested by sudden onset of dyspnea, chest pains, cough, fever & chills. Prolonged use can cause pulmonary fibrosis.
    Hemolysis can occur if the patient is Glucose-6-phosphate dehydrogenase (G-6-PD) deficient.

    Pregnancy Category B: AVOID last week of pregnancy due to potential for hemolytic anemia in newborn.

    Side effects
    GI upset is common. Give with food.
    Headache, dizziness, confusion.
    Dermatologic: exfoliative dermatitis

    Patient Education-Nitrofurantoins:
    Complete full course of therapy.
    Take with food or milk
    May cause brown discoloration of urine
    Notify physician if breathing difficulties, skin rashes or tingling in fingers & toes.

    Most common Drugs & dosage of this class
    • MacroBid (nitrofurantoin macrocrystals monohydrate)
      Dosage: 100mg BID with food.
    • Macrodantin (nitrofurantoin macrocrystals) 50mg and 100mg
      Dosage: QID with food. (is most commonly used for Urinary Tract Infection prophylaxis)
    Other Urinary Tract Antiseptics:
    • Methenamine Hippurate (Hiprex®)- is the salt of hippuric acid and methenamine. Available as 1 gram tablets.
    • Methenamine Mandelate (Mandelamine®)- is the salt of mandelic acid and methenamine, available as 500mg and 1gm tablets. Dose 1gm four times daily.
    Mechanism: an inactive weak base, slowly hydrolyzes in acidic urine to ammonia and the nonspecific antibacterial, formaldehyde. Formaldehyde is thought to act by denaturation of protein. It becomes effective when urinary pH is less than 5.5, so frequently Vitamin-C (ascorbic acid) 4-12 grams may be given to acidify the urine and increase efficacy.

    Used only for prophylaxis of UTI, not treatment.

    Of course, I always recommend generic drugs be prescribed. However, I tell my students that this drug should be prescribed by brand name and let the pharmacist substitute to the generic equivalent.

    We frequently get prescriptions for “Nitrofurantoin macrocrystals 100mg-one capsule BID” which is Macrodantin® which is dosed four times daily, or once daily for prophylaxis. We have to call the doctor’s office for clarification.

    We also get “Nitrofurantoin Macrocrystals Monohydrate 100mg HS for prevention” which is MacroBID®, which is not used for prophylaxis, but treatment. When prescribing on an EMR or Pharmacy software it is best to search by “MacroBID®” or “Macrodantin®”

    I had not dispensed any methenamine for at least 30 years, and currently I have 2 women on this drug for prevention. For treatment/prevention of UTI, it seems the “antique drugs” are more efficacious. Our local resistance rates for nitrofurantoin for E. Coli is 7%, where the resistance to fluroquinolones is 27% and resistance to Sulfamethoxazole/Trimethoprim is 25%.

    Sanford guide recommends NOT using fluoroquinolones if resistance rates are over 10%, and not using Sulfa if the resistance rate is over 20%. At the clinic our “go to” is Macrobid® (nitrofurantoinMM) 100mg twice daily for 7 days, once the risk of pyelonephritis is ruled out.

    Have a great day on the bench!!

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    Overview of Fluroquinolones

    FLUOROQUINOLONES
    Mechanism: involves inhibition of DNA topoisomerase. Disrupts DNA cell replication.
    Fluoroquinolones are considered bactericidal.

    Indications for use:
    Excellent Gram positive & gram-negative coverage. Activity against Pseudomonas. Coverage of Anaerobes is poor.

    Warnings/Precautions:
    • May cause QT prolongation. Caution with elderly or any patient taking drugs that prolong the QTc interval. (FDA Black Box warning)
    • Photosensitivity reactions can occur. Use a sunscreen.
    • Mental health: may cause mood or behavior changes such as nervousness, confusion, agitation, paranoia, hallucinations. (FDA Black Box warning)
    • May worsen symptoms of myasthenia gravis. (FDA Black Box warning)
    • Tendonitis: may not give to patients under 18! (FDA Black Box warning)
    • Avoid in pregnant women, nursing women & children due cartilage erosion in growing bone tissue. (FDA Black Box warning) Pregnancy Category D
    • Pseudomembranous colitis (Clostridium difficile associated diarrhea) FQ have been implicated in causing surges of the highly toxic 027/BI/NAP1strain of C. dif.
    • May affect blood sugar levels, especially in diabetics (esp. renal impaired). HYPOglycemia can occur within the first 3 days. HYPERglycemia usually doesn't show up until after 3 days. Advise extra blood sugar monitoring. (FDA Black Box warning)
    • 2018: increased risk of the aorta (the main artery of body) rupturing, causing massive bleeding and potentially, death.
    Side effects: rash, urticaria, photosensitivity

    Drug Interactions:
    Do not take with antacids, multivitamins, iron, calcium, magnesium, for at least 2 hours.
    Increases theophylline levels
    May increase prothrombin time or INR (warfarin interaction)

    Patient Education:
    • Use sunscreen if outside.
    • May take with food to decrease GI upset.
    • Avoid iron, magnesium, calcium, zinc or any divalent or trivalent ions.
    • Finish the entire course of therapy.
    Most common Drugs & dosage:

    Ciprofloxacin (Cipro®) FDA initial approval 1987
    Available as: 250mg, 500mg 750mg and XR 500mg & XR 1000mg tablets

    Typical dosage: 500mg every 12 hours
    • Primary use today is for urinary tract infections, skin/soft tissue and GI infections. Not for respiratory infections. Not for gonorrhea infections.
    • Historical note: In August 2000, the FDA approved ciprofloxacin for management of postexposure inhalational anthrax. First antimicrobial drug approved by the FDA for use in treating an infection due to a biological weapon.
    Levofloxacin (Levaquin®) (FDA approved: 12/1998)
    Available as: tablets 250, 500mg & 750mg also available as liquid (25mg/ml)
    Dosage: 500mg q24 hours for 10 days
    • Can be used for both UTI and respiratory infections
    • For sinusitis, may give 750mg daily for 5 days. The higher peak concentrations of levofloxacin provide more rapid and complete killing of pathogens, which may decrease the emergence of resistance.
    • Hospital discharge: IV to PO mg for mg
    Moxifloxin (Avelox®) (FDA approved 1999)
    available as 400mg tablets
    Dose: 400mg every 24 hours
    • Little renal penetration, used only for respiratory infection, and skin and soft tissue infections. Minimal value for urinary tract infections.
    • Does NOT cover pseudomonas.
    Delafloxacin (Baxdela®) --- FDA approved 2018
    “the exception to all of the fluoroquinolone rules”
    Dosage: 450mg orally every 12 hours ($675.00/ 5 days therapy) or 300mg IV q12h

    Uses:
    • Is an anionic fluoroquinolone antibiotic for treatment of Acute Bacterial Skin and Skin Structure Infections (ABSSSI’s)
    • More active than other FQ’s against Gram positive organisms such as multi drug resistant
      Strep pneumo and MRSA (methicillin resistant S. aureus).
    • Like other FQ: May cause tendinopathy.
    • Avoid polyvalent cations with administration.
    Special Notes:
    • Does not prolong QTc interval
    • Does not cause photosensitivity
    Gemifloxacin (Factive) – FDA approved 2003
    Was used for exacerbations of chronic bronchitis but is seldom used due to causing red exfoliative rash.

    And, you seasoned pharmacists remember the FIRST fluoroquinolone:

    Norfloxacin (Noroxin®) by Merck October 1986
    Only used for urinary tract infections, rarely used today.

    FLUROQUINOLONE RESISTANCE:
    We see major resistance to fluoroquinolones. Here are some resistance stats from my backyard: Escherichia coli accounts for 75-95% of urinary tract infections.
    Streptococcus pneumoniae was a big player in the pre-antibiotic era, thanks to child immunizations it is seen less frequently. However, is the most common agent in hospitalizations.

    USA 2017UPMC Altoona
    Altoona, PA
    Mount Nittany,
    State College PA
    E. coli resistance25%27%16%
    Strep pneumo resistance1%5%0%

    Altoona, PA where I practice is a community with an older population. State College PA, home of Penn State is a more affluent, healthier, younger, and better educated community, less likely to demand or need antibiotic therapy. There is a distance of about 35 miles between the two municipalities, but a major gap in fluoroquinolone resistance.

    https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0220265
    https://www-uptodate-com
    Special thanks to Ukwen Akpoji, from the Cleveland Veterans Hospital, John Rossi from Mount Nittany and the staff at UPMC Altoona Pharmacy.

    Once again, my fellow pharmacists, including my wife Denise, were helpful in guiding me through this overview. Ukwen Akpoji, Pharm D. provided some interesting data about the prevalence of resistance in the United States. He commented, “E. coli resistance to fluoroquinolones is about 30% at our VA (we have a unique population which may not be relatable to community).” With Ukwen’s population being much older and sicker, we might expect to see even higher resistance rates in other patient populations. Is there any wonder that the Cleveland Veterans Hospital needs a pharmacist specialized in antibiotic stewardship?

    At the clinic that I staff, we have changed our protocol for treatment of urinary tract infections, making nitrofurantoin the agent of choice for uncomplicated UTI’s due to resistance as well as the significant adverse effects of the fluoroquinolones.

    I remember as a young pharmacist when Noroxin® and Cipro® became available in the late 1980’s. They were a Godsend, as the patients no longer needed to be hospitalized to be treated with aminoglycosides for Pseudomonas infections. After 30 years of use, we have seen numerous side effects that require us to reign in overuse.

    Have a great day on the bench!!

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    Overview of Sulfonamide Antibiotics

    Sulfonamides

    Sulfonamide mechanism:
    • Sulfa drugs compete with para-amino-benzoic-acid (PABA) to block its conversion to dihydrofolic acid (DHFA)
    • Trimethoprim: block conversion of dihydrofolate to tetrahydrofolate
    Bacteria are obligate folic acid synthesizers, while humans obtain folate through dietary sources.

    Septra DS®, Bactrim DS® 800/160 and Bactrim® & Septra® (single strength) 400/80
    Liquid: 200mg SMZ/ 40mg TMP

    Adults: Septra DS®, BID for 7-10 days
    Child: 40mg/kg SMZ divided BID for 10 days.

    Indications for use:
    • Acute and chronic cystitis.
    • UTI caused by E.coli.
    • Used to treat P. Carinii infections (PCP pneumonia)
    • Also, for post-transplant antibiotic prophylaxis of PCP pneumonia
    • Methicillin resistant Staph aureus
    • Upper Respiratory Infections, Acute bronchitis
    • Acute otitis media (second line)
    • Lice- the combination of topical permethrin (Nix®) and oral (TMP/SMX) was a better second line treatment for head lice infestation than was PER alone. Monitor for adverse effects
    Warnings/Precautions: sulfonamides are perhaps the most allergenic of all antibiotics.
    About 3% - 4% of patients develop allergic reactions to sulfonamide antibiotics, also popularly known as "sulfa" antibiotics.
    • Sulfonylarylamines (the sulfa antibiotics: sulfamethoxazole, sulfisoxazole) along with the HIV protease inhibitors amprenavir and fosamprenavir)
    • NONsulfonylarylamines (loop diuretics, thiazide diuretics, sulfonylureas, celecoxib (Celebrex), acetazolamide, etc)
    • Sulfonamide moiety-containing drugs (e.g., sumatriptan, sotalol, and topiramate, etc)
    NONsulfonylarylamine and sulfonamide moiety-containing drugs need NOT be routinely avoided in patients with a history of allergy to sulfonylarylamines. However, these warning flags appear on most computer systems, and gently warn patients to watch for rash etc.

    Carries the highest risk of toxic epidermal necrolysis of the antibiotic classes. Can cause Stevens Johnson syndrome, hepatic necrosis, agranulocytosis. More likely to occur in HIV patients.

    Pregnancy Category-C:
    • Avoid in the first trimester of pregnancy since trimethoprim is a folic acid antagonist, and may have an association with folate-sensitive birth defects
    • Avoid at term. Can cause jaundice, hemolytic anemia and kernicterus. Both sulfa and trimethoprim easily cross placenta. Premature infants and infants with hyperbilirubinemia.
    Glucose-phosphate dehydrogenase deficiency: Any patient with G-6-PD (glucose-6- phosphate dehydrogenase) deficiency is at increased risk for adverse effects.

    Side effects:
    Photosensitivity (wear sunscreen!)
    GI upset including Nausea, Vomiting, Diarrhea
    Crystaluria— encourage patient to drink plenty of fluids.

    Drug Interactions: (Sulfa drugs)
    Warfarin: may prolong prothrombin time---significant drug interaction (increasing warfarin effect)
    Diuretics: in elderly can cause thrombocytopenia
    Potassium: may cause elevated potassium (hyperkalemia):
    Trimethoprim is structurally like the potassium-sparing diuretic amiloride. It competitively inhibits the sodium channels of the epithelium in the distal nephron, thereby impairing renal potassium excretion.

    Drug Monitoring:
    Watch for blood dyscrasias.
    Don’t give to patients with G-6-PD deficiency
    Watch for hypersensitivity reactions
    Adjust dose for a creatinine clearance of less than 30 mL/min
    Patient Education:
    Take full course of therapy. Drink large glass of water with each dose.

    Most Common Drugs & Dosage of This Class:
    Septra SS®, Septra DS®, Bactrim SS®, Bactrim DS® are most commonly used.
    5:1 ratio SMX to TMP
    • Double strength: 800mg sulfamethoxazole +160mg trimethoprim
    • Single strength: 400mg sulfamethoxazole + 80mg trimethoprim
    • Suspension: 200mg sulfamethoxazole + 40mg trimethoprim per teaspoonful

    The sulfonamides have a most interesting history. In the 1930’s sulfonamides became popular as one of the first true antibacterial agents, an outcropping from the dye industry. Demand for this product in a liquid form was met by the Massengil company by dissolving the powdered antibiotic in diethylene glycol—anti-freeze. Lethal kidney failure ensued.

    In just two months during September and October 1937, this drug was responsible for the deaths of more than 100 people in 15 states, from Virginia to California. The drug and the deaths led to the passage of the 1938 Food, Drug, and Cosmetic Act, which increased FDA’s authority to regulate drugs. Up until that point, drugs did not need to be proven safe, just labeled correctly.

    It was not until the Kefauver Harris Amendment in 1962 that assured efficacy. It took until I was 4 years old until the government made the drug companies show that their drugs worked! The Kefauver-Harris amendments were necessary due to the thalidomide tragedy that devastated Great Britain but was never approved in the United States.

    We seasoned pharmacists remember Gantrisin® (sulfasoxazole), Gantanol® (Sulfamethoxazole) and AZO-Gantanol®(phenazopyridine/Sulfamethoxazole). Today, most of us see only Trimeth/Sulfa, which early on in my career was co-marketed by Burrough Wellcome (Septra®) and Roche (Bactrim®).

    Have a great day on the bench!!


    September 2020

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    Overview of Macrolide Antibiotics

    MACROLIDES
    Erythromycin was first isolated in 1952 from the bacteria Saccharopolyspora erythraea
    Mechanism: may be bactericidal OR bacteriostatic. It binds to the 50S ribosomal subunit of the 70S ribosomal unit, thus inhibiting protein synthesis

    Indications for use: effective against many gram-positive bacteria, including strep (Streptococcus pneumonea) Corynebacterium, Neisseria & some strains of Mycoplasma, Legionella, Treponema & Bordetella. Some penicillin-G resistant S. aureus are susceptible to erythromycins. Are preferred drugs for Mycoplasma pneumoniae, Campylobacter, Legionnaires, Chlamydia, diphtheria & pertussis.

    Most common uses: Upper Respiratory Infection, Community Acquired Pneumonia, Chlamydia, atypicals.

    Warnings/Precautions
    Gastrointestinal distress (nausea, vomiting & diarrhea) occurs with all Erythromycins
    Allergies are rare, may see skin eruptions, fever, and eosinophilia
    Cholestatic hepatitis can occur (rare)
    Hepatotoxicity can develop with estolate salts of Erythromycin
    P450 blockers (except Azithromycin). Therefore, they may increase the effects of warfarin, digoxin & theophylline, some cholesterol drugs (simvastatin, atorvastatin).

    Side effects:
    Pseudomembranous colitis
    GI upset because it stimulates GI motility & increase pain and cramping

    Drug Interactions: Erythromycin and clarithromycin are CYP-P450 inhibitors. Both are 14 membered macrolides. Azithromycin is a 15 membered ring NOT metabolized by P-450 system, but excreted in the bile and then the feces, with very little unchanged drug appearing in the urine

    Patient Education:
    Take with food
    Take course until completed
    Watch for signs of liver dysfunction (pale stools, muscle cramps, yellowing of skin etc.)

    Most common Drugs & dosage of this class:

    Erythromycin base (Erytab®) (Erythrocin®) (old drug—extremely expensive $10-$17/tablet)

    Azithromycin (Zithromax®)
    Azithromycin was discovered by Pliva a Yugoslavian drug company. Pliva cross licensed azithromycin to Pfizer who launched it under the brand name Zithromax® in 1991
    Available as tablets: 250mg & 500mg. Suspension 100mg/5ml & 200mg/5ml
    Adults:
    Zithromax TriPack: 500mg tablets – one daily for 3 days
    Zithromax Zpack 250mg: Take 2 tablets first day. Then 1 tablet daily days 2—5.
    Child: 10mg/kg on day 1 then 5mg/kg on days 2-5.
    Otitis media can be given as 30mg/kg as a single dose.
    Pregnancy Category B

    Azithromycin has a half-life of 63 hours so coverage occurs for 5 days after the last dose.
    Once day doses (1gm) are also indicated for : Chlamydia, Chancroid, Non-gonococcal urethritis. Gonococcal is a 2gm dose.
    • NOT metabolized by cytochrome-p450 enzyme system
    • No dosage adjustment needed if renally impaired
    • Caution: may prolong QT interval—caution with heart patients especially if bradycardia, or other QT-prolonging drugs.
    • RESISTANCE: is a major problem with azithromycin. The current resistance rate for Strep pneumo (respiratory infections) for azithromycin (Z-pak) is around 47% in Altoona, PA.
    Clarithromycin (Biaxin®)
    Clarithromycin was developed by scientists at the Japanese drug company Taisho Pharmaceutical in the 1970s. Clarithromycin was developed to overcome the acid instability of erythromycin.
    Available as tablets: 250mg, 500mg and XL-500mg. Suspension 125 & 250/5cc
    Adults: 500mg twice daily with food or Biaxin XL 500mg: 2 tablets once daily.
    Child: 15mg/kg/day divided twice daily, every 12 hours for 10 days. Nasty bitter taste.

    Pregnancy Category: C
    ** more effective than Erythromycins against staph & strep. Also effective against Toxoplasmosis & Cryptosporidium species.
    Given with lansoprazole & omeprazole to eradicate Helicobacter pylori.
    • Cut dose in half if creatinine clearance is less than 30ml/min
    • Causes metallic taste in mouth
    • Caution: may prolong QT interval—caution with heart patients especially if bradycardia, or other QT-prolonging drugs.
    POTENT blocker of CYP450-3A4, and P-glycoprotein
    Increases warfarin (Coumadin®) levels—may cause increased bleeding risk.

    I remember in pharmacy school (now 40 years ago) one of my professors saying that the safest group of drugs were the erythromycins. They were reportedly “easy to dose, did not have drug interactions and didn’t cause resistance!” One out of three is correct.

    Macrolide resistance is a real problem. I spend a fair amount of time discussing macrolide resistance with my students, because azithromycin is “designed” to cause resistance.

    The package insert states that it is 5 days’ worth of meds that fights infections for 10 days. Using our simple pharmacokinetics, we see that after 10 days, the azithromycin levels would fall below the minimum inhibitory concentration (MIC), which is where resistance occurs.

    Since azithromycin has a half-life of 63 hours, and it takes 5 half-lives to get to a negligible amount, it would take 13 days after the last dose (day-5) to have a negligible amount (day-18). At a minimum, the levels of azithromycin fall under the MIC for at least 8 days! Simple pharmacokinetics show us why it is a flip of the coin whether an azithromycin pack will benefit our patients.

    Have a great day on the bench!!

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    Tetracycline Overview

    TETRACYCLINES

    Mechanism: Tetracyclines are bacteriostatic. They inhibit bacterial protein synthesis, working on ribosomal RNA.

    Indications for use:
    Covers most staph & strep strains, enterics, mycoplasma, spirochetes, rickettsiae, Chlamydia

    Drug of choice: acne & chlamydia, Rocky Mountain Spotted Fever, and Borrelia burgdorferi (Lymes)
    Doxycyline is approved for malaria prophylaxis.
    Doxycyline is less nephrotoxic and may be preferred in patients with renal disorders, as the drug is almost entirely excreted through the feces.
    Both Minocycline and Doxycycline are long acting with a half-life of 16 hours.

    Warnings/Precautions:
    • do not give with antacids, calcium, iron. (drug will not get absorbed)
    • photosensitivity
    • dental staining (not to be used in prepubertal children) ***
    • do not use in pregnant women or if breast feeding
    • May cause pseudotumor cerebri, a condition in which intracranial pressures increase
    Drug Interactions: any divalent or trivalent cations (magnesium, calcium, iron etc)
    • Decreases effectiveness of bactericidal antibiotics
    • May decrease effectiveness of oral contraceptives
    • Warfarin: increases effect. Increased bleeding risk.
    Class Side effect of tetracyclines: hepatotoxicity, nephrotoxicity, photosensitivity, dental staining, Pseudomembranous colitis is rare for this class of drugs

    Patient Education:
    • Avoid dairy products if using tetracycline. Does not seem to affect doxycycline.
    • May take with food to decrease GI upset
    • Wear sunscreen
    Most common Drugs & dosage of this class
    Tetracycline:
    Available as capsules 250mg & 500mg
    Dosage 250-500mg four times daily

    Doxycycline hyclate (Vibramycin®) Doxycycline monohydrate (Monodox®):
    Available as capsule=50mg & 100mg & 100mg tablets
    Dosage: 200mg first day, then 100mg daily for 10days. May use 100mg BID for 10 days.
    Minimal food drug interaction with doxycycline. Absorption is delayed.
    Common uses: Acne, Lyme disease, Upper Respiratory Infection, Community Acquired Pneumonia, Chlamydia, Community Acquired Methicillin Resistant Staph Aureus (CA-MRSA) Rocky Mountain Spotted Fever (RMSF)
    Not so common uses: bioterrorism: plague, anthrax, tularemia.

    ***Doxycycline is the most effective antibiotic for the treatment of suspected rickettsial infections, including Rocky Mountain spotted fever (RMSF). Delay in treatment of rickettsial diseases may lead to severe illness or death. Children are five times more likely than adults to die from RMSF.
    Misperceptions about the use of doxycycline for children prevent kids from getting lifesaving treatment. The old tetracyclines indeed cause dental staining and that warning in 1970 was given to the tetracycline family, even though it is NOT appropriate for doxycycline.
    Smile and take your DOXYCYCLINE: Doctors often avoid prescribing doxycycline to young children because of a warning that tooth staining may occur when used in children less than 8 years old. In a recent study, experts at the CDC and Indian Health Service (IHS) found that short courses of the antibiotic doxycycline can be used in children without causing tooth staining or weakening of tooth enamel.
    https://www.cdc.gov/rmsf/doxycycline/index.html#:~:text=Despite%20the%20current%20label%20warning,severe%20illness%20and%20save%20lives

    Doxycycline capsules: I always recommend and dispense doxycycline hyclate tablets. The doxycycline 100 mg capsules are huge and a potential choking hazard. I have had a couple of students who shared with me that had esophageal varices from doxycycline capsules getting stuck in their throat. My wife had a GI doctor share with her that he has seen this happen all to frequently and can be greatly reduced by exclusively dispensing the tablets.

    Doxycycline monohydrate (Monodox®):
    Available as tablets and capsules. Were believed to cause less GI upset. Not really proven.

    Minocycline (Minocin®):
    Available as capsules 50mg, 75mg & 100mg
    Dosage: 200mg stat; then 100mg BID q12h
    Minocycline may cause vestibular disorders, resulting in dizziness.
    Minocycline may cause pigmentation of skin & mucus membranes.

    How well I remember Achromycin-V® being dispensed for $4.00 for 100 capsules when I first started my career. Today the wholesale acquisition cost is almost $4.00 PER CAPSULE, and that price has dropped in half since last year! Remember 6 years ago when doxycycline was $4 per tablet cost, and now it is inexpensive again?

    Here’s an unusual use for tetracycline: It can be used as a biomarker in animals (and humans too!) The bait can be fed to the animal and then an allotted portion of time is allowed to pass. The critter (bear, raccoon etc) is given a second dose of tetracycline containing bait.

    A tooth is then extracted, sectioned in half and the “rings” of tetracycline can be measured and the animal’s growth can be measured. Tetracycline can also be used to measure vaccine distribution in wildlife, using tetracycline as a biomarker.
    Chlortetracycline was the first member of the tetracycline family, discovered in 1948. Aureomycin ophthalmic ointment was FDA approved in 1950. Tetracycline was first approved by the FDA in 1953, the patent given to Lederle Labs for the brand name of Achromycin-V®. Doxycycline was approved by the FDA in 1967 with the brand name of Vibramycin®. Minocycline (Minocin®) was approved by the FDA in 1971, the last tetracycline to be approved.

    Have a great day on the bench!!

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    Penicillin Allergy? Let’s Make Sure!

    Table 1. Classifications of β-lactam Reactions
    Levine ClassificationGell & Coombs ClassificationTime to Onset, hMediator(s)MechanismClinical Signs
    ImmediateType I≤1PCN-specific IgE antibodiesHistamine and vasoactive stormAnaphylaxis; angioedema; bronchospasm; urticaria (hives)
    Non-immediateType II≥72IgG, complementAntigen bound to hapten and fixed in tissue; increased clearance of RBCs, PltsGoodpasture's syndrome; PCN-related hemolytic anemia
    Type IIIIgG, IgM immune complexesTissue deposition of immune complexesSystemic Lupus; Penicillin-induced serum sickness
    Type IVT-cellsActivated T-cellsMorbilliform eruptions, contact dermatitis; Rarely more serious: e.g., Stevens-Johnson Syndrome
    So, penicillin allergies come in variations, with the Immediate Type-1 being the most serious. Those are the ones that physicians and pharmacists need to be most concerned about.

    So what’s the Big Deal… we have clindamycin and fluoroquinolones. From head to heart to skin infections (notably methicillin-susceptible Staphylococcus aureus or MSSA), beta-lactams like cephalosporins and penicillins are the drugs of choice. If they are “taken off the table,” we are forced to use broad-spectrum antibiotics like clindamycin and fluoroquinolones. Fluoroquinolones and clindamycin may not only be less effective for eradicating the bacteria (leading to antibiotic resistance), but also are a major cause of Clostridium difficile diarrheal infections!
    First-generation cephalosporins are commonly prescribed for surgical site infection (SSI) prophylaxis for almost all surgeries, either as monotherapy or as combination therapy. Preserving first-generation cephalosporins through antibiotic stewardship is critical to future patient care.

    Beta-lactam Cross-Reactivity: An OChem Rerun
    Cephalosporins are related to the structure and antimicrobial activity of penicillins. Both groups of antibiotics possess the core four-membered β-lactam ring. Cephalosporin cross-reactivity potential is related to the structural R1 side chain.
    For example, amoxicillin shares the same R1 side chain as ampicillin, cephalexin (Keflex®), cefadroxil (Duricef®), and cefaclor (Ceclor®). Patients allergic to penicillins should avoid cephalosporins with identical R1-group side chains. The third-generation cephalosporins, such as cefdinir (Omnicef®), cefpodoxime (Vantin®) and ceftriaxone (Rocephin IM/IV®), do not have R1 side chains that match the penicillins, so there is minimal chance of cross-reactivity.

    You Can Help to Set the [Allergy] Record Straight! Almost 80% of patients with IgE-mediated reactions lose their hypersensitivity after 10 years! Asking questions about their reaction symptoms, time since the initial reaction and whether they have taken other beta-lactam antibiotics since can be useful to “de-label” and remove allergies from the patients’ records. As pharmacists, we have a unique opportunity to ensure accurate documentation! We must make sure that when we document a patient-reported “allergy,” we delineate between allergies and side effects:
    • Allergy is an adverse drug reaction mediated by an immune response (e.g., rash, hives).
    • A side effect is an expected and known effect of a drug that is not the intended therapeutic outcome (GI upset, diarrhea).
    I've precepted 65 students now and am amazed with their success. Last week Ukwen Akpoji reached out to me and offered a guiding hand through the challenges of antibiotic stewardship, as well as navigating through patient reported allergies.

    With his experiences in that field, I am able to provide you some very useful information with regards to antibiotic use.

    “I’m allergic to penicillins. The last time I took Augmentin, I got horrible upset stomach and diarrhea. I can’t take penicillins.”

    How many times does that happen in our primary care and community pharmacy settings? Fortunately for me, I’ve precepted 65 students now, and some have become experts in their respective fields. Student #34 Ukwen Akpoji is such a superstar in the field of antibiotic stewardship. He shared the following with me for this session:

    Over 30 million people in the United States report a penicillin drug allergy. Less than 5% of these patients mount a type I hypersensitivity reaction mediated by IgE antibodies (i.e. anaphylaxis, angioedema, bronchospasm, etc.). These are histamine-related mechanisms, which is why diphenhydramine (Benadryl) usually helps relieve symptoms.

    Have a great day on the bench!!

    Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-99. https://pubmed.ncbi.nlm.nih.gov/30644987/
    Chaudhry SB, Veve MP, Wagner JL. Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity. Pharmacy (Basel). 2019;7(3):103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6789778/

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    Cephalosporins Overview

    CEPHALOSPORINS
    Mechanism: like their closest cousins the penicillins, cephalosporins bind to proteins in the cell wall, enabling it to inhibit cell wall synthesis of the bacteria, causing cell wall lysis and cell death (bactericidal).

    Indications for use:
    Differs between 1st, 2nd, and 3rd generation cephalosporins.

    1st GENERATION CEPHALOSPORINS:
    Gram positive activity, staph aureus, S.epidermidis, Strep pyogenes, Strep pneumoniae.
    Not active against MRSA/ MRSE.
    Some strains of Klebsiella, P.mirabilis, E.coli, Shigella (Gram Negatives)
    Primarily cover gram positive organisms: methicillin-sensitive S. aureus, group A strep
    Some gram-negative coverage: E. coli, Klebsiella species, P. mirabilis
    Poor anaerobic coverage

    Most Common 1st Generation Cephalosporins
    Cephalexin (Keflex®)
    • Available as: capsules 250mg & 500mg. Suspension: 125mg/5ml & 250mg/5ml
    • Adult dosage: 250- 500mg every six hours
    Cefadroxil (Duricef®)
    • Available as 500mg capsules & 1GM tablets. Suspension: 125/5ml; 250/5; 500mg/5ml
    • Adult dose: 1 to 2 gm per day in single or divided doses
    Most Common use: Methicillin Sensitive Staph Aureus (MSSA) skin/soft tissue. Urinary Tract Infection. Surgical prophylaxis

    2nd Generation
    Gram positive: same as above
    Gram negative: more extensive including: Acinetobacter, Citrobacter, Enterobacter, Neisseria, Proteus, E.coli & Klebsiella, Haemophilus influenza,

    Cefuroxime and cefprozil cover S. pneumoniae.
    Enhanced coverage of gram negative organisms: H. influenza, M. catarrhalis, Neisseria species
    Some anaerobic coverage. Cefoxitin and cefotetan cover B. fragilis.

    2nd Generation Cephalosporins
    Cefaclor (Ceclor®)

    Cefuroxime (Ceftin®) is a second-generation cephalosporin that maintains gram-positive activity of first-generation cephalosporins and adds activity against Proteus mirabilis, Hemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis
    Available tablets 125mg, 250mg, 500mg. Suspension: 125mg & 250mg/5cc
    Dosage: Adults 250mg-500mg every 12 hours, with meals
    Common use: Cefuroxime: Upper Respiratory Infection (URI), UTI, Lyme early stage, Otitis media, sinusitis.

    FIRST AND SECOND GENERATION cephalosporins have no activity against Listeria, Atypicals, MRSA, and Enterococci!

    3rd Generation: broad spectrum, most resistant to cephalosporinases.
    Some penetrate the CSF
    Gram positive: decreased compared to first & second generation
    Gram Negative: extensive coverage for Citrobacter, Enterobacter, Neisseria, Hemophilus, Serratia, with some Pseudomonas activity.
    Third-generation agents have enhanced activity against both gram-positive and gram-negative bacteria compared to 1st and 2nd generation.

    3rd Generation Cephalosporins
    Cefdinir (Omnicef®)
    Available as 300mg capsules susp:125mg/5cc & 250mg/5cc
    Dosage: Adults 300mg q12
    Child: 14mg/kg/day divided BID Suspension good for 10 days after reconstitution.
    Major Counseling point: Will turn stools red! occurs when cefdinir
    combines with iron to form a precipitate that gives stool a characteristic discoloration

    Cefpodoxime (Vantin®)
    Available as tablets: 100mg & 200mg. Suspension: 50mg/5cc & 100mg/5cc
    Dosage: Adults: 200-400mg/day divided BID. For skin may increase to 800mg/day

    Ceftriaxone (Rocephin®)
    Available only as injection: 500mg and 1gm injection GIVE IM or IV
    Adults: 1-2 gm daily. Pediatrics 50-75mg/kg. Max=2gm/day
    Dosed once a day. Avoid injection with calcium salts, precipitates in lungs and kidneys.

    COMMON USES: Third Generation Cephalosporins
    • Cefdinir: otitis media; upper respiratory infection.
    • Ceftriaxone: Lyme’s, otitis media, gonorrhea, upper and lower respiratory infections. skin infections
    • Some anaerobic coverage. No agents cover B. fragilis
    Warnings/Precaution: Crossover Allergy
    Cross-reactivity between penicillins and cephalosporins is less than 1%, (instead of 10% as previously thought) which is less likely with second- and third generation cephalosporins than first-generation cephalosporins.
    • Cefdinir (Omnicef®), cefuroxime (Ceftin®), cefpodoxime (Vantin®) or ceftriaxone (Rocephin®), are a safe choice because they do not have the “penicillin-like” side chains.
    Side effects: Cephalosporins
    Hematologic abnormalities: Some cephalosporins contain a methlythiotetrazole (MTT) side chain that increase risk of bleeding (hypoprothrombinemia)
    Rare: nephrotoxicity & hepatic enzyme abnormalities

    Drug Interactions
    Possible disulfiram reaction
    Probenecid inhibits tubular secretion

    Patient Education:
    Watch for severe penicillin allergy patients
    Take with food or milk
    Complete course of therapy

    As we previously discussed with the onset of penicillin therapy, bacterial resistance rapidly became problematic. Penicillinase producing staphylococci were wreaking havoc in the hospitals.

    Fortunately, in 1945 an Italian pharmacologist named Giuseppe Brotzu discovered an antibiotic-producing species of Cephalosporium (now Acremonium), isolated from a sewage outfall in Sardinia! Dr. Brotzu’s visit to a sewer pipe led to the discovery of one of the most used antibiotic classes today.

    As far as my historical experiences go, I remember when Eli Lilly’s brand of cephalosporin (Keflex®) was the first $1.00 per capsule back in 1979. As an intern, I remember Louie Rinovato, my preceptor, saying he doubts that the prices can go much higher! We were just at the beginning. Thanks to generics today, you can buy 100 capsules for what ten capsules of Keflex cost back in 1979!

    Have a great day on the bench!!

    August 2020

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    Penicillin: Still in Use 75 Years Later!

    PENICILLINS
    Mechanism: penicillin binds to proteins in the cell wall, enabling it to inhibit cell wall synthesis of the bacteria, causing cell wall lysis and cell death. Beta-lactam antibiotics (penicillins and cephalosporins) inhibit the growth of sensitive bacteria by inactivating penicillin binding proteins, which are involved in cell wall synthesis. Penicillins are bactericidal.
    Resistance: has been a problem since the introduction of penicillin in the 1940’s.
    • The binding sites can adapt and alter the permeability of the outer membrane
    • Decreasing affinity of the target site can be altered.
    • Resistance to the beta-lactam antibiotics is also due to production of enzymes that cleave penicillins (penicillinases), cephalosporins (cephalosporinases), or both (beta-lactamases)
    Indications for use
    Are highly effective against gram positive cocci and some gram-negative cocci. Little effect on GM- rods.
    • Penicillin-G is 5 to 10 times more active than Penicillin-V against gram negatives & some anaerobes.
    • Are ineffective against Staph aureus, due to beta-lactamase produced by staph.
    • Penicillinase resistant penicillins are not hydrolyzed by beta-lactamase.
    • Are drugs of choice for non-resistant Staph & strep. N. meningitidis, B. Anthracis.
    • Most common use: syphilis, susceptible pharyngitis and endocarditis and dental infections.
    • C. tetani, C. Perfringens, Listeria, Syphilis.
    Warnings/Precautions
    * Hypersensitivity reactions in 3 to 10 % (rash 4-8%) ; Anaphylaxis in 0.01% to 0.05% Rarely N/V with oral use

    Side effects: very rare- neurotoxicity at high doses. Neutropenia & nephrotoxicity. Broader spectrum penicillins: Amoxicillin can cause diarrhea due to disruption of normal GI flora.

    Drug Interactions: Probenecid increases blood levels.

    Patient Education: Finish entire prescribed dose. Report any rash to practitioner

    Most common Drugs & dosage of this class:

    Penicillin VK (PenVeeK® & V-Cillin-K®)
    Available as tablets: 250mg & 500mg. Liquid= 125mg/5ml & 250mg/5ml
    Liquid is reconstituted by pharmacist. Good for 14 days after mixing. Does have a bitter taste after reconstitution.

    Dose: 250mg-500mg two to four times daily.
    Pediatric:25-50mg/kg/day divided in 4 doses, every 6 hours.

    Penicillin parenteral is still measured in units.
    One unit of penicillin represents the specific activity in 0.6 mcg of sodium penicillin.
    1 mg of penicillin sodium represents approximately 1667 units of penicillin.
    Therefore, 250mg of Penicillin- 400,000iu

    Penicillin G (Pen G & Bicillin L-A)
    Penicillin G is a natural penicillin that is most commonly given intramuscularly (IM)
    • Penicillin G comes in two unique IM formulations: Benzathine Pen G and Procaine Pen G
    • These IM Repository formulations allow for steady release of medications at therapeutic doses for extended intervals
    • Great option for kids that a practitioner is worried that a caregiver may forget doses or non-compliant patients
    • Most common formulation/use: Benzathine Pen G 2.4 million units IM as a single dose for syphilis
    Penicillinase resistant Penicillins (“anti-staph penicillins”):
    Examples: methicillin, oxacillin (1971), cloxacillin (1971) & dicloxacillin (1968).
    Good for methicillin sensitive strep and staph. (not good for enterococci)
    Are not affected by beta-lactamase.
    Generally used for skin and soft tissue infection

    Extended Spectrum Penicillins
    Have a broad spectrum of coverage, but most importantly … Pseudomonas aeruginosa
    Because extended spectrum penicillins are sensitive to Beta-lactamase, they are coupled with Beta-lactamase inhibitors
    Examples: Piperacillin/tazobactam (Zosyn®) and Ticarcillin/clavulanate (Timentin®)
    Piperacillin/tazobactam (Zosyn®) is the safer option that is most commonly used
    Ticarcillin has been associated with electrolyte abnormalities and platelet inhibition Dosing and dosing intervals vary based organism/location of infection.

    I am amazed to read the stories of how the United States “ramped up” the manufacturing of penicillin to meet the demands of World War Two.

    It was indeed an international effort between the United States and Great Britain. Great Britain had the scientists and the technology, but their industrial complex was leveled due to the bombings.

    The US had the land and the fermentation tanks and equipment; with the help of British scientists, penicillin was rapidly produced. The most interesting part of the account I read, was in their search for a penicillin strain they spent most of their efforts with soil screenings.

    The big breakthrough came when the most productive strain was isolated on a rotten cantaloupe in the Peoria fruit market! My wife who describes cantaloupe as smelling like “dirty gym socks” was pleased to learn that her least favorite fruit has an extremely useful purpose!

    Have a great day on the bench!!

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    Anti-Infective Prescribing: The Ground Rules

    ANTI-INFECTIVE STEWARDSHIP IS A MUST!
    • Antibiotics are the only drug where use in one patient can impact the effectiveness in another.
    • If everyone does not use antibiotics well, we will all suffer the consequences.
    • Antibiotics are a shared resource, (and becoming a scarce resource).
    • Using antibiotics properly is analogous to developing and maintaining good roads.
    • Available data demonstrates that we are not doing a good job of using antibiotics in in-patient settings.
    • Several studies show that a substantial percentage (up to 50%) of in-patient antibiotic use is either unnecessary or inappropriate.
    Definitions
    • anti-infective: applies to any drug that is effective against pathogens.
    • antibiotic: technically refers to natural substances produced by a micro-organism that can kill other micro-organisms. However, most of us use antibiotic, anti-infective and antimicrobial interchangeably.
    • bacteriostatic: do not actually kill the bacteria but slow the growth of the organism. The body’s immune system can then dispose of the bacteria. Most bacteriostatic antibiotics disrupt protein synthesis.
    • bactericidal: kill the bacteria outright, usually by interruption of cell wall synthesis
    • minimum inhibitory concentration (MIC): concentration of an antibiotic which prevents growth of the culture.
    • minimum bactericidal concentration (MBC): the concentration that kills 99.9% of the inoculum. Often the MBC is 2 to 8 times that of the MIC
      • Antibiotics for which achievable blood concentrations regularly exceed the MBC of common pathogens are classified as BACTERICIDAL.
      • Antibiotics whose blood concentrations readily exceed MIC but usually do not exceed the MBC are classified as BACTERIOSTATIC.
      • Antibiotics whose blood concentrations do not reach MIC are RESISTANT.
    • time/kill curve: time dependent killing: little or no enhancement of bactericidal activity with drug concentrations above the MBC. Killing depends on maintaining the concentrations above the MBC for as much of the dosing interval as possible. Time kill curves are used to determine whether an antimicrobial is bactericidal or bacteriostatic.
    • post-antibiotic effect: when bacteria are exposed to an antibiotic at concentrations above MIC, the antibiotic is then removed.Bacterial replication does not resume as normal, for a variable period of time (usually hours) after removal of the antibiotic. The post antibiotic effect provides a rationale for pulse dosing of antibiotics. Serum antibiotic concentration falls below the MIC, for part of the dosing interval, the PAE may prevent bacterial multiplication during the brief time when the serum antibiotic concentration falls below the MIC before the next antibiotic dose.
    • superinfection: secondary infections caused when microorganisms normally present in the body are killed by the antibiotic. These normal organisms called host flora (or normal flora) inhabit the skin, upper respiratory, GU, and GI tract.
      • Examples: candida vulvovaginitis after amoxicillin therapy
      • C. difficile: after clindamycin therapy (or any broad-spectrum antibiotic)
    BACTERIOSTATIC ANTI-INFECTIVES
    DNA synthesis inhibitor:
    Fluoroquinolones
    RNA Synthesis inhibitor:
    Rifampin

    Protein synthesis inhibitors:
    Macrolides
    Tetracyclines
    Clindamycin
    Chloramphenicol

    Antimetabolites:
    Sulfonamides

    BACTERICIDAL ANTI-INFECTIVES
    Cell wall synthesis inhibitors:
    Penicillins
    Cephalosporins
    Vancomycin
    Carbapenems

    Cell membrane inhibitors:
    Isoniazid (bacteriostatic if stationary phase; bactericidal if growing) Amphotericin-B (fungicidal or fungistatic depending on concentration & organism)

    Protein synthesis inhibitors:
    Aminoglycosides

    I teach anti-infective therapy in the Summer semester at St. Francis in the Physician Assistant program. Knowing how much information is crammed in the Physician Assistant’s heads that year, I thought it would be prudent to cover antibiotic therapy.

    What do oxycodone, diazepam, penicillin, and ciprofloxacin have in common? I tell my students that antibiotics, benzodiazepines and opioids are drugs that we not only prescribe for the individual patient, but for society as well.

    Because benzos and opioids are considered as drugs with potential abuse, we must take precautions to minimize dependence and addiction and make certain that these drugs are not diverted. Diversion of opioids and benzos can become a societal problem.

    We must also be prudent in prescribing antibiotic therapy for our patients because they can create resistance to bacteria. Increasing bacterial resistance through reckless prescribing can cause an increase in resistant organisms in which current antibiotics can be futile.

    We have to look no further than the infamous “Z-pak” (Azithromycin) which, in our area, has a 48% resistance rate for Strep pneumo, a very common respiratory pathogen. It is a “flip of the coin” as to whether the “Z-pak” will cure your next community acquired pneumonia. Not being able to cure pneumonias in our patients is a societal problem as well.

    Have a great day on the bench!!

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    Migraine Headache Prevention is Easy…Unless We Are Looking at Real Patients!

    MIGRAINE COMORBIDITY AND COEXISTING CONDITIONS

    DISORDERCONSIDERAVOID OR CAUTION
    DepressionTCA, SSRI, SNRIBeta-blockers
    Bi-Polar disorderValproate, TopiramateTCA, SSRI, SNRI
    AnxietyTCA, SNRI, BB
    Sleep disturbancesTCABB
    StrokeAspirinErgot
    FibromyalgiaTCA, SSRI, SNRIBB
    ObesityTopiramate, SNRITCA, Valproate, SSRI
    EpilepsyTopiramate, ValproateTCA, SSRI, SNRI
    RaynaudsCCBBB, Ergots
    Over Age 60BB (due to stroke risk)
    SmokersBB (due to stroke risk)
    Uninsured patientsCGRP blockers $$$
    PregnancyCaution with all therapies. CCB seem to be safestTopiramate, Valproate

    TCA= Tricyclic Antidepressants such as Amitriptyline (Elavil) and Nortriptyline (Pamelor)
    SSRI= Selective Serotonin Reuptake Inhibitors such as fluoxetine (Prozac®), sertraline (Zoloft®)
    SNRI= Serotonin-norepinephrine reuptake Inhibitor such as venlafaxine (Effexor®), duloxetine (Cymbalta®)
    BB= Beta blockers such as metoprolol (Toprol-XL®, Lopressor®) and propranolol (Inderal®)
    CCB= Calcium Channel Blockers such as verapamil (Isoptin®)
    CGRP= Calcitonin gene-related peptide blockers such as Ajovy®, Aimovig®, Emgality®

    OPTIMIZING MIGRAINE MANAGEMENT
    Evidence based guidelines adopted by the AAFP, AAN
    • NSAIDS as FIRST LINE Therapy
    • Triptans (or Dihydroergotamine???) indicated for those who fail to tolerate or respond to NSAIDS
    • NO evidence to support the use of butalbital compounds (Fioricet®)
    • Little evidence to support use of isometheptene compounds (Midrin®)
    • Opioids reserved for use when other medications cannot be used. (Cardio patients)
    Remember when prescribing:
    • Drug overuse is a problem with sub-optimal therapy. Best to use the “one and done” approach. Think of using only Sumatriptan 100mg or Rizatriptan 10mg, rather than redosing with a lower strength.
    • Don’t take acute drugs more frequently than 5 half lives. Sumatriptan and Rizatriptan’s half-life is 2.5 hours.
    QUESTIONS to ASK
    • How often do you experience a headache of any severity per month?
    • How often do you experience severe or disabling headaches per month?
    • Has there been any change in either of these headaches over the past six months?
    • How often do you take Rx or OTC meds per month?
    Questions that don't work:
    • How many migraines per month?
    • On a scale of 1-10 how severe?
    As we health care professionals can attest, very seldom does a patient come in with only one chief complaint with no comorbidities. If that were the case, patients could go to a vending machine hit the migraine prevention button and the pills would magically drop out!

    Because of these complex patients, providers such as PA’s and physicians as well as pharmacists must always look at the entire patient and their comorbidities before selecting any therapy.

    Beta blockers are first line therapy for migraine prevention, unless the patient has bradycardia, hypotension, erectile dysfunction, fibromyalgia, depression, a smoker, or over 60 years of age. Hardly qualifies as “first line therapy” in a significant portion of the population.

    As one of the professors at St. Francis says, “Patients don’t come into the clinic with A, B, C or D selections on their forehead!”

    Have a great day on the bench!!

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    Treatment of Cluster Headaches

    TREATMENT OF CLUSTER HEADACHES

    Cluster headache: a form of migraine often characterized by brief, but frequently recurrent bouts of severe headache. Frequently referred to as “suicide headaches”. Headaches may last from 45 minutes to 3 hours, maximum. May occur every other day or up to 8 times per day, even the same time each day known as circadian periodicity.
    • Patients will not lie down; they are extremely agitated and incapacitated. They walk and pace and have been known to bang their head off a wall to deflect the pain.
    • Clusters may occur in groups of up to 8 a day lasting for weeks or months.
    • Pain is intense, concentrate on 1 side of head, accompanied by “Cranial autonomic symptoms” such as tearing of the eye, runny nose, fullness of the ear and a droopy eye on the same side.
    Origin: hypothalamus, near where circadian rhythm is governed.
    Typical patient: is a middle-aged male who smokes.

    TREATMENT of CLUSTER HEADACHE
    Oxygen: Flow rate is 12 liters per minute inhaled through a mask, sitting upright is safe and inexpensive, and works within 15 minutes. However, Medicare will NOT pay for oxygen for treatment of episodic cluster headache, even though it is the standard of care. (Fortunately for most, oxygen therapy is affordable.)

    Fast acting triptans: such as injectable sumatriptan (Imitrex®) 6mg subcutaneously, or sumatriptan 20mg nasal spray, or zolmitriptan (Zomig®) nasal spray 5mg. Sumatriptan injection and nasal spray are available as generics. Zomig® is brand only.

    Ergotamine preps: same as migraine dosage. Will help some patients. Save for patients who can’t use a triptan. Same dosage as migraines
    dihydroergotamine:
    Migranal® nasal spray 4mg/ml. ($315.00/dose)
    • Dosage: 1 spray (0.5mg) each nostril every 15 minutes for a maximum of 4 sprays.
    • Don’t exceed 3mg/day (6 sprays)
    • Don’t exceed 4mg/week (8 sprays)
    D.H.E.® injection: ($250.00/dose) DHE is usually given as a 1 mg intravenous bolus and may be repeated at one hour, with a maximum dose of 3 mg in 24 hours. Maximum= 3ml per 24hr if SC or IM. 2ml max if IV =6ml per week.

    Octreotide (Sandostatin®): may be effective in the treatment of acute cluster headaches.
    Dose: single dose of subcutaneous octreotide (100 mcg)

    Butorphanol (Staldol®) nasal spray: C-IV
    • Narcotic administered as a nasal spray. May provide relief esp. if nausea.
    • One nasal spray; wait 90-120 minutes before deciding to administer another dose.
    • Side effects: watch for drowsiness, may be habit forming.
    Lidocaine: Some success with intranasal Lidocaine. Lidocaine is hard to administer, and mixed results (33% efficacy).

    MEDICATIONS USED FOR PROPHYLACTIC THERAPY FOR CLUSTER HEADACHE

    Calcium channel blockers: Verapamil is the drug of choice. Use highest tolerable dose, (max=320mg/day). Watch for: incidence of electrocardiographic (ECG) abnormalities, including heart block and bradycardia. Best to do an ECG before starting therapy, and with dosage increases over 480mg.
    Watch for: edema, gastrointestinal discomfort, constipation, dull headache, and gingival hyperplasia

    Lithium: can be used but save for patients not responding to verapamil.
    Be sure to inform patient about side effects:
    • Drink 8 to 12 glasses of water a day. Watch for dehydration.
    • Take with food to minimize GI upset.
    • Therapeutic blood levels: maintenance 0.6 to 1.2 mEq/L
    Ergotamine preparations: are of limited value for prevention

    Corticosteroids- can be effective. Reserve for patients who don’t respond to verapamil. Usual dose: oral prednisone 60 to 100 mg once a day for at least five days, and then tapering by decreasing the dose 10 mg every day

    Melatonin: can help some patients. 10mg in the evening. This makes sense because melatonin levels are decreased in some patients with cluster headache.

    Anticonvulsants: Gabapentin (Neurontin®), Topiramate (Topamax®), and Divalproex (Depakote ER®) have all shown promise. Use doses as for migraine prophylaxis.

    Galcanezumab (Emgality®) Galcanezumab is a calcitonin gene-related peptide (CGRP) antagonist indicated in adults for
    • Preventive treatment of migraine AND
    • Treatment of episodic cluster headache (approved June 2019)
    • ligand antagonist a with a 25- to 30-day half-life
    NOTE: inform patients continue preventative treatment for 4 to 6 weeks after remission, to make sure cycle has ended
    Good resource: American Migraine Foundation

    I asked my neighbor at the pharmacy, Curt, who owns Penn-Med, what a non-rebreathing mask was, and he told me it was a typical oxygen mask. A rebreathing mask has the bag attached to the mask. When I asked him about providing oxygen to patients who suffered from cluster headaches, he told me of the reimbursement challenges of providing this service to patients who had normal pulse-ox readings. Yet another time when bureaucracy gets in the way of providing optimal care.

    Curt has a son who is a physical therapist, who specializes in treating migraine headaches by using physical therapy. His son can tell within three visits whether PT is going to be of any help or not. A lot of women are getting much needed relief with this specialized form of physical therapy.

    Have a great day on the bench!!

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    Herbal and Complementary Therapy for Migraine Prevention

    COMPLEMENTARY MEDICATIONS FOR MIGRAINE PREVENTION

    Butterbur: well-studied natural medicine. Treatment of both allergic rhinitis and for preventing migraine headache.
    Postulated mechanism: antispasmodic effects on smooth muscle and vascular walls. Possible anti-inflammatory effects by inhibiting leukotriene synthesis. The American Academy of Neurology (AAN) and American Headache Society (AHS) recommends petasites butterbur (50-75 mg bid), with a Level-A recommendation.
    Side effects: May cause GI upset, primarily burping as well as headache, itchy eyes, diarrhea, breathing difficulties, fatigue, and drowsiness.
    Caution: The raw, unprocessed butterbur plant contains chemicals called pyrrolizidine alkaloids (PAs). PAs can cause liver damage and possibly cancer. Only butterbur products that have been processed to remove PAs and are labeled or certified as PA-free should be used, for up to 16 weeks.

    Feverfew: reduces the frequency of migraines, and when migraines do occur, they tend to have less severe symptoms of pain, nausea, vomiting, and sensitivity to light and noise. AVOID if allergic to ragweed. AAN recommends feverfew (50-300 mg bid) with a Level-B recommendation. There is conflicting evidence about the efficacy of feverfew for migraine prevention.
    Side effects: nausea, digestive problems, and bloating; if the fresh leaves are chewed, sores and irritation of the mouth may occur. Avoid if pregnant. May interact with anticoagulants.

    Riboflavin: migraine prevention is its role in mitochondrial function because migraines could be partly due to mitochondrial dysfunction. Riboflavin is required as a precursor for factors needed for electron transport in mitochondria. Needs to be dosed at 400mg per day and takes at least 3 months to show efficacy. Vitamin B-2 is available in 100mg tablets, over the counter. In one study, the number needed to treat (NNT) for efficacy was 2.3 University of Pittsburgh. Well tolerated, discolors urine bright yellow.

    Magnesium: has been used for treatment and prevention of migraine headache. Some research shows that taking high-dose oral magnesium reduces the frequency and severity of migraine. Magnesium deficiency is related to factors that promote headaches, and people who get migraines seem to have lower levels of magnesium. The strongest evidence for magnesium’s effectiveness is in patients who have migraines with aura. It is believed magnesium may prevent the wave of brain signaling, which produces visual and sensory changes seen with aura. The guidelines from the AAN and the AHS say that magnesium is probably effective and should be considered for migraine prevention. Good choice for menstrual migraine.

    Dose is 400mg by mouth of Magnesium Oxide per day. IV magnesium can be used to abort an irretractable headache. Is in Pregnancy Category-A.
    Side effect: No surprise that diarrhea was the most common side effect.

    Coenzyme Q10 also affects mitochondrial function. Impaired oxygen metabolism and low cellular energy levels caused by faulty mitochondrial function might play a role in migraine headache pathogenesis. Coenzyme Q10 taken in a dose of 100 mg of three times daily appears to reduce migraine attack frequency, headache-days, and days-with-nausea. According to recent clinical research, the number needed to treat for one person to experience a 50% reduction in migraine attack frequency is three. Depending on the brand, it may cost up to $30 per month.

    Just because I know one of my most attentive readers wants to know...

    What About Medical Marijuana?
    Here are the highlights from an article in the Journal of Pain:
    Headache and migraine ratings were reduced by nearly 50% after using cannabis. Men reported larger reductions in headache after cannabis use than women. Cannabis concentrates were related to larger reductions in headache than flower. Evidence for tolerance to effects of cannabis on headache and migraine was detected. Evidence for medication overuse headache was not detected. This article shows a reduction in number of headaches and frequency. 40% of patients for whom medical cannabis was recommended for migraine reported a positive effect, with a decrease in migraine frequency from 10.4 to 4.6 migraines/month. Journal of Pain

    My students of St. Francis frequently hear me downplay complementary medications to treat or prevent disease. Especially with herbal therapy, there is no standardization in the United States.

    Products can vary from store to store since we do not have any system like the Komission-E monographs like Germany has, that spells out everything about purity and safety of herbal products. The only government help we have is just with the labeling of the products.

    When I see that butterbur must have the pyrrolizidine alkaloids removed to prevent liver toxicity and cancers, it makes me very reluctant to recommend the product given the lack of standardization of herbs.

    I am amazed, though, with the levels of efficacy shown by using riboflavin in the 400mg dose along with the magnesium oxide 400mg dose. The key is to have our patients use it for at least 3 months. Ah, the challenges of medication prescribing… getting our patients to “buy into” therapies that don’t show immediate benefit!

    Have a great day on the bench!!

    July 2020

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    Migraine Prophylaxis: Commonly Used Agents

    MIGRAINE PROPHYLAXIS: COMMONLY USED AGENTS

    BEHAVIORIAL MANAGEMENT

    Risk Factors
    • Stress (Note: Neurology April 2014 says stress reduction INCREASES migraine)
    • Menses
    Sensory Stimuli
    • Foods/stimulants
    • Weather fronts
    • Chronobiologic changes
    • Protective Factors
    • Stress management
    • Biofeedback
    • Regular Sleep & meals
    • Regular exercise
    • Adequate Hydration
    • Regular work/ school
    Indications for Pharmacological prevention
    Headache Frequency: greater than 8 days/ month or 2 days/week
    Significant disability MIDAS (Migraine Disability Assessment) > 10 or HIT-6 > 60 (measures of headache disability)
    Complications with Migraines
    Acute therapies are ineffective
    Migraine related complications

    Success: is defined as working in 50% of the patients to decrease headaches by 50%
    Expect at least 6 weeks to see benefit from migraine prophylaxis

    NEURONAL HYPEREXCITABILITY IN MIGRAINE
    Neuronal hyperexcitability predisposes individuals to migraine
    Increased neuronal hyperexcitability may be multi factorial
    Abnormal glutamate metabolism
    Deficiency of systemic and brain magnesium
    Abnormal calcium channels that influence presynaptic neurotransmitter release.
    Migraine may be prevented by reducing neuronal hyperexcitability.

    Encourage patients to identify and avoid triggers... skipping meals, disrupted sleep, stress, alcohol, wine, cheese, aspartame, etc. Men are 35% more likely to report overexertion as a migraine trigger. Men are more sensitive to light. Women are more sensitive to triggers of smell and are more likely to become nauseous.

    a) Beta blockers (considered first line for prophylaxis)
    These beta-blockers are lipid soluble and can penetrate the blood brain barrier
    • Propranolol (Inderal®)
    Dosage: 60mg to 360mg daily
    Side effects: fatigue, lassitude, depression, insomnia, postural symptoms
    • Metoprolol tartrate (Lopressor®) or metoprolol succinate (Toprol-XL®)
    Dosage: 50-200mg daily
    Side effects: same as propranolol

    Best to avoid beta blockers in smokers and patients over age 60

    b) General analgesics/NSAIDs (second line)
    • Aspirin 650-1950mg per day.
    • Naproxen 250mg to 550mg –twice daily
    Caution: regular use might lead to chronic headache.
    Avoid: CV disease, GI risk, hypertension

    c) Antidepressants (second line)
    • Amitriptyline (Elavil®) tablets
    Dosage: 25-75mg at bedtime (up to 150mg)
    Side effects: drowsiness, anticholinergic side effects, weight gain.
    Contraindicated in cardiac patients. Amitriptyline is the only tricyclic that has proven efficacy for migraine. No data on using other TCA’s
    • Venlafaxine (Effexor®) (second line)
    Side effects: headache, nervousness, insomnia, weight gain, GI disturbances.
    Caution: if hypertensive or recent heart attack.

    d) Calcium channel blockers (3rd line)
    • Diltiazem (Cardizem®, Cardizem CD®, Cardizem LA®)
    Dosage: 90-180mg daily
    Side effects: headache
    • Verapamil (Isoptin® or Calan SR®)
    Dosage: 80-160mg daily (up to 320mg/day)
    Side effects: Constipation, peripheral edema & cardiac conduction disturbances.

    Dr Robert Kaniecki: Headache Seminar: “Calcium channel blockers are not very effective”

    e) Anticonvulsants:
    • Topiramate (Topamax®) 25mg, 50mg , 100mg, 200mg
    Dosage: 25 to 150mg (Latest information suggests 50mg BID is sufficient)
    Side effects: confusion, weight loss, paresthesia, kidney stones
    Caution: over 200mg a day might decrease effectiveness of oral contraceptives
    • Divalproex (Depakote ER®)
    Dosage: Depakote ER® 500mg once daily for 7 days. Then increase to 1000 mg once daily. Do not crush or chew tablets.
    Side effects: weight gain, hair loss, tremor, diarrhea, and abdominal pain. During first 6 months of treatment watch for thrombocytopenia & hepatic failure.
    • Gabapentin (Neurontin®) -NOT effective- no better than placebo
    Dr. Robert Kaniecki: Headache Seminar:
    • Phenytoin, carbamazepine, phenobarbital are ineffective
    • Give 20% to 25% of maximum daily dose.
    f) Cyproheptadine (Periactin®)

    Often used for children

    4mg tablets, syrup: 2mg/teaspoon
    An antihistamine, with anti-serotonin properties
    Side effects: drowsiness, weight gain.
    Dosage: 4mg three times daily. Maximum 32mg/day

    Migraine headaches are disabling. Patients often want relief to not only get rid of them (with ‘-ditans’, ‘-triptans’ and ‘-gepants’) but also to keep the headaches from occurring in the first place. I find it amazing that success is defined as this: Half of your patients have half of the intensity/frequency of their headaches!

    Two weeks ago, we covered the CGRP inhibitors, all which cost around $725.00 per month. Virtually everything in this week's column is usually less than $20.00 per month.

    Have a great day on the bench!!

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    Treatment of Migraine Headache in Special Populations

    TREATMENT OF MIGRAINE HEADACHE IN SPECIAL POPULATIONS

    Treatment of Migraine Headache in Children

    In children, the pain is most often bilateral. Symptoms include photophobia (sensitivity to light), phonophobia (sensitivity to sounds), nausea, vomiting, and movement sensitivity.
    • Treatment (acute): Ibuprofen (7.5 - 10 mg/kg) max=800 mg.
    • Acetaminophen (2nd choice). Dose: 15 mg/kg up to 1000 mg.
    • If not effective, try sumatriptan (Imitrex®) nasal spray. Use 10 mg for kids weighing 44 -85lb. Use 20 mg for kids over 85 pounds.
    • Children age 6 to 10 years old weighing less than 110 lbs. should begin with the smallest available dose of triptan. (Sumatriptan-25mg)
    • Treat early for maximum effectiveness.
    Treatment of migraine headache in Pregnancy
    Migraine treatment of choice for pregnant patient: 1000mg Acetaminophen + 10mg metoclopramide.
    Second line: May also use butalbital/APAP/caffeine or Acetaminophen/codeine #3.

    REBOUND HEADACHES (MOH: Medication Overuse Headache) Key points:

    Diagnostic criteria include:
    • Headache - 15 or more days per month in a patient with a pre-existing headache disorder
    • Regular overuse for more than three months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache:
    Overuse of headache medications whether Rx or OTCs for just a few months can make their headaches worse when patients take meds frequently for migraine or tension headaches.

    Here are the drugs most likely to cause medication overuse headaches (MOH) and their % of reported incidence.

    Caution patients to avoid using:
    • butalbital/ acetaminophen (Fioricet®) for 5-8 or more days/month (causes 48% of MOH)
    • acetaminophen (Tylenol®) (causes 46% of MOH)
    • an opioid for 8 or more days/month (causes 33% of MOH)
    • aspirin analgesics (Excedrin®, Bufferin®), (aspirin causes 32% of MOH)
    • Triptans: do not use more than 10-14 days per month. That is why drugs like sumatriptan are packaged in 9 tablet boxes. (Triptans cause 18% of MOH)
    • NSAIDs (Motrin®, Aleve®) for 10 or more days/month. (10% of MOH)
    • Strategy for treating medication overuse headache:
      • Stop abruptly the over-used meds like NSAIDS and triptans
      • Taper butalbital and opioids.
    Treatment of withdrawal headaches:
    symptoms: worsening headache, anxiety, nausea or vomiting, disturbed sleep present for several days or longer.
    Select a drug from another class
    Antiemetic if needed- prochlorperazine (Compazine®) or metoclopramide (Reglan®) helps with nausea AND headache pain.
    Prednisone 100 mg/day for 5 days helps with inflammation but not pain.

    KEEP A HEADACHE DIARY
    • Chart your symptoms, even those that seem unrelated to headaches.
    • Be sure to include dates, times, and weather.
    • Chart what you were doing, eating, or drinking before the headache began. Log the duration of the headache.
    • Log the medications you took to treat the headache and their efficacy
    AVOID opioids and butalbital for headache treatment!!
    USE prophylactic therapy, which will be discussed in the next session.

    I was a leader of a Boy Scout Troop for almost 20 years. When I think of migraine headaches in kids one of my Scouts stands out. He got a migraine at almost every campout. Whether it was the smoke from the fire or just fatigue, he frequently went home with a massive headache.

    It taught me to remind every patient to keep a good headache diary and to isolate the trigger and do your best to avoid them.

    Rebound headaches can be challenging too. Sometimes the very therapies that are prescribed can be the most important contributory factor to causing rebound headaches.

    Have a great day on the bench!!

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    Acute Relief of Migraine Without ‘Triptans’

    GEPANTS AND DITANS

    CGRP Antagonists for TREATMENT of ACUTE MIGRAINE HEADACHE
    ‘Gepants’ are small molecule drugs which block the CGRP receptor and are effective at both relieving migraines and preventing them. ‘Gepants’, unlike the heavier monoclonal antibodies, rapidly penetrate the brain, so they work quickly; however, they are metabolized in the liver so there is a higher potential for interactions and possibly liver damage. Consider use after patients fail on two triptans, or can’t take triptans due to cardiovascular issues. Two have been approved to date:

    Ubrogepant (Obrelvy®) 50mg and 100mg tablets: Approved Dec 23, 2019
    Dose: 50 to 100mg with or without food, at first sign of migraine headache. If needed a second dose can be taken after 2 hours. Maximum daily dose is 200mg.
    Can be used to treat up to 8 migraines a month.
    Drug interactions: caution with strong CYP450-3A4 inhibitors or inducers. See package insert for liver failure, strong and moderate inducers or inhibitors of CYP450-3A4. Avoid in renal failure.
    Adverse effects: nausea, somnolence, dry mouth, dizziness, or upper respiratory tract infections between 2-5% of patients.
    Good news: no cardiovascular warnings, not controlled, not habit forming, savings card program.
    Bad news: cost is over $90 per pill

    Rimegepant sulfate (Nurtec ODT®): Approved Feb 27, 2020.
    Dose: 75mg one tablet as a single dose. Maximum is one tablet daily.
    Drug interactions: Avoid with strong CYP3A4 inhibitors, strong or moderate CYP3A4 inducers. Refer to package insert.
    Adverse effects: Nausea and vomiting
    Good news: no cardiovascular warnings, not controlled, not habit forming, savings card program.
    Bad news: cost is over $90 per pill

    Atogepant: A third ‘gepant’, atogepant, is currently being studied for use as a migraine preventive.

    ‘DITANS’
    Lasmiditan (Reyvow®) is a newly approved (October 2019) migraine abortive tablet. Available: 50- and 100-mg tablets, is a controlled (Schedule V) substance.
    Ditans: Referred to as a Neurally Active Anti- Migraine Agent (NAAMA); it is a specific 5HT1F agonist. Lasmiditan has much higher affinity for the 5-HT1F receptor than for the vasoconstrictor 5-HT1B receptor. No constriction of the coronary or cerebral vessels and offers an alternative for those who cannot take the triptans. No better or no worse with respect to efficacy compared to triptans.
    Warnings: do not drive for 8 hours after dosing, due to drowsiness even if not feeling impaired. Watch for serotonin syndrome.
    Take home: The efficacy of lasmiditan proves that vasoconstriction is not essential for acute migraine therapy and thereby points, in addition to a well-established trigeminal contribution, to central neuronal mechanisms in migraine pathophysiology.

    I tell my student pharmacists of a quote I once heard about health care. "Five years after you graduate, 50% of what you learned in pharmacy school will be obsolete." Neurology, more than any other discipline, supports that quote.

    In just the past 18 months we have had 7 drugs approved for the treatment of migraine headache. There are 4 CGRP monoclonals we discussed last week, 2 ‘gepants’ and one ‘ditan’!

    What fascinates me with this class of drugs is their lack of influence on the blood vessels. We all believed that the vasodilation was the cause of migraines and by "shrinking" those vessels we stopped the process. If that is the case, how do we explain ‘ditans’, ‘gepants’ and non-steroidal anti-inflammatory drugs having such efficacy in migraine treatment?

    As far as the brain goes, we are still in the infancy stage of our understanding of this amazing organ!

    Have a great day on the bench!!

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    Headache Prevention with CGRP Therapy

    CGRP BLOCKERS-- JUST WHAT OUR PATIENTS HAVE BEEN WAITING FOR? MAYBE SOME.

    CGRP (calcitonin-gene-related peptide) when released causes intense inflammation in the coverings of the brain (the meninges), and for most migraine patients, causes the pain of a migraine attack. This peptide causes vasodilatation which causes several pain processes, most notably migraine headache.

    Mechanism: drug therapy is directed against calcitonin gene related peptide (CGRP) or its receptor for the preventive treatment of migraine and cluster headache. Calcitonin gene-related peptide (CGRP) is a vasoactive peptide, involved in dilation of cerebral and dural blood vessels. Widely distributed throughout the body, CGRP levels in serum increase during migraine or cluster headache.

    MONOCLONAL ANTIBODIES----Prevention

    Erenumab-aooe (Aimovig®) 70mg ------cost $725/month approved April-2018
    Dosing: Recommended dosage for migraine prophylaxis is 70 mg once monthly given as a subcutaneous injection; some patients may benefit from a dosage of 140 mg once monthly. The 140 mg dose is administered once monthly as two consecutive injections of 70 mg each.
    Mechanism: CGRP-receptor antagonist (it blocks the CGRP receptor)
    Efficacy: the number of migraine days per month was reduced by 3.2 in the 70 mg erenumab-aooe group; 3.7 in the 140 mg erenumab-aooe group, and 1.8 in the placebo group.
    Half-life: 28 days
    Time to peak: 6 days
    Side effects: injection site reaction and constipation. Constipation may be significant, best to avoid in patients already suffering from constipation, or taking constipation inducing meds (TCA’s, opioids)
    Storage: Store under refrigeration. Allow to come to room temperature for 30 minutes before administration

    Fremanezumab-vfrm (Ajovy®) ----cost 725.00 per month. Approved Sept-2018
    Dosing: For migraine prophylaxis: Two subcutaneous dosing options are available to administer the recommended dosage:
    • 225 mg monthly, or
    • 675 mg every 3 months (quarterly) Given as 3 consecutive injections.
    Mechanism: Fremanezumab-vfrm attaches to the CGRP molecule, preventing it from activating CGRP receptors by distorting the CGRP protein so that less of it can connect to the receptors.
    Half-life: Estimated at 31- to 39-days Storage: Remove from the refrigerator. Prior to use, allow AJOVY to sit at room temperature for 30 minutes protected from direct sunlight.

    Galcanezumab (Emgality®) cost= $725/month Sept 2018
    Mechanism: calcitonin gene-related peptide (CGRP) antagonist that attaches to the CGRP molecule, preventing it from activating CGRP receptors by distorting the CGRP protein so that less of it can connect to the receptors. Galcanezuman is ligand antagonist.
    Half-life: 25- to 30-days
    Administration: SC injection.
    Indications and Dosage:
    Two adult indications:
    • Preventive treatment of migraine: First dose is a loading dose of 240 mg, or 2 injections of 120 mg each, which may be administered in the doctor’s office, or by the patient. After that inject 1 dose each month.
    • Treatment of episodic cluster headache (approved June 2019) The recommended dosage is 300 mg (three consecutive subcutaneous injections of 100 mg each) at the onset of the cluster period, and then monthly until the end of the cluster period.
    Aimovig®, Ajovy®, Emgality®:
    • All thee were approved between May and September 2018
    • All three cost the same $725.00 per injection. All have copay coupons for commercial insurance.
    • All three can be injected in the abdomen, upper thigh, or upper arm. All list injection site reactions as side effects
    • Aimovig® contains latex, the others are latex-free.
    • Only Emgality®, thus far is approved for cluster headache treatment. It also is available as an auto-injector (like the Trulicity® device)
    Eptinezumab-jjmr (Vyepti®) approved February 2020
    Mechanism: attaches to the CGRP molecule, preventing it from activating CGRP receptors by distorting the CGRP protein so that less of it can connect to the receptors.
    Administration & Dosage: IV infusion in a health care setting, every 3 months. Do not push IV.
    The recommended dosage is 100 mg administered by IV every 3 months; however, some patients may benefit from a dosage of 300 mg administered by IV every 3 months. No loading dose needed. Infuse over a 30-minute period.

    How well I remember in the early 1990’s when sumatriptan became available! Migraine sufferers before that time had Fioricet®, Fiorinal®, Midrin®, and Cafergot®. None of these products are recommended today. Now we have the CGRP blockers for acute migraine relief as well as prophylaxis.

    Will this new class of drugs be the wonder drugs of migraine therapy? So far patients either love them or hate them. I had one patient who had not met his deductible and had a $450 copay. He said, “for this ability to have a normal month I’m fine with paying $15 per day.” Now that he met his deductible his copay is $35 and both pharmacist and patient are a lot happier!

    Have a great day on the bench!!

    June 2020

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    The Use of Selective Serotonin Receptor Agonists in the Management of Migraine Headache

    TRIPTANS- THE GAME CHANGER IN MIGRAINE HEADACHE RELIEF

    TRIPTANS: The medications we discussed last week that we are not supposed to use for migraine headache treatment, were the mainstay of therapy until the early 1990’s. In December of 1992 Imitrex (sumatriptan) injection was approved by the FDA, and the oral dosage form was approved in June of 1995. This profoundly changed acute migraine headache treatment. No more caffeine/ergotamine and oxycodone for migraine treatment, and doctors stopped prescribing both of these drugs in the mid 1990’s for headache.

    Mechanism: activate 5HT1b and 5HT1d and 5HT1f, which make them laser focused for migraine treatment. The net effect of triptans is to constrict cranial blood vessels and suppress inflammatory neuropeptides.
    Even though these drugs are laser focused for migraine treatment, 7-30% of patients will not respond to triptans. When this occurs consider allodynia, where triptans are used after aggressive dosing of non-steroidal anti-inflammatories (NSAIDs).

    Adverse effects: tingling, paresthesias, sensation of warmth in neck & head chest and limbs. Do not use triptans within 24 hours of ergots or other triptans.

    Contraindications: ischemic heart disease, myocardial infarction, uncontrolled hypertension, other heart disease. To reduce the potential for angina, do not give if risk factors: obesity, diabetes, hypercholesterolemia, as well as smokers, men over 40 and post-menopausal women.

    Selective Serotonin Receptor Agonists (Triptans):
    BRAND NAMEGENERIC NAMEAVAILABLE STRENGTHDOSAGEMAX DAILY DOSAGEHALF-LIFEONSET(in minutes)
    Axert®AlmotriptanTablets 6.25, 12.512.5mg; repeat in 2 hours25mg3.5 hours60 min
    Imitrex®SumatriptanAvailable StrengthTablets 25, 50, & 100mg200mg2.5hr60-120 min
    Nasal spray 5mg, 20mg5 or 20mg. Repeat in 2 hours40mg15-20 min
    Inject 6mg/.5ml New:4mg/.5ml6mg, repeat in 1 hour12mg10-15 min
    Treximet®Sumatriptan + naproxen85/5001 tablet; may repeat in 2 hours. Max 2/day170/1000mg60-120 min
    Relpax®EletriptanTablets 20 & 40mg20mg-40 Repeat in 2 hours80mg5hr60 min
    Frova®Frovatriptan2.5mg2.5mg repeat in 2 hours7.5mg25 hours (longest)60-120 min
    Maxalt®RizatriptanTablet/wafer 5mg, 10mg5 or 10mg. Repeat in 2 hours30mg2-3 hours30 min
    Zomig®ZolmitriptanTablet/wafer 2.5mg, 5mg2.5-5mg repeat in 2 hours10mg2.5-4 hours45 min
    Amerge®Naratriptan1mg & 2.5mg1mg or 2.5mg repeat in 4 hours5mg6 hours60 min


    COST: all the products above are available as generics. However due to competition, or lack thereof, there is great variability in pricing of the generics. Sumatriptan and Rizatriptan are the cheapest, with almotriptan and frovatriptan being the most expensive.

    OK I give up why do we need 7 different triptans??????
    • If you fail on a triptan, the second choice might work better
    • Faster onset—injections work quicker (10-15 minutes) so do nasal sprays (15 minutes). Also, good if patient is vomiting. (note that orally disintegrating tablets do NOT work faster).
    • Long half-life drugs like Frovatriptan and Naratriptan may be more useful for menstrual migraines—more useful for prevention than to abort a headache.
    The Headache Specialist says, “Using TRIPTANS for Migraines”:
    • Reduces all aspects of migraine disability
    • Minimal or no sedation
    • Intrinsic antiemetic properties
    • Drug induced headache is uncommon if use optimally. (Use high dose early)
    • Use 1 pill per headache
    One of the best pieces of advice we can give our patients came from a headache seminar I attended was “Take one and you are done.” The specialist also advised to take the maximum dose available to get rid of the headache. “Hit the headache hard and early on.”

    Most patients know when a migraine is coming, and at the first sign they should take a full dose of a triptan. The specialist stated he had no time for sumatriptan 25mg or the 50mg.

    He also recommended “cleaning up” the inflammatory neuro peptides with NSAID therapy, such as ibuprofen or naproxen, both high doses. Triptans have indeed changed the management of migraine headaches, especially now that the class is very affordable.

    Have a great day on the bench!!

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    Ergots and Opioids: No Place in Migraine Management

    WHAT NOT TO USE FOR MIGRAINE HEADACHE RELIEF
    Ergotamine preparations
    Mechanism: in the cranial arteries, it promotes constriction and decreases pulsation.
    Migraine activity might be due to agonist activity at serotonin receptor subtypes
    5-HT1b and 5HT1d
    Adverse effects: can stimulate the chemoreceptor trigger zone and cause nausea and vomiting in 10% of patients. Weakness in legs, myalgia, numbness & tingling in periphery. May also cause angina-like pain.
    Ergotism from chronic or acute overdosage. Symptoms include hallucinations, severe gastrointestinal upset, abortions, dry gangrene, and a painful burning sensation in the limbs and extremities commonly known as “St. Anthony’s Fire”. Ergotism was commonly seen in the middle ages as a fungal infestation of grains, especially rye grains.
    Contraindications: ischemic heart disease, myocardial infarction, uncontrolled hypertension, other heart disease and pregnancy.
    To reduce angina: do not give if risk factors: obesity, diabetes, hypercholesterolemia, smokers, men over 40, post-menopausal women.

    Drug therapy:
    Ergotamine + caffeine:
    Cafergot®: tablets: 1mg ergotamine + 100mg caffeine.
    Dosage: Take 2 tablets at onset. Then every 30 minutes as needed.
    • Maximum daily dose: 6 tablets per day.
    • Maximum weekly dose: 10 tablets per week
    Dihydroergotamine:
    Migranal® nasal spray 4mg/ml.
    Dosage: 1 spray (0.5mg) each nostril every 15 minutes for a maximum of 4 sprays.
    Don’t exceed 3mg/day (6 sprays)
    Don’t exceed 4mg/week (8 sprays)

    D.H.E.® injection: Dosage 1ml IM, IV or SC every 1 hour to a maximum of 3ml per 24 hours. (2ml if IV)
    • Maximum= 3ml per 24hr if SC or IM. 2ml max if IV. max =6ml per week.
    • Best to combine with metoclopramide (Reglan) for nausea
    Dr Robert Kaniecki: headache seminar:
    • Ergotamines are “hopelessly outdated”.
    • All ergots are pharmacologically non-selective.
    • Narrow window of opportunity
    • Enhances Nausea
    • Modest efficacy (little difference from NSAIDS)
    • Cardiovascular effects
    OPIOIDS : GENERAL PRINCIPLES

    Side effects for opioids:
    Lightheadedness, dizziness, drowsiness, shortness of breath, nausea, vomiting, CONSTIPATION
    Contraindications for opioids:
    Alcoholics, heart failure, patients with opioid abuse potential
    Patient information for opioids:
    • Watch for drowsiness, caution driving. Avoid alcohol
    • Caution abuse potential, using and storage.
    • Do NOT adjust dose without consulting prescriber.
    • Caution if used in pregnancy
    REMEMBER: Patients treated with opioids as first-line therapy are significantly more likely to return to the emergency department with a headache within seven days of the original visit

    Dr Robert Kaniecki stated at the headache seminar:
    Use of opioids for migraine treatment:
    • Pro-inflammatory! (migraine is an inflammatory disorder)
    • Vasodilator
    • Increases nausea and vomiting
    • Sedating
    • Drug seeking behavior
    • (No contraindications with vascular disease: benefit)
    I was so frustrated when I saw a student pharmacist’s notes that had 29 pages of ergot alkaloids. Discussion of ergot alkaloids has a rich history that dates to known cases in the Middle Ages, that caused gangrene and hallucinations. The Salem witch trials were believed to be due to ergotism.

    It has been postulated that the 10th plague of the Egyptians was also due to wheat being infected by the ergot fungi (Claviceps purpurea) which caused ergotism, and then death of the first-born Egyptians. Yes, history is fun, but there is so much to learn about treatment of disease states with pharmacotherapies that are actually used.

    Dr Kaniecki with many years of headache management hit the nail on the head… “Ergots are hopelessly outdated.” I say they belong in the history books, and not occupy 29 pages in a student pharmacist’s lecture notes!

    Have a great day on the bench!!

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    First Line Therapy for Tension and Migraine Headaches

    USE OF GENERAL ANALGESICS FOR MANAGEMENT OF ACUTE HEADACHES
    (tension or migraine)

    For mild to moderate migraine attacks not associated with vomiting or severe nausea, simple analgesics (NSAIDs, acetaminophen) or combination analgesics are first choice agents because they are effective, less expensive, and less likely to cause adverse effects than migraine-specific agents such as triptans or ergots.

    ACETAMINOPHEN: Mechanism: possibly decreases central prostaglandin synthesis (?). (mechanism unknown)

    Acetaminophen dosing:
    • max: 4000mg /day in healthy patient
    • max: 3000mg if drinking alcohol (social)
    • max: 2000mg if an alcoholic- best to limit acetaminophen use
    Drug interactions/Adverse Effects:
    Acetaminophen-induced hepatotoxicity is the most common cause of acute liver failure in the U.S. Around 30,000 patients are hospitalized each year in the U.S. to undergo treatment for this condition.

    Acetaminophen: warfarin- may result in significant elevations of international normalized ratio (INR), putting patients at increased risk for hemorrhage. If acetaminophen is necessary at doses near or greater than 2 g/day for more than 1 day, an extra INR measurement should be considered.

    NONSTEROIDIAL ANTI-INFLAMMATORIES:
    Mechanism: NSAIDS inhibit cyclooxygenase (COX-1 & COX-2) which are enzymes that catalyzes the synthesis of prostaglandins, which are hormone-like substances that participate in a wide range of body functions such: as the contraction and relaxation of smooth muscle, the dilation and constriction of blood vessels, control of blood pressure, and modulation of inflammation. Prostaglandins are derived from a chemical called arachidonic acid.
    • Blocking COX-1 : causes blood thinning (good) and stomach ulcers (bad)
    • Blocking COX-2: causes coagulation (bad) and protects stomach (good)
    RX NSAIDS: Short-acting NSAIDS, with a duration of less than six hours include: ibuprofen (Motrin), diclofenac (Voltaren), etodolac (Lodine) and indomethacin (Indocin)

    Long-acting NSAIDS, with a duration of action over six hours including naproxen (Naprosyn), meloxicam (Mobic), celecoxib (Celebrex), nabumetone (Relafen)

    OTC NSAIDS:
    Aspirin: 325mg tablets, 165mg & 81mg tablets (Ecotrin max strength 500mg & 650mg)
    • Dosage: 1 or 2 tablets every 4 hours as needed for pain
    • Monitor for increased bleeding with warfarin and aspirin
    • May cause tinnitus.
    Ibuprofen (Advil®, Motrin®) 200mg tablets OTC 400,600,800mg RX
    • Dosage 200 every 4-6 hours prn
    • OTC maximum is 1200mg; Rx maximum is 3200mg
    Naproxen sodium (Aleve®) 220mg OTC Anaprox® 275 &550mg RX
    • OTC Dosage: 220 every 8-12 hours. OTC maximum=440-660mg
    • Rx maximum dose: Anaprox® (1100-1650)
    • Rx maximum dose: 1000-1500mg (Naproxen-Naprosyn®)
    Side effects for NSAIDS: GI toxicity, bleeding, ulceration
    Contraindications for NSAID:
    • Caution if renal impaired, may cause nephrotoxicity
    • All are pregnancy Category –D in third trimester
    • active GI disease
    • Caution in liver impairment
    • GI bleeding
    • Photosensitivity
    • Avoid Aspirin & alcohol while taking NSAID
    • Watch for increased hypertension
    • Exacerbation of heart failure
    • Increased risk of myocardial infarction, stroke, CV death
    Patient information:
    • Know signs and symptoms of GI bleeding
    • Photosensitivity
    • Avoid Aspirin & alcohol while taking NSAID
    • Take with food to avoid GI upset
    • Asthmatics –caution with aspirin
    • Do not take OTC NSAIDS with prescription NSAIDS
    Drug interactions:
    • All OTC medications should be used with caution in Warfarin patients, including acetaminophen
    • Do not take with other NSAIDS
    Numerous combinations of OTC meds with aspirin & acetaminophen:
    • Percogesic® (acetaminophen + diphenhydramine)
      • Acetaminophen 325 mg/diphenhydramine 12.5 mg: 2 tablets orally every 4 to 6 hours as needed
      • Acetaminophen 500 mg/diphenhydramine 12.5 mg: 2 tablets every 6 hours as needed
    • Excedrin® (aspirin 250mg + acetaminophen 250mg + caffeine 65mg) 2 caplets as a single dose
    • Bufferin® (aspirin 325mg + calcium carb+ mag carb + mag oxide) 2 tablets every 4 hours as needed (maximum of 12 per day)
    • Vanquish® (acetaminophen 194mg + aspirin 227mg + caffeine 33mg) max=8 caplets/day
    Other techniques to recover from headaches:
    • Lie down and relax
    • Use warm/cold compresses (your choice)
    • Warm bath or massage
    • LIMIT number of pillows!
    Dr. Robert Kaniecki: Headache Seminar offered the following about NSAID use for Migraine Headache:
    • Relatively unlikely to cause drug induced headache.
    • Safe in the presence of vascular disease
    • No Sedation
    • No Increase in Nausea
    • Efficacy for mild to moderated headache
    • High doses are to be used.
    Migraine is an inflammatory disorder.

    Can you imagine a world without over the counter ibuprofen and naproxen sodium? Up until May 18,1984, ibuprofen was prescription only. It was not until ten years later in January 1994, did naproxen come over the counter.

    I'm glad as a pharmacist we can recommend over the counter therapies to help our patients get inexpensive, quick and immediate relief for their headaches. When I spend two days a week at the Empower-3 family practice office, I see the "dark side" of NSAIDS. All of the providers are in agreement that these drugs need to be prescribed with a lot of caution. One of the physicians "detests" NSAIDs given to anyone with cardiac issues, renal issues and even hypertension that is not well controlled.

    If we see patients on long term NSAIDs at the clinic, we always check renal function to see if these prostaglandin blockers are inhibiting renal perfusion, as they are notorious for blocking afferent vasodilatation to the glomerulus.

    If ever we need a third class of drugs for pharmacist dispensing only, NSAIDs would be the first class of drugs I'd bring behind the counter... right next to the pseudoephedrine!

    Have a great day on the bench!!

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    Differentiating Between Types of Headaches: Tension, Migraine and Cluster

    TYPES OF HEADACHES

    Tension Headache definition: Also referred to as “chronic scalp muscle contraction headache”, tension headaches affect BOTH sides of the head and scalp with pain that may radiate to the jaw and shoulders. Due to blood vessel changes taking place from muscular components, causing a “band like vise” around the head. Chances are, that if an OTC recommendation can be made and is successful, it is probably a tension headache. Patients usually do not go to the physician to get treatment for tension headaches.

    Migraine headache definition: A migraine is a type of headache, usually occurring with symptoms such as nausea, vomiting, or sensitivity to light and sound. In many people, a throbbing pain is felt only on one side of the head. Migraines may last from 4-72 hours, patients will lay down for relief (turn out lights, have quiet). Migraine headaches tend to first appear between the ages of 10 and 45. Migraines may run in families. Source: Migraines start in the trigeminal nucleus caudalis.

    GENDER DIFFERENCES:
    • Women are twice as likely to get migraines than men (17.5% women experience migraines as opposed to 8.6% of men). Some women, but not all, have fewer migraines when they are pregnant.
    • Women report a longer attack duration, increased risk of headache recurrence, greater disability, and a longer period of time required to recover.
    • Women are more sensitive to triggers of smell and are more likely to become nauseous.
    • Men are 35% more likely to report overexertion as a migraine trigger. Men are more sensitive to light.
    Classic migraine (migraine with aura): recurring headache that strikes after or at the same time as sensory disturbances called aura. These disturbances can include flashes of light, blind spots and other vision changes like zigzags or loss of vision. Aura patients have more dramatic presentation of multiple clinical manifestations. Patients may feel a tingling sensation in the hand or face. Migraine with aura is associated with a 2-fold higher risk for ischemic stroke. About 1/3 of patients with migraine may experience aura although most do not experience aura with every migraine.

    Common migraine (migraine without aura): associated with nausea, vomiting, or both and are frequently accompanied by sensitivity to light, sound, and movement. If untreated, these headaches can last up to 72 hours.

    Allodynia: feel pain from stimuli that do not normally cause pain, such as combing one’s hair. Is caused by central sensitization in the brain.
    • Triptans do NOT work for allodynia
    • Treatment: start with Non-Steroidal anti-inflammatories, then follow up with a triptan in one hour.
      • (source: Dr. Gary Jay - PAINWEEK)
    Triggers: Encourage patients to identify and avoid triggers… skipping meals, disrupted sleep, stress, alcohol, wine, cheese, aspartame, etc.

    Cluster headache: a form of migraine often characterized by brief, but frequently recurrent bouts of severe headache. Frequently referred to as “suicide headaches”. Headaches may last from 45 minutes to 3 hours, maximum. May occur every other day or up to 8 times per day, even the same time each day known as circadian periodicity.
    • Patients will not lie down; they are extremely agitated and incapacitated. They walk and pace and have been known to bang their head off a wall to deflect the pain.
    • Clusters may occur in groups of up to 8 a day lasting for weeks or months.
    • Pain is intense, concentrate on 1 side of head, accompanied by “Cranial autonomic symptoms” such as tearing of the eye, runny nose, fullness of the ear and a droopy eye on the same side.
    Origin: hypothalamus, near where circadian rhythm is governed.
    Typical patient: is a middle-aged male who smokes.

    I had one of the best learning experiences in my professional career back in in 2006 when I attended “Migraine: A Day at the Office.” Where the faculty included the two top flight experts in migraine management on the East Coast, Mark W. Green Clinical professor of Neurology: Director of Headache Medicine, Columbia University and Dr Robert Kaniecki Asst. Professor of Neurology University of Pittsburgh; Director the Headache Center, Pittsburgh, PA.

    The 8-hour session I attended with my wife and daughter taught an incredible amount of information that I use to this day. For the past two Septembers, I spent a week in Las Vegas with my son-in-law Mark Garofoli and got at least 24 hours of pain management CE, including headache management.

    At the request of many fellow clinicians, I am starting a Neurology unit, since we spent five months covering Mental Health Meds. There are at least 6 new products that have been introduced in the past 2 years, and we need to learn the role of these medications. I remember well when the triptans came out in the 1990’s and changed headache management. Will the CGRP inhibitors do the same?

    Have a great day on the bench!!

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    Adolescent Sleep Deprivation: Addressing the Problem

    GETTING THE TEENS TO "UNPLUG"

    The teenage brain is not an adult brain with fewer miles on it. During adolescence, the teen brain is only 80% developed. The frontal lobe (responsible for reasoning, planning, judgement, emotional expression, problem solving, memory, language, and sexual behaviors) is not fully in gear until age 25-30.
    The adolescent brain more susceptible to alcohol induced toxicity. Adult brain cells recover faster. The teen brain is more susceptible to marijuana as well, by blocking cell signaling. What teens did last weekend still affects test taking skills on Thursday. Indulging in alcohol and marijuana over the weekend can cause a “Self-induced learning disability” Teens should not be consuming massive amounts of caffeine to keep alert due to lack of sleep

    PUT DOWN THE SCREEN and GO TO SLEEP!

    The blue light emitted by screens on cell phones, computers, tablets, and televisions restrain the production of melatonin, the hormone that controls their sleep/wake cycle or circadian rhythm.
    About 72 percent of children ages six to 17 sleep with at least one electronic device in their bedroom!
    • which leads to getting less sleep on school nights compared with other kids
    • almost an hour of sleep per night is lost
    • quality of sleep is negatively impacted
    Read a book! And here is why:
    Using any device in the hour before bed was associated with a 13 to 52 percent increase in the likelihood of needing more than 60 minutes to fall asleep. More than four daytime hours of screen time was associated with a similar increase in risk of “sleep latency,” or taking a long time to fall asleep. This technology provides excess stimuli and can trick your brain into thinking that it needs to stay awake.
    • Checking Facebook, Twitter, Instagram
    • Reading Email
    • Web surfing
    • Gaming
    GAMING: (source: Psychology Today, March 2011)
    • A growing body of evidence shows that video games and other electronics induce the fight-or-flight syndrome, putting the body in a state of stress. Think adrenalin and stimulation of the sympathetic nervous system.
    • Studies show sustained increases in blood pressure and pulse, even hours after playing a video game. It does not have to be a violent game, or even an action game-or even a game at all!
    • Over time, internet surfing and texting will similarly put the brain and body in a state of stress, just from the high level of visual and cognitive stimulation
    TAKING CONTROL of SLEEP---Sleep Tips to Promote Sleep and a Healthy Lifestyle
    Establish a regular sleep schedule
    During the day:
    • Exposure to light in the morning
    • Avoid caffeine, alcohol and nicotine
    • Exercise, but not too close to bedtime
    • Avoid lengthy or late naps
    Establish a regular bedtime routine
    About one hour before going to bed:
    • Engage in a relaxing, non-alerting activity
    • Do not drink or eat too much
    • Maintain a quiet, dark and preferably cool, but comfortable sleep environment. TV, computers, notepads, phones etc need to be turned off and powered down completely.
    Happy 5th Anniversary to Clinician’s Corner! The first Clinician’s Corner was published the first week in May 2015 for a local wholesaler to spread practical information to my fellow community pharmacists. The first column covered much needed information on Lyme Disease. In December 2015, with the help of Duquesne student Vinnie Longhi, who was doing the Rural Pharmacy Rotation and staying in our house showed me how to set up this MailChimp account. Vinnie insisted that I need to share my information with more than just customers of the warehouse.

    In the Fall of 2016 Kevin McCarthy from PharmCon “discovered” this column and made it part of his website at legacy.freece.com naming it “Professor Pete’s Practice Points” and made it available to over 50 thousand pharmacists nationwide. My first column for freece.com was published December 22,2016, discussing the concerns of Dextromethorphan cough syrup.

    The next big change came in December of 2019, when under the leadership of Kevin Hope and Julie Strickland from FreeCE, they began converting these columns to “micro-CE’s.” Recently an educator remarked that the average attention span today is about 22 minutes, so FreeCe.com is leading the way with my column in providing pharmacists continuing education in meaningful small bites.

    This column is #270, and I have never repeated a column that has been published by Freece.com. For the past 5 long months I have focused entirely on Mental Health (Psych) drugs. The Physician Assistants at the family practice clinic wanted me to cover psych drugs as they feel they needed brushing up on this class of meds. I am always willing to take requests and using my lecture notes I further develop topics that make for a quick 20 minute read.

    I am humbled to see how many of my fellow pharmacists, former students and physicians read this column to help provide the latest information to their patients. I am most appreciative to my colleagues at FreeCE.com.

    Have a great day on the bench!!

    May 2020

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    Adolescent Sleep Deprivation: Defining the Problem

    ADOLESCENT SLEEP DEPRIVATION: DEFINING THE PROBLEM

    The numbers and percentages are staggering. 85% of teens get less than the minimum requirement of 8 ½ hours of sleep. We all are aware that shortened sleep impairs learning, performance, health and safety. Nearly 55% of fall-asleep crashes involve drivers 25 years of age or younger. It is no surprise that almost ¼ of young adults report driving faster when drowsy.

    Why we need consistent sleep:
    • Sleep plays a vital role as adolescents develop and go through the maturation process. Adolescence is a time of increased responsibility, peer pressure and busy schedules.
    Sleep is:
    • food for the brain – produces alertness, enhances memory and the ability to learn
    • a biological requirement – helps the body perform effectively and safely
    • essential for development, particularly during growth and maturation
    • a key to good health – as important as good nutrition and regular exercise
    Sleep is a basic human drive regulated by two biological systems:
    • Sleep/Wake Homeostasis: The drive to sleep that increases the longer we are awake
    • Circadian Rhythms: The internal clock in our brain that regulates when we feel sleepy and when we are alert
    Sleep is regulated by a biological clock in the brain. The internal mechanism that regulates when we feel sleepy and when we feel alert resides in the brain and is affected by light and dark.
    • Melatonin: appears to increase the binding of GABA to its receptors by affecting membrane characteristics, not by increasing the number of receptors. GABA is an inhibitory pathway.
    • Orexin: is a neurotransmitter found in a specific part of the brain that can help keep a person awake.
    • “Non-24”: Non-24-hour sleep-wake disorder (N24) is a circadian rhythm sleep disorder in which an individual's biological clock fails to synchronize to a normal 24-hour day. Normally we fall asleep at the same time, but patients with this disorder will typically find their sleep time gradually delaying by minutes to hours every day.
    TEEN SLEEP DEPRIVATION
    • Teens need 8½ – 9½ hours of sleep, and 85% get less than the minimum requirement.
    • Teens often have poor sleep habits and irregular sleep patterns – trying to make up for sleep on weekends.
    • Teens regularly experience daytime sleepiness.
    • The biological clocks of children shift during adolescence, which drives them to a later bedtime schedule (around 11:00 pm) and a natural tendency to wake later in the morning.
    • This delayed phase syndrome can place them in conflict with their schedules – particularly early school start times.
    CONSEQUENCES of SLEEP DEPRIVATION

    PHYSICAL CONSEQUENCES
    • Cognitive, social, and behavioral performance become impaired.
    • Poor school performance and lower grades
    • Tardiness and absence from school
    • Difficulty remaining alert and paying attention
    • Reduced ability to concentrate, problem-solve, remember, and have a positive attitude
    EMOTIONAL CONSEQUENCES
    • Irritability and impaired moods
    • Problems controlling emotions and getting along with others
    • Greater risk for hyperactivity, depression and possibly violence and substance abuse
    • At risk for injuries and drowsy driving accidents
    • Overall, daytime sleepiness reduces enjoyment and quality of life.
    Even as a high school student back in the 1970’s, bedtime was no later than 9:30 on a school night. We got up every morning by 6:30am to get ready for school and catch the school bus at 7:25am. There were no negotiations; bedtime was a hard and fast rule with our family.

    Although my parents were inflexible about bedtime, there were none of the distractions that teens are “blessed” or more like cursed with. We did have a 13-inch black and white TV in the bedroom I shared with two brothers and that was it. There were no cell phones, iPads, gaming devices, Facebook, Twitter, Instagram and the countless electronic distractions that teens have today. The gray screens really do impact sleep induction so phones and tablets can mess up a good bedtime routine.

    Worse, are the gaming devices that many teens are addicted to. I hear of teens staying up until 3:00am and some as late as 5:00am playing games on their devices.

    Even in my days as a university student, I never stayed up past 11:00pm studying for any exam. My brain seemed to fry, and I was seeing less results as the night wore on. I was at the point of diminishing returns and a good night sleep gave me more benefit than cramming all night.

    Time management and sleep management are so sorely needed by today’s youth.

    Have a great day on the bench!!

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    Alternatives to amphetamines and methylphenidate to treat ADHD…

    TREATMENT OF ADHD FOR THE OTHER 20% WHO DO NOT RESPOND TO, OR CANNOT TOLERATE STIMULANTS:
    • Some antidepressants
      • Bupropion (Wellbutrin®) has the most efficacy for adult ADHD
    • Modafinil (Provigil®) functions as a stimulant for excess daytime sleepiness without the apparent severe side effects and withdrawal issues associated with the CII (amphetamines, methylphenidate) medications.
      • Mechanism: is a wake promoting agent but is not a direct- or indirect-acting dopamine receptor agonist. In lab studies modafinil binds to the dopamine transporter and inhibits dopamine reuptake.
      • Warnings: watch for dermatologic and psychiatric reactions.
      • Contraindication: not for use in children of any age
    Best options for “tics” induced by amphetamine use
    Background
    About 20% of ADHD patients have a tic disorder. Stimulants may worsen tics, at least in some patients. Labeling of some stimulant medications contraindicates their use in patients with tics or Tourette’s syndrome. However, recent studies suggest that stimulants can be used safely in patients with tics, and do not always significantly worsen tic

    Atomoxetine (Strattera®): ideal for patients with substance abuse history, tics, or failure on stimulants.
    Mechanism: selectively inhibits presynaptic norepinephrine reuptake in the prefrontal cortex.
    Dose: Given once daily or divided BID without regard to meals. Start with 0.5mg/kg; titrate to a maximum of 1.4mg/kg.
    Warnings:
    • Atomoxetine increased the risk of suicidal ideation in short-term studies in children or adolescents with ADHD
    • Adjust doses down in patients receiving strong CYP2D6 inhibitors such as paroxetine (Paxil®) and fluoxetine (Prozac®) or patients known to be CYP2D6 poor metabolizers. CYP2D6 is enzyme responsible for activating codeine to morphine.
    • May increase heart rate and blood pressure.
    • Frequently causes headache, insomnia and increased anxiety
    Efficacy:
    • stimulants are usually better than atomoxetine (Strattera)
    • You have to treat 5 children with atomoxetine (Strattera) to see a positive outcome
    • You have to treat 3 with methylphenidate to see a positive outcome.
    • Use a stimulant first for most patients
    • Half of patients who don't respond to methylphenidate will respond to atomoxetine (Strattera). (Possibly genetics?)
    • No need to taper the old med when switching to atomoxetine (Strattera)
    Central Alpha Agonists: decrease sympathetic outflow. May be a good choice for patients with tics or insomnia. Clonidine and Guanfacine may be useful in over aroused, easily frustrated, highly active, or aggressive individuals
    • Guanfacine extended release (Intuniv®): Causes sedation, fatigue and hypotension. Start with 1mg, may increase by 1mg per week. Max-4mg/day. Longer half life and fewer side effects than clonidine.
    • Clonidine extended Release (Kapvay®) 0.1mg
      • Dose: 0.1mg at bedtime; titrate to a maximum of 0.4mg at bedtime
    Theories for causing ADHD

    Psychiatry Today Advisor (dated April 14, 2020) listed the following as potential causes for ADHD:
    • Journal of the American Academy of Child & Adolescent Psychiatry suggests low maternal levels of Vitamin-D can cause ADHD (odds adjusted ratio-1.53)
    • Journal of Pediatrics- maternal obesity could contribute to ADHD. Depending on maternal BMI odds adjusted ratio could be as high as 1.96
    • JAMA Network Open: nonionizing radiation, a common exposure given its source in electric appliances, power lines, and wireless network infrastructure, could be another key risk factor in ADHD development
    August Birthdays?
    New England Journal of Medicine:
    Children with August birthdays who are sent to school with a September 1st cut off are more likely to be diagnosed and medicated for ADHD, due to immature behavior. There might be an age difference of one year in the same classroom between kids born in August versus September. The researchers analyzed data from a large insurance company to make this determination. Prescription data was also utilized.

    From the available data, it looks like stimulants have the upper hand in the treatment of ADHD. The downside of those drugs is the fact they are in Schedule-2 and have significant abuse potential. Clinicians always must consider not only the pediatric patient, but the potential of drug abuse from family members.

    About 15 years ago I got a call from the elementary school nurse in the town I practiced in. She asked me to verify what Adderall-XR 15mg caps looked like. My heart sunk, as most pharmacists would question as to whether a dispensing error was made. I described a blue and white capsule with “Adderall-XR 15mg” emblazoned on. She confirmed that is what the capsule looked like, so I wondered about her question.

    She asked what the contents looks like… I described that they were small round pellets kind of like Contact® cold capsules (only us old timers understand that analogy). She went on and said, “so it is not a plain white powder”, and I told her no, it looks like pellets. Just as she suspected a family member was dumping out the medicine and replacing it with a white powder substance (probably powdered sugar) and sending them to school!

    Always consider the family circumstances when prescribing any Schedule-2 substance.

    Have a great day on the bench!!

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    ADHD Treatment with Stimulants: Let’s Not Get Too Comfortable!

    TREATMENT OF ADHD: STIMULANTS

    A little taste of history…

    Amphetamines: blocks or reverse the direction of the neurotransmitter transporters that mediate presynaptic uptake of dopamine, norepinephrine and serotonin. Treatment of ADHD began in 1936 with the approval of Benzedrine®, the racemic mixture of amphetamine (both levo and dextro). Benzedrine® was first approved as an inhaler in 1933. It took until 1959 to require a prescription. According to the AAP (American Academy of Pediatrics), at least 80% of ADHD patients will respond positively to stimulants if used in a systematic fashion. 69.3% of kids with diagnosed ADHD take medication.

    Obetrol®: was a weight loss drug that contained mixed amphetamine salts. At one time Obetrol® had two methamphetamine salts and was withdrawn in the early 1970’s.
    It was reformulated by dropping the methamphetamine but kept the same name Obetrol® for weight loss. In 1996, it was renamed “Adderall” and was approved for treatment of ADHD.

    February 9, 2005: Health Canada has suspended market authorization of ADDERALL XR™ (amphetamine salts), a drug approved for Attention Deficit Hyperactivity Disorder (ADHD) in children. This was later reversed.

    Methylphenidate: Methylphenidate primarily acts as a norepinephrine–dopamine reuptake inhibitor (NDRI). It was synthesized in 1944 and identified as a stimulant and approved for use in 1955. The drug was named after the researcher’s wife “Rita” who used it for low blood pressure.
    Historical note: Ritonic®: tonic of methylphenidate, hormones and vitamins, marketed as Ritonic® in 1960, intended to improve mood and maintain vitality in women.

    Psychostimulants are considered first line agents for ADHD, unless the patient has a history of:
    • substance abuse
    • bipolar disorder
    • active psychotic disorder
    The use of ADHD drugs is on the rise as more adults are being diagnosed with ADHD.

    ADULTS: 4.4% of adult population is diagnosed with ADHD, although this number is believed to be higher. There is an 85% risk of adult ADHD if diagnosed as a child.

    FDA-approved psychostimulants for the treatment of ADHD:

    Considerations before prescribing amphetamines/ methylphenidate:
    • Stimulants increase blood pressure by 3 to 4 mmHg and heart rate by 1 to 2 beats per minute, on average, in children and adolescents.
    • In adults, they can increase systolic blood pressure by about 5 mmHg. These effects raise concern that stimulants may increase the risk of cardiovascular events
    • A weekend drug holiday might be effective for managing insomnia or appetite suppression; may also be tried to reduce effect on growth, especially in patients with a family history of short stature.
    • Stimulants and atomoxetine are unlikely to increase stroke, heart attacks, or sudden death. Still, avoid them in patients with serious heart problems, or if blood pressure or heart rate increase would be a problem. Adderall was temporarily removed from the Canadian market due to these adverse effects
    • Regardless of chosen medication, monitor heart rate, blood pressure, height, and weight.
    • Cases of painful and prolonged penile erections and priapism have been reported with methylphenidate products
    • Tolerance to stimulants is unlikely. Plateau effect after first week is not tolerance.
    • Stimulant dose based on weight, disease severity, and target symptoms (hyperactivity may require higher doses than inattentiveness).
    • Long-acting medications just as effective as shorter-acting agents. Long-acting agents usually preferred for convenience and to minimize breakthrough symptoms, irritability, and headache.
    • Common side effects include anorexia, abdominal pain, insomnia, and headache.
    • Rarely, stimulants may cause psychotic symptoms such as hallucinations. Final adult height might be decreased by less than an inch
    Typical maximum dosages:
    • Methylphenidate: 30mg up to 60 mg for adults
    • Methylphenidate XR (Concerta®); 54mg children; 72mg adults
    • Daytrana® patches maximum: 30mg
    • Quillivant® maximum dose: 60mg/day
    • Dexmethylphenidate tablets: 20 mg/day. XR capsules= 30mg children; 40mg adults
    • Dextroamphetamine 40mg (rarely 60mg)
    • Lisdexamphetamine 70mg maximum
    • Mixed amphetamine: 30mg child maximum for adults 60mg
    BENEFITS of TREATMENT:
    Treatment of ADHD with stimulants and psychotherapy has been shown to decrease disruptive behaviors and improve academic performance, self-esteem, cognition, and personal relationships. In addition, it has been reported that ADHD children treated with stimulant therapy during childhood are at lower risk for drug and alcohol abuse when they are older than those who are not treated.

    REASONS TO STOP TREATMENT
    • Hallucinations
    • Delusions
    • Paranoia
    • Aggression
    • Cardiovascular adverse event
    COMMONLY PRESCRIBED METHYLPHENIDATE & AMPHETAMINE PRODUCTS:
    • Ritalin® (methylphenidate) 5mg, 10mg 20m IR. SR20 and SR-30mg caps
      • Dose: Twice daily to three times daily (morning, noon, 4 PM if needed), preferably 30 to 45 minutes before meals
    • Concerta® (methylphenidate extended release tablets) 18, 27, 36, 54 mg ER tabs
      • Dose: given once daily in the morning (without regard to meals)
    • Metadate CD® (methylphenidate extended release caps) 10, 20, 30, 40, 50, 60 mg
      • Dose: Given once daily in the morning before breakfast. May be taken whole or sprinkled over applesauce. If sprinkled over applesauce, should be used immediately
    • Daytrana® (methylphenidate transdermal patch) 1.1 mg/hr (10 mg/9 hr)--1.6 mg/hr (15 mg/9 hr) 2.2 mg/hr (20 mg/9 hr)--3.3 mg/hr (30 mg/9 hr)
      • Dose: apply (1) patch daily in the morning. Worn daily for 9 hours (apply 2 hours before desired effect). Can be worn up to 16 hours if longer effect needed. Remove at least 3 hours before bedtime.
    • Quillivant® XR oral suspension 5mg/5ml oral suspension -extended release
      • Extended release methylphenidate. Give once daily in the morning with or without food. Reconstitute with water. Shake bottle vigorously for at least 10 seconds prior to administration. Use oral dosing dispenser for administration. Store reconstituted suspension at room temp for up to 4 months
    • Quillichew® XR chewable tablets 10, 15, 20, 30 and 40mg extended release tablets
    • Focalin®: dexmethylphenidate 2.5, 5, 10mg immediate release (generic)
      • Dose: Given BID at least 4 hours apart without regard to meals
    • Focalin XR®: 5, 10, 15, 20, 25, 30, 35, 40 mg caps (generic)
      • Dose: Given once daily in the morning. May be taken whole/ sprinkled over applesauce. (may dose every 8-12 hours)
    • Aptensio XR®: methylphenidate ER capsules 10mg, 15mg, 20mg, 30mg, 40mg, 50mg, 60mg
    • Journay PM®: 20,40, 60, 80 and 100mg ER capsules
      • Extended release methylphenidate dosed before bedtime. Dose is released for morning symptoms.
    --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
    • Dexedrine®: dextroamphetamine 5 and 10mg tablets
      • Dose: Given 2 to 3 times daily. First dose upon awakening; additional doses at 4 to 6-hour intervals.
    • Adderall® mixed amphetamine salts: 5, 7.5, 10, 12.5, 15, 20, 30 mg tablets
      • Dose: Usually given once or twice daily. May give second dose 6 to 7 hours after morning dose. Consider giving larger dose in the morning. Can split max dose 3 times daily
      • Prescriber note: all strengths are same price; all tablets are scored.
    • Adderall-XR®: mixed amphetamine salts. 5, 10, 15, 20, 25, 30 mg ER caps
      • Dose: Given once daily in the morning without regard to meals. May be taken whole or sprinkled on applesauce. Consume immediately
    • Vyvanse® (lisdexamfetamine) 20, 30, 40, 50, 60, 70 mg caps
      • is a pro-drug broken down when taken orally to the active form (dextroamphetamine). This limits its abuse potential when used IV or intranasally.
      • Dose: Given once daily in the morning without regard to meals. May be taken whole or contents dissolved in glass of water. Consume immediately.
      • VYVANSE for B.E.D.: Vyvanse is the first and only medication approved to treat moderate to severe Binge Eating Disorder in adults. It is NOT a weight loss drug, but rather for adults who have been diagnosed with moderate to severe B.E.D.
    • Mydayis®: Extended-release capsules: 12.5 mg, 25 mg, 37.5 mg, 50 mg
      • long-acting Mixed Amphetamine salts lasts 16 hours after dosing. For ADHD in patients 13 years and older. Not to be used in children 12 years and younger.
    I find it fascinating that stimulants were used for a number of years before they even required a prescription. After the Controlled Substance Act of 1970, it became one of the highest regulated prescription drugs, landing in Schedule-2! Amphetamines have a most interesting history from their discovery in the mid 1930’s to the homemade meth labs in the 2000’s.

    My students, both pharmacy and Physician Assistant, are amazed to realize that this methamphetamine is not some home-made clandestine drug, but rather is still available as a prescription product. I remember dispensing Desoxyn® and Desoxyn® Gradumets by Abbott Labs for weight loss.

    In the early 1990’s, the prescribing and dispensing of amphetamines as weight loss drugs fell out of favor. In the mid and late 1990’s a resurgence of amphetamine prescribing occurred as a treatment for ADHD. My daughter Elizabeth, an elementary school teacher, tells me she can tell the morning the kids miss a dose of their ADHD meds as they become completely unglued.

    Personally, these drugs scare me. In 2002, a local Boy Scout died at Summer Camp while taking his prescribed amphetamines for ADHD. The pharmacy where he got the prescription from was turned upside down, the summer camp was investigated, and the physician was scrutinized. The camp was ultimately sued (and found liable) for not having a defibrillator on site.

    Seeing a 12-year-old boy in a casket wearing his Boy Scout uniform has given me a great deal of respect and fear for this class of drugs. I believe that it is important, then, for pharmacists to understand both the history and current landscape surrounding the use of these drugs:

    Have a great day on the bench!!

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    Diagnosis of Attention Deficit/Hyperactivity Disorder

    DIAGNOSIS OF ATTENTION DEFICIT/HYPERACTIVITY DISORDER

    Since many of our patients and a few of us are “quarantined”, and I have a daughter who teaches in the elementary and middle schools, I thought It would be timely to cover under our Mental Health unit the diagnosis and treatment of ADHD.

    BACKGROUND: What’s in a name??

    Up until 1987, this condition was called attention deficit disorder (ADD), but this is an outdated term. The term was once used to refer to someone who had trouble focusing but was not hyperactive. Since 1987, ADHD is the term used by the American Psychiatric Association.

    ADHD affects between 5% of all children (American Psychiatric Association) and 11% (CDC’s number) possibly as many as 6.4 million American children. Boys are more likely to be diagnosed with ADHD than girls (12.9% compared to 5.6%)

    DIAGNOSIS
    There are three types of ADHD:
    • inattentive (trouble focusing, following instructions, and finishing tasks)
    • hyperactive-impulsive (constantly on the go, talking excessively, and interrupting others)
    • combined (symptoms of both inattention and hyperactivity-impulsivity)
    To meet the diagnostic criteria according to the DSM-5 (Diagnostic and statistical Manual of psychiatric disorders) a few aspects must be considered to meet a diagnosis of ADHD:

    Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
    1. Has lack of detail or makes careless mistakes.
    2. Has difficulty paying attention.
    3. Doesn't pay attention when spoken to directly.
    4. Doesn't follow instructions or fails to complete homework or other tasks.
    5. Often seems disorganized.
    6. Avoids tasks requiring sustained mental effort or concentration.
    7. Often loses things needed for tasks (toys, pencils, homework).
    8. Becomes easily distracted.
    9. Is forgetful.
    Hyperactivity/Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
    1. Often fidgets, taps hands, squirms in seat.
    2. Gets up and moves around during activities in situations when remaining seated is expected.
    3. Often runs or climbs in inappropriate situations.
    4. Is unable to play quietly.
    5. Seems "driven by a motor."
    6. Talks excessively.
    7. Blurts out answers before complete question is given.
    8. Can't seem to wait for his or her turn.
    9. Interrupts or intrudes others often.
    In addition, the following conditions must be met:
    • Several symptoms were present before age 12 years.
    • Several symptoms are present in two or more setting (such as home/school/work).
    • Symptoms interfere with, or reduce the quality of, social, school, or work functioning.
    • Ruled out other mental health disorders, situational or physical conditions.
    More severe cases of ADHD in children, as described by parents, were diagnosed earlier.
    • The median age of diagnosis for severe ADHD was 4 years.
    • The median age of diagnosis for moderate ADHD was 6 years.
    • The median age of diagnosis for mild ADHD was 7 years.
    When I begin this unit with my didactic class at St. Francis, I playfully ask the women in class “After a rough day in kindergarten, how many of you came home and lined up all of your doll babies, and siblings and played school.” Invariably almost every one of the women’s hands go up. When I ask the exact same question of the men, never in 15 years did a hand go up indicating that they went home and played school! I often say that classroom learning was never designed for boys and the numbers associated with ADHD seem to bear that out.

    I detested school as a kid. I would cry every morning before kindergarten and not want to go. When I see what my granddaughter learns in kindergarten, I wouldn’t have a chance today. Back in 1963 kindergarten consisted of a workbook, where you would circle the biggest house; nap time, cookies and milk, play in the sawdust box and go home. Today, Regina is learning sight words and how to add! When I graduated from Pitt in 1981 my mother hugged me and said of all her kids, she figured I would be the last one to stay in school this long! I often wonder what Mom thinks when she looks down from above and sees me going to school on Thursday mornings at St. Francis!

    Have a great day on the bench!!

    April 2020

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    Covering the Hypnotics that Work on the Benzodiazepine Receptor... Let the Chloride Rush In!

    COVERING THE HYPNOTICS THAT WORK ON THE BENZODIAZEPINE RECEPTOR

    Hypnotics working on the benzodiazepine (BZ) receptor:

    Mechanism: The GABA(A)-(gamma-aminobutyric acid type A) receptors are the major inhibitory neuronal receptors in the mammalian brain. Their activation by GABA opens the intrinsic ion channel, enabling chloride to rush into the cell causing hyperpolarization. Chloride is the major inhibitory ion in the CNS. The major isoform of the GABA-A subunit contains alpha, beta, and gamma subunits. The alpha1-containing BzR (benzo receptor) have been proposed to be responsible for the sedative action; the alpha2 and/or the alpha3 subtypes are responsible for the anxiolytic properties.

    Selected benzodiazepine hypnotics:

    Temazepam (Restoril®) capsules 7.5mg, 15mg, 22.5mg and 30mg
    • Most commonly used BZ hypnotic
    • Half-life is 3.5-18 hours
    • NOTE: one of the safer choices in its class for the elderly, as it is less like to accumulate. Metabolized by conjugation. Less dependent on global liver function.
    Estazolam (Prosom®) tablets 1mg and 2mg
    • Half-life is 8-28 hours
    Triazolam (Halcion®) tablets 0.125mg and 0.25mg
    • Very short acting. Peak 1-2 hours, with a half-life is 1.5 to 5.5 hours
    • Side effects: anterograde amnesia, sleep rebound
    THE “Z” Hypnotics= Zolpidem (Ambien®), Zaleplon (Sonata®), Eszopiclone (Lunesta®)
    [04-30-2019] The Food and Drug Administration (FDA) is advising that rare but serious injuries have happened with certain common prescription insomnia medicines because of sleep behaviors, including sleepwalking, sleep driving, and engaging in other activities while not fully awake (making phone calls, having "sleep sex", or preparing and eating food). These complex sleep behaviors have also resulted in deaths. These behaviors appear to be more common with eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien) than other prescription medicines used for sleep. All received a black box warning.
    • Mechanism: Basically, they all selectively attach to the GABA-BZ receptors found in close proximity to the benzodiazepine receptors. Specifically, they bind to GABA receptor complex located on the alpha subunit (BZ receptor). They are not benzodiazepines.
    Zolpidem (Ambien®) Schedule-IV
    Is an imidazopyridine, available as 5mg and 10 mg tablets, as well as extended release formulations:
    Ambien CR® 6.25 and 12.5mg. All formulations are generically available.
    • Usual adult dose: 10mg (12.5mg-CR) at bedtime. If elderly or debilitated or female start with 5mg. Don’t exceed the maximum dose of 10mg (12.5mg CR)
    • Peak after administration is 1.6hr. Half-life = 2.6hr (average)
    • Very little rebound insomnia upon discontinuation. Very little withdrawal syndrome.
    • Very little effect on sleep stages. Preserves deep sleep stages (3 & 4)
    • Pregnancy: Category- B
    Feb2018: FDA release: FDA has informed the manufacturers that the recommended dose of zolpidem for women should be lowered from 10 mg to 5 mg for immediate-release products. FDA recommends that the bedtime dose be lowered because new data show that blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving.

    Zaleplon (Sonata®) Schedule-IV
    Is a pyrazolopyridine, available as 5mg and 10mg capsules. Generic formulations are available.
    • Usual adult dose: 10mg at bedtime. If elderly or low weight start with 5mg. Take right at bedtime OR may take if having trouble falling asleep.
    • Maximum dose: 20mg if patient does not benefit from a trial of lower dose.
    • High fat meal does decrease absorption, and therefore reduce effect of Sonata on sleep latency.
    • Peaks within 1 hour of oral administration. Mean half-life= 1 hour
    • Little rebound insomnia. Has been reported in patients taking the 20mg dose. Was resolved by the second night.
    • Amnesia: may be caused by Sonata, which can be avoided if patient is able to get over 4 hours of sleep. Pregnancy: Category-C
    • Most common use: Zaleplon is the drug of choice for sleep lab studies.
    Eszopiclone (Lunesta®) tablets 1mg, 2mg 3mg Schedule IV (available 12/15/04)
    Is a cyclopyrrolone, available as 1mg, 2mg, and 3mg tablets. Generic formulations are available.
    • Usual adult dose: starting- 2mg immediately before bedtime. May increase to 3mg if indicated, which is more effective for sleep maintenance.
    • Elderly: starting: 1mg immediately before bedtime. May increase to 2mg. If can’t stay asleep, recommended dose is 2mg.
    • High fat meals decrease absorption & reduce effect upon sleep latency
    • Drug interactions: Cytochrome CP3A4 inhibitors start with 1mg. May increase to 2mg only if needed.
    • Onset of action= 60minutes, with a half-life = 6 hours
    • Precautions: drug will cause withdrawal symptoms if discontinued rapidly.
    • Pregnancy Category-C
    • Eszopiclone works quickly and should be taken right before bed because of risk of falling.
    • Avoid alcohol. Will increase side effects.
    • Do not take unless you are able to get 8 or more hours of sleep, before you must be active again.
    • Eszopiclone does not lose effectiveness over 6 month and was the first prescription sleep aid approved for long term use.

    We pharmacists love our mechanisms of action. What subunit do the Z-hypnotics bind to? They are not benzodiazepines …to me they work on the benzo receptor, they cause patients to sleep, patients must avoid alcohol, and they allow chloride to influx into the GABA channel.

    If it looks like a duck, and walks like a duck… well, you get the message!

    I’m not terribly comfortable with the amounts of the hypnotics we dispense. My sister who is an amazing nurse told me at one time they would dispense Chloral Hydrate (Noctec®) along with a shot of bourbon at the hospital in the early 1980’s. She said her floor was as quiet as the catacombs! This is referred to in the movies as “slipping a Mickey Finn.”

    I had a female patient who, during the night, fell down her basement steps and went back to bed, with a fractured wrist.

    My wife had a patient who got up in the morning with brownie batter all over her pajamas. She woke up during the night and started mixing a batch of brownies in the kitchen and went back to bed. Thank heavens she didn’t turn on the stove!

    I’m a believer in good sleep hygiene and adjusting one’s lifestyle to sleep patterns. We need to knock off the computers and gray screens a couple of hours before bed, one of the biggest reasons teenagers do not sleep as much. We must also control our diet and exercise; we are often mentally tired but seldom physically tired. I won’t lay in bed more than 15 minutes if I can’t fall back to sleep.

    On those mornings when I’m unable to sleep, I say “insomnia is God’s gift to busy people.” Next week we will cover the sleep aids that do not work on the benzo receptors.

    Have a great day on the bench!!

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    Still not sleeping... these drugs don't work on the GABA receptor.

    HYPNOTICS NOT WORKING AT THE GABA RECEPTOR

    Melatonin receptor agonists:
    Melatonin is a hormone synthesized in the pineal gland, collected by the venous capillary system, then secreted into the cerebrospinal fluid and the venous systemic circulation. It is produced from tryptophan. In the brain, melatonin appears to increase the binding GABA to its receptors by affecting membrane characteristics, not by increasing the number of receptors. No surprise that the pineal gland starts to function after 6 months, when babies start sleeping during the night. Pineal gland function declines as we age… no surprise their either!
    • MT1 receptor: activation of the MT1 receptor causes sleepiness
    • MT2 receptor: activation is related to light-dark synchronization, causing our natural circadian rhythms.
    Ramelteon (Rozerem®)
    available as 8mg tablets ($466.00/month) (generic= $120.00/month)
    Mechanism: selectively binds to the MT1 and MT2 receptors in the suprachiasmatic nucleus, inhibiting the neuronal firing that maintains wakefulness. Is NOT a CNS depressant. It is not a scheduled drug. Ramelteon shows no evidence of abuse, dependence or withdrawal, or rebound insomnia.
    Indications: for insomnia characterized with difficulty of sleep onset. Can be prescribed long term.
    Avoid in patients with severe hepatic impairment or taking fluvoxamine (Luvox®). Avoid with alcohol. May cause increased prolactin levels, and decreased testosterone levels. Patient information:
    • Take 30 minutes before bed and activities confined to preparing for bed.
    • Avoid hazardous activity (driving etc.) after taking
    • Do not take with, or immediately after a high fat meal.
    • Report cessation of menses, galactorrhea, decreased libido, and fertility problems.

    Melatonin (available OTC)
    cost about $10/month
    Available as 1mg, 3mg 5mg and 10mg capsules/tablets Melatonin is non-scheduled, non-habit forming Dose 1 to 10mg at bedtime. Don’t exceed 10mg.
    There is a slight increase for bleeding risk with melatonin. Monitor in suspect patients, frail, elderly, or patients that are anticoagulated.
    Jet lag: Melatonin can improve some symptoms of jet lag, such as alertness and psychomotor performance, may also be useful for daytime sleepiness and fatigue. Think of interaction with MT2 receptor.
    Might not be effective for decreasing sleep latency.

    Hetlioz® (tasimelteon)
    (cost about $10,000/month)
    Is another melatonin agonist that is only approved for non-24 sleep-wake disorder, where patients can't synchronize their internal clock to the 24-hour light-dark cycle. It occurs in over half of blind people, rarely in sighted people.
    Hetlioz increases nighttime sleep in blind patients about same as melatonin (28 minutes) at a cost of $10,000/MONTH.
    Do not prescribe Hetlioz for sighted or blind patients who don't have non-24.

    Antihistamines
    Diphenhydramine (Benadryl®), Tylenol PM®, Nytol®, Sominex®, Simply Sleep®
    Contain 25mg of diphenhydramine as an OTC sleep aid.
    Dose 50mg mg at bedtime. (generally, 25mg is adequate)
    Side effects: drowsiness, anticholinergic side effects, avoid in older males.
    Evidence: There is little evidence that diphenhydramine improves insomnia. Will also cause daytime sedation the next day. Use of diphenhydramine to treat insomnia is not recommended, especially for long term use.

    DRUGS FOR SLEEP MAINTENENCE

    Tricyclic Antidepressant
    Doxepin (Silenor)
    3mg and 6mg tablets (cost: $500.00/30tab) (30 Doxepin 10mg=$14.00/30)
    USE: Very low dose anti-depressant that is used for insomnia. It increases sleep time by 30 minutes and is most useful for patients having trouble staying asleep. Doesn’t help with sleep INDUCTION, just maintenance. Prescribing low dose doxepin (10mg) is a cheaper alternative than using Silenor or it’s expensive generic. The generic Silenor currently costs $400 for 30 tablets.

    Orexin receptor antagonist
    BELSOMRA (suvorexant)
    FDA approved Aug 14, 2014 Schedule- IV
    Dose: 5mg, 10mg,15mg, 20mg available (approx. $440/month)
    Start with 10mg, may increase to a max of 20mg if tolerated. Start with 5mg if CYP450-3A4 blocking drug.
    Indication: for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance
    Mechanism: is a highly selective antagonist for orexin receptors. Orexin is a neurotransmitter found in a specific part of the brain that can help keep a person awake. The mechanism by which BELSOMRA exerts its therapeutic effect is presumed to be through antagonism of orexin receptors.
    Precautions: A variety of cognitive, behavioral changes and other neuro-psychiatric symptoms, such as halucinations and amnesia have been reported to occur in association with the use of hypnotics. “Sleep driving” and other complex behaviors (preparing and eating food, making phone calls, or having sex), with amnesia for the event have been reported with the use of hypnotics.

    This class of drugs does not have any action at the GABA receptor, so it seems they could be safer. They seem to be a lot less habit forming and have a niche for patients that might have some abuse potential. Their high prices frequently require prior authorizations when prescribed.

    For the most part melatonin over the counter and doxepin low dose are the cheapest alternatives in this class. Don’t forget to remind your patients to practice good sleep hygiene:
    • Regular waking time (set alarm!) including weekends.
    • Go to bed only when sleepy. Avoid trying to “force sleep.”
    • Avoid daytime naps.
    • Exercise, but not within 1 hour of bedtime.
    • Sleep in a cool room (avoid temperature extremes).
    • Avoid alcohol and stimulants before bedtim (including chocolate, coffee, soda, etc).
    • Avoid stressful arguments.
    • Bedroom is for sleeping and sex.
    • NO TV, computers, or reading. AVOID GRAY SCREENS!
    • Schedule “worry time” during the day. Do not take your troubles to bed.
    • Avoid excess fluids in the evening, to avoid restroom trips.
    • Do something relaxing and enjoyable before bed.

    Have a great day on the bench!!

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    IF WE ARE TO HOLD BENZODIAZEPINES, WHAT IS LEFT TO TREAT ANXIETY?

    Non-habit forming anxiolytics:

    Buspirone (Buspar®) (FDA approved:1986)
    Mechanism: Is an azapirone, with no GABA receptor interaction. Buspirone interacts primarily with serotonin (5-HT31a) and dopamine and blocks alpha adrenergic receptors.

    Dosage: Initial dose: 15mg /day, may increase 5mg every 2 or 3 days. Don’t exceed 60mg.
    COMMON USES of Buspirone
    • Augment the effects of SSRI
    • Improves SSRI induced sexual dysfunction.
    • Long term anxiety control
    Worth knowing about buspirone
    • Not a Benzodiazepine, no anticonvulsant effect, no muscle relaxant effect.
    • Food does affect absorption, so take it at consistent times. May take with food to avoid GI upset.
    • No sedation. Slight chance of drowsiness.
    Link with href-->

    March 2020

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    SELECTION OF SECOND-GENERATION ANTIPSYCHOTICS

    April 2005: Black box warning on all atypical antipsychotics concerning “sudden death” due to use of these drugs in elderly patients, when used for “behavior” problems. Use with caution in debilitated or elderly patients. Black box warning below applies to ALL atypical antipsychotics. (Below is the black box warning for Zyprexa ®):

    Increased Mortality in Elderly Patients with Dementia-Related Psychosis — Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. ZYPREXA (olanzapine) is not approved for the treatment of patients with dementia-related psychosis (see WARNINGS).

    Time of effective results: Although many drugs may reach “steady state” in a matter of a few days, allow 4 to 6 weeks for drug to take effect.

    NON-ADHERENCE: Long acting salts: ideal for noncompliant patients.
    • Haloperidol (Haldol®) decanoate 50mg and100mg/mL (every 4 weeks)
    • Fluphenazine (Prolixin®) decanoate 25mg/mL (every 3 weeks)
    • Risperidone (Risperdal®) consta: 25, 37.5 or 50mg (every 2 weeks)
    • Aripiprazole (Abilify Maintena®) 400mg IM/month
    • Olanzapine pamoate (Zyprexa Relprevv®) 100-300mg every 2 weeks or 300mg-405mg every month.
    • Paliperidone (Invega Sustenna®) 117-234mg per month
    • Paliperidone (Invega Trinza®) 410-819mg every 3 months
    FDA-Approved Adult Indications for Atypical Antipsychotics (cms.gov)

    INDICATION ATYPICAL ANTIPSYCHOTICS
    Bipolar-1 disorderaripiprazole, asenapine, olanzapine, quetiapine, quetiapine extended-release (XR), risperidone, ziprasidone
    Bipolar depressionlurasidone, olanzapine, quetiapine, quetiapine XR
    Schizophreniaaripiprazole, asenapine, brexpiprazole, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, quetiapine XR, risperidone, ziprasidone
    Schizoaffective disorderclozapine, paliperidone
    Adjunct to Major Depressive Disorderaripiprazole, brexpiprazole, olanzapine, quetiapine XR
    Tapering doses: must be done gradually, watching for signs of re-occurrence. Reduce dose after acute episode, slowly and gradually reduce to lowest effective dose. Abrupt withdrawal may precipitate relapse.

    Monitoring of metabolic parameters:
    Many psych clinics are aware of the metabolic effects of the second-generation antipsychotics. Clinicians MUST be cognizant of the diabetes, obesity and dyslipidemias that these drugs can cause.
    • Clozapine and Olanzapine are the biggest offenders
    • Risperidone, Iloperidone and Quetiapine cause moderate weight gain
    • Aripiprazole, Ziprasidone, Asenapine, Paliperidone, Lurasidone are considered to be “weight neutral”
    Monitoring recommendations:
    • Weight: check at baseline and then 1, 2, and 3 months after starting or changing therapy and then every 3 months.
    • Fasting glucose and blood pressure: check at baseline, 3 months, and then at least annually.
    • Lipids: check at baseline, 3 months, then every 5 years if normal. Because of risk factors, however it is wise to check lipid parameters annually. NOTE: diabetes and hyperlipidemia been noted in patients who have not had significant weight gain.
    • Waist measurement: check at baseline, then annually
    Consider switch to different antipsychotic if glucose or lipids worsen or if patients have more than a 5% weight gain.

    SEXUAL SIDE EFFECTS:
    • 60 to 70 percent of patients taking paliperidone and risperidone experienced sexual side effects. (no surprise-think prolactin)
    • 50 to 60 percent of those on olanzapine, quetiapine, and ziprasidone
    • Less than 50 percent on clozapine
    • 16 to 27 percent on aripiprazole
    OTHER STUFF: There is little clinical evidence to support the use of combination therapy of antipsychotic drugs within the same class. The atypical antipsychotics may range in cost from $10 to $1200 per month. Some studies have shown evidence that prescribing 2 or more atypical antipsychotics increases the occurrence of extrapyramidal symptoms.

    PREGNANCY
    • Limited data available for 1st and 2nd generation antipsychotics in pregnancy
    • Chlorpromazine (Thorazine®) was at one time used for morning sickness, without causing reported teratogenesis
    • Only clozapine (Clozaril®) and lurasidone (Latuda®) have received a Category-B rating from FDA
    • Risk of weight gain which may be problematic in pregnancy are greater with second generation anti-psychotics

    CONDITION BEST CHOICE WORST CHOICE (AVOID)
    Minimize weight gainAripiprazole, Lurasidone, Asenapine, ZiprasidoneClozapine (worst), Olanzapine (worst), Quetiapine
    Minimize Extrapyramidal SymptomsQuetiapine, IloperidoneRisperidone, Paliperidone
    Minimize QT prolongationAripiprazole, Lurasidone, OlanzapineZiprasidone, Iloperidone, Paliperidone
    Minimize HyperprolactinemiaRisperdone, Paliperidone
    Minimize SedationAripiprazole, Risperidone, Paliperidone, Ziprasidone
    Treatment of Agitation or Treat insomniaOlanzapine, Quetiapine
    COST (for brevity brand names are listed)Risperidone, Clozapine, Olanzapine, Quetiapine, Aripiprazole, Paliperidone, & Ziprasidone are available genericallyAsenapine, Iloperidone, Lurasidone, Brexpiprazole, Cariprazine are still brand

    One of my students from St. Francis University took a job at Western Psychiatric Clinic in Pittsburgh after graduation. In her years there she never wrote for an anti-psychotic medication; that was the job of the psychiatrists!

    What she was responsible for was the management of the side effects that were caused by the medications that were written for. She was kept very busy monitoring the metabolic parameters for the second-generation antipsychotics. She would start patients on metformin, glipizide, and statin therapy as they developed Type-2 diabetes.

    She was a great asset to the treatment team, as most psychiatrists are not comfortable with the monitoring and management of the metabolic problems caused by the therapies that the prescribe. It gives me great appreciation of the side effect profiles of this whole class of drugs.

    Now that we are comfortable with the second-generation antipsychotics regarding their efficacy, let’s look at what separates them. Most feel it is the side effect profiles that separate these drugs. We’ll discuss the major parameters that separate this class of drugs. For the sake of brevity, I’ll use generic names on the charts.

    Have a great day on the bench!!


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    Switching antidepressants require knowing their mechanism of action. AntiDepressants and weight gain and pregnancy.

    SWITCHING METHODS for ANTIDEPRESSANT THERAPY

    Direct switch
    From one SSRI to another SSRI, venlafaxine (Effexor), or duloxetine (Cymbalta).
    • Can switch from paroxetine (Paxil) to sertraline (Zoloft), the next day.
    • Switching from fluoxetine (Prozac) should wait 4 to 7 days because of its long half-life. Then start another SSRI with low dose. Monitor for signs of exacerbation of depression.

    Cross-tapering
    Gradually reduce the dose of the old drug while simultaneously increase the dose of the new drug. Use when switching to meds with a different mechanism. Usually takes 1-2 weeks.
    • Such as switching from an SSRI to bupropion (Wellbutrin) or mirtazapine (Remeron).
    • Cross-tapering is also a good idea when switching from paroxetine (Paxil) or venlafaxine (Effexor). Because of short half-life may cause discontinuation symptoms.
    • When cross-tapering, new symptoms can be due to THREE different causes.
      • Discontinuation symptoms from stopping the first drug.
      • Side effects from the new drug.
      • Depression or anxiety symptoms because neither drug is working.
    Wash out
    A wash-out period is necessary when switching to or from an MAO inhibitor. Only after a 4 to 8-week trial of an antidepressant, switching is recommended. For partial responders you can choose between switching OR addition of a second agent.
    • MAOI to tricyclic: wait 2 to 3 weeks between stopping one drug and starting another.
    • SSRI to MAOI: wait 4 to 5 weeks
    • Elderly patients will tolerate a switch to venlafaxine (Effexor) rather than addition of Lithium, bupropion (Wellbutrin) or liothyronine (Cytomel)
    • Within the 3 groups anti-depressant response may be augmented by: Under psychiatric consult use Lithium or liothyronine (Cytomel 25mcg) (liothyronine-T3).
    WEIGHT GAIN on Antidepressants:
    Weight gain is problematic antidepressant therapy. As far as side effects sexual dysfunction (17%) and drowsiness (17%) with weight gain being third most common problem at 12%. Weight gain can be attributed to carbohydrate craving and improved appetite as patients experience remission of depression.
    Patients gain an average of 6 pounds on mirtazapine (Remeron) or paroxetine (Paxil)
    Weight-neutral SSRIs: suggest fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), or escitalopram (Lexapro).
    Weight loss antidepressant: Bupropion (Wellbutrin) is associated with about a 6 lb. weight LOSS

    MAINTENANCE:
    If first episode is after age 50 or before age 20, or 3 episodes at any age. Keep on indefinitely. If tapering is decided, reduce over several months, monitoring for relapse.

    TREATMENT OF DEPRESSION IN PREGNANT PATIENTS
    Depression occurs in 14-23% of pregnant women.
    Key points:
    • ALL SSRI are Pregnancy Category-C except Paxil (paroxetine) Cat-D
    • ALL SNRI are Pregnancy Category-C
    • TCA anticholinergic effects and toxicity in overdose limit usefulness


    Are seeing a 2-fold increase in cardiac congenital malformations. 2% (paroxetine exposed) vs 1% Persistent pulmonary hypertension: increase risk if SSRI used after 20th week. Poor neonatal adaptation: rapid breathing, hypoglycemia, Irritability, weak/absent cry, and seizures are seen in 15-30% of babies born to Moms taking SSRI in 3rd trimester.
    • Tapering SSRI in 3rd trimester leads to antepartum and/or postpartum depression.
    TREATMENT:
    Cognitive therapy is a must, before conception and during pregnancy.
    • Fluoxetine (Prozac) well studied, long half-life may cause accumulation. Increased risk of withdrawal symptoms after birth.
    • Stopping pharmacotherapy should be only attempted in women who do not have a history of severe recurrent depression. Do not consider stopping antidepressants if woman is suicidal, other concurrent psychiatric conditions or functional incapacitation.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560196

    No topic in the clinic seems to be discussed more than the switching of antidepressants. Some meta-analysis showed antidepressants no more effective than placebo. However, in a 2018 article in the Lancet showed that antidepressants are indeed more efficacious versus placebo, but that was during the first 8 weeks of study.

    The data supporting long term effectiveness of antidepressants doesn’t seem so robust. Because of these efficacy issues, we frequently switch antidepressants looking for one that will benefit our patients.

    Knowing how to switch antidepressants is a necessary skill in the family practice clinic.

    Have a great day on the bench!!

    March 2020

    Micro-Learning CE Associated - Click Here For Details

    Switching antidepressants require knowing their mechanism of action. AntiDepressants and weight gain and pregnancy.

    SWITCHING METHODS for ANTIDEPRESSANT THERAPY

    Direct switch
    From one SSRI to another SSRI, venlafaxine (Effexor), or duloxetine (Cymbalta).
    • Can switch from paroxetine (Paxil) to sertraline (Zoloft), the next day.
    • Switching from fluoxetine (Prozac) should wait 4 to 7 days because of its long half-life. Then start another SSRI with low dose. Monitor for signs of exacerbation of depression.

    Cross-tapering
    Gradually reduce the dose of the old drug while simultaneously increase the dose of the new drug. Use when switching to meds with a different mechanism. Usually takes 1-2 weeks.
    • Such as switching from an SSRI to bupropion (Wellbutrin) or mirtazapine (Remeron).
    • Cross-tapering is also a good idea when switching from paroxetine (Paxil) or venlafaxine (Effexor). Because of short half-life may cause discontinuation symptoms.
    • When cross-tapering, new symptoms can be due to THREE different causes.
      • Discontinuation symptoms from stopping the first drug.
      • Side effects from the new drug.
      • Depression or anxiety symptoms because neither drug is working.
    Wash out
    A wash-out period is necessary when switching to or from an MAO inhibitor. Only after a 4 to 8-week trial of an antidepressant, switching is recommended. For partial responders you can choose between switching OR addition of a second agent.
    • MAOI to tricyclic: wait 2 to 3 weeks between stopping one drug and starting another.
    • SSRI to MAOI: wait 4 to 5 weeks
    • Elderly patients will tolerate a switch to venlafaxine (Effexor) rather than addition of Lithium, bupropion (Wellbutrin) or liothyronine (Cytomel)
    • Within the 3 groups anti-depressant response may be augmented by: Under psychiatric consult use Lithium or liothyronine (Cytomel 25mcg) (liothyronine-T3).
    WEIGHT GAIN on Antidepressants:
    Weight gain is problematic antidepressant therapy. As far as side effects sexual dysfunction (17%) and drowsiness (17%) with weight gain being third most common problem at 12%. Weight gain can be attributed to carbohydrate craving and improved appetite as patients experience remission of depression.
    Patients gain an average of 6 pounds on mirtazapine (Remeron) or paroxetine (Paxil)
    Weight-neutral SSRIs: suggest fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), or escitalopram (Lexapro).
    Weight loss antidepressant: Bupropion (Wellbutrin) is associated with about a 6 lb. weight LOSS

    MAINTENANCE:
    If first episode is after age 50 or before age 20, or 3 episodes at any age. Keep on indefinitely. If tapering is decided, reduce over several months, monitoring for relapse.

    TREATMENT OF DEPRESSION IN PREGNANT PATIENTS
    Depression occurs in 14-23% of pregnant women.
    Key points:
    • ALL SSRI are Pregnancy Category-C except Paxil (paroxetine) Cat-D
    • ALL SNRI are Pregnancy Category-C
    • TCA anticholinergic effects and toxicity in overdose limit usefulness


    Are seeing a 2-fold increase in cardiac congenital malformations. 2% (paroxetine exposed) vs 1% Persistent pulmonary hypertension: increase risk if SSRI used after 20th week. Poor neonatal adaptation: rapid breathing, hypoglycemia, Irritability, weak/absent cry, and seizures are seen in 15-30% of babies born to Moms taking SSRI in 3rd trimester.
    • Tapering SSRI in 3rd trimester leads to antepartum and/or postpartum depression.
    TREATMENT:
    Cognitive therapy is a must, before conception and during pregnancy.
    • Fluoxetine (Prozac) well studied, long half-life may cause accumulation. Increased risk of withdrawal symptoms after birth.
    • Stopping pharmacotherapy should be only attempted in women who do not have a history of severe recurrent depression. Do not consider stopping antidepressants if woman is suicidal, other concurrent psychiatric conditions or functional incapacitation.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560196

    No topic in the clinic seems to be discussed more than the switching of antidepressants. Some meta-analysis showed antidepressants no more effective than placebo. However, in a 2018 article in the Lancet showed that antidepressants are indeed more efficacious versus placebo, but that was during the first 8 weeks of study.

    The data supporting long term effectiveness of antidepressants doesn’t seem so robust. Because of these efficacy issues, we frequently switch antidepressants looking for one that will benefit our patients.

    Knowing how to switch antidepressants is a necessary skill in the family practice clinic.

    Have a great day on the bench!!

    Micro-Learning CE Associated - Click Here For Details

    Let's just call them first generation antipsychotics! They have been around as long as I have!

    DOSAGE EQUIVALENTS AND SIDE EFFECTS OF TYPICAL ANTIPSYCHOTICS (FIRST GENERATION ANTIPSYCHOTICS)

    DRUG NAME YEAR EQUIV DOSE USUAL ADULT DOSE SIDE EFFECT SIDE EFFECT SIDE EFFECT
    EPS AC SED
    Chlorpromazine (Thorazine®) 1957 100mg 30-800mg ++ ++ +++
    Fluphenazine (Prolixin ) 1959 2mg 1-40mg ++++ + +
    Mesoridazine (Serentil®) 1970 50mg 100mg-400mg + +++ +++
    Perphenazine (Trilafon®) 1957 10mg 12-64mg ++ + +++
    Thioridazine (Mellaril®) 1962 100mg 150-800mg + +++ +++
    Trifluoperazine (Stelazine®) 1959 5mg 2-15mg +++ + +
    Thiothixine (Navane®) 1967 4mg 6-60mg +++ + +
    Molindone (Moban®) 1974 10mg 20-150mg ++ + +
    Loxapine (Loxitane®) 1975 10mg 20-250mg ++ + +
    Haloperidol (Haldol®) 1967 2mg 1-1000mg ++++ + +


    SIDE EFFECT ABBREVIATIONS:
    EPS: extrapyramidal side effects
    AC: anticholinergic side effects-note the more anticholinergic side effects, the less EPS
    SED: sedation or drowsiness.

    Prescribing notes:
    • These first-generation agents work in the central nervous system by blocking dopamine-2 (D2) receptors, which have the potential to interfere with dopamine transmission via the nigrostriatal tract and cause Parkinson like side effects.
      • perphenazine (Trilafon®) has a lower rate of extrapyramidal symptoms than the high-potency haloperidol and fluphenazine
    • In general, efficacy in treating patients with schizophrenia is similar for all of these agents. They differ by side effect profiles.
    • First generation antipsychotics are implicated with weight gain, possibly due to:
      • Increased appetite due to serotonin 5-HT2 receptor and dopamine D2 receptor blockade
      • Increased sedation and decreased physical activity due to histamine H1 receptor blockade
      • Weight gain: antipsychotic induced weight gain does not appear to be dose related
      • Pharmacodynamic profile of second-generation antipsychotics (5-HT2A antagonism, fast D2 dissociation, 5-HT1A agonism).
      • The main differences between first and second-generation antipsychotics (from a receptor binding perspective)is First-generation antipsychotics have significant potential to cause extrapyramidal side effects and tardive dyskinesia


    MAJOR SIDE EFFECTS
    Tardive dyskinesia:
    abnormal involuntary stereotyped movements of the face, mouth, trunk and limbs. May occur months or years (usually) after treatment. Affects 20-35% of treated patients. See a cumulative rate of 5% per year. They may be progressive and eventually become disfiguring. Predisposing factors: older age, years of treatment, cigarette smoking & diabetes Emphasis is on prevention.

    Prolactin Elevation:
    All typical antipsychotics elevate prolactin levels, apparently through blockade of tuberoinfundibular dopamine, allowing uninhibited secretion of pituitary prolactin. Remember dopamine puts the brakes on prolactin, therefore blocking dopamine allows prolactin to be released in higher amounts. Prolactin levels two to three times higher than normal are seen. Elevated prolactin levels cause menstrual irregularities, infertility, galactorrhea, loss of libido, and erectile and ejaculatory dysfunction.

    Extrapyramidal symptoms:
    Akathisia most common (20%). Usually occurs early and frequently mistaken for anxiety or exacerbation of psychosis. Characterized by the desire to be in constant motion, followed by the inability to sit or stand still, and consequent pacing. Increase incidence in women who smoke.

    I tell my class at St. Francis that “these are the typical antipsychotics, that we atypically use; and the atypical antipsychotics we typically use in practice today.” I prefer the new term first generation antipsychotics and the second-generation antipsychotics.

    This class of drugs as discussed last week is responsible for the emptying out of the state mental hospitals. While in high school my wife Denise volunteered at the Hollidaysburg State Mental Hospital and described the patients all had the same appearance. All of them smoked, had yellow tar stained fingers and hair from the constant cigarette smoke. Smoking was encouraged in the schizophrenic population, as it helped manage symptoms. Smoking however, also caused increased metabolism of the medications, and therefore higher doses were needed.

    Nearly 90 percent of people with schizophrenia smoke, most of them being heavy smokers, and 60 to 70 percent of people with bipolar disorder also smoke. According to recent research in China, nicotine restores dynamic intrinsic brain activity of people with schizophrenia. Maybe someday soon we’ll have the third generation of antipsychotics.

    Have a great day on the bench!!

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    Continuing our joruney through Mental Health medications...

    Between 1954 and 1975, about 15 antipsychotic drugs were introduced in the United States. Thorazine (Chlorpromazine) by SK&F was the first available. This drug began the exodus of patients from our mental hospitals. Since 1955 there has been a decline by 95% of available beds to treat the mentally ill. Almost 66 years later these medications still have their place in therapy. Clozapine (Clozaril) was introduced in 1990 and opened the era of "atypical" antipsychotic drugs (second generation). These medications have taken people plagued with mental illness to become productive members of society. The role of these medications, as well as other non-anti-psychotic treatment options on our geriatric population will be discussed.

    Schizophrenia…the Basics
    • Schizophrenia affects about 1% of the world’s population
    • diagnosed primarily on the presentation of psychotic symptoms (hallucinations and delusions)
    • patients suffering from schizophrenia often present themselves with concomitant negative symptoms (e.g. apathy, anhedonia) and cognitive dysfunction.
    • Dopamine (D2) receptor is responsible for schizophrenia
    • Since 1953, a total of 19 studies of toxoplasmosis (T. gondii) antibodies in persons with schizophrenia and other severe psychiatric disorders and in controls have been reported; 18 reported a higher percentage of antibodies in the affected persons; in 11 studies the difference was statistically significant. Two other studies found that exposure to cats in childhood was a risk factor for the development of schizophrenia. Click here for article
    Researchers have been able to confirm that patients with schizophrenia show increased
    • presynaptic dopamine synthesis
    • increased dopamine release
    • increased synaptic levels of dopamine with a largely unchanged postsynaptic dopamine receptor density.
    • Dopamine receptors (subtypes D1, D2, D3 and D4), which account for its different antipsychotic properties on productive and unproductive symptoms, in the mesolimbic dopamine system accounts for the antipsychotic effect whereas the blockade in the nigrostriatal system produces the extrapyramidal effects
    • Serotonin receptors with anxiolytic, and antiaggressive properties as well as an attenuation of extrapyramidal side effects, but also leading to weight gain and ejaculation difficulties.
    • Histamine receptors (sedation, antiemetic effect and weight gain)
    • Adrenergic receptors (lowering of blood pressure, reflex tachycardia, vertigo, sedation, hypersalivation and incontinence, weight gain as well as sexual dysfunction.
    • Muscarinic receptors (causing anticholinergic symptoms such as dry mouth, blurred vision, constipation, difficulty or inability to urinate, sinus tachycardia, electrocardiographic changes and loss of memory, but the anticholinergic action may attenuate extrapyramidal side effects).
    As a group, the typical antipsychotics are dopamine receptor antagonists (D2 receptors) block certain dopamine tracts:
    • nigrostriatal: movement disorders
    • mesolimbic: relief of hallucinations & delusions
    • mesocortical: relief of psychosis & worsening of negative symptoms
    • tuberoinfundibular: prolactin release
    • In general, efficacy in treating patients with schizophrenia is similar for all of these agents. They differ by side effect profiles.
    First generation antipsychotics are implicated with weight gain, possibly due to:
    • Increased appetite due to serotonin 5-HT2 receptor and dopamine D2 receptor blockade
    • Increased sedation and decreased physical activity due to histamine H1 receptor blockade
    • Although controversial, antipsychotic induced weight gain does not appear to be dose related
    • Pharmacodynamic profile of second-generation antipsychotics (5-HT2A antagonism, fast D2 dissociation, 5-HT1A agonism).
    • The main differences between first and second-generation antipsychotics (from a receptor binding perspective).
    A excellent fact sheet is available HERE

    With a 95% decrease in available mental health beds, and with 45% of homeless patients suffering from mental illness (Mentalillnesspolicy.org), we obviously need better medications for the treatment of schizophrenia.

    140,000 mentally ill patients are homeless; 392,000 seriously mentally ill patients are incarcerated. 1.2% of Americans (3.2) million are afflicted with this disease. Individuals with schizophrenia die at a younger age than do healthy people. Males have a 5.1 greater than expected early mortality rate than the general population, and females have a 5.6 greater risk of early death.

    Suicide is the single largest contributor to this excess mortality rate, which is 10 to 13 percent higher in schizophrenia than the general population. Obviously we need a better strategy to treat this disabled group of citizens.

    Have a great day on the bench!!

    January 2020

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    Our last three antidepressants...get out your wallet!

    Vortioxetine (Trintellix®) 5, 10, 15, 20mg IR tablets
    Released October 2013 with a cost of $450.00 per month. Was initially named "Brintellix" and was changed to Trintellix in June 2016 because of confusion with antiplatelet Brilinta (ticagrelor)

    Indication: treatment of major depressive disorder.

    Mechanism: enhances of serotonergic activity in the CNS through inhibition of the reuptake of serotonin. Only compound known to inhibit serotonin reuptake and act as an agonist at serotonin type 1A receptors, a partial agonist at serotonin type 1B receptors, and an antagonist at serotonin type 1D, 3, and 7 receptors

    Use: May help improve cognitive function, especially with major depression. This drug also has anxiolytic effects

    Dosage: start with 10mg.

    Side Effects: causes minimal sexual dysfunction, low weight gain. Common side effects include nausea, constipation, vomiting. Pregnancy Category-C

    Drug-Drug Interactions: with CYPP450 3A4 and 2D6 enzyme pathways. Weak metabolizers of 2D6 pathway should not exceed 10mg

    Vilazodone HCl (Viibryd®) 10,20,40mg tablets
    Released 2011 and currently costs around $320.00 per month

    Indication: treatment of major depressive disorder (MDD)

    Mechanism: Inhibits reuptake of serotonin and partial 5HT1a receptor agonist

    Use: Stimulation of 5HT1a may account for its quicker activity which may help cover the "therapeutic lag" seen with pure SSRI. Viibryd is marketed to both augment SSRI effects and to have SSRI effects itself. Similar to using Abilify (aripiprazole) or Buspar (buspirone) to augment SSRI effects. Marketed as having less sexual side effects

    Dosage: Starting Dose: initial dose of 10 mg once daily for 7 days, followed by 20 mg once daily for an additional 7 days, and then increased to 40 mg once daily. Available as a starter pack. Take with food because administration without food can result in inadequate drug concentrations and may diminish effectiveness

    Side effects: diarrhea (28%), nausea (23%), less sexual side effects. Pregnancy Category-C Drug Interactions: avoid strong inhibitors of CYP3A4 (e.g., ketoconazole) can increase vilazodone plasma concentrations by approximately 50%, so reduce dose to 20mg.

    Esketamine (Spravato) CIII
    Ketamine first became available in 1970; Spravato was approved 2019. Cost estimated at $900/dose.

    Mechanism: non-competitive N-methyl D-aspartate (NMDA) receptor antagonist indicated, in conjunction with an oral antidepressant, for the treatment of treatment-resistant depression (TRD) in adults.

    Dose:
    • Weeks 1-4: administer twice a week (induction)
    • Weeks-5-8 administer once a week
    • Weeks-9 and beyond: administer every 2 weeks, or every week.
    Available as a 28mg nasal inhaler. Doses range from 56mg to 84mg. Because it is clinic administered it will not appear on the PDMP.
    • Most adverse effects occur in the first two hours after administration.
    • Patients self-administer in a clinic-based setting to have their blood pressure (for hypertension) monitored and mental-status monitoring (dissociation reactions~41%)
    • Be sure patients stay on their oral antidepressants.
    St. John's Wort
    See Clinician Corner 5/17/18 for a thorough discussion of this herbal product. Serotonin Syndrome
    Serotonin is responsible for:
    • Central effects: regulates attention, behavior and body temperature.
    • Peripheral effects: regulating digestive process, blood flow and breathing.
    Culprits: All SSRI, SNRI, and MAOIs have the potential to cause serotonin syndrome, especially at higher doses. Most likely to occur with addition or increase of known serotonergic agent to an established medication regimen

    Drug-Drug Interactions
    • SSRIs, TCAs, SNRIs, mirtazapine, MAOIs
    • Carbamazepine, cyclobenzaprine
    • Sibutramine (appetite suppressant)
    • Linezolid
    • Dextromethorphan, meperidine, methadone, tramadol
    Symptoms of Serotonin Syndrome include:
    • Hyperthermia (high fever) and heavy sweating
    • Muscle rigidity, myoclonus (clonic muscle twitching), loss of coordination.
    • Changes in mental status and vital signs
    • Agitation, restlessness or confusion
    • Rapid heart rate, arrhythmias and high blood pressure
    • Dilated pupils
    • Diarrhea
    • Headache
    • Shivering and piloerection (goose bumps)
    • Unconsciousness, possibly leading to death


    That wraps up a very long journey through the antidepressants. These last three drugs don't seem to get used a lot primarily due to the costs. With aripiprazole (Abilify) and buspirone (Buspar) being so cheap most insurance companies want patients to try and fail on a SSRI or SNRI plus augmenting before they approve these expensive drugs.

    I doubt I'll ever see Spravato, given its use only in certified clinics. The only clinic serving Central Pennsylvania currently is in State College (Penn State). You can go to Spravato.com and see the nearest clinic serving your area. My only experience with ketamine was after cataract surgery... I remember bright and vivid colors and a feeling of relaxation.

    I added a discussion of Serotonin Syndrome (SS), since we frequently see flags when we are filling prescriptions warning about serotonin syndrome. Although it is rare, as we see higher and higher doses of antidepressants, we need to have a great deal of respect for this condition. I have only seen one case of serotonin syndrome. She was a 40-year-old Multiple Sclerosis (MS) patient that took 40mg of fluoxetine (Prozac). She came to the pharmacy escorted by her husband hand had jerked motions as well profusely sweating. They were just to the emergency department and she got SS after taking a couple doses of dextromethorphan!

    I have great deal of respect for dextromethorphan and its drug interactions with antidepressants.

    Have a great day on the bench!!

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    Misc antidepressants....oldies but goodies!

    Older Miscellaneous Antidepressants

    Trazodone (Desyrel®)
    {FDA approved Dec-1981}

    Mechanism of Action: 5-HT2A and 5-HT2C antagonist and inhibits the reuptake of 5-HT; defined as a SARI = serotonin antagonist/reuptake inhibitor
    Starting dose (adults)
    • IR: 50mg TID (can take BID, prefer to take at bedtime)
    • May increase 50mg/ day every 3-4 days
    • Maximum Doses:
      • Outpatient: should not exceed 400mg/day (in divided doses)
      • Inpatient: should not exceed 600mg/day (in divided doses)
    Side effects: dizziness, lightheadedness, confusion, drowsiness, fatigue, headache, dry mouth, priapism (even at lower doses)
    Other Uses
    • Decrease alcohol cravings
    • Reduce depression and anxiety in patients with alcoholism
    • Panic disorder and agoraphobia with panic attacks (300mg)
    • Insomnia due to SSRI or Venlafaxine (Effexor) for its sedative effect (range 50-150mg)
    • To increase SSRI efficacy, a dose of 100mg may be needed
      • Can add on to SSRI therapy
      • Use with great caution à Prozac and Paxil can eliminate Trazodone's metabolite leading to CNS stimulation
    Drug Interactions: CYP2D6 substrates, CYP3A4 substrates
    Distinguishing Features: causes orthostatic hypotension (caution in elderly, especially when dosed at bedtime), more commonly used for insomnia than major depressive disorder
    • Doses for insomnia are subtherapeutic for depression treatment
    Bupropion (Wellbutrin, Zyban)
    {FDA approved Dec-1985}

    Mechanism of Action: norepinephrine and dopamine reuptake inhibitor (NDRI)
    Available As
    • Immediate release: 75 & 100mg
    • Sustained release (SR) 12 hours: 100mg, 150mg & 200mg
    • Sustained release (XL) 24 hours: 150mg & 300mg
    Dosage
    • Starting dose: must be started low and increased to minimize the risk of seizures
      • SR: start with 100 or 150mg QAM for 3 days
      • Then increase to 100 or 150mg BID, separating doses by 8 hours
      • Full antidepressant effect may take 4 weeks.
      • Maximum 400mg/day (200mg BID)
      • XL: start with 150mg QAM for 3 days
      • May increase to 300mg once daily in the morning
      • Separate XL doses by 24 hours
      • Maximum 450mg/day QAM
      • IR: start with 100mg BID
      • May increase to 100mg TID
      • Maximum 450mg/day (150mg TID)
    Other Uses
    • Weight loss
    • Attention deficit disorder
    • Neuropathic pain
    • Smoking cessation
    • Adjunct to SSRI
    • Bupropion plus an SSRI is the most common antidepressant combination
    Side Effects
    • Less nausea, diarrhea, and sleepiness than SSRIs
    • Seizures: be sure to titrate slowly!
      • An estimated seizure 10-fold increase occurs in patients who are dosed between 450 & 600mg
    • Blurred vision
    • Agitation
    • GI disturbances
    • Tremor
    • Excessive sweating
    • Weight loss
    • Hypertension
    • Dry mouth
    • Insomnia
    • Constipation
    • Does NOT cause sexual dysfunction + is minimally sedating
      • Often the choice antidepressant for patients complaining of sexual side effects & decreased energy levels.
    ABUSE POTENTIAL: Bupropion is called "poor man's cocaine" because users say it gives them a cocaine-like high for about $2.50/pill
    Distinguishing Features
    • May be beneficial in patients with fatigue, poor concentration, and interested in smoking cessation
    • No anxiolytic properties
    • Appetite-suppressing effects (weight neutral)
    • No sexual dysfunction
    • Caution in patients with psychotic features
    • Contraindicated in patients with bulimia, anorexia, and seizure disorder
    Mirtazapine (Remeron®)
    {FDA approved: June 1996}

    Mechanism: does NOT block reuptake of dopamine, norepinephrine or serotonin. It blocks the Histamine-1 receptor, which accounts for its drowsiness and weight gain. Mirtazapine has been said to be a functional "indirect agonist" of the 5-HT1A receptor. Increased activation of the central 5-HT1A (serotonin) receptor is a major mediator of efficacy of most antidepressant drugs
    Dose: most commonly available as 7.5mg, 15mg, 30mg and 45mg tablets. Best given at bedtime due to sedation.
    Side effects: dizziness, drowsiness and weight gain.
    Unlabeled uses: sleep apnea, weight gain, antipsychotic induced akathisia

    This column is a “catch all” of the older miscellaneous drugs. All are available generically, and the newest one is 25 years old. What I love about this column all these drugs were introduced after Denise and I graduated pharmacy school in 1981.

    I remember the Mead Johnson representative coming to talk to me about Desyrel (trazodone) a new groundbreaking antidepressant, that was nothing like those old tricyclic antidepressants. We dispensed a lot of Desyrel® until the late 1980’s when Prozac and the other SSRI’s and later Effexor® and the SNRI’s tool over the depression market. Today trazodone is dosed mostly at bedtime for insomnia.

    Wellbutrin® was another one of those drugs with a peculiar mechanism, in that it did not cause sedation, like all the others. I remember when the insurance companies refused to pay for Zyban, because it was for smoking cessation. Practitioners then wrote for “Wellbutrin-SR”, then the insurance companies required a prior auth for all bupropion!

    Those insurance companies have been saying “NO” for a very long time! Next week will cover the “newer” miscellaneous antidepressants.

    Have a great day on the bench!!

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    MAOIs potent, yes; lots of food and drug interactions keep these drugs off of our shelves.

    Monoamine Oxidase Inhibitors (MAOIs) block monoamine oxidase, an enzyme in the synaptic cleft that breaks down neurotransmitters. MAO is released from the pre-synaptic nerve terminals. Norepinephrine is not broken down, and has more dramatic effect, not only in the brain but every else in the body. MAOIs are very seldom used due to side effects and life-threatening drug interactions.

    Hypertensive crisis: extreme increases in blood pressure when MAOIs interact with OTC meds and foods containing tyramine.
    • Defined by diastolic BP >120mmHg
    • Characterized by occipital headache, palpitations, neck stiffness/soreness, Nausea/Vomiting, sweating, dilated pupils, photophobia, tachy- or bradycardia, chest pain
    • This came to be known as “Cheese Effect” because aged cheeses contain a lot of Tyramine which naturally elevates blood pressure
    • Tyramine containing foods and OTC drugs that should be avoided:
      • Aged cheeses: blue, camembert, cheddar, Roquefort, stilton and Swiss
      • Anchovies
      • Dried, aged, smoked, fermented, spoiled, or improperly-stored meat, poultry, and fish
      • Tap and non-pasteurized beers
      • Red wine, (esp. Chianti), sherry
      • Many tropical fruits à bananas and avocados (especially if overripe)
      • Also avoid drugs with vasopressors (increase BP): chocolate, cola, coffee tea, broad beans
      • Sauerkraut and soy products (tofu, soy sauce, marmite)
      • OTC cold medications containing pseudoephedrine (Sudafed®)
      • Avoid amphetamines and appetite suppressants
      • Other antidepressants
    MAOI Drugs
    • Nardil® (phenelzine) 15mg tablets (FDA approved 1961)
      • Non-selective (will increase levels of dopamine, norepinephrine, and serotonin)
      • Distinguishing Feature: may cause hepatotoxicity
    • Parnate® (tranylcypromine) 10mg tablets (FDA approved 1961)
      • Non-selective (will increase levels of dopamine, norepinephrine, and serotonin)
      • Distinguishing Feature: structurally similar to amphetamine, so stimulating; less likely to cause weight gain
    • Marplan® (isocarboxazid) 10mg tablets (FDA approved 1959)
    • Non-selective (will increase levels of dopamine, norepinephrine, and serotonin)
    • EMSAM® (selegiline transdermal system) (FDA approved 2006)
      • Selective à less “Cheese Effect” due to no tyramine inhibition at low dose
      • First + only transdermal MAOI for treatment of depression
      • Three available strengths: 6mg/ 24 hours; 9mg/ 24 hours; and 12mg/24 hour (available in boxes of 30)
      • Change patch once a day at the same time each day!
      • Avoid sympathomimetic amines such as amphetamines or cold medications containing vasoconstrictors (pseudoephedrine-Sudafed®)
      • WARNINGS/ PRECAUTIONS
        • Because of the potential for serotonin syndrome EMSAM is contraindicated with SSRI, SNRI, TCA or MAOI
          • Wait 2 weeks after stopping SSRI, SNRI, TCA or MAOI mirtazapine, bupropion, dextromethorphan, cyclobenzaprine, tramadol methadone, propoxyphene, St. John’s Wort and carbamazepine
          • Must wait 5 weeks for fluoxetine (Prozac®)
      • Other side effects: application site reaction, headache, insomnia, diarrhea, dry mouth and dyspepsia
      • Benefits: reported sexual dysfunction similar to placebo; minimal weight change
      • Distinguishing Feature: no tyramine dietary modifications at the starting or target dose of 6mg/24 hours
        • If the dose is increased to the 9mg/24hr or 12mg/24 hr, then the tyramine diet must be used
        • Drug-drug interactions still a concern

      Monoamine oxidase inhibitors

      MAO-A MAO-B
      SUBSTRATES Norepinephrine
      Serotonin
      Dopamine
      Tyramine
      LOCATION Brain, gut, liver, placenta, skin Brain, platelets, lymphocytes
      INHIBITORS Nardil, Parnate Marplan, Emsam Eldepryl (low doses) Azilect
      THERAPEUTIC USE Depression Parkinson’s disease


      Like so many drugs that were discovered in the 1950’s MAOI’s existence is due to serendipity. Researchers discovered that one of the tuberculosis drugs, iproniazid caused relief of patient’s depression. This led to the discovery of monoamine oxidase, and soon after inhibitors of this enzyme were marketed for the relief of depression.

      Due to the side effects and significant food and drug interactions these drugs are seldom used. About the only time we see this class of drugs used is in treatment resistant depression, that have failed the more common therapies.

      Although it has been a long time since I have dispensed these drugs, our local warehouse does have Nardil, Parnate and their generics in stock, along with brand name Emsam.

      The selective MAO-B inhibitors used for Parkinson’s disease are a little more commonly dispensed in the community pharmacy.

      Have a great day on the bench!!

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    Tricyclic antidepressants are as old as this author... and still going strong... (like this author)

    Tricyclic Antidepressants (TCA)
    Mechanism: inhibit the reuptake of NE and 5-HT into the presynaptic terminal. Allows more serotonin and nor-epinephrine to be available in the synapses.

    Although there are 9 different tricyclic antidepressants (TCA) approved in the United States I have only 5 on my shelf in the community pharmacy where I practice. The TCA’s can be broken down between the secondary and tertiary amines. The most common secondary amines nortriptyline and desipramine are selective inhibitors of norepinephrine reuptake. The most common tertiary amines amitriptyline, imipramine, doxepin and clomipramine are selective inhibitors of serotonin reuptake. They are also broken down by side effects.

    With 9 different TCA's when do we use them?
    • MOST sedating: Amitriptyline, doxepin and imipramine
    • MOST likely to cause weight gain: Amitriptyline, doxepin and imipramine
    • CLEANEST: Nortriptyline and desipramine are less likely to cause sedation and weight gain.
    • NOCTURNAL ENURESIS: imipramine is most used
    • OCD: Clomipramine was the first drug that was approved for Obsessive-Compulsive disorder. (When we see its highly serotonergic effects, it is no surprise)
    • INSOMNIA: Doxepin is also available as Silenor® in 3mg and 6mg tablets used for sleep maintenance.
    The most common TCA's I see in my practice are amitriptyline and nortriptyline. The following is from my lecture notes to delineate the differences between the two:
    DIFFERENCES BETWEEN Amitriptyline (Elavil®) and Nortriptyline (Pamelor®)
    • Nortriptyline is the active metabolite of amitriptyline (via CYP450-2C19)
    • Nortriptyline is generally better tolerated than amitriptyline. It has much less sedation and anticholinergic side effects.
    • The mortality from nortriptyline in overdose is similar to that from SSRIs
    • Nortriptyline is the least problematic of the tricyclic antidepressants in terms of drug interactions. It is relatively safe to combine it with certain SSRIs (sertraline and citalopram).
    • Nortriptyline is better choice for elderly.
    • Maximum dose for Nortriptyline should never exceed 150mg.
    MOST TCA's
    • Common side effects: anticholinergic side effects, sexual dysfunction, daytime drowsiness
    • Cardiac effects: may alter rate, rhythm, & contractility. May cause orthostatic hypotension.
    • CNS- seizures, respiratory depression, disorientation & coma
    • METABOLISM: most of the available tricyclic antidepressants are metabolized by the CYP-2D6 pathway. Desipramine and nortriptyline are the least problematic of the TCAs in terms of drug interactions, being only weak CYP450-2D6 inhibitors.
      • Avoid tertiary amine-TCA's in patients known to be ultra-rapid metabolizers at CYP450-2D6 (think of codeine metabolism)
      • The tertiary amines are extensive metabolized through CYP450-2C19. Avoid tertiary amines in weak metabolizers of this enzyme system.
    COMMON USES: diabetic neuropathy, phantom leg pain, cancer pain, post herpetic neuralgia
    DOSING: commonly doses begin at 25mg and are titrated to 150-300mg. (300mg-inpatient). (Except Nortriptyline)
    COST: ALL are available generically, and relatively inexpensive.
    CAUTION must be exercised with TCA in patients with suicidal thoughts due to high lethality risks with overdose. The lethal dose is only EIGHT times the therapeutic dose, so if TCA's are ingested in an overdose, they may block the sinoatrial node in the heart. TCA are more dangerous than SSRI in overdose. Therefore, a seven-day supply of a maximally dosed tricyclic antidepressant could be lethal.

    GENERIC BRAND YEAR AC H1- NET SERT
    Imipramine Tofranil® 1959 ++ + + ++
    Amitriptyline Elavil® 1961 +++ ++ + ++
    Desipramine Norpramin® 1964 + + +++ +
    Nortriptyline Pamelor® 1964 + + ++ +
    Protriptyline Vivactil® 1967 +++ + +++ +
    Doxepin Sinequan® 1969 ++ +++ + +
    Clomipramine Anafranil® 1989 + + + +++


    AC: anticholinergic side effects (dry mouth, blurry vision, constipation, urinary retention)
    H1: histamine receptor (associated with weight gain and sedation)
    NET: nor-epinephrine transporter (increases levels of nor-epinephrine by blocking reuptake)
    SERT: serotonin transporter (increases levels of serotonin by blocking reuptake)

    The tricyclic antidepressants quickly followed after the first generation antipsychotic chlorpromazine (Thorazine), in the late 1950's. Pyschopharmacotherapy was in its infancy, and 7 more TCA's followed suit after imipramine's introduction in 1959. Climipramine was the last TCA, introduced in 1989 a few months after Prozac (fluoxetine). Clomipramine (Anafranil) was the first drug indicated for treatment of OCD.

    I remember well the sale reps from Ciba-Geigy not only educating providers about the drug but also the diagnostic criteria for Obsessive-Compulsive Disorder (OCD). OCD is now very much a layman's term that is thrown around when we check our locks on our doors, or have our pantry shelves arranged!

    Wishing you and yours a Happy 2020!
    Have a great day on the bench!!

    December 2019

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    SNRI's for weight management, depression, pain, ADHS???

    Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
    Mechanism: inhibits reuptake of both norepinephrine and serotonin in the presynaptic nerve terminal, allowing more serotonin and nor-epinephrine to be available in the synapses. The SNRI's are used for depression and pain management.

    SNRI Side Effects:
    • Side effects: very favorable profile: minimal sedative and cardiovascular effects.
    • Common side effects: nausea, anorexia, insomnia, nervousness, restlessness, and bruxism. All these side effects increase as dose is increased.
    Venlafaxine (Effexor®) - FDA approved 1993
    • Also approved for Generalized Anxiety Disorder and SAD
    • Unlabeled use: hot flashes, Premenstrual Dysphoric Disorder, PTSD
    • Caution: angle closure glaucoma or patients taking oral anticoagulants.
    Duloxetine (Cymbalta®) - FDA approved 2004
    • Dose: major depressive disorder: 40 mg daily (not much benefit over 60 mg/day)
    • Very low side effect profile
    • May cause decrease in body weight
    • Caution: CrCl less than 30; liver failure, alcohol abuse, closed angle glaucoma.
      • contraindicated in patients with heavy alcohol use or chronic liver disease; can lead to acute hepatitis
    • ***is approved for diabetic neuropathy and fibromyalgia***
    Desvenlafaxine (Prestiq®) - FDA approved 2008
    • Treatment of adults with major depressive disorder.
    • Is the active metabolite of Effexor. It does not require "activation" by the CYP2D6 metabolic pathway, minimizing the potential for drug interactions.
    • There was no evidence that doses greater than 50 mg/day confer any additional benefit.
    • Less sexual dysfunction.
    • Nausea most frequently during week one.
    • May increase blood pressure.
    • When discontinuing treatment, gradual dose reduction is recommended whenever possible.
    Milnacipran (Savella®) - FDA approved Jan-2009
    • Use: selective norepinephrine and serotonin reuptake inhibitor (SNRI) for management of fibromyalgia. First drug approved ONLY for fibromyalgia.
    • More potent inhibitor of norepinephrine reuptake than the other SNRIs.
    • Norepinephrine depletion is associated with pain and fatigue. 1 in 12 patients get about 50% reductions in fibro symptoms.
    • Adverse reactions: nausea, headache, constipation, dizziness, insomnia, hot flush, hyperhidrosis, vomiting, palpations, increased heart rate, dry mouth, and hypertension.
    • CAUTION: avoid in ESRD, chronic liver disease, or alcohol abuse.
    Levomilnacipran (Fetzima®) - FDA approved 2013
    • Once-daily serotonin and norepinephrine reuptake inhibitor (SNRI) for the treatment of major depressive disorder (MDD) in adults, has received FDA approval
    • Stronger inhibitor of norepinephrine than serotonin.
    • Dosage: 40 mg to 120 mg once daily, beginning with 20 mg once daily for 2 days and then 40 mg once daily. Dosage can be increased in increments of 40 mg at intervals of 2 or more days, with 120 mg the maximum recommended dose.
    • Monitor BP and heart rate for increases.
    • CAUTION: ESRD, angle closure glaucoma, hypertension, dose dependent erectile dysfunction.


    DRUG STARTING DOSE TARGET DOSE
    Desvenlafaxine (Pristiq) 25 to 50mg 50mg to 100mg
    Duloxetine (Cymbalta) 30 to 60mg 60mg to 120mg
    Levomilnacipran (Fetzima) 20mg 40mg to 80mg
    Milnacipran (Savella) 12.5mg 100 to 200mg
    Venlafaxine (Effexor tabs) 37.5 to 75mg 75 to 375mg
    Venlafaxine XR- (Effexor-XR) 37.5 to 75mg 75 to 225


    SSRI/SNRI and Elderly November-2018:
    HYPONATREMIA:
    older patients are more likely to develop hyponatremia with an SSRI or SNRI or mirtazapine than younger counterparts. Be sure to monitor sodium especially in patients with heart failure, or those taking hydrochlorothiazide. They made the Beers List for that reason.

    The SNRI’s came into the depression treatment arena about 5 years after Prozac broke the ground for new depression therapy. These drugs also seem, because of their effect on norepinephrine, seem to be more useful for pain management than the SSRI’s.
    • Tramadol (Ultram) is a weak SNRI and a weak opioid which was approved in 1995 for treatment of pain.
    • Sibutramine (Meridia) is an SNRI and was approved in 1997, which was the first drug approved for obesity in 30 years.
    • Atomoxetine (Straterra) primarily works on norepinephrine reuptake, with minimal effect on serotonin. It was first approved in 2002 for the treatment of ADHD.
    Wishing you and yours a most Happy 2020!

    Have a great day on the bench!!

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    When I'm feeling blue, all I gotta do is...Take a pill?

    Selective Serotonin Reuptake Inhibitors (SSRI)
    Mechanism: serotonin reuptake is blocked in the pre-synaptic nerve terminal. Allows more serotonin to be available in the synapses.

    Ground Rules for Prescribing Antidepressants
    • There is a 2 to 4-week lag time to clinical efficacy, but side effects occur rapidly
    • An adequate dose and duration of treatment of at least 4-8 weeks are required to establish an adequate trial of antidepressant.
    • Antidepressant dose should be increased if patient compliance is good and no response after 3 weeks. If partial response, adjust dose in 2 weeks.
    • 25% of patients who don't respond to one SSRI will respond to another. Therefore, it's reasonable to switch from one SSRI to another if a patient is not responding. However, if a patient fails more than one SSRI, then a class switch should be considered.
    DRUG INTERACTIONS (non-MAOI):
    • highest risk of drug interactions: fluoxetine (Prozac®), fluvoxamine (Luvox®), and paroxetine (Paxil®).
    • lowest risk of drug interactions: include citalopram (Celexa®), escitalopram (Lexapro®), mirtazapine Remeron®, venlafaxine (Effexor®), and desvenlafaxine (Pristiq®).
    SSRI (Selective Serotonin Reuptake Inhibitors)
    MOST SSRI
    • Common side effects for SSRI: headache, nausea, nervousness, insomnia, agitation, sexual dysfunction, bruxism
    • Costs of SSRI: All SSRI are available generically. Are now very inexpensive.
    • Bleeding Risk: SSRIs inhibit the uptake of serotonin in platelets. This depletes serotonin in platelets and therefore inhibits their ability to initiate blood clotting. Absolute risk is small. Greater risk when combined with Aspirin or NSAIDs
    • Risk of Torsades: Sertraline, paroxetine, and fluoxetine seem less likely to cause QT prolongation.
    • HYPONATREMIA: older patients are more likely to develop hyponatremia with an SSRI or SNRI or mirtazapine than younger counterparts. Be sure to monitor sodium especially in patients with heart failure, or those taking hydrochlorothiazide.
    • FALL RISK: SSRI are on Beers list for patients with a history of falls or fractures. Watch for sedation and blurred vision to decrease fall risk
    Selective Serotonin Reuptake Inhibitors (SSRI)
    Citalopram (Celexa®)
    • Do not exceed 40 mg/day for anyone. Max= 20 mg/day for most patients over age 60.
    • Higher doses of citalopram increase the risk of QT prolongation and torsades.
    • Caution: using citalopram in patients at risk due to underlying cardiac disease or low serum potassium or magnesium.
    Escitalopram (Lexapro®)
    • S-isomer (active isomer) of Celexa
    • When citalopram is not utilized based on risk factors for TdP, use of escitalopram is not likely the safest alternative. Based on current literature, fluoxetine, fluvoxamine, and sertraline appear to have similar, low risk for QT prolongation, and paroxetine appears to have the lowest risk. https://www.ncbi.nlm.nih.gov/pubmed/24259697
    Fluoxetine (Prozac®)
    • Only SSRI that is FDA approved for major depressive disorder in children and adults.
    • LONGEST half-life of SSRI’s (1 to 3 days)
      • Active metabolite (norfluoxetine) has 4-16-day half-life.
    • Along with sertraline (Zoloft®) is the MOST activating of SSRI
    Paroxetine (Paxil®) -
  • Paroxetine (Brisdelle® 7.5mg) marketed for hot flash treatment
  • MOST sedating of SSRI
  • MOST anticholinergic side effect of SSRI
  • Pregnancy Category D
  • Considered by most to be the “dirtiest” SSRI
  • Sertraline (Zoloft®)
    • MOST Activating SSRI (along with Prozac)
    DOSING CHART

    SSRI Starting Dose Target Dose
    Citalopram 20 20 to 40
    Escitalopram 10 10 to 20
    Fluoxetine 20 20 to 60
    Paroxetine 20 20 to 40
    Sertraline 50 50 to 200


    32 years ago this month the face of America changed with the introduction of Prozac (Fluoxetine) by Eli Lilly.

    MAOIs became widely used as antidepressants in the early 1950s. Patients with tuberculosis given iproniazid, experienced relief from their depression.

    Tricyclic antidepressants, the first being imipramine (Tofranil) in 1959, followed by amitriptyline (Elavil) in 1961 and then at least a dozen more until Prozac was introduced.

    Trazodone (Desyrel®) was introduced in late 1981 and was found to be too sedating. Today we see trazodone used for sleep induction, usually for people taking SSRI’s.

    Escitalopram (Lexapro®) was approved in 2002 and was the last SSRI to be approved. We buy most of our SSRI antidepressants (except paroxetine) in bottles of 500 and turn them over quickly.

    Before we had MAOI's in the 1950's amphetamines like Benzedrine in the 1930's and 1940's were used to treat mild depression, but quickly became drugs of abuse.

    And before the advent of the amphetamines, frankincense was used to treat depression. One of the ingredients in frankincense smoke called incensole acetate has been studied in mice and has shown to relieve depression. Most of us are familiar with frankincense as it was one of the three gifts brought by the Magi that came from the East to adore the Christ Child.

    With that in mind, I wish you and your families a Merry Christmas and a Happy New Year!

    Have a great day on the bench!!

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    Lots of anti-epileptic drugs can be tried for our patients with bipolar disorder.

    Stabilizing the mood with Anti-Epileptic drugs Valproic acid and Valproate:
    • Valproic Acid, which became available as Depakene in 1978, is seldom used due to GI upset.
    • Divalproex (Depakote®) was approved in 1982, as a delayed release tablet to minimize stomach upset.
    • Divalproex extended release (Depakote-ER®) is a once daily formulation that became available in 2000. Today all forms of valproic acid/valproate are available generically.
    Oral loading dose of acute mania: 20mg/kg/day. Therapeutic levels occur in 2-3 days. Is being used more first line due to the adverse effects associated with lithium pharmacotherapy
    Mechanism: possibly increases CNS levels of GABA
    Common use: is an anti-seizure drug and can also be considered as first line treatment for mania. Divalproex is also used for panic disorder and migraine prophylaxis. Divalproex is more effective than lithium in mixed episodes.
    Adverse effects: hepatotoxicity (Black box warning) increase risk for children under
    • Teratogenicity: pregnancy category-D
      • third line drug for female patients of childbearing potential
    • Pancreatitis
    • Stomach upset featuring nausea/vomiting and diarrhea
    • Do frequent CBC, and liver enzymes
    • Thrombocytopenia appears to be dose related

    Monitoring: therapeutic serum levels: 50-100mcg/ml
    Patient Education
    • GI upset: Take with food
    • Caution driving
    • NVD may signify pancreatitis. refer if necessary.
    • If alopecia occurs, supplement with zinc and selenium
    • Weight gain: Up to 70% of patients taking valproic acid may gain weight. Almost one-half of patients may gain >10% of baseline weight

    NOTE: Treatment of ACUTE mania in patients taking Lithium or Valproate usually requires addition of an antipsychotic drug

    Carbamazepine (Tegretol®): was first approved in 1968. It is commonly available in tablets 100mg (chew) and 200mg It is also available as extended release Tegretol XR tablets 100,200 and 400mg. Carbatrol® capsules are available as 100, 200 and 300mg extended release caps
    Initial dose:( adults): 200mg twice daily. Increase every week of no more than
    • 200mg per day using a 3-4 times daily regimen.
    • Maintenance: 800-1200mg/ day maximum dose for mania is 1600mg/day
    • Therapeutic blood level: 4—12mg/liter
    Mechanism: stabilizes cell membranes. Reduces polysynaptic responses.
    Common use: indicated for treatment of epilepsy, trigeminal neuralgia
    Unlabeled use: Postherpetic neuralgia, PTSD, alcohol withdrawal,
    Bipolar disorder: used for mania or mixed episodes

    Adverse effects: contraindicated if history of bone marrow depression
    • Stevens Johnson syndrome—severe dermal reactions.
      • Genetic testing: The HLA*15:02 allele has since been associated with carbamazepine-induced Stevens Johnson Syndrome (Toxic Epidermal Necrolysis) in Taiwanese, Chinese, Indians, Malay, and Chinese- Americans, but not in Caucasians or Japanese individuals
    • Pregnancy: category D
    • Aplastic anemia—black box warning
    • Is a CYP-450 enzyme inducer-----lots of drug interactions. Also induces its own metabolism. monitor more closely during the first few months of therapy because carbamazepine induces hepatic enzymes
    Monitoring of carbamazepine
    • Baseline: complete blood tests then periodic evaluation
    • Baseline liver function, then periodic evaluation
    • Baseline and periodic eye exam
    • Urinalysis
    • BUN
    • Therapeutic blood level: 4—12mcg/liter
    Lamotrigine (Lamictal®) : was FDA approved in December 1994 Is available generically in tablet formulations chew: 5mg & 25mg. immediate release tablets: 25, 100, 150 &200mg
    Mechanism: unknown: may interfere with sodium channels and stabilize neuronal membranes, modulation presynaptic excitatory amino acid release (glutamate & aspartate)
    Lamotrigine use:
    • Lamotrigine has better evidence of efficacy than lithium for monotherapy for bipolar depression.
    • Best choice for prevention of recurrent depressive episodes.
    • The combination of lithium plus lamotrigine can be considered for patient’s refractory to monotherapy.
    • Lamotrigine should not be used for treating mania and has limited efficacy for preventing mania.
    Dosage: watch for drug interactions!
    There are different dosage regimens to follow:
    • Adding Lamictal to AED regimen containing Divalproex (a CYP-450 blocker)
      • 25mg every other day, for 2 weeks. Then 25mg every day for 2 weeks.
    • Adding Lamictal to EIAED (enzyme inducing anti-epileptic drug) . CBZ, DPH, PBARB without valproic acid.
      • 50mg daily for 2 weeks. Then 100mg daily in 2 divided doses for 2 weeks.
    • Using lamotrigine in patient taking neither an inducer or blocker:
      • 25mg daily for 2 weeks, then in crease to 50mg daily
    **Closely consult prescribing information when making Lamictal dosage adjustments. **
    Adverse effects: skin rash (discontinue if it appears)-Black box warning. Titrate slowly especially if taking Valproic acid.
    Contraindications:none.
    Drug interactions: many drug interactions between enzyme blockers and inducers.
    • Although Lamictal does not induce or inhibit other drugs, its metabolism is affected.
    • Inhibits dihydrofolate reductase. Folic acid supplementation may be necessary.
    ·Adding valproic acid to Lamictal, will increase Lamictal steady state concentration 2X!

    Drug Monitoring: optimal blood level: 4 to 20 mcg/ml. Allow 4-5 days to reach steady state
    MONITORING of MOOD STABILIZERS:
    • Trough lithium concentrations should be kept at 0.8 to 1.2 mEq/L;
    • Trough valproate levels should be kept at 50 to 125 mcg/mL
    • Trough carbamazepinelevels should be kept at 4 to 12 mcg/mL
    We dispense a fair amount do this well-known seizure medications, divalproex, carbamazepine and lamotrigine. However, most of the prescriptions filled are prescribed by psychiatrists rather than neurologists. These three drugs are most commonly used as “mood stabilizers” in the treatment of bipolar disorder.

    Of these drugs the one that takes up a lot of space in my Pharmacology notes is carbamazepine. Carbamazepine is a big-time CYP450-3A4 inducer. It is so effective at enzyme induction it induces it’s own metabolism. This can be a nightmare when a patient is taking warfarin. We don’t have a significant Asian population in Central Pennsylvania, but where you are practicing your Asian patients really need your expertise!

    Although Levetiracetam (Keppra) is a lot “cleaner” than the drugs mentioned in this newsletter, results for mood stabilization have been mixed. Although not FDA approved, we also see Topiramate (Topamax) and Gabapentin (Neurontin) used as well for bipolar disorder. But then again, we see these drugs used for a lot of non-FDA approved conditions.

    Have a great day on the bench!!

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    We Steeler fans are happy... then sad...are we bipolar? Not according to this definiton!

    Bipolar disorder... and most effective treatment is LITHIUM!
    People who live with bipolar disorder experience periods of great excitement, overactivity, delusions, and euphoria (mania) and other periods of feeling sad and hopeless (depression). Mood stabilizers (lithium, valproate, lamotrigine) are the cornerstone of the pharmacotherapy of bipolar disorder. Antipsychotics, alone or in combination with mood stabilizers, are also commonly used. There is no evidence that any one anti-psychotic is more effective than the others.

    Mood swings OR bipolar disorder? Patients with mood swings experience fluctuations in mood are caused by a situation, person, or events in their lives. While the moods of people with bipolar disorder can be affected by situational variables, people with bipolar disorder also frequently become manic or depressed for no apparent reason.

    Duration: Bipolar patients experience an elevated or irritable mood for at least four consecutive days. A patient with bipolar may have depressive episodes that last for at least two weeks at a time. Emotions tied to watching a Steeler game is not bipolar!

    BENEFITS of THERAPY:
    In addition to preventing relapse in patients with bipolar disorder, maintenance pharmacotherapy may be associated with reduced rates of violent behavior. A national registry study identified 494 convictions for violent crime (eg, assault, robbery, or threats/intimidation) in 11,918 patients with bipolar disorder and examined the time periods when patients were or were not prescribed mood stabilizers (eg, lithium, valproate, lamotrigine, or carbamazepine) or antipsychotics.

    The rate of violent behavior when mood stabilizers were prescribed was 60 percent less, compared with times when mood stabilizers were not prescribed. In addition, prescription of antipsychotics was associated with a 50 percent decrease in interpersonal violence.

    Lithium
    History: The first recorded use of lithium for the treatment of mania, based in part on the urate/lithium connection, was 1871. Use of lithium carbonate to prevent depression came in 1886. In 1948 an Australian psychiatrist started using lithium after he treated guinea pigs and noticed they became more docile. It wasn’t until 1970 the FDA approved lithium, under the trade names of Lithonate® and Eskalith® for the treatment of mania.

    Mechanism: affects synthesis, storage, and reuptake and release of central Monoamine neurotransmitters. NE, 5-HT, DA, ACH and GABA

    Dosage: acute mania- optimal response 600mg three times daily or 900mg twice daily if SR. Lithium is available in capsules and tablets as 150mg, 300mg and 600mg. Lithium is also available in sustained released tablets in 300mg and 450mg tablets. The sustained release tablets cause less stomach upset but cause more diarrhea due to more distal GI absorption.

    Common use: Lithium is effective for prevention of both manic and depressive episodes. Lithium also reduces the risk of suicide, perhaps by reducing agitation and impulsivity.
    • Considered drug of choice for maintenance treatment of bipolar disorder.
    • Considered drug of choice specially to PREVENT manic episodes
    • Using lithium reduces the risk of relapse by approximately 30 percent.
    Unlabeled uses: neutropenia, cluster headaches, premenstrual tension, bulimia, Alcoholism, Syndrome of Inappropriate Excretion of ADH, Tardive dyskinesia, psychosis. Also being used to augment the effects of antidepressants.

    Adverse effects: fine hand tremor, polyuria, mild thirst, nausea, hair loss & metallic taste.

    Monitoring: ideal blood levels: acute mania: 0.8-1.2 mEq/liter

    Maintenance is 0.6-1mEq/liter to minimize side effects.
    • Draw blood levels 12 hours after last dose.
    • Check blood levels: 5-7 days after initiation & any change in dosage.
    • Maintenance: every 1-2 months. In stable patients 6-12 months.
    • Monitor more frequently if volume depletion, or diuretic use, diarrhea or vomiting.
    • Check thyroid and renal function before starting lithium and every 6-12 months.
    • Hypothyroidism can occur and contribute to bipolar exacerbations.
    Drug Interactions:
    Increases lithium level
    • Thiazide diuretics (HCTZ, chlorthalidone)
    • Nonsteroidal anti-inflammatory drugs except aspirin
    • Angiotensin converting enzyme inhibitors (lisinopril, captopril)
    • Angiotensin receptor blockers (Irbesartan, valsartan, losartan)
    • Antibiotics tetracyclines and metronidazole (Flagyl®)
    Decreases lithium level
    • Potassium-sparing diuretics (triamterene, amiloride, spironolactone)
    • Theophylline (Theo-Dur®, Uniphyl®)

    Most providers do not feel comfortable managing Lithium, due to the toxicity and side effects. One of my former PA students that graduated around 2009 landed a job in a psychiatric hospital. Her job was unique, she managed the patient’s disease states brought on by the potent psych meds that were prescribed. Family practice providers see a lot of the metabolic abnormalities brought on by the antipsychotic drugs, so it is important to be familiar with problems brought on by these very potent medicines.

    Two years ago, I was counseling a patient who was on Lithium at the Empower-3 clinic. At our first meeting in the summer I reminded him (as I do all my lithium patients) to drink plenty of fluids. I explain to them when the “beaker”, that is your body goes low in water the concentration goes up and can cause toxicity.

    At the next meeting his caregiver said he was “chugging” 2 liters of water at a time about every 30-60 minutes. I immediately thought of the renal toxicities lithium can cause. After Vince, the Physician Assistant went in, did a complete physical and ordered blood work, it was determined he had “lithium induced nephrogenic diabetes insipidus”

    Just simple counseling a patient about their water intake lead to this rare diagnosis. That’s why we’ll take a long journey through the psych meds, because so frequently these problems fall on the lap of the family practice providers.

    Have a great day on the bench!!

    November 2019

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    More and more of our patients need our help with their psych meds!

    Behavioral Health Pharmacology
    Mental health services are challenging to get for our patients. Most psychiatrists are booked in advance, and mid-level practitioners such as CRNP’s and PA-C’s are carrying the burden. Even with their help mental health services are difficult to get for our patients. More and more mental health care is being provided by the family practice clinicians. At the request of the Physician Assistants that I work with at Empower-3, we will begin the journey through drug therapy for mental health disorders.

    Before we start the drug categories, we need to do a quick overview of the neurotransmitters.

    What makes a neurotransmitter:
    • It is synthesized in a neuron
    • Is synthesized/stored and released by the pre-synaptic terminal. When released it has a specific effect when it attaches to the receptor on the post-synaptic terminal
    • When given as a drug it exerts an identical reaction on the post synaptic terminal’s receptors
    • A specific mechanism removes the drug from the synaptic cleft,
      • either by pre-synaptic uptake (recycling) or
      • destruction by a specific enzyme
    In addition to depressed mood, abnormalities of neurotransmitter function are associated with different symptoms: Dopamine: (decrease in dopamine function)
    • Decreased ability to experience pleasure
    • Decreased motivation
    • Decreased attention
    • Cognitive slowing
    • Weight gain
    Norepinephrine (decrease in norepinephrine function)
    • Low energy & lethargy
    • Decreased alertness
    Serotonin (decrease in serotonin function)
    • Obsessive –compulsive behavior.
    NEUROTRANSMITTER SPECIFIC EFFECTS:
    SEROTONERGIC SIDE EFFECTS (excess serotonin):
    • Sexual dysfunction
    • Weight gain
    • Suppression of dopamine neurotransmission which may result in:
    • Decreased ability to experience pleasure
    • Apathy and decreased motivation
    • Decreased attention
    • Cognitive slowing
    • GI upset
    • Sleep Disturbances
    NORADRENERGIC SIDE EFFECTS (excess norepinephrine)
    • Tremor
    • Tachycardia
    • Dry mouth
    • Insomnia
    DOPAMINERGIC SIDE EFFECTS (excess dopamine)
    • Psychomotor activation
    • Aggravation of psychosis
    • Activation of motivation: rewards pathway
    • PERIPHERAL effects of dopamine:
      • At very high doses: ventricular arrhythmia, atrial fibrillation, ectopic beats, tachycardia, anginal pain, palpitation, cardiac conduction abnormalities, widened QRS complex, bradycardia, hypotension, hypertension, vasoconstriction.
      • dyspnea.
      • azotemia.
      • piloerection.
    GABA (gamma-aminobutyric acid)
    GABA is the chief inhibitory neurotransmitter of the CNS. Opposes the effect of glutamate. When released latches onto the GABA receptor which has a calming effect. Benzodiazepines work on the GABA receptor and cause a release of chloride, which is the major inhibitory ion in the CNS. Chloride ions are negatively charged causing hyperpolarization of the neuron. GABA's effects can be modulated by drugs such as benzodiazepines, barbiturates, steroids, and alcohol.
    NET EFFECT on the GABA receptor
    • Barbiturates increase the duration of chloride ion channel opening at the GABA receptor, to increase the efficacy of GABA.
    • Benzodiazepines increase the frequency of the chloride ion channel opening at the GABA receptor to increases the potency of GABA.
    GLUTAMATE
    Glutamate is the major excitatory neurotransmitter. Glutamate pathways are linked to many other neurotransmitter pathways, and glutamate receptors are found throughout the brain and spinal cord in neurons and glia. So diverse and widespread are the glutamate receptors only three prescription medications have been developed that specifically target glutamate or glutamate receptors, memantine (Namenda®), ketamine (Spravato®), and D-cylcoserine (Seromycin®). I find it incredulous that an Alzheimer's drug, an antidepressant and an anti-tuberculosis drug are all related to their effect on the glutamate receptor.

    One of the more challenging topics to teach to my Physician Assistant Sciences students is Behavioral Health. There are numerous disease states, numerous categories of drugs, and numerous generations of drug categories.

    It all began in 1954 with the introduction of Thorazine® (chlorpromazine) which began the emptying out of mental health hospitals. Today we have lots of drugs for treatment of bipolar, schizophrenia, depression and numerous other behavioral health conditions.

    The first Behavioral Medicine exam I gave at St. Francis had an average of 69%. Talk about PTSD; both the students and their professor still remember that morning back in 2005!

    Have a great day on the bench!!

    Naproxen, Ibuprofen, Meloxicam or dialysis. What would your diabetics choose??

    NSAIDS: Proceed with caution especially with Diabetics and Cardiovascular patients!!!

    NSAID use was associated with a 1.18-fold increased risk of Chronic Kidney Disease (CKD) in subjects taking NSAIDs for 1 to 89 days; and a 1.32-fold increased risk of CKD in hypertension subjects taking NSAIDs for ≥90 days, compared with subjects not taking any NSAIDs, after controlling for the confounding factors.

    https://www.ncbi.nlm.nih.gov/pubmed/26169048?dopt=Abstract

    NSAIDs reduce blood flow to the glomerulus by inhibiting production of vasodilating prostaglandins. NSAIDs can increase blood pressure, cause fluid retention, and worsen renal function in these patients. Among patients with hypertension, those who take NSAIDs for three months or longer are about 32% more likely to have chronic kidney disease than nonusers.

    TRIPLE WHAMMY: Watch combinations of NSAIDS/ ACE inhibitors and diuretics! In the normal kidney, glomerular filtration is related to glomerular blood flow.
    • NSAIDS: block prostaglandin mediated afferent arteriolar VASODILATION. (lets blood perfuse into the glomerulus)
    • ACE/ARB: block Angiotensin-2 mediated efferent arteriolar VASOCONSTRICTION (increases pressure for filtration)
    • DIURETICS: decrease plasma volume


    Above is a slide I created for FreeCE.com that I also use in my lectures, showing how NSAIDS slow down the blood flow to the kidney by blocking prostaglandin mediated vasodilatation. On the other side at the efferent arteriole vasoconstriction is blocked by ACEi/ARBS like Lisinopril or Losartan. We use ACEi and ARBs for nephroprotection because they stabilize the basement of the glomerulus. Avoiding NSAIDs is the best way to keep ACEI/ARBs on board and minimize renal problems. Above all, remember the most effective method to prevent diabetic nephropathy is tight glycemic control and control of BP and cholesterol. Weight reduction, exercise, and avoidance of smoking also help.

    Commentary:
    My wife and I frequently attend drug company sponsored dinners. It gives us pharmacists a chance to get out from behind the counter and interact with fellow health care professionals.

    Dr. Vijay Bahl, Chief of Endocrinology at UPMC Shadyside Hospital in Pittsburgh, was the presenter at the last dinner we attended. He was discussing the renal protection of canagliflozin and was talking about NSAIDs have a detrimental effect on the afferent arteriole. I asked Dr Bahl,"so you are saying NONE of our diabetic patients should EVER get an NSAID?"

    He said "correct, no diabetic patient should ever get an NSAID". Some in the room pressured him, asking if any NSAIDS are safer; some talked about acetaminophen’s lack of efficacy. Dr Bahl replied, “I tell my patients, you can either take acetaminophen for your pain, or eventually go to dialysis three times a week.” He said no one ever selects the dialysis option!

    Have a great day on the bench!!

    Do your pharmacist and patients a favor... prescribe aspirin, if indicated!

    Aspirin Dosage: for relief of mild to moderate pain is 325-1000mg every 4-6 hours., with a maximum dose = 4000 mg/day. Up to 3-4 g per day has been used for the treatment for rheumatoid arthritis, lupus, and other rheumatologic conditions. Of course watch for GI bleeding.

    Most of us pharmacists seldom see aspirin used for pain and inflammation, but rather for aspirin’s antiplatelet activity with the dose being 81-325mg/day. For acute myocardial infarction, the AHA/ACCF recommends chewing 162 to 325 mg immediately, unless patient already taking daily aspirin.

    PLATELETS before PAIN
    Aspirin’s cardiovascular benefits stem from its permanent inactivation of platelet COX-1, which blocks the production of thromboxane A2. Blocking Thromboxane A2 inhibits thromboxane A2-dependent platelet function and vasoconstriction. Aspirin irreversibly blocks platelets for their lifetime of 7 days. Complete blocking of platelet activity can be achieved with only 75 to 150 mg of aspirin.

    DOES EVERYONE GET ASPIRIN?
    The newest recommendations (ACC/AHA) : New guidelines say that daily, low-dose aspirin should be used infrequently to prevent primary cardiovascular disease. The bleed risk isn’t worth the benefit, until you have had an event. The American College of Cardiology and the American Heart Association conclude that aspirin should be reserved for people with the highest cardiovascular risk and the lowest risk for bleeding.

    Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a clinician–patient risk discussion before starting on pharmacological therapy, such as antihypertensive therapy, a statin, or aspirin. ASCVD calculators are found online and in many Electronic Medical Records.

    Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit. Men seem to benefit by prevention of myocardial infection, while women get their benefit from reduction of ischemic strokes.

    RISKS vs BENEFITS
    • Avoid aspirin in patients with additional GI risks unless their CV risk is high enough to outweigh the higher bleeding risk.
    • Make sure blood pressure is controlled before starting aspirin to reduce the risk of hemorrhagic stroke.
    • Always access the risk for potential for GI bleeds when combined with other NSAIDS. Don’t forget to include over the counter ibuprofen (Advil) and naproxen (Aleve).
    • Stop Aspirin with a 7 to 10-day washout before major surgical procedures.
    • Stopping aspirin in patients with a prior heart attack leads to 4 extra heart attacks per 1000 patients per year. Aspirin is serious therapy, and I advise prescribers to write a prescription for aspirin therapy.
    PRESCRIBING ASPIRIN:
    It is best to prescribe aspirin in the following circumstances:
    • Post stenting- bare or drug-eluting: indefinitely
    • Combined with Niacin ER (Niaspan, because it blocks prostaglandin mediated vasodilatation. That is, if anyone is using Niacin for mixed hyperlipidemia.
    • Combined with clopidogrel (Plavix) or ticagrelor (Brilinta) post stent
      • Bare Metal (non-ACS) 1 month up to 12months
      • Drug-eluting: 12 months post ACS
    • Ticagrelor (Brilinta) per package insert, patient must take an 81mg aspirin with one of the two Brilinta doses daily
    • MONA (Morphine, Oxygen, Nitroglycerin, Aspirin) therapy for myocardial infarction in the Emergency Department setting..
    Aspirin has been around 120 years now, and we still have not figured it out yet!

    Vince Capone one of the Physician Assistants I work with at Empower-3, also pulls an occasional shift in the Trauma Unit at UPMC Altoona. Vince tells me that frequently people come in with aspirin on board and have bleeding due to trauma. They frequently use DDAVP (desmopressin) to reverse the action of aspirin on the platelets.

    DDAVP, can be used for Von Willebrand’s disease, for bed wetting, diabetes insipidus and to reverse the effects of aspirin. Now that is a versatile drug!

    Have a great day on the bench!!

    October 2019



    Whats up with Cox-1 and Cox-2

    MOST NSAIDS inhibit COX-1 and COX-2 : Cyclooxygenase are the enzymes that produce prostaglandins. There are two types of COX enzymes simply named, COX-1 and COX-2. Both enzymes produce prostaglandins that promote inflammation, pain, and fever; however, only COX-1 produces prostaglandins that activate platelets and protect the stomach and intestinal lining.
    Blocking COX (Cyclooxygenase) inhibits prostaglandin and thromboxane synthesis.

    Here are the 4 A's of Cox inhibition
    • Anti-inflammatory (reduces inflammation)
    • Antipyretic effect (reduces fever)
    • Antithrombotic effect (reduces platelet stroke risk)
    • Analgesic effects (reduces pain)
    All NSAIDs inhibit COX-1 and COX-2 to different degrees. Mechanisms of inhibition:
    • Category 1: rapid competitive reversible binding of COX-1 and COX-2 (ibuprofen, piroxicam)
    • Category 2: rapid, lower-affinity reversible binding followed by time-dependent, higher-affinity, slowly reversible binding of COX-1 and COX-2 (diclofenac, indomethacin, naproxen)
    • Category 3: rapid reversible binding followed by covalent modification of COX-1 and COX-2 (aspirin)
    PRECAUTIONS for NSAIDs:
    BAD NEWS: GASTRIC DISTRESS
    REALLY BAD NEWS: CARDIOVASCULAR RISK as well as RENAL RISK
    • KIDNEY: Caution if renal impaired, may cause nephrotoxicity by blocking afferent vasodilatation. We will devote an entire column to renal effects of NSAIDS
    • PREGNANCY: All are pregnancy Category –D in third trimester, (near delivery) due to premature closing of the ductus arteriosus. Use lowest effective dose, intermittently if possible, especially in late pregnancy (avoid during last eight weeks of pregnancy).
      • First Trimester: link to miscarriage and certain rare birth defects in the first trimester
    • NURSING MOMS: Because of its extremely low levels in breastmilk, short half-life and safe use in infants in doses much higher than those excreted in breastmilk, ibuprofen is a preferred choice as an analgesic or anti-inflammatory agent in nursing mothers. Best to avoid Naproxen (Aleve®) http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
    • STOMACH: active GI disease
    • LIVER: Caution in liver impairment.
    • HEART: Exacerbation of heart failure, as well as increased risk of myocardial infarction, stroke, CV death. If an NSAID is needed Naproxen is a safer choice.
    • EVERYTHING ELSE:
      • photosensitivity
      • Avoid Aspirin & alcohol while taking NSAID
      • Watch for increased hypertension
    PREVENTION OF GASTROINTESTINAL RISKS:
    • Proton pump inhibitors
    • High dose H2RA Pepcid (famotidine) 40mg twice daily, will reduce risk of both gastric and duodenal ulcers
    • Misoprostol due to cramping, diarrhea and four times daily administration is seldom used.
    I remember as a kid growing up in the 1960's my Mom had a glass prescription bottle that had a paper note written inside. On the paper was written "DON-NO", indicating my brother was never to be taking this drug.

    The well-worn prescription label read "Butazolidin alka". Mom said it "almost knocked out his kidneys." She would ensure that there would be no repeat of that major side effect.

    I also remember my Dad at that time had a large glass bottle of "Ascriptin" which contained aspirin plus Maalox® (magnesium and aluminum hydroxide). The Maalox® was added to the aspirin to buffer the acidic effects of the aspirin.

    Until ibuprofen came over the counter in 1984, that is all we had in the NSAID family without a prescription.

    History has taught us to respect NSAIDS!

    Have a great day on the bench!!

    1898-Heroin; 1899-ASPIRIN both came from Bayer Pharmaceuticals

    NSAIDS, The Basics
    Non-steroidal anti-inflammatory drugs (NSAIDs); we use them every day in our practice. We’ve had them for many years and new information about when NOT to use them seems to come out rather frequently. With all the pressure on prescribers to avoid opioids NSAIDs are being called upon to pull the pain relief wagon. Even though a couple of these drugs (aspirin, ibuprofen, naproxen and ketoprofen) have over-the counter status, these drugs are certainly not innocuous. There are at least 16 NSAIDS with different pharmacokinetic profiles. The first and still most famous NSAID aspirin was developed by the Bayer Company in Germany in 1899, one year after Heroin® (diacetyl morphine) was introduced.

    The earliest NSAID came from white willow bark and contained salicin, similar to aspirin (acetylsalicylic acid). Our local aspen and birch trees also have salicin in their bark. Salicin was a precursor to aspirin before its development, and was used for reducing pain and inflammation. Hippocrates, the Greek physician (460 to 377 B.C.), wrote that willow leaves and bark relieved pain.

    Edward Stone, rediscovered aspirin in 1767, in effect, when he wrote that powdered willow bark seemed to benefit 50 patients with ague (malaria) and other maladies. The next big advance for non-steroidal anti-inflammatory drugs came when Felix Hoffman and Arthur Eichengrun reacted sodium salicylate with acetyl chloride to form aspirin. This compound was later marketed by Bayer under the trade name Aspirin which was registered as a trade name in January 1899.

    Mechanism: inhibit prostaglandin synthesis from arachidonic acid by inhibiting enzymes COX-1 and COX-2. Aspirin inhibits platelets by irreversible inhibition of platelet Cox-1 and inhibition of Thromboxane-A2. Today most patients use aspirin for cardiovascular protection, which will be covered later.

    AVOID: aspirin in kids under 18, due to the risk of Reye’s syndrome. Reye's syndrome is a rare but serious condition that results in fatty changes of the liver and acute encephalopathy mostly in children and teenagers recovering from a viral illness such as influenza or chickenpox. Ammonia accumulates and enters the central nervous system resulting in nausea/vomiting and altered mental status. The persistent vomiting seen with Reye's syndrome can result in dehydration and electrolyte abnormalities, especially in young children. Left untreated, patients can experience minor brain damage, seizures and possibly death. Also avoid other forms of salicylates such as Pepto-Bismol, menstrual products with magnesium salicylate and Alka-Seltzer.

    What ever happened to the other salicylates?
    • Salsalate (Disalcid): is a weak inhibitor of cyclogenase. Salsalate is a nonacetylated dimer of salicylic acid
    • Choline magnesium trisalicylate (Trilisate) is a nonacetylated dimer of salicylic acid.
    • Diflunisal (Dolobid) is a difluorophenol derivative of salicylic acid approved in 1982.
    Like Kasimir Funk, the Father of Vitamins, AlbertEichengrun is another forgotten scientist that made a huge impact on medicine.

    There are different references that describe a controversy between Dr. Albert Eichengrun and Felix Hoffman for the discovery of aspirin. In 1949, Arthur Eichengrün published a paper in which he claimed to have planned and directed the synthesis of aspirin along with the synthesis of several related compounds.

    Eichengrun claimed that Hoffmann's role was restricted to the initial lab synthesis using his (Eichengrün's) process and nothing more. Bayer denied his account of the story.

    Dr Eichengrun had another treatment that impacted the health care of its time. Dr Eichengrun developed Protargol (silver proteinate) in 1897. This drug had bactericidal properties and was the standard of care for treatment of gonorrhea for 50 years, until the availability of antibiotics.

    Have a great day on the bench!!

    Second and third generation antihistamines are valuable treatment for our allergy sufferers.

    2nd and 3rd Generation Antihistamines
    Last week we discussed the role of antihistamines in the treatment of seasonal allergies, and delineated the three generations of antihistamines. Since everything we do as practicing clinicians revolves around patient care, let’s discuss counseling points to share with each patient that utilizes our expertise.

    SECOND GENERATION ANTIHISTAMINES: do NOT cross BBB, causing minimal sedation, and NO anticholinergic side effects.
    • PREGNANCY: ACOG also recommends cetirizine and loratadine after the first trimester in patients who cannot tolerate or do not respond to maximal doses of chlorpheniramine. (All three drugs are Pregnancy Category B)
    • FYI: Cetirizine is the active metabolite of the prescription drug Hydroxyzine (Vistaril®, Atarax®)
    THIRD GENERATION are the "active enantiomers" of the second generation antihistamines
    • FEXOFENADINE: Fruit juices such as grapefruit, orange and apple juice may decrease the oral bioavailability of fexofenadine by inhibiting the activity of OATP1A2. Fexofenadine is a substrate of the intestinal uptake transporters organic anion transporting polypeptide 1A2.
    • DESLORATADINE: Desloratadine is the active metabolite of loratadine.
      • Novel use for treatment Lyme Disease: Loratadine metabolite "desloratadine" blocks BmtA (Borrelia metal transporter A). Desloratadine (which is the brand name "Clarinex") blocks manganese from entering the cell. Transition metals, including iron (Fe), zinc (Zn), and manganese (Mn), are critical to both bacterial metabolism and virulence. When these metals are blocked it starves the Borrelia burgdorferi and causing it to die in test tubes. Obviously this is way too early in the research phase for us to recommend this to our patients, so we will have to wait and see. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330029/




    REMEMBER SELDANE® ?? (removed from market in 1998) Fexofenadine is a primary metabolite of terfenadine (SeldaneRx). When terfenadine's hepatic conversion to the fexofenadine was blocked by other drugs or disease, levels of the parent drug (terfenadine) rise resulting in heart rhythm disturbances. Fexofenadine is effective in allergic disorders, and less cardiotoxic.

    REMEMBER HISMANAL®??(removed from market in 1999) Astemizole was the active ingredient in this second-generation antihistamine. This drug was also removed due to QTc interval prolongation and related arrhythmias when used with high doses, especially when taken with CYP inhibitors or grapefruit juice. This product was marketed by Janssen Pharmaceuticals.

    Both of these second generation antihistamines were pulled from the market leaving only loratadine (Claritin), cetirizine (Zyrtec), and fexofenadine (Allegra).

    Claritin became available over the counter in November 2002. Zyrtec became available in November 2007 without a prescription, and Allegra got its OTC approval in January 2011.

    Have a great day on the bench!!

    Antihistamines have been around for almost 75 years. Can you imagine life without them----Ahhhh-CHOO!!!!

    FIRST GENERATION ANTIHISTAMINES
    Last week we discussed the abundance of ragweed and its associated effects. This week we will discuss the use of antihistamines, of the first generation. Many of us “seasoned” pharmacists remember when these drugs were moved from behind the counter to OTC status. Although safe and effective, pharmacist expertise is necessary in quite a few patient groups.

    A brief HISTORY of antihistamines:
    • 1942 Bernard Halpbern introduced the first antihistamine: N-diethylaminoethyl-N-benzylalanine- Institute Pasteur in Paris
    • 1945 diphenhydramine became available, followed by chlorpheniramine, brompheniramine and promethazine later in the 1940's. Chlorpheniramine and Brompheniramine became over the counter September 9, 1976.
    • Diphenhydramine became available first as an antitussive in Aug-1981 (Benylin); as a sleep aid (50mg) in 1982 (Sominex-2), and as an antihistamine (25mg) Jan-1985 (Benadryl)

    • MECHANISM: H1-antagonists competitively inhibit the action of histamine on tissues containing H1-receptors. Some also block histamine release, but only in excessive doses. The H1-antagonists do not block antibody production or antigen-antibody interactions.
      USES: Symptomatic treatment (sneezing, rhinorrhea, and itching of eyes, nose, and throat) of allergic rhinitis, chronic idiopathic urticarial, as well as motion sickness & nausea/vomiting. Always best to start antihistamine therapy at least two hours before exposure.

      Structural Classes: Active Ingredient(s):
    • Alkylamines - brompheniramine, chlorpheniramine, triprolidine, pheniramine
    • Ethanolamines - clemastine, diphenhydramine, doxylamine
    • Ethylenediamines - pyrilamine (has some diuretic effects)
    • Piperidines - fexofenadine, loratadine
    • Piperazines: cetirizine, hydroxyzine, meclizine

    THREE GENERATIONS OF OTC ANTIHISTAMINES: First generation are the older, and more sedating antihistamines. They also cause numerous anti-cholinergic side effects. They cross the blood brain barrier.
    • Examples: Chlorpheniramine (Chlor-Trimeton), Clemastine (Tavist), Diphenhydramine (Benadryl), Brompheniramine (Dimetane)
    • First generation antihistamines are commonly used for allergy, hives, sleep induction, cough, vertigo, motion sickness, itching, adjunct for nausea and vomiting and runny nose. A lot of the benefits of these first-generation antihistamines is tied to their anti-cholinergic side effects.
    • Anticholinergic side effects: blurred vision, dry mouth, urinary retention, constipation. (“can’t see, can’t spit, can’t pee, can’t sh*t”)

    AVOID FIRST GENERATION ANTIHISTAMINES:
    • AVOID in ELDERLY: All first-generation antihistamines are listed in the Beers List. Due to their highly anticholinergic activity and reduced clearance with advanced age. Tolerance develops when used as hypnotic; may also see increased risk of confusion, dementia, cognitive impairment, dry mouth, and constipation. May also increase fall risk
    • Avoid in men with BPH (prostate hypertrophy)
    • Avoid in children under age six
    The second generation (non-sedating) do NOT cross the blood brain barrier, causing minimal sedation, and NO anticholinergic side effects.
    • Examples: Loratadine (Claritin) and Cetirizine (Zyrtec)
    • Third generation are the “active enantiomers” of the second generation antihistamines
      • Fexofenadine (Allegra) We will explore the second and third generation antihistamines next week.
    A retired allergist once told me that Central Pennsylvania was the best place on earth to practice!

    How well us seasoned pharmacists remember when antihistamines were made available over-the-counter. I remember when Benylin came over the counter, and we pharmacists were using it for everything from urticaria, insomnia to allergies.

    Antihistamines becoming over the counter started the beginning of pharmacists having a role in saving health care dollars. For every ONE dollar a patient spends in the front of our store, they save the health care system SEVEN dollars.

    The first prescription I filled as a newly licensed pharmacist in August of 1981 was for Benadyl 50mg capsules by Parke-Davis. I often wonder how many times I checked and rechecked that one!

    Next week we will cover another game changer in self care, the second and third generation antihistamines.

    Have a great day on the bench!!

    Keep the windows closed, and the air conditioner running!

    Achoooo.. That most familiar sound we hear this time of the year as the ravages of ragweed in the fields affects our patients.
    Flower pollens like those from annual plants like marigolds, petunias and impatiens rarely cause allergy, as their pollen is moved by bees. It is the windborne pollens that present the most difficulty to allergy sufferers. According to the Allergy and Asthma Foundation of America, 10-20% of us suffer from ragweed allergy.
    Here are some more teaching points to share with your ragweed patients:
    • Ragweed is most common in the Eastern states and the Midwest, mostly in rural areas. It includes several members of the daisy family.
    • A single plant produces up to 1 billion pollen grains.
    • Ragweed flowers mature and release pollen. The pollen must become airborne to fertilize other seeds.
    • Warmth, humidity and breezes after sunrise help the release. Pollen levels are highest in the morning & early afternoon (10am-3pm)
    • The pollen must then travel by air to another plant to fertilize the seed for growth the coming year.
    • Pollens can travel up to 400 miles out to sea, but most fall locally.
    Some treatment approaches can be:
    • Avoiding the peak pollen times for outdoor activity between 10am and 3pm.
    • Use central air conditioning, and HEPA filters. Maintain filters often.
    • Let the pollen outside! If you spend a lot of time outside during peak pollen time:
      • Take your shoes off outside
      • Don't wear your "outside" clothes to bed
      • Take a shower and shampoo your hair at night before going to bed.
    • Use of antihistamine therapy, which we will discuss in the next two weeks
    • Use of immunotherapy if insufficient response to antihistamines. They help desensitize the patient. Two immunotherapy options are available for severe cases of ragweed allergy:
      • Allergy shots can help build resistance to ragweed allergens.
      • Tablets that dissolve under the tongue are available by prescription. These sublingual tablets must be started 12 weeks before the beginning of ragweed season.
    Ragwitek: (Short ragweed pollen allergen extract) (cost $360.00/month)
    contains small amounts of natural short ragweed pollen that builds tolerance to decrease sensitivity to ragweed pollen.
    Use: Treatment of short ragweed-induced allergic rhinitis with or without conjunctivitis, that has been diagnosed by an allergist using skin testing.
    Dose: 1 tablet sublingual once a day (12 Amb 1-unit). Approved for ages 18-65. First dose must be dosed under medical supervision in a doctor’s office. Ragwitek® can cause severe allergic reactions that may be life-threatening.
    Medication should be laid under the tongue, and patient does not swallow for 1 minute. Patients should NOT take with food or beverages and not eat or drink for at least five minutes after administration.
    Notes: Should be started at least 12 weeks before the expected onset of ragweed pollen season and continue throughout the season. symptom score improved by approximately 18% or more.

    Next week we will explore the antihistamines.

    A retired allergist once told me that Central Pennsylvania was the best place on earth to practice!

    We have the deciduous and evergreen tree pollens in the spring, then the grass pollens in the summer. The rainy days of spring and summer produce lots of molds, leading into fall when the ragweed is in full bloom until the first killing frost. Couple that with our cool nights and everyone opens the windows (and even puts a fan in the window) to suck in all these outdoor allergens!

    We have a lot of treatment options to help our allergy suffering patients. We'll explore those treatment options in the coming weeks. We will cover first , second and third generation antihistamines.

    Wait! There are three generations of antihistamines??? Stay tuned for the next couple of weeks.

    Have a great day on the bench!!

    September 2019

    This handy chart will help you make decisions about therapy for your Type-2 patients with diabetes.

    NEWS FLASH--- oral GLP-1 available!!!

    Class / Generic name Brand name Physiologic action (Mechanism) Comments
    Biguanides (HbA1c=-1.5) Decreases hepatic glucose production Used first line. Weight neutral. GI side effects.
    Metformin Glucophage
    Sulfonylureas (2nd gen) (HbA1c= -1-1.5) Increases insulin secretion from the beta cells of pancreas Causes hypoglycemia, weight gain (5lb) , low durability
    Glyburide Micronase or Diabeta Avoid Glyburide in elderly (Beers List)
    Glipizide Glucotrol
    Glimepiride Amaryl
    Meglitinides (HbA1c=- 1-1.5) Increases insulin secretion Fast acting. Give with meal. May cause hypoglycemia
    Repaglinide Prandin
    Nateglinide Starlix
    Thiazolidinediones (HbA1c-.5-1) "TZD's" Increases insulin sensitivity No hypoglycemia, some weight gain (7lb) , heart failure,
    Pioglitazone Actos Bladder cancer(?)
    Rosiglitazone Avandia Heart failure (?)
    Alpha glucosidase inhibitors (HbA1c=-.5-.8) Slows intestinal carbohydrate digestion and absorption GI upset, gas, dosed with each meal. Must use glucose tablets for hypoglycemia
    Acarbose Precose
    Miglitol Glyset
    DPP4 inhibitors (HbA1c= -.5-1) Increase insulin secretion; blunts glucagon secretion Weight neutral. No hypoglycemia. Pancreatitis (?)
    Sitagliptin Januvia
    Saxagliptin Onglyza
    Linagliptin Tradjenta No renal adjustment No drug interactions
    Alogliptin Nesina
    SGLT-2 Inhibitors (HbA1c=-.5-1) Blocks reabsorption of glucose. Increases glucose in urine Slight increase in candida genital infections. Weight loss (-5 lbs)
    Canagliflozin Invokana
    Empagliflozin Jardiance (cardio protective)
    Dapagliflozin Farxiga
    Ertugliflozin Steglatro


    NON-oral MEDICATIONS
    GLP-1 agonists (HbA1c=-1-1.5) Decrease glucagon secretion, increases insulin secretion. Slows GI emptying, increases satiety Rarely causes pancreatitis and gastroparesis. Weight loss (-6lb). once weekly GLP's may cause medullary thyroid carcinoma.
    Exenatide Byetta and Bydureon Byetta dosed twice daily. Bydureon given once a week
    Liraglutide Victoza Dosed once daily cardioprotective
    Liraglutide Saxenda Dosed once daily Approved only for weight loss
    Dulaglutide Trulicity Dosed once weekly
    Semaglutide Ozempic Rybelsus-oral Dosed once weekly oral Rybelsus approved Sept 26,2019 dose 7mg or 14mg once daily in am.
    Lixisenatide Adlyxin Dosed once daily
    Insulin (HbA1c-greater than 1.5) Weight gain 7-11 lbs. Hypoglycemia
    Inhaled Afrezza Ultra-rapid acting First inhaled insulin
    Lispro Humalog Admelog Fast acting Mealtime insulin
    Humalog U-200 U-200 Kwikpen Double strength Mealtime insulin
    Aspart Novlog Fiasp Fast acting (Fiasp:2.5 minute onset) Mealtime insulin
    Glulisine Apidra Fast acting Mealtime insulin
    Regular Novolin-R Humulin-R
    NPH insulin Humulin-N Novolin-N Intermediate acting
    Detemir Levemir Long acting Basal insulin
    Glargine Lantus Basaflar Long acting Basal insulin
    Glargine Toujeo U300 Long acting First U-300 insulin. 300units/ml
    Degludec Tresiba Long acting Available as U-100 and U-200pens
    Insulin/Incretin combos
    Glargine & lixisenatide Soliqua 100/33 Long acting insulin + incretin Inject once daily, within one hour of first meal of the day. Use alternative treatments if doses below 15 Units or above 60 Units are required. Discard pen 14 days after first use.
    Degludec& liraglutide Xultophy 100/3.6 Dose 10-50 units (max) same time each day; with or without food.
    Glucagon Glucagon (Eli Lilly) (glucagon for reconstitution) Ultra-short acting treatment for hypoglycemia. Glucagon increases glucose by mobilizing conversion of glycogen stored in the liver Used to rescue insulin dependent diabetics with hypoglycemia, that can't swallow. (naturally produced in alpha cells in Islet of Langerhans)
    Auto injector Gvoke® (Xeris Pharmaceuticals) Stabilized glucagon for injection. 1mg and 0.5mg Autoinjector (Hypopen®) and prefilled syringe available
    Nasal powder Baqsimi® (Eli Lilly) Powder for nasal inhalation Available as 3mg powder


    Not much to say... here's your chart.

    My students frequently ask me for charts and I made this one a few years back, and always seem to be adding to it. Here are the past 15 newsletters rolled into one!

    If you want a PDF file of this chart, feel free to e-mail me.

    One hour before I was to launch this newsletter Novo-Nordisk announced the availability of Rybelsus(r) oral semaglutide. 7mg and 14mg. Whew... that was close.

    Have a great day on the bench!!

    Health care providers and diabetics REJOICE!!! We have glucagon that is easily administered!!

    Glucagon---now available in easy to use dosage forms!
    Paul Langerhans, a 22-year-old medical student discovered in 1869 islands of clear cells that bear his name. In 1907, another medical school student Michael Lane was able to differentiate between the alpha and beta cells. In 1922 Charles Best, a medical student working with Dr. Frederick Banting is credited with the discovery of insulin. 1923 Charles Kimball, a biochemistry student, isolated glucagon from the alpha cell, as he worked at the University of Rochester. In spite of this life-saving discovery that he named glucagon, he was never granted a PhD from that institution.

    The beta cells are associated with insulin production, while the alpha cells are associated with the production of glucagon. I find it amazing that these signifcant discoveries in diabetes were discovered by students!

    GLUCAGON: THE BASICS
    Simply put, glucagon raises blood sugars. In healthy patients, a rise in blood glucose activates both a glucose dependent and independent inhibition of glucagon secretion from alpha cells. Glucagon increases glucose by mobilizing conversion of sugar (glycogen) stored in the liver. Glucagon is further controlled by GLP-1 (glucagon like peptide) which inhibits glucagon release from the alpha cells and potentiates glucose induced insulin secretion. GLP-1 can be administered by injection with such drugs like Byetta®, Victoza®, Trulicity® and Ozempic®. Glucagon is administered for the treatment of severe hypoglycemia, especially for patients unable to swallow. Up until 2019, glucagon could only be administered as an injection that needed reconstituted. This cumbersome product required diluent placed in a vial of dry powder, swirled, withdrawn into a syringe and injected in the patient. Think about trying to utilize such a product in the event of an emergency… with your loved one. July and September 2019 brought diabetics and those of us who care for them some very good news.

    Glucagon for Injection (Eli Lilly) (cost is $300.00)

    GlucaGEN hypokit for Injection (NovoNordisk) Glucagon Emergency kit was approved in September 1998. The powder in vial needs to be reconstituted and yields a dose (adult) of 1mg SC, IM or IM. The pediatric dose for a child under 20kg= .5mg
    • Inject glucagon into the individual's buttock, arm or thigh, following the manufacturer's instructions.
    • When the individual regains consciousness (usually in 5-15 minutes), they may experience nausea and vomiting.
    • Inform provider about glucagon use to discuss hypoglycemia.
    Baqsimi ($300.00 per dose)
    is a glucagon nasal power dosed at 3mg approved by the FDA in July 2019 and marketed by Eli Lilly. Baqsimi is approved to treat severe hypoglycemia in patients with diabetes 4 and older.

    Efficacy: Baqsimi demonstrated efficacy comparable to injectable to glucagon 1mg injection. 98.9% experienced treatment success versus 100% for glucagon injection.
    Adverse effects: Aside from nausea and vomiting, nasal irritation and redness in the eyes can occur due to route of administration.
    Ease of use: Baqsimi is given on one side of the nose. It does not need to be insufflated. It is effective if a patient has nasal congestion due to cold, or if taking cold medicine. Emergency services should be called at once, and after 15 minutes another dose can be given if there is no response.

    Gvoke® ($300.00 per dose) by Xeris Pharmaceuticals
    was released this month (Sept-2019) and is the first and only premixed, pre-filled, and pre-measured liquid glucagon product, now approved for the treatment of severe hypoglycemic events among adults and pediatrics with diabetes ages two and older. Gvoke is available as a prefilled syringe as well as an autoinjector (Hypopen)

    Efficacy: Gvoke® demonstrated its ability to effectively resolve severe hypoglycemia showing 99% of adults and 100% of children achieved treatment success, which occurred in less than 14 minutes.
    Packaging: Gvoke® has two pre-measured dosing options: one for adults (1 mg/0.2 mL) and one for children (0.5 mg/0.1 mL), available in one or two-device packages.
    Ease of use: In usability studies, 99% of people were able to successfully administer a full dose of Gvoke in a simulated emergency setting

    About three years ago I attended a drug company promotional dinner for an insulin product. The chief of Endocrinology at Geisinger Dr Rick Sunderlin did an awesome presentation. After his brilliant lecture on basal insulin, I asked this question of the manufacturer “When are you going to develop an autoinjector for glucagon?”

    The manufacturer recently developed an auto injector for naloxone to complement their epinephrine auto injector. I said to the sales representatives “think about it, when a person needs to utilize an epinephrine pen, they are usually able to self-administer the dose. When a Type-1 diabetic needs a dose of glucagon they are unable to swallow and could be having seizures. The caregiver would be the one to administer glucagon and the only available devices are so cumbersome.”

    Dr Sunderlin looked at the representatives and said, “I never thought about that, your company should get working on that immediately!” So, my many years of complaining about an easy to use glucagon device has come to an end. I am thrilled with Eli Lilly and Xeris for making these life-saving drugs available to our diabetic population at a price that matches the cumbersome glucagon emergency kit.

    I don’t say it often, but “well done drug companies.”

    Have a great day on the bench!!

    Is NPH a reasonable choice to hold costs down??

    NPH --soon to be 70 years old... does it have a place in diabetes management??

    NPH “Neutral Protamine Hagedorn” as we mentioned in the history of insulin is regular insulin that is matched molecule for molecule with the protein protamine. Protamine is a protein used in the hospitals to reverse excessive bleeding caused by heparin. The first commercially available NPH was available in 1950. The human insulin formulations became available in the early 1980’s.

    Humulin-N® or Novolin -N® U-100 (isophane insulin) has an onset of action= 1.5-4 hours, with a peak between 4-12 hours. NPH insulin has a duration of action of 24 hours.

    COMPARING LONG ACTING (BASAL) insulins to NPH
    • The type of insulin (basal or prandial) does not appear to affect cardiovascular outcomes, according to the HEART2D trial. (source: https://www.ncbi.nlm.nih.gov/pubmed/19246588)
    • A large health care delivery system studied and found there was no benefit of insulin analogs compared with NPH in reducing emergency department or hospital admissions for hypoglycemia. NPH group had slightly better control (HbA1c=7.9) versus basal insulin (HbA1c 8.2) suggesting both groups were managed aggressively.
    IS NPH a reasonable choice to replace basal insulins due to cost?
    • Standard long-acting insulin analogs like glargine (Basaglar/Lantus) and detemir (Levemir) are not superior to NPH insulin in efficacy terms as determined by the number of participants reaching HbA1c targets.
    • The use of the glargine and detemir which have flatter curves, showed 50% less nighttime hypoglycemia, when compared to NPH.
    • All insulin analogs, both short- and long-acting insulin analogs, contribute to a reduced rate of overall hypoglycemia and less weight gain compared with therapies based on regular human insulin and NPH insulin.
    • SUMMARY: NPH and basal insulins show equal efficacy. Basal insulins have less night time hypoglycemia. Basal insulins have less weight gain than NPH
    COST:
    It depends… the wholesale acquisition prices are as follows:
    • Lantus 10cc vial ($300.00 per vial)
    • Humulin NPH ($160.00)
    • Novolin-N ($150.00)*** one of the big box stores has a special agreement with Novo-Nordisk for $25.00 per vial.
    Keep in mind that human insulin whether NPH, Regular or mixed 70/30 is over the counter. However, a prescription needs to be issued for a pharmacist to bill insurance.

    We know who the "big box" company is that I refer to with the $25.00 insulin. I won't mention their name because they have more lawyers than I do!.

    I commend them for being able to negotiate, with Novo-Nordisk for such a fabulous price for the treatment of diabetes. My question is why won't Novo-Nordisk make this available to all of the pharmacies? Every time a representative from Eli Lilly come to the pharmacy or the clinic I tell them this is a great opportunity to get back at Novo-Nordisk, and price their Humulin NPH, Regular and 70/30 for $25.00!

    Imagine... a world where our patients who lose their insurance coverage could go to any pharmacy and buy insulin at a reasonable price. Imagine glargine costing $32.00 per bottle... (imagine Canada!!)

    Many clinicians feel that moving from glargine to NPH is taking a 20 year step backward. The might have a point with regard to nocturnal hypoglycemia and weight gain. As far as efficacy, both products are similar; as far as costs go it isn't even close.

    Have a great day on the bench!!

    Rapid acting insulins-- for mealtimes and pumps!

    RAPID ACTING INSULINS
    Rapid acting insulins are used for mealtime management of blood sugars. The insulin is given before a meal, with some clinicians telling patients “have a fork in one hand, and your insulin pen in the other!” Ideally the patient does their carb counting and calculates the dose of mealtime insulin based on their correction factor, as well as an insulin:carb ratio. Because so many patients are unable to accurately count carbohydrates, clinicians offer a fixed dose for mealtimes along with a correction factor after the patient does a mealtime finger stick.

    INSULIN LISPRO
    Insulin lispro is a rapid acting insulin formulation, where the original human insulin amino acid sequence is changed to make it faster acting than the regular insulin our own pancreas produces. Lispro insulin substitutes lysine for proline at position B28, and proline for lysine at position (B29). Lispro has an onset of action= 0.25 hours, with a peak = .5 to 1.5 hours.
    Expect a duration of action around 2.5 hours.

    Humalog® U-100 (Lispro) by Lilly, was approved in June of 1996. It is available as a vial and Kwikpen®. The vial is available as U-100 concentration. The Kwikpen® is available as both U-100 and U-200 pens. The U-200 pen might be of value in patients that take higher doses of Humalog in that net absorption is reduced with increasing size of the subcutaneous depot. The smaller size of the depot might lead to better and more predictable absorption.
    • Admelog® U-100 (Lispro) by Sanofi-Aventis, available in vials and pens, and is considered to be a biosimilar to Humalog. Since Admelog is not FDA approved as a generic, it cannot be automatically interchanged by the pharmacy without a new prescription from the provider. As far as cost difference, currently the Humalog U-100 Kwikpens® have a wholesale acquisition cost (WAC) of $530.40, and the Admelog® Solostar has a WAC of $252.47.
    • Insulin Lispro Kwikpen® by Eli Lilly, is an” authorized generic” available with a WAC of $265.20, which was Eli Lilly’s response to Sanofi’s Admelog Solostar. Both vials and Kwikpens are now available.
    INSULIN ASPART
    Likes lispro, aspart is a rapid acting mealtime insulin that the amino acid sequence is changed to provide a more rapid response than our own regular insulin produces. Insulin aspart has a single proline to aspartic acid switch at position (B28). Aspart has an onset of action= .25 hours, with a peak in 1-2 hours, and a duration of 3-5 hours.

    Novolog® U-100 (Aspart) by Novo Nordisk, was approved in June 2000 and is available as vials and Flexpens. Novolog Flexpens have a WAC of $558.53 per box of 5 pens, for a total of 1500 units.

    Fiasp®, competitor of Novolog, also made by Novo Nordisk, approved in September 2017. Fiasp has vitamin B3, (niacinamide) which makes it more fast-acting. Both Novolog® and Fiasp® contain insulin aspart and are priced the same at $558.83 (WAC). Fiasp can be taken as much as 20 minutes after starting a meal, while other injected mealtime insulins are best taken 15-20 minutes before eating.

    INSULIN GLULISINE

    Insulin glulisine, is the third rapid acting formulation. Like the other two it has amino acid substitutions that allow for a more rapid absorption. Glulisine has an asparagine to lysine substitution at (B3) and a lysine to glutamic acid substitution at (B29). Glulisine has an onset of action= 0.25 hours, with a peak of 30-90 minutes and a duration of 2-4 hours

    Apidra® U-100 (glulisine) was approved in July 2004. Apidra is available as vials and Solostar pens. A box of 5 Solostar pens has a WAC of $548.52.



    It is nice to see Eli Lilly respond to the noise being generated about ridiculous insulin prices by offering a generic for Humalog. According to Global News Canada, caravans are travelling to Canada to buy a vial of insulin for $30.00! https://globalnews.ca/news/5249662/americans-driving-canada-insulin-prices/

    Lots of noise has been made about insulin prices including from this writer. Back when I was a new pharmacist in 1982, the independant I worked for had an “insulin club” where we offered the 13th bottle of insulin free. At that time our insulin price was $5.99 per bottle, and the 13th bottle was free!

    Yes, I know I didn’t include Afrezza® the ultra-rapid acting insulin. This column has always focused on “clinically relevant” information! Should I ever dispense Afrezza, my opinion might change. Afrezza seems headed to the same demise as did Exubera, the first inhaled insulin. I still have my original Exubera inhaler kit. Most providers refer to these mealtime insulins as "logs" .

    I teach my students that the "logs" (Novolog and Humalog) are mealtime insulin. For the other two, Fiasp I call "fast insulin aspart." For Apidra, just unscramble the letters to get "a rapid".

    Have a great day on the bench!!

    August 2019

    CLEARing up the differences in basal insulins!

    The human body spends about 12 hours in the “basal” state and 12 hours in the prandial state, and the other 12 hours in the “fed state”. In April 2000, the biggest change in diabetes therapy since the introduction of human insulin in the early 1980’s occurred. Lantus (insulin glargine) came to the market. NPH insulin was the mainstay of diabetes management since its introduction in the late 1940’s. By rearranging the amino acid sequence of human insulin, they were able to make a 24-hour insulin. No zinc acetate buffers (Ultralente), no protamine (PZI, NPH), but rearranging the sequence by changing amino acid asparagine at position A21 and replacing it with glycine. Two arginines are added to the C-terminus of the B-chain. The pH is adjusted to 4.0 to allow for complete solubility, and its clear appearance. After injection into the subcutaneous tissue, the acidic solution (pH=4) becomes neutralized, leading to formation of microprecipitates from which small amounts of insulin glargine are slowly released. The low pH is responsible for the “stinging” patients experience upon injection

    Insulin Glargine
    • Lantus ® U-100 (insulin glargine) by Sanofi-Aventis
    • Basaglar® U-100 (biosimilar insulin glargine) by Eli Lilly
    • Toujeo ® (insulin glargine) by Aventis is a U-300 insulin. May substitute unit for unit with Lantus. Some patients may need a dosage adjustment.
    Glargine has an onset of 1.1 hours, and a duration of 24 hours. It has no pronounce peak, referred to as a zero-order release. Because of the low pH, other insulins should not be mixed in the same syringe with glargine. Glargine is usually dosed in the evening; can be dosed in the morning if morning hypoglycemia is a problem (especially with the elderly). Many clinicians split the dose as well. Glargine has an expiration date of 28 days after first use of either a pen or vial.

    Insulin Detemir
    Levemir® (detemir) by Novo Nordisc became available to mount a challenge to Lantus in 2005. Like Lantus it has a one hour onset, and is peak less, but that is where the similarities end. Levemir has a duration of 16-20 hours. Very few patients get the “up to 24 hours” of coverage. Levemir is made long acting by binding the fatty acid (myristic acid) to the lysine amino acid at position B29. It is quickly absorbed after which it binds to albumin in the blood through its fatty acid at position B29. It then slowly dissociates from this complex. It’s pH is more physiologic (pH=7.4). If converting from glargine, it is NOT unit for unit and may require 1.5 to 2x increase in units. Most patients require twice daily dosing. Detemir has an expiration date of 42 days from first use of a vial or pen.

    Insulin Degludec
    Tresiba (Degludec) by Novo Nordisc, released in 2015, was another attempt to unseat glargine from its hold on the basal insulin market. Degludec has an onset and peak similar to glargine and detemir BUT has a duration of action of 42 hours which allows for more flexible dosing. Degludec is made long acting by binding hexadecanedioic acid to lysine at the B29 position which allows for the formation of multi-hexamers in subcutaneous tissues. Also, amino acid threonine in position B30 has been omitted. This allows for the formation of a subcutaneous depot that results in slow insulin release into the systemic circulation, which is active at physiologic pH. Tresiba has a pH of 7.6
    Tresiba® is available in 2 concentrations: 200 units/mL and 100 units/mL, available only in pens, and carries an expiration date of 56 days.

    Lantus came with great fanfare in 2000 and caused some confusion with patients. They were accustomed to their long acting insulin (NPH) being cloudy and their mealtime insulin (Humalog, Novolog, Regular) being clear. Sanofi did make the vial as a long skinny vial.

    Insulin glargine (Lantus and Basaglar) are the mainstays for basal insulin therapy in our area. I have maybe two patients on Levemir, and maybe three using Tresiba.

    Clinicians are most comfortable with glargine, and for the most part are reluctant to switch patients due to poor glycemic control. Now if we could get the prices under control!

    Have a great day on the bench!!

    Insulin therapy is almost 100 years old. Do we have it figured out yet?

    Basics of Insulin Therapy... first a little history
    HISTORY: Frederick Banting (who was an orthopedic surgeon), Charles Best, James Collip, and John Macleod are credited with the monumental discovery of insulin at the University of Toronto in 1922. The discovery was followed shortly after by the successful large-scale production of insulin in 1923 by the USA company Eli Lilly, resulting from a collaboration between the Toronto researchers and the company’s director of biochemical research George Clowes. Leonard Thompson, a Canadian, was the first human to receive an insulin injection, which was from the pancreas of a dog. Banting and Best used an ox pancreas as the source of insulin.

    August Krogh, who was a Danish physiologist and winner of the 1920 Nobel Prize. While touring the United States was granted permission to produce insulin in Denmark. On his return to Denmark, Krogh, together with Hans Christian Hagedorn, founded the Nordisk Insulinlaboratorium with the financial support of pharmacist August Kongsted. H.C Hagedorn: In the 1930’s this Danish chemist, prolonged the action of insulin by adding protamine (remember protamine reverses heparin) to form a precipitate. We older pharmacists remember PZI insulin (Protamine Zinc Insulin) with its 24-36 hour duration of action. In 1946 Hagedorn mixed equal portions of protamine with regular insulin, at pH of 7. This Neutral Protamine suspension of insulin was named after Dr. Hagedorn. We refer to this insulin as NPH (Neutral Protamine Hagedorn)

    Frederick Sanger in the early 1950’s determined the chemical structure of the two-chains of the mature human insulin molecule. He was awarded the Nobel Prize in 1958 for his work in elucidating the amino acid sequence for insulin, which was the first protein to have its amino acid sequence determined.

    Herbert Boyer: Finally, an American! It gets even better!! Dr Boyer was born in Derry Pennsylvania in 1936 and attended St. Vincent College enrolling in their pre-med program. One of our local practitioners, Dr. William Aigner a retired family practice physician was a classmate of Dr Boyer’s. Dr Aigner relates the story that Herb was more interested in genetics, than going to med school. His classmates questioned his decision. Herb went on to found Genentech, and in 1978 produced synthetic insulin with the use of a genetically modified bacteria (E. coli). By the way in 1990, he gave $10 million to Yale, their largest gift ever received. In 2007 St. Vincent College named the School of Natural Sciences, Biology and Computing after him. I guess Herb made a good decision not attending med school!

    Source: the insulin used today is “human insulin”. In days of old sources of insulin were
    • beef: which is 3 amino acids different than human insulin
    • pork: which is 1 amino acid different (less antigenic)
      • (dogs and pigs have the SAME amino acid sequence)
    • these insulins were extracted from the pancreas of cattle and hogs.
    Human insulin: is manufactured today by 3 major drug companies:
    Eli Lilly: “Humulin®” is manufactured by recombinant gene coded to make insulin inserted into the bacterium E.coli.
    Novo Nordisk: “Novolin®” by Novo Nordisk manufactured by a recombinant gene inserted into baker’s yeast
    Sanofi Aventis: “Lantus ”and “Apidra® are produced by recombinant DNA technology utilizing a non-pathogenic laboratory strain of Escherichia coli (K12) as the production organism.

    “Regular insulin” as produced by pancreas, in healthy non-diabetic patients has the following profile:
    • onset: .5-1 hour.
    • 2-3 hour peak
    • 6-8 hour duration
    Modifications on the insulin molecule, allow for shorter durations, and much longer durations of action. Insulin can be instituted at ANY point for Type-2 diabetes and should NOT be considered as last resort for treatment of the disease. Insulin should never be perceived as a “punishment” for a Type-2 diabetic.
    Insulin resistance: Insulin resistance occurs when the body does not respond properly to its own natural insulin. Insulin is a hormone in the body that helps convert blood sugar to energy so it can be used by the body's cells. In individuals with insulin resistance, the pancreas tries to keep up with the demand for insulin by producing and releasing more. Eventually, the pancreas cannot keep up with the body's need for insulin, and excess sugar builds up in the bloodstream.

    Beta cell failure rate:
    • In a healthy adult patient, beta cells fail at about 0.3% per year. (Loss of 3% in 10 years)
    • In an adult patient with Type-2 diabetes, the beta-cell failure rate is 4-6% (loss of 40-60% in 10 years).
    • It is fair to say that if a patient develops Type-2 diabetes early enough in life, if living long enough he will need insulin therapy.
    • We are born with 91million beta cells; at diagnosis of T2DM patients have 45million
    Other points of wisdom come from Dr Vijay Bahl- endocrinologist, Pittsburgh PA.
    • We have “thrifty genes” that save energy, that have not adapted.
    • 11% of diabetics are hospitalized due to hypoglycemia
    • “insulinase” breaks down insulin in the kidney, be cautious of declining renal function
    • We are “terribly underdosing” diabetics. Most require 60-65 units of insulin, average dose in western PA is around 42 units.

    U-10 insulin. Check out the attached website for some really fun pictures from the Novo-Nordisk website.

    When Denise and I graduated Pharmacy School in 1981, ACE inhibitors were just coming to market. AIDS was part of the trademark for an adhesive dressing. Lots has changed in our 38 years of practice, but nothing more dramatically than insulin therapy. Open our refrigerators in 1981 and we had Iletin I (which was a port/beef insulin mixture) and Iletin-II (which was all beef or all pork), we had PZI, NPH, Regular, Lente, Semi-Lente, and Ultra Lente. We had insulin available in U-40, U-80 and U-100. We also hand insulin formulations from "Squibb-Novo" what was made by Novo-Nordisk.

    Most of all I remember the "Insulin club" we had at the local chain I worked at. We sold insulin for $5.99 for a bottle of "NPH-Squib" U-100 which was a beef insulin. That's right 10 cc of insulin for that ridiculous of a price, and if you bought 12 bottles you got the 13th one free!

    Today the pricing of insulin is outrageous to say the least. I remember the Lilly rep telling us in 1982 that their Humulin insulin would no longer rely on the prices of pancreases from the slaughterhouses and the prices would stabilize. In August of 2011, the cost for a 10cc vial of Lantus was $98.36 and now 8 years later the cost is $285.00! Do the math, it is a 3 fold increase!

    On January 23rd, 1923 Banting, Best, and Collip were awarded the American patents for insulin which they sold to the University of Toronto for $1.00 each. They saw so much good with their discovery. I'm sure they would be so disappointed with insulin prices today.

    Have a great day on the bench!!

    Diet and exercies are FIRST LINE treatment for Type 2 diabetes. Let's talk about weight loss with diet.

    Health benefits occur with just a 5% weight loss, however most patients need to lose a greater percentage. A 5-7% weight loss provides beneficial effects for reduction of cardiovascular disease, dyslipidemia, hypertension, and diabetes mellitus. More than a 30% weight loss goal usually requires bariatric surgery. A 15% weight loss is considered to be a success.
    The AHD study was a multi-center trial emphasizing weight loss. Patients who lost 5-7% of their body mass showed reduced use of antihypertensive medications, statins, and insulin; reduction in urinary incontinence, sleep apnea, and depression; and improvements in quality of life, physical functioning, sexual functioning, and mobility. Before we blame the fork and spoon, let’s look at some other potential causes of weight gain in the pharmacy.

    It’s my meds causing weight gain!
    • Valproic acid: Depakene/Depakote
    • Mirtazapine (Remeron)
    • Paroxetine (Paxil)
    • Amitriptyline (Elavil)
    • Prednisone
    • Insulin and sulfonylureas
    • Depo-Medroxyprogesterone
    • All first generation antipsychotics (Thorazine, Stelazine, Haldol, etc)
    Here is a breakdown of the second-generation antipsychotics:

    HIGHEST WEIGHT GAIN
    • Clozapine (Clozaril®)
    • Olanzapine (Zypexa®)
    LOWEST WEIGHT GAIN
    • Ziprasidone (Geodon®)
    • Aripiprazole (Abilify®)
    • Lurasidone (Latuda®)
    • Paliperidone (Invega®)
    It’s my thyroid causing weight gain!
    “ITS MY THYROID” if this is suspected…have the patients physician order a blood test!
    • Most of the extra weight gained in hypothyroid individuals is due to excess accumulation of salt and water.
    • In general, average about 7lb of body weight may be attributable to the thyroid, depending on severity.
    • If weight gain is the only symptom of hypothyroidism that is present, it is less likely that the weight gain is solely due to the thyroid.
    The golden rule is there are roughly 3,500 calories in a pound of fat. Think of the waist line as an individual checking account. Deposits are in the form of calories consumed and withdrawals in the form of exercise and decreased caloric intake. If less is added, and more is withdrawn, weight loss occurs.
    • Lower calorie intake by 500 kcal per day (3x 12 oz soda) lose one pound per week.
    • Deduct 500 calories per day by exercise, lose 2 pounds per week.
    • Don’t replace “fat calories” with carbs. Balance is the key to any diet plan.
    More weight loss tips for your T2DM patients
    • Adopt a healthy lifestyle
    • Follow “My-Plate” -remember it is a 9-inch plate! (go ahead—measure your dinner plate!)
    • Focus on fruits and vegetables, lean meat, low fat dairy, and whole grains
    • All foods can fit, portion control is key
    • Don’t skip meals
    • Avoiding eating-out—save calories and money too!
    • Rethink-your drink- avoid any drink that has calories. Nothing hydrates better than water.
    • Move more!!
    • Schedule an appointment with your dietician.


    Think about your T2DM learning experiences in your school’s curriculum. For all the times we recommend diet and exercise, how little exposure do we get to these concepts in our formal training? A consult from a dietician is most valuable to treat T2DM.

    We have been extolling the virtues of exercise, and my wife Denise reminded me of a quote from one of our Physician Assistant students, “you can’t exercise off a bad food choice”. Is there any wonder that our waistlines have expanded in proportion to the number of restaurants in our area?

    From 2015 to 2016, for the first time in history, Americans spent more money at bars and restaurants ($54.857 billion) than they did on groceries ($52.503 billion).

    It has been estimated that Americans eat 1/3 of their calories away from home. Huge portions of tasty, mouthwatering foods, full of calories and salt make it impossible for weight loss if patients frequent restaurants more than just on special occasions. The average restaurant meal exceeds a home cooked meal by at least 200 calories..

    Have a great day on the bench!!

    We love receptors, mechanisms of action and classes of drugs... what is first line treatment for most disease states???

    EXERCISE: FIRST LINE TREATMENT
    Since the first line treatment of Type-2 diabetes is lifestyle modification (diet and exercise) let’s discuss the benefits of exercise this week. Obesity is now killing triple the number of people who die from malnutrition as it claims more than three million lives a year worldwide, according to a landmark study.
    (http://www.telegraph.co.uk/health/healthnews/9742960/Obesity-killing-three-times-as-many-as-malnutrition.html)
    According to data by Marketdata Enterprises, Americans spend over $66 billion annually to try to lose pounds, on everything from paying for gym memberships and joining weight-loss programs to drinking diet soda. (2017 data)

    Benefits of Exercise:
    • Exercise lowers blood sugar levels, improves insulin sensitivity, and strengthens the heart.
    • Strength training, which increases muscle and reduces fat, may be particularly helpful for people with diabetes.
    • Exercise will lower HbA1c by 1-2%
    • The challenge with Diet and Exercise is that a review of the adherence literature suggests that as a group, patients with diabetes are largely nonadherent. In one early study, only 7% of the diabetic patients were judged to be “fully adherent with all aspects of their regimen”. Which put another way 93% of our patients will NOT adhere to diet and exercise in the treatment of Type-2 diabetes. Because of this, the American Diabetes Association recommends starting metformin therapy at the first visit. http://care.diabetesjournals.org/content/20/2/215.full.pdf.
    Use it or Lose it Study
    To do this, ten healthy young men decreased their daily activity level from a mean of 10,501+/-808 to 1,344+/-33 steps/day for 2 weeks. After two weeks of this inactivity the results were:
    • energy expenditure was reduced
    • body weight increased
    • decline in lean body mass in the trunk and legs
    • 6–7% reduction in cardiorespiratory fitness
    • 17% drop in peripheral insulin sensitivity. Which means, by simply increasing a patient’s activity level, they can have about a 17% decrease in the insulin they require.
    Source: J Appl Physiol. 2010 May;108(5):1023-4.

    Remind your patients of the following benefits for exercise:
    • GOALS: Patients should aim to get at least 30 minutes of aerobic exercise most days of the week. Thirty minutes can be broken up into chunks—10 minutes here and there. Build up to 30 minutes gradually.
    • PUMPING UP: Lifting weights for 20-30 minutes two or three times a week is enough to get the full benefits of strength training.
    • INCREASES HDL: A 5-10 percent weight-loss can result in a five-point increase in HDL cholesterol (good cholesterol).
    • LOWERS TRIGS: Losing 5-10 percent of body weight was shown to decrease triglycerides by an average of 40 mg/dl
    • LOWERS BP: By losing 5-10 percent of one’s weight, blood pressure, both systolic and diastolic, decrease by 5 mmHg on average
    • LOWERS HbA1c: A 5-10 percent weight-loss can decrease HbA1c by half a point on average.
    • IMPROVES SLEEP: A 5-10 percent weight-loss may improve sleep apnea and sometimes if the apnea was not very severe, one can be weaned from the CPAP breathing machine.
    EXERCISE ADHERENCE: Unfortunately, a 10-year study of 255 diabetic patients enrolled in a diabetes education program that emphasized exercise, 80 percent at six weeks were still exercising to less than 50 percent at three months to less than 20 percent at one year.

    TEST BLOOD SUGARS: If the pre-exercise blood glucose is <100 mg/dL, insulin- or sulfonylurea-treated patients should ingest extra food, in the form of 15 to 30 grams of quickly absorbed carbohydrate (such as glucose tablets, hard candies, or juice), 15 to 30 minutes before beginning exercise. Easy to remember 15-30 GM ingested 15-30 minutes before exercising if finger sticks are below 100.

    Encourage your patients to follow all aspects of their physician’s treatment plan. We pharmacists are the “adherence experts” as well as the drug experts. With only 7% of our patients adhering to drugs, diet and exercise we can make a big impact in their treatment of Type-2 diabetes.

    The first line therapy for osteoporosis, heart failure, hypertension, depression, asthma, pain management, and of course is DIET AND EXERCISE.

    Think about your training in pharmacy school, med school, PA school, and nursing school. Diet and exercise physiology are topically covered (if at all). I find it interesting that all health care disciplines miss the opportunity to teach the FIRST LINE THERAPY for the most common treated disease states!

    Have a great day on the bench!!

    Selecting combination therapy for your Type-2 diabetics is simple math...well maybe not so simple!

    We are all familiar with Metformin (Glucophage) knowing it is the first drug prescribed for our Type-2 Diabetic (T2DM) patients. As we are all aware, rarely is this monotherapy effective unless our patient makes the necessary lifestyle modifications. Most references show that only 7% of T2DM patients will make the necessary lifestyle/dietary modifications necessary to combat this disease that is now affecting 1 out of 10 Americans. For the other 93% of our patients we need to look at additional pharmacotherapy to manage their Type-2 Diabetes.

    COMBINATION THERAPY
    Even with drug treatment Type-2 diabetics, will eventually need additional therapy to treat their hyperglycemia.
    • After 3 years, 50% of patients will need a second drug
    • After 9 years, nearly 75% will need the second drug added.
    • Most common combination therapy if cost is a concern is sulfonylurea + metformin.
    • As diabetes progresses a third drug is often added—either another oral agent, GLP-1, or insulin.
    • Addition of insulin should NOT be postponed in patients with poor glycemic control that have failed on multiple drug regimens.
    • Look at the patient, consider need for weight loss, adherence, insurance coverage, cost of medications etc.
    PUTTING IT ALL TOGETHER FOR COMBINATION THERAPY

    Treatment Expected decrease in HbA1c Estimated monthly cost
    Exercise, diet weight loss 1-2%
    Metformin 1.5% $8.00
    Avandia/Actos 1-1.5% $12.00
    Sulfonylurea (glipizide, glimepiride, eglyburide) 1.5% $8.00
    Alpha glucosidase inhibitors (Precose/Glyset) 0.5-0.8% $22.00
    Glinides (Starlix/Prandin) 0.5-1% $30.00
    Incretins (Victoza, Trulicity, Ozempic) 1-1.5% $800.00
    DPP4 inhibitors (Januvia, Tradjenta) 0.5-1% $500.00
    SGLT2 inhibitors (Invokana, Jardiance, etc) 0.5-1% $550.00
    insulin -basal 1 vial 1.5-3.5% $320.00


    *Consider initial therapy with insulin if HbA1c is greater than 10%.
    Example: the goal A1C you set is 7% for example. If a patient comes in with a HbA1c =9 there is NO way he can get there by adding Januvia®!


    Xigduo, Invokamet, Glyxambi, Stegluromet, Metaglip, Glucovance, Actomet-Plus, Janumet, Jentadueto, Kombiglyze XR, Kazano…everyone wants to be second choice after metformin. These combinations, which most are not even on my shelf, show the manufacturers attempt to get their expensive drug on board with metformin.

    I tell my student pharmacists and physician assistant students that using these drugs are a simple math problem. Start with the HbA1c and see if the HbA1c lowering adds up to the lowering you need to reach a goal HbA1c of 7.

    When you look at the estimated monthly cost column, it becomes even more of a math problem! Diabetes is an expensive disease, and for the most part the better control we get of the HbA1c the higher the price tag.

    Managed care organizations don’t really know what to do. The want to keep costs down, but a stay in the hospital or a visit to the emergency room negates any costs saved by withholding these expensive medications. As always look at your patient, and do what's best for them.

    Have a great day on the bench!!

    July 2019

    The last four drug classes have 4 different mechanisms of action. The "ominous octet" of diabetes is finished.

    OTHER T2DM TREATMENTS

    ALPHA GLUCOSIDASE INHIBITORS
    Mechanism: decrease gut carbohydrate absorption and slows carbohydrate absorption, by inhibiting the enzyme alpha-glucosidase, which is needed to digest complex sugars, in the brush border of the small intestines.
    Expected reduction: HgBA1C= (.5-.8%) Expect lowering of fasting plasma glucose 35-40 mg/dl.
    Target population: elevated post prandial glucose and normal fasting glucose.

    Acarbose (Precose®)- Available strengths 25,50 & 100mg
    Miglitol (Glyset®)- Available strengths 25,50,100mg
    DOSE: Both acarbose and miglitol: Titrate gradually to decrease adverse effects. Usual dose is 50mg-100mg three times daily with meals.
    Side Effects: dose related side effects include flatulence, diarrhea, and abdominal discomfort. Pregnancy Category B - both miglitol and acarbose

    PATIENT INFORMATION- alpha glucosidase inhibitors
    • Contraindicated in inflammatory bowel disease.
    • Administer 4g chewable glucose tablets or 15g gel in patients who develop hypoglycemia. -- Patients should carry these with them
    • Recommend liver function test every 3 months the first year then periodically.
    • If a patient skips a meal, then the alpha-glucosidase inhibitor should be skipped.
    • COST: Acarbose now generic less than $30/month
    Other use: prevention of dumping syndrome in post bariatric surgery patients. Dumping syndrome is the effect of rapid gastric emptying, leading to rapid glucose absorption, and it is particularly common among post-bariatric surgery patients.

    Dumping syndrome occurs in up to 75% of patients after Roux-en-Y gastric bypass surgery. By slowing up glucose absorption after a meal, there is a significant reduction in dumping syndrome.

    NON-SULFONYLUREA SECRETAGOGUES
    Structurally different from the sulfonylureas, but also bind to ATP sensitive potassium channels in the beta cell to cause insulin release. Both are rapidly absorbed and cause peak plasma insulin levels within 30-60 minutes. Are always taken before a meal.

    Repaglinide (Prandin®) available as 0.5mg, 1mg and 2 mg tablets
    • short acting - causes quick insulin release from pancreas.
    • works well for post prandial hyperglycemia
    • starting dose: 0.5mg three times daily 15 minutes before a meal
      • may double the dose each week - up to 4mg before meals up to 4 times daily.
      • Maximum daily dose = 16mg
    • May be combined with metformin or glitazone.
    • If you skip a meal, SKIP that dose. ADD a dose if you add a meal
    • cleared by hepatic metabolism and may be useful alternative to sulfonylureas in patients with renal impairment
    Nateglinide (Starlix®) available as 60 and 120 mg tablets (available generically)
    • short acting - causes quick insulin “pulse” from pancreas
    • works well for post-prandial hyperglycemia
    • starting dose: 120mg three times daily. take 1-30 minutes before a meal.
      • 60mg TID can be given if near HbA1c goals.
    • May be used as monotherapy or combined with metformin, or glitazones.
    • Omit dose if meal is skipped.
    BROMOCRIPTINE (Cycloset®) 0.8mg
    Mechanism: dopamine receptor agonist that “normalizes aberrant hypothalamic neurotransmitter activities that , that induce, potentiate and maintain the insulin resistant and glucose intolerant state”
    Dose: 0.8mg daily, increased until therapeutic dose 1.6mg-4.8mg (2-6 tabs/day)
    Benefits: cardiovascular safety and low risk of hypoglycemia and weight gain. only lowers A1C about 0.5%. Costs up to $900/month
    CAUTION: fainting as dose increases; also nausea, dizziness and drowsiness. Avoid if nursing. Because of unique release mechanism, you may NOT prescribe generic Parlodel (bromocriptine) for Type-2 diabetes.

    COLESEVELAM (Welchol®)
    Mechanism: first lipid drug approved for glycemic control. Colesevelam is a bile acid sequestrant, like cholestyramine (Questran). Bile acids play a role in cholesterol and glucose metabolism. Reducing bile acid absorption can improve both.

    DOSE: (both available generically for around $180.00 per month)
    • 6 huge pills daily (or 3 tablets twice daily).
    • Or one packet (3.75gm) packet once daily with a meal. Mix 1 cup of water, fruit juice, or diet soft drink. Stir well and drink.
    USE: add to metformin, insulin or sulfonylureas.
    Benefit: lowers HbA1c 0.5%, but may lower LDL 20%
    CAUTION in patients with triglycerides over 300 mg/dL; Avoid if over 500 mg/dL. May increase triglycerides especially when combined with insulin or sulfonylureas. Advise taking glyburide, oral contraceptives, levothyroxine, or narrow therapeutic index drugs at least 4 hours before colesevelam.

    We’ve come a long way since the discovery of sulfonylureas in the 1950’s. There have been a lot of new drugs with unique mechanisms that we have covered the past couple of months. Today’s four classes of drugs are seldom used, with acarbose being the most popular. For the most part, acarbose is used in our Type-2 diabetics that have undergone bariatric surgery.

    We’ve discussed drugs that affects the “ominous octet” in the treatment of diabetes. We’ve discussed the drugs that affect the following pieces of the ominous octet:
    1. Beta cell- impaired insulin secretion—(SULFONYLUREAS & GLINIDES)
    2. Alpha cell- increased glucagon- (DPP4s & GLP-1’s)
    3. Intestines- decreased incretin effect - (DPP4s & GLP-1’s)
    4. Fat cells – Lipolysis (TZD’s)
    5. Kidney- increased glucose resorption (SGLT2 inhibitors)
    6. Muscles- decreased glucose reuptake (TZD’s)
    7. Brain– neurotransmitter dysfunction (Bromocriptine)
    8. Liver- Increased hepatic glucose production (Metformin)
    Have a great day on the bench!!

    Even the cheapest SGLT2 inhibitor is over $300.00 per month

    SGLT2 INHIBITORS “Glucuretics”
    Mechanism: effectively work to reduce blood glucose independently of insulin. Glucose resorption in the kidney plays an important role in glucose balance. The kidney filters about 180g of glucose each day, with virtually all glucose being “recycled” back into circulation.

    SGLT2 is a major sodium-glucose co-transporter in the kidney and is an insulin-independent pathway for the re-absorption of glucose back into the blood. The healthy kidney spills glucose into the urine, once serum glucose levels exceed 180mg/dl. Selective inhibition of SGLT2 facilitates the excretion of glucose and associated calories in the urine, thereby lowering blood glucose levels. SGLT2 inhibitors “dial back” the glucose threshold from 180mg to about 80 or 90mg/dl.

    Negative effects of SGLT2 therapy:
    • Increase in genital infections and urinary tract infections
    • SGLT2 inhibitors cannot be used in stage IV nephropathy (GFR less than 30ml/min) due to mechanism of action.
    Positive effects of SGLT2 Inhibitors:
    • No hypoglycemia
    • As monotherapy or added to metformin will see reductions in blood pressure of 3-5mmHg systolic and 2mmHg diastolic.
    • No change in heart rate
    • No syncope
    • Weight loss (losing 50-85gm of glucose equates to 200-340 kcal/day
    • Mechanism of action is INDEPENDENT of insulin secretion.
    • Expect reductions in HbA1c of 0.5%-1%
    Precautions for SGLT2 Inhibitors
    • Dehydration - especially if:
      • have low blood pressure
      • take medicines to lower your blood pressure, including water pills (diuretics)
      • are on a low salt diet
      • have kidney problems
      • are 65 years of age or older.
    • Vaginal yeast infection.
    • Yeast infection of the penis. (Be sure to ask your male patients, especially if there uncircumcised) We had a patient at the clinic that was using iodine to treat his balanitis (ouch!)
    Canagliflozin (Invokana®) (Johnson & Johnson) approved April 2013
    • lowers CV risk, carries warnings of amputation
    Dapagliflozin (Farxiga®) (AstraZeneca) approved January 2014

    Empagliflozin (Jardiance®) (Boehringer/Ingelheim) approved August 2014
    • Reduces both CV risk and death
    Ertugliflozin (Steglatro®) (Merck) approved Dec 2017

    My first introduction to SGLT2 inhibitors happened in June 2012. I was updating my St. Francis lecture notes and looked up “new diabetes therapies”. I stumbled across an article about canagliflozin and how it caused the excretion of sugars from the kidney. I thought “what a crazy idea.” Since pharmacy school we were trained that glucosuria is always bad! I thought the idea would never catch on. Remember the days of Tes-Tape and Diastix measuring for sugar in the urine?

    About 3 months later I was approached by PharmCon to do a program on a new class of diabetes drugs. I asked Kevin “are these the ones that make you pee sugar?” He answered that they were, and three of them were waiting FDA approval. My mission was to introduce the world of pharmacists to SGLT2 therapy.

    After a lot of research, I learned that these “glucuretics” are a useful category of drugs. Shortly after the presentation, Invokana was approved followed by Farxiga and Jardiance. The basis for these drugs has been around for a long time. In 1835, French chemists first isolated a substance known as phlorizin from the bark of apple trees, but the doses needed to achieve lowering of blood sugars caused to many GI side effects.

    Because Invokana, Farxiga and Jardiance have a price tag of $500.00 per month, and Steglatro has a $300.00 price per month utilization in uninsured patients, and insured patients with high deductibles should be avoided.

    Have a great day on the bench!!

    $800 dollars a month will buy a lot of groceries... no wonder this class of drugs cause weight loss!

    INCRETIN MIMETICS (GLP-1 receptor agonists)
    Brand Name Generic ManufacturerYear released Year released Dose
    Byetta® exanatide Astra-Zeneca 2005 5mcg-10mcg twice daily, before meals
    Victoza® liraglutide Novo-Nordisk 2010 0.6-1.8mg /day any time
    Bydureon®BCise exenatide -er Astra-Zeneca 2012 2mg once a week
    Trulicity® dulaglutide Lilly 2014 .75- 1.5mg/week
    Ozempic® semaglutide Novo-Nordisk 2017 .25-1mg/week

    All of the incretin mimetics (GLP-1 agonists) are adjunctive therapy to improve glycemic control in Type 2 diabetics who are taking metformin, a sulfonylurea or a combination, and not having adequate control.

    2017: AACE (American Association of Clinical Endocrinologists) recommends incretins as first add on in Type-2 diabetes, after established metformin therapy. Many endocrinologists are using the GLP-1 agonists along with a basal insulin to decrease the need for mealtime “log” insulins three times daily.

    How it works: mimics natural physiology to provide self-regulating glycemic control by enhancing insulin secretion only in the presence of HYPERGLYCEMIA. GLP-1 stimulates the pancreas to INCREASE insulin and DECREASE glucagon secretion. Insulin secretion decreases as blood glucose concentrations approach normal.

    All above incretins are synthetic exendin-4 and has properties similar to naturally occurring gut hormone GLP-1 (glucagon like peptide-1), which:
    • stimulates insulin secretion in response to glucose absorption
    • suppresses glucagon production during periods of hyperglycemia.
    Incretin mimetics have been shown to suppress elevated glucagon secretions during periods of hyperglycemia and reduce food intake. It slows gastric emptying time.

    In clinical trials, most patients lost weight. Proposed weight-loss mechanisms include: Incretins bind to the GLP-1 receptor in the hypothalamus, thereby suppressing appetite. Incretins delay gastric emptying, which may cause patients to feel full faster and longer.

    Byetta dosage (exantide): ($750.00/month)
    • 5mcg/ dose given twice daily, anytime during the 60 minute period before morning and evening meal. Do NOT give AFTER a meal.
    • Dose can be increased to 10mcg twice daily after one month based on glycemic response and tolerability
    • NOT recommended in renal impairment
    • Supplied as 30 day prefilled pens.
    Victoza dosage (liraglutide): ($950.00/month)
    • 1 pen available. You dial up dose on pen for 0.6mg or 1.2mg or 1.8mg.
    • Administered once daily any time of day without regard for meals
    • Start 0.6mg daily for 1 week. After 1 week increase dose to 1.2mg. If not acceptable glycemic control may increase to 1.8mg. Use abdomen, thigh or upper arm.
    • Reduce both CV risk and death
    Bydureon dosage BCise (Exantide-extended) ($725.00/month)
    • 2mg once a week, every 7 days.
    • Comes as 4 syringe/vials per tray (one month supply)
    • NOT recommended in renal impairment
    Trulicity dosage (dolaglutide) ($785.00/month) 0.75mg and 1.5mg pens
    • Initiate at 0.75 mg subcutaneously once weekly. Dose can be increased to 1.5 mg once weekly for additional glycemic control
    • Amazing delivery device. Auto injector.
    Ozempic dosage (semaglutide) ($800/month)
    • Initiate with 0.25 mg subcutaneously once weekly for 4 weeks, then 0.5 mg for at least another 4 weeks. May be escalated to a max dose 1 mg.
    • Carries warning for diabetic retinopathy.
    INCRETIN MIMETICS – general prescribing rules:
    • Careful if existing stomach disease. Careful if pancreatitis risk. Caution in renal failure.
      • Do not administer incretin mimetics & DPP-4’s together – pancreatitis risk!
    • Increased risk of hypoglycemia if there is a sulfonylurea. Adjustment of sulfonylurea might be required, but do not adjust GLP-1.
    • No additional glucose monitoring is required to determine dose.
    • No additional dose planning around meal size or amount of exercise is required.
    • Risk of Thyroid C-cell tumors (black box warning- seen in rodents)
    Storage requirements: Keep under 77 degrees, do not freeze. Keep refrigerate until first use. Remember to write for pen needles for these devices.

    Insulin/Incretin combos
    Glargine & lixisenatide Soliqua® 100/33 Long acting insulin + incretin Inject once daily, within one hour of first meal of the day. Use alternative treatments if doses below 15 Units or above 60 Units are required.
    Degludec & liraglutide Xultophy® 100/3.6 Long acting insulin + incretin Dose 10-50 units (max) same time each day; with or without food.
    Although “Lizard spit” sounds like a component of witch’s brew, saliva from the Gila monster lead to one of the most important breakthroughs in Type-2 diabetes management.

    Exenatide (brand Byetta) is the synthetic version of a protein called exendin-4, which comes from the saliva of the Gila monster. The Gila monster eats only once or twice a year, and researchers were able to isolate what turned on the Gila monster’s endocrine system.

    GLP-1 agonists have vaulted into the top slot for many patients after metformin therapy is instituted. The drugs not only turn on insulin, turn off glucagon and cause weight loss, they pack quite a punch to the patient’s wallet. A month’s supply of any of the GLP-1 agonists hit the wallet between $750-$950 dollars per month. Uninsured patients can’t possibly afford any medications in this class.

    My wife Denise had a patient today that was insured but had a high deductible plan. This patient had to leave the prescription in the store, with its $800 price tag. Sounds like the manufacturers of this class of drugs are pricing themselves out of the market.

    Have a great day on the bench!!

    DPP4 INHIBITORS
    Mechanism: GLP-1 (incretin) is inactivated by the proteolytic enzyme dipeptidyl peptidase-4 (DPP-4). These drugs block DPP4 and cause increases in the concentrations of endogenous GLP-1 concentrations.

    Look at the chart above. Note that the incretins that we naturally produce blunt glucagon release and stimulate insulin release when blood sugars are elevated. Incretins, released in response to a meal, also slow digestion and promote satiety (a feeling of fullness). We have an enzyme called DPP4- (dipeptidyl peptidase) which breaks down our incretins.
    • Levels of GLP-1 decrease over time in diabetics, consequently, these DPP-4 inhibitors would be expected to be of most benefit in early Type-2 diabetes.
    • Better at reducing post prandial glucose levels than fasting levels
    • Will be mostly used as an “add-on” drug. Lowers HbA1C by only 0.6-0.8%
      • Most feel their price (Januvia cost $460. 00/month) isn’t worth the minimal HbA1c lowering
      • Only Nesina (alogliptin) is available as a generic. Is still in short supply and cost is over $200.00
    • Avoid concurrent administration with incretins (Trulicity, Victoza, Ozempic, etc) to decrease risk of pancreatitis.
    REPRESENTATIVE PRODUCTS
    • Januvia (sitagliptin) by Merck - October 2006
    • Onglyza® (saxagliptin) by Astra Zeneca - July 2009
    • Tradjenta ((linagliptin) by Eli Lilly - June 2011
    • Nesina (alogliptin) (by Takeda- Jan 2013
    Dosage of DPP4 inhibitors based on Cr Cl or drug interactions:

    Creatinine clearance Onglyza®
    saxagliptin
    Nesina®
    alogliptin
    Januvia®
    sitigliptin
    Tradjenta®
    linagliptin
    50ml/min 5mg/day 25mg/day 100mg/d 5mg/day
    30- 50ml /min 2.5mg/day 12.5mg/day 50mg/d 5mg/day
    < 30ml/min 2.5mg/day 6.25mg/day 25mg/d 5mg/day
    CYP450 3A4/5 2.5mg/day none none 5mg/day

    As we pharmacists and providers are aware treating diabetes is an expensive proposition. The DPP-4 inhibitors truly frustrate me, seeing that we are lucky to lower HbA1c by even 1%. These meds are expensive for the lightweights they are with respect to Type-2 Diabetes therapy.

    Only Tradjenta® (linagliptin) doesn’t require renal dosing, but with a price tag of $450.00 it is hardly a bargain. We have drugs with better efficacy than the DPP-4 inhibitors, now only if we can get prices down to a reasonable level. The DPP-4’s are considered “weight neutral”, which is about their only redeeming value.

    Have a great day on the bench!!

    June 2019

    I found us another cheaper treatment--TZD's for T2DM !! I just can't spell THIAZOLIDINEDIONES (or say it either!!)

    THIAZOLIDINEDIONES (“glitazones”) (“TZD’s”)
    • Troglitazone (Rezulin) - removed from market in late 90’s due to drug induced hepatitis..
    • Pioglitazone (Actos)-Available strengths= 15, 30 and 45mg (available generically rather inexpensive)
    • Rosiglitazone (Avandia)= available strengths= 2,4,8mg
    Mechanism of TZD’s:
    • work on the peroxisome proliferator-activated receptors (PPARs) gamma receptors, increasing insulin sensitivity in adipose and muscle tissue.
    • main action occurs in muscle tissue (~80%), where they increase insulin stimulated glucose disposal.
    • also affect the liver (~20%) where they decrease excessive hepatic glucose production.
    • can take 6 to 14 weeks to achieve maximum effects.
    • Caution using TZD’s with patients with CHF. Liver function tests at baseline, then periodically, thereafter for both TZD’s.
    • TZD’s might also increase fracture risk especially in women.
    • Weight gain is possible—over a period of 6 months-1 year a 2-3 KG increase can occur and can be much higher. Combination therapy with insulin can produce an even more dramatic weight gain.
    • Expected reduction: HgBA1c = (0.5- 1.4%) Fasting plasma glucose: 25-50mg/dl
    • Target population: insulin resistant
    • Monotherapy, but usually add-on to Metformin
    Actos ® (pioglitazone) available generically. Very inexpensive. (released July 1999)
    initial= 15-30mg (usual=15-45mg) ( max=30mg if combined with other agents)
    • Actos ® pioglitazone LOWERS triglycerides about 9% to 12% while Avandia® rosiglitazone can INCREASE triglycerides up to 15%. Like fibrates, Pioglitazone works on the PPAR-alpha receptors, which might account for its lipid lowering effect.
    • Actos® pioglitazone also raises HDL about 12% to 19% as compared to 8% to 19% for Avandia® rosiglitazone
    • Potential to cause bladder cancer. Avoid if potential for bladder cancer.
    Avandia ® (rosiglitazone) (released May 1999)
    initial= 4mg QD or divided BID max= 8mg. (max= 4mg if using sulfonylureas)
    COST= very expensive- no generics due to no demand, cost is$180/month.
    November 2007 required GlaxoSmithKline to include a black box warning about heart risks on the drug’s label. In 2010 a REMS program was instituted. In 2013 restrictions were lifted by FDA.

    COMMENTS:
    • Caution using TZD’s with patients with heart failure. Liver function tests at baseline, then periodically, thereafter for both TZD’s.
    • TZD’s might also increase fracture risk especially in women.
    • Weight gain is possible—over a period of 6 months-1 year a 2-3 KG increase can occur, and can be much higher. Combination therapy with insulin can produce an even more dramatic weight gain.
    • TZD’s are effective for Polycystic Ovary Disease, however, are not commonly used because they are Pregnancy Category C. Frequently when poly cystic ovary disease is treated, ovulation returns and pregnancy can occur.
    • D/C if ALT levels > 2.5 times Upper Normal Limit (UNL) or jaundice is observed.
    Educate your patients about the signs of liver toxicity: nausea, vomiting, abdominal pain, fatigue, anorexia, jaundice (skin and eyes), dark urine.

    At the Empower-3 clinic I staff on Mondays and Tuesdays, we frequently have patients that have no insurance and need treated for Type-2 Diabetes. As far as affordable medications we have only metformin, sulfonylureas and now pioglitazone.

    We don’t use much pioglitazone, due to the bad press that Avandia got 10 years ago.

    I attended a drug company sponsored dinner and an endocrinologist from Pittsburgh stated he uses a lot of pioglitazone. Most in the audience looked skeptically and some slightly cringed. His rationale was that pioglitazone doesn’t have the problems that rosiglitazone caused.

    Pioglitazone costs around $15.00 per month. Pioglitazone is significantly cheaper than the DPP-4 inhibitors (Januvia, Tradjenta) and has a greater lowering of HbA1c.

    If your patient has no cardiac contraindications or bladder cancer concerns, this might be a reasonably priced treatment option especially if uninsured.

    Have a great day on the bench!!

    Hard to believe we once were skeptical about prescribing metformin? Now we wonder if they should put it in the water!!

    Remember life before metformin?
    Metformin (Glucophage)

    Mechanism of action:
    • Decreases hepatic glucose production & improves insulin sensitivity in hepatic and peripheral tissues.
    • Major effects occur in the liver to decrease hepatic glucose output, and to a lesser extent, by increasing peripheral glucose utilization. Figure this drug works about 80% in the liver and 20% in the periphery.
    EXPECTED REDUCTIONS:
    • Reduction in HgBAc1: (1.5%)
    • Reduction in Fasting plasma glucose: 50-70 mg/dl
    Target population: overweight, insulin resistant and children (approved for patients over age -10)
    DOSE: Start low and go slow to avoid gastrointestinal upset.
    • initial: 500 BID or 850 QD (XR=500mg at supper)
    • usual: 1000mg BID or 850 TID maximum dose=2550mg/day (XR=1500-2000 at supper)
    • COST: both immediate release and extended release are available generically are inexpensive. Wide formulary coverage.
    CAUTION: Metformin XR 1000mg is ridiculously expensive. The cheapest generic formula for Metformin ER 1000mg is nearly $900.00 for 60 tablets. Valeant Pharmaceuticals makes a generic that the wholesale acquisition is $6,000 for 60 tablets.

    We can fill 120 generic Metformin XR-500mg for less than $20.00!!

    Metformin should be prescribed at the first office visit when the diagnosis of Type-2 diabetes is made. Metformin can be used as monotherapy or:
    • Combined with Sulfonylurea (Glucovance®= metformin + glyburide)
    • Combined with Thiazolidinediones (ActoPlus Met ®=metformin + pioglitazone)
    • Combined with DPP-4 inhibitors (Janumet® = (metformin + sitagliptin)
    • Combined with SGLT2 Inhibitors (Invokamet= metformin + canagliflozin)
    • Can be combined with insulin or GLP-1 agonists.
    Patient Information
    • Watch for Lactic Acidosis (rare - 3/100,000 patient years). Here are signs and symptoms:
      • feeling very weak, tired or uncomfortable
      • unusual muscle pain or cramps
      • trouble breathing
      • unusual or unexpected stomachache, decreased appetite or diarrhea
      • feeling cold, dizzy or light-headed
      • developing an irregular heartbeat
    • Contraindicated if serum creatinine over 1.5 in males or over 1.4 in females.
    • Caution if ethanol abuse & hepatic insufficiency.
    • Metformin medications should be stopped at the time of or prior to CT studies with IV Contrast, and withheld for 48 hours after the procedure.
    • Most experts prefer using creatinine clearance because it's adjusted for the patient's age, weight, and gender. (Cockcroft-Gault equation). When using creatinine clearance, avoid in patients with clearance less than 30 ml/minute
    • Take with food to minimize GI upset.
    • Titrate slowly to decrease adverse GI side effects (metallic taste, diarrhea, nausea, abdominal pain)
    • HEART FAILURE: Metformin is no longer contraindicated. It was thought that decreased kidney perfusion in patients with worsening heart failure could cause lactic acid accumulation. Metformin is beneficial in STABLE heart failure patients and does NOT increase lactate levels. Collectively, metformin has consistently been associated with an approximately 20% lower mortality rate compared with other antihyperglycemic agents
    WATCH for Metformin induced Vitamin B12 deficiency
    • Up to 30% of patients on metformin have reduced B12 absorption which could eventually lead to B12 deficiency. Besides ANEMIA, Vit-B12 deficiency can cause peripheral nerve damage, which can be mistaken for Diabetic Peripheral Neuropathy (DPN). I have treated four men who were taking metformin who had tingling in their hands, and Vitamin B-12 stopped the tingling.
    • Check B12 levels if new DPN or neuropathy gets worse. The lower B12 levels may cause an increased risk of peripheral neuropathy.
    • Treatment: Injectable B-12 usually not necessary, oral B12 (1000mcg PO daily) is enough. Don’t stop metformin, just treat the B12 deficiency.
    Polycystic Ovary Disease:
    Also used for Polycystic ovary disease. Also lowers serum androgen concentrations and leads to increased rates of ovulation in patients with Polycystic Ovary Disease. Pregnancy Category=B


    Another plant is the source of a very common diabetes drug. The biguanides were first discovered in the French lilac or goat's rue. The medicinal value of this plant in lowering blood sugars was elucidated in the 1700’s but it wasn’t until 1995 that this drug became available in the United States as “Glucophage®”.

    I remember when metformin was introduced, most of us were skeptic since it was a close cousin to phenformin (D.B.I.) which was pulled from the market in 1978 due to significant lactic acidosis.

    It wasn’t until the endocrinologists started prescribing this drug for a few years before the family practice doctors were comfortable.

    Have a great day on the bench!!

    Chevy Belairs, Elvis and sulfonylureas... all got their start in the 1950's

    Sulfonylurea history: 1950’s medicine!

    In the late 1930’s Dr. Marcel Janbon while working on a sulfa compound for typhoid fever, noticed that it caused hypoglycemia. Some patients experienced prolonged and profound hypoglycemia. This was about 15 years after the discovery of insulin by Dr. Frederic Banting and his student Charles Best at the University of Toronto. In 1946 it was confirmed that indeed sulfonylurea products caused insulin release as long at the pancreas was producing insulin.
    Mechanism of action: interact with ATP sensitive potassium channels in the beta cell membrane to increase the secretion of insulin, at all levels of glucose concentration. Second-generation drugs penetrate cell membranes more easily than first-generation sulfonylureas.

    Most believe that at time of diagnosis of T2DM, about 50 of beta-cell function is already lost. With long term use, the patient’s total number of beta cells decreases, beta cell function declines and these drugs become less effective. Failure rates are about 5-10% per year. When they fail, a different type of drug should be added. (Don’t replace with another sulfonylurea if the patient fails on a sulfonylurea.)

    Common adverse events: include weight gain, hypoglycemia, and water retention. First-generation sulfonylureas tend to produce an increase in adverse events, ionically bind to plasma proteins, and lead to more drug–drug interactions.

    FIRST GENERATION SULFONYLUREAS (still available as of 2019-seldom used)

    GENERIC NAME Available in USA DAILY DOSE RANGE DURATION of ACTION EQUIV. DOSE
    Tolbutamide (Orinase®) May 1957 500-2000mg/day in divided doses 6-12 hours 1000mg
    Tolazamide (Tolinase®) July 1966 100-1000mg/day in divided doses Up to 24 hours 250mg
    Chlorpropamide (Diabinese®) Oct 1958 100-500mg single dose 24-72 hours 250mg
    Acetazolamide Dymelor® 1964 Not available


    SECOND GENERATION SULFONYLUREAS

    GENERIC NAME Available in USA DAILY DOSE RANGE DURATION of ACTION EQUIV. DOSE
    Glyburide (Micronase) (Diabeta) May 1984 1.25- 20mg/ day in single or divided doses Up to 24 hours 5mg
    Micronized Glyburide (Glynase®) March 1992 1.5-18mg/day in single or divided doses Up to 24 hours 3mg
    Glipizide (Glucotrol®)) May 1984 2.5-40mg/day in single or divided doses 6-12 hours 10mg
    Glipizide-XL Glucotrol-XL® April 1994 Up to 20-30mg daily Up to 24 hours 10mg
    Glimepiride Amaryl® Nov 1995 1-4mg as a single dose Up to 24 hours 2mg


    REVERSAL of SULFONYLUREAS: (Overdose)
    Treatment of sulfonylurea induced hypoglycemia: Octreotide is used in extreme emergency only. Octreotide is a somatostatin analog that is known to suppress numerous hormones including insulin. It inhibits release of insulin from the beta cells. Frequently referred to as “Endocrinologist’s bleach” Typical doses administered in emergency room setting:
    • In adults, the dose of octreotide is 50 to 150 mcg administered by intramuscular, or subcutaneous, injection every six hours.
    • In children, the dose of octreotide is 1 to 1.5 mcg/kg (up to 150 mcg) every six hours
    Dextrose itself induces insulin secretion, thus theoretically contributing to rebound hypoglycemia when used to treat hypoglycemia.

    Who’s at risk for sulfonylurea induced hypoglycemia?
    (Duration of hypoglycemia in overdose of some sulfonylurea agents can be up to 72 hours.)
    • A single tablet of glipizide or glyburide can cause symptomatic hypoglycemia in infants or toddlers.
    • Risk factors for sulfonylurea-induced hypoglycemia include young age, malnutrition, alcohol use, and kidney or liver disease.
    SULFONYLUREAS? Yeah, they are cheap, but should we be practicing 1950’s medicine?
    • Metformin is always first line for type 2 diabetes. Start at first visit when first diagnosed
    • Don’t trash Sulfonylureas completely as they lower A1C about 1% and cost about $10/month instead of up to $800/month for the newer meds like the GLP-1’s (Ozempic, Trulicity and Victoza).
    • Consider sulfonylureas when cost is a concern, such as with uninsured patients.
    • Since they're likely cranking out insulin sulfonylureas may be a good choice for patients within about 5 years of diagnosis.
    • Caution about use in elderly patients or those with renal impairment. Avoid glimepiride and glyburide. Glipizide is least likely to cause hypoglycemia in these patients.

    We all know what Type-2 diabetes mellitus looks like. We all know this is a rapidly growing disease. I won’t spend a lot of your precious time discussing the incidence of this very common disease. One factor stands out. The incidence of T2DM was about 1% of our nation when the sulfonylureas came to market in the mid 1950’s. Just in that short span the incidence of diabetes mellitus Type-2 is now almost ten times that.

    A Center for Disease Control and Prevention (CDC) report finds that as of 2015, 30.3 million Americans – 9.4 percent of the U.S. population –have diabetes. Another 84.1 million have prediabetes, a condition that if not treated often leads to type 2 diabetes within five years. The patient profile is typically adults over 40, with a higher frequency in overweight teens.

    Cause: poor insulin metabolism in the body, or reduced insulin production by pancreas, or both. After several years of insulin resistance, insulin production decreases. The result is the same as Type-1, glucose builds up in blood and body cannot make efficient use of its source of fuel.

    So, do sulfonylureas have a place in T2DM therapy. As always it depends... on the patient (or more specifically their insurance or lack thereof)

    Have a great day on the bench!!

    Helping our cirrhosis patients lower ammonia levels... Might cost $40, could be $2,500.00 per month!

    TREATMENT OF EXCESSIVE AMMONIA LEVELS IN HEPATIC INSUFFICIENCY

    Mechanism:
    Alcohol’s harmful effects on liver cells not only interfere with the normal functioning of the liver but also impact distant organs, including the brain. Prolonged liver dysfunction resulting from excessive alcohol consumption can lead to the development of a serious and potentially fatal brain disorder known as hepatic encephalopathy, which is believed to be due to excess circulating ammonia levels.

    Hepatic encephalopathy is a complication of hepatic cirrhosis and is characterized by a spectrum of neuropsychiatric abnormalities such as personality changes, deterioration of mental status with psychomotor dysfunction, impaired memory, sensory abnormalities, etc. Clinical manifestation can range from subtle cognitive abnormalities to coma. Overt hepatic encephalopathy occurs in about 30%-45% of patients with cirrhosis.

    PHARMACOLOGICAL MECHANISMS OF TREATMENT:
    • sugar molecules to decrease systemic absorption of ammonia OR
    • antibiotics to reduce the bacteria which produce ammonia in the gastrointestinal tract
    • correct hypokalemia, since low potassium levels increases renal ammonia production.
    Lactulose (cost for 64 oz= $40.00/month)
    • Lactulose (Chronulac, Constulose®) alters the acidity in the colon, which prevents absorption of ammonia, one of the toxins. Remember biochemistry, where the charged ions are less likely to be absorbed. By acidifying the colonic contents to a pH of approximately 5, the ammonia ion becomes protonated, thus positively charged, and less likely to be absorbed.
    • This partially dissociates, acidifying the colonic contents (increasing the H+ concentration in the gut). This favors the formation of the nonabsorbable NH4+ from NH3, trapping NH3 in the colon and effectively reducing plasma NH3 concentrations.
    • The laxative action of lactulose moves the ammonia ions out of the colon, by stimulating bowel movements.
    DOSE: oral dose of 15–30 ml twice daily
    EXPECT 3-4 loose bowel movements per day
    PRECAUTIONS: Overdosage can result in ileus, severe diarrhea, electrolyte disturbances, and hypovolemia. Hypovolemia may be sufficiently severe as to actually induce a flare of encephalopathy symptoms

    Rifaximin (Xifaxan 550) ($2500.00/month) oral antibiotic agent with minimal gut absorption that concentrates in the GI tract. It has a broad-spectrum in vitro activity against gram-positive and gram-negative aerobic and anaerobic enteric bacteria, and has a low risk for bacterial resistance since it's not systemically absorbed. This drug is usually added to lactulose, not instead of lactulose. DOSE: Rifaximin, oral dose of 550 mg twice daily Rifaximin (Xifaxan) was approved in May 2015 FDA for treatment of IBS with diarrhea (IBS-D) in adults.

    Less commonly used antibiotics:
    • Neomycin ($150.00/month)
      • Is a non-absorbable aminoglycoside antibiotic that decreases the ammonia forming bacteria in the gut.
      • DOSE: oral dose of 500 mg four times daily (use high doses with caution). High doses may cause ototoxicity and nephrotoxicity.
    • Metronidazole (Flagyl) oral dose of 250 mg four times daily—short term use only.
    • Vancomycin (Vancocin) oral dose of 250 mg four times daily
    AVOID: Avoid medications that depress central nervous system function, especially benzodiazepines. Patients with severe agitation and hepatic encephalopathy may receive haloperidol as a sedative.

    Alcoholism can contribute to declining health in a lot of ways. We've reviewed the needs of vitamin supplementation (March 21,2019) for our alcoholic patients. Alcoholism can also damage kidney function.

    The liver seems to take most of "the beating" from excess alcohol consumption. Lots of meds need to be adjusted with liver dysfunction, most notably acetaminophen. It is fascinating to me the connection between our gut, which produces ammonia, and our liver which breaks down ammonia, and our brain that is affected by these elevated ammonia levels.

    My "go to" website for liver toxicity is operated by the National Institutes of Health and can be found at: https://livertox.nih.gov/

    Have a great day on the bench!!

    May 2019

    We have 3 major treatment options to help our patients abstain from alcohol.

    Last week we discussed the role of common drugs such as the benzos- Librium, Valium, Ativan, Gabapentin and Tegretol for the treatment of alcohol detoxification. Let's now take a look of keeping our patients with alcohol use disorder from relapsing.

    Alcohol Relapse Prevention Agents
    Naltrexone (ReVia®)     (approved 1984)
    Mechanism: Blocks opioid receptors to reduce the pleasurable effects from alcohol. Increases abstinence days, reduces heavy drinking days and improves overall outcome.
    DOSAGE: 25-50mg per day by mouth, up to 100mg per day.
    • BEST CHOICE (Pros): Abstinence from alcohol is NOT required for therapy. Helps for patients with high levels of cravings, especially in risky drinking situations. Helps prevent relapses into heavy drinking in patients who are not completely abstinent
    • CONTRAINDICATIONS: opiate abusers. Patients with severe liver pathology. Can't be given to patients currently receiving opioid therapy. Don't use for kidney disease.
    • Patients should carry identification noting that they are on naltrexone in case of an injury requiring opioid therapy
    Naltrexone Injectable extended release (Vivitrol® 380mg)-     (approved 2006)
    once a month current cost : over $1,300.00
    • To avoid sudden opiate withdrawal, must be taken 7-14 days after last consumption of opioids; must not be actively drinking at time of injection. Good choice if patient compliance is an issue
    • Patient should stop drinking before Vivitrol injection.
    • May cause injection site reactions such as necrosis.
    • If pain management is needed, Vivitrol blocks opioid receptors for 28 days.
    Disulfiram (Antabuse®)      (approved 1951)
    Mechanism: blocks acetaldehyde dehydrogenase. Acetaldehyde increases 5-10 times higher. Acetaldehyde causes: flushing, throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pains, palpitations, hypotension, tachycardia, syncope
    • Initial dose: 500mg daily for 1-2 weeks. May take HS if drowsiness.
    • Maintenance: 250mg/day (average) range: 125-500mg
    Patient counseling points
    • Avoid alcohol in all forms
    • Clinically it reduces drinking days, but does not enhance abstinence.
    • Compliance is THE major factor determining efficacy of disulfiram.
    • Pros: for a person who needs emergency help to stop drinking NOW.
    • Does not reduce cravings.
    • CONTRAINDICATIONS: use of alcohol, coronary artery disease, liver disease, severe myocardial disease.
    Acamprosate (Campral®) 333mg enteric coated tablets     (approved 2004)
    Mechanism: reduces the anxiety & other unpleasant effects of alcohol withdrawal. It works by balancing the GABA and glutamate neurotransmitters in the brain. It is for patients who are abstinent and decrease relapse to heavy drinking. (Better effect with Campral and Naltrexone together) Dosage: two tablets (666mg) three times daily. (333 TID if moderate renal impairment; CrCl=30-50ml/minute)
    • Do not give if severely renal impaired.
    • Adverse Effects: Diarrhea, itching, depression, insomnia, cardiomyopathy (rare)
    Patient counseling points:
    • BEST CHOICE: for patients with significant liver pathology, because it is excreted unchanged in the kidneys. Patients with SEVERE alcohol withdrawal symptoms. Patients able to initiate abstinence but have difficulty in maintaining newly regained abstinence. Most successful outcomes in studies when patients were abstinent of alcohol. Better evidence for achieving abstinence than naltrexone.
    • ADHERENCE: adherence is the biggest challenge with acamprosate with three times a day dosing.
    • CONTRAINDICATIONS: severe renal impairment. Creatinine Clearance less than 30ml/min
    • MAJOR SIDE EFFECT: diarrhea
    Thiamine & Multivitamin
    • Chronic alcoholism interferes with the absorption of Thiamin and Folic acid
    • Thiamine (Vitamin B 1) 100mg daily to prevent Wernicke-Korsakoff syndrome, an often fatal encephalopathy.
    Treatment should begin at the beginning of alcohol withdrawal and continue at least through the alcohol withdrawal period. Ensure folic acid is in multivitamin and prevent such complication as megaloblastic anemia

    How long should treatment last?
    • Patients who maintain abstinence or adequately reduce heavy drinking, should continue psychosocial treatments for at least six months
    • Medication treatment should last one year, longer if tolerated.
    • Stability time increases as treatment time increases.
    One of the parameters we monitor at the Empower-3 clinic is adherence. Adherence can be verified by a simple interview question. I usually say "I see you are on a lot of medications, let's say in the course of a month how many times do you miss a dose of your medications?" Most people are honest, and I always follow up by asking "What do you attribute your success to? Do you use an app on your phone, or a plastic pill reminder?" Fortunately if they have insurance that is billed our system can look up refill history, which occasionally points out a discrepancy.

    Adherence to statins and ACE-inhibitors can be part of our Star Ratings calculations, so it is important for our patients to be adherent to these medications. However, adherence is of critical importance in the treatment of alcohol use disorder. All these medications are effective, but only if patients take them.

    Unfortunately, on all therapies, half the patients relapse after 3 months. Looks like many opportunities for patient counseling by your community pharmacist.

    Have a great day on the bench!!

    Benzos are still the mainstay of treatment of alcohol withdrawal

    Prevalence of Drinking:
    https://bewellfinder.com/alcohol-facts-and-statistics/
    Who's drinking? According to the 2015 National Survey on Drug Use and Health (NSDUH),
    • 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime
    • 70.1 percent reported that they drank in the past year
    • 56.0 percent reported that they drank in the past month.
    Prevalence of Binge Drinking and Heavy Alcohol Use: defined as NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours
    • in 2015, 26.9 percent of people ages 18 or older reported that they engaged in binge drinking in the past month;
    • 7.0 percent reported that they engaged in heavy alcohol use in the past month
    Alcohol Use Disorder (AUD): defined a chronic relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences
    • Adults (ages 18+): According to the 2015 NSDUH, 15.1 million adults ages 18 and older (6.2 percent of this age group) had AUD.
    • This includes 9.8 million men (8.4 percent of men in this age group) and 5.3 million women (4.2 percent of women in this age group).
    • About 6.7 percent of adults who had AUD in the past year received treatment. This includes 7.4 percent of males and 5.4 percent of females with AUD in this age group.5
    Alcohol Use Disorder in the Youth:
    • Youth (ages 12-17): According to the 2015 NSDUH, an estimated 623,000 adolescents ages 12-17 (2.5 percent of this age group) had AUD.
    • This number includes 298,000 males (2.3 percent of males in this age group) and 325,000 females (2.7 percent of females in this age group).
    • About 5.2 percent of youth who had AUD in the past year received treatment. This includes 5.1 percent of males and 5.3 percent of females with AUD in this age group.
    TREATMENT OF ALCOHOL DETOXIFICATION
    Benzodiazepines are the mainstays of treatment for alcohol withdrawal, particularly inpatient, however anticonvulsants are becoming increasingly popular for outpatient detox due to good efficacy and a lower potential for abuse
    • The doses of benzodiazepines used for alcohol detox are much higher than those used to treat anxiety.
    • IV therapy required for ALL patients with seizures or DT (delirium tremors). Convert to oral dosing as soon as possible. Avoid IM due to erratic absorption.
    • Adverse effects: Sedation, dizziness, delirium, hypotension, respiratory depression

    Drug Dose Pros Cons
    Chlordiazepoxide (Librium) 50-100mg Q 6 hours initially, then taper down Long acting, fewer breakthrough symptoms Very sedating
    Diazepam (Valium) 10-20mg Q 6 hours initially, then taper down Fast onset of action, long acting Higher abuse potential
    Lorazepam (Ativan) 2-4mg Q 6h, then taper down Less sedation. Treatment of patients with advanced cirrhosis or acute alcoholic hepatitis. Shorter acting, more breakthrough symptoms, unlabeled use
    Oxazepam (Serax) 15-30mg QID, then taper down Less sedation, lower abuse potential, better for elderly patients. Treatment of patients with advanced cirrhosis or acute alcoholic hepatitis. Patients may experience more breakthrough or rebound symptoms

    Anticonvulsants
    • Becoming increasingly popular for outpatient detox due to good efficacy and a lower potential for abuse
    • Use of anticonvulsants for alcohol detox should be considered in patients where there is a high potential for abuse, or for whom sedation poses a serious concern
    • Detox using anticonvulsants may be used in outpatient settings where withdrawal symptoms are less severe, and patients are at a lower risk for serious complications
    • Phenobarbital: works synergistically with benzodiazepines, which increase the frequency of GABA chloride channel opening, and barbiturates, which increase the duration of channel opening. Used for refractory DT's
    Carbamazepine (Tegretol)
    Dosed: 200mg QID x 1 day, then 200mg TID x 1 day, then 200mg BID x 1 day, then 200mg QD x 2 days. May be OK for outpatient alcohol withdrawal, little effect for DT's
    • Less sedating, and less abuse potential than benzos
    • Many drug interactions (enzyme inducer)-speeds up metabolism of other drugs
    • Watch for blood dyscrasias, liver failure, Stevens Johnson syndrome
    Gabapentin (Neurontin)
    Dosed 400mg TID x 3 days, then BID x 1 day. Three 100mg rescue doses may be used daily
    • Less sedating, and less abuse potential
    • Fewer drug interactions than carbamazepine
    Next week we will discuss Alcohol Relapse Prevention Agents

    I am always impressed with the doses of benzodiazepines for alcohol withdrawal. They seem outrageously high, but certainly needed to treat the withdrawal as well as the delirium tremors (TD's)

    Just this past week two of my former physician assistant students texted me about using a benzo in a patient with liver dysfunction. I remember the three drugs by the acronym ""LOT" lorazepam (Ativan), oxazepam (Serax) and temazepam (Restoril).

    These three drugs are metabolized by glucuronide conjugation, and NOT by CYP metabolism. They are also the best choice benzos for elderly patients, who have declining CYP function, as glucuronide conjugation doesn't drop as significantly as people age.

    (Remember of course we should always avoid benzos in the elderly if possible due to increase fall risk).

    Have a great day on the bench!!

    With the cost of cigarettes... Chantix looks like a bargain!

    Last week we discussed the role of nicotine replacement products. This week we will focus on the role of prescription drugs indicated for smoking cessation.

    The effect of smoking on drug metabolism:
    Hydrocarbons found in tobacco smoke induce CYP450 microsomal enzymes (primarily CYP1A2). Smoking cessation or the use of nicotine products may alter the clearance of many drugs that are metabolized by this enzyme system. When a patient quits smoking, levels of these drugs have the potential to increase: Theophylline (Theo-24) , clozapine (Clozaril), olanzapine (Zyprexa), and tizanidine (Zanaflex), caffeine and acetaminophen.

    Bupropion-SR 150mg -------cost $20.00/month
    Mechanism: Blocks re-uptake of dopamine and norepinephrine. Weak nicotinic receptor antagonist.
    Usual dose: 150mg daily for 3 days. Then increase to 150mg twice daily. Separate doses by 8 hours.
    Initiate treatment when patient is still smoking. Takes 1 week to achieve steady state blood levels.
    Set a target quit date within the first 2 weeks of treatment. Continue treatment for 7 to 12 weeks. After 7 weeks of treatment failure, unlikely patient will succeed. Consider stopping therapy.

    May be combined with nicotine patches. Consider for smokers with history of depression. This drug is safe for patients with cardiovascular disease. BEST OPTION: This drug may be useful in delaying weight gain from smoking cessation. AVOID: if bipolar, pregnant or history of seizures and patients with significant anxiety

    Varenicline (Chantix®) cost----$450.00/month Mechanism: nicotinic receptor partial agonist. Having the drug on board blocks some of the pleasurable effects that patients get if they smoke. Have patients set quit day around day 8, after full titration. STARTER PACK: Dose: day 1-3: 0.5mg daily
    • Day 4-7: 0.5mg BID
    • Day 8-through end of treatment- 1mg BID
    • Assess after 12 weeks. If successful start a second 12-week drug course.
    Common Adverse effects: Nausea, dream changes, constipation, gas and vomiting. Prescribe with caution:
    • Avoid: Chantix should NOT be used by pilots, air traffic controllers, truckers, and bus drivers. This recommendation was first made in 2008. Chantix is still on the “Do not issue- Do not fly” list as of February 21, 2019. (source faa.gov)
    • Mental Health effects: Patients should stop taking Chantix and call their health care professionals right away if they notice any side effects on mood, behavior, or thinking. Suggested link to heart attacks, seizures, diabetes, dizziness, and confusion. The black box warning for adverse psychiatric events was removed on December 16,2016
    • Cardiovascular risk: A comprehensive evaluation of cardiovascular (CV) risk with CHANTIX suggests that patients with underlying CV disease may be at increased risk; however, these concerns must be balanced with the health benefits of smoking cessation. (Chantix package insert). Most sources agree Chantix is save for CV patients, as smoking is a greater risk factor.
    • Renal dosing: Severe Renal Impairment (estimated creatinine clearance less than 30 mL/min): Begin with 0.5 mg once daily and titrate to 0.5 mg twice daily. For patients with end-stage renal disease undergoing hemodialysis, a maximum of 0.5 mg daily may be given if tolerated. (Chantix package insert)
    Patient education:
    • Set a quit date. Start Chantix® one week before that. Prescribe the “starter pack.”
    • Take after a meal with a full glass of water to minimize GI upset.
    • Caution driving until patient sees how the drug affects them.
    • Caution if kidney problems, pregnant (Category-C) or nursing.
    Second Line Drugs for Smoking Cessation:
    • Nortriptyline (Pamelor): Blocks reuptake of norepinephrine with a lesser effect on serotonin. Similar efficacy to bupropion or nicotine replacement, but safety profile limits its usage.
    • Clonidine (Catapres): Stimulates alpha-2-adrenoceptors in the brainstem and reduces sympathetic outflow
    Money, Money. When I first started practicing in 1981, there was a sign in the window Cigarettes $.69 per pack. Patients commented “when those cigarettes cost one dollar per pack, I’ll QUIT!

    38 years later the average cost of a pack of cigarettes in Pennsylvania cost $8.27 which includes $3.07 in taxes. Our neighbors to the north in New York state lead the nation with an average pack price of $10.45 including $4.75 in taxes. The state of Missouri has the lowest average price per pack at $4.38 with only 36 cents worth of tax. You can look up your states information at: https://www.salestaxhandbook.com/cigarette-tax-map

    I’ve never had a patient pay cash for Chantix, but the truth is a two-pack per day smoker would break even buying Chantix. If a patient quits smoking all together after 12 weeks, they would save $480 per month or $5760 per year!! Just the financial incentive should help patients see the light and quit smoking.

    Clinicians Role: Dr. Boris Lushniak (former Acting Surgeon General) at a Salus University commencement address stated that ALL health care professionals should discuss at EVERY encounter diet, exercise and smoking cessation. No matter if you are a physical therapist, optometrist or pharmacist we need to offer our skills to these patients!



    Have a great day on the bench!!

    How many times should we encourage our patients to quit smoking.......... as long as it takes!

    "Quitting smoking is easy. I've done it a thousand times" -Mark Twain
    • In 2017, an estimated 14% (34.3 million) U.S. adults were current cigarette smokers. More than 16 million Americans live with a smoking-related disease. While this number is down from rates in the mid 90's, it still presents a huge public health concern. Smoking is responsible for about 90% of deaths due to lung cancer and COPD.
    Estimates show smoking increases the risk:           source cdc.gov/tobacco
    • For coronary heart disease by 2 to 4 times
    • For stroke by 2 to 4 times
    • Of men developing lung cancer by 25 times
    • Of women developing lung cancer by 25.7 times
    • Smoking causes diminished overall health, increased absenteeism from work, and increased health care utilization and cost.
    Nicotine's effect on the body:
    • Nicotine stimulates the CNS meso-limbic dopamine system, which is believed to be the neuronal mechanism underlying the reinforcement and reward experienced with smoking.
    • Smoking cessation is associated with a flu-like syndrome, cravings, irritability, insomnia, headache, and fatigue.
    • Nicotine withdrawal can lead to insomnia, anxiety, and depression, and exacerbate underlying psychiatric disorders.
    • Blood pressure: it is recommended not to measure a patient's blood pressure within 30 minutes after nicotine exposure (vaping, cigarettes or smokeless tobacco)

    TREATMENT OPTIONS ADVANTAGES DISADVANTAGES
    Bupropion
    Zyban®
    May be used in combination with other therapies, Insurance coverage for cost Risk of seizures, Other side effects, Prescription only
    Varenicline
    Chantix®
    More effective than Zyban or Nicotine Replacement Expensive. Risk of suicidality Nightmares, Psychiatric disturbances
    Counseling Highly successful, Cost effective with peer support, Availability Depression, Withdrawal side effects.
    Combined Therapy Many options, adaptive to each patient, lower cost if not using medications Withdrawal side effects. Costs if using drugs.
    Cold Turkey Minimal Costs, can be managed alone, One-step process Tolerating withdrawal symptoms, usually not successful if not fully committed
    Nicotine Fading Inexpensive, Easy to follow Patient must be highly committed to quitting
    Nicotine Patch (OTC) Able to purchase OTC, Easy to apply, can be managed alone Patient must be highly committed. Must not smoke while using the patch, Side effects, having to apply every 24hrs, Costs
    Nicotine Gum(OTC) Inhaler(Rx) Nasal(Rx) Can be managed alone, Able to purchase OTC, Easy to use. Patient must be highly committed. Must completely stop smoking while using, Side effects, Can’t use with dentures, Highly addictive, Costs


    Nicotine Replacement Prescribing Information
    • Nicotine replacement products (gum, patches, lozenges) are all equally effective in helping patients kick the habit.
    • Use a patch for continuous relief from cravings and the gum, spray, or inhaler for breakthrough urges if needed, depending on the patients choice of dosage form
    • Don't prescribe nicotine replacements with Varenicline (Chantix). The combo causes more nausea and probably won't work any better.
    Next week we can focus on the prescription drug therapy for smoking cessation

    Commentary:
    "Why should I quit now, the damage is done?" asked a patient I saw today at the clinic. He was age 56 years old, took Ranexa, Metoprolol, Spiriva, Cozaar, Plavix, aspirin and a few others. He survived a massive heart attack a few years ago, and never stopped his pack and a half habit.

    According to the CDC.gov/tobacco website there are plenty of good reasons for him to quit to quit:
    • Quitting smoking cuts cardiovascular risks. Just 1 year after quitting smoking, your risk for a heart attack drops sharply.
    • Within 2 to 5 years after quitting smoking, your risk for stroke may reduce to about that of a nonsmoker’s.
    • If you quit smoking, your risks for cancers of the mouth, throat, esophagus, and bladder drop by half within 5 years.
    • Ten years after you quit smoking, your risk for dying from lung cancer drops by half.
    Dr. Boris Lushniak, the acting Surgeon General under President Obama said at a graduation I attended “At every encounter with every patient we need to discuss weight control, exercise and smoking cessation.” At the Empower-3 clinic where I staff, I take his advice. Every patient, every time.

    Mark Twain's quote gives them permission to fail...I just want them to try!

    Have a great day on the bench!!

    Lowering uric acid levels can cost from $20.00 per year up to $572,000 per year!!!

    Lets stop those gout flares, tophi and kidney stones by lowering uric acid levels.

    Ground Rules for Prophylactic Drug Therapy for GOUT:
    • Neither uricosurics or xanthine oxidase inhibitors should be initiated aggressively in patients with active acute gouty arthritis.
    • Patients after an acute gouty arthritis attack are candidates for long term prophylaxis aimed at reducing the serum uric acid levels.
    • Goal of chronic therapy is to decrease future attacks, and reduce body stores of urate, and reversing the effects of urate deposits.
    • The most widely recommended goal range of urate-lowering therapy the magic number for serum urate is less than 6 mg/dL, which is substantially below the urate solubility limit. Urate levels over 11mg/dl is a significant risk for kidney stones.
    XANTHINE OXIDASE INHIBITORS:
    How they work: Xanthine oxidase is an enzyme that drives the conversion of hypoxanthine to xanthine and can further catalyze the oxidation of xanthine to uric acid. Hypoxanthine and xanthine are more water soluble than uric acid. By blocking this conversion step of purines, the water-soluble precursors are excreted, and uric acid’s formation is blocked. There are currently two xanthine oxidase inhibitors available.

    ALLOPURINOL (Zyloprim®)
    is available in tablets of 100mg & 300mg strengths. This drug was first approved 1966. MECHANISM OF ACTION: Allopurinol is a xanthine oxidase inhibitor which is metabolized to oxypurinol, which is also active in inhibiting xanthine oxidase. This facilitates the clearance of oxypurines which are the more water-soluble precursors of uric acid. INDICATIONS FOR USE: Control of gout and hyperuricemia. Management of patients with primary and secondary sign/symptoms of gout (frequent gout attacks, tophi, joint destruction, uric acid lithiasis & nephropathy). Allopurinol is not an innocuous drug. Not recommended for treatment of asymptomatic hyperuricemia.

    RECOMMENDED DOSE: start low to prevent acute gouty flare-ups. Start with 100mg daily. If CrCl <30, start at 50mg. Increase by 100mg each week until uric acid level is 6mg/dl or less. Average dose is 200-300mg for mild gout. For patients with severe tophaceous may need 400-600mg/day. May be dosed once daily, however if over 300mg/day is required, divided doses. Maximum=800mg/day to get uric acid level under 6mg/dL. Take with food or mild to minimize GI upset. Must have good renal function for this dose of 800mg.

    Patients need to take NSAID or colchicine when starting to prevent acute flare.

    WARNINGS/PRECAUTIONS/ADVERSE EFFECTS
    • A rash might occur during therapy, which should be reported to practitioner at once. This rash may be simple rash or serious Stevens-Johnson syndrome (which is exfoliative and erythematous)
    • Rarely: alopecia, neutropenia, hepatitis
    • Diarrhea & nausea
    • Pregnancy Category: C
    • Bone marrow depression is rare
    • Test for human leukocyte antigen (HLA-B*5801 in Asian patients (Chinese, Thai and Korean). Do not administer allopurinol in patients that test positive for this antigen.
    DRUG INTERACTIONS:
    Increase in skin rash with Amoxicillin and Ampicillin. Increases levels of 6-mercaptopurine (Purinethol) and azathioprine (Imuran) by reducing their metabolism. Reduce dose of these drugs by 75% if they are used with allopurinol. This should be considered a life-threatening interaction

    DRUG MONITORING:
    • Titrate to dosage to lower uric acid to 6mg/dl
    • Decrease dose if renal impaired for maintenance.
    • If Creatinine clearance:
      • 20ml/min= 200mg daily.
      • 10ml/min = 100mg daily
    PATIENT EDUCATION--allopurinol
    • Report sign of rash, painful urination, blood in urine immediately to practitioner
    • Continue acute therapy. Optimal allopurinol may take 2-6 weeks.
    • Increase fluid intake to decrease renal stones
    • Take with food to minimize GI irritation.
    Febuxostat (Uloric) 40mg and 80 mg (approved 2009) cost: over $380/month
    Mechanism: xanthine oxidase inhibitor. Will lower uric acid more effectively, than allopurinol, but does NOT prevent gout flares any more effectively then allopurinol.
    BLACK BOX WARNING: Febuxostat has a higher risk of death than allopurinol Allopurinol should be used first line for most patients. If using Uloric, titrate the dose up to 80mg/day if needed to get serum uric acid below 6 mg/dL in patients with good renal function. No dosage for mild to moderate renal impairment, but if CrCl <30 mL/min, there is no evidence – not recommended. Check LFT at 2months and 4 months, then periodically.
    For both xanthine oxidase inhibitors: Azathioprine (Imuran) & 6-mercaptopurine (Purinethol) both are chemo drugs & immunosuppressants are metabolized by xanthine oxidase pathway. Allopurinol & febuxostat will increase the levels of these drugs to dangerous levels

    URICOSURIC:
    PROBENECID (Benemid®)
    (ColBenemid® has colchicine added) 500mg tablets
    MECHANISM OF ACTION: uricosuric: promotes excretion of uric acid by blocking its reuptake in the proximal convoluted tubule.
    Dosage: 250mg BID for 1 week. Then increase to 500mg BID thereafter. Do NOT start until acute attack has subsided. Take with food.

    WARNINGS/PRECAUTIONS/ADVERSE EFFECTS
    • 10% patients may develop uric acid stones. Advise drinking 2 liters of water per day
    • Pregnancy Category: B
    • Patients with urolithiasis or a creatinine clearance of less than 60ml/min should avoid probenecid.
    DRUG INTERACTIONS: prevents tubular secretion of weak organic acids and has potential drug interactions: penicillin, cephalosporin, nitrofurantoin, and Rifampin. AVOID ASPIRIN: interferes with uric acid secretion.
    Diuretics such as Lasix® (furosemide) and Hydrochlorothiazide (HCTZ) are magnified. Patients taking sulfonylureas should be monitored closely. May precipitate acute gouty arthritis attack

    PATIENT EDUCATION
    • Drink at least 2 liters of water per day to decrease uric acid stone formation.
    • Take with food if GI upset occurs.
    • Avoid Aspirin may antagonize uricosuric effect
    LOSARTAN (Cozaar) Losartan has a mild uricosuric effect, that maxes out at 50mg dose. Figure about 0.5mg/dl reduction. Other ARBs like irbesartan do NOT have a similar uricosuric effect. Good drug to consider for hypertensive patients with hyperuricemia.

    URATE TRANSPORTER INHIBITORS LESINURAD: Zurampic®200mg was removed from the market February 2019 due to economic reasons. and not related to any efficacy, safety or clinical concerns with lesinurad.
    Mechanism: Lesinurad inhibits the urate transporter, URAT1, which is responsible for most of the renal reabsorption of uric acid which increases uric acid excretion and thereby lowers UA.
    Combination drug: Duzallo® (approved August 17,2017) (removed from market 2/1/2019)

    VITAMIN-C (ascorbic Acid)
    Might help increase renal excretion of uric acid and reduce gout flares. Suggested dose 500 to 1000 mg/day from food or supplements. Expect a maximum of 0.5mg/dl lowering

    Urate-Oxidase (Recombinant)Enzyme PEGLOTICASE (Krystexxa®) by Savient Approved 9/14/2010
    Mechanism: Krystexxa is a uric acid specific enzyme that reduces uric acid by metabolizing uric acid to harmless chemicals that are excreted in the urine. Pegloticase is a recombinant porcine-like uricase. Similarly to rasburicase, both enzymes metabolize uric acid to allantoin. This reduces the risk of precipitates, since allantoin is five to ten times more soluble than uric acid.
    Dosage: given every 2 weeks as an infusion
    Adverse reactions: 25% experience severe allergic reactions.
    • May also see gout flares, injection site bruising, irritation of nasal passages, constipation, chest pain and vomiting.
      • Pretreat with antihistamine and corticosteroid to prevent anaphylaxis.
      • Pretreat with NSAIDS or colchicine 1 week before to prevent gout flares.
      • Cost= about $22,000 per vial. he recommended dose and regimen of KRYSTEXXA for adult patients is 8 mg (uricase protein) given as an intravenous infusion every two weeks. The optimal treatment duration with KRYSTEXXA has not been established. (Over half million dollars per year)
    What if our patient has no symptoms (ASYMPTOMATIC HYPERURICEMIA)?

    Most agree that a persistent urate level of >8 mg/dL as the threshold for initiating evaluation and, where warranted, lifestyle and/or pharmacologic intervention with xanthine oxidase inhibitors for management of asymptomatic hyperuricemia


    I remember 14 years ago back in 2005 preparing my gout lecture for St. Francis. I told the students that this was my favorite unit since not one thing changed from when I graduated in Pharmacy School in 1981 until that point.

    We learned about allopurinol, probenecid, colchicine, indomethacin, naproxen and ibuprofen in pharmacy school.

    For the next 4 years I used the same introduction. In 2009 my gout lecture changed with the addition of febuxostat, and then in following years I added peglitocase, and then lesinurad followed by Vitamin-C and losartan!

    Like every category of drugs new information is always coming out, and we are challenged to keep up with it.

    Have a great day on the bench!!

    April 2019

    We'll have lots of educating to do with our patients. FDA labeling changes on fat soluble vitamins are sure to cause lots of confusion.

    TREATMENT OF ACUTE GOUT ATTACKS

    Ground Rules for Drug Therapy
    • Neither uricosurics or xanthine oxidase inhibitors should be initiated aggressively in patients with active acute gouty arthritis.
    • Patients after an acute gouty arthritis attack are candidates for long term prophylaxis aimed at reducing the serum uric acid levels.
    • Goal of acute treatment is to relieve pain and inflammation. The “villain” is monosodium urate crystals.
    • Goal of chronic therapy is to decrease future attacks, and reduce body stores of urate, and reversing the effects of urate deposits.
    BENEFITS AND RISKS OF PHARMACOLOGICAL THERAPY
    • Even without treatment attacks of gout will end in 3 to 10days.
    • The goal of therapy is to relieve pain.
    • Use uric acid lowering drugs if patient has 2 or more attacks per year.
    • Long term goal of therapy is to prevent acute attacks.
    • Risks will be discussed with each pharmacological agent.
    NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
    NSAIDS are a reasonable option in patients without contraindications such as decreased kidney function or stomach ulcers. Indomethacin (Indocin) was approved in June 1965, and due to adverse GI effects, is only used for treatment of acute gout flares. There is no convincing evidence that it is any more effective than other NSAIDS, such as Ibuprofen (Motrin, Advil), Naproxen (Naprosyn, Aleve) or celecoxib (Celebrex). For cardiac patients naproxen is the safest choice of the NSAIDS.

    NSAIDS should be dosed as soon as onset of symptoms and taken on a consistent basis, not as needed until resolution of the acute gout flare.

    CORTICOSTEROIDS
    Instead of NSAIDs for acute gout- just as effective for pain relief and are sometimes better tolerated.

    Recommended dose: Prednisone 30 to 60 mg/day for acute gout until symptoms resolve. May take 5 to 7 days. Tapering is not necessary at this dose and duration

    Adverse effects: have patients with diabetes monitor blood sugars more frequently. May also cause fluid retention, hypertension and CNS adverse effects.

    COLCHICINE (Colcrys®)
    MECHANISM OF ACTION: Inhibits phagocytosis of urate crystals by leukocytes. Reduces inflammatory response to the deposited crystals. Although it is anti-inflammatory, it is not analgesic. Will not prevent the progression of gout to chronic gouty arthritis.

    INDICATIONS FOR USE
    • Specifically indicated for treatment and relief of pain in acute attack
    • Recommended for prophylactic use between attacks
    • Effective in aborting an attack at the first sign of articular discomfort.
    • If used for acute flare, must be started within 36 hours of symptom onset.
    Acute attack: COLCRYS instructions: 1.2 mg (2 tablets) at the first sign of the flare followed by 0.6 mg (1 tablet) one hour later. The maximum recommended dose for treatment of gout flares is 1.8 mg over a 1-hour period. (3 tablets maximum).

    Prophylactic dosing: 1-2 tablets per day for the first six months of urate lowering therapy. Remember, the initiation and titration of urate lowering therapy can cause a gout flare. Colchicine as prophylaxis, for the first 6 months of urate lowering therapy, is optional.

    WARNINGS/PRECAUTIONS/ADVERSE EFFECTS
    • Nausea, vomiting and diarrhea and bloating occur in up to 80% of patients.
    • Do not give to patients with active peptic ulcer disease
    DRUG INTERACTIONS:
    Life threatening interactions can occur with colchicine. Colchicine is a known substrate for p-glycoprotein (PGP) a transmembrane protein that acts to eliminate drugs by expelling them into the bile, urine and intestine and acting as blood brain barrier.

    CAUTION: using colchicine with clarithromycin, Erythromycin, Cyclosporine, Amiodarone, azole antifungals, Simvastatin and Verapamil. Symptoms of colchicine toxicity include diarrhea, myalgia and abdominal pain, may see dehydration, pancytopenia and acidosis. Of the 117 deaths from normal doses of colchicine reviewed by FDA, over half were taking clarithromycin (Biaxin®) New dose recommendation: if taking any of these CYP450 inhibitors: Two tablets only. Don’t repeat for 3 days.


    For pharmacists our typical gout patient comes hobbling into the store, usually an overweight guy, with the toe cut out of a pair of slippers.

    Of all the drugs that we dispense for an acute gout flare, colchicine is the most fun to talk about with student pharmacists and student PA's. "Back in the old days" we would dispense: Colchicine 0.6mg #12 tablets with the SIG: Take 2 tablets stat, then 1 tablet every 2 hours until bloody vomit or bloody diarrhea occurs. We were not so kind and gentle back in the day with acute gout flares!

    Colchicine comes from the Autumn crocus (Colchicum autumnale), and first mentioned for joint swelling in the Ebers papyrus. Initially, colchicine was used as a purgative, because it caused so much gastrointestinal distress. It wasn't used for gout because of the horrible gastrointestinal effects. Once the dose o 0.6mg became commonly used colchine fell in favor for gout flare treatment.

    In 1962 Kefauver Harris Amendment or "Drug Efficacy Amendment" required drugs to prove efficacy before they could appear on the U.S. market, however previously available drugs like colchicine were grandfathered in. Colchicine was cheap and readily available, until....

    In 2006, the FDA launched the “Unapproved Drugs Initiative,” which targeted old drugs, like colchicine that had never been approved by the FDA. The rationale was that older unapproved drugs, like colchicine despite obvious efficacy, deserve as much scrutiny for efficacy and safety as do newer drugs. The price went from $6.00 per 100 tablets to $6.00 per tablet.

    Have a great day on the bench!!

    We'll have lots of educating to do with our patients. FDA labeling changes on fat soluble vitamins are sure to cause lots of confusion.

    TREATMENT OF ACUTE GOUT ATTACKS

    Ground Rules for Drug Therapy
    • Neither uricosurics or xanthine oxidase inhibitors should be initiated aggressively in patients with active acute gouty arthritis.
    • Patients after an acute gouty arthritis attack are candidates for long term prophylaxis aimed at reducing the serum uric acid levels.
    • Goal of acute treatment is to relieve pain and inflammation. The “villain” is monosodium urate crystals.
    • Goal of chronic therapy is to decrease future attacks, and reduce body stores of urate, and reversing the effects of urate deposits.
    BENEFITS AND RISKS OF PHARMACOLOGICAL THERAPY
    • Even without treatment attacks of gout will end in 3 to 10days.
    • The goal of therapy is to relieve pain.
    • Use uric acid lowering drugs if patient has 2 or more attacks per year.
    • Long term goal of therapy is to prevent acute attacks.
    • Risks will be discussed with each pharmacological agent.
    NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
    NSAIDS are a reasonable option in patients without contraindications such as decreased kidney function or stomach ulcers. Indomethacin (Indocin) was approved in June 1965, and due to adverse GI effects, is only used for treatment of acute gout flares. There is no convincing evidence that it is any more effective than other NSAIDS, such as Ibuprofen (Motrin, Advil), Naproxen (Naprosyn, Aleve) or celecoxib (Celebrex). For cardiac patients naproxen is the safest choice of the NSAIDS.

    NSAIDS should be dosed as soon as onset of symptoms and taken on a consistent basis, not as needed until resolution of the acute gout flare.

    CORTICOSTEROIDS
    Instead of NSAIDs for acute gout- just as effective for pain relief and are sometimes better tolerated.

    Recommended dose: Prednisone 30 to 60 mg/day for acute gout until symptoms resolve. May take 5 to 7 days. Tapering is not necessary at this dose and duration

    Adverse effects: have patients with diabetes monitor blood sugars more frequently. May also cause fluid retention, hypertension and CNS adverse effects.

    COLCHICINE (Colcrys®)
    MECHANISM OF ACTION: Inhibits phagocytosis of urate crystals by leukocytes. Reduces inflammatory response to the deposited crystals. Although it is anti-inflammatory, it is not analgesic. Will not prevent the progression of gout to chronic gouty arthritis.

    INDICATIONS FOR USE
    • Specifically indicated for treatment and relief of pain in acute attack
    • Recommended for prophylactic use between attacks
    • Effective in aborting an attack at the first sign of articular discomfort.
    • If used for acute flare, must be started within 36 hours of symptom onset.
    Acute attack: COLCRYS instructions: 1.2 mg (2 tablets) at the first sign of the flare followed by 0.6 mg (1 tablet) one hour later. The maximum recommended dose for treatment of gout flares is 1.8 mg over a 1-hour period. (3 tablets maximum).

    Prophylactic dosing: 1-2 tablets per day for the first six months of urate lowering therapy. Remember, the initiation and titration of urate lowering therapy can cause a gout flare. Colchicine as prophylaxis, for the first 6 months of urate lowering therapy, is optional.

    WARNINGS/PRECAUTIONS/ADVERSE EFFECTS
    • Nausea, vomiting and diarrhea and bloating occur in up to 80% of patients.
    • Do not give to patients with active peptic ulcer disease
    DRUG INTERACTIONS:
    Life threatening interactions can occur with colchicine. Colchicine is a known substrate for p-glycoprotein (PGP) a transmembrane protein that acts to eliminate drugs by expelling them into the bile, urine and intestine and acting as blood brain barrier.

    CAUTION: using colchicine with clarithromycin, Erythromycin, Cyclosporine, Amiodarone, azole antifungals, Simvastatin and Verapamil. Symptoms of colchicine toxicity include diarrhea, myalgia and abdominal pain, may see dehydration, pancytopenia and acidosis. Of the 117 deaths from normal doses of colchicine reviewed by FDA, over half were taking clarithromycin (Biaxin®) New dose recommendation: if taking any of these CYP450 inhibitors: Two tablets only. Don’t repeat for 3 days.


    For pharmacists our typical gout patient comes hobbling into the store, usually an overweight guy, with the toe cut out of a pair of slippers.

    Of all the drugs that we dispense for an acute gout flare, colchicine is the most fun to talk about with student pharmacists and student PA's. "Back in the old days" we would dispense: Colchicine 0.6mg #12 tablets with the SIG: Take 2 tablets stat, then 1 tablet every 2 hours until bloody vomit or bloody diarrhea occurs. We were not so kind and gentle back in the day with acute gout flares!

    Colchicine comes from the Autumn crocus (Colchicum autumnale), and first mentioned for joint swelling in the Ebers papyrus. Initially, colchicine was used as a purgative, because it caused so much gastrointestinal distress. It wasn't used for gout because of the horrible gastrointestinal effects. Once the dose o 0.6mg became commonly used colchine fell in favor for gout flare treatment.

    In 1962 Kefauver Harris Amendment or "Drug Efficacy Amendment" required drugs to prove efficacy before they could appear on the U.S. market, however previously available drugs like colchicine were grandfathered in. Colchicine was cheap and readily available, until....

    In 2006, the FDA launched the “Unapproved Drugs Initiative,” which targeted old drugs, like colchicine that had never been approved by the FDA. The rationale was that older unapproved drugs, like colchicine despite obvious efficacy, deserve as much scrutiny for efficacy and safety as do newer drugs. The price went from $6.00 per 100 tablets to $6.00 per tablet.

    Have a great day on the bench!!

    We no longer eat liver, kidneys, thymus glands and pancreases but our diet today can elevate our uric acid levels.

    PHARMACOLOGICAL AGENTS THAT MAY CAUSE OR WORSEN HYPERURICEMIA:
    • Alcohol
    • Chemotherapeutic drugs
    • Levodopa
    • Salicylates greater than 2g/day. BUT greater than 5gm/day decrease uric acid.
    • Low dose (81mg) aspirin does not affect uric acid levels.
    • Nicotinic acid (niacin)
    • Cyclosporine (Neoral), tacrolimus (Prograf)
    • Diuretics: all diuretics (especially loop and thiazide diuretics) except spironolactone cause hyperuricemia, by the following mechanisms:
      • A direct effect of diuretics on promoting urate reabsorption by the proximal tubule, increasing serum uric acid.
      • Indirect effect of diuretic-induced volume depletion on increasing urate reabsorption by the proximal tubule
    Conditions that can increase uric acid levels:

    Hypothyroidism- may predispose patients to hyperuricemia
    Psoriasis- quick turnover of cells and systemic inflammation may contribute to hyperuricemia
    Obesity- can be a contributory factor
    Primary Hyperuricemia: Can be caused by increased production of purines OR decreased renal clearance of uric acid.
    MEN account for 80% of hyperuricosuric kidney stones (uric acid or calcium) . Peak onset is age-45 The serum uric acid is elevated (over 7.5mg/dl) in 95% of patients who have measurements during the attack. During attack ESR (erythrocyte sedimentation rate) and white cell count are frequently elevated.

    Uric Acid Stones
    • Up to 20% of patients with gout develop uric acid stones.
    • Uric acid stones are found in 5-10% of urinary stones. Additionally, 15-20% of patients with calcium stones have hyperuricosuria.
    • The urinary solubility of uric acid depends on its concentration in urine and the urinary pH. At a pH below 5.5, nearly 100% of uric acid exists in an undissociated form.
    • Expect one or more of these factors may be found in patients with uric acid-related calculi. The 3 mechanisms responsible for uric acid related stone formation include:
      • an acidic urinary environment (pH < 5.5) is the most important factor observed in patients with uric acid stones
      • dehydration
      • hyperuricosuria. Urine uric acid levels in these patients may be elevated or within the reference range
    High purine foods to avoid if following "gout diet"
    Most of us are acutely aware that gout was called the "King’s disease" since excessive consumption of purine-rich foods and alcoholic drinks are independent risk factors for gout. Since most of us do not consume organ meats such as liver, kidneys and “sweatbreads” research has recently shown that fructose (think high fructose corn syrup) and sugar-sweetened soft-drinks increase the risk of developing gout. Here is a quick list of foods to be avoided:
    • Organ meats and seafood
    • Meat extracts and gravies
    • Yeast and yeast extracts, which includes beer and other alcoholic beverages
    • Beans, peas and lentils
    • Oatmeal
    • Spinach, asparagus, cauliflower, mushrooms
    SAFE FOODS: Low-fat dairy products, coffee, and vitamin C appear to have a protective effect. As you can see from the list above, following this low purine diet can be challenging, since so many nutritional foods need to be avoided.

    Definitive diagnosis: Definitive: birefringent monosodium urate crystals in affected joint appear as needle like shape

    Suggestive:
    • More than 1 attack of arthritis
    • Development of maximum inflammation within 1 day
    • Redness over joint
    • Painful or swollen first metatarsophalangeal joint (great toe)
    • Unilateral attack on first metatarsophalangeal joint
    • Unilateral attack on tarsal joint
    • Tophus
    • Hyperuricemia
    • Asymptomatic swelling within a joint.
    NON-PHARMACOLOGICAL TREATMENT MEASURES
    • Modification of diet (at best lowers UA by 1mg%)
    • Rest of the joint
    • Application of ice
    • Physiotherapy
    • Losing weight decreases stress on affected joint. Big toe gets most "shock" and most likely to be affected by uric acid crystals. Because the great toe is the coldest joint, due to distance from core of the body, the insoluble uric acid crystals are more likely to settle there.
    Gout is the most common inflammatory arthritis, affecting approximately 8.3 million Americans (6.1 million men and 2.2 million women).

    Gout prevalence has been increasing over the last half century, due to the aging of the population, increased use of medications that can trigger gout, and the obesity epidemic. It is no longer a disease of the rich and well fed.

    Gout occurs when the rather insoluble uric acid forms crystals that precipitate in the joints, most commonly the big toe. Gout attacks usually occur suddenly at night, may cause a patient to wake up. Gout attacks are often triggered by stressful events, alcohol, drugs, or another illness.

    These nasty uric acid crystals can also precipitate in the kidneys causing stones, and under the skin. Tophi (singular: tophus) are a nodular mass of uric acid crystals. Tophi are characteristically deposited in different soft tissue areas of the body in chronic (tophaceous) gout. Tophi are definitive lesions for gout diagnosis.

    Have a great day on the bench!!

    Can we recommend vaping for smoking cessation...for now, probably NOT.

    VAPING VS NICOTINE REPLACEMENT FOR SMOKING CESSATION

    A British study enrolled 900 people who wanted to quit smoking. The United Kingdom National Health Service stop-smoking services did a study where half of the participants randomly got e-cigarettes. The other half got traditional treatment: nicotine patches plus gum, lozenges, nicotine inhalers or whatever kind of oral nicotine they preferred. "The e-cigarettes were significantly more effective than nicotine replacement treatment," the researchers reported.

    As reported in the New England Journal of Medicine online, about 10 percent of people with standard treatment quit smoking for at least a year, while 18 percent of the people given e-cigarettes had quit. Almost two times as many quit smoking with vaping.

    HOWEVER of the 18% who vaped 90% of them continued to vape after one year and of the 10% who quit who used standard treatment, 80% were completely done with nicotine replacement at one year. The vapers were addicted to the nicotine. Incidentally, the e-cigarettes used in this study contained much lower levels of nicotine (18mg/ml) than found in some common brands used in the US (such as Juul at 23mg and 40mg per 0.7ml pod)

    Vaping Cigarettes
    NO tar Tar
    NO carbon monoxide Carbon Monoxide
    4 ingredients Thousands of chemicals (7,000)
    No second-hand smoke Second hand smoke
    No stink Stinks


    Bronchiolitis obliterans: also known as “popcorn lung” is a type of lung disease, which is not cancer. Inflammation causes scarring which leads to lung damage. A link between breathing in a chemical called diacetyl, a flavor enhancer, was made when a cluster of popcorn factory workers were all found to have the rare lung condition. It was not related to use of e-cigarettes, because e-cigarettes were not developed yet. Cherry, custard, and pastry flavors are most likely to contain diacetyl as a flavor enhancer.

    The chemicals found in e-cigarette liquid, known as "e-juice," may be a potential cause of popcorn lung. According to the American Lung Association, using electronic cigarettes or vaping, particularly the flavored varieties, can cause popcorn lung. However, e-cigarette vapor has been proven to contain diacetyl.

    JUUL LABS EFFORT TO COMBAT UNDERAGE USE:
    (see juul.com for complete list)
    • Pledged $30 million over the next three years to independent research, youth and parent education and community engagement.
    • Will use ID matching and age verification for online purchase.
    • Restricting the sales of flavored JUUL pods (Mango, Fruit, Cucumber, and Creme)
    • Funding secret-shopper program, which will now check compliance with bulk-purchasing restrictions.
    • Stopping social media like Facebook and Twitter to promote Juul products
    The best studied smoking cessation strategies include:
    • behavioral therapy, such as individual counseling or smoking cessation classes.
    • nicotine replacement therapy, such as a long-acting nicotine patch and short-acting nicotine gum
    • medications to reduce the urge to smoke, such as varenicline (Chantix) or bupropion (Zyban).
    • at every patient encounter smoking cessation should be discussed
    Recommending electronic cigarettes is still unproven and more head-to head controlled studies need to occur before we should be comfortable recommending e-cigarettes for smoking cessation.

    Prevention through Education
    For now, we, as health care professionals should focus on prevention of smoking, by educating teenagers and their parents. E-cigarettes are highly addictive and could cause lifelong problems. Every effort should be made to keep our youth away from electronic cigarettes.

    Hardly a day goes by at the Empower-3 clinic where when we discuss smoking cessation one of our patients, they will state that "I quit smoking; I’m just vaping now."

    Yes, they quit using the combustible tobacco, but they are still satisfying their nicotine addiction with electronic cigarettes. The truth is according to a 2015 Harvard study, "dual use" of tobacco products — vaping and smoking cigarettes — is not rare, nearly 60% of e-cigarette users also smoked cigarettes.

    Many people are still using combustible tobacco and vaping when it is not convenient for them to smoke.

    Have a great day on the bench!!

    We'll have lots of educating to do with our patients. FDA labeling changes on fat soluble vitamins are sure to cause lots of confusion.

    Use of E-cigarettes or Juuling

    JUULING—Today’s Health Concern

    Juul® pods are becoming a health concern for all of us clinicians and parents. The individual sucks on a small device that looks like a USB flash drive and it delivers unusually heavy doses of nicotine. Juuling is the act of vaping from a device known under the brand name Juul®. It looks like a flash drive and can be plugged into a laptop's USB slot to recharge. The Juul® was developed by two men who found it inconvenient go outside to smoke. These devices were originally developed to be used adults using combustible tobacco and “marketed” to those that are committed to stop smoking. However, these devices are becoming increasingly popular to many teenagers.

    According to the CDC, during 2016-2017, JUUL Labs’ sales increased 641 percent — from 2.2 million devices sold in 2016 to 16.2 million devices sold in 2017. By December of 2017, JUUL Labs’ sales comprised nearly 1 in 3 e-cigarette sales nationally, giving it the largest market share in the United States. Both combustible tobacco and vape liquids contain nicotine, which is highly addictive. The first e-cigarette “Vuse” was introduced in 2013 therefore there is less than seven years of experience to observe the outcomes. No deaths have been reported yet, due to lack of long-term exposure data.

    National Institute on Drug Abuse points out that the one-year increases in the prevalence of nicotine vaping translate into approximately 1.3 million additional adolescents who vaped in 2018, as compared with 2017. In September 2018, FDA announced the issuance of more than 1,300 warning letters and civil money penalty complaints to retailers who illegally sold JUUL and other e-cigarette products to minors. With vaping occurring for less than 6 years the FDA has acted (466 less years than combustible tobacco!) These warning letters are important because it found that 74 percent of youth who used JUUL reported obtaining the device from a physical retail store, and about half reported obtaining the device from a social source such as a friend or family member.

    America’s teens report a dramatic increase in their use of vaping devices in just a single year, with 37.3 percent of 12th graders reporting “any vaping” in the past 12 months, compared to just 27.8 percent in 2017. These findings come from the 2018 Monitoring the Future (MTF)

    HOW DO THEY WORK? “Smoking with a battery” The Juul is battery operated and works by heating a pod of e-liquid or “juice”. This juice contains nicotine, flavorings and other chemicals. Once heated the liquid creates an aerosol or vapor that the user inhales, and the user gets a very quick and powerful burst of nicotine.

    DOES JUULING CAUSE ADDICTION? Each pod contains the same amount of nicotine that is in one pack of cigarettes. The nicotine cycle is one that is most difficult to break because nicotine is vaporized, travels through the body in only 5-10 seconds, crosses the blood brain barrier, and causes dopamine release. (Dopamine is released and makes you feel good). This “feel-good” neurotransmitter causes one to crave more nicotine. When the nicotine level drops the smoker craves another puff on the Juul. The more addicted one becomes the more one must use to get the same effects. Nicotine suppresses insulin production, which staves off hunger, and provides appetite control. Hence, when a patient fears smoking cessation because of potential weight gain, that concern should be addressed.

    People currently report an uptick in nicotine use when starting to vape because that initial buzz that is seen with cigarettes is not achieved, there for a higher milligram or increased frequency can be seen. Vaping solutions are available in different concentrations: 0, 3, 6, 12, 18, 24 and 36 mg/mL. Depending on the flavor, JUUL pods are available in 3% or 5% strength. Each 5% JUUL pod contains about 40 mg per pod. Each 3% JUUL pod contains about 23 mg per pod. Each pod contains about .7ml of nicotine.

    Sources:

    Denise and I had the privilege of attending a program sponsored by our local Chamber of Commerce, featuring Dr. George Zlupko.

    Dr. Zlupko is our areas leading pulmonologist, who founded the Lung Disease Center of Central Pennsylvania and has provided services to the Altoona area for 3 decades.

    He spent an hour discussing the latest health concern, that being of e-cigarettes. I decided that we can spend the next two columns focusing on this heath threat. In the next two “Clinician Corners” we will use the term “Juuling” as this is the most popular vaping device. Certainly, all electronic cigarettes are part of this epidemic, especially with our concerns to our youth.


    According to the Boston University Medical Center, it all started on October 15,1492, when the Native Americans offered Christopher Columbus a gift of tobacco leaves. It took until 1964, when the Surgeon General's report on "Smoking and Health" was published elucidating the dangers of tobacco use.

    It took 472 years for the government to publish information that tobacco consumption was a health risk! In 1966 warning labels started appearing on packs of cigarettes (190 years after signing the Declaration of Independence). In 1971 the last ads for cigarettes appeared on America’s television sets.

    Have a great day on the bench!!

    March 2019

    Bariatric patients- have great need for our vitamin expertise, from vitamins to appropriate dosage forms.

    The special needs of bariatric surgery patients:

    We've finished our journey through the vitamin aisle, and many of our patients are need of our acquired vitamin expertise. This column will address the need of patients who have undergone gastric bypass surgery.

    • Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death.
    • The medical costs for people who are obese are at least $1,500 higher than those of normal weight.
    Bariatric surgery is becoming increasingly popular to treat America's "expanding" epidemic. Pharmacists are needed to insure that the nutritional requirements are being met for this population. We are the experts in dosage form selection, as well as cost management. Here are some of the most common deficiencies that may occur in our bariatric surgery patients.

    CALCIUM: Calcium carbonate requires an acidic environment for dissolution and subsequent absorption in duodenum and proximal jejunum. Bypass may produce relative decrease in stomach acid production. Calcium citrate might be best option. Chewable calcium citrate, or gummies are the best option.

    VITAMIN-D: Decrease in fat absorption can lead to deficiency in fat-soluble vitamins. Roux-en-Y gastric bypass and biliopancreatic diversion are more likely to produce vitamin D deficiency than other surgeries. Have the physician check 25-hydroxy-vitaminD levels. Also: 10,000 IU of vitamin A, 2000 IU of vitamin D, and 300 mcg of vitamin K per day.

    IRON: avoid sustained release iron and enteric coated products. Might see decreased iron absorption due to decreased stomach acid production.

    VITAMIN B-1 (thiamine): is absorbed primarily in the duodenum and proximal jejunum. Bariatric surgery bypasses the duodenum and proximal jejunum and thiamine deficiency may occur within three weeks post-op. If the patient has persistent vomiting or severely diminished oral intake, they are at a higher risk of deficiency. Thiamine deficiency may be exacerbated by changes in the gut flora.

    VITAMIN- B-12 (cyanocobalamin): most common deficiency after Roux-en-Y surgery. At least 33% of patients will become vitamin deficient. Noticeable symptoms of a vitamin B12 deficiency can take years to develop, since we carry about 2 years of Vitamin B-12 in our livers. Irritability, weakness, numbness, anemia, loss of appetite, headache, personality changes, and confusion are some of the signs and symptoms associated with very low levels of vitamin B12. Supplement with 500-1000mcg/day orally per day. Consider Vitamin B-12 injections if patients are deficient after using the oral forms.

    FOLIC ACID: supplement with 0.4-2mg/day. Especially important in women that are still menstruating.

    TABLET SIZE: two months postoperatively, all medications should be given in a liquid dosage form, a crushed tablet, or an opened capsule. If a tablet must be used, start with the smallest tablet available. Solid dosage forms: recommend smaller than M&M’s candy.

    EXCIPIENTS: avoid sucrose, corn syrup, maltose, fructose, lactose, honey, mannitol, sorbitol to minimize dumping syndrome. Dumping syndrome can occur in up to 50 percent of post gastric bypass patients when high levels of simple carbohydrates are ingested. Dumping may contribute to weight loss in part by causing the patient to modify his/her eating habits. Early dumping syndrome has a rapid onset, usually within 15 minutes, due to rapid emptying of food into the small bowel. Due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in low blood pressure and a sympathetic nervous system response. Patients often present with colicky abdominal pain, diarrhea, nausea, and racing heartbeat. Acarbose (Precose®) lowers both postprandial glucose hyperglycemia and reactive hypoglycemia, which subsequently lead to a significant reduction in dumping symptoms.

    Here are the chilling statistics about our nations obesity rates:
    • 93.3 million of U.S. adults are obese.
    • Seven states (Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma and West Virginia) had adult obesity rates of 35 percent or higher, led by West Virginia at 38.1 percent. West Virginia had the highest adult diabetes rate at 15.2% and the highest hypertension rate at 43.5 percent
    • 18.5% of our youth are obese.
    • The lowest adult obesity rates were in Colorado (22.6 percent), the District of Columbia (23.0 percent) and Hawaii (23.8 percent).
    • Data for 2016 showed that 22.2 percent of adult college graduates had obesity, compared with 35.5 percent of adults with less than a high school education.
    Best advice might be, stay youthful, go to college and live in Colorado!

    Have a great day on the bench!!

    Alcoholics need our expertise in selecting vitamins:

    ALCOHOLICS NEED VITAMINS:

    Alcoholics often eat poorly, limiting their supply of essential nutrients and affecting both energy supply as well as cell and organ system structure maintenance. In general, moderate drinkers (two drinks or less per day) seem to be at little risk for nutritional deficiencies. Furthermore, alcohol affects all the pharmacokinetic parameters:

    Digestion: decreasing secretion of digestive enzymes from the pancreas, as well as damaging the absorptive surface of the stomach.

    Storage: a damaged liver doesn’t store the Vitamins A and Vitamin E

    Renal Damage: alcohol consumption, especially binge drinking can lead to dehydration, affecting kidney function. Liquor selectively increases renal perfusion and basal metabolic rates of renal tubes hence causing an increase in diuresis, leading to massive dehydration. Elevations in blood pressure from alcohol can cause renal damage.

    Excretion of nutrients: improper digestion of fats might cause a decrease in the fat soluble vitamins A, D ,E, & K.

    Vitamin Supplementation in the Alcoholic Patient:
    • Vitamins A, D, E, and K — Vitamin A, D, E, and K levels are often deficient in patients with chronic pancreatitis or alcoholic liver disease.
    • Thiamine (B-1) deficiency is found in up to 80 percent of adults with chronic alcohol use.
    • Pyridoxine (B-6) deficiency occurs in over 50 percent of alcoholic patients and is caused by reduced intake and increased breakdown of pyridoxine during ethanol metabolism.
    • Folic Acid (B-9) Two-thirds of binge drinkers will have folate deficiency caused by malabsorption, reduced intake, and increased urinary excretion. This can cause macrocytic anemia and intestinal malabsorption.
    • Zinc: Alcoholics up to half of that population need zinc supplementation due to poor diet.
    • Vitamin B-12: The presence of alcoholic liver disease elevated the serum concentration of vitamin B12 but not the level of folic acid. The vitamin B12 concentration reflects the degree of hepatocytes injury by alcohol. Alcoholics may have normal to high normal levels of Vitamin B-12.
    Our alcoholic patients have a variety of nutritional needs. Poor eating habits, combined with the depletion that alcohol can cause in the body make this population in need of our expertise.

    Here is a handy checklist of the vitamins that alcoholics need

    Rx:
    Thiamine 100mg: once daily
    Pyridoxine 50mg: once daily
    Folic acid 1mg: once daily
    Zinc 50mg: once daily

    Have a great day on the bench!!

    It's been a long walk through the supplement section of the pharmacy. We are finally at the end: ZINC!

    ZINC

    Zinc is considered to be an essential “trace element” that has to come from the diet. Zinc is an enzyme cofactor and protects and stabilizes cell membranes from lysis caused by complement activation and toxin release. Involved in over 100 enzymes, zinc deficiency presents as growth failure, primary hypogonadism, skin disease, impaired taste and smell, impaired immunity and resistance to infection. Zinc deficiency is rare in the United States, but very common worldwide, especially in developing countries.

    SOURCES FOR ZINC: Daily Value (DV) for zinc is 15 mg for adults and kids age 4 and older.
    • red meat, poultry and eggs
    • beans, nuts
    • Oysters are the highest (34mg/serving 340% of DV) seafood (such as crab and lobster),
    • whole grains, fortified breakfast cereals, and dairy products
    • Phytates, which are present in whole-grain breads, cereals, legumes, and other foods—bind zinc and inhibit its absorption. Zinc from plants and grains is lower- but still is adequate. Iron and coffee contain phytates, which can inhibit zinc absorption.
    • IRON (over 25mg) may decrease zinc absorption. Take iron between meals
    ZINC DEFICIENCY signs and symptoms:
    • loss of appetite and impaired immune function.
    • Severe zinc deficiency causes hair loss, diarrhea, weight loss and increase in pneumonias, mostly seen in developing countries.
    • Zinc deficiency in poor countries causes an increase in pediatric infections. Has been evaluated as an effective therapeutic and preventative measure for infections.
    • Eye and skin lesions
    • Delayed sexual maturation, impotence, hypogonadism in males
    • •Delayed wound healing, taste abnormalities, and mental lethargy can also occur
    PATIENTS NEEDING ZINC SUPPLEMENTATION:
    • GROUPS at greatest risk: GI surgery- especially gastric bypass surgery, ulcerative colitis and Chron’s disease.
    • Alcoholics up to half of that population need zinc supplementation due to poor diet.
    • Vegetarians require 50% more of RDA, due to lack of intake of meat products.
    • Sickle cell anemia and alcoholics. Zinc deficiency also affects approximately 60%–70% of adults with sickle cell disease. Zinc supplementation has been shown to improve growth in children with sickle cell disease
    • ZINC FOR COLD: a 2004 review showed zinc lozenges may reduce the duration and severity of cold symptoms, when taken within 24 hours of onset of symptoms. The safety of intranasal zinc has been called into question due to numerous reports of anosmia (loss of smell), which may be long-lasting or permanent, from the use of zinc-containing nasal gels or sprays.
    • ZINC FOR THE EYES (AMD): zinc is not effective for the primary prevention of early adult macular degeneration (AMD), although zinc might reduce the risk of progression to advanced AMD.
    DRUG INTERACTIONS INVOLVING ZINC
    • May bind tetracyclines as well as fluoroquinolones (Cipro, Levaquin)
    • Diuretics may lower zinc levels by 60%
    • Iron blocks zinc absorption
    • Zinc may increase bleeding risk when taken with
      • Anticoagulants (warfarin, Xa inhibitors-Xareolto®, Eliquis®, Savaysa®)
      • Antiplatelet drugs (Clopidogrel-Plavix®)
      • NSAIDS (Naproxen,etc))
    • Zinc may lower blood sugar levels
    EXCESS ZINC : may cause nausea, vomiting, loss of appetite, abdominal cramps, diarrhea, and headaches. Over 150mg of zinc per day may cause
    • low copper status
    • altered iron function
    • reduced immune function
    • reduced levels of high-density lipoproteins
    • Affect urinary physiology
    • Look for zinc-free denture adhesives, especially if using in large quantities
    We started this journey through the vitamin aisle on November 1,2018 with Clinician’s Corner. Now 4 and ½ months later we wrap up this journey through the vitamins and supplements with Zinc.

    We’ve covered everything from “A” to “Zinc”, with one notable exception. Fluoride was not covered in this unit, because oral fluoride requires a prescription. I covered this very important ion in the dental section, back on April 20, 2017.

    Next Clinician’s Corner we’ll talk about specific patients, and who should be talking these vitamins and supplements. I’ll provide you with information that applies to specific patients, because if what we read doesn’t apply to patient care, it is simply pharmacy trivia!

    Remember... the "Request line" is always open. If there is a topic relevant to patient care that applies to pharmacy and general practice patients, feel free to e-mail me with any requests. With my lecture notes from St. Francis University, I can cover most any topic of interest to the primary care providers, CRNP's, Physician Assistants and pharmacists.

    Have a great day on the bench!!

    Calcium: lots of choices in our supplement aisle. Make sure our patients get the best one, for them!

    Let's discuss one of the most common supplements in our vitamin section, calcium. Calcium is most abundant mineral in our body. Calcium is found in some foods, added to others, available as a dietary supplement in out vitamin section, and present in some medicines, we recommend as an antacid (Tums).

    Our bodies use calcium for vascular contraction and vasodilation, muscle function, nerve transmission, intracellular signaling and hormonal secretion., however less than 1% of total body calcium is needed to support these critical metabolic functions. The other 99% is stored in bones and teeth.

    Frank calcium deficiency is rare especially with our diet. Over the long term, inadequate calcium intake may cause osteopenia which if untreated can lead to osteoporosis. Older individuals may suffer from bone fractures due to osteopenia and osteoporosis. Rickets can be seen, but this is usually attributed to Vitamin-D deficiency.

    About 43% of the U.S. population (including almost 70% of older women) uses dietary supplements containing calcium, increasing calcium intakes by about 330 mg/day among supplement users. Our job as pharmacists is to make sure they are taking the RIGHT calcium supplement.

    AGE of PATIENT MALE FEMALE
    14-18 years 1,300mg 1,300mg
    19-50 years 1,000mg 1,000mg
    51-70 years 1,000mg 1,200mg
    71+ years 1,200mg 1,200mg


    Calcium carbonate: (Os-Cal-500 and generics)
    • Contains 40% Calcium (1250mg Calcium carbonate yields Calcium++ 500mg)
    • Should be taken with a meal. Optimal absorption occurs in the presence of gastric acid. May cause constipation, divided dosing and adequate fluids should alleviate its occurrence
    • Must divide doses. Approximately 500mg can be absorbed at a single time
    Calcium Citrate (Citracal® and generics)
    • Contains 21% calcium by weight. May be taken with or without meals. Does not require stomach acid for absorption. Best choice for elderly with reduced gastric acid.
    • Best choice for patients on proton pump inhibitors or H2 receptor antagonists.
    • Digoxin
    • Works best for patient’s complaining of GI upset.
    • Must divide doses, is a higher pill burden.
    Calcium Consultation Points
    • Tetracyclines, fluoroquinolones--decreased efficacy of the antibiotic. Separate doses by at least 2-3 hours.
    • L-thyroxine & Bisphosphonates--decreased efficacy by decreasing absorption. Separate dose from calcium by 4 hours.
    • Corticosteroids decrease absorption of calcium, and over time can lead to osteoporosis.
    • Thiazide diuretics increase urinary calcium reabsorption. Studies have shown fewer fractures on patients on thiazide diuretics. If diuresis is needed, a thiazide would be a good choice. Loop diuretics increase the excretion of calcium.
    • Most agree the optimal daily dose for adults is 1200mg Calcium along with Vitamin-D 800iu (20mcg)
    Who should supplement:
    • Post-menopausal women
    • Pregnant women
    • Vegetarian, because they eat more plant based diet, the consume more oxalic and phytic acids which block absorption of calcium.
    • Prednisone can cause calcium depletion and eventually osteoporosis if used chronically
    • Patients using acid suppressing therapy- proton pump inhibitors (Omeprazole etc.) and histamine-2 receptor blockers (Ranitidine, etc.)
    • Bariatric surgery weight loss patients should use calcium citrate, preferably a chewable dosage form.
    As we live longer, the bones might need a little help from calcium supplementation. The aging process does cause wear and tear on our bones. Every time I check a prescription for Omeprazole (Prilosec), Pantoprazole (Protonix), Ranitidine (Zantac) and Famotidine (Pepcid) I should wonder about the impact these drugs have.

    The adverse effects of proton pump inhibition (PPI's) and Histamine-2 receptor blockade (H2RA) are well know such as B-12 deficiency, calcium deficiency, magnesium deficiency, Clostridium difficile and pneumonia. Like B-12 deficiency, calcium malabsorption caused by PPI's and H2RA's is an easy fix in the community pharmacy.

    When we buy our Omeprazole and Pantoprazole in bottles of 1000 in the small corner drugstore where I work, I cant help but wonder how much untreated calcium deficiency is slipping out the front door. Calcium citrate should be flying off the shelf in the front of the store as briskly as the omeprazole and ranitidine fly out of the pharmacy!

    Have a great day on the bench!!

    February 2019

    Iron keeps the blood happy, but not necessarily the GI tract!

    IRON SUPPLEMENTATION

    Let's discuss another very common cation, which approximately 14% to 18% of Americans supplement their diets with. Iron is a mineral that is naturally present in many foods, used to fortify some food products, and available as a dietary supplement. Iron is an essential component of hemoglobin, a red blood cell protein that transfers oxygen from the lungs to the tissues. Iron is also in myoglobin, a protein that provides oxygen to muscles, iron also supports metabolism. Iron is also needed for growth, development, normal cellular functioning, and synthesis of some hormones and connective tissue.

    Sources: The richest sources of heme iron in the diet include lean meat and seafood (about 15% of Western diet). Dietary sources of nonheme iron include nuts, beans, vegetables, and grain products that are fortified (about 85%). Heme iron has higher bioavailability.

    Correction of iron deficiency:
    • Bone marrow response to iron is limited to 20mg/d of elemental iron
    • An increase in hemoglobin level of 1g/dL should occur every 2-4 weeks
    • Oral: only 10% of an oral iron dose is absorbed in patients with normal iron stores.
    • 20% to 30% of oral iron dose is absorbed in persons with inadequate iron stores
    • May take up to 4 months for iron stores to return to normal after hemoglobin is corrected.
    • Goal dose: Ferrous sulfate 325mg by mouth three times daily. May increase compliance by starting slowly. One tablet at bedtime on empty stomach, may increase 1 tablet every week. Take 1 or 2 hours before a meal because food can decrease absorption by 50%. If GI upset occurs, may take with small snack such as crackers. NO milk or tea.
    • Extended-release or enteric-coated formulations have been found to transport iron past the duodenum and proximal jejunum, thereby reducing the absorption of iron. Vitamin C is added to some products to enhance iron absorption
    • Orange juice (Vitamin-C) can double the absorption. About 200 mg is needed to increase absorption of 30 mg of elemental iron.
    • Take 1 hour before or 3 hours after antacids. Food decreases absorption. Proton Pump inhibitors (Prilosec), Histamine-2 Receptor blockers (Zantac) will impair iron absorption.
    • If constipation occurs initiate stool softener with docusate (Colace®) 100mg one daily


    Iron salt Yields elemental iron Percentage
    Ferrous sulfate 325mg 65mg 20%
    Ferrous gluconate 35mg 12%
    Ferrous fumarate 99mg 33%


    What about Nu-Iron or Ferrex? (iron polysaccharide) Iron polysaccharide causes somewhat less GI upset than ferrous sulfate. Despite the adverse GI side effects, the ferrous sulfate shows a better hematological response versus the iron polysaccharide. Iron polysaccharide, because of its delayed release is not as well absorbed as ferrous sulfate.

    Iron-Drug Interactions be sure to AVOID:
    • Fluoroquinolones
    • Tetracycline
    • Digoxin
    • Carbidopa/levodopa (Sinemet, Stalevo)
    • Levothyroxine (AVOID iron by 4 hours!)
    Most common side effects:
    Metallic taste, constipation, nausea, diarrhea, dark stools, and abdominal pain

    REMEMBER: Insist on child resistant packaging if there is ANY chance small children may be in the home. Iron is still the #1 cause of pediatric fatalities due to toxicity. Before the mandatory child resistant packaging, iron overdose accounted for 1/3 of pediatric poisonings.

    Patient groups most likely to need iron supplementation
    • Pregnant women
    • Infants and young children
    • Women with heavy menstrual bleeding
    • Frequent blood donors
    • Patients with cancer
    • Patients with gastric disorders (gastrectomy, weight loss surgery, ulcerative colitis, celiac disease)
    • Proton pump inhibitors
    • reduce absorption of non-heme iron.
    • ACE cough: iron might inhibit the dry cough associated with ACE inhibitors.
    When to consider IV iron:
    allergic reactions to the older formulation of iron dextran made clinicians reluctant to consider IV. With the newer formulations of iron salts, allergic reactions to IV iron are much rarer.
    • ongoing blood loss
    • physiologic or anatomic abnormality that interferes with oral absorption
    • intolerable gastrointestinal side effects of oral iron.
    Iron is another nutritional supplemented along with thiamine, niacin, riboflavin, folic acid, to enriched flour. In the United States, about half of dietary iron comes from bread, cereal, and other grain products. We have a lot of patients who in spite of the ubiquitous presence of iron in our grains still require iron supplementation.

    Iron supplementation is an opportunity for the pharmacist to do some beneficial counseling to our patients. Gradually introducing the ferrous sulfate is key to decreasing GI upset. If a patient gets GI upset negotiate with them to get this important supplement on board. An empty stomach is best for absorption, but if GI upset occurs consider a light snack of water and crackers.

    Encourage them to take about 250mg of Vitamin-C along with the iron to get the most absorption. Even dosing the iron every other day is of great benefit, and better than the patient giving up on iron therapy.

    Be sure to use this information to work with patients to decrease chance of drug interactions. Levothyroxine and iron is the most common interaction. Separation of doses are critical. If a patient is taking their iron three times a day, and we need to separate the levothyroxine by 4 hours I frequently have patients take their Levothyroxine at bedtime when they brush their teeth.

    Have a great day on the bench!!

    Too much of a good thing, and a lot harder to treat: HYPERkalemia

    TREATMENT of HYPERkalemia

    Last week we discussed potassium supplementation and the treatment of hypokalemia. Even more challenging is when the potassium levels rise excessively, due to chronic kidney disease, heart failure, excessive tissue trauma (burns, etc.) or medications.

    Hyperkalemia: serum potassium level greater than 5.5 mEq (mmol)/L. Hyperkalemia is a serious and potentially life-threatening disorder. It can cause: muscle fatigue, weakness, paralysis, nausea and life threatening cardiac arrhythmias.

    Drugs noted for causing HYPERkalemia:
    • NSAIDS (Ibuprofen, Naproxen, etc)
    • Potassium Sparing Diuretics (triamterene, amiloride, spironolactone)
    • Angiotensin Converting Enzyme inhibitors (Lisinopril, Enalapril Captopril etc)
    • Angiotensin Receptor Blockers (Valsartan, Irbesartan, Losartan etc)
    • Heparin
    • Trimethoprim (Bactrim-DS)
    • Excess doses of potassium supplements
    Treatment for hyperkalemia involves three goals, namely restoring normal potassium balance, preventing serious complications, and treating the cause Treatment for severe hyperkalemia can be broken down into three steps:
    1. Antagonizing the effects of potassium on excitable cell membranes
      • Calcium gluconate is used to antagonize the effects of potassium on the heart muscle in patients with severe hyperkalemia. NO effect on blood levels of K+

    2. Redistributing extracellular potassium into cells Beta agonists (high-dose nebulized albuterol) help shift potassium from the extracellular fluid to intracellular fluid in patients with severe hyperkalemia. Insulin can be used to help shift potassium from the extracellular fluid to intracellular fluid in patients with severe hyperkalemia. Give with glucose to prevent hypoglycemia.

    3. Enhancing elimination of potassium from the body. Beta agonists (high-dose nebulized albuterol) help shift potassium from the extracellular fluid to intracellular fluid in patients with severe hyperkalemia. Insulin can be used to help shift potassium from the extracellular fluid to intracellular fluid in patients with severe hyperkalemia. Give with glucose to prevent hypoglycemia.
      • Dialysis
      • Diuretics (loop diuretics)
      • thiazide diuretics can be used only down to CrCl=40
    ORAL DRUG THERAPY (Potassium Binders)

    Sodium polystyrene sulfonate
    (Kayexalate, Kionex, SPS) -available 1958


    Mechanism: ion exchange resin absorbs potassium in the intestinal lumen.

    Dose: The average daily adult dose of the resin is 15 g to 60 g. Each gram of resin may bind as much as 1 mEq of potassium and release 1 to 2 mEq of sodium

    Side effects: GI disturbance, Constipation, Hypokalemia, Hypocalcemia Hypomagnesemia, Sodium retention, Nausea, Vomiting GI tract ulceration or necrosis, which could lead to perforation.

    Avoid in patients on opioid therapy, post op patients, C. dif patients, and patients prone to small or large bowel obstruction.

    Use SPS only the following criteria are met:
    • Potentially life-threatening hyperkalemia
    • Dialysis is not readily available
    • Other therapies to like diuretics, or rapid restoration of kidney function have failed or are not possible
    Veltassa (patiromer) released October 2015, is the first new treatment for hyperkalemia in 50 years. Mechanism: is powder form that spherical beads bind to potassium in exchange for calcium, primarily in the colon. The potassium is then excreted from the body fecally.

    Limitation of Use: Veltassa® should not be used as an emergency treatment for life threatening hyperkalemia because of its delayed onset of action.

    Dosage: Administer Veltassa at least 6 hours before or 6 hours after other oral medications. Administer with food. Starting dose of Veltassa is 8.4 grams patiromer once daily. Available in individual packets. Monitor serum potassium and adjust the dose of Veltassa based on the serum potassium level and the desired target range.
    All of the drugs for treatment of hyperkalemia require a hands on approach for mixing and measuring the resins. This is a great opportunity for the independent pharmacist to provide the “hands on” care these complicated patients require.

    Lokelma (sodium zirconium cyclosilicate) “ZS-9” released November 2018

    Limitation of Use: do not use as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action.

    Mechanism: potassium binder. Sodium zirconium cyclosilicate is a non-absorbed zirconium silicate that preferentially exchanges potassium for hydrogen and sodium. This complex is passed out fecally with bound potassium.

    Dosage/Administration: Recommended starting dose is 10 g administered three times a day for up to 48 hours.
    • For maintenance treatment, recommended dose is 10 g once daily. (2.1)
    • Adjust dose at one-week intervals as needed (by 5 g daily) to obtain desired serum potassium target range
    Avoid: patients with severe constipation, bowel obstruction or impaction, including abnormal post-operative bowel motility disorders

    Good things come to those who wait! It took almost 60 years to get a potassium binder than wouldn’t cause bowel necrosis and do more harm than good.

    Kayexalate (SPS) was first introduced the year I was born in 1958. The two new potassium binders came out the past two years.

    Veltassa is available as a specialty pharmacy drug. The starting dose for Veltassa, is 8.4grams per day, GoodRx prices it around $900.00 per month.

    Lokelma is stocked in our warehouse with average wholesale price of $786.00 per month, and is readily available in the community pharmacy practice setting. Loretto, PA 15940

    Have a great day on the bench!!

    Beef, chicken, tomato, orange or cherry---having trouble picking a potassium supplement??

    POTASSIUM

    Another important cation we frequently dispense in the pharmacy is potassium. Potassium is the most abundant cation in intracellular fluid, where it is responsible for maintaining intracellular fluid volume. Intracellular fluid, which is found inside the cells accounts for 55% of our body’s total water volume. Potassium is important for establishing resting membrane potential in neurons and muscle fibers. Potassium also regulates the pH of body fluids when exchanged for H+. Normal range for potassium is 3.7 to 5.2 mEq/L.

    Potassium is lost through the kidneys when patients take diuretic therapy for high blood pressure, heart failure, kidney failure to help remove excess fluid. Diarrhea, vomiting and corticosteroid use can also deplete potassium. Thiazide diuretics “lightweight diuretics” – HCTZ, chlorthalidone can cause potassium depletion, but the more potent “loop diuretics” -Lasix (furosemide); Demadex (torsemide), Bumex (bumetanide)can cause significant potassium loss.

    Hey doc, do I have to swallow those horse pills? Can’t I just eat a banana? I never recommend potassium rich foods to replace potassium chloride supplements when they are prescribed. Consider the following:

    • Bananas: contain 1mEq of potassium per inch, and a 10 inch banana contains about 140 calories. Bananas cost about 59-79 cents per pound. Could you imagine eating 4 large bananas a day, at almost 600 calories!
    • Orange juice to get 10mEq of potassium you need to drink 7 ounces which is 90 calories. To replace 40mEq would be nearly 400 calories.
    • Potassium rich foods contain potassium phosphate, not potassium chloride, which is important with diuretic loss as well as vomiting and diarrhea.
    Guidelines for potassium repletion:
    • Loop or thiazide diuretics: 20 mEq potassium per day is sufficient to prevent hypokalemia with diuretics
    • 40 – 100 mEq potassium required to correct mild potassium deficits
    • Up to 120 mEq required for severe deficiencies
    • Total daily doses should be divided in 3 – 4 doses to prevent GI side effects
    Alternative therapies for Potassium Repletion K-sparing diuretics- work in the distal tubule and exchange sodium for potassium, and help retain potassium.
    • Spironolactone (Aldactone) and Eplerenone (Inspra) inhibit the effects of aldosterone to decrease potassium elimination, and are more effective in lowering blood pressure than are amiloride (Midamor) & triamterene (Dyrenium), which work independently of aldosterone. Eplerenone is a “go to” drug for patients complaining of gynecomastia due to spironolactone therapy.
      • *Excessive urinary potassium wasting may require potassium-sparing diuretics + potassium supplementation (CHF, cirrhosis or nephrotic syndrome)
    Patient counseling points
    • All potassium tablets should be taken with food to minimize GI upset.
    • To reduce esophagitis with oral potassium, counsel patients to drink at least 100 mL of water and stay upright for five to ten minutes after administration.
    • Watch salt substitutes. Contain 15-20 mEq per ¼ teaspoon serving
    • Advise patients about the potential for seeing “ghost tablets: in their stool, the left over wax remnants (especially the bright yellow ones!)

    Remember Kaon®, Kato® and Potage®? Kaon was a potassium gluconate supplement, that fell out of favor, knowing that chloride needed to be supplemented too. Kato was a tomato juice flavored potassium supplement, the drug company’s rationale was if you have to drink something salty, might as well be something that goes well with salt.

    Even more ridiculous was the potassium supplement Potage®, which is the French word for soup. Potage, playing off the fact that soups contain salt offered two different flavors the patient could choose from both chicken and beef! We also had effervescent tablets called K-lyte® and K-lyte Cl, which had a salty orange or salty cherry flavor.

    Today we have only a couple of options, like sustained released capsules (Micro-K-10®), sustained released wax based tablets (Klotrix® and K-tabs®) and microencapsulated tablets (K-Dur® and Klor-Con-M). Most patients have their preferences for their potassium tablet—I’m just glad we no longer must deal with what flavor to select. “I’m sorry ma’am but your insurance plan only covers beef flavor, and not chicken; chicken flavor requires a prior auth!!”

    Next week, we’ll discuss too much of a good thing. “Hyperkalemia”.

    Have a great day on the bench!!

    Diuretic therapy makes us think of potassium---but don't forget magnesium!

    MAGNESIUM

    Magnesium is important for:
    • managing bone metabolism
    • nerve transmission, cardiac excitability, neuromuscular conduction, muscular contraction, vasomotor tone, and blood pressure
    • managing bone metabolism
    • Insulin and glucose metabolism
    Sources of magnesium:
    • Food sources of magnesium include green leafy vegetables, nuts, legumes, and whole grains
    • 50% stored in bone, the other half in soft tissues, less than 1% in blood.
    • Low magnesium leads to decreased levels of calcium and potassium- mag homeostasis is related to K+ and Ca++
    • Magnesium level: 1.7-2.2mg/dL (1.8-3.6mg/dl, depending on labs)
    Uses for magnesium:
    • Intravenous magnesium is used for treatment of torsade de pointes
    • Treatment of eclampsia and preeclampsia
    • Headache: cluster and migraine sufferers generally have low magnesium levels. Low magnesium levels relate to factors that promote headaches, including neurotransmitter release and vasoconstriction.
    • Severe asthma exacerbations
    • Constipation
    Magnesium loss can cause: cardiac arrhythmias, tremors and neuromuscular hyperexcitability, lowered potassium and calcium levels.

    Patients most susceptible to magnesium deficiency:
    • Patients with diabetes: will have lower magnesium levels due to the diuresis caused by high urine glucose levels. Low magnesium levels might worsen insulin resistance, a condition that often precedes diabetes, or it might be a consequence of insulin resistance. There is insufficient evidence to promote magnesium supplementation to prevent diabetes.
    • Patients with alcoholism (30%) substitute alcohol for food as well as malabsorption syndrome
    • diuretic therapy, especially loop diuretics like Lasix, Bumex, Demadex: magnesium gets washed out. Addition of amiloride (Midamor), a potassium sparing diuretic may help with magnesium loss by increasing reabsorption in the distal tubule.
    • Chronic diarrhea and chronic steatorrhea
    • Proton pump inhibitors (omeprazole, pantoprazole etc.) if used over a year, especially if on diuretic therapy. Patients on PPI therapy should have their magnesium levels checked periodically.

    Salt Brand name % Mag Points to consider
    Mag Chloride Slow-Mag; Mag-64 12% 20% absorbed
    Mag citrate Citroma 16% Limited absorption
    Mag hydroxide Milk of Magnesia 42% Minimal absorption
    Mag Oxide Mag-Ox-400 60% 4% absorbed


    Rx to OTC Connection:

    Rx Treatment: If magnesium loss due to diuretic use, consider the addition of a potassium-sparing diuretic (amiloride/ spironolactone), to help retain magnesium (as well as potassium)

    Drug Interactions: Magnesium can greatly reduce the absorption of tetracyclines, fluoroquinolones (Cipro, Levaquin), and most important Levothyroxine (Synthroid). Be sure to separate by 4 hours. Sustained-release preparations (Slow-Mag) have the advantage that they are slowly absorbed and thereby minimize renal excretion of the administered magnesium

    As we have wrapped up all the vital-amines (vitamins) lets discuss some other critical supplements. First let’s start with magnesium. We all know that potassium gets most of the attention when we think of diuretic use, but magnesium is becoming equally important. Magnesium is the 2nd most abundant intracellular divalent cation. Involved in more than 300 metabolic reactions in the body, Including protein synthesis, cellular energy production and storage, cell growth and reproduction, DNA and RNA synthesis, and stabilization of mitochondrial membranes.

    Have a great day on the bench!!

    January 2019

    Our pharmacists that work in a grocery store see more of this fat soluble vitamin than the rest of us do!

    Got broccoli? Got Kale? That's where most of us can buy our Vitamin-K!
    Let’s wrap the last fat soluble vitamin. This one we never get to recommend over the counter. We get plenty from our diet, as well as make our own in our gut. We learned in school that fat soluble vitamins are accumulated, and water soluble vitamins are quickly removed. Not the case for Vitamin-K, which hangs around in our bodies for less than one week.

    Sources for Vitamin K: leafy vegetables, vegetable oils, liver, & synthesis by intestinal flora. Phylloquinone (Vitamin K-1) is present primarily in green leafy vegetables and is the main dietary form of vitamin K. Menaquinones (Vitamin K-2), especially long-chain menaquinones, are produced by bacteria in the human gut.
    • Function: essential for formation of clotting Factors VII, IX, X, prothrombin, proteins C and S
    Deficiency States: When we ingest Vitamin-K the body retains only about 30% to 40% of an oral physiological dose, while about 20% is excreted in the urine and 40% to 50% in the feces via bile. This rapid metabolism accounts for vitamin K's relatively low blood levels and tissue stores compared to those of the other fat-soluble vitamins.
    • May be due to excessive antibiotic use. Newborns & preemies at increased risk. Deficiency cause hemorrhage due to prothrombin deficiency.
    • Cystic fibrosis patients because of fat malabsorption and broad-spectrum antibiotic use (that kills off bacteria that produces Vitamin-K) should be supplemented with Vitamin-K
    • Vitamin-K stores are small- deficiency may develop in a week.
    Interactions: warfarin antagonizes the Vitamin K in the clotting cascade We are familiar with using Vitamin-K to reverse the effects of Warfarin. However, this approach is not too frequently used. Vitamin-K (Mephyton®) is now over $60 per tablet! Since this product is only available in 100 count bottles, most pharmacies will not have $6,000 worth of inventory sitting on the shelf for a patient needing two tablets.
    • If the INR is over goal, and less than 4.5—just hold the next dose of warfarin
    • If the INR is between 4.5-10, Vitamin K is usually not administered, unless there is a pressing need like surgery, or there is an active bleed. Just simply hold 1 or 2 doses.
    • If the INR is over 10, give 2.5 to 5 mg whether bleeding or not.
    • If there is a major bleed, use PCC (Prothrombin complex concentrate-Kcentra®) is preferred over FFP (Fresh Frozen Plasma). Of course, the cost of K-Centra® being over $10,000 per dose maybe it is not so preferred!
    Counseling points: Lots of the foods we are told to eat to maintain a healthy and balanced diet are loaded with Vitamin-K. It is best we don’t discourage our patients from eating healthy. Here are some rough guidelines for Vitamin-K consumption if our patients are being managed on warfarin (Coumadin®).
    • High in vitamin K foods: limit to (1) serving per day
      • (kale, spinach, collard greens, Swiss chard, parsley)
    • Moderately high: limit (3) servings per day
      • (broccoli, Brussels sprouts, endive, green lettuce)
    Best advice: eat a consistent diet!

    In the mid 1980’s as a young pharmacist I had a discussion with one of my patients about her Coumadin®. Generic warfarin was not available at the time, but her cardiologist was frustrated with her because her INR was always “out of whack.”

    The cardiologist even went so far as to “accuse” me of dispensing a generic for Coumadin. I asked her about her diet, and she stated, “my heart doctor is always yelling about my weight, so I’ve been eating mostly salads and I lost a few pounds.” I told her that was probably the reason there was so much of a struggle with her INR. Her doctor doubted that that could cause such fluctuations! Now the anticoagulant clinics always discuss diet, because we know that Vitamin K content in food has a significant effect on patients taking warfarin and trying to manage their INR.

    Coumadin® (warfarin) hit the US market in 1954, and the generic version was only approved in 1997. President Dwight Eisenhower was the first celebrity to be managed with Coumadin® after his heart attack in 1955. Even though this molecular entity has been available for over 65 years, we still have not figured it out!

    Genetic variations in metabolism, Vitamin-K sensitivity and the food interactions with Vitamin-K in our diet are making the newer Factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) much more desirable to manage our patients in need of anticoagulation.

    Have a great day on the bench!!

    Recommending Vitamin-E for everything-- those were the good old days!

    Vitamin E (tocopherol)
    is a fat-soluble vitamin with antioxidant properties; it protects cell membranes from oxidation and destruction. A few decades ago it was widely touted for everything, however lately its use has fallen out of favor. As an antioxidant, it protects cells from the damage caused by free radicals. Free radicals are produced from the conversion of food to energy. People are also exposed to free radicals in the environment from cigarette smoke, air pollution, and ultraviolet light from the sun.
    • Source: there are 8 naturally tocopherols. The most active is d-alpha-tocopherol.
    • Dietary sources: Vegetable oils, wheat germ, leafy vegetables, egg yolk, margarine, legumes.
    Cancer: The Selenium and Vitamin E Cancer Prevention Trial (SELECT) was published in October 16, 2011 edition of The Journal of the American Medical Association.
    • 400 IUs /day & over significantly increased the risk of prostate cancer among healthy men when compared with healthy men taking placebo.
    • The researchers found that the increased risk means that there will be 1 to 2 more prostate cancers per 1000 patients who took the high dose vitamin E for one year. Interestingly, in men who received both vitamin E and selenium, there was no increased rate of prostate cancer.
    Heart disease: Most clinical trials have not provided evidence that routine use of vitamin E supplements prevents cardiovascular disease or reduces its morbidity and mortality. However, participants in these studies have been largely middle-aged or elderly individuals with demonstrated heart disease or risk factors for heart disease.

    Cognition: most research results do not support the use of vitamin E supplements by healthy or mildly impaired individuals to maintain cognitive performance or slow its decline with normal aging. Weak evidence suggests a possible role in slowing the progression of Alzheimer disease, tardive dyskinesia, and macular degeneration. Not much current evidence is available to support supplementation of Vitamin-E for prevention or treatment of cancer, cardiovascular or cerebrovascular disease.

    Dosage: Most sources do not recommend supplementing with more than 400iu of Vitamin E- d-alpha tocopherol.

    CAUTION: increased bleed risk with anticoagulants (warfarin). High doses of Vitamin-E inhibit platelet aggregation, and significantly increase risk of bleeding.

    Under the FDA’s new labeling regulations for foods and dietary supplements that take effect by January 1, 2020 (for companies with annual sales of $10 million or more) or January 1, 2021 (for smaller companies), vitamin E will be listed only in mcg and not IUs. New labeling requirements for FAT SOLUBLE vitamins are to take effect, to label fat soluble vitamins by their weight (in mcg) as opposed to measure activity (in IU). It gets even more confusing for Vitamin-E.

    To convert Vitamin E if the product label has dl-Alpha-tocopherol (blended)[synthetic] as the ingredient:
    From IU to mg: IU * 0.9 = mg

    INTERNATIONAL UNITS (old labeling) MICROGRAMS (new labeling)
    30iu 27mg
    100iu 90mg
    200iu 180mg
    400iu 360mg
    800iu 720mg
    1000iu 900mg


    To convert Vitamin E if the product label has d-Alpha-tocopherol (pure d-alpha) [natural] as the ingredient:
    From IU to mg: IU * 0.67 = mg.

    INTERNATIONAL UNITS (old labeling) MICROGRAMS (new labeling)
    30iu 20.1mg
    100iu 67mg
    200iu 134mg
    400iu 268mg
    800iu 536mg
    1000iu 670mg


    Walking out to my vitamin section and recommending Vitamin E, for me is a very rare occurrence… if at all!

    A possible use for Vitamin-E: Treatment of fibrocystic breast disease: There is a possible beneficial effect of vitamin E on breast pain in premenstrual women who experience breast pain that fluctuates during the menstrual cycle. One study showed a dose of Vitamin-E 200 IU twice daily for two months improved symptoms in women with cyclic breast pain. Minimal benefit was observed after 4 months.

    Decades ago we were recommending Vitamin E for everything from memory improvement, Parkinson's disease to cancer prevention. We seldom recommend it today, as excess Vitamin-E is likely to cause harm. I'd avoid recommending it in our older male patients as well as anyone taking any blood thinning medications. Our diet seems to provide us with adequate Vitamin-E

    Have a great day on the bench!!

    Got Sun??? Not in Central Pennsylvania for sure. Let's go to the vitamin aisle and buy some Vitamin-D

    Vitamin-D

    Sources: very few foods contain natural Vitamin-D: fish liver oils, egg yolk, fortified milk, synthesized in skin exposed to UV light. Vitamin-D3 (cholecalciferol) comes from animal source. Vitamin-D2 (ergocalciferol) comes from plant sources.

    Function: acts as a hormone, and plays a role in calcium homeostasis. Vitamin D regulates calcium and phosphorus metabolism. Following conversion to active metabolites (eg, calcifediol, calcitriol), maintenance of normal calcium and phosphate concentrations is achieved by promoting intestinal calcium and phosphate absorption in the gut, mobilization of calcium from bone, and reduction of renal calcium/phosphate excretion. Calcitriol is the most active metabolite.

    Deficiency: More adults are deficient in vitamin D for the following reasons:
    • increased use of sunscreens
    • spending more time indoors
    • and less efficient vitamin D absorption as people age
    • Darker skin and living at higher latitudes also increase risk.
    • renal failure, hypoparathyroidism, estrogens, phenytoin, phenobarbital, fat malabsorption, high alcohol consumption
    • Consider testing for patients who are likely to be deficient such as house bound elderly, especially in a nursing home.
    Rickets: still common in tropical countries even though adequate skin exposure. Soft bones in children become easily deformed. Low blood calcium & phosphate occur because of Vitamin-D deficiency. Lack of Vitamin -D stimulates parathyroid hormone to restore calcium levels.

    DOSE: adults recommend 800-2000iu per day. Feel comfortable recommending up to 2000iu of Vitamin-D without doing the 25-hydroyx-vitamin-D level. Most evidence from studies suggests that to prevent falls, a dose of at least 800 IU per day is required for our elderly patients.

    Do I have to swallow a capsule, what about drinking milk, or exposure to sunshine? Dairy Products: It takes about 5 quarts of milk, to equal 2000iu in a capsule…. not to mention over 2750 calories!

    Sun Exposure: Sun Exposure (Ultraviolet-B) 2 to 3 times a week during mid-day. Bare arms & legs for10-15 minutes per session is usually adequate. The effect of sunlight exposure and vitamin D synthesis is reduced in individuals with darker skin pigment. Effective use of a sunscreen does block the synthesis of Vitamin-D in the dermis. Middle aged and elderly persons who use sunscreens daily have significantly lower serum concentrations of 25-Hydroxyvitamin D3. However, the benefits of using a sunscreen, far outweigh the disadvantages of a decrease in Vitamin-D. A local dermatologist told me “it is easier to treat Vitamin-D deficiency than it is to treat skin cancer...so use a sunscreen.”

    What is the difference between ergocalciferol (Vit-D2) and cholecalciferol (Vit-D3): Vitamin D2 (ergocalciferol) available as Drisdol® comes from ergosterol, a plant sterol, and yeast. Vitamin D3 (cholecalciferol) is synthesized in the skin via 7-dehydrocholesterol, a cholesterol precursor. The vitamin D2 in supplements is made by irradiating ergosterol from yeast, and vitamin D3 in supplements is made by irradiating 7-dehydrocholesterol from lanolin. Both D2 and D3 are efficient at raising serum vitamin D levels. But at high doses vitamin D3 seems be almost twice as potent. In patients with renal disease (especially stage 5 or dialysis patients), production of active vitamin D (calcitriol) is impaired, and use of calcitriol (Rocaltrol) or other active vitamin D sterol may be indicated.

    What about Infants & children?
    • Recommended daily intake of vitamin D is 400 IU per day in all infants (beginning in the first few days of life), children, and adolescents.
    • Breastfed and partially breastfed infants should begin vitamin D supplementation beginning in the first few days of life.
    Excessive dose: Side effects with excessive use may include nausea, anorexia, weight loss, constipation, polyuria, polydipsia, hypertension, weakness, and muscle aches or stiffness.

    Under the FDA’s new labeling regulations for foods and dietary supplements that take effect by January 1, 2020 (for companies with annual sales of $10 million or more) or January 1, 2021 (for smaller companies), vitamin D will be listed only in mcg and not IUs. New labeling requirements for FAT SOLUBLE vitamins are to take effect, to label fat soluble vitamins by their weight (in mcg) as opposed to measure activity (in IU)

    To convert Vitamin D: From IU to mcg: IU/40 = mcg

    INTERNATIONAL UNITS (old labeling) MICROGRAMS (new labeling)
    400iu 10mcg
    800iu 20mcg
    1000iu 25mcg
    2000iu 50mcg
    5000iu 125mcg
    50,000iu Rx only 1250mcg= 1.25mg


    As we continue our review of the fat soluble vitamins, lets discuss Vitamin-D, the one fat soluble vitamin we should be recommending. In a study done in 2011, the overall prevalence rate of vitamin D deficiency was 41.6%, with the highest rate seen in blacks (82.1%), followed by Hispanics (69.2%).

    With 41% of the population being vitamin D deficient, especially in these latitudes, we need to be recommending this Vitamin a whole lot more. Drinking milk and sun exposure is not the answer to correcting this wide scale deficiency. People low in vitamin D who take a supplement may be less likely to fall. That makes sense, given that vitamin D plays a key role in keeping bones and muscles strong.

    Have a great day on the bench!!

    Next time you are in the butcher shop... avoid the polar bear liver!

    Now we start our journey through the fat-soluble vitamins of A, D, E, K. These vitamins can accumulate and cause adverse effects. Rarely does someone get excess fat-soluble vitamins from the diet, but excess supplementation may cause accumulation and potential serious side effects. Vitamin-A

    What it does: Vitamin A is the name of a group of fat-soluble retinoids, which are involved in immune function, vision, reproduction, and cellular communication. Vitamin A is critical for vision as an essential component of rhodopsin, a protein that absorbs light in the retinal receptors, and because it supports the normal differentiation and functioning of the conjunctival membranes and cornea. Vitamin A also supports cell growth and differentiation, playing a critical role in the normal formation and maintenance of the heart, lungs, kidneys, and other organs
    • Dietary sources: fish liver oils, egg yolks, green leafy, orange & yellow vegetables.
    • Random useless fact: Toxic doses of Vitamin-A if polar bear liver is consumed.
    Deficiency States:
    • Night blindness: early sign of Vitamin-A deficiency. May progress to xerophthalmia which is dryness & ulceration of the cornea. May progress to blindness.
    • See decrease in heath and integrity of skin
    • Patients that need Vitamin supplementation include those taking Orlistat (Alli/Xenical), cystic fibrosis patients; however, deficiency is rare in the United States.
    Adverse effects: dry mucus membranes, cheilitis, yellowing of skin, fatigue, nausea, hair loss, headache, vertigo, blurred vision, birth defects, loss of muscular coordination, dry scaly skin. To help remember the side effects of Vitamin A therapy think of the topical side effects of Accutane (isotretinoin), which is a Vitamin-A analog.
    • Multivitamin supplements typically contain 2,500–10,000 IU vitamin A, often in the form of both retinol and beta-carotene
    • RDAs for vitamin A are given as mcg of retinol activity equivalents (RAE) to account for the different bioactivities of retinol and provitamin A carotenoids.
    • Excess Vitamin-A supplementation: leads to increased intracranial pressure (pseudotumor cerebri), dizziness, nausea, headaches, skin irritation, pain in joints and bones, coma, and even death.
    Under the FDA’s new labeling regulations for foods and dietary supplements that take effect by January 1, 2020 (for companies with annual sales of $10 million or more) or January 1, 2021 (for smaller companies), vitamin A will be listed only in mcg RAE and not IUs. New labeling requirements for FAT SOLUBLE vitamins are to take effect, to label fat soluble vitamins by their weight (in mcg) as opposed to measure activity (in IU)
    • To convert Vitamin A as retinol: From IU to mcg: IU/3.33 = mcg
    INTERNATIONAL UNITS (old labeling) MICROGRAMS (new labeling)
    a5000iu 1500mcg (1.5mg)
    8000iu 2400mcg (2.4mg)
    10,000iu 3000mcg (3mg)
    • To convert Vitamin A as beta-carotene: From IU to mcg: IU/1.66 = mcg
    INTERNATIONAL UNITS (old labeling) MICROGRAMS (new labeling)
    25,000iu 15,000mcg (15mg)


    Smokers should avoid Vitamin-A supplements. Taking beta-carotene seems to increase the risk of lung cancer in people who smoke (especially those smoking more than 1 pack per day), former smokers, asbestos exposure, and those who use alcohol (one or more drinks per day) in addition to smoking. Beta-carotene from the diet does not seem to have this adverse effect. (CARET and ATBC studies)

    As the writer of these practice points, I always try to write things that are clinically relevant, that is applicable to a patient you might see in your pharmacy or clinic. I frequently use the example of polar bear liver as a fun fact, but of no clinical applicability. I have yet to have ever seen a case of hypervitaminosis-A due to eating polar bear liver. We have lots of grocery stores in our area, but I’ve never seen polar bear liver for sale!

    Research has shown that a healthy adult person can tolerate a maximum of around 10,000 units of vitamin A. Adverse effects occur comes 25,000 and 33,000 units of ingestion. One pound of polar bear liver — a fist-sized chunk and barely a meal — can contain 9 million units of vitamin A!

    Knowing to avoid Vitamin-A supplementation in smokers is far more critical to our patient’s safety, than the knowledge of the adverse effects of polar bear liver consumption!

    Have a great day on the bench!!

    We expect a LOT from our vitamin-C ! From prevention of colds to cancer!

    Let’s wrap up all of the water-soluble vitamins this week. We are familiar the B-complex, they are short lived in the body, but remember that Vitamin-B-12 is stored in the liver and we have 2 years on board! So…. What happened to the other Vitamin-B numbers??
    • Vitamin B4: adenine: is synthesized by the human body.
    • Vitamin B8: adenosine monophosphate, is synthesized by the human body.
    • Vitamin B10: para-aminobenzoic acid (PABA)
    • Vitamin B11: pteryl-hepta-glutamic acid, one of five folates necessary for humans
    So here is our last water soluble vitamin…
    Vitamin-C (ascorbic acid)

    Source:
    citrus fruits, tomatoes, potatoes, cabbage, green peppers, kiwifruit, broccoli, strawberries, Brussels sprouts, and cantaloupe.
    Uses in the body: Vitamin-C is seen as a necessary co-factor for fatty acid transport, collagen synthesis, neurotransmitter synthesis, and nitric oxide synthesis. Is necessary for wound healing.

    Deficiency States
    • Scurvy: due to increased requirements or low intake. Became common during long voyages at sea. The timeline for the development of scurvy varies, depending on vitamin C body stores, but signs can appear within 1 month of little or no vitamin C intake (below 10 mg/day)
    • Will see capillary fragility (especially in gingival), loose teeth and hemorrhages. In children abnormal bone and tooth development. May see swollen joints.
    • Adverse effects: renal calculi, GI irritation & diarrhea at high doses
    • Beneficial drug interaction: increases iron absorption. I recommend patients take orange juice (or Vitamin-C) with their ferrous sulfate to help double the absorption of the iron.
    May help decrease gout flares, if taken chronically. Ascorbic acid is an antioxidant which binds up free radicals. Ongoing research is examining whether vitamin C, by limiting the damaging effects of free radicals through its antioxidant activity, might help prevent or delay the development of certain cancers, cardiovascular disease, and other diseases in which oxidative stress plays a causal role.
    Adequate intake levels for Vitamin-C:
    • Men age 19 and older: 90 mg/day
    • Women age 19 year and older: 75 mg/day
    • Smokers (or if exposed to second hand smoke): add 35mg
    Vitamin-C and the common cold: In the general population, use of prophylactic vitamin C modestly reduced cold duration by 8% in adults and 14% in children. When taken after the onset of cold symptoms, vitamin C did not affect cold duration or symptom severity. Best to take Vitamin-C long term, as its benefits at onset of cold are minimal. (source nih.gov)

    Excess supplementation of Vitamin-C: Approximately 70%–90% of vitamin C is absorbed at moderate intakes of 30–180 mg/day. However, at doses above 1 g/day, absorption is less than 50%. Absorbed, unmetabolized Vitamin-C is excreted in the urine. Taking excessive doses isn’t more beneficial and may cause adverse effects. The most common complaints are diarrhea, nausea, abdominal cramps, and other gastrointestinal disturbances due to the osmotic effect of unabsorbed vitamin C in the gastrointestinal tract. Excess supplementation is not recommended in any patients with a predisposition to form oxalate stones in the kidney, especially men.

    Linus Pauling, winner of two Nobel Prizes one for Chemistry and for Peace was the biggest advocate for excess Vitamin C supplementation. In 1970 he published a book "Vitamin-C and the Common Cold", where advocated taking 3 grams of ascorbic acid per day. He also wrote a book "How to Live Longer and Feel Better." which also advocated mega doses of Vitamin-C. He indeed generated a lot of controversy within the medical community as advocating Vitamin C to prevent the cold and flu.

    As we are gearing up for cold and flu season my advice to my patients is to wash hands frequently, get your flu shot, get plenty of rest and of course ...avoid those humans!

    Have a Happy and Healthy 2019!!!

    Have a great day on the bench!!

    December 2018

    I see myself recommending this more than any other supplement--Vitamin B-12 (cyanocobalamin)

    Vitamin-B12 (cyanocobalamin)

    Source of B12:
    muscle meats, liver & dairy products. Not found in vegetables. Vegetarians are at risk.
    • Function: involved in cell division, and recycling of folate. Folate deficiency is observed as a feature of B12 deficiency. Symptoms of deficiency are reflected in organ systems with rapidly duplicating cells. Vital for cell growth and mitosis. This includes the hematopoietic system, gastrointestinal tract and neurological systems. Vitamin B12 is required for proper red blood cell formation, neurological function, and DNA synthesis
    • Deficiency:
      • Pernicious anemia which is a megaloblastic anemia.
      • Untreated Vitamin B12 deficiency may cause neuropathy.
      • Like folic acid Vitamin B-12 is involved in homocysteine metabolism, which high levels are implicated in myocardial infarctions. The American Heart Association has concluded that the available evidence is inadequate to support a role for B12 and other B vitamins in reducing cardiovascular risk
    • Remember –large doses of folic acid will correct the hematological symptoms but will allow neurological damage to progress.
    • Vitamin B12 is bound to protein in meats and dairy products and is released by the activity of hydrochloric acid and gastric protease (an enzyme that breaks down protein) in the stomach. When synthetic vitamin B12 is added to fortified foods and dietary supplements, it is already in free form and, thus, does not require this separation step. Free vitamin B12 then combines with intrinsic factor, a glycoprotein secreted by the stomach’s parietal cells, and the resulting complex undergoes absorption within the distal ileum. If there is insufficient intrinsic factor, a small amount is absorbed through passive diffusion.
    • Decreased production of intrinsic factor: due to pernicious anemia, gastrectomy or bariatric surgery.
    Causes of Vitamin B12 deficiency
    • Dietary deficiency of Vitamin B-12 is rare. Noticeable symptoms of a vitamin B12 deficiency can take years to develop. Irritability, weakness, numbness, anemia, loss of appetite, headache, personality changes, and confusion are some of the signs and symptoms associated with very low levels of vitamin B12. True vegans need to supplement B12 however fortified breakfast cereals are a readily available source of vitamin B12 with high bioavailability.
    • Many patients have trouble absorbing B12 from food due to reduced gastric acidity from Proton Pump Inhibitors (PPIs) (Prilosec, Nexium and others) or H2RA’s (Zantac, Pepcid, and others) or lack of intrinsic factor. Remember the Vitamin B-12 injection shortage? Oral supplements can be used since about 1% of oral supplements will be passively absorbed, without gastric acid or intrinsic factor.
    • Metformin long term will deplete vitamin B12 levels. The challenge becomes that Vitamin B12 deficiency may look like diabetic peripheral neuropathy, with numbness and tingling in the feet and hands.
    **Note: biological half-life of B12 is 1 year, therefore more than 2 years must elapse after a complete cessation of B12 intake before clinical manifestations of deficiency are apparent. Noticeable symptoms of a vitamin B12 deficiency can take years to develop. Irritability, weakness, numbness, anemia, loss of appetite, headache, personality changes, and confusion are some of the signs and symptoms associated with very low levels of vitamin B12.

    ORAL VITAMIN B12 standard dosing
    • Begin with 1000mcg per day. (because of poor absorption, about 5mcg/dose is absorbed)
    • Tablets, lozenges or sublingual gels are frequently marketed as having superior bioavailability, although evidence suggests no difference in efficacy between oral and sublingual forms
    INJECTABLE VITAMIN B12 standard dosing
    • Cyanocobalamin is commonly available as 1000mcg /ml injections
    • Start with 1000mcg IM every day for 1 week. Then 1000mcg IM weekly for 4 weeks, then 1000mcg IM monthly for prevention.
    • Recommend injectable B12 for patients with more severe deficiency or those who may not absorb it due to diarrhea, vomiting, or bowel resection.
    • Vitamin B12 injections are also recommended for patients with GI- bypass surgery (for weight loss).
    • Vitamin B12 depletion is also implicated in patients with tinnitus (ringing in the ears); supplementation might be of benefit. Poor vitamin B-12 and folate status may be associated with age-related auditory dysfunction.
    Anyone taking any acid suppressing drugs, metformin or any stomach surgery are excellent candidates for vitamin B12 therapy. When I look at the bottles of 1000 of metformin, omeprazole, ranitidine and pantoprazole, I can't help wonder how much more Vitamin B12 deficiency is undiagnosed. The challenge with Vitamin B12 is due to its storage in the liver and depletion takes a while to manifest itself.

    I have reversed at least 6 patients “neuropathy” by recommending Vitamin B12 1,000mcg per day. What they really had was a B12 deficiency, and not neuropathy. Give it that some thought especially with those Type-2 diabetics who are complaining of neuropathy, especially if their HbA1c is in the acceptable range.

    Have a great day on the bench!!

    The most important B vitamin... just ask GrandDad!

    Folic Acid---Vitamin B-9

    Dietary sources: Folate is found naturally in a wide variety of foods, such dark green leafy vegetables, fruits and fruit juices, nuts, beans, peas, dairy products, poultry and meat, eggs, seafood, and grains. Spinach, liver, yeast, asparagus, and Brussels sprouts are among the foods with the highest levels of folate. By FDA requirement, manufacturers add folic acid to enriched breads, cereals, flours, corn meals, pastas, rice, and other grain products, since 1998. This accounts for 100-180mcg per day.

    Why we need it: Folic acid is required for nucleoprotein synthesis and maintenance of normal RBC formation. Stimulates the production of red & white blood cells and platelets in certain megaloblastic anemias. Conversion to tetrahydrololate (the active form) in the gut is Vitamin B12 dependent. Oral synthetic folic acid however is completely absorbed following administration even in the presence of malabsorption syndromes.

    Indications for use: megaloblastic anemia due to deficiency of folic acid.

    Warnings: Pernicious anemia: if folic acid is given in doses over 0.lmg daily, it may obscure pernicious anemia in that hematologic remission can occur while the neurological manifestations may continue to progress. Severe nervous system damage can occur before the correct diagnosis is made.

    Pregnancy: decreased incidence of Spina bifida and anencephaly. Because of its role in the synthesis of DNA and other critical cell components, folate is especially important during phases of rapid cell growth. Supplement 400-800mcg before pregnancy occurs, since the neural tube closes between day 21 and 28 after conception. If high risk for spina bifida, may use up to 4mg (4000mcg).

    All women of child bearing capability should be taking supplemental folic acid of at least 400mcg. Since 1998, when the mandatory folic acid fortification program took effect in the United States, spinal bifida and anencephaly rates have declined by 25% to 30%. Keep in mind that half of pregnancies in the United States are unplanned, adequate folate status is especially important even before conception (planned or unplanned) occurs.

    Alcoholism: People with alcohol dependence frequently have poor-quality diets that contain insufficient amounts of folate.

    Cardiovascular: Folic acid (and vitamin B12) supplements lower homocysteine levels. However, these supplements do not actually decrease the risk of cardiovascular disease, although they appear to provide protection from stroke. Lowering homocysteine levels didn’t provide protection from myocardial infarction but did reduce risk of stroke by 25%. The dose was 2.5mg per day for a total of 5 years.

    Dementia: folic acid supplementation showed no benefit for prevention of Alzheimer’s.

    DRUGS that LOWER folic acid
    • Seizure medications: CYP450 inducers (phenytoin, phenobarbital, carbamazepine)
    • Oral contraceptives
    • Proton pump inhibitors (PPI’s) such as omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium) and others, by blocking acid formation reduce folic acid absorption.
    • Histamine-2 Receptor Antagonists (H2RA such as ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) decrease acid release and lower absorption of folic acid.
    • Methotrexate (for Rheumatoid Arthritis)
    • Trimethoprim
    • Sulfasalazine (Azulfidine®) DMARD and ulcerative colitis- by inhibiting the intestinal absorption of folate
    Since we all dispense birth control pills, have many females of child bearing age, and those taken acid suppressing drugs like PPI’s and H2RA’s this is an amazing opportunity to recommend folic acid supplementation. When was your last folic acid recommendation???
    • Folic Acid is available in multivitamins, prenatal vitamins, single entity over the counter 400mcg and 800mcg, and prescription strength 1mg.
    L-methylfolate----“super folic acid”
    • L-methylfolate is the primary biologically active isomer of folate and the primary form of folate in circulation. It is also the form which is transported across membranes into peripheral tissues, particularly across the blood brain barrier, while folic acid does not.
    • USE: distinct nutritional requirements of individuals who have suboptimal L-methylfolate levels in the cerebrospinal fluid, plasma, and/or red blood cells and have major depressive disorder (MDD) especially if patient is on antidepressant therapy. Adjunctive use for treatment of depression and schizophrenia
    • One Deplin® 7.5mg tablet is bioequivalent to taking sixty-six 800 mcg folic acid pills. (53 of the 1mg tablets)
    When I look across the numerous vitamin choices, natural, synthetic, combination senior vitamins, stress vitamins, the list goes on and on. Vitamins are marketed to every age group and both sexes. We have feet upon feet of shelves of vitamins in our pharmacies.

    Lots of opportunities are available in our vitamin aisle, probably none is more important than supplementation with folic acid. That’s the pharmacist and grandfather in me talking!

    Have a great day on the bench! Merry Christmas and a Happy New Year. Be sure to slip a bottle of folic acid in her stocking this Christmas season! ??

    Have a great day on the bench!!

    With lab assay interference, be sure to chart if your patients are taking biotin!

    Let’s cover two less common vitamins, pantothenic acid (Vitamin-B5) and biotin, (Vitamin B-7). Deficiencies of these vitamins are rare, but with long term antibiotic use levels may be affected.

    Pantothenic Acid
    • Use: breakdown of fats and carbohydrates for energy, vitamin B5 (like all B- complex)
    • Deficiency is very rare, but can cause paresthesias (tingling in the feet). Pantothenic acid is synthesized by bacteria in the colon, as well as dietary intake.
    • critical to the manufacture of red blood cells, as well as sex and stress-related hormones (adrenal hormones).
    • Vitamin B5 is also important in maintaining a healthy digestive tract, and it helps the body use other vitamins, particularly B2 or riboflavin
    Drug Interactions:
    AVOID with cholinesterase inhibitors (donepezil, rivastigamine, etc). Pantothenic acid also blocks absorption of tetracyclines.

    Biotin (Also known as Vitamin-H)
    • Recommended intake is 30mcg/day. Deficiency in developed countries is rare. High levels found in liver, cauliflower, salmon, carrots, bananas, cereals, nuts, chocolate and yeast. Also synthesized by intestinal microflora. Biotin deficiency may lead to muscle pain, dermatitis, or glossitis (swelling of the tongue)
    • Excess consumption of raw egg whites lower biotin by binding to avidin, a protein found in egg whites.
    • About half of pregnant women in the United States develop a marginal biotin deficiency, especially in the early weeks of gestation. Supplementation with biotin and folic acid, reduces some teratogenic conditions, including neural tube defects.
    • Smoking may contribute to biotin deficiency
    Biotin uses:
    • functions as a cofactor for four different enzymes that catalyze carboxylation retentions. Helps metabolize carbs, fats and amino acids
    • Hair and nails: although improves the keratin infrastructure (a basic protein that makes up hair, skin, and nails) deficiency is RARE. Evidence is weak for using biotin to strengthen hair and nails. Some supplements contain 5,000mcg of Biotin, which can interfere with lab tests.
    • Deficiency state: hair loss, dry scaly skin, cheilitis, glossitis, dry eyes, loss of appetite, fatigue, insomnia, and depression
    • Excess: slower release of insulin, skin rashes, lower vitamin C and B6 levels and high blood sugar levels.
    Drug interactions: Antibiotics, by destruction of normal flora in the gut, might decrease synthesis of biotin. CYP-450 3A4 INDUCERS (such as phenytoin, carbamazepine, phenobarbital and rifampin) speed up metabolism of biotin, and decrease levels.

    Biotin Interference with Lab Assays:
    • High doses of biotin, such as those found in the Hair, Nails and Skin supplements may interfere with common laboratory immunoassays for other tests, including troponin, digoxin, and progesterone. A falsely low result for troponin, a clinically important biomarker to aid in the diagnosis of heart attacks, was reported to the FDA.
    • Biotin can also interfere with commonly used assays for thyroid-stimulating hormone (TSH) and thyroid hormone (T4), as well as detection of anti-TSH receptor antibodies.
    • If a patient’s lab values don’t match the diagnosis, verify the results with lab personnel and rule out potential biotin interference with assays. Many lab assays do not use biotin-based analyzers.
    • Always “chart” any vitamins or nutraceuticals your patient takes.
    I frequently tell my Physician Assistant Sciences students to write prescriptions for everything a patient takes, especially for the over-the counter products. I always ask in a patient interview what OTC products they take, and when we see potent former prescription products like omeprazole, fluticasone nasal spray, cetirizine and ranitidine therapeutic decisions must based on what the patient is taking.

    If it is not charted, how will a clinician know? Vitamin therapy should always be charted, we know the classic interactions between calcium supplements and tetracycline, ferrous sulfate and levothyroxine, and magnesium and fluoroquinolones. These interactions between the divalent and trivalent cations with these drugs is well documented.

    On November 28, 2017 the FDA handed out a Safety Communication #586505 that warned about the interference of lab assays with biotin based analyzers. There are many well know references that discuss all the lab interferences.

    I printed those assays out and our lab techs at Empower-3 clinic spent the morning diligently combing through all of their testing materials to see if there were any biotin-streptavidin assays. They found none. So, at that clinic we don’t need to be concerned about biotin interference, but other labs might be using that technology. Always best to chart vitamins, especially if they are taking biotin.

    Have a great day on the bench!!

    Getting nauseated from pregnancy? Getting headache from kung pao chichen? Got kidney stones? Vitamin B-6 might be the answer!

    Pyridoxine (B6)

    Sources:
    meat, fish, legume, dry yeast, potatoes and other starchy vegetables and non-citrus fruits. Function: as a coenzyme for a variety of essential reactions in the metabolism of certain amino & fatty acids. Vitamin B6 in coenzyme forms performs a wide variety of functions in the body and is extremely versatile, with involvement in more than 100 enzyme reactions, mostly concerned with protein metabolism

    Deficiency States:
    may lead to anemia, convulsions in infants, cheilosis (cracked lips), seborrhea like skin reactions and neuropathy. As with riboflavin, the deficiency state consists of rather diffuse symptoms, probably no wonder that Casimir Funk didn’t discover this B vitamin. Dialysis patients, and those deficient in other B-vitamins are more likely to express symptoms of Vitamin-B-6 deficiency. Health benefits conferred by ODA: may alleviate PMS symptoms, improves mood, decreases risk of heart disease, and stimulates immune system. Possibly decrease nausea of pregnancy.

    Treatment of Nausea of Pregnancy:
    Remember Bendectin? It was that combination of pyridoxine/doxylamine that was pulled from the market in the early 1980’s. Both drugs are Pregnancy Category-A, but Merrill Dow grew tired of defending claims in court. The same formulation is available as DICLEGIS: a fixed dose combination drug product (Delayed-release tablets containing 10mg doxylamine succinate and 10 mg pyridoxine hydrochloride. Diclegis dosage: Take two tablets daily at bedtime. The dose can be increased to a maximum recommended dose of four tablets daily (one in the morning, one mid-afternoon and two at bedtime) (cost: almost $600.00/ 100 tablets). The American Congress of Obstetrics and Gynecology (ACOG) recommends monotherapy with 10–25 mg of vitamin B6 three or four times a day to treat nausea and vomiting in pregnancy. If the patient’s condition does not improve, ACOG recommends adding doxylamine. Patients can find doxylamine under the brand name of Unisom SLEEPTABS 25mg, and have patients split in half. Make sure they are the SLEEPTABS, and not other Unisom formulations that contain diphenhydramine.

    Supplement B-6 with the following drugs that DEPLETE Vitamin B-6:
    • Isoniazid- to decrease peripheral neuropathy
    • Birth Control pills
    • Long Term corticosteroid use
    • Loop diuretics
    • Phenytoin, carbamazepine
    B-6 and Chinese Restaurant Syndrome:
    Proper metabolism of Monosodium Glutamate (MSG) requires sufficient vitamin B6. Supplementation may eliminate symptoms which often include headache, skin flushing, and sweating.

    Kidney stones:
    Vitamin B6 and magnesium supplementation can prevent calcium oxalate kidney stones in patients predisposed to forming these stones

    Early on in my career, we would dispense LAROBEC, which was a combination vitamin that did not contain Vitamin-B-6 due to the interaction of B-6 with oral Levodopa. It is suggested that pyridoxine accelerates systemic metabolism of levodopa, thereby decreasing availability of the amino acid to pass the blood brain barrier. Pyridoxine reduced the levels of plasma levodopa by two thirds. The combination of levodopa and carbidopa (Sinemet, Rytary) prevents the loss of levodopa effect produced by exogenous pyridoxine, so this interaction is no longer clinically significant.

    When we examine the cost savings of over $600 between Diclegis® versus Vitamin B-6 and Unisom SLEEPTABS, pharmacists and prescribers can really impact the costs of health care. We do it every day behind the counter; expertise in the vitamin aisle can also present opportunities for us as well.

    Have a great day on the bench!!

    November 2018

    Another one of Casimir Funk's vitamins... NIACIN

    Niacin (Vitamin B-3)

    Dietary sources: meat, fish, legumes, whole grains. Grains are supplemented with micronutrients such as thiamin, riboflavin, niacin, iron and folic acid.

    Function: oxidation reduction reactions it is an essential co-enzyme for many dehydrogenases in Krebs cycle. Lipid & protein metabolism.

    Deficiency states are rare, due to the presence in most of the foods we ear. Niacin deficiency causes Pellagra “translation: rough skin”. Primary symptoms involve the 3 D’s of Pellagra: Dermatitis, Diarrhea, Dementia.

    Health benefits conferred by Optimal Daily Allowance (ODA) : decreases cholesterol & triglycerides. Decreases risk of heart disease (?)

    Adverse effects: flushing, GI upset, and may increase blood sugar levels. The “flushing” is similar to a hot flash, and is driven by prostaglandins. This flushing can be blocked by taking an Aspirin 325mg tablet one hour before the dose of niacin. Acetaminophen (Tylenol) does NOT work.

    Supplemental doses: 50mg, 100mg, 250mg & 500 mg (immediate release release)
    • No Flush niacin (inositol hexaniacinate) not as effective for hyperlipidemia
    • At doses over 1 gram per day, Niacin will increase the chances of rhabdomyolisis, if a patient is currently taking a statin. Use only if benefits outweigh the risks
    • OTC-Niacin: The immediate-release niacin formulations are more likely to cause flushing, especially first dose. Long-acting niacin Slo-Niacin (long acting niacin) is more likely to cause liver problems. Don’t recommend it for hyperlipidemia.
    Let’s discuss prescription Niacin extended release:
    • Niaspan® (Rx only) is an extended release prescription product that is used for hyperlipidemia, with minimal risk for liver dysfunction. Has fallen out of favor since September 2014. AIM-HIGH study: was stopped 18 months early because interim analysis showed lack of benefit of simvastatin/niacin vs simvastatin alone.
    Niacin does NOT improve cardiovascular outcomes more than a statin alone when LDL is around 70 mg/dL. Adding niacin to bump up HDL makes number look better, but does not improve outcomes.

    Patient Education for niacin therapy:
    • Cutaneous flushing- may be managed with Aspirin 325mg 1 hour before dose.
    • Take with food or light snack to decrease GI upset.
    • Swallow whole, with cold water.
    • Avoid sudden changes in posture. May cause dizziness.
    • Avoid alcohol and hot drinks during administration.
    • Increase blood glucose monitoring if diabetic.
    • Watch niacin content in multivitamin.
    SAFETY: For every 1000 patients treated for about 4 years with a statin plus niacin ( + aspirin), about 18 more will develop diabetes and 37 more diabetics will have worse glycemic control, compared to patients on a statin alone. Knowing that hyperlipidemia and diabetes go hand-in hand, this hardly seems a good trade-off.

    RECOMMENDATION: Niacin is associated with stomach upset, diarrhea, rash, muscle pain, and flushing with possibly more infections and GI bleeding. If they have low LDL and stable cardiovascular disease recommend stopping the Niacin

    The latest on Niacin: Oral Nicotinamide to Reduce Actinic Cancer (ONTRAC) study showed a form of vitamin B3 (niacinamide) showed a reduction in the risk of skin cancer of 23%. The though is that niacinamide may help repair sun-damaged skin and prevent immune suppression in the skin after sun exposure.
    • Dose is 500mg BID if they have non-melanoma skin cancer. Reduces risk by 1 lesion per year. No proof of efficacy if patient does NOT have skin cancer.
    • Keep recommending proper application of sunscreen and protective clothing.
    “Urban Legend”:
    No scientific evidence indicates that taking niacin can alter a urine drug test result. However, readily accessible information on the Internet lists ingestion of niacin as a way to prevent detection of tetrahydracannabinol (THC), the main psychoactive ingredient of marijuana. High dose niacin, may cause liver toxicity.

    As we journey through the water-soluble vitamins, lets focus on Niacin (Vitamin B-3) which is available both as an extended release prescription product, as well as over the counter in our vitamin aisles. Niacin (B-3) is one of the vitamins discovered by Casimir Funk. In the early 1900’s this condition was common in the southern United States due to diets being heavy in corn-based products. United States Surgeon General Joseph Goldberger observed the link in pellagra and orphanages and mental hospitals. In 1926 he established a diet that supplemented Brewers yeast to correct this deficiency. Pellagra can also occur in populations that are homeless, alcoholic or psychiatric patients who refuse food.

    Here's a word that we don't use in our daily conversation: NIXTAMALIZATION: which is a process the ancient Aztecs and Mayans used when processing corn (maize). By cooking the corn in a lime solution, it would free up the bound niacin in the corn kernel, and allow it to be absorbed. This is how the Central America Indian populations ate a corn based diet, but didn't suffer from pellagra. Over 90% of the niacin in corn is bound up, and is not absorbed unless the corn is nixtamalized.

    Have a great day on the bench!!

    Riboflavin does more than turn your pee neon yellow!

    Vitamin B-2 (Riboflavin)

    Function of riboflavin:
    Function: central component in a number of enzyme systems. Acts as a cofactor for various respiratory flavoproteins.

    Dietary sources: milk and eggs, meats, fish, green vegetables, yeast, and enriched foods such as fortified cereals and breads. Grains have been fortified with B vitamins since the 1950’s. Folic acid was added to the grain fortification program in 1998 to prevent neural tube defects. Because riboflavin is light sensitive, milk is usually commercially sold in an opaque container.

    Deficiency States: Riboflavin deficiency is extremely rare in the United States. In addition to inadequate intake, causes of riboflavin deficiency can include endocrine abnormalities (such as thyroid hormone insufficiency) and some diseases.
    • Cheilosis: (inflamed lips) cracks and sores at corners of the mouth
    • Stomatitis (inflammation of oral mucosa)
    • Ophthalmologic: Corneal Vascularization, amblyopia, dimness of vision without detectable lesions of eye
    • Sebaceous dermatosis
    Potential riboflavin deficiency states:
    • Patients with anorexia nervosa
    • Very rarely, inborn errors in metabolism of riboflavin dependent enzymes
    • Maladaptive syndromes including celiac disease
    • Long term phenobarbital use may speed up oxidation of riboflavin
    • Lactose intolerant patients who avoid dairy products.
    Migraine Prophylaxis:
    Many neurologists will try first line for migraine prophylaxis. A few small studies found evidence of a beneficial effect of riboflavin supplements on migraine headaches in adults and children. In a randomized trial in 55 adults with migraine, 400 mg/day riboflavin reduced the frequency of migraine attacks by two per month compared to placebo. Riboflavin is available over the counter in 100mg tablets.

    Drug interactions/Adverse effects: minimal. Not toxic due to limited GI absorption. This is the vitamin that turns your urine a bright yellow a couple hours after ingestion.

    Riboflavin (Vitamin-B-2) was not one of Casimir Funk's discoveries, probably because of it's non-specific symptoms in a state of deficiency. Although most of our patients get adequate riboflavin intake from their diet, we dispense a fair amount or riboflavin.

    Most of our neurologists will start a patient on riboflavin (200mg-400mg/day) along with magnesium oxide 400mg twice a day. In high doses the magnesium can cause diarrhea. Due to limited gastrointestinal absorption of riboflavin excessive doses rarely cause harm.

    Have a great day on the bench!!

    Thiamine: necessary for select groups of patients.

    Vitamin B-1 (Thiamine) (also spelled “thiamin”)

    Function of Thiamine:
    Function: precursor for thiamine pyrophosphate, which is a coenzyme required for carbohydrate oxidation. Thiamine plays a role in nerve conduction.

    Deficiency States:
    Also associated with malabsorption, dialysis, and protein-calorie under nutrition. In addition to insufficient intakes of thiamine from the diet, the causes of thiamine deficiency include lower absorption or higher excretion rates than normal due, for example, to certain conditions (such as alcohol dependence or HIV/AIDS) or use of some medications
    • Dry beriberi: nervous system deficiency resulting in a degenerating neuropathy characterized by neuritis, paralysis, and atrophy of muscle. Some patients develop “Wrist drop” and marked wasting of lower extremities. Accompanied by low calorie intake and inactivity. Heavy alcohol intake may cause Wernicke’ encephalopathy & Korsakoff’s psychosis.
    • Wet beriberi: involves cardiovascular system, resulting in edema, partly due to myocardial insufficiency, palpitations, tachycardia, and abnormal EKG. Accompanied by severe physical exertion, and high carbohydrate intake. Has marked peripheral vasodilation.
    Alcoholics:
    Most thiamine deficiencies in the US are due to alcoholism. Chronic alcohol use disorders appear to be the most common cause of thiamine deficiency. Up to 80% of people with chronic alcoholism develop thiamine deficiency because ethanol reduces gastrointestinal absorption of thiamine, thiamine stores in the liver, and thiamine phosphorylation.

    People with alcoholism tend to have poor nutritional intake and therefore inadequate intakes of essential nutrients, including thiamine. Wernicke-Korsakoff syndrome is one of the most severe neuropsychiatric sequelae of alcohol abuse. The “triad of Wernicke” symptoms are: encephalopathy, oculomotor dysfunction and gait ataxia. All patients with alcohol abuse should be supplemented with thiamine.

    Other patient groups prone to thiamine deficiency:
    • Patients with HIV/AIDS
    • People with Type-1 and Type-2 diabetes have 75% less thiamine levels (increase renal clearance)
    • People with gastric bypass surgery
    • Furosemide (Lasix®) increases the clearance of thiamine from the kidneys leading to deficiency.
    • Other intake deficiencies: dieting, starvation hyperemesis of pregnancy
    How much Thiamine should I recommend?
    Dosing of Thiamine (Vitamin B-1):
    • Dietary requirements for thiamine are only 1 to 2 mg daily, absorption and utilization of thiamine are incomplete, and some patients have genetically determined requirements for much larger dose. Most over the counter once daily vitamins contain 1.5 mg of thiamine.
    • Most patients are started on IV thiamine in the hospital.
    • After discharge daily oral administration of 100 mg of thiamine (Vitamin B-1), is recommended until the patient is no longer at risk.


    Thiamine is the first vitamin we will study that Casimir Funk discovered. Funk experimented with extracts made from the dark outer coating of rice that was removed during polishing. He found that there was a substance within that coating that cured beriberi.

    He experimented with pigeons by feeding them polished rice (rice without the hulls). The pigeons got sick and showed signs of beri-beri. When Funk fed them an extract from the rice hulls, he reversed the beri-beri. Knowing that the pigeons were given adequate protein he knew it was not a protein deficiency. In 1936 Dr Funk was able to elucidate the structure of thiamine.

    Three more of Funk's vitamins left to study!

    Have a great day on the bench!!

    Out in the vitamin aisle are a LOT of questions, and our patients are counting on our expertise!

    Last week we covered the regulation of vitamins, this week as we continue “Vitamin Boot camp” we will do an overview of these amazing compounds that sit out front on the shelves of our stores. The first question we will answer is “what does a vitamin do?” Vitamins in general work in the body by 3 different mechanisms:

    Who takes them:
    1. Coenzymes: Most water soluble vitamins are co¬enzymes. Remember in biology we learned that an enzyme is a catalyst for biochemical reactions. Co-enzymes are non-protein compounds that are necessary for the functioning of an enzyme.
    2. Antioxidants (Vitamin A, C & E)- are enzymes or other organic substances, that are capable of counteracting the damaging effects of oxidation in animal tissue. They protect tissues from damage by “free radicals”
    3. Hormones (Vitamin A, D, K are hormones) A hormone by definition is internally secreted compound, that affect the functions of specifically receptive organs or tissues when transported to them by the body fluids.
    The next question becomes; how much should I recommend for a patient?
    1. RDA: (Recommended Daily Allowance) is the level of intake of essential nutrients that are considered adequate to meet the known nutritional needs of practically all healthy patients.
    2. The DRI (Dietary Reference Intake) also include other reference values such as the Estimated Average Requirement (EAR) , and Adequate Intake (AI). The RDA, EAR, and AI all define nutritional intake adequacy. These are all for healthy individuals.
    3. The Dietary Reference Intakes (DRI) also includes the tolerable upper intake level of vitamins (UL). The UL is defined as the highest level of intake of a nutrient that will not pose risk of adverse health effects to most individuals in the general population.
    Vitamin deficiencies… not so much in America, in the USA will see syndromes of vitamin excess rather than deficiency, especially with vitamins A, D, B-6. Vitamin deficiency is usually insidious in nature, with rather non-specific symptoms. Therefore, a physical exam is rarely helpful in diagnosis. Most characteristic physical findings are seen late in the course of the syndrome. For example, swelling of the tongue (glossitis) and dry scaling and cracking of the lips (cheilosis) are seen with deficiencies in many of the “B” vitamins. These abnormalities suggest a nutritional deficiency, but NOT for a specific nutrient.

    The following chart is the MDR and dietary sources for the vitamins.

    VITAMIN MDR-adults Dietary Sources
    Thiamine (vitamin B1) 1.2mg/day Peas, pork, legumes, whole grains
    Riboflavin (vitamin B2) 1.1-1.3mg/day Liver, eggs, dark greens, whole grains
    Niacin (vitamin B3) 14-16mg/day Liver, fish, poultry, meat, whole grains
    Pantothenic acid (vitamin B5) 5mg/day liver, kidney, meats, egg yolk, whole grains, and legumes.
    Pyridoxine (vitamin B6) 1.3mg/day Pork, meats, whole grains, greens.
    Biotin (vitamin B7) 30mg/day liver, kidney, egg yolk, milk, most fresh vegetables, grains
    Folic acid (vitamin B9) 400mcg/day Liver, meats, fish, whole grains, legumes citrus
    Cobalamin (vitamin B12) 2.4mcg/day meats, liver, kidney, fish, eggs, milk and milk products, oysters, shellfish
    Ascorbic acid (vitamin C) 75-90mg/day Plant foods; citrus is highest
    Vitamin-A 3000iu (men)
    2300iu (women)
    fish liver oils, egg yolks, green leafy & yellow vegetables
    Vitamin-D 600iu fish liver oils, egg yolk, fortified milk, synthesized in skin exposed to UV light
    Vitamin-E 22.5iu Vegetable oils, wheat germ, leafy vegetables, egg yolk, margarine, legumes
    Vitamin K 120mcg leafy vegetables, vegetable oils, liver, & synthesis by intestinal flora


    Casimir Funk (1884-1967), a Polish biochemist who is credited with formulating the concept of vital amines, which today we call “vitamins”, and matching them to their deficiency disorders. In 1912 Dr. Funk wrote a book postulating that the diseases of beriberi, scurvy, pellagra, and rickets could be prevented with “vitamines”. He realized that poor nutrition, specifically white rice, lead to disease states which could be manage with appropriate nutrition, such as brown rice.

    He is considered the Godfather of the vitamin movement. We have sections in our drug stores that are there due to the efforts of this little recognized researcher, who never received the Nobel prize. Dr Funk elucidated the causes, and therefore the management of four disease states, and was never appropriately honored for his efforts.

    Have a great day on the bench!!

    Hey doc? Which one of these vitamins should I take??

    Vitamins--does everyone need them?

    Who takes them:
    • More than one-half of Americans take multiple vitamins either single entity or multivitamins
    • 70% of adults over the age of 65 report taking a vitamin or mineral supplement.
    • Total spent is $12 billion per year.
    • About one in four young children takes an MVM.
    • Adolescents are least likely to take them.
    Who regulates them:
    The FDA loosely regulates dietary supplements, under the Dietary Supplement Health and Education Act of 1994 (DSHEA ’94).
    In June 2007, FDA established dietary supplement "current Good Manufacturing Practice" (cGMP) regulations requiring that manufacturers evaluate their products through testing identity, purity, strength, and composition. Dietary supplementary are: vitamins, minerals, other botanicals, amino acids, enzymes, organ tissues, glandular, and metabolites. These dietary supplements fall under the category of "foods" and not "drugs".

    They do NOT need FDA approval before marketing nor do they need to be registered with the FDA before being produced or sold. The manufacturer does not have to prove that the supplement is effective, unlike for drugs. The manufacturer can say that the product addresses a nutrient deficiency, supports health, or reduces the risk of developing a health problem, if that is true. If the manufacturer does make a claim, it must be followed by the statement “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.”

    FDA regulates the label content and health claims. Claims that can be used on food and dietary supplement labels fall into three categories: health claims, nutrient content claims, and structure/function claims. Here are some examples of permissible supplement claims:
    • “Supports a healthy immune system”
    • “Builds strong bones”
    • “Maintains bowel regularity”
    • “Decreases blood platelet stickiness”
    • “A good source of Vitamin-C”
    Notice no disease state is mentioned, such as “prevents osteoporosis”, or “prevents stroke”. Burden of proof is on the FDA to prove that a supplement is Unsafe, before that product can be removed from the market. It is the responsibility of the manufacturer to ensure product safety and product efficacy.

    Reporting by patients and manufacturers:
    Starting December 22, 2007, any serious adverse events reported to a dietary supplement manufacturer must be reported to FDA within 15 days of the manufacturer receiving the adverse event report. Adverse drug events can also be reported directly to the FDA via the MedWatch program. https://www.fda.gov/Safety/MedWatch/default.htm

    For the next couple of months, we will journey through our vitamin aisle. We are expected to have a high level of expertise with vitamins. Unfortunately, our level of training with respect to over the counter therapies taught in pharmacy school is minimal. I’ll be providing you with the therapeutic uses of each vitamins, as well as uses for vitamins as therapeutic agents. We will also focus on vitamin depletion caused by the prescription products we commonly dispense. I’m not a “vitamin nut” I believe appropriately recommended vitamins are of great value to our patients. Next week we can discuss “at risk” populations and therapeutic dosing of vitamins and supplements.

    Good resource to read:
    https://www.hopkinsmedicine.org/health/healthy_aging/healthy_body/is-there-really-any-benefit-to-multivitamins

    Have a great day on the bench!!

    October 2018

    SERMS- very specific targets in the woman's body.

    As we move through the month of October, we are discussing women’s health issues. The first three units we discussed breast cancer. Last week we discussed raloxifene and tamoxifen, which are SERMS (selective estrogen receptor modifiers). Estrogen receptors are present throughout the body. SERMs act as agonists or antagonists on various estrogen tissue receptors, including breast, bone, endometrium, hypothalamus and coagulation system. We will discuss in detail the three other SERMS, not associated with breast cancer prevention.
    • Nolvadex® (tamoxifen): (BREAST CANCER PREVENTION)is considered first line therapy of estrogen receptor positive breast cancer. Both for pre-menopausal and post-menopausal women. (No effect on vaginal tissue)
    • Evista® (raloxifene): (BREAST CANCER PREVENTION/OSTEOPOROSIS) is for reduction in risk of invasive breast cancer in postmenopausal women with osteoporosis OR if at high risk for invasive breast cancer. (No effect on vaginal tissue)
    Osphena (ospemifene) (DYSPAREUNIA) 60mg tablets
    Dose: take (1) tablet daily
    Mechanism: estrogen agonist on vaginal tissue. Minimal effect in uterine tissue and serves as an estrogen antagonist in breast tissue. Ospemifene may have a positive effect on bone tissue. Up to 45% of postmenopausal women can experience vulvovaginal atrophy due to estrogen loss.
    Indications: approved by the FDA to treat moderate to severe dyspareunia (painful intercourse), due to estrogen deficiency of menopause.
    Watch for: May make hot flashes worse. Scan for CYP4503A4 interactions
    NOTES: expect about 45% of postmenopausal women to experience vulvovaginal atrophy (VVA) due to declining estrogen levels. Symptoms of VVA may include dryness, itching, irritation, and dyspareunia. Diagnosis of VVA is based on symptoms as well as various laboratory findings. Vaginal lubrication decreases and vaginal pH increases. One of the best indicators of VVA is a pH of 5 or higher. On a cellular level, increases in the number of parabasal cells are seen as well as a decrease in the superficial cell layer.
    USE: being promoted for its estrogenic effect on vaginal symptoms.

    Duavee®: (conjugated estrogens/ bazedoxifene) (MENOPAUSAL SYMPTOMS)
    Use: moderate to severe hot flashes and preventing osteoporosis. Estrogen is used for menopausal symptoms & osteoporosis. Bazedoxifene (SERM) is added to inhibit estrogen's endometrial effects (instead a progestin). Must have intact uterus, because SERM reduces risk of endometrial hyperplasia.
    BEST USE: women who want to use estrogen for menopausal symptoms but need an alternative to a progestin.

    Clomifene (Clomid):
    (FERTILITY) is a nonsteroidal estrogen receptor modulator (SERM). It inhibits the negative feedback response on the hypothalamus by bonding to estrogen receptors. This causes an increase in release of FSH (follicle stimulating hormone) and LH (luteinizing hormone). This promotes follicular growth and maturation. Enhancement of the natural hypothalmic-pituitary-ovarian axis is the primary mechanism of action.
    Dosage: 50mg daily beginning day 5 of the cycle.

    The first SERM available was (Clomid (Clomifene) which was first approved in 1967. Clomid was the first ever drug to "enhance" fertility. It increases the odds of pregnancy from 1.3% to 5.5% per cycle.

    Nolvadex (tamoxifen) was released in 1977 for prevention of breast cancer. It wasn't until 1997 when another SERM became available, Evista (Raloxifene) for osteoporosis. Both Duavee (bazedoxifene) and Osphena (ospemifene) were released in 2013.

    Have a great day on the bench!!

    Breast Cancer Prevention medications available in the community pharmacy

    For the month of October our focus is on breast cancer its diagnosis and prevention. This week we discuss our role as community pharmacists in the treatment with drug therapy. Here is a brief review of the two main classes of drug therapy, along with counseling points for those therapies.

    Role of Anti-Estrogens: (SELECTIVE ESTROGEN RECEPTOR MODULATORS)

    For breast cancer that is estrogen receptor positive, ANTI-Estrogens are the mainstay of treatment. Antiestrogens bind to estrogen receptors and prevent receptor mediated gene transcription, and are therefore used to block the effect of estrogen on the end target. 70-75% of Breast cancer tumors are estrogen receptor positive.

    Nolvadex® (tamoxifen): available as tablets 10 & 20mg is an estrogen antagonist, structurally related to the synthetic estrogen diethylstilbestrol (DES) and is considered first line therapy of estrogen receptor positive breast cancer. Tamoxifen is the only “anti-estrogen” that can be used for BOTH pre-menopausal and post-menopausal women.

    Side effects include: hot flashes, nausea, skin rash, vaginal bleeding, hypercalcemia, increased bone pain if tumor has metastasized to the bone. Thrombotic events (PE and DVT) cataract formation, uterine cancer.

    Dosage: Breast cancer patients: 20-40mg daily (divide dose if more than 20mg) High risk women: use 20mg daily for 5 years.

    Evista® (raloxifene) Available as tablets: 60mg
    Dosage: 60mg once daily
    Indications: Reduction in risk of invasive breast cancer in postmenopausal women with Osteoporosis OR if at high risk for invasive breast cancer.

    Adverse effects: Venous thromboembolic potential. (PE, DVT, stroke). May cause hot flashes, muscle aches & pains.

    Mechanism: binds to estrogen receptors. Binding results in activating some and blocking other pathways. Effects on bone similar to estrogen therapy. However, it acts as an antagonist on receptors in the breast and endometrium.

    Efficacy: seems to be less effective than Tamoxifen for breast cancer treatment.

    ROLE of Aromatase Inhibitors for prevention of Breast Cancer
    In postmenopausal women and women whose ovaries have been removed, the main source of estrogen is derived from the peripheral conversion of androstenedione produced by the adrenal gland into the female hormones estrone and estradiol. This conversion requires the aromatase enzyme, which also catalyzes the conversion of androgens to estrogens in the ovary of pre-menopausal women and in extra-glandular tissue, including the breast itself, in post-menopausal women. Aromatase inhibitors effectively reduce the levels of circulating estrogens. Indicated only for post-menopausal women.

    Side effects: hot flashes, infrequent vaginal bleeding, do not predispose to endometrial cancer. All these drugs are available generically and are rather inexpensive therapies.
    • Arimidex® (anastrozole) available as 1mg tablets dosed once daily.
    • Femara® (letrozole) available as 2.5mg tables dosed once daily.
    • Aromasin® (exemestane) available as 25mg tablets dosed once daily after a meal
    Counseling points for breast cancer during drug treament:
    • Drug therapy is used following “adjuvant therapy” which consists of surgery & radiation to “clean up” cancer cells that may have spread beyond breast
    • Goal of hormonal therapy is block estrogen’s growth promoting effect. Continue anti-estrogen therapy for 5 years—patient adherence is paramount!
    • Tamoxifen and aromatase inhibitors are first line. Remember that only tamoxifen can be used in pre-menopausal women.
    • Hot flashes are most common side effect.
    Aromatase inhibitors cause less hot flashes that Tamoxifen. SSRI/SNRI’s may be of benefit: Effexor® (venlafaxine) & Celexa® (citalopram) are best choices.

    Avoid Prozac® (fluoxetine), Cymbalta® (duloxetine), Wellbutrin® (bupropion) & especially Paxil® (paroxetine) because they decrease formation of active metabolite of tamoxifen, decreasing efficacy of tamoxifen.
    • Teach patients symptoms of venous thromboembolism (tamoxifen side effect):
      • Shortness of breath
      • Chest pains worsen with breathing or coughing.
      • Coughing up blood
      • Pain, tenderness, swelling, warmth, redness in one leg
    • Aromatase inhibitors may cause significant bone loss. Osteoporosis and fractures have been reported. Treat accordingly- drugs like Alendronate (Fosamax®) are a good choice.
    We pharmacists should always be preaching adherence for all medications, be it for an antibiotic for a urinary tract infection, or for Type-2 diabetes medications.Adherence for these drugs for the prevention of breast cancer are critical indeed. According to a study women on tamoxifen with an adherence rate of less than 80% (determined by prescription records) had an increased risk of mortality at a median duration of 2.4 years. Adherence makes a huge difference for the breast cancer prevention with tamoxifen or the aromatase inhibitors.

    Missing just 6 doses a month can be cause a significant rise in mortality. Recommend any of the adherence apps on a patients phone, set an alarm, and recommend using a plastic pill box to improve adherence. I also recommend enrolling any of these breast cancer patients in your pharmacy's medication synchronization program.

    Have a great day on the bench!!

    More than wearing a pink ribbon... share this information with your patients (guys too!)

    Prevention--Mammograms save lives The newest recommendations from the American Cancer Society recommends all women should begin having yearly mammograms at age 45 and can change to having mammograms every other year beginning at age 55. Women should talk to their health professional if they have any symptoms or changes in their breasts, or if breast cancer runs in their family. Some patients as young as 40 years of age can begin annual mammograms.

    Breast Self-Exams- a smaller role in decection
    Breast self-exam (BSE) is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their health professional right away. Benefits of breast exam is minimal whether performed by a health care provider or the patient. Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly after their period) which involves a systematic step-by-step approach to examining the look and feel of one’s breasts. Other women are more comfortable simply feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam. Sometimes, women are so concerned about “doing it right” that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The goal, with or without BSE, is to report any breast changes to a doctor or nurse right away. Bottom line: The American Cancer Society does not recommend clinical breast examination (CBE) for breast cancer screening among average-risk women at any age. (source JAMA)

    Common Types of Breast Cancer
    Ductal carcinoma. The most common kind of breast cancer. It begins in the cells that line the milk ducts in the breast, also called the lining of the breast ducts. Ductal carcinoma in situ (DCIS). The abnormal cancer cells are only in the lining of the milk ducts and have not spread to other tissues in the breast. Has a higher risk of subsequent invasive cancer. Invasive ductal carcinoma. The abnormal cancer cells break through the ducts and spread into other parts of the breast tissue. Invasive cancer cells can also spread to other parts of the body. Lobular carcinoma. In this kind of breast cancer, the cancer cells begin in the lobes, or lobules, of the breast. Lobules are the glands that make milk. Lobular carcinoma in situ (LCIS). The cancer cells are found only in the breast lobules. Lobular carcinoma in situ, or LCIS, does not spread to other tissues. Invasive lobular carcinoma. Cancer cells spread from the lobules to the breast tissues that are close by. These invasive cancer cells can also spread to other parts of the body

    Reducing Risk of Breast Cancer
    • Keep a healthy weight and exercise regularly (at least four hours a week).
    • Get enough sleep.
    • Don’t drink alcohol, or limit alcoholic drinks to no more than one per day.
    • Avoid exposure to chemicals that are carcinogenic
    • Reduce exposure to radiation during medical tests like mammograms, X-rays, CT scans, and PET scans.
    • Discuss with prescriber about hormone replacement therapy or oral contraceptives and the risks associated with therapy. Remember for estrogen replacement… lowest possible dose for shortest period of time.
    • Breastfeeding may be protective
    What about the guys? (source: American Cancer Society)
    • About 2,550 new cases of invasive breast cancer will be diagnosed in men in 2018
    • Treatment: mastectomy is indicated but follow-up with radiation or chemotherapy is not as definitive as it is for women. Most breast cancer in men is treated the same as in women.
    • About 480 men will die from breast cancer in 2018
    • Overall odds of a male getting breast cancer is 1:833
    • Overall odds of a woman getting breast cancer are 1:8
    • White males are 1/100th as likely to die of breast cancer compared to white women, while black men are 1/70th as likely as black women to die from breast cancer.
    Breast cancer treatment including surgery, radiation and chemotherapy have indeed become more specialized in the 37 years I've been practicing. At one time it was the realm of the general surgeon, while today there are surgeons who specialize in breast cancer surgery and reconstruction.

    Even the rural hospital in the small town of Tyrone where I live has its own breast cancer treatment center, with outstanding surgeons and radiologists. There are plenty of resources for our female (and male!) population in detection, prevention and treatment of breast cancers. It is our job as health care professionals to see that our patients are encouraged to use these available resources.

    Have a great day on the bench!!

    We need to do more for our female patients than just wear a pink ribbon!

    Breast Cancer Basics

    After skin cancer, breast cancer is most common cancer in women, causing more deaths than any malignancy other than lung cancer. The lifetime risk of developing breast cancer in women is 1 in 8 (13%). There was a 7% drop in breast cancer incidence in 2003, probably due to drop in Hormone Replacement Therapy due to publication of the Women’s Health Initiative (WHI) study in 2002. This study established that HRT increases risk of breast cancer.

    Breast cancer warning signs and symptoms
    • Breast lumps: Single painless mass that feels solid. Breast pain is not usually a symptom of malignancy, but it can occur.
    • Skin changes: areas of thickening, swelling, depression, dimpling, redness, irritation or unusual appearance on the breast or underarm.
    • Veins on surface of one breast have become more prominent.
    • Nipple discharge: bloody or watery from one nipple only is cause for most concern
    • Nipple changes: turning inward, rash, changes in nipple skin texture.
    • Breast cancer develops in the breast tissue, usually in the milk ducts (ductal carcinoma) or glands (lobular carcinoma)
    Factors that increase risk for breast cancer Risk factors for a 2-5 fold increase:
    • Age: 78% of women with invasive breast cancer are 50 or older
    • Inherited genetic mutations: Genes BRCA-1, BRCA-2 have a 60-85% chance of developing breast cancer.
    • Personal history: previous breast biopsy result of atypical hyperplasia increases risk 4 to 5 times
    • Women with breast cancer in one breast have a 3-4 times greater risk of developing a new cancer in the other breast, or the same breast..
    • High dose radiation the chest (Hodgkin’s disease treatment)
    • Family history: 1 first degree relative (mom, sister, and daughter) doubles risk. First degree relatives is 5 times the risk
    Risk Factors for a 1.1 to 2 fold increase
    • Race (white women are more susceptible)
    • Use of estrogen
    Current or recent use of HRT- risk returns to normal in 5 years after stopping hormone replacement.

    Use of oral contraceptives: no increase risk if stopped greater than 10 years ago Prolonged estrogen stimulation
    • Early menstruation (less than age 12)
    • Late menopause (over age 55)
    • Pregnancy: no children, or first pregnancy after age 30.
    • Lifestyle: alcohol consumption: greater than 3 drinks per day.
    • Obesity
    Breast cancer receptors:
    1. Estrogen: About 80% of breast cancers are estrogen receptor positive. Cancers grow in response to estrogen. Known as ER positive.
    2. Progesterone: About 65% of the estrogen receptor positive receptor positive breast cancers are progesterone receptor positive. Cancer grows in response to progesterone. Known as PR positive.
    3. Human epidermal growth factor receptor-2: (HER2) – is a protein which promotes the growth of cancer cells. Is not inherited from a parent. It accounts for about 20% of all breast cancers,and are the most rapid growing and aggressive cancers.
    Any of these three cancers are treatable, with specific therapy directed at the receptor to help destroy the rapid growing cells.

    And now for the really bad news:
    Triple-Negative Breast Cancer
    Between 10% and 20% of breast cancers are known as “triple negative” because they don’t have estrogen and progesterone receptors and don’t express the HER2 protein. Many breast cancers associated with the gene BRCA1 are triple negative.
    • There are currently no “targeted therapies”, so treatment includes surgery either lumpectomy or mastectomy, followed by chemotherapy or radiation. Chemotherapy is considered to be the “backbone” for TNBC therapy.
    • TNBC is more commonly diagnosed in women younger than 40 years compared with hormone-positive breast cancer. (twice the incidence in some studies versus hormone receptor positive)
    • African American women have a higher incidence than non-African American women.
    • Pre-menopausal women have a higher incidence than that of post-menopausal women
    • One study demonstrated that breast feeding women were at a lower risk for TNBC, however this study has not been duplicated.
    • Prognosis is poorer than women with other receptor positive cancers.
    With October being breast cancer awareness month, let's focus on our female patients, and provide them with sound, clinical information concerning breast cancer. Breast cancer awareness should be more than just using those "Breast Cancer Awareness" prescription bags, or wearing a pink ribbon.

    Let's pledge to provide our female patients with good information about breast cancer, and encourage them to get their mammograms. As pharmacists we can also do our part to encourage adherence to the medications prescribed for the treatment of the hormone positive breast cancers.

    Have a great day on the bench!!

    September 2018

    Is it time to get out the DDT? What to do when exposed to bedbug infestation!

    Bedbugs---what to do when they show up!

    Treatment of a bitten patient:
    • Treatment might not be necessary, as the bites usually resolve without any intervention.
    • Oral antihistamines to relieve itching
    • Prednisone, at doses of 40-60mg per day seem to be of little value.
    • Topical corticosteroids seem to be effective Use mild potency such as triamcinolone 0.1% cream on the bites.
    • May have to treat secondary infections.
    Prevention:
    • using a hair dryer on end seams of mattress will “chase” the bed bugs out of hiding for detection.
    • Check out hotel/motel rooms and look for bedbugs or their feces before climbing into bed. Be sure to check out the mattress cords and crevices in box springs.
    • Placement of luggage on a luggage rack or away from the bed or upholstered furniture while traveling. Some sources recommend placing luggage in the bathtub, as bedbugs can’t crawl up that slippery surface.
    • Placement of worn garments in a sealed plastic bag to minimize bedbug attraction to worn clothing.
    • It’s no bargain mattress even if the bedbugs are free! Examine carefully garage sales or resale shops (especially bedding items), for bedbugs or bedbug feces prior to bringing them inside the home
    • Rid Home Lice, Bedbug and Dust mite Spray: contains Permethrin 0.5% - might be of benefit to spray areas that are not directly slept on.
    Eradication of Bedbugs:
    Insecticides and heat treatment are the best options. Combinations of insecticides are generally used to avoid failure due to resistance. Long-lasting residual insecticides may be necessary for heavy infestations. Heat treatment involves use of equipment to heat rooms to a lethal temperature. All stages of bedbugs can be killed at 50°C (122°F) Cold treatment can be successful in the home environment if the freezer is set to 0- degrees F. You must leave the items in the freezer at that temperature for four days

    Your Friendly Exterminator says:
    (January 2011) We are using Pyrethrins; Also using heat—over 120 degrees will kill bedbugs. Bedbugs are attracted to carbon dioxide (CO2). We have CO2 machines that attract bedbugs, and then get trapped in plastic traps. Note: The EPA says Some bed bug populations have become resistant to pyrethrins and pyrethroids

    (August 2018):
    use Alpine WSG (Dinotefuran) to treat. This is a broad spectrum insecticide. The exterminator described a huge problem in Altoona Housing projects. He spends more time in the housing projects combating infestation than in hotels. Hotels deal immediately with the problem, and keep things cleaned up afterward. Such is not the case with the residents in the housing projects. Alpine WSG (dinotefuran) is a neonicotinoids are synthetic forms of nicotine and act on the nicotinic receptors of the nervous system by causing nerves to fire continually until they fail. Because neonicotinoids use this different mechanism of action, bed bugs that are resistant to other pesticides will remain susceptible to the neonicotinoid. (source: EPA)

    Permethrin spray that we use as a mosquito and tick repellent is designed for clothing and gear and lasts up to 6 weeks. We spray our hiking and gardening clothes every 6 weeks to keep the deer ticks off. Repellent should be applied outdoors and before clothing is worn; hang clothing, spray and let dry two hours (four hours in humid conditions).

    We also spray our suit cases with permethrin 0.5% before packing for a trip. Make sure they are closed. Package reads “for clothing and gear” , so it is appropriate to use on our suitcases. Seems like a good idea to keep these critters from hi-jacking a ride back to Tyrone, PA ! That hotel room you just checked into is only as clean as the last guests who left!

    Have a great day on the bench!!

    Wanna sleep tight? Make sure these little guys don't hitch a ride from the hotel to your bedroom! View this email in your browser

    BEDBUG BUG BASICS

    BEDBUGS (Cimex lectularius) are wingless insects about the size of an apple seed that feed on warm blooded animals. Bedbugs are nocturnal and hide during the day. Bedbugs are associated with unsanitary conditions but may be found in the cleanest of homes, hotels, or other buildings and have occurred in all social and economic classes. Infestations most often occur where there is a high turnover of occupants, such as hotels, motels, cruise ships, dormitories, apartment complexes, and shelters.

    The Care and feeding of bedbugs:
    • Bedbugs feed on a blood meal for about 10 minutes, injecting an anticoagulant. Females need a blood meal at least every 14 days to produce eggs. Females lay one to three eggs per day, and up to 500 eggs in a lifetime. Males also need a blood meal every 14 days to mate.
    • Unlike fleas or ticks, they do not live on their food source. They hide near their host, and bite during the night.
    • Adult bedbugs can live without feeding for 2 or 3 months which makes getting rid of them such a challenge. (Not like lice that are dead in 10 days without a human host)
    • Presentation: The bite reaction usually presents as a red bump (wheal) ranging in size from a few millimeters to 1 centimeter and does not usually have a red puncture mark in the middle. The bites can occur in lines or clusters of three or four.
    Where to look:
    Around the bed, they can be found near the piping, seams and tags of the mattress and box spring, and in cracks on the bed frame and headboard. If the room is heavily infested, you may find bed bugs:
    • In the seams of chairs and couches, between cushions, in the folds of curtains.
    • In drawer joints.
    • In electrical receptacles and appliances.
    • Under loose wall paper and wall hangings.
    • At the junction where the wall and the ceiling meet.
    • Even in the head of a screw.
    The role of DDT

    DDT’s history parallels closely the presence of bedbugs. DDT (dichloro-diphenyl-trichloroethane) was developed as the first of the modern synthetic insecticides in the 1940s. Initially used effectively to combat malaria, typhus, and the other insect-borne human diseases among both military and civilian populations. DDT was also effective for insect control in crop and livestock production, institutions, homes, and gardens. DDT was banned in 1972, was considered to be the first victory for the environmentalist movement.

    DDT is still present in the environment
    • will accumulate in fatty tissues, and
    • can travel long distances in the upper atmosphere
    • DDT is one of 12 pesticides recommended by the World Health Organization for indoor residual spray programs.
    Because of DDT use in the 1940’s, bedbugs were virtually eliminated. After the year 2001, they have made a resurgence, as the DDT has “worked out” of the environment.

    Next week we will discuss Treatment and Prevention of Bedbugs.



    I, Peter Kreckel of sound mind and body, bequeath this box of DDT to...

    When my father-in-law passed away back in 2012, I helped my wife Denise and her sisters clean out his garage. The garage was full of "treasures" like jars of nails, nuts, bolts, tools and even a bumper off of a Corvair! I left with the grand prize that I have pictured here, a box of unopened DDT, that back in the day retailed for $1.99 for a one pound box!

    I keep it in my garage, and my wife insists if a bedbug ever finds its way from a hotel into our house, she will be more than prepared to bring it to it's demise! I'm sure it will remain unopened, and when the day comes that Gretchen and her siblings clean out my garage, this family heirloom will move to the next generation!

    Good night, sleep tight and thanks to the DDT in my garage, the bedbugs won't bite!!

    Have a great day on the bench!!

    This should be the last column that leaves you scratching!

    SCABIES

    Caused by the mite: Sarcoptes scabei . Mostly affects the interdigital & popliteal folds, axillary folds, umbilicus & scrotum. Spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Transmitted through direct contact, and frequently sexual contact. Can survive off a human host 24-36 hours under normal conditions of heat and humidity. Increased humidity prolongs survival off the host.

    Clinical presentation:
    • Severe itching and an inability to sleep.
    • Excoriations in the interdigital web spaces, wrists, buttocks, elbows groin & scalp.
    Diagnosis:
    • Look for burrows made by the mite, and skin scrapings. Short irregular mark, 2-3 cm long and the width of a hair.
    • The diagnosis of scabies is confirmed by detecting scabies mites, eggs, or feces with microscopic examination.
    Permethrin 5% (Elimite) DRUG of CHOICE available in 60 gm tubes

    Warnings/Precautions / Adverse Effects
    • Pregnancy category-B
    • Not recommended if nursing.
    • Can be used in children over age 2 months.
    • Caution with asthmatics.
    Patient Education
    • Thoroughly massage cream from the head to the soles of the feet. Rarely do scabies affect the heads of adults. They may infest the infants or geriatrics around the hairline.
    • Remove cream by washing off in bathtub or shower after 8 to 14 hours.
    • One application is generally curative. (30gm is sufficient for 1 adult)
    • Patients may experience itching after treatment, rarely a sign of treatment failure. Living mites after 14 days would indicate that re-treatment is necessary
    Crotamiton lotion 10% and Crotamiton cream 10%
    10% (Eurax®); Crotan® approved by the FDA for treatment of scabies, but due to frequent treatment failures is seldom used.

    Ivermectin (Stromectol®) may be a safe and effective treatment for scabies, although not FDA-approved for scabies. Consider for patients who have failed treatment with or who cannot tolerate FDA-approved topical medications for the treatment of scabies. If used for classic scabies, two doses of oral ivermectin (200µg/kg/dose) should be taken with food, each approximately one to two weeks apart.

    A patient weighing 75kg (165lbs) would take 15,000mcg or 15 mg. Dose would be five tablets as a single dose.
    (SHORTCUT: weight in pounds divided by 33 equals the number of 3mg tablets of ivermectin)

    Might be a good option for nursing homes, where head to toe treatment of each patient is impractical. After successful treatment, patients may continue to itch for several weeks.
    • A steroidal cream like Triamcinolone 0,1% cream will help resolve the dermatitis.
    • Short course of corticosteroids, like prednisone will also decrease itching.
    • Oral antihistamines like diphenhydramine (Benadryl) or hydroxyzine (Atarax) might be of some benefit to relieve itching.
    • If no relief of itching, recheck for reinfestation.
    Worst of the worst: Crusted scabies or “Norwegian scabies” — occurs only in people with a weakened immune system (such as HIV infection, lymphoma, or other conditions). This condition may also affect older adults or those with Down syndrome. Ivermectin or permethrin 5% are used to treat this condition. Lesions appear as large, crusty red patches or bumps on the skin.

    Scabies is another one of those dreaded skin conditions, that after reading this article will leave you scratching. A patient with ordinary scabies may have an average of 12 mites; however, those with crusted scabies (Norwegian scabies) may have thousands of mites. The infestation occurs at all ages, but particularly in children. It is a common public health problem in poor communities and is widespread in many underdeveloped countries.

    It can spend a maximum of only 2 weeks without a human host to live upon and when doing so hides out in clothing, bed linens and sleeping bags. Called the “seven year itch” because it used to wax and wane in about seven year epidemic cycles, the little critters are no longer sticking to that schedule and have become more difficult and resistant to former treatments.

    I love the shortcut for dosing the ivermectin. I can see that being very helpful if you had a large population to dose such as in a nursing home or large family.

    Vince, one of the excellent Physician Assistants I work with at Dr. Gates office, tells me he is a scabies expert because of his time serving in the U.S Army. When we see that scabies thrive in close quarters and can live in sleeping bags without a human host for 14 days, our servicemen are definitely at risk.

    Have a great day on the bench!!

    Those sneaky little head lice are becoming resistant to over-the- counter products!

    Prescription Products for Pediculosis

    OVIDE® (malathion)
    Mechanism: is an organophosphate cholinesterase inhibitor. Widely used as a lawn and garden insecticide. Has been on, and off the market for the past several years. Has “high” Ovicidal activity. This seems to be the “go to” product when concern of resistance to permethrins. Malathion was first registered as an insecticide in 1956. Became prescription product (Ovide®) in 1982.

    Warnings/Precautions /Adverse Effects
    • Flammable!! 78% alcohol. Do not expose to flame or hairdryers or electric curlers.
    • Don’t use if under age 6. May use down to 24 months if resistance is a problem. (AAP) The safety and effectiveness of malathion lotion has not been established by well controlled trials in children less than 6 years old. Malathion is contraindicated in children younger than 2 years of age.
    • Unpleasant odor, due to sulfhydryl groups
    Application Information:
    1. Avoid any open flames.
    2. Apply to dry hair, especially back of head and behind ears.
    3. Wash hands after application.
    4. Allow hair to air dry (no hairdryers!)
    5. After 8-12 hours wash hair with non-medicated shampoo
    6. Reapply in 7-9 days only if required.
    ULESFIA® (benzyl alcohol lotion)

    Mechanism: does not have ovicidal activity. It inhibits lice from closing their respiratory spiracles which allows the product to penetrate lice, causing them to asphyxiate. Can be used on age 6 months and older.

    Application Information: As with the other topical agents, two applications of Ulesfia, separated by at least seven days are necessary to eradicate lice. May be a good choice for parents concerned with “pediculicides” NOTE: because it suffocates the lice (a physical action), less likely to develop resistance to this product. I tell my students it is like an ant becoming resistant to a sledge hammer!

    NATROBA® (spinosad)

    One treatment is usually needed with Natroba ® Repeat in 7 days only if live lice are seen again.

    Mechanism: Spinosad causes neuronal excitation and involuntary muscle contractions in lice. After periods of excitation, the lice become paralyzed and die. Use in patients at least 6 months of age.

    Dosage: Apply to dry hair. Leave on 10 minutes. Rinse thoroughly. Combing not required.

    STROMECTOL (ivermectin) 3mg tablets (usual dose 200mcg/kg)

    Mechanism:
    Ivermectin binds to glutamate chloride channels in nerve and muscle cells of lice. This leads to an increased permeability to chloride ions resulting in paralysis and death. Based on this mechanism, it would appear that ivermectin is not ovicidal.

    Dosage: used for certain parasitic infections (off-label for scabies or lice) use 400mcg/kg. a 15kg child would take about 2 tablets. Repeat dose in 7 days to eradicate any newly hatched lice.

    SKLICE (Ivermectin topical)
    Can be used in patients 6 months of age and older.
    Completely coat hair. Leave on 10 minutes, then rinse well. No combing needed

    Lindane
    old brand name was Kwell®, now only as a generic. Second-line treatment.

    Mechanism: neurotoxic to head lice and their eggs.
    Indications: has fallen into disfavor because of potential toxicities, and its efficacy is LESS than other agents available. 45-70% ovicidal

    Warnings/Precautions /Adverse Effects/Drug Interactions
    • Patient MUST weigh at least 110 pounds.
    • Do not prescribe more than 2 oz. of product
    • Do not retreat.
    • Black box warning: neurological toxicity. Has caused seizures and deaths.
    • Avoid using in infants, children, and elderly. Must weigh over 110lbs.
    • Pregnancy category-C
    • Caution if using with drugs that lower seizure threshold (theophylline, Wellbutrin, quinolones, antidepressants, meperidine, methocarbamol)
    Trimethoprim-sulfamethoxazole —
    Combination therapy with topical permethrin (Nix) and oral trimethoprim-sulfamethoxazole (Bactrim) may be more effective than treatment with permethrin alone. The mechanism of action of trimethoprim-sulfamethoxazole may involve the death of symbiotic bacteria in the louse gut that produce B vitamins necessary for louse survival. This combo is 92% effective compared with only 72% efficacy with permethrin alone. By itself Trimeth/sulfa was shown to be 78% effective. With risks of Stevens-John Syndrome, and allergic reactions it is best to reserve this combo for resistant cases.

    Head Lice Chart

    Brand name Generic Name Minimum treatment age Ovicidal? (kills nits?) Major warnings/precautions
    Nix crème rinse Permethrin 1% 2 months of age and older Good activity resistance is becoming a problem
    RID/ A-200 Pyrethrins/pipronyl butoxide Over 2 years of age NO Retreat in 7-9 days. Avoid if allergic to chrysanthemums or ragweed.
    Ovide Malathion 0.5% Over 6 years of age.
    Contraindicated if under age-2 yrs
    Partially ovicidal Flammable. No hair dryers
    Ulesfia Benzyl alcohol 5% Over 6 months of age NO, it suffocates live lice Retreat in 7 days
    Sklice Ivermectin lotion 0.5% Over 6 months of age Prevents newly hatched nymphs from surviving. Single treatment only. No combing needed.
    Natroba Spinosad 0.9% Over 6 months of age Kills live lice and unhatched eggs Nit combing not required
    Lindane (Kwell) Lindane Must weigh over 110 lbs About 50% ovicidal Second line. Potent neurotoxin. (AVOID!)


    Last week we covered the OTC options for Head Lice Control. Although safe and effective, resistance is becoming a problem and sometimes the need to bring out the “big guns” to take care of those pesky bugs.

    Keep in mind though, a lot of treatment failures are due to inadequate environmental controls and are not so much as resistance as re-infestation. Other causes might be improper use of the products dispensed be it not completely covering the hair or not leaving the product on long enough.


    I was also amazed to learn about using trimethoprim/sulfamethoxazole (Bactrim) for head lice. I have not seen it used as a treatment for head lice, but after reading the literature, it might be an option as resistance keeps popping up. When DDT was banned in the 70's there was a scramble for insecticides to replace that very potent bug killer. My favorite extreme example of drug pricing going crazy is malathion. Malathion is frequently used as an insecticide around the home and garden, in a 50% strength, while the prescription strength is 1/100% as whet we can buy in a hardware store! Of course we cant recommend the lawn/garden product for human use, but this yet another example of how ridiculous the drug prices can be!!

    Have a great day on the bench!!


    Same ingredient, but when dispensed as a prescription the price goes up exponentially.
    ORTHO MALATHION IS NOT FOR HUMAN USE!!!

    August 2018

    We can treat those pesky head lice without a prescription!

    The first line therapy for head lice is over-the-counter...

    Permethrin 1% Crème rinse (NIX®):
    Made from a natural chrysanthemum extract, pyrethrins are neurotoxic to lice. Permethrin is a synthetic pyrethroid. Was first approved in 1986 by prescription and in 1990 was moved to over the counter. Is available as a 1% crème rinse, which is considered to be first line treatment for head lice. Mechanism: acts on the parasites nerve cell membrane. Resulting in paralysis of the pest. Remains on hair shaft for 14 days, despite normal shampooing. Can be used prophylactically, in “epidemics” where over 25% of the population (family, daycare, or classroom) is affected. Is 70-80% ovicidal. We are seeing an increase of resistance to permethrin. May be used for a child as young as 2 months.

    Directions for Permethrin creme rinse:
    1. Wash hair first, with regular shampoo.
    2. Towel dry briskly
    3. Apply a sufficient amount of permethrin crème rinse to saturate hair and scalp (especially problem areas)
    4. Let on hair for NO longer than 10 minutes.
    5. Rinse with water
    6. May reapply in 7 days if necessary. One application is generally curative. However, Permethrin’s adherence to the hair shaft can be affected by conditioners and silicone-based additives present in almost all currently available shampoos. This may impair efficacy of the crème rinse. Many experts routinely advise re-treatment on day-9.
    Piperonyl Butoxide (4%), Pyrethrum Extract (Equivalent to 0.33% Pyrethrins) (Rid®

    Brand: RID® and other generics are available over the counter
    Pyrethrins are naturally occurring pyrethroid extracts from the chrysanthemum flower. Pyrethrins are safe and effective when used as directed. Pyrethrins can only kill live lice, not unhatched eggs (nits). Piperonyl Butoxide/pyrethrin Lice Killing Shampoo is designed to be used on DAY ONE and then again 7 to 10 days later, but not before. To apply the shampoo, follow the directions on the package, including:
    1. Protect child's eyes—Use towels to protect child's eyes from treatment and prevent clothes from getting wet.
    2. Apply Piperonyl Butoxide/pyrethrin Lice Killing Shampoo—Apply thoroughly to DRY HAIR or other affected area. Wetting the hair dilutes the treatment making it less effective.
    3. Let set for 10 minutes—first apply behind the ears and to the back of the neck. Lice can crawl up and down the shaft of the hair very quickly, so it is important to apply the treatment from the roots to the ends of the hair. Allow product to remain on the hair (or other affected area) for 10 minutes, but no longer.
    4. PRECAUTION: A second treatment is recommended 9 to 10 days after the first treatment to kill any newly hatched lice before they can produce new eggs. Pyrethrins generally should not be used by persons who are allergic to chrysanthemums or ragweed. Piperonyl Butoxide/pyrethrin is approved for use on children 2 years of age and older.
    For all lice killing shampoos: All topical pediculicides should be rinsed from the hair over a sink rather than in the shower or bath to limit skin exposure and with warm rather than hot water to minimize absorption attributable to vasodilation. Removal of nits immediately after treatment with a pediculicide is not necessary to prevent spread, because only live lice cause an infestation. Individuals may want to remove nits for aesthetic reasons or to decrease diagnostic confusion. Because none of the pediculicides are 100% ovicidal, manual removal of nits (especially the ones within ½ inch of the scalp) after treatment with any product is recommended by some.

    RID LICE CONTROL SPRAY (permethrin 0.5%)
    Contains permethrin 0.5% (just like the tick repellant for clothing). Spray only those garments and parts of bedding, including mattresses and furniture that cannot be either laundered or dry cleaned. Most agree that this treatment is no more effective than a thorough vacuuming with a Shop-vac. Some sources recommend against using these insecticides at all. Viable nits are unlikely to incubate and hatch at room temperatures which are cooler than a human host; if they did, the nymphs would need to find a source of blood for feeding within hours of hatching. Next week we will discuss the prescription treatment of head lice infestations, and I’ll provide a summary treatment chart.

    Last week we covered the topic of head lice, and patient consultation points. This week's discussion focuses on the OTC recommendations we can use for the treatment of head lice. In this week's column are the directions, and counseling points to share with those “slightly” upset caregivers.

    Probably our first step is to always reassure the very upset parent, then provide all of the counseling points to insure a successful treatment. Be sure to share last week's column with those parents who seem to be full of misinformation.

    Help educate parents and schools that there's no medical reason to keep kids out of school after treatment. Explain that remaining nits or itching doesn't indicate treatment failure, only live lice do.

    Have a great day on the bench!!

    School opens soon--- time to "brush up" on our lice treatments!

    SEPTEMBER IS NATIONAL HEADLICE PREVENTION MONTH!!

    With school around the corner, one of the biggest concerns parents have is if their child brings home some unwanted friends, those being of the six-legged variety… head lice! This week we will cover the basics of head lice and next week we can cover the pharmacological treatment.

    PEDICULOSIS (LICE): Pediculosis is a skin infection caused by blood sucking lice. They are small flat wingless insects with stubby antennae and 3 pairs of legs that end in sharp curved claws.

    There are 3 major types of lice:
    • Head Lice : Pediculus humanus capitis
    • Body Lice : Pediculus humanus corporis
    • Pubic Lice: Pthirus pubis (note: different species than above)
    Life cycles of the human louse:
    • All lice need human warmth to survive.
    • Head and pubic lice spend their entire life cycle on the skin of human host.
    • Head & pubic lice deposit their eggs (known as nits) on hair strands, about 1/4th of an inch from the skin. Each louse develops from eggs (nits) that incubate 1 week. When the eggs hatch the nymphs appear the eggs are small and gray white.
    • Each louse survives about 1 month as a mature adult.
    • The female head louse can produce 3-6 eggs per day. Head lice nits can survive 10 days off a body.
    • Nits are easier to find than the live adults. Check around the back of the ears, and the nape of the neck (warmest parts of the body). Nits are cemented to hair shaft, unlike dandruff that can be brushed away.
    Non-Pharmacological treatment of lice:
    • Change clothing daily
    • All household contacts should be inspected and treat if necessary
    • Bed linens and clothes should be washed in hottest water (130degrees or hotter), and dried on heated air cycle for at least 20 minutes to kill both the lice and nits. Dry cleaning also kills head lice and nits. Only items that have been in contact with the head of the infested person in the 48 hours before treatment should be considered for cleaning.
    • Wash hairbrushes, combs, toys in hot water (130degrees) for at least 10 minutes.
    • Stuffed animals, pillows and articles that can’t be laundered. Stuff into large trash bag, seal the bag, and hold for 2 weeks.
    • All household items, carpets, chairs & couches should be thoroughly vacuumed. OTC sprays such as A-200 or R&C spray are no more effective than vacuuming
    HEAD LICE MYTHS are numerous! The following FACTS should reassure and inform patients and parents!
    • No significant difference in incidence between various socioeconomic classes or races.
    • Hygiene & hair length are NOT contributing factors.
    • Head lice do not fly or jump. They can crawl about 3 feet.
    • Head lice do NOT carry other disease. (Body lice can)
    • Head lice cannot be contracted from pets.
    • Head does NOT have to be shaved to get rid of the lice.
    • Washing head with brown soap is not effective.
    • Head lice are not related to ticks
    • Hair does NOT fall out because of infestation
    • Head lice can occur at any time of the year.
    HEAD LICE TRUTHS:
    • Females are more susceptible to head lice infestations.
    • White children are more susceptible that black children in the United States
    • Pruritus occurs as an allergic reaction to lice saliva injected during feeding
    No Nit Policy…. NO WAY!!!
    From the CDC website---Here’s why “no-nit” policies should be discontinued” Both the American Academy of Pediatrics (AAP) and the National Association of School Nurses (NASN) are in favor of stopping the common practice of “no-nit” policies for the following reasons:
    • Many nits are more than ¼ inch from the scalp. Such nits are usually not viable and very unlikely to hatch to become crawling lice, or may in fact be empty shells, also known as ‘casings’.
    • Nits are cemented to hair shafts and are very unlikely to be transferred successfully to other people.
    • The burden of unnecessary absenteeism to the students, families and communities far outweighs the risks associated with head lice.
    • Misdiagnosis of nits is very common during nit checks conducted by nonmedical personnel.
    As we approach the end of August the school buildings that have been quiet for nearly three months are coming back to life. In Central Pennsylvania where we live, the sports page, full of football stories is the harbinger to the first day of school. Kids are getting their backpacks ready, and the first day of school of outfits are hanging in the closet.

    The kids are excited, and the parents are looking forward to the first day as well. However one facet of the beginning of school is the return of the six legged critters, head lice.

    Nothing upsets and frustrates parents more than when their kids bring home these unwanted inhabitants of the kids hair! I made sure that the generic permethrin creme rinse is stacked up in the front shelves of the store. I sure it wont be there for long!

    In the next two weeks we will cover the over the counter lice treatments, followed by the prescription treatments for pediculosis capitis.

    Have a great day on the bench!! (you can stop scratching now!)

    You'll never flush your toilet again without thinking about this newsletter!

    Steatorrhea and Pancreatic Enzymes

    Why is fat content of the stool most important:
    Healthy people, excrete less than 6 grams of fat per day even if intake is increased to 100 to 125 g of fat/day. Most patients experiencing steatorrhea excrete more than 20 gram of fat per day in their stool. The pancreas normally responds with between 700,000 and 1,000,000 lipase units (USP) per meal.

    The activity of the lipase in patients with EPI (exocrine pancreatic insufficiency) is generally 10% of that of healthy individuals. Since all three enzymes (amylase, protease and lipase) are excreted parallel, lipase is used to determine the appropriate dose of pancreatic enzyme supplements.

    Absorption: Of all the macronutrients (fat, carbohydrates, and protein), the absorption process of fat is the most complex and tends to be the most sensitive to interference from disease processes.

    Calories: Fat is the most calorically dense macronutrient and, therefore, its malabsorption is a critical factor in the weight loss that often accompanies malabsorptive disorders. Protein and carbohydrates contain 4 kcal per gram, while fat contains 9 kcal per gram.

    Patients should be followed up in two weeks to assess and titrate PERT (pancreatic enzyme replacement therapy) dose if needed. The dosage should be individualized and adjusted based on:
    • Clinical symptoms
    • Degree of steatorrhea present
    • Fat content of the diet
    As unpleasant as this may sound patients need to report the frequency and consistency of their stools, along with the following symptoms:

    Clinical Symptom tracker
    • Frequency of diarrhea or loose stoolst
    • Bloating
    • Excessive gas
    • Abdominal pain
    • Rush to bathroom during the night
    Stool appearance indicating steatorrhea:
    • Stool color- pale yellow
    • Foul smelling stool
    • Stool floats on top of water, rather than sinking
    • Hard to flush stool
    • Greasy appearance
    • Droplets of oil in your toilet
    Degree of steatorrhea present
    • Foul smelling stools (we are aware than no one’s stools smell good, but have your patients report on foul smelling stools)
    • Do their stools float on the top of the water in the toilet bowl?
    Fat content of the diet:
    Restriction of the fat content to 20gm per day is recommended. If this is unsuccessful, pancreatic enzymes need to be taken. Remember though that fat is an important macronutrient. Medium chain triglycerides (MCTs) can be supplemented to provide extra calories in patients with weight loss and a poor response to diet and pancreatic enzyme therapy

    Adherence Of course, before we make any adjustments to therapy, we need to ask the patient about adherence and measure their understanding about the pancreatic enzymes.
    • Remind the patient that PERT should be taken with meals and snacks to aid in digestion
    • Confirm that the total daily dose of PERT is divided among approximately 3 meals and 2 to 3 snacks a day
    • Ensure the patient understands that half of the prescribed enzyme dose for an individualized full meal should be taken with each snack
    Self-Care Strategies:
    • Vitamin supplementation, including fat-soluble vitamins A, D, E, and K
    • A nutritionally well-balanced diety
    • Abstaining from alcohol
    • Smoking cessation
    Follow up care:
    • After 12 months, 61% of PERT patients are still on their starting dose
    • 67% of patients are under dosed on their PERT
    Most of us did it today, and if not, will be doing it tomorrow. Yet most of us feel very uncomfortable discussing our bowel movements let alone listening to someone else’s vivid description of theirs.

    As unpleasant as these discussions are, stool consistency is about the only gauge our patients have to assist with appropriate dosing of pancreatic enzymes.

    Most of us cringe when we head out to our laxative section, where we often get excruciating descriptions of patient’s bowel movements. When we are monitoring the efficacy of pancreatic enzyme replacement therapy, such descriptions are necessary for clinicians to gauge the success of the therapy.

    I'd recommend discussing the contents of this column with all of your patients within the two weeks suggested after a new start. For pharmacists, at the first refill it would be worth discussing specifically adherence, as well as stool appearance. Hey, we're accustomed to hearing such descriptions anyway!

    I remember one of my first lower GI consults, after I was recently licensed in 1981. A rough old gent walked into the store and asked me for a “physic” after asking him what he meant, as I’ve never heard that term before. He said “listen buddy I can’t s----” , using the four letter work my Mom would wash our mouths out with soap if she caught us saying that!

    The available pancreatic enzymes: Creon® (Abbvie), Zenpep® (Allergan), Pancreaze® (Janssen), Viokace® (Allergan), and Pertzye® (Digestive Care) are currently the only FDA-approved PEPs that are marketed in the United States. They have excellent websites, that have savings programs for our patients. The sales representatives are a wealth of information as well.

    Have a great day on the bench!!

    Patient information to help our patients get the most benefit from their pancreatic enzymes

    When Our Patients Pancreas Fails--

    Your six-inch pancreas is quite a busy organ, producing close to 2000ml (2 quarts) of pancreatic juices that aid in digestion. As discussed last week when the pancreas fails to produce adequate enzymes we see several symptoms of inappropriate digestion such as diarrhea, gas, unexplained weight loss and steatorrhea.

    SOURCE: The digestive enzymes lipase, protease and amylase are extracted from the pancreas of pigs. Both Muslim and Jewish leaders approve these pork derived enzymes if there are no other alternatives for treatment of the patient’s condition.

    HISTORY: In July 1991, FDA announced that all pancreas enzyme products (PEPs) must be approved, and the companies were required to submit a New Drug Application, even though these drugs have been around a long time. This was done to assure the safety, effectiveness, and product quality, due to variations between the actual enzyme content in the product and the amount indicated on the label. Some companies began the application process soon after that announcement. The FDA required approval of all marketed PEPs by April 28, 2008. Because the manufacturers struggled with this time frame the FDA extended the approval deadline to April 28,2010 The FDA provided technical assistance to all manufacturers of PEPs and extension of the approval deadline, however some of the products failed to get FDA approval for marketing prior to the April 28, 2010 deadline.

    DOSING: The initial dose of pancreatic enzyme replacement therapy (PERT) can be calculated, based on the weight of the patient. Dosage adjustments thereafter are based on the following 3 parameters:
    • degree of steatorrhea present
    • content of dietary fat in the ingested meal
    • clinical symptoms of the disease
    The recommended dosage of all pancreatic enzyme replacement products is 500 lipase units/kg/meal. These patients based on symptoms can be titrated to a maximum of 2,500 lipase units per kg/meal.

    Starting dose: Looking at the math a 180-pound patient (80kg) patient should be taking around 40,000 units per meal as a starting dose. Think Creon® 36,000 one capsule at each meal.

    Maximum dose: The above patient would be able to take a maximum dose of 200,000 lipase units per meal. (after titration of course). Think a maximum of Creon® 36,000 at a dose 5 capsules per meal. Most patients should be on 2 capsules per meal (72,000 units)

    Observing these calculations, most patients (estimated 2/3) are under dosed. Unfortunately, after 12 months at least 60% of the patients are on their initial starting dose and have not been upwardly titrated. Tell patients it may take 1-2 weeks for a patient to adjust their dose of the new PEP. Patients usually take half of a mealtime dose for each substantial snack.

    Approved Products include: Creon® (Abbvie), Zenpep® (Allergan), Pancreaze® (Janssen), Viokace® (Allergan), and Pertzye® (Digestive Care) are currently the only FDA-approved PEPs that are marketed in the United States Viokace is the only pancreas enzyme product (PEP) without an enteric coating. Viokace must be taken with a proton pump inhibitor (PPI). The PPI decreases stomach acid to help prevent the drug from breaking down in the stomach and delays the release of the drug until it reaches the lower digestive tract.

    PATIENT INFORMATION
    • Take with every meal or snack or the symptoms of malabsorption may return if doses are missed.
    • Heat labile: Capsules must be swallowed with a cold drink, as a hot drink might weaken the enzymatic activity. Also, enzymes should not be carried in trouser pockets, due to body radiating heat.
    • The capsules should be swallowed whole and must not be crushed or chewed. If opened and sprinkled it should be on an acidic food (such as applesauce). Do not retain in the mouth, due to potential irritation of oral mucosa.
    • If you are having a large extended meal more than 2 courses, divide dose during the meal.
    Since use of PEPs preceded the Federal Food, Drug and Cosmetic Act of 1938, they had been marketed without formal FDA approval, and major differences were reported between the actual enzyme content in the product and the amount indicated on the label.

    After reading this letter it is obvious that we pharmacists at each refill should be questioning our patients as to the level of improvement of their gastrointestinal symptoms, especially steatorrhea. Although these enzymes are expensive, the biggest waste of money comes if the patients are not deriving benefit due to improper dosing or adherence.

    Next week we will discuss follow up care.

    Have a great day on the bench!!

    We think a lot about insulin and the pancreas... let's explore the other function of our pancreas.

    Digestive enzymes and your "tired" pancreas...

    Digestive enzymes are available in the front of our stores, but most often are prescribed and dispensed from the pharmacy. With all the Type-2 diabetics we care for, we realize the function of the pancreas is to produce insulin from the beta cells, and glucagon from the alpha cells in the islet of Langerhans. Another extremely important, and often forgotten function of the pancreas is to produce the digestive enzymes to process the foods we eat.

    Just as the endocrine function (insulin and glucagon production) may fail, the effectiveness of the exocrine function (production of digestive enzymes) may fail as well. When the exocrine function becomes impaired, this condition is referred to as EPI (Exocrine Pancreatic Insufficiency)

    In people with EPI, it is the exocrine function of the pancreas that is affected. EPI occurs when prandial enzyme output is ≤10% of normal. The undigested food moving through the intestines that causes the unpleasant symptoms of EPI.

    EPI is a condition that can be managed with prescription medication called PERT (pancreatic enzyme replacement therapy). PERTs replace the enzymes the pancreas is no longer making. The capsules/tablets are taken with every meal to help break down food into nutrients that can be absorbed. They contain the enzymes lipase which breaks down fats, protease which breaks down proteins, and amylase which breaks down carbohydrates.

    SYMPTOMS OF EPI
    • Frequent diarrhea (usually characterized by frequent, soft bowel movements that appear pale)
    • Unexplained weight loss
    • Steatorrhea (due to excess fat content, stools are loose, floating, oily, foul smelling, and hard to flush)
    • Flatulence and bloating
    • Abdominal pain
    • Conditions associated with EPI:
      • Chronic pancreatitis (CP)
      • Cystic fibrosis (CF
      • Pancreatic cancer
      • Partial resection or total pancreatectomy
      • Diabetes mellitus
    DIAGNOSIS OF EPI
    • Fecal Elastase-1 Concentration (done with a single stool sample)
    • Fecal Fat Collection (done over a 72-hour time period)
    • Secretin and/or cholecystokinin (CCK) stimulation tests (available in specialized pancreatic centers- not done routinely)
    TREATMENT of EPI
    Along with the pancreatic enzyme replacement therapy (which we will “digest” next week) the following should be recommended:
    • A nutritionally well-balanced diet
    • Vitamin and mineral supplements, including fat-soluble vitamins A, D, E, and K
    • Lifestyle modifications such as abstaining from alcohol and smoking cessation
    • Check the med list: Most drugs report diarrhea as a side effect, but especially watch out for:
      • Selective Serotonin Reuptake Inhibitors (Citalopram, fluoxetine, sertraline and others)
      • Other antidepressants such as bupropion and trazodone
      • Lithium
      • Metformin- frequently prescribed for our Type-2 diabetics, who are also at risk for EPI
      • Proton pump inhibitors (omeprazole, esomeprazole) along with H2RA’s like ranitidine and famotidine (very rare)
      • Bisphosphonates (alendronate, ibandronate, risedronate)
      • Colchicine
      • NSAIDS- (ibuprofen, naproxen and others)
      • ACE inhibitors
      • Chemotherapeutic drugs
    Our pancreas is an important organ to keep us going metabolically. We quickly think of insulin from the beta cells, maybe glucagon from the alpha cells, but equally important is the digestion of our foods from the exocrine function of the pancreas. After the next couple weeks of discussion with relationship of digestive enzymes we will come to appreciate this six inch organ, that weighs only 2 to 3 ounces even more!

    Have a great day on the bench!!

    JULY 2018

    I take a statin and my legs hurt... will Co-Q -10 help??

    Statin Induced Myopathy Treatment and Prevention:

    Coenzyme Q-10 has been touted for everything from eye disease, heart disease to HIV. Most of the time we are using it for people who complain about muscle pain while on a statin for cholesterol management. Many of our patients complain about muscle aches, some of them are not even on statins. Here are the terms used to describe muscle pain. First recommendation is to have a creatine kinase (CK) level done.

    • Myopathy - a general term related to any muscle complaint. Muscle weakness (not due to pain), with or without an elevation in Creatine Kinase (CK) level.
    • Myalgia - muscle complaints (i.e., ache, weakness) without elevations in CK. This is the most common myopathy reported with statins
    • Myositis – inflammation of the muscles
    • Myonecrosis – Elevation in muscle enzymes compared with either baseline CK levels (while not on statin therapy) or the upper limit of normal that has been adjusted for age, race, and sex:
      • Mild – Threefold to 10-fold elevation in CK.
      • Moderate – 10-fold to 50-fold elevation in CK.
      • Severe – 50-fold or greater elevation in CK.
    • Rhabdomyolysis - markedly elevated levels of CK, usually greater than ten times the upper limit of normal; usually accompanied by creatinine elevation, acute renal failure including brown urine, and urinary myoglobin. Defined as myonecrosis with myoglobinuria or acute renal failure (an increase in serum creatinine of least 0.5 mg/dL).
    Many of the elevations in CK are due to statin therapy but is not usually a concern until it is over 10 times the upper limits of normal. This is very rare, and occurs in less than 0.5% of patients. Unfortunately, many patient’s statin therapy is discontinued due to perceived side effects of muscle pain. Hypothyroidism, acute or chronic renal failure, and obstructive liver disease can also enhance to statin induced muscle pain.
    • If the patient has muscle pain my first approach would be to recommend switching to a hydrophilic statin. Pravastatin (Pravachol®) -a lightweight- and rosuvastatin (Crestor®) -a powerhouse- are both available generically and are hydrophilic. Those two are least likely to cause muscle pain.
    • A lot of the elevations of CK might be due to statin drug interactions with CYP450-3A4, and rosuvastatin and pravastatin are not metabolized by this enzyme system, and are safer.
    • I am not a huge fan of Zetia (ezetimibe), which blocks the absorption of cholesterol. Most clinicians feel the liver “up-regulates” cholesterol production in response to decreased absorption. Most want a statin on board with ezetimibe therapy, which now is rather cheap to use.
    • Always avoid gemfibrozil (Lopid®) with statin therapy.
    • Never prescribe Simvastatin (Zocor®) 80mg due to increased risk of rhabdomyolysis.
    CoQ10 for myopathy prevention: The link to statin therapy-
    Statins inhibit CoQ10 formation many theorize low CoQ10 levels might lead to myopathy. There's no conclusive proof that CoQ10 works for statin induced myopathy but some anecdotal reports suggest it might be helpful.

    Dosage: If patients want to try CoQ10, suggest starting low and dividing doses over 100 mg. Take two to three times daily to minimize nausea and diarrhea.

    Adverse effects: Most studies have not reported serious side effects related to CoQ10 use. The most common side effects of CoQ10 include insomnia, increased liver enzymes, rashes, nausea, upper abdominal pain, dizziness, sensitivity to light, irritability, headaches, heartburn, and fatigue.
    • CoQ10 should not be used by women who are pregnant or breastfeeding.
    • Statins may lower the levels of CoQ10 in the blood. However, it is unclear what type of health effect this may have on an individual.
    • CoQ10 may make warfarin, an anticoagulant (blood thinner), less effective.
    The only way I recommend Co-Q10 if that is the only thing that will keep a patient on their statin. I think of it as an expensive placebo! We struggle to find cheaper prescription prices for our statins, and it is counter-intuitive to recommend a very expensive supplement. A few case reports have noted benefit with doses of 30 to 250 mg daily. There is currently inadequate evidence to recommend CoQ10 supplementation for prevention of statin-induced muscle toxicity.

    Have a great day on the bench!!

    Another benefit of this drug...you don't have to check the PDMP!!!

    Melatonin-- a good night sleep might be in our supplement section!

    Melatonin is classified as a “dietary supplement by the FDA.
    Endogenous melatonin, secreted by the pineal gland is a neurohormone used to regulate sleep-wake cycles or circadian rhythms. Melatonin is synthesized from the amino acid tryptophan. Melatonin secretion begins around the third or fourth month of life, peaks in pediatric years, and lessens as we age. This decline in melatonin secretion seems to be due to calcification of the pineal gland. A 70-year-old has about ¼ of the melatonin secretion as young adults do. Supplementation of melatonin seems to be a reasonable option for sleep induction.

    • USE: May be useful may help to regulate sleep disturbances that occur with insomnia, jet lag, rotating shift-work, depression, chronic kidney disease.
    • Jet lag: Melatonin can improve some symptoms of jet lag, such as alertness and psychomotor performance, may also be useful for daytime sleepiness and fatigue.
    Might not be effective for decreasing sleep latency.
    • DOSE: 0.3—1 mg produce physiological melatonin levels in the circulation; Suggest higher doses of (2—6 mg) which are needed to obtain beneficial effects. Maximum: 10 mg/day. Doses over 10mg may produce supraphysiologic concentrations of melatonin which can produce numerous biological effects. Daytime sleepiness, impaired mental and physical performance, hypothermia , and hyperprolactinemia can be caused by excessive melatonin doses. These effects are not observed with physiologic concentrations of melatonin.
    Novel uses for melatonin:
    • is an orphan drug for blind people who have no light dark cycle, and cant synchronize sleep.
    • is being studied for relief of perioperative anxiety (3-5mg) – causes less respiratory depression, sedation and delirium than the benzos.
    Ramelteon (Rozerem®) available as 8mg tablets ($490.00/month) Mechanism: selectively binds to the MT1 and MT2 receptors in the suprachiasmatic nucleus , inhibiting the neuronal firing that maintains wakefulness. Rozerem® shows no evidence of abuse, dependence or withdrawal, or rebound insomnia and can be prescribed long term.

    Tasimelteon (Hetlioz®) is approved for non-24 sleep-wake disorder, where patients can't synchronize their internal clock to the 24-hour light-dark cycle. It occurs in over half of blind people, rarely in sighted people. Hetlioz increases nighttime sleep in blind patients about same as melatonin (28 minutes) at a cost of $10,000/MONTH. Do not recommend Hetlioz for sighted or blind patients who don't have non-24.

    Melatonin warnings:
    • Asthma: melatonin may play role in the expression of asthma symptoms- patients should seek advice before starting this therapy.
    • Drowsiness precautions, driving, dangerous tasks that require alertness.
    • Avoid during pregnancy and breast feeding.

    We all see a lot of issues using the traditional sleep aids in our patients, especially the elderly. We often hear of reports of “sleep driving” on zolpidem (Ambien), not to mention the risk of falls. Many of our patients seeing that their benzodiazepines, like temazepam (Restoril), and the “Z” hypnotics like zolpidem are not covered for sleep and look in the over the counter aisle for relief. Keep in mind that due to their anticholinergic effects the antihistamines are not recommended for the elderly due to exacerbation of prostate symptoms and increase fall risk. That rules out all the “PM” products that contain diphenhydramine. Melatonin seems to be an option worth exploration.

    Sleep hygiene is also worthy of discussion. Use of laptops, tablets, smartphones before bedtime can have a negative impact on melatonin secretion, circadian rhythms, and sleep. Any device with a “gray screen” all which are low light emitting, and dilates the pupils can cause this effect. One study compared the effects of reading an “e-book” versus a printed book for four hours prior to bedtime for five consecutive nights. The e-book readers had suppressed melatonin concentrations in the early part of the night, a delayed endogenous circadian melatonin phase, felt less sleepy before bed, took longer to fall asleep, and reported feeling sleepier the following morning, than the “paper book” readers. Looks like this gray haired pharmacist needs to create these columns in the morning, and NOT before bedtime.

    Have a great day on the bench!!

    Milk thistle-- should we get out the "weedeater" or the mortar and pestle?

    Milk Thistle—this invasive weed might have health benefits for your liver.

    Latin Name: Silybum marianum also called “Mary thistle” or “holy thistle”

    Milk thistle grows in North and South America, and throughout most of the world, as it is native to the Mediterranean region. This plant is considered by most to be an invasive species. Silymarin is the main component of milk thistle seeds.

    People have used milk thistle for liver disorders, such as hepatitis and cirrhosis, and gallbladder problems. Silymarin is the most commonly used herbal supplement in the United States for liver problems. Silymarin has chemo preventive effects on hepato-cellular carcinoma, according to in vivo and in vitro studies. The silymarin exerts antioxidant activity, stabilizes liver cell membranes, promotes regeneration of the hepatocytes, and inhibits fibrogenesis in the liver, which drives the progression of chronic liver disease. Silymarin also increases survival time in patients with alcoholic cirrhosis.

    Milk thistle products are available as capsules, powders, and extracts. Capsules are available in 175mg, 250mg and 1000mg strengths.

    EVIDENCE:
    The 2008 Hepatitis C Antiviral Long-Term Treatment Against Cirrhosis (HALT-C) study, sponsored by the National Institutes of Health (NIH), found that hepatitis C patients who used silymarin had fewer and milder symptoms of liver disease and somewhat better quality of life but no change in virus activity or liver inflammation. A 2012 clinical trial, higher-than-usual doses of silymarin were no better than placebo for chronic hepatitis C in people who had not responded to standard antiviral treatment.

    DIABETES:
    Milk thistle might lower blood sugar in people who have type 2 diabetes

    NASH:
    NonAlcoholic SteatoHepatitis (NASH) is a more severe form of liver disease with inflammation and sometimes fibrosis, which is becoming one of the most frequent causes for liver transplants. Weight loss, statins and pioglitazone (Actos) may reduce liver fat, fibrosis and inflammation. Use pioglitazone (Actos) whether patient has diabetes or not. Milk thistle seems to be of minimal value.

    SAFETY:
    In clinical trials, milk thistle appears to be well tolerated in recommended doses. Occasionally, people report various gastrointestinal side effects.

    CYP2C9 interactions:
    milk thistle is an inhibitor of CYP450-2C9 and might potentially produce clinically significant increases in warfarin (Coumadin and diazepam (Valium). Other references discount any CYP family interactions with milk thistle.

    ALLERGIC REACTIONS:
    Milk thistle may produce allergic reactions, which tend to be more common among people who are allergic to plants in the daisy family (for example, ragweed, chrysanthemum, marigold, and daisy).

    DIABETES:
    Compounds in milk thistle may lower blood sugar levels in people with type 2 diabetes. Some of the compounds in milk thistle have peroxisome proliferator-activated receptor (p-par) agonist properties similar to the TZD’s like Actos (pioglitazone) People with diabetes should use caution, and monitor for hypoglycemia.


    Next I'm walking around the fields and forests of Central Pennsylvania, and my shoelaces get untied by this noxious week, I will have a greater respect for milk thistle! Milk thistle, although originally from the Mediterranean area can easily be spotted along hedgerows and in the farmers fields of most areas of our country.
    This herbal might have a place in therapy, although not useful for NASH, it might benefit certain populations suffering from liver disease. With its low incidence of drug interactions, and minimal adverse reactions I'm OK with my patients trying this herbal product. Although it doesn't lower viral load in our hepatitis patients, the HALT-C study showed a better "quality of life." Isn't that after all what healthcare is all about?

    Have a great day on the bench!!

    Is ginger effective for treatment of nausea and vomiting?

    Ginger snaps and ginger ale... good for snacks, not so for vomiting!

    Latin Name: Zingiber officinale

    Ginger can be found in our kitchens as spice for “ginger snaps” and in “ginger ale”. Ginger which is found in the tropics has green-purple flowers and a rhizome (a bulky underground stem) that is the basis for its use in the kitchen. Ginger has been used since antiquity, especially in Asian medicine, dried ginger has been used for thousands of years to treat stomach ache, diarrhea, and nausea.

    Dramamine offers as a brand extension an all-natural product with ginger root (2 capsules=1000mg), along with its dimenhydrinate 50mg and meclizine 25mg versions! Foods containing ginger as a flavoring agent, like ginger ale or ginger snaps are not effective in treatment of nausea.

    Ginger has been studied for nausea for a variety of situations, such as motion sickness, post op nausea, and chemotherapy. It is more effective than placebo, however prescription medications are more effective for treatment of vomiting. Ginger provided little benefit in treatment of nausea and vomiting due to chemotherapy. Ginger’s most common strengths are 250mg and 550mg per capsule.

    Nausea of Pregnancy: the usual dose of ginger is 250mg four times daily. This supplement might bring adequate relief, but for hyperemesis gravidarum using metoclopramide (Reglan) or ondansetron (Zofran) would provide greater benefit. According to a meta-analysis by the American Board of Family Medicine, ginger (Z. officinale) was better than placebo in improving nausea of early pregnancy when given at doses of 1 gram/day for a duration of at least 4 days. The ACOG (American College of Obstetricians and Gynecologists) list ginger as a treatment option for nausea of pregnancy. Safety in pregnancy has not been adequately proven.

    Side Effects

    Heartburn: For non-pregnant patients, GI reflux has been commonly reported with ginger. In a study of the prevention of postoperative nausea and vomiting, 8% of subjects had heartburn after taking 1 gram of ginger.

    Bleeding risk: advise caution if the patient is currently taking any anti-platelet drugs (aspirin, clopidogrel) or anticoagulants as ginger could possibly increase bleeding risk.
    As with all herbal supplements in the United States there is variation between products due to lack of standardization.


    Back when Zofran® (ondansetron) came to market in 1992 it was extremely expensive costing around $40.00 per tablet. Its unique mechanism of action is that it blocks serotonin, a natural substance that causes nausea and vomiting. This was a godsend to oncologists who struggled with the vomiting caused by chemotherapy regimens, especially cisplatin.

    Family practice physicians were using other alternatives such as prochlorperazine (Compazine) promethazine (Phenergan) and metoclopramide (Reglan). The extrapyramidal side effects of these "dopamine blockers" could make treatment of nausea and vomiting a challenge.

    Ginger was frequently recommended for the simple nausea of "the flu", or due to motion sickness. Ginger is better than placebo, but is not as effective as the serotonin or dopamine blockers.

    Today ondansetron tablets are very inexpensive, and are frequently prescribed for treatment of all forms of nausea and vomiting. However in September 2011, the FDA warned "Ondansetron may increase the risk of developing abnormal changes in the electrical activity of the heart, which can result in a potentially fatal abnormal heart rhythm"

    Have a great day on the bench!!

    JUNE 2018

    Urinary Tract infections: prevention with cranberry juice or tablets are of no value. Save your cranberries for your next turkey dinner!

    When the first urinary tract infection is caused by Escherichia coli, women appear to be more likely to develop a second UTI within six months than those with a first UTI due to another organism. A study done in Finland showed 44 percent of women with an E.coli urinary tract infection had a recurrence within one year. This is indeed a very common complaint with our female patients and the go to our supplement aisle looking for a “natural” product to prevent these bothersome infections.

    Cranberry (Vaccinium macrocarpon) is an evergreen bush that grows in North America. For years it has been touted for its use in prevention of urinary tract infections. Here is what you need to share with your patients.


    Cranberry therapy is not worth trying: Any of the oral cranberry products to date have no data to support its use, and causes significant GI upset and heartburn. Withdrawal rates have been quite high (up to 55%), suggesting that these products may not be acceptable over long periods. Adverse events include gastrointestinal intolerance, weight gain (due to the excessive calorie load) and drug-cranberry interactions (due to the inhibitory effect of flavonoids on cytochrome P450-mediated drug metabolism).
    • Drinking cranberry juice appears to be safe, although large amounts can cause stomach upset and may over time increase the risk of kidney stones.
    • Large doses of cranberry may alter levels of warfarin (Coumadin).
    Approaches to Urinary Tract infection prophylaxis that are worth trying:
    • Post coital antibiotic treatment: antibiotic treatment after each act of sex using: trimeth/sulfa SS; Nitrofurantoin 50mg or 100mg capsules (not MacroBID), cephalexin 250mg or ciprofloxacin 125mg
    • Continuous antibiotic prophylaxis: daily antibiotic treatment with trimethoprim 100mg (watch for resistance), trimeth/sulfa SS, nitrofurantoin 50mg or 100mg (not MacroBID), cephalexin 250 or ciprofloxacin 125mg
    • Self-treatment: women who can self-diagnose and who are compliant can be given a course of therapy with Trimeth/Sulfa DS or Ciprofloxacin or Levofloxacin. Women should call provider if symptoms are not resolved in 48 hours
    Patient counseling tips that work to prevent recurrent urinary tract infections:
    • Urinate immediately after having sexual intercourse. Urinating flushes out bacteria that may have entered the urethra during intercourse.
    • Use proper hygiene. Wipe front to back.
    • Rinse the vulva after sex.
    • Keep well hydrated with water and avoid “holding it” throughout the day
    • Wear regular cotton underwear. Thong underwear can lead to UTI’s by tracking bacteria from the rectal area into the urethra via the vagina.
    • Don’t smoke, it lowers your immunity.
    • Avoid condoms coated with nonoxynol-9

    We see a lot of patients coming to our pharmacies getting Trimeth/Sulfa DS, Nitrofurantoin, Levofloxacin and Ciprofloxacin for urinary tract infections. Of course, some of us gray haired pharmacists remember Mandelamine®(Methenamine mandelate) and Hiprex® (methanamine hippurate), which became available in 1967, are seldom used today.

    Females, due to their own special structural anatomy have a shorter urethra and the E.coli more easily “climb” through this shorter urethra and colonize in the bladder.

    Another challenge becomes finding appropriate therapy for treatment of urinary tract infections. The Sanford Antibiotic Guide recommends avoiding Trimeth/Sulfs DS (Bactrim-DS) if local E. coli resistance rates are over 20%. The same reference recommends avoiding fluoroquinolone (levofloxacin/ciprofloxacin) therapy if local resistance rates are over 10%. The latest antibiogram from our local hospital calculates a 27% resistance rate for Trimeth Sulfa and a whopping 35% resistant rate for the fluoroquinolones against E. coli.

    Fortunately our nitrofurantoin resistance rate is just 6% for E. coli. Bacterial resistance is becoming a bigger challenge for our female patients suffering from urinary tract infections.

    Have a great day on the bench!!

    What about all natural Red Yeast Rice for management of cholesterol?

    Red yeast rice (RYR) (Monascus purpureus) is a nutraceutical that lowers LDL-C levels by 20 to 30 percent. Red yeast rice is a fermented rice product that has been used in Chinese cuisine (like Peking duck) and medicinally to promote "blood circulation”. Because it is a “natural product “patients assume it is a safer alternative to the prescription statins.

    Red yeast rice may also induce muscle complaints because of its statin-like content. The product contains varying amounts of a family of naturally occurring substances called monacolins that have HMG CoA reductase inhibitor activity. The LDL-C lowering effect of red yeast rice is due to the presence of monacolin K, a compound like lovastatin (Mevacor®).

    According to a meta-analysis it will:
    • lower LDL-C by 19-62 mg/dL
    • increase HDL by 3mg/dL
    • lowers triglycerides by 23mg/dL
    When we directly compare it to lovastatin, the daily lovastatin content of red yeast rice was 0.2 percent of the total product, which at the recommended dose of red yeast rice of 2.4 g/day translates into a daily lovastatin dose of 4.8 mg, compared to lovastatin (Mevacor®) that we have available in the pharmacy. The capsules are available as 600mg and can be dosed as two capsules twice daily.

    My concerns:
    • Wide variability exists in the amount of lovastatin-like compounds in commercially available RYR products. In a study that evaluated the content of twelve preparations of commercially available red yeast rice, the total monacolin content ranged from 0.31 to 11.15 mg/capsule and monacolin K (similar to lovastatin) ranged from .1mg to 10 mg per capsule. This study also showed that four of the preparations had elevated levels (1.6mcg/day) of citrinin, a potentially kidney damaging mycotoxin.
    • Although red yeast rice lowers LDL-C like a mild potency statin, and may be tolerated by some patients who have discontinued statin therapy for muscle side effects, this therapy is not recommended due to lack of clinical outcomes data, variable drug bioavailability, and possible toxic effects from contaminants.
    • In 1998, the FDA determined that a red yeast rice product that contained a substantial amount of monacolin K was an unapproved new drug, not a dietary supplement. On several occasions since then, the FDA has acted against companies selling red yeast rice products that contain more than trace amounts of monacolin K, warning them that it is against the law to market these products as dietary supplements. Truth be known our patients and we pharmacists have no idea what is in these products, as the labels state only the amount of red yeast rice that they contain, not the amounts of monacolin K or other monacolins.
    • Lack of standardization, nephrotoxicity, as well as the costs of these products do not allow me to recommend this product. Most products are well over $18.00/month.

    Before recommending Red yeast rice, think about the active compound in this natural product, that being lovastatin or Mevacor®. Lovastatin is considered a sensitive CYP3A4 substrate, since its levels may be increased five-fold or higher by CYP3A4 inhibitors. Lovastatin was a game changer in the world of hyperlipidemia management. Up until Mevacor® became available in 1987 clinicians managed cholesterol levels with diet, exercise and bile acid sequestrants, such as cholestyramine (Questran) and colestipol (Colestid).

    Simvastatin (Zocor®) and Pravastatin (Pravachol®) became available in 1991. Fluvastatin (Lescol®) followed in 1993, to be joined by the blockbuster atorvastatin (Lipitor) in 1996.

    Cerivastatin (Baycol®) came to the market in 1997, only to be withdrawn after four years in 2001, because of 52 deaths attributed to drug-related rhabdomyolysis that lead to kidney failure.

    Rosuvastatin (Crestor®) came to the market in 2003, and the last one to join the HmgCo-A reductase family was pitavastatin (Livalo®) in 2009. Except for pitavastatin, all of the statins are now available generically.

    When we recommend statins, we think of drug interactions, cost and potency and of course insurance coverage. Most clinicians when selecting a statin today gravitate toward rosuvastatin because it meets the parameters of minimal drug interactions and potency.

    Most would agree that the active ingredient in red yeast rice (lovastatin) would be our last choice. Red yeast rice with the potential for contamination with citrinin, along with the lack of standardization between products, should be our last choice in the management of hyperlipidemia.

    Have a great day on the bench!!

    Ceiling fans and dry tee shirts might be your patients best treatment option for hot flashes!

    Black Cohosh:
    • Cimicifuga racemose- rhizomes and roots are used. It is a member of the buttercup family.
    • USE: extracts seem to modestly reduce symptoms of menopause, such as hot flashes. However, there is considerable variability in the preparations used in clinical trials, and in the results obtained. Historically was one of the ingredients in Lydia Pinkham’s Vegetable Compound
    • Remifemin® contains only black cohosh, and has been one of Germany's top proprietary herbs since the 1960's. It is not recommended to be used over 6 months.
    • Germany's Commission E has found this extract of black cohosh effective for the treatment of dysmenorrhea, PMS, and climacteric ailments since 1989. Remifemin is the only formulation approved by Commission E.
    What the US studies show: With a daily dose of 40 mg, for a mean duration of 23 weeks, compared to placebo, hormone therapy, red clover and fluoxetine. Reported outcomes included vasomotor symptoms, vulvovaginal symptoms, menopausal symptom scores and adverse effects. There was no significant difference between black cohosh and placebo. Source:http://www.ncbi.nlm.nih.gov/pubmed/22972105 Results for evening primrose oil and flaxseed have also been disappointing.

    Adverse effects: Stomach upset, headache are common side effects. There have been reports of liver damage in patients, one patient needing a liver transplant.

    Drug interactions: because of the potential (not yet proven) estrogenic effects of black cohosh, do not recommend in patients taking tamoxifen (Nolvadex). No other drug interactions have been reported.

    Non-Hormonal alternatives for hot flashes:
    • most references recommend venlafaxine (Effexor), desvenlafaxine (Pristiq), paroxetine (Paxil, Brisdelle), citalopram (Celexa), and escitalopram (Lexapro) have a similar modest benefit for hot flashes. Most sources seem to favor citalopram as the favorite at a 20mg dose for hot flashes.
    • Gabapentin (Neurontin) is a good option for women who have their hot flashes at night. It is effective when the hot flashes occur in the first four hours of sleep, especially if the hot flashes wake up the woman.
    So, as with so many of the herbal preparations there just isn’t a lot of evidence for use of black cohosh. This drug seems to be safer than most herbal supplements for most of our middle aged women, and for some it might be worth a try. Share this information that there isn’t a lot of evidence for use of black cohosh. Might be best to save the money and turn on the ceiling fan in the bedroom!

    I remember back in the day in the 1980’s when we bought our Premarin 0.625 and Premarin 1.25mg in bottles of 1000! We would sell 100 Premarin for around $15.00. Then the HERS trial came out at the turn of the millennium, and we have all but stopped dispensing this drug. Back in the 1980’s we were using it for everything from osteoporosis, hot flashes, prevention of colon cancer and even cardiac protection. After the results of the HERS trial, estrogen was to be used for relief of vasomotor symptoms, at the lowest possible dose for the shortest period of time. Estrogen is no longer recommended for prevention of chronic heart disease, osteoporosis, or prevention of dementia. That same bottle of 100 Premarin® costs the pharmacy almost $550.00 !!

    “Hot flashes” are the most common complaint during the menopausal transition, occurring in up to 80 percent of women. However, only about 20 to 30 percent of women seek medical attention for treatment. Indeed, estrogen has fallen out of favor, and our female patients (including our wives!) are looking for relief of hot flashes and turn to the over the counter supplements such as black cohosh, the active ingredient in Remifemin®.

    Have a great day on the bench!!

    Valerian root might be an option for our anxious patients... and you don't have to check the PDMP!!

    Valerian... seems good for insomnia--- and unlike Zolpidem, you can "tweet" !!

    Valerian (Valeriana officinalis) is a perennial plant native to North America, Europe and Asia. For hundreds of years it has been used in Europe as a sedative and an antispasmolytic to relieve insomnia, anxiety, muscle spasms and stress induced palpitations. Native Americans boiled the roots into a tea for calming the nerves. The roots contain essential oil with monoterpenes and sesquiterpenes (valerenic acids).

    Various compounds have been detected in valerian, including alkaloids, flavonoids, and GABA, which seem to have some affinity for the GABA receptor. Remember from our basic pharmacology when the GABA receptor is activated by benzodiazepines we will see sedative, hypnotic, anxiolytic, anticonvulsant, and muscle relaxant effects. Could we then expect the same from valerian?

    Source: Valerian products are made from its roots, rhizomes (underground stems), and horizontal stems. Dried roots are prepared as teas or tinctures, and dried plant materials and extracts are put into capsules.

    Efficacy: Some studies suggest that valerian may be useful for insomnia and other sleep disorders; results of other studies do not. Some of these studies had small sample sizes, used different amounts and sources of valerian, measured different outcomes, or did not consider potential bias resulting from high participant withdrawal rates. Overall, the evidence from these trials for the sleep-promoting effects of valerian is inconclusive.

    Numerous trials have not shown it to be better than placebo, while some other trials showed it had less side effects than placebo! One study showed a decrease in slow-wave sleep onset (13.5 minutes) compared with placebo (21.3 minutes). Another study enlisting 75 patients comparing Valerian 600mg to oxazepam (Serax®) 10mg. Both groups had the same improvement in sleep quality but the valerian group reported fewer side effects than did the oxazepam group. Those patients experienced less morning drowsiness. NCBI

    Adverse effects: Few adverse events have been reported because of valerian. As we would expect from its sedative properties, valerian can cause drowsiness or dizziness. The risk of respiratory depression should be considered if valerian is used with multiple sedating drugs (like benzos) and/or significant alcohol consumption. Valerian can cause abdominal pain in large doses.

    Worth recommending? Valerian is a seems to be a safe herbal choice for the treatment of mild insomnia and has good tolerability. Valerian seems to be more effective when used continuously rather than as an acute sleep aid. Most references recommend using 400mg-900mg one hour before bedtime. Best results occur when a person takes it for at least 28 days. A potential advantage of valerian over benzodiazepines is the lack of sleepiness on awakening when used at the recommended dosages. Valerian also may be helpful in weaning patients with insomnia from benzodiazepines.

    In 1960 the first benzodiazepine, chlordiazepoxide (Librium) hit the market, introduced by Roche Labs. In 1963 diazepam (Valium) was released and the market really took off. All the benzodiazepines work on the GABA receptor to allow chloride to rush into the neuron. Chloride is the major suppressing ion in the CNS. The Z-hypnotics zolpidem (Ambien®), zaleplon (Sonata®) and eszopiclone (Lunesta®) work at the same receptor, causing influx of chloride and causing the same net effect.

    When combined with opioids, benzodiazepines can cause an increase in opioid deaths. More than 30 percent of overdoses involving opioids also involve benzodiazepines. According to Psychiatry-Online (18March2016) between 1996 and 2013, the number of adults filling a benzodiazepine prescription increased 67 percent, from 8.1 million to 13.5 million. Among those filling benzodiazepine prescriptions, the median cumulative quantity filled over the year increased by 140 percent, from 86.8 mg to 208.0 mg lorazepam equivalents. Meanwhile in this time frame deaths involving benzodiazepine increased fivefold.

    Pharmacists and prescribers are feeling the heat when it comes to prescribing benzodiazepines and opioids, especially in combination. Valerian root might be an option, rather than another new start on a benzo!

    In recent news actor Roseann Barr blamed her controversial tweet on "Ambien tweeting". Sanofi quickly responded: "People of all races, religions and nationalities work at Sanofi every day to improve the lives of people around the world. While all pharmaceutical treatments have side effects, racism is not a known side effect of any Sanofi medication."

    My take on valerian: If it works for a particular patient, that is one less benzo we have to check the PDMP for!

    Have a great day on the bench!!

    May 2018

    Since I turned 60 last weekend, these men's health issues have become more important!

    Saw Palmetto, how effective is it for BPH?

    Common Names: saw palmetto, American dwarf palm tree, cabbage palm, is a tree native to South Eastern United States.

    Latin Name: Serenoa repens, Sabal serrulata
    • USE: urinary symptoms associated with benign prostatic hyperplasia (BPH), as well as for chronic pelvic pain, bladder disorders, decreased sex drive, hair loss, hormone imbalances, and prostate cancer.
    • Medicinal part: The ripe fruit of saw palmetto is used in several forms, including ground and dried fruit or whole berries. It is available as liquid extracts, tablets, capsules, and as an infusion or a tea. The saw palmetto berry contains over 100 different compounds, mostly fatty acids, long chain alcohols and sterols.
    EVIDENCE: (or lack thereof) Some studies compare saw palmetto’s efficacy to that of finasteride (Proscar), which “shrinks” the prostate gland allowing for better emptying of the bladder.
    • Placebo-controlled, double-blind studies of its use in benign prostatic hyperplasia (BPH) have been carried out in > 2000 patients in Germany. A 1998 meta-analysis of published trials concluded that compared to finasteride, saw palmetto appears to produce similar improvements (28%) in urinary tract symptoms and flow measures. Some studies suggest that it's comparable to finasteride, less effective than alpha-blockers.
    • 2011 NCCIH-cofunded study in 369 older men demonstrated that saw palmetto extract administered at up to three times the standard daily dose (320 mg) was no more effective than placebo. The supplement should be a fat soluble saw palmetto extract that contains 85 to 95% fatty acids and sterols.
    • A 2012 study in JAMA concluded that increasing doses of a saw palmetto fruit extract did not reduce lower urinary tract symptoms more than placebo. This study reached the same conclusion as the New England Journal of Medicine in 2006, of the lack of efficacy of saw palmetto.
    • UP-To-Date® does not recommend any herbals for BPH until herbals are further studied. Given the body of evidence against herbal products, efficacy is likely tied to the placebo effect.
    DRUG INTERACTIONS:
    • Saw Palmetto does have anti-coagulant properties, do not recommend if patient takes any blood thinning drugs such as warfarin, aspirin, Plavix, Xarelto, or NSAIDS.
    • Because of saw palmetto’s mechanism of action being anti-estrogenic and anti-androgenic, it may decrease the efficacy of oral estrogen and oral contraceptives. It is recommended that a condom be used to prevent pregnancy if partner is using birth control pills.
    • Speaking of drug interactions, certain medications need to be avoided in men of my age group, especially if they have BPH:
    MEDICATIONS to Avoid with BPH:
    • Testosterone: causes prostate enlargement and growth
    • Sympathomimetic agents: may cause or worsen urinary difficulty in patients with prostate enlargement due to smooth muscle contraction in the bladder neck via stimulation of alpha-1 adrenergic receptors. Therapy with sympathomimetic agents should be administered cautiously in patients with hypertrophy or neoplasm of the prostate. Avoid amphetamines, pseudoephedrine and phenylephrine.
    • Drugs with significant anticholinergic (antimuscarinic) adverse effects: decrease urinary bladder detrusor muscle contractility, resulting in urinary retention (antihistamines, TCA, phenothiazines). However, drugs like Detrol® (tolterodine) poses little risk of urinary retention, IF there is good flow. Antimuscarinics work during storage, rather than voiding.
    • Anticholinergics: same as above (benztropine, hyoscyamine)
    • Diuretics: polyuria secondary to high dose therapy may present as urinary frequency.
    CAUTION: Be sure that prostate cancer has been ruled out before recommending saw palmetto.

    According to the May 2016 fact sheet from the Department of Professional Employees, more than 26.2 percent of pharmacists were 55 years or over in age. As this gray haired 60-year-old pharmacist approaches senior citizen status let’s talk about saw palmetto and its use in treatment for BPH.

    Benign Prostatic Hypertrophy (BPH) is characterized by too frequent urination, having trouble starting or maintaining urination, and needing to urinate during the night. The urethra, the tube that “drains” urine from the body, runs through the prostate gland in men. When the prostate gland is enlarged, obstruction of the urethra occurs and men may have trouble urinating.

    At the Empower-3 clinic where I practice two days a week, we have changed three men from Flomax (tamsulosin) to alfuzosin (Uroxatrol) which both drugs have generic formulations that are inexpensive. According to Up-To-Date®, tamsulosin decreased the volume of ejaculate in more than 90 percent of patients, with 35% had no ejaculate.

    Silodosin (Rapaflo) produces retrograde ejaculation (semen gets rerouted into the bladder) in 28 percent of patients. There are no reports of Alfuzosin (Uroxatrol) causing these ejaculatory difficulties. Have that conversation with your sexually active males on alpha-1 blockers!

    Have a great day on the bench!!

    Ginkgo biloba for memory, circulation, tinnitus?? Depends what side of the ocean you are on. Germans consider it first line.

    When is the last time you wrote or filled a prescription for Ginkgo biloba?

    GINKGO BILOBA
    Ginkgo biloba “maiden hair tree” said to be the world's oldest living tree species. The leaves are used with the highest concentrations occurring in the autumn when the leaves begin to change color. Even so, the compounds need to be extracted. Dried leaves, and teas are probably ineffective. Dose 120-240mg daily in 2-3 doses. USE: dementia, including Alzheimer's, vascular, and mixed dementia. Also used for cerebral vascular insufficiency. Ginkgo has also been used for peripheral occlusive vascular disease (intermittent claudication). It has also been tried for sexual dysfunction, multiple sclerosis and tinnitus.

    CAUTION:
    if taking oral anticoagulant therapy. Ginkgo inhibits the binding of platelet-activation factor (PAF) to platelets; this action may increase bleeding time and can augment effects of anti-coagulant therapy. Stop 2-3 weeks before elective procedure. Also use caution if given with other NSAIDS and herbals like turmeric.

    SIDE EFFECTS:
    headache, nausea, gastrointestinal upset, diarrhea, dizziness, or allergic skin reactions. More severe allergic reactions have occasionally been reported.

    CANCER:
    According to a study done on rats and mice by the National Toxicology Program, Ginkgo biloba extract caused cancers of the thyroid gland in male and female rats and male mice and cancers of the liver in male and female mice.

    German Commission E:
    monograph states that Ginkgo Biloba Extract formulation (which is the dry leaf extract and is standardized) is effective for symptomatic treatment of organic brain syndrome caused by cerebral insufficiency or dementia syndromes. This is dated 1994, and whether these results can be extrapolated to other ginkgo products is uncertain. German physicians still consider Ginkgo extract to be the first choice for their dementia patients; it is also used for depression, Raynaud’s disease and tinnitus.

    Here is what the studies say: (and it is all bad news for gingko)
    GEM Study (Gingko Evaluation of Memory study) which enrolled 3,000 volunteers over the age of 75, were taking 240mg of standardized gingko daily. They were followed for an average of 6 years. Analysis of the data was disappointing, showing that ginkgo was ineffective in slowing cognitive decline, lowering blood pressure, or reducing the incidence of hypertension. This study was funded by NCCIH (National Center for Complementary and Integrative Health)
    National Institute on Aging did a trial of more than 200 healthy adults over age 60 found similar results in that ginkgo taken for 6 weeks showed no improvement in memory.

    Alzheimer’s disease, which is the most common cause of dementia and affects as many as 5.1 million Americans age 65 and older in the U.S., may triple in the next 40 years. (With my 60th birthday coming this Friday, I now pay attention to these statistics!!)

    We all dispense a lot of Donepezil, Rivastigmine and Galantamine. Only 1 in 12 patients on these cholinesterase inhibitors show any improvement. Not to mention that 1 in 12 patients have significant side effects, usually GI upset (due to increased GI secretions), as well as bradycardia and fainting.

    These cholinesterase inhibitors are first line for mild to moderate Alzheimer's if the patient or family wants to try drug therapy. Cholinesterase inhibitors increase the levels of acetylcholine, which may cause increase in increase in urinary incontinence, which is usually treated with an anti-cholinergic. The two opposing drugs may lead to a pharmacological stalemate.

    Many of our caregivers, sometimes out of desperation will turn to herbals or over the counter supplements to help their loved ones. Gingko biloba and DHA, a component of fish oil are touted as being beneficial for “memory support”.

    Have a great day on the bench!!

    We dispense a lot of generic antidepressants to our patients. Are there any over-the counter treatment options??

    St. John's Wort and treatment of depression

    Common Names: St. John’s wort, hypericum, Klamath weed, goatweed.
    Latin Name: Hypericum perforatum: flowering tops of St. John's wort are used to prepare teas, tablets, and capsules containing concentrated extracts. St. John's wort consists of the dried, above ground parts of H. perforatum gathered during flowering season near the end of June around the Feast of St. John the Baptist (June 24th). Antidepressant activity of SJW is attribute to its hyperforin content, which is highest in the plant during its flowering season. Hyperforin has strong reuptake inhibitor effects on all four of the mood neurochemicals (serotonin, norepinephrine, dopamine and GABA)

    USE: depression, dysthymia, and sleep disturbances.
    DOSE: most common regimen is 300mg up to 3 times daily up to 6 weeks Before we even discuss all the ramifications of using this drug, consider the following:
    • Should we even be considering the treatment of depression as “treatable” condition for our patients? Do we have the clinical skills necessary to manage treatment of depression? This pharmacist certainly does not.
    • Before recommending this herbal, remember that inadequately treated depression may become severe and, in some cases, may be associated with suicide.
    EVIDENCE
    • The German Commission E has recognized St. John's wort as a "modestly effective" antidepressant. Some sources say it is comparable to low dose SSRI’s (like Prozac) or Tri Cyclic Antidepressants (like Elavil)
    • Doubtful efficacy for the treatment of moderate to severe major depressive disorder
    • Remember: Some studies highlight the ongoing concerns with placebo response rates in antidepressant studies which have recently been estimated to be as high as 35—45%. Almost ½ of your patients will get a positive effect from taking a placebo.
    • Usual dose: The usual dose for mild depression and mood disorders is 300 mg (standardized to 0.3% hypericin extract), 3 times per day, with meals. As with all antidepressants expect about three weeks for benefit.
    • Topical use: some value for treating Herpes labialis. Dynamiclear is a single application product for cold sore treatment. He topical oil may have some value in treatment of psoriasis lesions.
    PRECAUTIONS
    • potent photosensitizer- make sure patients are using sunscreen. Risk increases when patients take 2-4 grams of St. John’s Wort extract (contains 5-10mg hypericin)
    • may precipitate manic attack if a patient is bipolar
    • Combining St. John’s wort with certain antidepressants can lead to a potentially life-threatening increase of serotonin, thus precipitating “serotonin syndrome”. Serotonin syndrome symptoms range from tremor and diarrhea, confusion, muscle stiffness, tachycardia (rapid heartbeat), seizures, hyperthermia (high fever), and even death. Dextromethorphan may also precipitate serotonin syndrome when given with antidepressants.
    • Avoid if pregnant or nursing
    DRUG: DRUG INTERACTIONS: CYP450-3A4 inducer (expect to decrease levels of interacting drugs), avoid using St. John’s Wort with any drug metabolized by the CYP450-3A4 pathway especially:
    • Warfarin and anticoagulants
    • Phenobarbital and phenytoin
    • Digoxin
    • Other antidepressants
    • Birth control pills
    • Some HIV drugs (NNRTI and Protease inhibitors)
    • Monamine oxidase inhibitors (MAOI)
    • Alprazolam (Xanax) will speed up its metabolism and decrease efficacy by half.
    We can tell that by our purchases of generic Zoloft, Prozac, Celexa and Lexapro in bottles of 500 or 1000 that depression is one of the most common conditions we treat in our pharmacies. Although this herb is in the “Top 10” of herbs used in the United States it also made the “Top 4 Herbal Supplements Your Doctor Hates” list by US News and World Report (2/22/12).

    If our patient's would insist on counseling or the appropriateness of St. John's Wort the minimum "screening questions" we could ask are: (source: aafp.org)
    • "During the past month, have you often been bothered by feeling down, depressed, or hopeless?"
    • "During the past month, have you often been bothered by having little interest or pleasure in doing things?"
    Given the facts of the drug interactions, the placebo effect of treating depression, the potential for serotonin syndrome and even suicide, self-management of depression for our patients is not recommended. Let’s leave the treatment of this condition to clinicians with some level of experience. I'm not recommending that we become amateur psychiatrists!

    Have a great day on the bench!!

    Most of our migraine patients will do anything to alleviate the severity or frequency of their headaches. This herbal product might be of benefit.

    Feverfew... neurologist recommended!

    Petasites is a genus of flowering plants in the sunflower family, that are commonly referred to as butterburs and coltsfoots. Tanacetum parthenium, Chrysanthemum parthenium (feverfew, bachelor’s buttons, featherfew) is ranked #19 as the most often used herb in the US. The leaves or flowers, which can be fresh or dried, as well as a tincture are available. The active ingredient parthenolide, has been studied to prevent menstrual cramps, cancer, as well as treat rheumatoid arthritis and migraine headaches. Petasin appears to be a major active compound of petasites hybridus extract. It has inhibitory activities on leukotriene generation in eosinophils and neutrophils. This indicates that it may have anti-inflammatory and anti-allergy properties.

    EVIDENCE FOR USE:
    • MIGRAINE HEADACHES: Some research suggests that feverfew may be helpful in preventing migraine headaches; however, results have been mixed and more evidence is needed from well-designed studies. Five trials (total 343 patients) were unable to establish that feverfew is efficacious for preventing migraine. There is insufficient evidence from some controlled clinical trials that feverfew was better than placebo for migraine treatment. Side effects were minimal with only mild and transient adverse events were reported in the included trials. Some of the trials used an alcoholic extract, while trials that used the dried leaves seemed to show more efficacy for migraine treatment.
    • Some studies showed patients reported a decrease in severity and frequents of headaches, as well as a decrease in nausea. American Academy of Neurology and the American Headache Society suggest that a feverfew extract may be effective and should be considered for migraine prevention. Petadolex® is the brand most studied.
    • RHEUMATOID ARTHRITIS: One study found that feverfew did not reduce rheumatoid arthritis symptoms in women whose symptoms did not respond to conventional medicines. It has been suggested that feverfew could help those with milder symptoms. It was found to no more effective than placebo for the treatment of rheumatoid arthritis.
    • CANCER: Did show some anti-cancer effects in lab studies. Human studies are needed.
    FEVERFEW PRECAUTIONS:
    • If allergic to other members of the daisy family (which includes ragweed and chrysanthemums) are more likely to be allergic to feverfew.
    • Pregnancy and nursing: NOT recommended during pregnancy, because of its abortifacient properties in early pregnancy.
    • People taking anticoagulants should use feverfew with caution because feverfew may potentiate the activity of anticoagulants such as warfarin
    • Side effects: Common: Minor gastrointestinal distress; oral ulcerations from chewing fresh feverfew leaves; airborne contact dermatitis; exacerbated dermatitis following use of a moisturizer containing feverfew.
    Feverfew got its name from the Greeks, who thought it reduced fever, but is of minimal value. In the 1980’s it was frequently recommended along with magnesium and Riboflavin (B2) for the prevention of migraine headaches. Many of our local neurologists start patients with Magnexium Oxide and Riboflavin (B-2) as initial prophylactic therapy.

    As we journey through the many herbals that are available to our patients, we wont seen many that are endorsed by traditional medical societies. Feverfew is one exception to that notion. After reading that the American Academy of Neurology and the American Headache Society recommend it's use, I'd feel comfortable recommending it to my patients.

    The challenge, as always in the United States, is the lack of standardization of these herbal products. Petadolex® seems to be the product with the most support for efficacy. It is available through our pharmacy warehouses, and retails around $45.00 per month. Most references, particular in Canada require feverfew supplements should be standardized to contain at least 0.2% parthenolide.

    Have a great day on the bench!!

    Echinacea... might be better for our patients than a Z-pak!

    Our next herbal product...Echinacea

    Echinacea is one of the top five herbs that our patients have questions about. Many have their own notions on this herbs efficacy. Like all products we sell it does come with a few warnings that might not make it appropriate therapy for a select group of patients. Efficacy seems to be another issue.

    Ecinacea comes from the Echinacea angustifolia, or E.purpurea, or E.pallida (American cone flower, Kansas snake root). It is found widely throughout North America and was used by the Native Americans both topically and orally for the treatment of burns, snakebites, pain, cough, and sore throat. All nine species are native to North America. The fresh or dried roots or above-ground parts that are collected at the time of flowering of the Echinacea angustifolia, is what is used in medicinal preparations.

    USE:
    Echinacea is used today in the prevention and treatment of the common cold to decrease both the duration and severity. According to most current literature, prevention and treatment of common cold is modest at best. Well-designed clinical trials have not proven its benefit in treatment/prevention of upper respiratory infections, including the common cold.

    PRECAUTIONS:
    • Allergy to related plants in the daisy family: ragweed, chrysanthemums, marigolds, and daisies.
    • The immune stimulating effects of Echinacea have led to concerns regarding the use of Echinacea in patients with autoimmune disorders. It isn’t known whether Echinacea may exacerbate autoimmune disorders, such as Lupus, Sjogrens syndrome or rheumatoid arthritis. I wouldn’t recommend Echinacea in any of these patients. Patients that have atopic dermatitis have increase likelihood of allergic reactions and should also avoid echinacea.
    • According to one study the authors noted that there were small trends in the direction of a benefit from echinacea—an average half-day reduction in duration, or an approximate 10 percent decrease in severity—the researchers concluded that echinacea, at this dose formulation, does not significantly change the course of the common cold.
    • A 2001 study of 80 adult male and female subjects showed a reduction of duration of cold symptoms from 9 days for the placebo group versus 6 days for the echinacea group. https://www.ncbi.nlm.nih.gov
    • Dose most frequently studied: (The echinacea tablets contained the equivalent of 675 mg of E. purpurea root and 600 mg of E. angustifolia root.) Most common strength available OTC is 400mg capsules.
    • Commission E monographs from Germany: Only two preparations have been approved by the German Commission E. These include the root extract of Echinacea pallida used to support and promote natural powers of resistance of the body, especially infectious conditions (influenza and colds), and the expressed juice of Echinacea purpurea, as a supplemental treatment for upper respiratory and urinary tract infection.
    So it seems like Echinacea doesn’t have the evidence that supports our recommendation for treatment or prevention of the common cold. As we with Vitamin C, patients need to be on it chronically to reduce the duration or intensity of the common cold. Antibiotic prescriptions that many prescribers send our way, actually do more harm.

    The latest antibiograms from Central Pennsylvania hospitals are showing resistance to Azithromycin (Z-pak) of 50%. Thanks to the indiscriminate use of antibiotics, Azithromycin is ineffective against the most common bacterial pathogen half of the time! All of a sudden now using echinacea for the common cold doesn’t seem like such a bad idea!

    Just make sure it is for the right patient. With the lack of standardization of herbal products in the United States, and the fact there are 9 different species of coneflower makes consistency of Echinacea very challenging.

    Remember if you treat the common cold it lasts 7 days; if untreated it lasts one week!

    Have a great day on the bench!!

    April 2018

    We have insulin, sulfonylureas, SGLT2 inhibitors, gliptins, alpha glucosidase inhibitors, DPP4 inhibitors and biguanides... how about a sprinkle of cinnamon?

    Instead of all those pills, can I take a natural product for my Type-2 diabetes?

    Cinnamon fits into both the food and medicinal herb categories. We have our “Cinnamon Toast Crunch” (my kids favorite) cereal for breakfast, and we sell cinnamon in our herbal section to improve glycemic control for our diabetics. Because of the lack of standardization in the United States, and the very conflicting data, I am hesitant to recommend this herbal product. Cinnamon contains coumarins, which in high doses can lead to liver toxicity, when doses exceed 7grams. Here is some background information:

    From Cinnamomum aromaticum, a small evergreen tree native to Southern India and Sri Lanka, Malaysia and Madagascar. Cinnamon bark (Cinnamomum verum) is the most common type used in the Western world, as a cooking spice. Bark most commonly used and occasionally, leaves and buds.

    Use: Treatment of Type-2 Diabetes. Cassia cinnamon (“Chinese cinnamon”) is believed to be most effective. This type of cinnamon is commonly found in herbal products in pharmacies and health food stores. As of now most believe it is to be used as “adjunctive” therapy, when added to sulfonylurea therapy (8.22% to 7.86% after 12 weeks) in a well-designed study. Seemed to be of some benefit in those with poor glycemic control, by increasing sensitivity at the insulin receptor.

    ADA journal article: 60 DM Type-2 patients studied for 60 days: After 40 days, all three levels of cinnamon reduced the mean fasting serum glucose (18–29%), triglyceride (23–30%), LDL cholesterol (7–27%), and total cholesterol (12–26%) levels; no significant changes were noted in the placebo groups. Dose used was 1g, 3g, 6g of cinnamon. (2004 article). Patients took 1, 3 and 6 grams of cinnamon in the study arm. This study was done in Pakistan.

    National Institutes of Health: “High-quality clinical evidence (i.e., studies in people) to support the use of cinnamon for any medical condition is generally lacking”

    University of Connecticut School of Pharmacy: Diabetes Care. 2008;31(1):41. PRECAUTIONS/CONTRAINDICATIONS:
    • RESULTS: Five prospective randomized controlled trials were identified. Upon meta-analysis, the use of cinnamon did not significantly alter A1C, Fasting Blood Glucose, or lipid parameters. Subgroup and sensitivity analyses did not significantly change the results.
    • CONCLUSIONS: Cinnamon does not appear to improve A1C, FBG, or lipid parameters in patients with type 1 or type 2 diabetes.
    CAUTION: Cassia cinnamon contains coumarin, consuming large amounts my lead to liver toxicity.
    DRUG/FOOD INTERACTIONS: Cinnamon may reduce the effectiveness of tetracycline antibiotics. PREGNANCY: Use of cinnamon in amounts greatly exceeding those found in foods is not recommended during pregnancy

    In 1958 the rate of Type-2 diabetes in the United States was 1%, sixty years later we are approaching the 10% mark. Many of our patients want to take "natural" products to manage their Type-2 diabetes. Most often they inquire about cinnamon, and the results are variable indeed.

    Depending on what the patients want to believe they can find evidence supporting claims that cinnamon is useful for Type-2 diabetes management.

    There is a plant called goats rue (Latin: Galega officinalis) that is endemic to the temperate climates of Europe and the United States. By studying some of the compounds in this plant the biguanide class was discovered which includes phenformin (D.B.I) which was removed from the market in the 1970's due to lactic acidosis, as well a metformin (Glucophage). Goat's rue was considered an agricultural pest and placed on the "Federal Noxious Weed List" in the United States. Think of that next time you prescribe or dispense metformin!

    The newest class of diabetes drugs, the "flozins" or SGLT-2 inhibitors like canaglaflozin (Invokana) also came from a natural product. Phlorizin, a naturally occurring compound extracted from the root bark of an apple tree in 1835 and later identified as a SGLT1 and SGLT2 dual inhibitor, was the precursor to this category of drugs.

    Maybe there is an active compound in cassia cinnamon that will be elucidated as a treatment for Type-2 diabetes, but for now tell your patients that it is best to sprinkle their cinnamon on a fresh apple!

    Have a great day on the bench!!

    Bright yellow and in our spice cabinet, this Indian herb may be beneficial to our arthritis patients.

    Turmeric---not just for cooking!

    Latin name: Curcuma longa

    Common Name: Indian saffron or curcuma which is related to ginger, is grown throughout India, other parts of Asia, and Central America. Turmeric is a major ingredient in curry powder. The medicinal part of the plant used is the dried rhizome.

    Primary active ingredients: curcuminoids, which are bright yellow and used to color foods and cosmetics. Turmeric is what gives curry it’s bright yellow color in cooking. The German Drug Codex monograph requires turmeric to contain not less than 3.0% curcuminoids, calculated as curcumin, and not less than 3.0% volatile oil.

    Possible uses: osteoarthritis, digestive disorders, and potentially stroke prevention by quelling inflammation in blood vessels,

    Possibly effective: Osteoarthritis-- Some turmeric extracts can improve symptoms of osteoarthritis. Taking a specific turmeric extract (Meriva by Indena) 500 mg twice daily seems to reduce pain and improve functionality in patients with osteoarthritis of the knee after 2-3 months of treatment. Patients using this product saw decreased use of NSAIDS.

    The University of Arizona Health Sciences secured an NIH grant to conduct studies of turmeric (CLaRA study), where they found turmeric to be effective as an anti-inflammatory, in rheumatoid arthritis patients. Researchers also found that turmeric blocks a protein that causes bone breakdown in these patients.

    The rhizome contains an anti-inflammatory and choleretic volatile oil. Anti-inflammatory actions may be due to leukotriene inhibition, as well as COX-2 inhibition. Turmeric has been used as a “digestive aid”; as a choleretic it increases release of bile, therefore it is contraindicated if the patient has gallstones.

    PRECAUTIONS/CONTRAINDICATIONS:
    • High doses of turmeric can act as a blood thinner, and also cause stomach upset. Avoid turmeric/curcumin in patients that take blood thinners such as warfarin (Coumadin).
    • Are about to have surgery
    • Pregnant
    • Have gallstones or any gallbladder disease
    Dose:
    • Osteoarthritis: In capsule form use 400 mg to 600 mg, three times per day.
    • Rheumatoid Arthritis: 500 mg twice daily.
    In last week’s column, I invited all my readers to feel free to e-mail me their request for whatever herb they would like covered. My first response was from one of my pharmacist colleagues who is 87 years old, and still practicing part time. He is a voracious reader, and is a self-proclaimed “nerd” as I am. To respond to this very seasoned pharmacist’s request the first herb we will cover is Turmeric or Tumeric.

    Our warehouse has at least 12 different brands of turmeric capsules available, and most cost less than $10.00 per month. This is one herb I will feel comfortable recommending to our arthritis patients, as long as they do not have any contraindications as listed in this newsletter. There seems to be a fair amount of efficacy for this herb, and our questions about its use will be answered when the CLaRA study is completed.

    Have a great day on the bench!!

    Herbal Therapy-- pharmacists are expected to have some degree of proficiency!

    Herbal Pharmacy --- what a challenge!

    So often it is difficult to substantiate any benefit from Herbal therapy, while side effects seem to appear rapidly. I find these products to be particularly challenging, given the fact we seem to have better pharmacotherapeutic choices in the prescription department.

    Herbals: Challenges for pharmacists
    • our training is very limited- including mine
    • the prescribing community knows even less!
    • consistency of products between distributors and manufacturers
    • At best supporting literature is weak. Frequently we see conflicting studies and results.
    Best website I’ve found: National Center for Complementary and Integrative Health.
    https://nccih.nih.gov/health
    • For this project I’ve joined the American Botanical Council (ABC) for access to the Commission-E monographs. The cost is $50 per year, which allows you access to this herbal website. You can read about each herb individually, or can look up therapeutic categories, and the herbs that are associated with treatment of that disease state.
    Herbal Regulations
    • The FDA loosely regulates dietary supplements, under the Dietary Supplement Health and Education Act of 1994 (DSHEA ’94)
    • Dietary supplementary are considered to be: vitamins, minerals, other botanicals, amino acids, enzymes, organ tissues, glandular, and metabolites. These dietary supplements fall under the category of "foods" and not "drugs".
    • Consequently, scientific data supporting claimed benefit are not always available as for traditional pharmaceuticals. The burden of proof for safety and adulteration of products lays on the Food and Drug Administration (FDA)
    • Consumers should also note that rigid quality control standards are not required for nutraceuticals and substantial variability can occur in both the potency and the purity of these products.
    • Given the regulatory structure for herbal medicines, there is substantial variation in the quality of commercially available products in the United States and elsewhere. Variability in product quality can impact the product's efficacy, safety, and therefore clinical usefulness.
    What Germany does so well:
    • Commission-E is Germany’s equivalent to the FDA in the United States.
    • There are 380 monographs evaluating the safety and efficacy of herbs for licensed medical prescribing in Germany. Published in 1998.
    • Official monographs that give the approved uses, contraindications, side effects, dosage, drug interactions and other therapeutic information essential for the responsible use of herbs and phyto-medicines.
    • Up to 70% of German doctors prescribe "phytomedicines"
    SAFETY of Herbals: Despite ephedra products comprising only 0.8 percent of all dietary supplement sales in 2001, they were responsible for 64 percent of all herb-related adverse events reported to United States Poison Control Centers during the same year. Fortunately, the FDA banned all products containing ephedra in April 2004. Then the manufacturers substituted bitter orange (citrus aurantium) which contains “synephrine” for ephedra in weight loss products. Synephrine has been associated with serious cardiovascular and neurological side effects.

    I think most of us pharmacists would feel better about recommending these herbal products if we had the guidance of the FDA, as do our pharmacists in Germany have with the Commission-E monographs. Until that happens, I will continue to proceed with caution. Patients seem to equate safety with natural products. I always remind my patients that one of our favorite botanicals is “digoxin” from the foxglove plant, knowing that 1mg can stop a person’s heart. Natural does not equate to safety!

    Feel free to send me an email, so we can explore in depth herbals you might have questions about.

    Have a great day on the bench!!

    Fresh fruits and vegetables might be adequate to prevent constipation, but when it comes to opioid induced constipation, a pharmacist recommendation is critical.

    Management of Opioid Induced Constipation

    Numerous side effects are commonly seen with opioid use such as euphoria, respiratory depression, sedation, GI upset and constipation. Of all the common side effects associated with opioid use, the patient never develops a tolerance to constipation. Opioid induced constipation (OIC) occurs in approximately 40% of patients treated with opioids.
    • Use Rome III criteria (less than 3 BM per week)
    • OIC is dose related. As doses escalate, OIC becomes more prevalent
    • Mechanism: opioids bind to mu receptors in the GI tract inhibiting peristalsis.
    Over The Counter:
    • Stool softeners can result in "all mush, no push" simply because there's not enough GI motility. Stool softeners are of little value for OIC.
    • For patients on opioids (hydrocodone, oxycodone, codeine etc.) recommend a stimulant laxative (senna or bisacodyl) to increase GI motility plus docusate if the stool is too hard to pass.
    • OTC Polyethylene Glycol 3350 (MiraLAX) is another excellent choice.
    Peripherally Acting Mu-Opioid Receptor Antagonists (PAMORAs)
    How they work: preferentially block mu-opioid receptors in the GI tract and do not interfere with the pain-relieving effects of opiates on the mu receptor in the central nervous system.

    Methylnaltrexone: (Relistor®)
    • Mechanism: Methylnaltrexone is a PAMORA with a quaternary amine structure, blocking the ability of methylnaltrexone to cross the blood-brain barrier.
    • Indication: Treatment of opioid-induced constipation in patients with advanced illness who are receiving palliative care, when response to laxative therapy has not been sufficient.
    • Warnings/Precautions/Adverse Effects:
      • Contraindicated if known or suspected mechanical gastrointestinal obstruction
      • Discontinue therapy if severe or persistent diarrhea occurs
      • Use with caution in patients with known or suspected lesions of the GI tract
      • May cause gastrointestinal perforation (serious adverse effect)
      • Pregnancy category: B
      • May cause diaphoresis, abdominal pain, flatulence, nausea, dizziness (common adverse effects)
    • Effects can be seen within 4 hours of administration
    Relistor® (methylnaltrexone) injection dosage:
    cost around $125 for 12mg vial


    Injection is based on body weight. Typical dose is 12mg SC once a day for chronic non-cancer pain.
    Relistor 150mg (ORAL) tablets cost: $1635.00/month
    Dose: 3 x150mg tablets (450mg) daily in the morning half hour before first meal of day

    Naloxegol (Movantik®) cost: $314/month
    opioid antagonist indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain.
    Dose: 25mg once daily; if not tolerated reduce to 12.5mg daily. If renal impairment less than 60ml/min, use 12.5mg daily. Take on empty stomach, one hour before a meal or 2-3 hours after a meal.
    Drug interactions: Avoid CYP450-3A4 inhibitors (diltiazem, verapamil, erythromycin), or reduce to 12.5mg daily. Avoid grapefruit juice.
    STOP all maintenance laxatives before starting Naloxegol, may restart in 3 days if not effective.
    • effective in people who have taken opioid pain medicines for at least 4 weeks
    • if opioid is stopped, stop Movantik®
    Naldemedine (Symproic®) cost: $314/month
    opioid antagonist indicated for the treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain. Is a derivative of opioid antagonist naltrexone. It has a large polar side chain to prevent penetration into the CNS. Works by blocking opioid receptors in the GI tract.
    Dose: 0.2mg tablet once daily, any time of day, with or without food.
    Drug interactions: is a substrate of CYP 450 3A4 watch for drug interactions with rifampin (induce). CYP-450 3A4 blockers can cause excessive levels of naldemedine.
    Prescription medications for treatment of OIC
    • Methylnaltrexone (Relistor) 12mg SC daily (chronic non-cancer pain)
      • Relistor 150mg tablets 3 tablets in the morning
    • Naloxegol (Movantik) 25mg orally in the morning
    • Naldemedine (Symproic) 0.2mg tablet orally daily in the morning
    • Lubiprostone (Amitiza) 24mcg orally twice daily (see last week’s newsletter)
    Opioid induced constipation can be a challenge to treat. So often a clinician will recommend docusate for prevention which for most cases is not adequate to treat OIC. Addition of fiber like Metamucil or Citrucel is a worse choice as lack of peristaltic activity can lead to impaction.

    Fresh fruits and vegetables might be adequate for a teenager who has their wisdom teeth extracted to prevent constipation for their acute hydrocodone prescription. However for our patients taking chronic opioids, this newsletter will be of great benefit helping clinicians select appropriate treatment. Stimulant laxatives over the counter are the most economical ways to handle OIC, however for patients receiving higher doses of opioids, prescription treatment might be indicated.

    Have a great day on the bench!!

    March 2018

    We'll explore some of the most expensive treatment options for constipation...of course they are prescription!!

    PRESCRIPTION TREATMENT of CIC and IBS-C!

    Let’s look at the prescription options for treatment of chronic idiopathic constipation (CIC) and Irritable bowel syndrome constipation predominant (IBS-C)

    NEWER TREATMENTS OF CHRONIC CONSTIPATION

    AMITIZA® (Lubiprostone) : 8mcg and
    24mcg(AWP=445.32)
    First approved 2006


    Mechanism: Lubiprostone is a locally acting chloride channel activator that enhances a chloride-rich intestinal fluid secretion without altering sodium and potassium concentrations in the serum. By increasing intestinal fluid secretion, lubiprostone increases motility in the intestine, thereby increasing the passage of stool and alleviating symptoms associated with chronic idiopathic constipation. Indication

    • Treatment of chronic idiopathic constipation (CIC) in adults.
    • Treatment of irritable bowel syndrome with constipation (IBS-C) in women over 18 years old
    • Also indicated for opioid induced constipation.
    Warnings/precautions/adverse effects
    Potential to cause miscarriage (have negative pregnancy test, use contraceptive measures) Pregnancy category: C
    May cause nausea, diarrhea, abdominal distention, loose stools, flatulence and vomiting
    May also cause headache, dizziness and peripheral edema

    Amitiza® (lubiprostone) 24mcg and 8mcg CIC: Dosage: 1 capsule (24mcg) BID with food IBS-C: 8mcg BID for women age 18 and over.

    LINZESS® (linaclotide) 72mcg, 145cg and 290mcg caps
    (AWP=$464.47)-
    First approved:2012


    Indication: irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC).

    Dose: one capsule each day on an empty stomach, at least 30 minutes before your first meal of the day. Swallow LINZESS capsules whole. Do not break or chew the capsules
    Mechanism: guanylate cyclase-C agonist. By increasing the concentration of cyclic guanosine monophosphate (cGMP), linaclotide leads to secretion of chloride and bicarbonate into the intestinal lumen which causes an increase in fluid and GI transit time.
    • For IBS-C, linaclotide should be dosed as 290 mcg once daily on an empty stomach. For IBS-C, Linzess decreases PAIN from IBS-C
    • For CIC, the approved dose is 145 mcg or 72mcg once daily on an empty stomach
    • Do not use in patients less than 18 years of age
    TRULANCE® (plecanatide) 3mg tablets ($466.16)
    First approved-2017

    Trulance (plecanatide) 3 mg tablets is indicated in adults for the treatment of
    • Chronic Idiopathic Constipation (CIC) and
    • Irritable Bowel Syndrome with Constipation (IBS-C).
    Mechanism: Except for a single amino acid substitution, Trulance is structurally identical to human uroguanylin. Uroguanylin activity modulates within the changing pH environment of the intestines, coinciding with areas of fluid secretion, and decreases pain sensation.
    Dose: 3mg once a day, taken with or without food.

    Next week we will discuss the prescription treatment options for opioid induced constipation.

    TFiber supplements and stimulant laxatives have been around for a very long time. Many of us “seasoned” pharmacists remember “if not nature---Metamucil” and “Doxidan in the PM for a BM and the AM.” We cant forget to mention "Natural and Gentle Fletcher's Castoria".

    And of course every Saturday night Lawrence Welk would be promoting "Serutan--that is Natures spelled backward." There have always been a lot of advertising for laxatives in the media, but our patients always asked for our recommendations.

    Since 2006, we have had three new laxatives on the prescription shelves that are indeed effective and very expensive. We've seen ads on TV for Amitiza "move to your own beat" as well as Linzess "ease the pain"-- just ask your doctor!! Just be sure to have enough in your health savings accounts!

    Have a great day on the bench!!

    When fiber and softeners are not quite enough, we have to "get things moving" with a stimulant laxative.

    Sometimes our patient's boels need a little "push"

    Laxatives that Result in Soft or Loose stool in 6-12 hours

    Bisacodyl (oral) Dulcolax® 5mg 5-15mg daily HS
    Senna Senokot® 8.6mg 2HS, max=4 daily
    Magnesium hydroxide Milk of Magnesia (400/5) 30-60ml HS


    Stimulant agents

    Indication: Are effective as initial therapy to treat constipation but should not be used for more than 1 week. Chronic use was believed to lead to cathartic colon, which results in poorly functioning colon, resembling ulcerative colitis. However, most of these cases are reported before 1960 when toxic cathartics were used (podophyllin). Still a subject of controversy whether mild laxatives can be used long term.

    Mechanism: Increases propulsive contractions by local irritation or action on the intramural nerve plexus of the intestinal smooth muscle, stimulate secretion of water and electrolytes.

    Patient information:
    • Causes discoloration of urine
    • Temporary measure, do not use for longer than one week, without consultation.
    • These agents are often abused.
    • Are excreted in breast milk.
    • May cause harmless melanotic pigmentation of colon
    • May color the urine from pink to brown.
    Senokot® (senna) 8.6mg/ tablet.
    Dosage: start 2 tablets at bedtime; do not exceed 2 tablets twice a day. Senna is often combined with docusate.

    Dulcolax® (bisacodyl) 5mg tablets Dosage: start with 1 tablet at bedtime. Usual adult dose is 2 tablets at bedtime. NOTE: this product is enteric coated do not crush or chew. Do not take within 1 hour of antacids, milk or any product that raises gastric pH.

    Magnesium hydroxide

    Indication: can be used as an antacid for temporary relief of heartburn, or occasionally as a laxative.

    Mechanism: Highly osmotic ions draw water into the intestine and cause an increase in the intraluminal pressure, thereby exerting a mechanical stimulus that increases intestinal motility. Increase cholecystokinin – pancreozymin which is an enzyme that increases the secretion of fluids into the GI tract.

    Drug interactions: Oral anticoagulants, Digoxin, Tetracyclines, Quinolones

    Patient information:
    • May lead to hypermagnesemia (as much as 20% Mg may be absorbed)—problem if renal impaired. Patients with a CrCl <30 mL/minute should be monitored by serum magnesium levels.
    • Sodium: hypertensive or CHF patients should not receive these on a long term basis due to fluid retention from sodium absorption.
    • May see abdominal cramping, excessive diuresis, Nausea, vomiting, dehydration electrolyte disturbances, incontinence.
    • Milk of Magnesia 400mg/5ml
    Is an 8% suspension of magnesium hydroxide Antacid: For the temporary relief of heartburn, upset stomach, sour stomach, or acid indigestion. Laxative: For relief of occasional constipation. Expect results within 30 minutes to 6 hours. Dose: 1 to 2 ounces at bedtime. Shake well before using and follow dose with 8 oz of water.

    Thanks to the frequent practice of "cross-branding" we pharmacists should always be consulted before our patients make a laxative purchase. Some companies use their Proprietary name to enhance a whole line of products. I feel Dulcolax is the worst offender as they have the "Dulcolax" name blasted across their softener which actually contains docusate sodium.

    Among us older practitioners Dulcolax has always meant bisacodyl. Clinicians should encourage patients to consult the pharmacist before purchasing laxative products. Better yet it is prudent for clinicians to write a prescription for the patient to decrease confusion.

    However, I once received a prescription from a physicians office that was computer generated. It said "Dulcolax" (docusate) - take 4 capsules at bedtime the night before the test. I called the physician's office and told them this was the same as "Colace" . The nurse told me, that was the first thing that came up under "Dulcolax". She authorized me to switch it to the bisacodyl product.

    You can only imagine how confused our patients can get with this very foolish practice. As I tell my students---"when I become head of the FDA...this is the first thing I will change!"

    Have a great day on the bench!!

    Sometimes we need more than prunes and psyllium!

    Laxatives that cause softening of feces in 1-3 days

    Generic Representative Brand Dosage
    STOOL SOFTENER
    Docusate sodium Colace® 50, 100 50-360mg/day
    Docusate calcium Surfak 240mg 50-360mg/day
    MINERAL OIL Kondremul® 15-30ml
    LACTULOSE Chronulac®, Constulose® 15-30ml
    SORBITOL 30-50gm
    PEG 3350 soln Miralax® 1 cap 17gm in 8oz water


    Stool softeners

    Indication: Beneficial in anorectal conditions in which passage of a firm stool is painful. Generally used for prevention of constipation.

    Mechanism: Anionic surfactants increase the wetting efficiency of intestinal fluid, thereby softening fecal mass. Facilitates admixture of fat and water to soften stool.
    FYI: Docusate is a “soap” and bridges the barrier between the lipid stool, and water. Cut open a capsule, add to a small prescription vial, add water and shake. Looks like dish-washing soap.

    Patient information:
    • Take with fill glass of water.
    • Do not take with any mineral oil containing laxatives, as this will lead to the oil’s absorption and cause hepatotoxicity.
    Available as:
    • Colace® (docusate sodium) 50mg (rarely used) 100mg (common) 50- 300mg daily in divided doses.AKA : “DOSS”or “DSS””: dioctyl sodium sulfosuccinate
    • Surfak® (Docusate calcium) 240mg dose: one capsule daily.
    Emollients (lubricants)
    Indication: prophylactically in patients who should not strain (anorectal surgery, MI)

    Mechanism: Softens fecal contents by coating them, thereby preventing the colonic absorption of water.

    Patient Information:
    • Do NOT give with stool softeners (Colace, Surfak)
    • Avoid in any patient with the potential to aspirate such as GI reflux, as this could cause lipid pneumonia
    • May cause anal leakage leading to anal pruritis. May stain clothes/furniture.
    • If used long term, supplement with fat soluble vitamins (ADEK) as this will impair their absorption.
    • Take on an empty stomach.
    Available as:
    • Mineral oil: dose 15-45ml HS
    • Kondremul® (mineral oil emulsion) dose: 30-75 ml at bedtime. This product is a pleasantly flavored marshmallow liquid, and is much more palatable than straight mineral oil.
    Lactulose
    Chronulac® (Rx only) Indication: useful particularly in elderly patients. Not usually first line. Takes at least 24-48 hours for action.
    • Also used for hepatic encephalopathy to decrease blood ammonia levels.Because colon contents are now more acidic than blood, ammonia migrates from blood to colon, acid colon contents convert NH3 to the ammonium ion (NH4+) trapping it and preventing its reabsorption.Also because of the laxative effect of lactulose, the ammonia spends less time in the colon, decreasing time for absorption to occur.
    Mechanism: disaccharide used orally or rectally. Metabolized by colonic bacteria to form lactic acid, formic acid, acetic acid and carbon dioxide. Increase osmotic pressure and acidify the colonic contents, thus increasing stool water content and softening.

    Patient information:
    • Give with fruit juice, water or milk to increase palatability.
    • Will cause significant gas, leading to -flatulence, abdominal pain and cramping.
    • May also cause diarrhea and electrolyte imbalances.
    • Because it contains galactose & lactose, use with caution in diabetics.
    • If used over 6 months in elderly measure: electrolytes (K & Cl) & carbon dioxide periodically.
    Available as: Chronulac® (lactulose) 10gm / 15ml available in pints and quarts Dosage 15-30ml daily. Increase to 60ml if necessary.

    Sorbitol
    Not available as a laxative but is available as a sweetening agent for prescription compounding. Along with mannitol, these are alcohol sugars that are used as sweeteners. If your patients are ingesting excessive sugar free candy or gum diarrhea can occur.
    Mechanism: similar to lactulose.

    Polyethylene glycol laxatives
    Indication: Used for colon cleansing before diagnostic procedures or colorectal operations. Can also be used in lower doses for chronic constipation.

    Mechanism: is an osmotic laxative that large molecules draw water into the gut, and increased volume results in distention of the intestines, increasing peristalsis and bowel motility, and softening stools.
    FYI: the number 3350 is the molecular weight of this particular polyethylene glycol.

    Patient information
    • May cause abdominal cramping, flatulence, rectal irritation and incontinence.
    Miralax® contains PEG 3350 (this product for long term management of constipation)

    Dosage: 1 capful (17gm) in 8 oz of water once daily.
    • Available prescription sizes: 255gm (2 weeks supply) and 527gm as (1 month supply).
    • Caution: some generic caps are “oversized” and have a fill line inside. May cause over dosage—more than 17 grams.17gm= 1 heaping tablespoonful
    • Also available over the counter in 7-day, 14-day and 28-day packaging.
    GoLytely, CoLyte, Nu-Lytely: contains PEG 3350, in a 4 liter jug, (approximately 230-240Gm)

    The 4L jug should be reconstituted to the fill line early in the morning, then refrigerated. Do not add flavors (unless provided by manufacturer) or colors to the solution. Follow prescribers protocol.
    • Some prescribers give Metoclopramide (Reglan®) to decrease nausea
    There is always a lot of opportunities for us to discuss laxative use with our patients. Often the intake of water, fiber supplements, fresh fruits and vegetables on't produce the desired results.

    Of all the products we discuss today, docusate (Colace®) and PEG3350 (Miralax®) are the most common we use in the pharmacy. PEG3350 falls nicely into the "softener" category when taken as a 17gm dose once a day. I remember as a much younger pharmacist we had a patient who had multiple sclerosis. She battled constipation for many years.

    Her very astute neurologist would have me break down a bottle of the bowel preparation, and she would mix a portion with water and drink it over a 2 day period. In 1999, Miralax was finally released as a single daily dose of 17 grams. In 2006 the Bayer company got FDA approval to sell this product over-the-counter. In 2012 the product became available as a generic.

    This laxative is the "go to" for pediatric patients (with a doctors recommendation).

    Have a great day on the bench!!

    Less than 10% of our patients ingest enough fiber for bowel regularity. What can we do to help them...

    An apple a day is a good start!!

    The traditional classification of laxatives by mechanism of action is not very useful. Many mechanisms have not been elucidated. Most work by promotion of mechanisms associated with diarrhea, such as electrolyte secretion, decreased water & electrolyte secretion, increased intraluminal osmolarity, and increased hydrostatic pressure in the gut.

    Classification is best accomplished by dividing the drugs into categories based on their time to onset of action. for the next couple newsletters we will focus on laxatives that cause soften of feces in 1-3 days

    Generic Representative Brand Dosage
    BULK FORMING AGENT
    Methylcellulose Citrucel® 4-6 gm per day
    Wheat Dextrin Benefiber® 2 teaspoon up to 3 times daily
    Psyllium Metamucil®, Konsyl® Varies
    Polycarbophil FiberLax®, Fibercon® 4-6gm per day


    Bulk Forming Agents:

    Fiber are natural or synthetic polysaccharide derivatives that absorb water to soften stool and increase bulk, which stimulates peristalsis. Because dietary fiber works in both small and large intestines the onset of action is slow (12-24 hours—up to 72 hours.). Fiber supplements are used to prevent rather than treat constipation. Insoluble fiber does not absorb water; while soluble fiber does. Both help material move through your digestive tract, but soluble fiber can help give stool a softer, bulkier consistency that’s easier to pass.

    Metamucil®: is made from ground psyllium husks, from the plantago ovata plant. Adult dose is 1-2 rounded teaspoonful in 8oz of water 1 to 3 times daily. If using the “Orange Smooth-Real Sugar” product the dose is 1 tablespoonful.

    Fun Fact: Metamucil website has dosages for
    • For helping feel less hungry between meals
    • For promoting and maintaining digestive health
    • For helping lower cholesterol to promote heart health- (psyllium traps bile acids)
    • For helping maintain healthy blood sugar levels as part of your diet
    Patient counseling points:
    • There are Metamucil capsules available, if patients complain of grittiness especially if they wear dentures
    • Make sure patients mix with adequate water
    • Because of fermentation it may cause abdominal cramping, bloating, flatulence, distention, esophageal obstruction, intestinal obstruction, allergic reactions
    • Drug interactions: oral anticoagulants, digitalis, salicylates, tetracycliness
    Citrucel®
    is a synthetic bulk laxative containing methylcellulose. Methylcellulose is derived from cellulose which comes from the cell walls of green plants. It is less likely to cause fermentation leading to bloating and flatulence.
    Dose: 1 tablespoonful 1 to 3 times daily.

    Patient counseling points:
    • Available as orange flavor, sugar free and caplets.
    • Be sure to mix with adequate fluids to prevent esophageal obstruction.
    • Mix with cold fluids, avoiding carbonated beverages and milk.
    Benefiber®
    ingredient: wheat dextrin, which is extracted from wheat starch. Wheat dextrin is a soluble fiber which absorbs water in the intestine to form a viscous liquid which promotes peristalsis and reduces transit time. Helps lower cholesterol (LDL and total cholesterol), reduces risks of coronary heart disease and type 2 diabetes. May be beneficial lowering blood sugar and reducing risk for heart disease.
    Dose 2 teaspoonfuls daily, up to 3 times daily. Benefiber® promotes wheat dextrin as a "prebiotic" which are carbohydrates that act as food for beneficial bacteria in the gut. These carbs (or starches) travel undigested to the colon, where they ferment and produce small chain fatty acids that feed the gut flora. Prebiotics encourage growth of good flora and crowd out the "bad flora"

    Patient counseling points:
    • Will not thicken in liquid, no taste, no gritty texture.
    • Will not alter taste of food or beverages.
    • May mix with water, juice, coffee, baked goods
    • Patients should avoid if they are gluten sensitive
    Calcium polycarbophil (FiberLax®, FiberCon & Equilactin): can be used for both diarrhea and constipation. Is a “stool normalizer”. Polycarbophil absorbs about ten times its own weight of water under acidic conditions, but the swells to 70 times its weight in the neutral pH of the small and large intestines.
    Each caplet contains 625mg calcium polycarbophil=500mg polycarbophil
    Dose: 2 caplet 1 to 4 times daily.

    We discuss another common problem that presents in our clinics, that in many cases can be ameliorated by adequate diet, exercise and hydration. The recommended levels for dietary fiber is 25 grams/day for adult women, 38 grams/day for adult men (consisting of fruits, vegetables, legumes, whole grains)

    About 90% of the US population does not consume this level of dietary fiber, averaging only 15 grams/day.

    "An apple a day keeps the doctor away" with its 4.4 gm of fiber. You will do better with a pear (5.5gm), or half of an avocado (6.75gm) or best of all 1 cup of navy beans at 19.1 grams! Adequate dietary intake as well as exercise and hydration might be all our patients need.

    Have a great day on the bench!!

    We do this every morning! You'll see things in a different way next time you flush!

    There are different types of constipation!!

    We clinicians have a real opportunity to bring comfort to our patients that present to us with constipation. We’ve been all trained to ask about stool frequency, consistency, remitting factors, diet, and exercise but we also need to inquire about the presence of pain. Pain in the belly seems to be the determining factor between Chronic Idiopathic Constipation(CIC) and Irritable Bowel Syndrome Constipation Predominant (IBS-C).

    But as always before we act on any such symptom we need to check the medication list for DRUGS frequently causing constipation:
    Medications that can affect the color of our stools (feces)

    Opioids Calcium channel blockers
    Anticholinergics Calcium carbonate
    Aluminum antacids Iron supplements
    Antidepressants Clonidine
    Antipsychotics Sucralfate
    Diuretics Cholestyramine


    CHRONIC IDIOPATHIC CONSTIPATION (CIC)

    Chronic idiopathic constipation is frequently referred to as “functional constipation”. It is estimated that 14% (as many as 35 million) patients may suffer from this condition.
    • Chronic constipation was more common in females, in older subjects, and those of lower socioeconomic status. 58% of patients suffering from CIC are female
    • Chronic constipation has also been linked to impaired quality of life, especially among the elderly.
    • 72% of CIC patients self-treat with OTC medications, while 13% receive prescription therapy.
    IRRITABLE BOWEL SYNDROME-Constipation predominant (IBS-C)
    Irritable bowel syndrome is defined as abdominal pain or discomfort associated with constipation. This condition is long-lasting and keeps recurring. Patients will have hard or lumpy stools at least 25% of the time, and loose or watery stools less than 25% of the time. It is estimated that 5% (as many as 13 million) patients may suffer from IBS-C. 64% of IBS-C patients are female, and 66% are under the age of 50, therefore this seems to be a “younger woman” problem.
    • Pain is what separates IBS-C from CIC, patients will complain “it feels like a knot in my guts”. 62% will experience abdominal pain.
    • 72% of the patients are constipated, and 59% will have incomplete evacuation on bowel movements
    • 57% of IBS- C patients will self-treat with OTC medications, while 15% will receive prescription medications.
    • OTC meds most often recommended by physicians
      • 52% fiber supplements: psyllium, methylcellulose, wheat dextrin etc.
      • 32% OTC laxatives: senna, docusate, bisacodyl etc.
    Next week we will begin discussions of the pharmacological treatment of constipation.

    We pharmacists are frequently asked what to recommend for constipation. We all have shelves full of laxatives. For the next couple of weeks we will discuss all of the treatment options for constipation, but first we need to know if we should even recommend a self-care product.

    Simply getting the bowels to move might not be adequate treatment for our IBS-C patients. Referral to a gastroenterologist is prudent when there is any type of belly pain or any appearance of blood in the stool.

    Have a great day on the bench!!

    February 2018

    We do this every morning! You'll see things in a different way next time you flush!

    The consistency of our patients stools depend on a lot of factors!!

    Getting to know your innards:
    How long does it take my food to digest? That depends on a lot of factors, depending on the food types we eat, and medications we might be taking to decrease our stomach acid. The pH of your stomach is 1.5 to 3.5, because your stomach excretes about 1.5 liters of gastric acid daily. Fat takes longer to leave the stomach than other foods, sometimes remaining in the stomach for up to six hours. Remember a big meal of a double burger and fries? You feel full for a very long time. Liquids take around 20-30 minutes to exit the stomach. Water and liquids do fill you up, but that effect doesn’t last very long. Complex carbohydrates break down at a slower rate than simple carbohydrates. Proteins take about 1.5 hours to leave the stomach.

    Usually, most of a regular-sized meal empties from the stomach within two hours. After that it takes about 6 hours to pass through the small intestine, where bicarbonate is added to the mix to bring the pH to a more neutral 7. Your small intestine as around 22.5 feet long and about 1.5 inches wide. Food enters the large intestine, which is around 5 feet long, for more digestion and absorption of water and essential vitamins. Undigested material gets pushed toward the anus for elimination. It takes an average of 33 hours (almost 1.5 days) for foods to reach from the mouth to the anus.
    Once it gets to the end, for elimination our stools can be graded for texture and even color depending on medications being taken: Bristol Stool Scale: is a scale that gastroenterologists use to “classify” our feces. Feel free to see the Bristol Stool Scale charts on-line!
    • Type 1: Separate hard lumps, nut-like in appearance
    • Type 2: Sausage-shaped, but lumpy
    • Type 3: Like a sausage but with cracks on its surface
    • Type 4: Like a sausage or snake, smooth and soft. (most normal stool)e
    • Type 5: Soft blobs with clear cut edge
    • Type 6: Fluffy pieces with ragged edges, a mushy stool
    • Type 7: Watery, no solid pieces, entirely liquid
    Medications that can affect the color of our stools (feces)

    Color Agents
    black Iron, charcoal, bismuth (PeptoBismol)
    Red or orange phenazopyridine, rifabutin, rifampin, or antacids with aluminum. Cefdinir interacts with iron in baby formulas, and breast milk
    White speckled Antacids with aluminum
    Yellow Alli (orlistat) or anything that inhibits fat absorption
    Green Chlorophyll, iron or drugs causing diarrhea (antibiotics, laxatives)
    Red or black tarry stools GI bleeding due to aspirin, NSAIDs, antiplatelet drugs, or anticoagulants
    Pale stools Liver injury from hepatoxic drugs


    Most of us seasoned practitioners have our own favorite stories about patients and their vivid descriptions of their bowel movements! Most often when they need a laxative they go to great lengths to describe their consistency of their stools.

    When I was first licensed an elderly gentleman came to the pharmacy and asked for a good "physic". He got a blank stare from this newly minted pharmacist. I asked him what he meant, and he said "Kid I need to take a good s---t" What a lesson in vocabulary building!

    I have also had patients on wax matrix potassium supplements bring in a "ghost tablet" from their stool to prove to me that the potassium I dispensed wasn't working because it did not dissolve!

    For the past 36 years I remember to tell all of my potassium patients about the ghost tablets and this is a normal sighting. My question is why don't the makers of potassium wax matrix tablets make them brown in color, rather than orange (Klotrix®) or bright yellow (K-tabs®) !

    Tomorrow morning when you flush the toilet, you will have a greater appreciation for your gastrointestinal tract! Next week we will start covering laxatives.

    Have a great day on the bench!!

    Not exactly billion dollar GI drugs... but they are still used!

    Miscellaneous GI drugs to treat GERD and Ulcers.

    We’ll wrap the last of the stomach drugs of the 1980’s three drugs with unique mechanisms of actions.
    SUCRALFATE (Carafate®) approved Oct- 1981 Indications: indicated in the short-term (up to 8 weeks) treatment of active duodenal ulcer. Because it does not suppress acid formation or release it is minimally effective for GERD.

    Mechanism: a mucosal protectant, nonabsorbable disaccharide containing sucrose and aluminum. It heals chronic ulcers without altering gastric acid or pepsin secretion or significantly buffering acid. It stimulates small-vessel formation, and granulation tissue. It binds to the injured tissue and protects it from pepsin and acid.

    Warnings/precautions/adverse effects
    • Constipation, metallic taste, hypophosphatemia (with long term)
    • Compliance problems with QID administration
    • Pregnancy Category: B
    Drug interactions – the aluminum salt is responsible for the impairment in the absorption of several drugs:
    • Bind tetracyclines & fluoroquinolones decreasing their absorption
    • Decreases warfarin absorption
    • Decreases digoxin & quinidine absorption
    • Decreases phenytoin absorption
    • Decrease levothyroxine absorption
    Counseling points:

    Sucralfate should be given on an empty stomach about half hour before meals to “coat” the lining of the stomach.

    Reglan® (metoclopramide) approved Dec-1980

    Indications: short term use (4-12 weeks) for GERD who fail to respond to conventional therapy. Also, used for diabetic gastroparesis. Metoclopramide (Reglan®) also used off label for improved lactation, by increasing serum prolactin. Generally used in patients with motility disorders, or if patients fail on high dose Proton Pump Inhibitors.

    Mechanism: is a dopamine antagonist (blocker) that stimulates motility of upper GI tract, without stimulating gastric, biliary or pancreatic secretions. Appears to sensitize tissues to acetylcholine.

    Warnings/precautions/adverse effects (Major)
    • Depression, restlessness, gynecomastia
    • Tardive dyskinesia
    • Extrapyramidal effects--Parkinson like symptoms
    • May cause drowsiness.
    • Pregnancy Category: B
    Drug interactions: increases alcohol absorption rapidly absorbed in small intestine. Decreases absorption of: cimetidine, digoxin.

    Patient counseling
    • Do not use for more than 12 weeks.
    • Dosed 5mg-10mg four times daily 30 minutes before meals and bedtime
    • Report any signs of tremor. A local neurologist tole me “Pete, before I check a suspected patient for Parkinson’s disease I always check the med list and look for metoclopramide”
    MISOPROSTOL (Cytotec® )Approved Dec-1988 Indications: prevention of NSAID gastric ulceration, in patients at high risk for complications (over 60, debilitating disease, history of ulcers) relief of GERD, reduced gastric acid secretions.
    Mechanism: has anti-secretory (inhibits gastric acid secretion) and mucosal protective properties. NSAIDs inhibit prostaglandin synthesis, a deficiency of prostaglandins within gastric mucosa may lead to diminished bicarbonate and mucus secretion, contributing to damage of gastric mucosa by NSAIDs. Misoprostol is a prostaglandin that increases bicarbonate, and mucus production, and maintains mucosal blood flow. Is also available combined with diclofenac as a single tablet (Arthrotec®)

    Warnings/precautions/adverse effects
    • Abortifacient: black box warning
    • Pregnancy Category-X
    • Diarrhea, abdominal pain up to 40% (usually dose related-take with food)
    • Use Contraceptives in female patients
    • Must have negative pregnancy test in the past 2 weeks.
    • Oral and written warnings.
    Drug interactions: none

    Back in November we talked about the fact that Tagamet was the first billion-dollar drug. The second drug to reach the billion-dollar drug rank was Zantac.

    By 1990 Zantac hit the two-billion-dollar mark. In the 1980’s there was a lot of interest in developing drugs for peptic ulcers, along with gastroesophageal reflux disease.

    A lot of us believe that the proliferation of these “stomach drugs” parallels the exponential increase in restaurants and fast food! Think about that the next time you pull the omeprazole, pantoprazole, esomeprazole, lansoprazole, rabeprazole, dexlansoprazole, ranitidine, cimetidine, famotidine and others off the shelf.

    Have a great day on the bench!!

    Flu season is in full swing... does oseltamivir make your cash register ring???

    $100.00 or more for one day of benefit... at best!

    Oseltamivir (Tamiflu) has been available for treatment of the flu since 1999. It works by inhibition of neuraminidase. By binding to neuraminidase proteins, oseltamivir prevents flu viruses from spreading from infected cells to other healthy cells. Oseltamivir is a prodrug and is pharmacologically similar to zanamivir. After oral administration, oseltamivir is readily absorbed from the gastrointestinal tract and extensively converted to the active metabolite.

    So far this flu season of 2018, influenza viruses have been susceptible to the neuraminidase inhibitor antiviral medications, which also includes zanamivir (Relenza®), and peramivir (Rapivab®).

    Indications for use:
    • Patients two weeks of age and older, who have had flu symptoms for 2 days (48 hours) or less. Oseltamivir is effective against both influenza type A and B. Therapy should begin within 48 hours of the onset of symptoms. Oseltamivir may reduce symptoms by 1 day.
    • Prevention of influenza A and B in patients one year of age and older
    Warnings/Precautions/ Adverse effects:
    • Nausea, vomiting, headache and pain.
    • Drug interactions: probenecid causes a 2-fold increase due to decreased tubular secretion.
    • CDC warning: November 13, 2006: The FDA approved a labeling supplement to include a precaution about neuropsychiatric events for Oseltamivir (Tamiflu®). Self-injury and delirium has been observed in Japan primarily among pediatric patients. Monitor pediatric patients for signs of unusual behavior.
    Representative Products:

    Tamiflu® (oseltamivir) 30mg, 45mg, 75mg capsules, (generics are available)
    and powder for suspension 6mg/ml: 60 ml per bottle Adults: 75mg twice daily for 5 days. Children: based on body weight If younger than 1 year old: 3 mg/kg/dose twice daily If 1 year or older, dose varies by child’s weight:
    • 15 kg or less, the dose is 30 mg twice a day (suspension: 5ml BID)
    • >15.1 to 23 kg, the dose is 45 mg twice a day (susp: 7.5ml BID)
    • >23.1 to 40 kg, the dose is 60 mg twice a day (susp: 10ml BID)
    • >40 kg, the dose is 75 mg twice a day (susp: 12.5ml BID)
    Patients should start the 5-day regimen as soon as possible. Take two doses the first day, no matter when the prescription is received.

    The prophylaxis dose is the same as above EXCEPT all doses are given ONCE daily for 10 days. Patients need to be over 1 year of age to receive prophylaxis.

    What oseltamivir doesn’t do:
    • It does not prevent bacterial infections
    • It is NOT a substitute for the annual flu vaccine
    • Of no value if started later than 48 hours after onset of symptoms.
    APPROACH WHEN TAMIFLU (oseltamivir) liquid is not available: (from the Tamiflu® website) For patients who cannot swallow capsules, TAMIFLU for oral suspension is the preferred formulation.
    • When TAMIFLU for oral suspension is not available from wholesaler or the manufacturer, TAMIFLU capsules may be opened and mixed with sweetened liquids such as regular or sugar-free chocolate syrup, corn syrup, caramel topping, or light brown sugar (dissolved in water).
    • During emergency situations and when neither the oral suspension or the age-appropriate strengths of TAMIFLU capsules to mix with sweetened liquids are available, then a pharmacist may prepare an emergency supply of oral suspension from TAMIFLU 75 mg capsules.
    The following chart shows how to make Tamiflu in an oral suspension of 6mg/ml

    Total Volume of Prepared Oral Suspension 37.5ml 75ml 100ml 125ml 150ml
    Number of Tamiflu 75mg strength
    capsules (total strength)
    3 capsules (225mg oseltamivir) 6 capsules (450mg oseltamivir) 8 capsules (600mg oseltamivir) 10 capsules (750mg oseltamivir) 12 capsules (900mg oseltamivir)
    Amount of water 2.5ml 5ml 7ml 8ml 10ml
    Volume of vehicle (Cherry Syrup (Humco);
    OR Ora-sweet SF (Paddock Laboratories) OR simple syrup
    34.5ml 69ml 91ml 115ml 137ml


    STEPWISE DIRECTIONS:
    1. Place specific amount of water in PET or Glass bottle
    2. Separate capsules and pour powder from those capsules into bottle
    3. Gently swirl suspension to ensure adequate wetting of powder
    4. Slowly add specified amount of vehicle. Use only the vehicles listed above. Cap the bottle.
    5. Shake well for 30 seconds. Add shake well label to bottle.
    6. Stability
      1. Refrigeration: Stable for 5 weeks (35 days) when stored in a refrigerator at 2° to 8°C (36° to 46°F).
      2. Room temperature: : Stable for five days (5 days) when stored at room temperature, 25°C
    7. Counsel patient on storage, instruct to shake well, discuss dosing regimen, provide a liquid measuring device.


    Remember rimantadine (Flumadine®) and amantadine (Symmetrel®)? High levels of resistance to amantadine and rimantadine persisted among circulating influenza A viruses. Adamantanes are not effective against influenza B viruses. They have not been recommended for treatment of the flu for at least 10 years.

    All we have in the prescription department to combat influenza are the neuraminidase inhibitors. I have not dispensed Relenza® (zanamivir) in years. When I see many copays crashing the $100.00 mark, as many of elderly have not met their Medicare-D deductibles, we often put the medication back in stock.

    When we see that oseltamavir only shortens the duration by a little over one day, and has to be started within 48 hours of onset, we can see how important influenza vaccines are!

    Frequent hand washing, avoiding sick people, covering mouth and nose when sneezing are all practical tips for staying healthy this time of the year. Remember the flu virus can “live” on some surfaces for up to 24 hours. Routine cleaning of surfaces may reduce the spread of flu.

    Oseltamivir with its high cost over $100 for many, the narrow window of opportunity, and limited efficacy fo shortening flu by one day, make those flu shots in October very important indeed!

    Have a great day on the bench!!

    Hand Holding and dry crackers can only go so far in treating hyperemesis gravidarum. Prescription treatment might be warranted

    Help for Mom, when she needs it the most! Rx treatment of hyperemesis gravidarum

    Last week we discussed using two rather common over the counter medications (with physician’s approval) Vitamin B-6 and Doxylamine. As discussed, this combo could be used instead of the very expensive Diclegis®. However, Diclegis is the only FDA approved drug for treatment of nausea of pregnancy.

    The other prescription drugs listed below are being used off label for treatment of nausea and vomiting of pregnancy. This week we can discuss the prescription treatment of nausea of pregnancy, and the more intensive form: hyperemesis gravidarum.

    I’m well aware that the FDA is phasing out the traditional pregnancy categories, but they still serve as a guide for many clinicians



    DRUG THERAPY FOR NAUSEA OF
    PREGNANCY/ HYPEREMESIS GRAVIDARUM
    Pregnancy Category Comments
    Doxylamine (Unisom®) A Very safe combined with B-6
    Pyridoxine (Vitamin-B6®) A First line. Alone or in combo with Doxylamine
    Diclegis® 10mg/10mg (doxylamine succinate and
    pyridoxine hydrochloride delayed-release tablets)
    A Only FDA approved treatment for nausea of pregnancy; not for hyperemesis gravidarum
    Dramamine (Dimenhydrinate)
    Diphenhydramine (Benadryl)
    Meclizine (Antivert/Bonine/Dramamine-II)
    B Generally safe- may cause drowsiness. None are considered to be teratogenic
    Dolasetron (Anzemet®)
    Granisetron (Kytril®)
    Ondansetron (Zofran)
    B Limited human data- animal data suggests low risk. Zofran –most studied-
    Metoclopramide (Reglan®) B Watch Mom for drug induced movement disorder. Monitor baby for extrapyramidal symptoms at birth.
    Hydroxyzine (Atarax & Vistaril®) C Caused 5.8% rate major birth defects
    Chlorpromazine (Thorazine®)
    Perphenazine (Trilafon®)
    Prochlorperazine (Compazine®)
    Promethazine (Phenergan®)
    C All considered as 3rd line agents. Watch for QT prolongation and extrapyramidal effects, and movement disorders.
    Corticosteroids C
    D-1st trim
    Oral clefting first trimester exposure. Last resort.


    Ondansetron (Zofran) can be dosed at 4mg every 8 hours, up to a maximum dose of 16mg/dose. Ondansetron can cause QT prolongation, and serotonin syndrome in susceptible patients. As far as the baby goes there is a slight increase in heart defects and cleft palates, but most obstetricians feel the very small risk of these side effects are superseded by all of the well-known problems of prolonged dehydration caused by nausea and vomiting.

    According to the American College of Obstetrics and Gynecology (ACOG) prenatal vitamins in the preconception period may reduce the severity of nausea and vomiting in early pregnancy. Most clinicians do not recommend ginger supplements, due to lack of standardization, but will recommend ginger containing food such as lollipops, candy, and tea.

    Hyperemesis may lead to dehydration, vitamin deficiency, and weight loss, therefore, adequate hydration, vitamin replacement, nutrition, and antiemetic therapy is critical to avoid maternal morbidity. Most physicians feel the risk of ondansetron therapy is worth the benefit.

    So often with our pregnant population when they complain of nausea, reassuaance and dietary modifications may be all that is necessary. Basic recommendations include avoiding stimuli that trigger nausea and vomiting such as sensory stimuli to strong odors, and other sensory stimuli such. Dietary counseling about frequent small meals and avoidance of spicy or fatty foods is appropriate even though the evidence is lacking for such a recommendation.

    Most obstetricians are quite comfortable using ondansetron for nausea and vomiting of pregnancy. Now that the generics are so inexpensive obstreticians seldom hesitate to use it if needed. Remember back in 2012, when Zofran 4mg was $22.00 per tablet! We have a lot of reasonable priced medications to treat these women with very safe drugs to insure a happy and healthy pregnancy.

    Have a great day on the bench!!

    January 2018

    Help share the joy with the new mother, and make her tummy feel better too!

    Treatment and Prevention of Nausea of Pregnancy

    Often referred to as “morning sickness” 75-80% of pregnant patients complain of morning or evening nausea. The peak time for morning sickness is in the first trimester between weeks 5-12 of pregnancy. Most women experience this discomfort, and by adjusting diet or routines, have minimal difficulty as resolution occurs at the beginning of the second trimester.

    Hyperemesis gravidarum – the worst kind of morning sickness: 15% of pregnancies experience nausea and vomiting until delivery. Persistent vomiting may cause weight loss, dehydration, starvation ketosis, hypochloremic alkalosis and hypokalemia. This severe vomiting might also lead to transient elevation of liver enzymes.

    The exact cause of nausea and vomiting during pregnancy is unknown. However, it is believed to be caused by a rapidly rising blood level of human chorionic gonadotropin (HCG), which is produced in the placenta. High levels of HCG is most common with multiple gestations. High-fat diets and Helicobacter pylori infection also contributes to the incidence and severity of hyperemesis gravidarum. Helicobacter pylori, the bacteria that causes stomach ulcers in the general population, is seen in 90% of the patients with hyperemesis gravidarum.

    • Reassurance and dietary advice is all that is required in most instances.
    • Best to hospitalize patient in private room with bed rest.
    • The hospitalized patient should not eat or drink (NPO) for 48 hours, electrolyte balance and hydration should be maintained by parenteral nutrition.
    • Place patient on “dry diet” plus clear liquids 1 hour after eating.
    • Get plenty of rest.
    • Avoid smells that are bothersome.
    • Eat five or six small meals each day instead of three large meals.
    • Eat small snacks high in protein (such as a glass of milk or a cup of yogurt) throughout the day.
    • Avoid spicy foods and fatty foods.
    First line (always weigh risks versus benefits). Most over-the counter products do carry pregnancy warnings, so it is safest to use these products on a physician’s recommendation.

    • Vitamin-B-6 (pyridoxine) 10-25mg every six hours. Most often dosed at night before bed, then additional doses in the morning and in the late afternoon, IF NEEDED
    • Doxylamine (Unisom®) since 25mg is the lowest dose available in the United States, it is reasonable to use 12.5 to 25mg along with the dose of pyridoxine at bedtime, then in the morning and late afternoon if needed. Just make sure the patient is buying the “Sleep-tabs®” which contain doxylamine, and not SleepGels® which contain diphenhydramine.
    DICLEGIS: fixed dose combination drug product (Delayed-release tablets containing 10mg doxylamine succinate and 10 mg pyridoxine hydrochloride) direct cost is nearly $700 per 100 tablets Dosage: Take two tablets daily at bedtime. The dose can be increased to a maximum recommended dose of four tablets daily one in the morning, one mid-afternoon and two at bedtime. (cost: $600.00/ 100 tablets). BONJESTA is the same combination, but each tablet contains 20mg of pyridoxine and doxylamine.

    Writing this column takes me back 32 years ago, when my wife Denise was pregnant with our second daughter Elizabeth. She was the textbook case for hyperemesis gravidarum. She lost so much weight during her pregnancy, she weighed less after delivery than before she got pregnant!

    Of course back in 1986, we didn't have the medications we do today to help control the nausea and vomiting, on an outpatient basis. At her check-up her obstetrician was so disturbed by her weight loss, he admitted her to the hospital, for IV fluids to re-hydrate her. After spending a few days in the hospital she came home, and was able to eat small meals. She never fully got back her appetite until delivery.

    Next week we will discuss the prescription therapy for hyperemesis gravidarum. For simple cases of nausea, the pyridoxine and doxylamine may be of great benefit. Many of us seasoned pharmacists remember Bendectin® which was withdrawn by the manufacturer, as they got tired of defending this product in court.

    The ingredients in Bendectin, are the same as in Diclegis, which are rated as Pregnancy Category-A: " Controlled studies show no risk or find no evidence of harm" With the physician’s approval we can easily save our patients over $500.00 per month by substituting these over-the-counter recommendations.

    Have a great day on the bench!!

    We'll have lots of educating to do with our patients. FDA labeling changes on fat soluble vitamins are sure to cause lots of confusion.

    Hey, are you out of Vitamin D-2000? All I see out here is Vitamin-D 50!!

    I was dumbfounded when our OTC manager brought back a bottle of Vitamin-D and asked what this microgram stuff is about? Don't they make Vitamin D-2000 any more??

    In May 2016, the U.S. Food and Drug Administration (FDA) announced regulations that require amendments to the existing supplement facts label, which uses units and conversions based on the Recommended Daily Allowances that were established back in 1968. The new regulations will be mandatory in 2019-2020. On Sept. 29, 2017, the FDA released its proposed rule to extend the compliance dates for Supplement and Nutrition Facts Labeling. The agency said it wanted to give manufacturers more time to comply, citing concerns from stakeholders that the current deadlines would not give them enough time to do so. Some of the vitamin companies have made the labeling change, which I’m sure will cause a lot of confusion, both for patients and prescribers. Let’s hope EPIC and other electronic medical records convert soon, as the new nomenclature is appearing on our shelves!

    To convert Vitamin A as retinol:
    From IU to mcg: IU/3.33 = mcg


    INTERNATIONAL UNITS
    (old labeling)
    MICROGRAMS
    (new labeling)
    5000iu 1500mcg (1.5mg)
    8000iu 2400mcg (2.4mg)
    10,000iu 3000mcg (3mg)


    To convert Vitamin A as beta-carotene:
    From IU to mcg: IU/1.66 = mcg


    INTERNATIONAL UNITS
    (old labeling)
    MICROGRAMS
    (new labeling)
    25,000iu 15,000mcg (15mg)


    To convert Vitamin D:
    From IU to mcg: IU/40 = mcg


    INTERNATIONAL UNITS
    (old labeling)
    MICROGRAMS
    (new labeling)
    400iu 10mcg
    800iu 20mcg
    1000iu 25mcg
    2000iu 50mcg
    5000iu 125mcg
    50,000iu 1250mcg= 1.25mg


    To convert Vitamin E if the product label has dl-Alpha-tocopherol (blended) as the ingredient:
    From IU to mg: IU * 0.9 = mg

    INTERNATIONAL UNITS
    (old labeling)
    MICROGRAMS
    (new labeling)
    30iu 27mg
    100iu 90mg
    200iu 180mg
    400iu 360mg
    800iu 720mg
    1000iu 900mg


    To convert Vitamin E if the product label has d-Alpha-tocopherol (pure d-alpha) as the ingredient:
    From IU to mg: IU * 0.67 = mg

    INTERNATIONAL UNITS
    (old labeling)
    MICROGRAMS
    (new labeling)
    30iu 20.1mg
    100iu 67mg
    200iu 134mg
    400iu 268mg
    800iu 536mg
    1000iu 670mg


    I called our primary vitamin vendor, and asked why they made these label changes. She assured me those changes are being made by the FDA's insistence. I asked her if they are providing conversion charts for the pharmacies, and prescribers. She answered, "not that I know of !"

    Some of the labels are not "cross referenced" so we might not see both strengths on the label. According to the FDA both micrograms and international units may be on the label. I looked all over for charts for the conversions for the new labeling changes for the fat soluble vitamins.

    So in my frustration I created this chart, so you wouldn't have to. Feel free to copy this chart, make shelf talkers out of it, anything to take care of your patients.

    The next vitamin representative that comes to my store, will face a very long discussion. I'm all for FDA compliance, but I'm also for excellent patient care! The vitamin companies need to "step up" and assist the health care practitioners in this conversion.

    Have a great day on the bench!!

    Treatment of diarrhea... should we or shouldn't we??

    What goes along with nausea and vomiting?

    Why of course it is diarrhea!! Diarrhea, like vomiting is frequently due to a response of the gastrointestinal tract to remove bacteria and toxins. The most frequent problem that diarrhea causes is dehydration. As with vomiting, our goal for patients with gastroenteritis is to prevent dehydration.

    This is the time of year we see patients standing in the gastrointestinal section, holding a box of Imodium, and looking our way for some help. Before you pull that box of loperamide off the shelf, I have a few (actually quite a few) questions?
    • How long and how often do you have these episodes?
    • Any other symptoms?
    • Which anti-diarrhea medications have you tried?
    • Characteristics of your stool?
    • Have you changed your diet? Drinking non-chlorinated water?
    • Have you recently traveled to a foreign country?
    • Anyone in your household have diarrhea or can you contribute it to a particular food?
    • What medications are you currently taking?
    • Any medical conditions or chronic illnesses?
    Refer to physician immediately if any of the following (source: cdc.gov)
    • Elderly age
    • History of chronic medical conditions or concurrent illness
    • Fever over 102.2 °F
    • Visible blood in stool
    • High output of diarrhea, including frequent and substantial volumes of stool
    • Persistent vomiting
    • Signs consistent with dehydration (e.g., sunken eyes or decreased tears, dry mucous membranes, orthostatic hypotension or decreased urine output)
    • Change in mental status (irritability, apathy, or lethargy)
    • Suboptimal response to oral rehydration therapy already administered or inability to administer oral rehydration therapy
    May I check your med list?
    Here are some drugs that have the potential to cause diarrhea:
    • Laxatives
    • Antibiotics (broad spectrum)
    • Magnesium salts
    • Propranolol
    • Parasympathomimetics (pilocarpine, cevimeline bethanechol)
    • Metoclopramide
    • Digitalis
    • Colchicine
    • Seldom used drugs: indomethacin, methyldopa, theophylline, misoprostol
    What if it is the “Stomach flu”- gastroenteritis:
    • Follow rehydration protocol as for nausea and vomiting. Oral rehydration solutions (Pedialyte®)
    • Antimotility agents such as (diphenoxylate/atropine) Lomotil® or (loperamide) Imodium® should be considered only in adult patients who are NOT febrile or having bloody/mucoid diarrhea. Antimotility agents may reduce diarrheal output and cramps, but do not accelerate cure.
    • Antimotility agents are generally contraindicated for children.
    'Tis the season for the big three... nausea, vomiting and diarrhea. I had three different patients today, presenting with flu symptoms. I have yet to dispense Tamiflu® (oseltamivir) which is approved by the FDA for treatment of acute uncomplicated influenza within 2 days of illness onset. Most patients seem to be well past that 48 hour window where oseltamivir is effective, when they seek medical advice.

    With Tamiflu's wholesale acquisition cost being over $150.00, and the generic being over $100.00 is it a good investment to treat most of our patients? I'm a believer in re-hydration, management of fever with acetaminophen and of course frequent hand washing!

    Refer patients to the physician when appropriate. Be sure to share the information in the past three Clinician Corner Columns with your patients, especially with regard to hydration and introduction of solid foods.

    Have a great day on the bench!!

    OTC treatment for Nausea and Vomiting--- a lot cheaper than a visit to the Emergency Department!

    OTC treatment options for treatment of vomiting...

    Now that we have had the big “germ exchange” also known as the holiday season, a lot of patients are coming to ask our advice for treatment of nausea and vomiting. I know of one physician office where they tell the patients to stay home, keep hydrated and stay off work! The nurses won’t even give the adult patients an appointment! We talked in previous columns about the viruses that cause nausea and vomiting.
    Last week we discussed the prescription treatment of nausea, so this week we can address the needs of those patients who come to us first for treatment of this quickly spreading viral gastroenteritis. The first concern we will always have is that our patient doesn’t get dehydrated. That must be the first, and only concern we should have. As we discussed before vomiting is our body’s way of getting rid of bacteria, viruses and toxins that shouldn’t be there. Our goal need not so much be stopping of the vomiting, rather the prevention of dehydration.

    Signs and symptoms of DEHYDRATION
    • Dry or sticky mouth
    • Lethargy or coma (severe dehydration)
    • Low blood pressure
    • Low or no urine output, concentrated urine that looks dark yellow. (Consult MD if more than 8 hours)
    • Sunken soft spots (fontanelles) on the top of an infant's head. (Consult MD)
    • No tears
    • Sunken eyes
    We have a couple of products over-the counter that are traditionally used for nausea. Their efficacy is doubtful.
    • Emetrol®: mixture of dextrose, fructose and phosphoric acid. Is hyperosmolar and works on GI wall to decrease smooth muscle contraction and delay gastric emptying time. Best for food and drink nausea.
    • Cola syrup (Coke®) contains the same sugars and phosphoric acid. Don’t use regular soda, even de-fizzed.
      • 2-12 years old: 5-10 ml every 15 minutes until vomiting stops; not to exceed 5 doses per hour. Not recommended if under 2 years
      • 12 years old: 15-30 mL every 15 minutes until vomiting stops; not to exceed 5 doses per hour
    WHO (World Health Organization) ELECTROLYTE FORMULATION:
    Available on-line, recipe and dosing. Contains: sodium chloride, potassium chloride, sodium bicarbonate, sugar and water.

    Commercially Available Electrolyte Replacements
    • Oral fluids should be replaced quickly, but in a controlled fashion, to prevent the dehydration from becoming more severe. Recommend a teaspoon (5 mL) every five minutes until the patient can tolerate more.
    • Oral replacement should start at 50 to 100 mL/kg with an extra 2 mL/kg for each emesis or 10 mL/kg for each loose stool.
    • Pedialyte®: is an oral electrolyte replacement solution, sold in liters and a variety of flavors: bubble gum, mixed fruit, plain, blue raspberry, cherry punch, grape. Generic formulations are available.
    Dosing of Electrolyte Solutions
    • For infants under 1 year of age: Consult your doctor.
    • For children 1 year and older and adults: Begin with small frequent sips every 15 minutes, increasing serving size as tolerated. Continue for as long as diarrhea is present.
    • To maintain proper hydration, 1-2 liters (32 to 64 fl oz) of Pedialyte may be needed per day. Consult your doctor if vomiting, fever, or diarrhea continues beyond 24 hours or if consumption needs are greater than 2 liters (64 fl oz) per day
    WHAT TO AVOID: Fluids to be avoided include:
    • hypertonic fruit juices and drinks
    • carbonated beverages and caffeine containing beverages,
    • powered gelatin mixes which can make diarrhea worse, and lack the necessary electrolytes.
    • Even our beloved Gatorade diluted with water, still contains too much sugar for treatment of diarrhea. If anything, recommend sugar free Gatorade (G2®)
    The return to solid foods: BRAT diet:
    The BRAT diet is a bland-food diet that is often recommended for adults and children. BRAT stands for Bananas, Rice, Applesauce and Toast. The BRAT diet helps recovery upset stomach or diarrhea for the following reasons:
    • It includes “binding” foods. These are low-fiber foods that make stools firmer. It includes bananas, which are high in potassium and help replace nutrients the body has lost because of vomiting or diarrhea.
    • Some clinicians feel this diet lacks adequate protein for long term use.

    I remember as a student pharmacist that one of my jobs was pouring "Coca-Cola®" syrup into four ounce bottles. We would buy our Coke syrup in gallon jugs, package them up, slap on a label from the Coca-Cola company onto the amber bottle giving directions for use. Most of the time we would tell patients to dump the Coke syrup over crushed ice and sip slowly.

    This activity of bottling up Coke syrup came to a screeching halt after the Tylenol Tragedy of 1982, when tamper resistant packaging was required for Over-the Counter sales. Today we buy it nicely packaged in four ounce bottles from a variety of distributors under the name "Cola Syrup"

    With the every sky-rocketing prices of an Emergency Department visit, we pharmacists can save the health system a pile of money by treating vomiting over-the counter. I have a flyer I created on the BRAT diet that I share with my patients. Often when the nausea subsides they start eating a regular diet which seems to aggravate the gastrointestinal tract.

    The BRAT diet for a day or so seems to be an easy way to ease back into a normal diet. Keep reminding your patients that effective hand washing is the most beneficial way to prevent viral gastroenteritis.

    Wishing you and your family a Health and Happy 2018!

    Have a great day on the bench!!

    December 2017

    Treatment of nausea and vomiting... lots of receptors we can block!

    Prescription treatment of nausea and vomiting

    Antihistamine-anticholinergic agents (histamine-1 blockers)
    Examples: doxylamine (Unisom), diphenhydramine (Benadryl), hyoscyamine (Levsin)


    Indication: for mild nausea and vomiting. Are of greater benefit in prevention of nausea arising from motion sickness.

    Mechanism: appear to interrupt various visceral afferent pathways, that stimulate nausea and vomiting. Most antihistamines do have anticholinergic activity, and can be useful for nausea and motion sickness.

    Adverse effects: Drowsiness, confusion, blurred vision, dry mouth, urinary retention, possible tachycardia in elderly. Increased sedation with alcohol—careful on cruise ships!


    Phenothiazines (dopamine blockers)
    Examples: promethazine, prochlorperazine, haloperidol

    Promotility agents (dopamine blockers)
    Example: metoclopramide (Reglan)


    Indication: more severe nausea and vomiting. Are inexpensive and are used for long term nausea. Most useful in patients with viral gastroenteritis or those receiving mildly emetogenic doses of chemotherapy.

    Mechanism: act on the CTZ (Chemoreceptor trigger zone) by inhibiting dopaminergic transmission. Also decrease vomiting caused by gastric irritants suggesting they inhibit stimulation of peripheral vagal and sympathetic afferents. Metoclopramide (Reglan) has a unique mechanism of action that is to stimulate motility in the upper GI tract. Metoclopramide has a similar side effect profile to the phenothiazines.

    Adverse effects: Extrapyramidal reactions, Parkinson-like side effects, hypersensitivity with possible liver dysfunction, marrow aplasia, excessive sedation

    5-HT-3 Receptor Antagonist (serotonin blockers)
    Examples: ondansetron (Zofran) granesitron (Kytril)


    Indication: effective in prevention of chemotherapy induced vomiting. Also, effective for post-op nausea, and radiation induced nausea. Frequently combined with corticosteroids (dexamethasone or methylprednisolone) for maximal emesis control.

    Mechanism: mucosal entero chromaffin cells in the GI tract release serotonin which stimulates 5HT3 receptors. This causes vagal afferent discharge, inducing vomiting. With the binding of the 5HT3 receptors serotonin stimulation is blocked and hence vomiting is blocked.

    Adverse effects: headache, constipation, Can prolong the QT interval. May cause torsades, ventricular arrhythmias, or sudden death. If given to a high-risk drug to a high-risk patient such as the elderly, women, or those with heart failure, bradyarrhythmias, or low serum potassium or magnesium.

    NK-1 receptor antagonist
    Example: aprepitant (Emend)


    Indication: antiemetic in combination with other antiemetics for nausea with highly emetogenic cancer chemotherapies
    Mechanism: selective high affinity antagonist or human substance –P/ neurokinin-1 receptor. Little or no affinity for 5-HT3, dopamine, and corticosteroid receptors. Antagonizes the NK-1 receptor
    Adverse effects: Many GI, cardiovascular and CNS effects, diaphoresis and alopecia, drug interactions

    Cannabinoids
    Examples: dronabinol (Marinol) , marijuana


    Indication: used as an appetite stimulant and antiemetic. Effective in treating nausea caused by chemotherapy, but associated with CNS side effects in most patients.
    Mechanism: THC (tetrahydrocannabinol) appears to affect the central cerebral cortex axis. Available as dronabinol. Antiemetic effect associated with a “high” and appears better tolerated in the young.
    Adverse effects: Orthostatic hypotension, drowsiness, sedation, dry mouth, euphoria

    Keep in mind that the reason we have vomiting is a protective mechanism to keep our body from retaining harmful bacteria, viruses and toxins. Suppression of vomiting should be necessary only after a few days, and dehydration can occur. Next week we will discuss the over-the counter treatments, as well as patient care information for vomiting


    I remember when Reglan (metoclopramide) came out in the early 1980's to much fanfare as another treatment option for GERD. It was the first treatment option since the phenothiazines in the 1950's!! It quickly became the "go to" for nausea and vomiting for the oncology doctors. We quickly found out that the 10mg four times daily dose caused a lot of Parkinson like side effects.

    I had a neurologist tell me "Pete, before I even check a patient for cogwheel rigidity to diagnose Parkinson's disease, I check the med list and look for Reglan first!" Usually drug induced Parkinsonism presents as a bilateral tremor. Parkinson's disease usually first presents as a tremor on one side, before progressing to the other side.

    In the 1990's ondansetron (Zofran) became available. I remember when Zofran was nearly one thousand dollars for a bottle of 30. We only used Zofran for nausea induced by cancer chemotherapy. Today the generics cost the pharmacy less than ten dollars for a bottle of 30 tablets, and I see ondansetron being used for any kind of nausea and vomiting from chemo, nausea of pregnancy to simple GI upset!

    Have a great day on the bench!!

    Be sure to avoid these "uninvited guests" at your next Holiday Party!!

    Vomiting... don't let it ruin your holidays.

    Vomiting is a protective reflex that allows us to rid ourselves of ingested toxins or poisons. There are five principle neurotransmitter receptors responsible for vomiting. Gastroenteritis is most commonly associated with the dopamine and serotonin receptors. I have listed examples of drugs that react with those receptors:

    Name of Receptor Drug working on that receptor
    muscarinic (M1) anticholinergics: dicyclomine (Bentyl), hyoscyamine (Levsin))
    dopamine (D2) metoclopramide (Reglan), prochlorperazine (Compazine)
    histamine (H1) diphenhydramine (Benadryl) doxylamine (Unisom)
    serotonin (5HT3) ondansetron (Zofran), granisetron (Kytril)
    neurokinin 1 (NK1) Aprepitant (Emend)


    Who invited these guys to my Christmas Party…? Listed below are the three most common viruses implicated in nausea and vomiting.
    • Norovirus (Norwalk-like virus) is common among school-age children. It may also cause outbreaks in hospitals and on cruise ships. It is the most common GI virus.
    • Rotavirus is the leading cause in children. It can also infect adults who are exposed to children with the virus, and people living in nursing homes. Vaccination has greatly reduced this virus
    • Enteric adenovirus: can cause systemic infection
    The Christmas Germ Exchange- We exchange presents, cards, food, handshakes, hugs and kisses at Christmas time. We also exchange a lot of bacteria and viruses!
    • Most viruses and bacteria are passed from person to person by unwashed hands. Other potential causes can be:
      • Improper handling of food
      • Improper cooking of shellfish
      • Improper hand washing after toileting
      • Surfaces not properly sanitized after food preparation.
    • A vaccine to prevent rotavirus infection is recommended for infants starting at age 2 months. (Rotavirus is the leading cause of viral gastroenteritis in kids up to 2 years of age)
    .
    I have this vomiting …was it something I ate at the party??

    Raw seafood Norwalk-like virus, Vibrio, hepatitis A
    Raw eggs Salmonella
    Undercooked meat or poultry Salmonella, Campylobacter, E. coli (STEC), Clostridium perfringens
    Unpasteurized milk or juice Salmonella spp, Campylobacter, E. coli, Yersinia enterocolitica
    Unpasteurized soft cheeses Salmonella, Campylobacter, E.coli (STEC) Yersinia enterocolitica, Listeria monocytogenes
    Homemade canned goods Clostridium botulinum
    Raw hot dogs, deli meat Listeria monocytogenes


    GETS YOU SICK (less serious) GETS YOU TO THE HOSPITAL (serious)
    Novovirus Clostridium botulinum
    Salmonella Listeria
    Clostridium perfringens Shiga-Toxin producing Escherichia coli (STEC)
    Campylobacter Vibrio
    Staphylococcus aureus


    Now What Happens??
    • The CTZ (chemoreceptor trigger zone) is located in the 4th ventricle of the brain. It is the major chemosensory organ for emesis, usually associated with chemically induced vomiting. Because of its location, blood-born and cerebrospinal fluid toxins have easy access to the CTZ. It is our defense against ingesting poisons; our brain works to eliminate these toxins form our GI tract. This mechanism frequently “kicks in” during cancer chemotherapy. This mechanism also “kicks in” to eliminate those toxins and viruses that we are exposed to these holidays.
    Next week we will discuss treatment of nausea and vomiting.

    Hand-washing should be our first line of defense against the bacteria and viruses that can cause vomiting.

    Here is what the CDC says about hand washing on their website:

    "Hand-washing is like a "do-it-yourself" vaccine—it involves five simple and effective steps (Wet, Lather, Scrub, Rinse, Dry) you can take to reduce the spread of diarrheal and respiratory illness so you can stay healthy. Regular hand-washing, particularly before and after certain activities, is one of the best ways to remove germs, avoid getting sick, and prevent the spread of germs to others. It's quick, it's simple, and it can keep us all from getting sick. Hand-washing is a win for everyone, except the germs."

    Source: CDC

    Have a great day on the bench!!

    Antacid therapy --- not as harmless as we might believe??

    Antacids: Warnings, Precautions and Drug Interactions

    After last week’s inorganic chemistry lesson, lets get down to the information that impacts our patients! All the reactions had one thing in common, generation of a chloride salt: aluminum chloride, magnesium chloride, calcium chloride or sodium chloride. Many of our patients can experience adverse effects from these mono and polyvalent cations..

    Warnings/precautions/adverse effects of antacid therapy.
    • Use calcium carbonate, and magnesium antacids cautiously in renal impaired patients
    • Sodium bicarbonate is contraindicated in hypertension, heart failure, renal disease & edema. Do not use for ulcers. Zegerid OTC contains both omeprazole and sodium bicarbonate.The manufacturer states sodium bicarbonate “protects the omeprazole from stomach acid”, but still it is sodium bicarbonate!
    • Use antacids cautiously in elderly where there is decreased GI motility
    • Aluminum containing antacids cause constipation.Use with caution with patients suffering with dehydration or intestinal obstruction.Caution in dialysis patients.
    • Chronic administration of calcium carbonate should be avoided because of hypercalcemia, and because calcium ions cause further stimulation of acid secretion.Calcium carbonate causes constipation.
    • Magnesium containing antacids may cause diarrhea.
    • Hypophosphatemia and osteomalacia can occur with long term use of aluminum hydroxides, but can occur with short term use in malnourished patients like alcoholics.
    Drug interactions with antacid therapy:
    • Tetracyclines & fluoroquinolones are BOTH bound by antacids. Separate tetracyclines by 2 hours, and fluoroquinolones by 4 hours.
    • Enteric coated drugs: coating is destroyed by antacid exposure.
    • Antacids interfere with absorption of: digoxin, cimetidine, ranitidine, anticholinergics, phenothiazines, phenytoin, quinidine and ketoconazole (they require acid for absorption). Separate these drugs from antacids by 2 hours.
    • Separate from Levothyroxine (Synthroid) by 4 hours
    .
    After reviewing all of the potential drug: antacid interactions we pharmacists have another opportunity to interact with our patient population in providing expertise. Antacid therapy is not as innocuous as we might believe.

    Have a great day on the bench!!

    Did you eat too much at your holiday party??

    Antacid Therapy

    Indications for antacid therapy: Antacids today should be only used short term. Antacids work quickly to treat ulcer pain and heal ulcer. They neutralize gastric acid, which in turn increases Lower Esophageal Sphincter (LES) tone. The LES tone is important to keep the gastric contents from “splashing up” into the esophagus. Antacids inhibit the conversion of pepsinogen to pepsin thus raising the pH of the gastric contents.

    Antacids have a rapid onset (5-15min) short duration (30-60minutes). They are ideal for immediate relief of gastrointestinal distress.

    Mechanism: reduces concentration and total load of acid in gastric contents. The hydroxide ions or the carbonate ions neutralize the hydrogen ions (H+).

    Active ingredients of antacid therapy: the chemistry behind antacid therapy:

    Aluminum hydroxide: Al(OH)3 + 3HCl à AlCl3 + 3 H2O. Aluminum hydroxide plus hydrochloric acid produces aluminum chloride and water.

    Magnesium hydroxide: Mg(OH)2+2HCl à MgCl2+2H2O. Magnesium hydroxide plus hydrochloric acid produces magnesium chloride and water.

    Calcium carbonate: CaCO3 + 2HClà CaCl2 + H2O +CO2. Calcium carbonate plus hydrochloric acid produces calcium chloride, water and carbon dioxide

    Sodium bicarbonate: NaHCO3 + HClà NaCl + H2O + CO2. Sodium bicarbonate plus hydrochloric acid produces sodium chloride, water and carbon dioxide

    Simethicone is frequently included in antacid formulations as an “anti-gas” agent: Mechanism: silicon polymers that reduces surface tension of gas bubbles embedded in the intestinal mucosa. Simethicone is often added to antacids to reduce gas pain. The gas bubbles then coalesce and then are more easily eliminated through belching (upper GI) of flatulence (lower GI). Simethicone dosages: Children: less than 24 months: 20mg 4 times daily Age 2-12: 40mg 4 times daily Adults: 40-360mg after meals and at bedtime as needed.

    I hope you enjoyed this "throwback" to Freshman Inorganic Chemistry!! Next week we can discuss the warnings, precautions and side effects of antacid therapy.


    Since Tagamet came out in 1977, what were out patients with peptic and duodenal ulcer disease? I remember my Dad using Pro-Banthine® (propantheline), an anticholinergic which was approved in 1953. Robinul® (glycopyrrolate), another anticholinergic was approved in 1961 and also used to inhibit stomach acid secretion. Pushing doses of these anti-cholinergic drugs did indeed inhibit gastric secretions, but at what a price given all the side effects of dry mouth, blurry vision, constipation, urinary retention, etc.

    Antacid therapy was the mainstay for these patients. Most patients always had a bottle of Maalox (mag/alum hydroxide) or Mylanta in their medicine cabinets, work lockers and even in their car.

    The standard regimen included one ounce (30ml) one hour before each meal, one ounce after each meal and at bedtime. Patients could go through 7 ounces of antacid per day, and many bought a couple of bottles at a time. Talk about inconvenient dosing regimens.

    We can now see how back in 1977 Tagamet (cimetidine) was met with such enthusiasm!

    Have a great day on the bench!!

    November 2017

    Happy 40th Birthday Histamine-2 Receptor Antagonists!!! Hoooray for H2RA's!!!

    Tagamet has been around for 40 years...we still love this class of drugs!

    Mechanism: competitively inhibits the histamine at parietal cell receptor sites, thus reducing the volume and hydrogen ion concentration of gastric acid secretions.

    Indications: Histamine-2 receptor antagonists (H2RA) are preferred to antacids because of compliance, and lack of effect on GI motility. Reasonably effective to treat mild/moderate gastroesophageal reflux disease (GERD). Less reliable for healing erosive esophagitis. May be useful for PUD or hypersecretory states (Zollinger-Ellison syndrome). H2RA work faster than proton pump inhibitors (which may take up to 3 days). The onset of action for the H2RA’s is within one hour and lasts between 6-12 hours.



    Drug Year of Rx INTRO-USA Approved OTC Healing Dose Prevention Dose OTC Brand/Strength
    Cimetidine (Tagamet®) 1977 June 1995 800mg HS 400mg HS Tagamet HB 200mg
    Ranitidine (Zantac®) 1983 December 1995 300mg HS 150mg HS Zantac 75mg, 150mg tabs
    Famotidine (Pepcid®) 1986 April 1995 40mg HS 20mg HS Pepcid AC-10
    Pepcid AC-20
    Nizatidine (Axid®) 1988 May 1996 300mg HS 150 HS Axid-AR-75mg


    Counseling Points:
    • All H2RA are listed a Pregnancy Category-B (no proven risk in humans). However, all packages do carry the warning to consult physician if pregnant.
    • Cimetidine (Tagamet): weak anti-androgenic effects; male gynecomastia & impotence at high doses. May cause feminization of male fetus. Even though cimetidine is Pregnancy Category-B, I would never advise a pregnant patient to use this drug.
    • Pepcid Complete contains: Famotidine 10 mg, Calcium carbonate 800 mg, Magnesium hydroxide 165 mg. I don’t recommend calcium containing antacids, because the calcium will stimulate gastric acid release.
    • Axid-R-75mg is not current available.
    Drug interactions
    Cimetidine reduces hepatic metabolism of drugs metabolized by cytochrome P450 pathway.
    • CYP450*3A4 -simvastatin, Protease Inhibitors (HIV)
    • CYP450*2D6- codeine, fluoxetine etc.
    • CYP450*1A2 – fluoxetine, EtOH, amitriptyline, clopidogrel
    • CYP450*2C9 –ibuprofen, naproxen, glipizide
    • Ranitidine (Zantac) has about 10% affinity for CYP450 3A4 than that of cimetidine, so we expect insignificant drug interactions.
    • Nizatidine (Axid) and famotidine (Pepcid) have no affinity for CYP450 3A4.

    Cimetidine (Tagamet®) was the first billion-dollar drug released back in the 1970’s for treatment of stomach ulcers. In 1964, it was well known that histamine stimulated gastric acid release. However the traditional anti-histamines (Benadryl, ChlorTrimeton) had no effect on gastric acid release. I remember in Medicinal Chemistry class back in 1980 the professor discussing how this class of drugs will change the way drugs are developed, since this was one of the first classes of drugs designed based on the discovery of the receptor site, and developing drugs to fit that receptor.

    Ranitidine (Zantac®) was introduced in US market in 1983 and was the world's biggest-selling prescription drug by 1987. It has since largely been superseded by the even more effective proton-pump inhibitors, with Prilosec (omeprazole) taking over the acid suppression market for many years.

    Have a great day on the bench!!

    Lots of information about PPI's... should they even be over the counter??

    Sending out this newsletter one day early... Tis the season for overeating... Happy Thanksgiving!

    As we discussed last week, there have always been safety concerns with these medications. Denise and I were to a drug company sponsored dinner last week, and I specifically asked one of the local GI docs about “deprescribing PPI’s”. He acknowledged this as a hot topic in the GI arena, but he said that neither he or his colleagues were in any rush to stop this therapy, given the amazing benefits that appropriate PPI therapy brings to our sickest patients. He reminded us about GI bleeds, Zollinger Ellison, NSAID induced gastropathy and Barrett’s esophagitis. Of course, this astute GI doctor sees only the sickest of patients.

    I also reminded him that “deprescribing” PPI’s will be a huge challenge, given the fact that they are available over the counter. With the life-saving potential of PPI therapy let’s discuss the adverse effects, and how we can best help our patients.

    • Fracture risk: at higher doses, new research shows increase risk of hip fractures possibly due to impaired calcium absorption. Fracture risk is a greater concern with high dose, and long term (over 1 year) of PPI therapy. Remind patients to take calcium (citrate), vitamin-D, and to exercise. Elderly patients on PPI therapy will benefit by using calcium citrate, because its absorption is less dependent on stomach acid.
    • B-12 deficiency: May also cause a cobalamin deficiency due to protein-bound dietary Vit-B12 malabsorption. Long term PPI use will decrease serum B-12 levels. Keep in mind that our liver has about two years of Vitamin-B12 on board so deficiency may take a while. Folate levels appear to be unaffected.
    • Decreased Magnesium levels: becomes more apparent with long term PPI use. Low magnesium levels can occur three months into PPI therapy, but risk is higher after one year. Patients should watch for muscle cramps, heart palpitations, dizziness, tremors, or seizures.
    • Pneumonia: PPIs increase gastric pH, which may allow more bacterial growth. The resulting change in gastrointestinal (GI) and respiratory flora may increase the risk for infection. The incidence of hospital-acquired and community-acquired pneumonias appears to be increased with PPI therapy.
    • Clostridium difficile: increase in Clostridium difficile infections and diarrhea occur as a direct result of PPI usage. About 42% of patients being treated for C. difficile while taking a PPI will have a recurrent infection within 90 days. Infections may be decreased by limiting PPI use to patients who truly need them
    • Alzheimers : (?) The results of one study showed that of the 2950 patients who were regularly using a PPI had a significantly higher risk for dementia compared with those not taking this drug. Later refuted by a study was published in the Journal of the American Geriatrics Society (2017) which addressed previous studies that suggested that PPI use was linked to increased risk of cognitive impairment in adults aged 75 years or older. For now, Alzheimer's seems to be unlikely caused by PPI use.
    • Renal Failure: Compared with patients who took an H2 blocker (Zantac, Tagamet, etc), PPI users had a 19% increased risk of estimated glomerular filtration rate (eGFR) falling below 60 mL/min/1.73m2 and a 26% increased risk of CKD (eGFR below 60 on 2 separate occasions at least 90 days apart, based on the Chronic Kidney Disease Epidemiology Collaboration equation). Source: www.renalandurologynews.com. The Taiwanese National Health Insurance data did a rather large study of two groups of over 16,000 patients taking and not taking PPI’s. Here is what their observations were:
      • PPI users were 42% more likely to have Chronic Kidney Disease (CKD) than non-users
      • CKD risk rose by 23% with each milligram increase in PPI dose
      • CKD risk rose by 2% per month of PPI use

    If you thought about starting Prilosec OTC or any other proton pump inhibitor (PPI) because of holiday over indulgence, after reading this newsletter you might want to reconsider!

    In 1982 when Helicobacter pylori was first reported, the world of GI disease was forever changed. Now Americans spend nearly 11 Billion dollars on PPI use, and up to 1/3 is believed to be inappropriate. The numbers are staggering when one sees that only Dexilant (Dexlansoprazole) is the only brand name; the rest are quite inexpensive. The 1200 square foot neighborhood drug store I work in buys its Omeprazole-20 and Pantoprazole -40 in bottles of 1000!

    Counseling points:
    • Inform patients that PPI’s take about three to five days to see benefit. It takes that long to “shut down” acid production.
    • If they are buying these PPI’s over the counter, the package specifically says they are to be used only for two weeks at a time, and then no more than three “cycles” per year.
    • Always scan the patient profile looking for Clopidogrel (Plavix). Some of the PPI’s do block the activation of clopidogrel. Pantoprazole (Protonix) is our “go to” PPI for patients taking clopidogrel.
    Have a great day on the bench!

    We are a little too comfortable with Proton Pump Inhibitors...

    Proton Pump Inhibitors and Acid Suppression

    As my student pharmacists will tell you that half of my conversations start out with “Back in the old days, when I was your age...” Back then the histamine-2 receptor antagonists (H2RA) were just in their infancy. Physicians and patients rejoiced when we no longer had to use high dose anticholinergics such as Pro-Banthine (propantheline) and Robinul (glycopyrrolate) to suppress stomach acid. General surgeons whose bread and butter were gastrectomy procedures due to stomach ulcers were maybe not quite so excited. Guys like my Dad and Grandfather were delighted, as they both had two previous gastrectomies due to recurrent stomach ulcers. Tagamet (cimetidine) released in August of 1977and became the blockbuster drug of the 1970's, being the first drug to reach one billion dollars in sales. I remember going to the drug store for my Grandpa and spending $27 for one hundred tablets!

    A question on my state board licensure exam was “Which of the following drugs is free of side effects, and drug interactions?” The answer was Tagamet! It was sold by one of my all-time favorite drug reps, a gentleman named “Ray”. In June of 1983 Ray met some very stiff competition when Zantac (ranitidine) was approved.

    Tagamet was initially approved as four times a day dosing, then changed to 400mg twice daily dosing to compete with Zantac. The battle was on, and Zantac wrestled a good bit of this lucrative business away from the original H2RA. It became apparent that Tagamet after being used by millions of patients, indeed had side effects such as blocking CYP-450-3A4, as well as causing gynecomastia in men by blocking testosterone formation. I hope they changed that state board question!

    The very lucrative H2RA market joined by Pepcid (famotidine) and Axid (nizatadine) came to a screeching halt in the 1990's. Omeprazole was first marketed in the United States in 1989 by Astra, now (AstraZeneca), under the brand name Losec. In 1990, at the request of the FDA, the brand name Losec was changed to Prilosec to avoid confusion with the Lasix 20mg (furosemide). As when the FDA intervenes, things often go amiss, and the new name led to confusion between omeprazole (Prilosec) and fluoxetine (Prozac)!!

    I remember discussing this new class of stomach acid suppressants with none other than “Ray” the Tagamet salesman. Ray said “no doubt this Losec shuts down stomach acid production better than Tagamet, but the question becomes... how much is too much” Ray said certainly stomach acid does more than causes stomach ulcers, and aids digestion; but what about its protective effect. Possibly could stomach cancers become more common with this drug. No one seemed concerned about this excess acid suppression, obviously Ray had to try to protect his turf. Prilosec buried the competition.

    In 2002 the generics were approved by the FDA, and prices dropped like a rock. Insurance companies no longer required prior authorizations, because they were so cheap. Today most pharmacies are lucky to get reimbursed $10 a month! People get prescribed these drugs and are left on them indefinitely. Much to my amazement this powerhouse acid blocker went over the counter in 2003, and was welcomed by all consumers as a cheaper alternative to the prescription variety. Other proton pump inhibitors like Zegerid and Prevacid followed suit., and had their own OTC formulations. Patients didn't even need to consult a physician or a pharmacist. Sure, the FDA required a 14 day limit on the box, and a warning of no more than 3 cycles of 14 tablets per year; as the companies sold these drugs in “warehouse packs”!

    Today the focus is “deprescribing” proton pump inhibitors. How do we even begin, when the patients can buy these potentially harmful drugs without a prescription? Next week we will discuss the numerous potential side effects of these commonly (over)prescribed drugs. My salesman friend “Ray” might have been on to something!


    How well I remember how the dreaded "stomach ulcers" ravaged my family. My Dad and Grandpa were always plagued by GI ulcers. Both had stomach resections due to "bleeding ulcers". Both took H2RA therapy and did very well on them.

    Next week we will discuss the ramifications of long term PPI therapy. If there is EVER a reason for a "behind the counter" class of drugs, the Histamine-2 blockers and Proton Pump Inhibitors should be the first to be regulated.

    Have a great day on the bench!

    Instead of $800 to treat EACH person, let's use an effective over-the -counter treatment for pinworms!

    PYRANTEL PAMOATE

    Mechanism: It is poorly absorbed from the GI tract in humans and acts by paralyzing worms. Pyrantel causes the release of acetylcholine, inhibits cholinesterase, and stimulates ganglionic neurons, acting as a depolarizing neuromuscular blocking agent in pinworms. These actions cause extensive depolarization of the pinworm’s muscle membrane, producing tension of the pinworm's muscles, which causes paralysis and release of their hold to the intestinal wall. They are unable to latch onto the intestinal mucosa, and are passed out in the stool.
    • Pyrantel pamoate is available over the counter as a 50 mg/mL suspension.
    • The dose of pyrantel pamoate for pinworms is 11 mg/kg of base, up to 1 g, given orally as a single dose. The dose should be repeated after two weeks. Package has detailed instructions by weight.The over-the counter products have detailed weight based dosing instructions. Approved for 2 years of age and older. Maximum dose is 1gram.
    • May administer with food, milk or fruit juice, at any time of day. Fasting, purgation, or special diets are not necessary for effective treatment
    • Does not reliably kill pinworm eggs. Give second dose is to prevent re-infection by adult worms that hatch from any eggs not killed by the first treatment.
    • There are numerous brand names, such as: Pin-X , Pin-Rid, Antiminth, Reese’s Pinworm Medicine. Cost is around $15.00 per ounce. Became OTC in 1986
    PREVENTION of REINFESTATION
    • Repeated infections should be treated by the same method as the first infection.
    • Treat all household members if more than one is infected. In institutions, mass and simultaneous treatment, repeated in 2 weeks.
    • Good hand washing hygiene! Soap and water after toilet.
    • Best to not allow children to share the same bathwater, reuse or share washcloths. Showering may be preferred to avoid possible contamination of bath water.
    • Clip fingernails regularly, and avoid biting the nails and scratching around the anus.
    • Frequent changing of underclothes and bed linens first thing in the morning is a great way to prevent possible transmission of eggs in the environment and risk of reinfection. Do not shake out bed linens, the eggs can become airborne. These items should be \ carefully placed into a washer and laundered in hot water followed by a hot dryer to kill any eggs that may be there.
    • Clean shared surfaces like doorknobs, toilet seats, and furniture with a disinfectant, such as bleach
    • Pinworm eggs are spread easily and even the cleanest and most careful people can get them. Be sure to re-assure parents and caregivers.

    Last week we discussed prescription treatment options for pinworm infestation. We explored treatment options such as Emverm® (mebendazole) and Albenza (albendazole).

    Both products were extremely expensive costing as much as $400.00 for initial treatment, followed by a second dose in two weeks. Today we pharmacists can step in and use a very affordable self-care treatment option for our patients.

    Just as important as the treatment, is the second follow-up dose as well as the prevention of re-infestation. Treatment failures are rare, and re-infestation is common. Be sure to share these "practice points" wih all of your patients.

    Have a great day on the bench!

    "Quit scratching down there".... better have a look. It might be pinworms!

    PINWORMS - The basics and prescription Treatment.

    Pinworm infections are caused by a small, thin, white roundworm called Enterobius vermicularis. This infection affects all people, especially children, institutionalized persons, and household members of persons with pinworm infection. Pinworms are spread by humans, and not by pets!

    Epidemiology
    Mode of transmission: Pinworms are transmitted from fecal to hand to mouth. Eggs may also be ingested by inhalation. The incubation period for pinworms is 1 to 2 months or longer for the adult gravid female to mature in the small intestine.

    These eggs are deposited around the anus by the worm and can be carried to common surfaces such as hands, toys, bedding, clothing, and toilet seats. By putting anyone’s contaminated hands (including one’s own) around the mouth area or putting one’s mouth on common contaminated surfaces, a person can ingest pinworm eggs and become infected with the pinworm parasite. Since pinworm eggs are so small, it is possible to ingest them while breathing.

    Symptoms: often asymptomatic, but itching around the anus (pruritis ani) is common.

    Diagnosis:
    • Seeing worms in the perianal region 2 to 3 hours after the infected person is asleep.
    • Touch the perianal skin with transparent tape to collect possible pinworm eggs around the anus at first rising. Use tongue blade with double side tape
    • Microscopically test for eggs under the fingernails (since anal itching is a common symptom)
    RX Treatment Options
    • Mebendazole (Emverm®-100mg)
      WAC=$369.00 per tablet AWP=$442.80
      • Dose= 100mg as a single dose. A second dose in 2 weeks may be appropriate if needed; both CDC and Sanford Guide recommend a second dose 2 weeks later. Tablets may be chewed, swallowed whole, or crushed and mixed with food.
      • Do not take concurrently with Metronidazole (Flagyl®) due to an increase incidence of Stevens-Johnson’s Syndrome
      • Approved for children 2 years of age and older
      • Emverm.com is a patient friendly website with good information. Also has a $60 coupon available.
    • Albendazole (Albenza®-200mg) currently
      $365.64 for 2 tablets AWP=$438.77/2
      • THIS IS AN OFF LABEL USE: Dose= 400mg (2 tablets) as a single dose. Repeat dose in 2 weeks. It is listed in the Sanford guide as a secondary treatment option.
        • Can be dosed down to 1 year old (200mg/dose)



    Pinworm and eggs, from the CDC website. Lots of good patient information for pinworms on the CDC website.


    So, as we can see there is only one prescription option that has FDA approval for treatment of pinworms. Next week the pharmacists can “take over” and we will cover a reasonable treatment option, along with patient counseling points for pinworm infections.

    Have a great day on the bench!

    October 2017

    My grandkids Luke and Anna made a big contribution to this column. Antibiotic associated diarrhea happens this time of year.

    Cefdinir and Amox/Clav- useful for ear infections - but be sure to "cover their butts"

    Now that winter is approaching and respiratory and ear infection season is closely approaching, we pharmacists can be instrumental in prevention of diaper rash. 18-35 percent of all children exposed to antibiotic therapy will develop antibiotic associated diarrhea. The more broad-spectrum antibiotics will cause a higher incidence of diarrhea. Amoxicillin/clavulanate and cefdinir are the pediatrician’s favorites.

    Amoxicillin/Clavulanate (Augmentin®) is notorious for causing stomach upset and diarrhea. Most of the gastrointestinal distress can be traced back to the clavulanate component which increase efficacy of amoxicillin by destroying the beta-lactamase that the bacteria produce. By blocking the effect of the beta-lactamase, the amoxicillin can do its job of destroying the bacteria. The problem is there are numerous strengths of amoxicillin/clavulanate, and for pediatric patients we need to dose based on the amoxicillin component at 80-90mg/kg/day (referred to Amox/Clav HD). For illustration let’s assume we have a 37 lb child (16.5kg). The calculated dose would be 1500mg per day.

    Drug To get 1500mg amox You get this much clavulanate daily
    Augmentin 125/31.25 12 teaspoons 375mg
    Augmentin 250/62.5 6 teaspoons 375mg
    Augmentin 400/57 3.75 teaspoons 213.75
    Augmentin-ES 600/42.9 2.5 teasp 107.25
    Augmentin 250/125 6 tablets 750mg
    Augmentin 500/125 3 tablets 375mg
    Augmentin 875/125 2 tablets 250mg


    As you can see from the above chart for a child getting Amoxicillin 1500mg per day (37lb child) would get 107.25mg of clavulanate should the prescriber use Augmentin ES 600, versus 375mg of clavulanate should the prescriber use Augmentin 250/5.

    Whenever you are prescribing Augmentin therapy HD (high dose) as is recommended for otitis media, it is critical to use Augmentin ES 600mg/42.9 to minimize clavulanate exposure and decrease incidence of severe GI upset and diarrhea. Always call the prescriber if a child has otitis media, and the prescriber writes for anything other than Amox/clav -ES 600/5ml to minimize the clavulanate exposure and therefore the gastrointestinal side effects. Remind patients to keep the suspension refrigerated at all times, and to use a protective diaper rash paste BEFORE administering the first dose.

    Cefdinir (Omnicef®) is a third-generation cephalosporin that causes a lot less gastrointestinal upset. It is dosed at 14mg/kg/day in 1 or 2 doses. Because it is broad spectrum, it can kill off more gut bacteria and cause diarrhea. In infants, especially if they are formula fed, the cefdinir binds to the iron in the milk and can cause a red stool, resembling blood which can greatly upset the parents. Be sure to warn them of this harmless side effect.

    Also with Cefdinir, dispense in the box to keep the glass bottle from breaking, give with food, and do not refrigerate. And like amox/clav it carries a 10-day expiration date. Be sure to always give an appropriate measuring device.




    Yes, a picture is worth a thousand words!


    Imagine a new Mom changing her infants diaper, and seeing these red streaks in the diaper, which could be easily confused for rectal bleeding. Fortunately the Mom was my daughter Gretchen, who is a doctor of Pharmacy, and teaches Clinical Pharmacy Practice at West Virginia University. Her son Luke, was being treated for a case of recurrent otitis media. So dramatic is this specimen, she snapped a picture for me to share with my students and colleagues. The color would even be brighter for a formula fed baby. For comparison, we snapped a picture of my son Phil's daughter Anna's diaper a normal breast fed diaper.

    Keep this image in mind when you are either prescribing, or dispensing Cefdinir (Omnicef®)

    Special thanks to Luke and Anna for your input (well, I guess output) for this column.

    "We interrupt our discussion about diaper rash" ---- Hand, Foot, Mouth Disease is spreading. Be ready to help your patients NOW!

    Hand, Foot, Mouth Disease affects...hand, foot and mouth! (of course).

    I will delay discussing diaper rash induced by antibiotics because of an “epidemic” that is spreading in our area. Recently, hand, foot, and mouth disease is on the rise with cases affecting local school districts. One of the local school districts ordered cases of hand sanitizers from a local pharmacy. I can’t think of a disease that has a more descriptive name than “Hand, Foot and Mouth Disease” abbreviated HFMD.

    Etiology:
    Hand, foot, and mouth disease is caused by viruses that belong to the Enterovirus genus, which includes the polioviruses, coxsackieviruses, echoviruses, and enteroviruses.

    Coxsackievirus A16:
    is the most common cause of hand, foot, and mouth disease in the United States, but other coxsackieviruses can also cause the illness.

    Enterovirus 71:
    has also been associated with cases and outbreaks of hand, foot, and mouth disease. Less often, enterovirus 71 has been associated with severe disease, such as encephalitis. Patients can be affected with a couple of different enteroviruses.

    Epidemiology:
    Patients with HFMD is most contagious during the first week of illness and be contagious for days or weeks after symptoms go away. Adults, may not develop any symptoms, but they can still spread the virus to others. Everyone especially those with direct contact with children and infants must maintain good hand hygiene so they can minimize their chance of spreading or getting infections. Daycares because of their multiple diapering “events” can see this virus spread quickly through a classroom.

    Patient Information:
    Here’s some useful information about this condition that Karen Quach one of my student pharmacists would like to share.

    Hand, foot, and mouth disease is a common childhood infection most often occurring in confined spaces, such as daycares and schools, in the summer and fall months. It is characterized by small sores that can form in the mouth, and on the hands, feet, buttocks, and genitals. This is the main symptom to look out for, and the sores can appear as small red spots, bumps, or blisters. In addition, some children may present with a mild fever. Although this infection is generally mild, it is highly contagious and may cause pain, including painful swallowing.

    Hand,Foot,Mouth disease on 15 month old

    The infection itself is not treated and should resolve without medicine within one week. Until then, children should maintain adequate fluid intake to prevent dehydration. If needed, over the counter medications such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can be used to relieve pain. Cool liquids and foods such as popsicles and ice cream may help to numb the pain.

    The virus travels in body fluids, including mucus from the nose, saliva, bowel movements, and fluid from the sores. Therefore, the most important method to prevent spread of infection is proper hygiene. Tips include washing hands frequently with soap and water, using alcohol-based hand sanitizers, covering the mouth and nose when sneezing and coughing, properly disposing infected tissues, and disinfecting contaminated surfaces and objects. Additionally, infected children should be kept home when they have symptoms to prevent spread to other children.



    We got a request to put together a newsletter about hand, foot and mouth disease because of a local outbreak. Like any good preceptor, I turned the project over to my student pharmacist.

    We have two students living with us right now and last week for Pharmacy Month, Gabrielle Dziuba published a newsletter on Poison Prevention. I turned this project over to Karen Quach. She did a stellar job, and we also published her newsletter in the local paper. Her research is the information that contains the patient information.

    Karen Quach, PharmD Candidate
    University of Pittsburgh School of Pharmacy Class of 2018

    Treating Diaper Rash, and saving the money for the college fund!

    Treating Diaper Rash--simple as A-B-C-D-E!!!

    Diaper rash is almost always caused by Candida albicans, and like any yeast thrives where it is warm, dark and moist. Here are some treatment strategies to help manage diaper rash in our pediatric population. It’s as easy as A, B,C, D & E.

    A = air out the skin by allowing the child to go diaper-free, best to do on a hard surface floor for easy clean up. Don’t expose to sun for longer periods of time to prevent possible sunburn.

    B = barrier; use a paste or ointment to protect the skin. Protectants: are first line therapy and can be used for protection (anticipated during antibiotic therapy) or treatment. Provides physical barrier to protect skin against irritants and moisture. Also provides lubrication to reduce skin-to diaper friction.

    C = clean; Clean area with water—avoid rubbing area. Use a squirt bottle, pat and air dry. If using Baby wipes, they should be free of soaps, dyes, perfume and alcohol.

    D = disposable diapers; are best option during an episode of diaper rash, rather than cloth diapers. If using cloth diapers, avoid plastic panties.

    E = educate; educate your patients about how to prevent a recurrence of diaper rash

    Pharmacologic Measures:
    Antifungal agents
    • Don’t use routinely, only when C. albicans is suspected.
    • Characterized by beefy red plaques, with scales and satellite papules & pustules. Pustules are superficial.
    • May use Miconazole and Clotrimazole which are OTC, or Nystatin (Rx-only)

    Vusion® (miconazole 0.25%) – is a product for diaper rash. Contains also white petrolatum & Zn oxide. Lower concentration causes less systemic absorption, however higher strength Miconazole has not been shown to cause problems. The cost of a 50gm tube of Vusion diaper rash ointment is $560.00!

    “GrandDad Kreckel” has calculated that 90gram of Zinc Oxide + 15g Miconazole 2% will yield a concentration of miconazole .28%. The leftover $550.00 can be applied to the grandkids college fund!

    Cholestyramine/Aquaphor -compounded medication for Diaper Rash Cholestyramine is a bile acid sequestrant, and Aquaphor is a greasy vehicle to protect the bottom. Usually made as a 20% paste. INGREDIENTS:
    • Cholestyramine light powder (80% anhydrous) ---------------25gm
    • Petrolatum ointment base (Aquaphor) --------------------------75gm
    • Dispense as 100gm. Good for 180 days.
    What not to use: Talc and cornstarch- not recommended due to potential inhalation by the infant. OTC Antibiotic ointments: Over-the-counter antibiotic creams or ointments (such as Neosporin or Bacitracin) are not recommended because neomycin and bacitracin cause allergic reactions.
    • Bacitracin is the 2003 Allergen of the Year (American Contact Dermatitis Society)
    • Neomycin is the 2010 Allergen of the Year (American Contact Dermatitis Society)
    Corticosteroids: Hydrocortisone 1% (otc): can be used for moderate to severe diaper rash, or allergic dermatitis. Can be used for up to 2 weeks maximum. Do NOT use stronger corticosteroids (avoid all RX!!)
    Peruvian balsam: Butt Paste (Boudreaux Butt Paste) – contains Zn oxide, Peruvian balsam, boric acid, castor oil and petrolatum. (FDA cautions that Peruvian balsam may cause skin sensitivities.)

    Treating diaper dermatitis can be challenging and even frustrating for parents. There are a lot of old time remedies that shouldn't be used today, especially being the powders. When you think about the ingredients in the common powders, they can do more harm than good. Talc is actually a mineral, or stone that is pulverized to dust. Corn starch is a "starch" which we remember from biochem class is a string of sugar molecules linked together, which is just like "feeding" the Candida albicans. The talc being a mineral can be inhaled into the child's lungs, and long term exposure can cause damage. Although both do reduce friction between skin folds, they are not recommended for treatment.

    I am a huge fan of plain and simple. When Regina, Luke or Anna get diaper rash the miconazole and zinc oxide combination works very well. It is only used when Candida is suspected, and not for prophylaxis.

    Next week we will discuss diaper rash, and provide counseling points to parents when giving their children antibiotics.

    Have a great day on the bench!!

    When the grandkids get diaper rash... GrandDad comes to the rescue!

    When Candida albicans affects the grandkids... treatment of diaper dermatitis

    This week we continue our discussion of yeast and fungi focusing on Candida albicans, in a different patient population, that is in our infants and diaper wearing toddlers. When we think of the ideal environment for yeast and fungi to grow, we think of warm, dark and moist. What better place to grow than a baby’s diaper! Candida albicans is the most common cause of diaper rash in infants. The fungi take advantage of the warm, moist conditions inside the diaper.

    Causes of diaper dermatitis:
    • Too much moisture
    • Rubbing and friction
    • Skin contact with urine and feces
    • Allergic reaction to the diaper material or to creams, powders or wipes

    Role of Candida albicans:
    • Infection often occurs after 48-72 hours of active eruption.
    • It is isolated from the perineal area in as many as 92% of children with diaper dermatitis.
    • Other microbial agents have been isolated less frequently, perhaps more because of secondary infections.
    • Peak incidence occurring when the individual is aged 9-12 months
    • Diaper dermatitis is prevalent in 7-35% of the infant population.

    Pathophysiology
    • Wet skin increases the penetration of irritant substances.
    • Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria.
    • Irritation occurs because:
      • Urease has a mild irritant effect on nonintact skin.
      • Lipases and proteases in feces mix with urine on nonintact skin and cause an alkaline surface pH, adding to the irritation. The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect

    Prevention
    • Change your baby's diaper often.
    • Keep the diaper loose enough to let air reach the skin inside the diaper.
    • Gently clean the affected skin with warm water. Pat gently with a clean, soft towel.
    • Don't use wipes that contain alcohol or perfume.
    • If you use cloth diapers and wash them yourself, use very hot water. Rinse carefully
    • Note: Feces in breastfed infants have a lower pH, and breastfed infants are less susceptible to diaper dermatitis.
    • Broad spectrum antibiotics can cause Candida albicans to overgrow by destruction of “good” bacteria.
      • Amoxicillin/clavulanate (Augmentin®)
      • Third generation cephalosporins
        • Cefdinir (Omnicef®)
          • Recommend topical protection before the first dose of broad spectrum antibiotics

    This area of study is of particular interest to me not only as a young pharmacist when we had three kids in four and one-half years, but now we are blessed with three grandchildren!

    Our three year old Regina is potty trained but our 15 month old grandson Luke, and 9 month old granddaughter Anna are in diapers, and GrandDad comes to the rescue to treat diaper dermatitis.

    This week we covered the basics, and next week we will discuss treatment of diaper rash, and of course what NOT to use! The money we can save in the treatment of diaper rash will go a long ways for their college funds.

    Have a great day on the bench!!

    September 2017

    Our female patients can benefit from these treatment options

    Treatment of Vaginal Candidiasis..

    The most mentioned vaginal yeast infection that our patients experience is actually the second most common vaginal infection. Candidiasis is the second most common cause of vaginitis symptoms and accounts for approximately one-third of vaginitis cases. Bacterial vaginosis is the most common, but no over-the counter treatment exists. Ten to twenty percent of healthy women of reproductive age have Candida albicans present in the vaginal tract.

    Risk Factors for vulvovaginal candidiasis are as follows
    • Patients with Type-2 diabetes, are more prone to candida albicans infections especially if they are not well controlled
    • Patients exposed to antibiotic therapy-25-33 % of females exposed to antibiotic therapy. This is due to the destruction of the normal healthy flora, allowing the overgrowth of candida species. Lactobacillus is of no value in treatment or prevention.
    • Immunosuppressed patients- patients with a less than robust immune system, either due to corticosteroid therapy, or HIV are more susceptible to candida infections.
    • Elevated estrogen levels: patients taken oral contraceptives, or estrogen supplements have a higher incidence.
    • Sexual activity: vaginal candidiasis is not considered a sexual transmitted infection, because it is part of the normal flora. Patients report an increased incidence of yeast infections when they begin sexual activity.

    Symptoms: itching of the vulva is the most common sign, remembering that yeast isn’t the only organism that causes itching. Patients may experience vulvar burning, soreness, and irritation. Some patients may experience burning on urination, with the source of the burning being the vulva and not the urethra. Patients may experience dyspareunia as well. Symptoms are often worse during the week prior to menses.

    Treatment:

    Diflucan® (Fluconazole) (Rx only)
    150mg tablet given as a single dose. Fluconazole remains in the vaginal secretions up to 72 hours. Avoid if pregnant.

    Miconazole (Monistat®) (OTC) Is available as a cream, or vaginal suppository, or insert
    • Monistat-3: (200mg supp.) 1 supp vaginally at bedtime for 3 nights
    • Monistat-3 (4% prefilled cream 200mg each) vaginally at bedtime for 3 nights
    • Monistat-7: (100mg supp) 1 supp vaginally at bedtime for 7 nights
    • Monistat-7 (2% cream, 100mg each dose): 1 applicatorful vaginally at bedtime for 7 nights. Best treatment option for treatment of patients who are pregnant, or patients with diabetes.
    • Monistat-1 Combo pack: miconazole 1200mg insert plus miconazole cream for application to vulva
    CAUTION: potential CYP 4503A4 interactions due to topical absorption of miconazole

    Clotrimazole (Gyne Lotrimin®) Available as a cream
    • Gyne-Lotrimin 1% cream: 1 applicatorful vaginally at bedtime for 7nights
    • Gyne-Lotrimin 2% cream: 1 applicatorful vaginally at bedtime for 3 nights
    Terconazole (Terazole®) (Rx only) Available as cream or suppository.
    • Terazol 0.4% cream: 1 applicatorful vaginally at bedtime for 7 nights
    • Terazol 0.8% cream: 1 applicatorful vaginally at bedtime for 3 nights
    • Terazol 80mg supp: 1 suppository vaginally at bedtime for 3 nights
    Butoconazole (Gynazole®) Rx Only 2% cream 5gm
    • Insert one applicator at bedtime as a single dose. May weaken diaphragms or condoms, due to mineral oil in the formulation.

    Women indeed are very proactive in their healthcare,and we pharmacists have the opportunity to guide them through the feminine hygiene aisle.

    When Monistat (miconazole) first became available in 1991, there was great concern from gynecologists that these products might be misused. Labeling on these vaginal candidiasis products specifically say " Do not use if you have never had a vaginal yeast infection diagnosed by a doctor."

    Patients should really have had a previous diagnosed yeast infection, and be aware of the symptoms before purchase of such a product. Remember that yeast isn't the only condition that itches.

    Have a great day on the bench!!

    They're in a rush to treat their thrush!

    Candida albicans-- a pathogen in our crosshairs...this week!

    Now that we have learned how to wipe out the Trichophyton species, especially T. rubrum, we switch to another pathogen that we frequently see on our mucus membranes, Candida albicans, which is more specifically a yeast. Our first mucus membrane we will cover is the oral-pharyngeal cavity.

    Candida albicans infection of the mouth is commonly referred to as “thrush”. Candida albicans is a yeast of our normal flora, that is kept “in check” by a variety of bacteria especially Lactobacillus . When the immune system is weakened, or the bacteria are wiped out by antibiotics, Candida albicans can overgrow.

    Symptoms: Candidiasis in the mouth and throat is most often seen as white patches on the inner cheeks, tongue, roof of the mouth, and throat. Other symptoms might include: redness or soreness, feeling like cotton in the mouth and loss of taste. Patients may also experience pain while eating or swallowing or angular cheilitis (cracking and redness at corners of the mouth).

    Who is at risk: Candidiasis in the mouth, throat, or esophagus is uncommon in healthy adults. People who are at higher risk for getting candidiasis in the mouth and throat include babies, especially those younger than one-month old, and people who:
    • Wear dentures
    • Have diabetes
    • Have cancer
    • Have HIV/AIDS: thrush is one of the most common infections seen in the AIDS population.
    • Take antibiotics or corticosteroids, including inhaled corticosteroids for conditions like asthma
    • Take medications that cause dry mouth or have medical conditions that cause dry mouth
    • Smoke
    Treatment of Adults:
    The treatment of oropharyngeal candidiasis in patients without AIDS is usually accomplished with local therapy for 7 to 14 days. For topical agents, successful therapy depends on adequate contact time between the agent and the oral mucosa. Options include:
    • Clotrimazole troches or lozenges are dosed at 10mg 5 times a day slowly dissolved in the mouth for about 15-30 minutes. They are effective, however adherence to a five time per day regimen is difficult. Often patients with radiation to salivary glands, or patients with Sjogrens syndrome lack adequate saliva, and might have difficulty getting these lozenges to dissolve. Don’t eat or drink while using.
    • Nystatin suspension 100,000 units/ml swish and swallow 4-6 ml four times daily is effective but has a bitter taste. It also contains sucrose, which can cause dental caries when used over prolonged time periods.
    • Fluconazole tablets: 200mg first dose then follow with 100mg-200mg daily. Best option for topical treatment failures. Has 90% success rate.
    Children Doses for Candida albicans eradication:

    Nystatin Oral suspension 100,000 units/ml:
    • For older infants: 2 mL four times a day.
    • For premature and low-birth-weight infants: 1 mL four times a day.
    • Because treatment is topical, and maximal contact time improves efficacy, the suspension should be retained in the mouth for as long as possible before swallowing.
    • Infants should avoid feeding for 5 to 10 minutes after administration to keep nystatin from washing out of the mouth.
    Fluconazole: available as 10mg/ml and 40mg/ml in 35ml bottles for reconstitution
    • Dose: 6 orally once on the first day (maximum dose 200 mg followed by 3 once per day (maximum dose 100 mg) for a total of 7 to 14 days. Doses are higher for HIV infection.
    Prevention of reinfection in babies
    • Sterilize items that are placed in the infant's mouth. Bottle nipples and pacifiers that are to be reused should be boiled after each use.
    • Breast feeding: Topical miconazole or clotrimazole is applied to the nipples to treat the lactating woman. Azoles are preferred over nystatin since there is less resistance of Candida species. Wipe off prior to feeding and reapply after each feeding.

    Thrush is treated first line with topical therapy either nystatin or clotrimazole. Reinforce to the patient that is the contact with the inside of the mouth is what will lead to resolution of the yeast infection. Nystatin ahs been round since the early 1950's and still has a place in therapy for Candida albicans only. It has no effect on any other fungi other than C. albicans. Nystatin was discovered in 1950 by Rachel Fuller Brown and Elizabeth Lee Hazen named nystatin after the New York State Health Department in 1954.

    These patients do require a lot of patient counseling, and if appropriate an accurate measuring device.

    Have a great day on the bench!!

    Do your toenails look unsightly? Some of the treatments lack efficacy!

    Toenail fungus--persistence is the key to efficacious treatment

    Your fingernails and toenails are composed of keratin and adherent connective tissue, the same stuff that your hair is made of. Nails grow at an average rate of 0.1 mm/day (1 cm every 100 days).

    Finger nails require 3 to 6 months to re-grow completely while toe nails require 12 to 18 months. Onychomycosis is a fungal infection of the nails, sometimes caused by Candida species, however 80% of the toenail infections are caused by dermatophytes (Trichophyton rubrum), whose name sounds very familiar to us!

    Diagnosis is based on clinical exam and history, microscopy, and culture. Back when both oral prescription drugs were expensive and cost over $600 for a course of therapy, the insurance companies required a positive culture for approval. Now that the oral treatments are available generically, that requirement has been lifted.
    • OTC nail lacquers (Fungi-Nail®) treat fungus around the nail, they don't penetrate the nail plate. Don't recommend them due to minimal efficacy. Contains undecylenic acid, and despite its trade name is only for athlete’s feet.
    • Rx products provide best treatment option.
    • Advise patients about possible recurrence.
    Treat fingernails for 6 weeks and treat toenails for 12 weeks. (reference: Sanford guide 2017)
    • Terbinafine (Lamisil®)- fewest drug interactions; check liver function; most efficacy: Cure rate: (46%). Side effects include headache, gastrointestinal disturbance (diarrhea and/or dyspepsia), rash and elevated liver enzymes.
      • Dose: 250mg every 24 hours
    • Itraconazole (Sporanox®)– CYP4503A4 interactions; need liver function tests. Cure rate (23%pulse). Side effects include, skin rash, high triglycerides, cardiac side effects and gastrointestinal effects (nausea, bloating, and diarrhea)
      • Pulse Dose: 200mg BID for 1 week/month x 2-3 months
      • or 200mg/ day for 3 months
    • Fluconazole (Diflucan®) Cure rate:(28%), less drug interactions than itraconazole. Frequent relapse, due to poor retention in the nail.
      • Dose: 150-300mg every week for 3-6 months.
    • Ciclopirox (Penlac®) nail lacquer -Complete cure rate (7%)
    • Efinaconazole (Jublia®) nail lacquer- Complete cure rate (17%)
    • Tavaborole (Kerydin®) nail lacquer- Cure rate (<10%)
    Vicks Vap-o-rub?
    • A small study of 18 participants, where fifteen of the 18 participants (83%) showed a positive treatment effect. Source: J Am Board Fam Med. 2011 Jan-Feb;24(1):69-74. doi: 10.3122/jabfm.2011.01.100124
    • 5 of 18 (27.8%) had a mycological and clinical cure at 48 weeks;
    • 10 of 18(55.6%) had partial clearance
    • 3 of 18 (16.7%) showed no change.
    Since our enemy Trychophyton rubrum is everywhere, re-infection is a possibility if measures are not taken to make the feet an inhospitable environment for this fungus. Fungus breed where it is warm, dark and moist. Here are some points to share with our patients:
    • 1 in 5 “cures” will relapse (20%) within 2 years
    • Keep feet clean and dry
    • Change socks often
    • Antifungal product for feet and shoes.
    • Sports shoes that fit well will reduce microtrauma to the nail plate. Wear sandals when possible.
    • Using communal showers leads to fungal infection, so these should be avoided
    • Care with hygiene is needed to reduce cross-infection between family members
    • Throw out old “creek shoes”.
    • Emollients can be used to avoid cracks in the skin that allow fungus to enter.
    Certain-Dri®—Prevention of onychmycosis
    • Contains aluminum chloride-12%.This product stops the feet from sweating, creating the moist environment for the fungus to grow.
    • Water-based and unscented which makes it gentler on skin
    • Should not wash off after bathing or showering, if application instructions are followed. Use only a few times a week.

    Onychomycosis treatment varies from practitioner to practitioner. I've seen podiatrists use the Terbinifine 250mg daily for 84 days, with great results. I've seen podiatrists remove the entire nail, and treat with Terbinifine 250mg for 84 days.

    I once had a patient tell me that her dermatologist said "I'm not knocking out your liver so you can have pretty toenails." He went on to say "It is a cosmetic condition, and if treated it will come back... just get over it." She went to her podiatrist, he did the necessary blood work, like liver function testing, was treated for 84 days and she has been "fungus free" for over 15 years. She is meticulous about her foot care.

    One of the points we want to share with our patients is that re-infection is indeed a possibility, and we should counsel our patients to follow the steps necessary to prevent re-infection.

    Have a great day on the bench!!

    Another fungus among us...look what the cat (or puppy) brought in!!

    What is this rash that looks like a worm??

    Trichophyton rubrum is the most common cause (about 47%) of tinea corporis commonly known as “ringworm”. This is the same organism that can also cause jock itch, athlete’s foot, and nail fungus. Tinea corporis usually begins as a circular or oval, scaling patch that is itchy and spreads centrifugally on the smooth skin, (other than the scalp, groin, palms, and soles). The center of the lesion clears while an active, advancing, raised border remains. The result is a ring-shaped plaque from which the disease derives its common name of ringworm. How do I get it? Epidemiology:
    • May result from contact with infected humans, animals, or inanimate objects. Commonly transmitted by kittens and puppies.
    • Occupational risk: farm worker, zookeeper, laboratory worker, veterinarian
    • Environmental exposure: gardening, contact with animals, towels and shared grooming appliances.
    • Recreational exposure: contact sports especially wrestling, contact with sports facilities (gym mats, locker room floors). Interestingly enough the ringworm spread by wrestling has its own specific name: “Tinea corporis gladiatorum” named after the gladiators of Rome.
    How do I get rid of it? Treatment of Tinea corporis (ringworm):

    TOPICAL THERAPY
    • Terbinifine (Lamisil®): apply once daily for 7 days
    • Clotrimazole (Lotrimin®): apply twice daily for up to 14 days
    • Miconazole (Micatin): apply twice daily for up to 28 days
    SYSTEMIC THERAPY
    May be indicated if tinea corporis includes extensive skin infection, immunosuppression, resistance to topical antifungal therapy (azoles and allylamines) , or the comorbid presence of tinea of the scalp or of the nails.
    • Terbinafine (Lamasil®) 250 mg per day for one to two weeks.
    • Itraconazole(Sporanox®) 200 mg per day for one week
    • Fluconazole (Diflucan®) 150 to 200 mg once weekly for two to four weeks
    • Griseofulvin (remember that drug?) seldom used because 4 weeks of treatment are needed.
    • Itraconazole and Griseofulvin are the most expensive treatment options. Fluconazole and Griseofulvin are the longest treatment options.

    When I was discussing this column with a fellow pharmacist they asked me the differences between "tinea versicolor" and "tinea corporis". Although they share the name "tinea", both affect the smooth skin, and are caused by a fungus which thrives in hot and humid conditions, there is a huge difference between the two.

    Ringworm as we can read from this column ringworm is caused by the Trychophyton genus, where Tinea versicolor is caused by Malassezia furfur. The Malassezia furfur fungus is part of our normal flora, while ringworm is not. We don't get tinea versicolor by spreading from other sources as it is part of our normal skin flora. Versicolor is much harder to control because we harbor it on our skin.

    However, once ringworm is eradicated, a patient needs to be re-exposed to get another ringworm infection.

    Have a great day on the bench!!


    August 2017

    Hey doc---I got “gaulded”--- what do you got for that??

    Tinea Cruris "jock itch"

    Tinea cruris (jock itch) is a dermatophyte infection involving the fold between the upper thigh and groin area. Most common cause is Trichophyton rubrum, other species of tinea may cause jock itch as well. Tinea cruris is far more common in men than women. Often, infection results from the spread of the dermatophyte infection from concomitant tinea pedis, moving up the leg. Tinea on the groin looks like scaly, itchy, red spots, usually on the inner sides of the skin folds of the thigh. Predisposing factors include copious sweating, obesity, diabetes, and immunodeficiency. Infection may spread to the perineum and perianal areas, into the gluteal cleft, or onto the buttocks. Usually the scrotum in males is not involved.

    Treatment: first line therapy is topical antifungals, azoles or squalene epoxidase inhibitors. If unsuccessful consider oral treatment.

    • Terbinafine (Lamisil cream):
      • Mechanism- inhibits squalene epoxidase, thus weakening the fungal cell wall
      • For tinea cruris apply once a day for 7 days
    • Clotrimazole (Lotrimin) or Miconazole (Micatin):
      • Mechanism- inhibits ergosterol synthesis.
      • Apply twice daily for 2 weeks.
      • Any of the OTC or Rx azole antifungals are equally effective
    “Tightie whities” or boxers?? Cotton briefs hold moisture and keep it against the skin, allowing dark, warm moist conditions that the dermatophytes thrive in. If you choose briefs, say at the gym or running, choose moisture-wicking synthetic materials and be sure to shower and put on a fresh pair after working out. Going “commando” (or naked) would be the best.

    Here is a tip… put on your socks before underwear to minimize the chance of the athlete's foot fungus from moving to the groin area.


    I remember my first week working in a rural area of Central Pennsylvania. An old woodsman came in and asked me if I could help him. Being that energetic (and inexperienced) pharmacist I said sure. He told me he got "gaulded" , which I thought he said "scalded", and he pointed "down there". Needless to say I've learned a lot about being "gaulded" (tinea cruris) over the past number of years. Back then we didn't have much to help our patients until the antifungals became OTC.

    One year at Boy Scout Camp, when I was the Scoutmaster, one of my 6th graders came to me. He said he was "hurting" down there...I asked him to describe what was going on. He said "Mr K it feels like my crotch is on fire" I asked him if he was showering, and he said "every day, but because the showers are not private we are all showering with our swimming suits on, so no one can see our equipment". I left camp, bought a can of clotrimazole spray (in case the other guys got it) and gave it to him, with instructions to not shower in a swimming suit! He was better the next day, and many years after at his Eagle Scout Banquet I presented him with the left over spray.

    Have a great day on the bench!!

    ATHLETE'S FOOT - Tinea pedis

    Athlete’s foot is usually treated topically due to decreased side effects of this route of administration. It is the most common dermatophyte infection, affecting up to 70% of adults. Causative organisms: Trichophyton, Epidermophyton or Microsporum. Infection is usually acquired by means of direct contact with the causative organism in “surface reservoirs”, as may occur by walking barefoot in locker rooms or swimming pool facilities. If unchecked, osteomyelitis can result from mycotic infections of the feet, including tinea pedis. These complications are seen more frequently in patients with diabetes. Diabetics should check their feet every day with a mirror, and look between the toes for signs of athlete’s foot. The fissures between the toes can serve as a major port of entry for Staph aureus, the major cause of osteomyelitis in patients with diabetes, which may lead to amputation.

    TREATMENT
    • Terbinafine (Lamisil cream):
      • Mechanism- inhibits squalene epoxidase, thus weakening the fungal cell wall
      • For tinea pedis apply twice a day x 7 day. Apply for 2 weeks if bottom/sides of feet are affected.
    • Miconazole (Micatin) or Clotrimazole (Lotrimin):
      • Mechanism- inhibits ergosterol synthesis.
      • Apply twice daily for 4 weeks.
      • Any of the OTC or Rx azole antifungals are equally effective
    Unfortunately, athlete’s foot symptoms may linger for up to 4 weeks. Recurrence might be due to previous treatment failure. Because patients experience recurrence 70% of the time, prevention is warranted. Share these prevention tips with your patients:
    • Patients should be advised to wear non-occlusive footwear such as sandals as frequently as possible, but especially in the summer.
    • Wash socks after each wearing in the hot cycle of the washer and dried in the hot cycle of the dryer before wearing again. Athletic shoes also may be sprayed with disinfectants and/or treated with bleach to destroy fungi.
    • During the bath or shower, patients must wash the feet and toes carefully each day. Patients should be taught to dry the feet thoroughly after each bath or shower, paying closer attention to the interdigital spaces.
    • Wait for 10 to 15 minutes after bathing to don socks and shoes to help the feet dry. The goal is to have the feet completely dry other than when bathing.

    What about us??? Most of us as business professionals, should wear socks and leather shoes that “breathe” and reduce sweating. We should also change to sandals as soon as we can and wear them until bedtime or go barefoot around the house as much as possible (except for diabetic patients with peripheral neuropathy)

    Socks? Wool socks: If your feet are often cold, or you live a in a cold climate (like Central Pennsylvania), wool socks may be a better fit. Wool fibers are both hydrophobic (repels water) and hygroscopic (absorbs water), which is a fancy way of saying that it can absorb or give off moisture. In fact, they - wool fibers - can absorb up to 1/3 of their own weight in moisture before feeling "wet". Merino wool is less like to be itchy. Merino wool socks are more expensive, it is best not to machine wash wool socks. I wear wool socks for extra padding on my feet. The outer layer of wool fibers have a high concentration of fatty acids, which have anti-bacterial properties, and reduce foot odor.

    Cotton socks: less itchy, are cheaper and absorb moisture but they saturate quickly and dry slowly. Are cooler on the feet and are machine washable. When cotton socks get damp/wet they will continue to feel cold and damp, which wetness and increased friction may enhance blister formation.

    Have a great day on the bench!!

    Mechanisms of action are the best clue as to what to recommend for the "fungus among us"!

    We pharmacists love our mechanism of actions, and knowledge of where the multitude of antifungals fit in drives our product selection. Below is a chart, that describes the mechanism of actions for efficacious treatment of dermatophytic and candida infections. Although there are other agents available, I am highlighting the most common and most effective agents we use in community pharmacy practice.

    Agents used in the treatment of dermatophyte infections.

    Oral Azole Antifungals
    Impairs the synthesis of ergosterol, the main sterol of fungi membranes, allowing increased permeability and leakage of cellular components. Inhibits fungal CYP-450 14-alpha-desmethylase thereby decreasing ergosterol.
    Ketoconazole (Nizoral) (Rx)
    Most potent azole blocker of CYP-450. Most drug interactions and side effects of oral azoles. As of 2013 NOT recommended as oral therapy for treatment of dermatophytes.
    Fluconazole (Diflucan) (Rx)
    Widest therapeutic window. For treatment of thrush and vaginal candidiasis. Not effective for filamentous fungi (aspergillosis).
    Itraconazole (Sporanox) (Rx)
    May induce heart failure. Caution in cardiac patients.
    Oral Antifungal
    First antifungal; isolated in 1939, produced from Penicillium griseofulvin. Disrupts spindle formation. Skin infections only. It is deposited in newly forming skin where it binds to keratin precursor cells, protecting the skin from new infection. Therapy must continue until new tissue replaces old diseased tissue.
    Griseofulvin (Gris-Peg) (Rx)
    Absorption improves with a high fat meal. Takes 2-6 weeks for treatment. (6 months for onychomycosis).
    Oral Squalene Epoxidase Inhibitor
    These antifungal agents are reversible, noncompetitive inhibitors of the squalene epoxidase. The buildup of squalene is toxic to the cell wall. This causes pH imbalances and malfunction of membrane bound proteins.
    Terbinifine (Lamisil) (Rx)
    Most often used for onychomycosis (nail fungus). Doesn’t reach effective levels for treatment of skin infections.
    Topical Azole Antifungals
    Impairs the synthesis of ergosterol, the main sterol of fungi membranes, allowing increased permeability and leakage of cellular components. Inhibits fungal CYP-450 14-alpha-desmethylase thereby decreasing ergosterol. For topical treatment of dermatophytes, no azole antifungal Rx or OTC is superior to another.
    Miconazole (Micatin, Monistat)
    Topical use for dermatophytes or vaginal yeast infections. Caution with warfarin may ↑ INR, by blocking CYP-450 metabolism and cause bleeding.
    Clotrimazole (Lotrimin), Butoconazole(Gynazole)
    OTC available for treatment of vaginal yeast infections. Clotrimazole cream for topical dermatophytes.
    Ketoconazole (Nizoral), Econazole (Spectazole) (Rx)
    Prescription only for treatment of topical dermatophytes.
    Terconazole (Terazol) (Rx)
    Terconazole contains a triazole ring, a structure developed specifically to improve antifungal activity. Rx only for vaginal candida infections.
    Topical Squalene Epoxidase Inhibitors
    These antifungal agents are reversible, noncompetitive inhibitors of the squalene epoxidase. The buildup of squalene is toxic to the cell wall. This causes pH imbalances and malfunction of membrane bound proteins.
    Terbinifine (Lamisil)
    Most effective OTC treatment for dermatophytes.
    Topical antifungal inhibiting cell membrane staility.
    Binds to trivalent cations (iron and aluminum), which inhibit essential co-factors in enzymes. Can be fungicidal or fungistatic.
    Ciclopirox (Loprox, Penlac) (Rx)
    Available as cream, gel, suspension, shampoo and nail lacquer.
    Topical Anticandidal Agents
     
    Nystatin (Mycostatin) (Rx)
    Polyene antifungal binds to ergosterol in fungal membrane causing membrane to become leaky. Only effective for candida (yeast). Too toxic for parenteral use. Used only topically, usually for diaper rash.
    Miscellaneous
     
    Zinc Pyrithione-ZPT (Head & Shoulders)
    Shown to significantly reduce the numbers of yeast organisms. Helps prevent the dandruff-causing microbe, Malassezia globosa, from forming scalp irritants, and normalizing keratinization.
    Selenium Sulfide (Selsun) 2.5% (Rx)
    For treatment of dandruff and tinea versicolor via its anti-Malassezia effect and significantly reduces the rate of cell turnover.


    Where is the Undecylenic Acid, Tolnaftate, Absorbine Junior, Gold Bond, etc.? Although I also did leave out some prescription products as well (sertaconazole, oxiconazole, naftifine), this comprehensive guide will treat the topical fungal infections the community pharmacist sees. Our treatment decisions must be dictated by efficacy, cost and of course patient safety. In the upcoming weeks we will be covering specific topical disease states such as tinea pedis, cruris, corporis, thrush, vulvovaginal candidiasis, onychomycosis, and diaper rash. After this "series" we will feel much better treating "the fungus among us"!!

    Have a great day on the bench!!

    Are you left scratching your head on how to treat dandruff patients?

    Treatment options and patient care points for dandruff

    Etiology: Dandruff is the most common form of scalp seborrheic dermatitis. We are familiar with the appearance of dandruff, which the scalp shows fine, white, diffuse scaliness without underlying erythema. The rate of turnover of the epithelial cells is about twice the normal rate in patients affected with dandruff. Malassezia (formerly called Pityrosporum) is a “lipid dependent” fungus (yeast) that lives on the scalps of most healthy patients. Sometimes it grows out of control, feeding on the oils secreted by hair follicles and causing irritation that leads to increased cell turnover. The result is many dead skin cells, which fall off, clump together with oil from hair and scalp, and become visible. Unfortunately, they end up on our black tuxedos or cocktail dresses!

    Factors influencing overgrowth: increased oil production; hormonal fluctuations; stress; illness; neurological disorders, such as Parkinson's disease; a suppressed immune system; infrequent shampooing and extra sensitivity to the malassezia fungus may contribute to the development of dandruff.

    Treatment : The 2017 Sanford Guide recommends two first line treatments for dandruff: ketoconazole 2% or selenium sulfide 2.5%

    Nizoral® Ketoconazole 2% Shampoo(Rx) only:
    • Acts by blocking the biosynthesis of ergosterol, the primary sterol derivative of the fungal cell membrane. Ketoconazole weakens the fungal cell membrane.
    • Apply twice a week. Leave on for 5 minutes and thoroughly rinse.
    • Patient Care points: immediate lather hair when starting shower, to let ketoconazole saturate the hair and scalp for 5 minutes to get full benefit. Nizoral® A/D shampoo 1% is the over the counter version
    Selenium Sulfide 2.5% (lotion/shampoo)
    • Controls dandruff via its anti-Malassezia effect and significantly reduces the rate of cell turnover.
    • Usually applied twice a week. Thoroughly rinse.
    • Patient care points: Remove jewelry to prevent staining from sulfide. Although this is the most effective treatment for dandruff, the sulfide (“rotten egg”) smell steers patients away from this drug. Selsun Blue 1% is the over the counter version.
    Head and Shoulders® Zinc pyrithione (ZPT)
    • Heals the scalp by normalizing epithelial keratinization, sebum production, or both. Also shown to significantly reduce the numbers of yeast organisms. Helps prevent the dandruff-causing microbe, Malassezia globosa, from forming scalp irritants
    • Dosage: Is effective if used three times a week.
    • Patient care points: Don’t alternate between ZPT and non-medicated shampoos.Use only ZPT containing product if using every day.
    Neutrogena T/gel: Coal tar based .5%
    • Mechanism: Keratolytic agent which reduces rate of skin cell formation, and also softens keratin; also elicits antiseptic & antibacterial properties
    • Dosage: best if used twice a week.
    • Patient care points: Use caution in exposing scalp to sunlight after applying this product. It may increase your tendency to sunburn for up to 24 hours after application. Does smell like a freshly paved road.

    Lots of marketing goes into shampoos for a good reason. Most people need them, and use them every day. Most patients have their favorite, and that is what they stick with.

    My "oily skin" and very abundant growth of Malassezia, make me a primary candidate for using a dandruff control. What is my favorite? I don't like the smell (neither does Mrs. Kreckel!) of the selenium sulfide. I have had the best success with ZPT, since I want to use it every day.

    Have a great day on the bench!!

    Only our fungi get motivated in this hot and steamy weather!

    TINEA VERSICOLOR -- Pathology and Treatment

    With the very warm weather we have been experiencing, the heat may make us humans feel lethargic. However, the yeast that causes Tinea versicolor gets “supercharged” and grows more rapidly in this heat and humidity. Tinea versicolor is a superficial skin infection -often referred to as “sweat rash” caused by Malassezia furfur (aka: Pityrosporum ovale or Pityrosporum orbiculare) M. furfur can be found in normal skin flora. Under the right conditions yeast converts to the hyphal phase and causes disease. Most often seen in hot/ humid climates, oily skin, hyperhidrosis, hereditary factors, corticosteroid treatment, and immunosuppression. Look around shirt collar lines, under bra’s, folds of skin, armpits etc. and you will see these flat discolored lesions. These lesions don’t change colors with sun exposure; they are lighter in the summer than surrounding skin, and darker in the winter. The lesions will glow yellow/green when lit up with a Wood’s lamp (“black light”).

    TREATMENT OF TINEA VERSICOLOR

    • (selenium sulfide 2.5% shampoo (Rx).
    Apply a thin layer covering the body surface from the face to the knees once daily for seven days. Leave on skin for five to ten minutes before rinsing. Remind patients to remove jewelry before application, as it may damage jewelry. Apply once a month for 3 applications to help prevent recurrences. Disadvantages: odor of the product which smells like rotten eggs. Some patients a stinging sensation after application
    • Head and Shoulders shampoo (OTC): Zinc pyrithione shampoo(ZPT) applied once daily, leave on for 5 minutes. Apply daily for 2 consecutive weeks.
    • Nizoral® ketoconazole 2% shampoo (Rx) single application for five to ten minutes is effective (80% mycotic cure rate). May be applied up to 3 days.
    • Topical azoles: usually applied daily for 14 days. Examples: Clotrimazole (Lotrimin-OTC) Miconazole (Micatin-OTC), Ketoconazole (Nizoral-Rx), Econazole (Spectazole-Rx)
    • Oral Treatment of tinea versicolor:
      • Fluconazole 400mg as a single dose.Exercise to a sweat, and do not shower for 12 hours.
        • Alternative: 300mg once a week for 2 consecutive weeks (75% cure rate)
      • Itraconazole 400mg every 24 hours for 3-7 days
      • Ketoconazole (??) Oral ketoconazole is no longer approved by FDA as of 2013 for any topical infections due to hepatotoxicity and other safety concerns, such as adrenal insufficiency and multiple drug interactions.
      • Terbinifine (Lamisil) oral tablets are of little value in the treatment.It does not achieve fungicidal levels in the skin.A 1% topical solution applied to the skin was effective in clinical trials.

    Relapse rates: Tinea versicolor’s causative agent is “normal flora.” 60% of cases relapse one year after treatment, and 80% relapse after two years. Prophylaxis (especially in warm weather) use selenium sulfide 2.5% or ketoconazole 2% shampoo applied to the entire body for ten minutes once per month is an effective prophylactic therapy.

    Tinea versicolor is commonly seen this time of the year. As the heat and humidity increase, so does the activity of our oil and sweat glands! This provides a perfect breeding ground for overgrowth of our normal flora M. furfur.

    Because more of our patient's skin is exposed due to our summer clothing and bathing suits, this common dermatological condition is more readily seen, and frequently patients come seeking our advice.

    Up until a few years ago, most dermatologists were using Ketoconazole 200mg tablets, taken as 2 tablets after a high fat meal. Patients were told to exercise until a heavy sweat, and then don't shower for 12 hours so the ketoconazole could be exposed to the M. furfur. After the FDA sternly warned practitioners in 2013 not to use ketocnazole for tinea infections, this is no longer used and a whole host of other treatments have been used. Although ketoconazole is still in the 2017 Sanford Guide, it is NOT recommended.

    I feel that prevention of recurrence is as important as appropriate treatment of the initial infection.

    Have a great day on the bench!

    July 2017

    The kidney and parathyroid are the big players in calcium and potassium levels.

    Potassium and Calcium

    POTASSIUM
    The kidney is the major player in potassium homeostasis, regulating about 90% of excretion. K+ balance is maintained by adjusting secretion into the urine in response to dietary intake. Low levels of potassium can result in muscle weakness, adverse effects on the kidneys and cardiac arrhythmias.

    Drugs that Lower Potassium Levels

    THIAZIDE DIURETICS
    Work in the distal tubule of the kidney. Keep dose under 25mg/day to decrease likelihood of hypokalemia.
    Loop Diuretics
    Furosemide, Torsemide, Bumetanide
    20 mEq potassium per day is sufficient to prevent hypokalemia with diuretics. Use 40-100mEq to correct deficiency
    Antipsychotic drugs
    (Risperidone and quetiapine)
    Can be a concern in the elderly
    Carbonic Anhydrase Inhibitors Acetazolamide (Diamox) Mild diuretic that works in the proximal convoluted tubule. A weak diuretic most commonly used for glaucoma and altitude sickness.
    Amphotericin B Half of patients will get hypokalemia
    Excessive sweating, vomiting and diarrhea. Colon cleansing. Contribute to hypokalemia by K+ loss


    CALCIUM
    Serum calcium is regulated by parathyroid hormone (PTH) and vitamin D. These hormones effect the bone, kidney, and the gastrointestinal tract. Parathyroid hormone decreases calcium excretion in the kidney, increases absorption of calcium in the gut, and increases bone resorption.

    Drugs that lower calcium levels

    Bisphosphonates
    (Alendronate (Fosamax®), Risedronate (Actonel®), Ibandronate (Boniva®) etc)
    Block osteoclast re-absorption of bone
    Calcitonin (Miacalcin®) Block osteoclast re-absorption of bone
    Cinacalcet (Sensipar®) Lowers serum calcium (binds to receptors on parathyroid gland)
    Phenytoin (Dilantin®) (and other inducers of Vitamin-D) Phenytoin, being an inducer speeds up conversion of vitamin D to inactive metabolites
    Vitamin-D deficiency Blocks absorption of calcium from gut
    Corticosteroids Increase renal calcium excretion and decrease gastrointestinal calcium absorption, resulting in reduced serum calcium
    Excess phosphate levels (seen in chronic kidney disease) May lead to decrease calcium absorption from the gut.
    Low magnesium levels (most commonly due to
    alcoholism, malabsorption, and diuretic therapy)
    Magnesium depletion can cause hypocalcemia by producing parathyroid hormone (PTH) resistance,


    Last week, in response to a request from a Physician Assistant, we covered drugs that caused excessive levels of potassium and calcium. This week we will explore the common causes of deficiency of these two ions. Potassium and calcium are frequently checked in the physicians office, and sometimes drug therapy can be responsible for their low levels.

    Have a great day on the bench!!

    Remember learning about parathyroid hormone and aldosterone?

    Drugs causing Hypercalcemia and Hyperkalemia
    One of my former Physician Assistant Students asked me to write my next column about drugs that affect calcium and potassium. Lots of physiological events can cause increases in these two very important cations, as well as drug therapy. Here are the highlights of drugs causing elevated levels of calcium and potassium.

    Drugs causing HYPERCALCEMIA

    THIAZIDE DIURETICS
    Hydrochlorothiazide, chlorthalidone
    Cause calcium retention by increased resorption of calcium in renal tubules.
    Calcipotriol (Dovonex ®) Caution with high doses or in patients with severe, extensive psoriasis
    Lithium (Eskalith) Usually mild, likely due to increased secretion of parathyroid hormone (PTH). May take 4 weeks post lithium to resolve
    Excessive Calcium Supplementation Obviously!
    Theophylline toxicity Results in mild hypercalcemia
    Vitamin-A intoxication May cause stimulation of bone resorption
    Vitamin-D intoxication In the gut increases the absorption of calcium
    HYPERPARATHYROIDISM Hypercalcemia from hyperparathyroidism is usually mild, asymptomatic, and sustained for years
    MALIGNANCIES Rapidly progressive; a RAPID rise in calcium levels should increase suspicion of malignancy.
    RENAL FAILURE Especially if given calcium carbonate or calcium acetate as phosphate binder


    DRUGS CAUSING HYPERKALEMIA

    Potassium-sparing diuretics
    (triamterene, amiloride)
    Block directly the K+-Na+ exchange in the collecting tubules.
    Aldosterone antagonist (spironolactone/epleronone) Compete with aldosterone for receptor sites
    NSAIDs By inhibiting renal function (block afferent vasodilatation of arterioles). May also inhibit renin secretion.
    ACE inhibitors
    (lisinopril,enalapril,quinapril, benazepril etc.)
    By blocking Angiotensin-II, aldosterone is decreased. Aldosterone is responsible for increasing the excretion of potassium.
    Angiotensin-receptor blockers
    (ARBs) (Losartan, Irbesartan, olmesartan, etc)
    By blocking Angiotensin-II, aldosterone is decreased. Aldosterone is responsible for increasing the excretion of potassium.
    Non Selective beta-blockers
    (propranolol, labetalol)
    Interfere with the beta-2-adrenergic facilitation of potassium uptake by the cells. Selective BB like atenolol (mostly ß-1) have minimal effect. All ß-blockers at high dose lose beta selectivity.
    Cyclosporine or tacrolimus Due to reduced efficiency of urinary potassium excretion
    Trimethoprim-sulfamethoxazole Trimeth blocks apical membrane sodium channels in the mammalian distal nephron, blocking the excretion of K+
    Heparin Reversible aldosterone suppression
    Ketoconazole Inhibits aldosterone synthesis
    Herbs Alfalfa, Dandelion Horsetail, Nettle are high in potassium
    Miscellaneous: Pentamidine & Metyrapone Inhibits distal nephron reabsorption of Na+ by blocking apical Na+ channels in a manner similar to "potassium-sparing" diuretic
    Potassium supplements in excessive doses Obviously!


    So, as we can see many of our commonly used drug therapies can have a significant impact on these two very important ions. The concern becomes even greater in our patients that are elderly or frail.


    "The Request line is open"

    Do you remember those days of listening to the local AM radio station? How excited we would be when the announcer would say "the request line is open", and we would jam the phone lines with our requests to hear the Beatles, Beach Boys, or Sonny and Cher!!

    I have tons of material to share with my column readers, but I also am delighted when I get an e-mail requesting a specific topic that my readers find of clinical interest. Today's column's request came from a practicing physician assistant who wanted a quick column on the drugs that cause changes in calcium and potassium. Next week we can discuss drug therapy that can cause lowering of potassium and calcium.

    Have a great day on the bench!!

    We always are promoting "covering up" and sunscreen....what happens when our patients don't listen???

    TREATMENT OF SUNBURN
    • Most sunburn is self-treatable. Most are usually first or second degree burns. First degree burns are simple redness of the skin. Second degree burns are when blisters appear. Apply cool compresses; frequent cool baths or showers. Pat skin dry with towel. Do not rub.
    • Minor burns can be treated with protectants which reduce dryness of skin, and prevent friction damage.
    • No topical spray will stop the underlying burn process, or stop the formation of blisters.

    Let’s talk about the two most common “remedies” for sunburn treatment:
    Dermoplast® spray: (Benzocaine 20%) is the most effective topical anesthetic. Using a strength less than 20% is not effective. Benzocaine may cause hypersensitivity reactions (1%)
    Solarcaine® gel: (Lidocaine) Caution with broken skin (might precipitate cardiac arrhythmia)
    • Best not to recommend topical anesthetics, due to short duration of effectiveness: max= 45 minutes, and potential for side effects. Do not recommend for small children.

    Ibuprofen: Did you notice after a major sun exposure, a day later the redness gets worse? Erythema becomes clinically apparent 3 to 6 hours after exposure, peaks at 12 to 24 hours, and usually subsides at 72 hours. Three hours after UVB exposure, neutrophilic infiltration begins and peaks at 24 hours, and continues up to 48 hours later.
    • Prostaglandins and nitric oxide are most commonly implicated in the delayed erythema reactions that follow within 14-20 hours after exposure and persists for 1 to 3 days. So, by using an oral medication that blocks prostaglandins, like NSAIDS we can arrest the delayed onset erythema (redness).
    • Best option for treatment of sunburn to manage the pain, and slow down the delayed erythema is IBUPROFEN. Start use immediately after a “major” exposure.

    Refer to a physician when:
    • If more than 10% of body surface of a child is sunburned, a physician should be consulted.
    • If a patient presents with: fever, headache, confusion, nausea, vomiting chills
    • Secondary infection may develop, leading to scarring.Infection is hard to treat because dead skin is an excellent medium for microbial growth.Signs of infection include increased pain, swelling, redness drainage or pus from blisters.

    Does Sunscreen cause Vitamin-D Deficiency? The short answer is “yes”
    • Effective use of a sunscreen blocks the synthesis of Vitamin-D in the dermis. Middle aged and elderly persons who use sunscreens daily have significantly lower concentrations of 25-Hydroxyvitamin D3.
    • The benefits of using a sunscreen, far outweigh the disadvantages of a decrease in Vitamin-D. A local dermatologist told me: “ It is easier to treat Vitamin-D deficiency than skin cancer”

    We see a lot of requests for recommendations for sunburn treatment this time of year. Lots of people are looking for aloe gel and other sunburn remedies. The truth is, just cooling down the skin makes our patients feel better, so a spray bottle filled with water is as effective as any topical cooling gel. Topical anesthetics are of short term value, and has risks if the skin is broken or the patient is very young or very old.

    Incidence: the estimated sunburn prevalence among all adults in the US was approximately 34 percent. Sunburn occurs more frequently among adolescents and young adults. In nation-wide surveys in the United States, approximately 70 percent of adolescents aged 11 to 18 years and 50 percent of adults aged 18 to 29 years reported at least one sunburn in the previous year.

    A lot of patients need our expertise!

    Have a great day on the bench!!

    Let's look at PREVENTION of Sunburn!

    Last week, we discussed the mechanics of sunscreens and product selection. Here are some tips to share with your patients about sunscreens.

    UVA Light: is continuous throughout the day and may exceed the intensity of UVB by up to 1,000 fold. UVA light penetrates to the dermis and is responsible for producing tanning, but may also damage blood vessels. UVA causes photo aging which is the dry, scaling, yellow and deeply wrinkled, thinner & more fragile skin. Photo aging is NOT simply an accelerated aging process. UVA exposure is associated with photo-sensitivity, drug reactions, and basal cell carcinoma.

    UVB Light: penetrates the epidermis and is responsible for erythema (burn). Most intense between 10am and 4pm. More intense in summer months and higher elevation. A positive effect of UVB exposure is that it induces the production of Vitamin-D in the skin.

    Tips for sunburn prevention
    • Avoid long term exposure during peak hours (10am - 4pm)
    • Sunglasses: Make sure they are UV protected. With cheap dark glasses, pupil dilates allowing more harmful UV rays to damage the retina. Better not to wear sunglasses than cheap sunglasses that are not UV protected!!! UV blocking sunglasses also prevent cataracts.
    • Clothing: Hats, long sleeve shirts, and long lightweight pants. A typical summer tee shirt has an SPF of only about 7. Down to 3 if wet. Yes, I was amazed too when I read how little protection a tee shirt offered. It is better than going "unprotected" and re-application isn't necessary! Check out the fabrics "UPF" (Ultraviolet Protection Factor), which indicates what fraction of the sun's unltraviolet rays can penetrate the fabric. A shirt with a UPF of 50, for example, allows just 1/50th of the sun's UV radiation to reach the skin.
    • Hats: Baseball caps leave the ears, neck and lower face unprotected. Wear wide brimmed hats to ensure that the tips of the ears are covered. Take it from a guy who has had two actinic keratosis lesions removed from his left ear!
    • Automobiles: UVB does not penetrate window glass. Windshields have UVA filters, but side windows do not. Consider sunscreen in the car if photosensitive, even if windows are up.

    Application and general information for sunscreens
    • Apply 30 minutes before sun exposure and cover all exposed areas evenly and liberally. Figure 1 0z. per adult application in a swimsuit.
    • Water Resistant: The formula retains SPF after 40 minutes of activity in water, sweating or perspiring.
    • VERY Water Resistant: The formula retains SPF after 80 minutes of activity in water, sweating or perspiring.
    • Water resistance claims on the product's front label must tell how much time a user can expect to get the declared SPF level of protection while swimming or sweating, based on standard testing. Two times are permitted on labels: 40 minutes or 80 minutes. Apply frequently!

    FDA CLASSIFICATION of Sunscreens
    (June 18, 2012 - FDA.gov)
    • "Broad Spectrum" and "SPF 15" (or higher) not only protect against sunburn, but, if used as directed with other sun protection measures, can reduce the risk of skin cancer and early skin aging. For these broad spectrum products, higher SPF (Sun Protection Factor) values also indicate higher levels of overall protection.
    • Any sunscreen not labled as "Broad Spectrum" or that has an SPF value between 2 and 14, has only been shown to help prevent sunburn. "Skin Cancer/Skin Aging Alert: Spending time in the sun increases your risk of skin cancer and early skin againg. This product has been shown only to help prevent sunburn, not skin cancer or early skin aging."

    "What should I wear to the beach??? Well, certainly my readers or patients wouldn't be asking me for fashion advice!! Here is some practical advice to protecting you and your patients from the damaging effects of the sun's rays. Although, we pharmacists are the experts in selecting medications both oral and topical, we can offer advice to our patients with respect to clothing, as well as automobile glass when it comes to sun protection!

    I learned a lot putting this column together! Be sure to share these safety tups with your patients.

    There is an excellent website I used as a reference: www.skincancer.org

    Have a great day on the bench!!"

    June 2017

    When choosing an SPF, more isn't always better!

    Sunscreens - The basics

    Skin Protection Factor (SPF) : how the efficacy of a sunscreen is expressed. It is a ratio of the time required to produce minimal redness with a sunscreen, to the time to produce minimal redness without a sunscreen. An SPF of 15 will allow a person to remain in the sun without burning 15 times longer, than if the skin was unprotected.
    Minimal Erythema Dose (MED): is the amount of solar radiation to produce minimal skin redness. MED times SPF =Safe Duration of Exposure. The MED is not a standard amount of exposure. It varies from person to person. Dark skinned individuals demonstrate higher MED. Fair skinned individuals (like redheads) have lower MED. Let’s consider two patients:
    1. Fair skin, redhead: Without sunscreen gets red in the sun within 10 minutes.
    2. Dark skinned brunette: Without sunscreen she gets red in the sun in about 30 minutes.
    • If both use a sunscreen with an SPF of 30, the redhead will turn red in 300 minutes (5 hours) while the brunette would turn red in 900 minutes (15 hours). This IS assuming they are applying the sunscreen frequently according to package instructions.
    • Your patients will have varying responses to sunscreens based on their individual skin type.
    Chemically: absorb a specific portion of the spectrum thus preventing harmful rays from hitting the skins surface. Examples: PABA, Cinnamates, Ethylhexylsalicylates, Benzopheones. Most sunscreens contain combinations of 2 or 3 of the classes.
    Physically: provide a physical barrier to UV radiation and scatter or reflect the harmful rays. Most commonly referred to as “sunblock” Examples: Zinc oxide, red petrolatum, Titanium dioxide. An SPF of at least 15 is recommended for most people by the Skin Cancer Foundation. HOWEVER...
    • Products with SPF over 30 only block UVB slightly more than those of SPF=30. The higher concentration of chemicals increases potential for adverse effects, such as skin rashes. SPF over 30 are labeled as “SPF 30 plus”. An SPF of 30 blocks 97% of the UVB rays.An SPF of 15 blocks 93% of UVB rays. Higher SPF products do increase the likelihood of allergic reactions.
    • By bumping the SPF from 15 to 30, it may offer an extra margin of safety to consumers who do not apply a sunscreen as frequently as indicated.


    “An ounce of prevention is worth a pound of cure”, is a well-worn adage we pharmacists use when discussing blood pressure, Type-2 diabetes, and osteoporosis. This adage is even more applicable with summer officially here as of June 21st at 12:24am. With the appearance of much desired sunshine and hence the need to protect our patients from the sun's damaging rays, our expertise is needed. Let's make the summer vacation of 2017 a safe and fun time whether enjoying the mountains of Pennsylvania, the beautiful sands of Myrtle Beach, or wherever your favorite summer destination is! This week let’s describe the basics of sunscreens. We will cover in the upcoming weeks the proper application of sunscreen and the treatment of sunburn.

    Oral corticosteroids are great--just make sure they are prescribed long enough!

    Treatment of Poison Ivy- the RIGHT way!
    Last week we discussed avoiding the Toxicodendron family of plants. I can easily identify the plant, when it appears growing on the side of a tree or along a hedgerow. The challenge becomes when the leaves are chopped up by a weed eater, or a lawnmower! So let’s discuss the treatment of poison ivy when a patient comes into your pharmacy or clinic.

    Refer to a prescriber when:
    • Over 25% of body surface area is contaminated, or if any sign of infection.
    • Limited but disabling involvement (hands, face, area around mouth/eyes, or genitals)
    • If patient has history of severe reactions
    Treatment of poison ivy-needs at least 14 days!
    Have you noticed when a patient gets a methylprednisolone dosepak that after the pack is completed a few days later they come back, and think they got “another batch” of poison ivy? Truth is, it is the original case but the treatment was not long enough in duration, and the patient is experiencing “rebound symptoms”. A six day treatment pack is not adequate.
    • Oral prednisone: 0.5 to 2mg/ kg / day tapered over 14 to 21 day period. Usually start with 60mg per day, and taper down over a 14-21 day period. Using a 21 day regimen will decrease the likelihood of rebound dermatitis.
    • Medrol dosepak (6 day therapy) is not long enough of duration.
    Topical treatment of poison ivy
    • Oatmeal baths might be soothing but are not of much value. They might make the tub slippery, and clog the drain!
    • Calamine actually hinders treatment and is of minimal value for poison ivy. It will help with the itching. Hydrocortisone 1% OTC is of limited value—use only in mild cases.
    • Avoid: topical antihistamines, topical anesthetics, topical antibiotics, as well as poison ivy extracts. Jewelweed (Impatiens biflora) extract is promoted for relief of poison ivy, but is of no value.
    • Burows solution is available over the counter: (aluminum acetate): dissolve 1 packet (Domeboro®) in 1 pint of water, and apply as a wet dressing for 15-30 minutes 3 to 6 times daily. This self care product greatly relieves itching.
    • Topical prescription corticosteroids are most effective in early stages BEFORE the blisters form. They will help with itching, and promote drying of the lesions. They are of little value once the blisters form.


    We see a lot of poison ivy in our area, and frequently it is treated with a Methylprednisolone six day dosepak. The patients will come back a couple of days after completion of the pack, and think they got into another "batch" of poison ivy. The truth is they were not treated adequately the first time.

    I saw such a patient today, her arms slathered with Calamine lotion Her arms were blistered, and she had a prescription for a Methylpred 4mg dose pack, and an 80gram tube of triamcinolone 0.1% cream. After reading this newsletter, it is obvious that all three treatments were wrong. Calamine is worthless, and needs to be scrubbed out; the triamcinolone cream is not recommended since the blisters were present AND the corticosteroid should be given 14-21 days! (Feel free to share this newsletter with your colleagues!)

    Poison Ivy--it's all about the oil. Identification is key to prevention!

    Poison Ivy: Leaflets three let them be! Hairy vine no friend of mine!
    The Toxicodendron (“means poisonous tree”) genus of plants causes more contact dermatitis than all other causes combined. Ten to fifty million Americans develop allergic contact dermatitis to a Toxicodendron annually. In one study 10% of all occupational injuries among seasonal farm, workers in PA and NY were due to poison ivy contact. The genus/species names are as follows:
    • common or northern poison ivy (Toxicodendron radicans)
    • western poison ivy (Toxicodendron rydbergii)
    • eastern poison oak (Toxicodendron toxicarium)
    • western poison oak (Toxicodendron diversilobum)
    • poison sumac (Toxicodendron vernix)
    Regardless of the species name all the treatment protocols are the same. Allergic Contact Dermatitis (ACD) has 2 distinct phases.
    • A sensitization phase where a specific hypersensitivity to the allergen is acquired.
    • An elicitation phase during which dermatological response is visible.
    Identification of Poison Ivy:
    • Poison ivy is typically a hairy, ropelike vine with three shiny green (or red in the fall) leaves budding from one small stem. “Leaves of three let them be!” and “Hairy vine, no friend of mine”.
    • May have yellow or green flowers and white to green-yellow or amber berries
    • Poison sumac, may be harder to identify because it more often forms leaflets of five, seven, or more that angle upward toward the top of the stem.Poison sumac presents as a woody shrub that has stems that contain 7-13 leaves arranged in pairs
    Here’s what happens
    • Urushiol, which is an oleoresin (lacquer) oozes from the broken leaf and stems, causing the characteristic black dots which is oxidized urushiol (due to the enzyme laccase found in the oleoresin) and can be found on plant leaves within 10 minutes of its exposure to oxygen. Urishiol can be transmitted to the patient by contact with the plant, or pets, tools, gloves, shoes and clothing for months. Washing clothes in regular laundry detergent will decontaminate fabrics. Poison Ivy should NEVER be burned, as it vaporizes the oil, causing lung damage.
    • The characteristic wheals and blisters of poison ivy contain serum, and NOT the urushiol. Poison ivy and other poison plant rashes can't be spread from person to person. But it is possible to pick up the rash from plant oil that may have stuck to clothing, pets, garden tools, and other items that have come in contact with these plants.
    In summary, make sure your patients are educated about Lyme disease, and are using insect repellents, wearing long sleeve shirts and pants treated with permethrin, and know appropriate tick removal procedures. Have them seek care in case of a tick bite. As you see from this column, untreated Lyme can have some devastating effects on our patients.

    When contacted:
    When a patient is exposed to a poisonous plant, like poison ivy, oak or sumac:
    • Immediately rinse skin with rubbing alcohol, poison plant wash, or degreasing soap (such as dishwashing soap) or detergent, and lots of water. Professor Pete takes a half bar of Fels Naphtha soap (old fashioned washboard soap) in a nylon stocking, and carries it backpacking or ties it to his canoe seat. The soap is always handy, and never gets soggy.
    • Rinse frequently so that wash solutions do not dry on the skin and further spread the urushiol.
    • Scrub under nails with a brush.
    • Wash exposed clothing separately in hot water with detergent.
    • After use, clean tools with rubbing alcohol or soap and lots of water. Urushiol can remain active on the surface of objects for up to 5 years. Wear disposable gloves during this process.



    Leaflets three--let them be!
    (Notice the "hairy vine")

    I've spent almost 20 years in leadership positions with Cub Scouts and Boy Scouts, and teaching about poison ivy seems to be the one condition that the general public is most misinformed about! First concern people have is about spreading poison ivy, when the rash starts to blister and seep. These lesions contain serum and can't be spread. The only way the rash can occur is direct contact with the urushiol to a sensitized patient. Identification of poison ivy is another teaching moment. Last week in our landscaping in the front of our home, I found a beautiful specimen of poison ivy. I gently removed it with a rake, and put it on the front curb and took a picture, which appears in this edition. I have gotten poison ivy several times while planting flowers at our cemetery. I guess I'm not good at identifying poison ivy when it is chopped up with a weed-eater or lawn mower! People love to dump stuff on their poison ivy lesions that often does more harm than good-- next week we will talk about appropriate treatment of poison ivy, both from the patients standpoint, as well as the prescriber's standpoint.

    What happens when the tick bite goes undiscovered or untreated?

    Progression of Lyme Disease

    As we discussed last week, Lyme disease, caused by the spirochetal bacterium Borrelia burgdorferi, remains the most common vector-borne disease in the United States. Lyme disease was first described in 1977 as "Lyme arthritis" in studies of a cluster in Connecticut of children who were thought to have juvenile rheumatoid arthritis. When some of these kids got ear infections, and were treated with amoxicillin the “arthritis” went away. The multisystem nature of the infection became clear as involvement of other systems was soon identified.

    The problem with Lyme disease isn’t so much with the tick we remove, but the one that is never discovered, and inoculates our patient with the Borrelia burgdorferi spirochete. Only about 25 percent of patients with erythema migrans recall the tick bite that transmitted Lyme disease. The characteristic rash erythema migrans (the “bullseye” rash) occurs in 70 to 80% of the cases. We can also say that 20-30% of the time patients do not get the rash. Here is what happens if Lyme disease remains undiagnosed and progresses.

    Early Disseminated Lyme disease
    Occurs days to weeks after tick bite and left untreated, the infection may spread and see:
    • Additional erythema migrans lesions appear in other areas of the body
    • Neurological consequences:
      • Facial or Bell's palsy (loss of muscle tone on one or both sides of the face)
      • Severe headaches and neck stiffness due to meningitis (15% of patients)
    • Pain and swelling in muscles and the large joints (such as knees) (60% of patients)
    • Shooting pains that may interfere with sleep
    • Heart palpitations and dizziness due to changes in heartbeat (1% of patients)

    Late Disseminated Lyme disease
    • Occurs a few months to years post-tick bite
    • Approximately 60% of patients with untreated infection may begin to have intermittent bouts of arthritis, with severe joint pain and swelling. (60% of untreated patients)
    • Affects Large joints (knees) see pain and significant swelling.
    In summary, make sure your patients are educated about Lyme disease, and are using insect repellents, wearing long sleeve shirts and pants treated with permethrin, and know appropriate tick removal procedures. Have them seek care in case of a tick bite. As you see from this column, untreated Lyme can have some devastating effects on our patients.

    Here is the latest on treatment of Lyme disease with of all things loratadine (Claritin) and desloratadine (Clarinex). Here is what happens:

    Loratadine metabolite “desloratadine” blocks BmtA (Borrelia metal transporter A). Desloratadine (which is the brand name “Clarinex”) blocks manganese from entering the cell. Transition metals, including iron (Fe), zinc (Zn), and manganese (Mn), are critical to both bacterial metabolism and virulence.When these metals are blocked it starves the Borrelia burgdorferi and causing it to die in test tubes. Obviously this is way too early in the research phase for us to recommend this to our patients, so we will have to wait and see…..Source: http://www.pnas.org/content/106/9/3449.full

    There is lots of information on the CDC website with patient friendly downloads on Lyme disease: https://www.cdc.gov/lyme/toolkit/index.html
    (Hey, we pay our taxes, might as well reap some benefits)

    Appropriate prophylaxis and treatment of Lyme disease

    Lyme Disease - Treatment Options

    Let’s assume our patients didn’t adequately follow last week’s prevention tips. We can cover two scenarios. The first we will discuss when a patient finds a tick on their skin, and then remove it. Then we can discuss treatment when the characteristic rash appears.

    Pharmacological Prophylaxis of Lyme disease: The Infectious Disease Society of America recommends prophylaxis of a tick bite only when:
    • Attached tick identified as an adult or nymphal deer tick (Ixodes scapularis)
    • Tick is estimated to have been attached for 36 + hours
    • The antibiotic can be given within 72 hours of tick removal
    • The local rate of tick infection with B. burgdorferi is ≥20 percent.
    • Doxycycline is not contraindicated. Don’t give if the patient is pregnant, nursing or a pediatric patient.
    Recommended dose: Doxycycline 100mg (2) tablets as a single dose with food. Dispense #2 tablets.

    Pharmacological Treatment of Lyme Disease
    The first sign of infection is usually a circular rash called erythema migrans or EM. This rash occurs in approximately 70-80% of infected persons and begins at the site of a tick bite after a delay of 3 to 30 days. A distinctive feature of the rash is that it gradually expands over a period of several days, reaching up to 12 inches (30 cm) across. The center of the rash may clear as it enlarges, resulting in a bull’s-eye appearance. It may be warm but is not usually painful. Some patients develop additional EM lesions in other areas of the body Treatment of early erythema migrans: (appearance of red “bulls-eye” rash)
    • Doxycycline (Vibra-tab) 100mg twice daily for 14-21 days. Avoid doxycycline if pregnant or under age 8.
    • Amoxicillin (Amoxil) 500mg three times daily for 14-21 days
    • Cefuroxime (Ceftin) 500mg twice daily for 14-21 days
    • Erythromycin (Ery-tab) 250mg four times daily for 14-21 days (extremely expensive)
    Note: 10 days may be as effective as 20 days. (Source: Sanford Guide)

    Since pharmacists are indeed the “drug experts” as well as the “cost experts” consider the following:
    • I personally do not dispense the doxycycline capsules, and use only tablets due to the choking hazard of the capsules. Some European countries ban the capsules for this reason. I have had two students in my class say they had esophageal burns due to capsules getting stuck in the throat. Remember to avoid doxycycline in children whose teeth are not fully erupted.
    • Amoxicillin is equally effective as doxycycline, but it needs to be dosed three times a day. Best option for pediatrics and pregnant women. Amoxicillin is still the least expensive treatment for Lyme erythema migrans. Amoxicillin should NOT be used for prophylaxis (as doxycycline is). Amoxicillin might also be a better choice for patients who experience photosensitivity on previous doxycycline therapy.

    "As we discussed last week, prevention is indeed key for our patients who are headed to the outdoors. Although we commonly think of Boy Scouts, hikers, campers, and fishermen keep in mind that other outdoor activities such as gardening and even golf may expose patients to deer ticks.

    This morning I decided to take my 5K hike through the neighboring farm, and through the woods. My wife reminded to put on my hiking pants, that I previously sprayed with permethrin. The grass was up to my waist in the fields. I saw a big doe (probably hiding her fawn) in the first field. After I got on the road, my pants were soaked with the morning dew, but there wasn't a tick anywhere on my light polyester pants.

    One of the first patients I saw this morning was at the minute clinic, and brought a prescription for Doxycycline for 2 of the 100mg tablets. I gave her the flyer from last week, and she said she did have the permethrin, but neglected to treat her clothes this year! She promised me she would spray them when she got home. The lady behind her was listening in and quickly picked a can of permethrin of the shelf and bought it. My wife Denise called and told me she treated a patient with doxycycline for erythema migrans, who never heard of permethrin clothing spray! He was curious when the doxycycline would be "washed out" so he could canoe again, since he had such a photosensitivity rash last time. Amoxicillin might have been a better choice for this patient. So you see we have a lot of educating to do. Even though the IDSA guidelines came out in 2006, and have not changed many clinicians might not be choosing the optimal therapy for their patients."

    May 2017

    Lyme Disease is in Full Swing in the United States

    Lyme Disease

    CAUSED: by the bacterium Borrelia burgdorferi and is transmitted to humans by the bite of infected blacklegged ticks (Ixodes scapularis).
    SYMPTOMS: include fever, headache, fatigue, and a characteristic skin rash called erythema migrans, which occurs 3-30 days after the tick bite.

    THE RASH "Erythema migrans"
    • May occur anywhere on the body, and appears in approximately 70 to 80 percent of infected persons. (Keep in mind that 20-30% of the time there is NO rash.)
    • Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days)
    • Expands gradually over a period of days reaching up to 12 inches or more (30 cm) across
    • May feel warm to the touch but is rarely itchy or painful
    • Sometimes clears as it enlarges, resulting in a target or “bull’s-eye” appearance

    PREVENTION: “An ounce of prevention is worth a pound of cure”- Benjamin Franklin
    • Wear high socks, long pants and long sleeve lightweight shirts. Best if color is white or very light to spot ticks easier. Walk in the center of a trail, and avoid tall grasses in fields and meadows
    • Checking for ticks: Check legs and feet frequently. Know how to spot and identify ticks. Nymphal ticks are as small as a poppyseed. Use bright light and magnifying glass. Check each other in hard to see areas, especially folds of skin.
    • Pets: use a scheduled tick killing shampoo. Brush pet daily outside the house.

    INSPECTION:
    • Bathe or shower as soon as possible after coming indoors (preferably within 2 hours) to wash off and more easily find ticks that are crawling on you.
    • Conduct a full-body tick check using a hand-held or full-length mirror to view all parts of your body upon return from tick-infested areas. Parents should check their children for ticks under the arms, in and around the ears, inside the belly button, behind the knees, between the legs, around the waist, and especially in their hair.
    • Examine gear and pets. Ticks can ride into the home on clothing and pets, then attach to a person later, so carefully examine pets, coats, and day packs.
    • Tumble clothes in a dryer on high heat for an hour to kill remaining ticks

    TICK REMOVAL: Removal with tweezers and magnifying glass. Wear gloves place tweezers on head of tick as near skin as possible. Pull slowly, steadily and upward. Don’t twist, squeeze, jerk or crush tick. Save tick in jar or vial. Wash site of removal with soap and water. Do not use matches, petroleum jelly, gasoline, kerosene, nail polish remover.

    INSECT REPELLANTS:

    Deet (N,N-diethyl-3-methylbenzamide) can be used directly to the skin. Use repellents that contain 20 to 30% DEET (N, N-diethyl-m-toluamide) on exposed skin and clothing for protection that lasts up to several hours. Always follow product instructions. Parents should apply this product to their children, avoiding hands, eyes, and mouth.
    Permethrin: Use products that contain permethrin on clothing. Treat clothing and gear, such as boots, pants, socks and tents with products containing 0.5% permethrin. It remains protective through several washings. Permethrin is available OTC as a solution for application to clothing. Available Sawyer Clothing Insect Repellant, or Repel Clothing and Gear. Once applied to clothing it remains effective for up to 6 weeks, even after several launderings. Good for clothes that are exposed to tick infested areas. Effective against ticks that carry Lyme disease and Rocky Mountain Spotted Fever. Repellant should be applied outdoors and before clothing is worn; hang clothing, spray and let dry two hours (four in humid conditions).

    "In Pennsylvania we love our sports teams, the Eastern Side of the state has the Phillies, Eagles and Flyers; the western side has the Pirates, Steelers and Penguins. These teams over the years have been “#1” in their respective sports. The whole state has its “#1” in statistics too, that being for the third straight year, leading the nation in number cases of Lyme disease.

    Now that winter has released its clutches on our country, everyone is headed to the great outdoors either for picnics, hiking, camping and even less enjoyable, gardening and mowing the lawn! Many of our patients are presenting to our pharmacies/offices with questions about Lyme disease. I just sprayed my hiking pants with Permethrin spray!

    Lots of good information on the CDC website. Below is a picture of the rash and other Lyme symptoms."


    Hey doc.. I have a lot of pain with this tooth. What can I take?

    If it's mechanical-- only the dentist can help

    Dental pain: Basically, if a mechanical problem exists (broken tooth, ill-fitting dentures, missing fillings, chipped or broken tooth), our patient should always be referred to the dentist. In the meantime, dental pain from a toothache is best treated orally with NSAIDS (ibuprofen, naproxen). Topical treatment is short lived and is not of much use and should be discouraged. Make sure that NSAIDS are appropriate for that patient. One of the more common OTC treatments many patients use is Anbesol which contains phenol and is of no use in treating dental pain. It will however, in high enough dose, cause caustic chemical burns in the mouth. Advise against its use.

    Teething pain in babies: recommend acetaminophen or ibuprofen if old enough (over 6 months). Do not recommend benzocaine topical products, homeopathic remedies or heaven forbid rubbing whiskey on the gums (sorry Grandma!). Have patient consult pediatrician for appropriate doses if under two years of age.

    Missing fillings, cracked caps, broken off teeth? Don't apply any sort of medication, such as aspirin, or topical anesthetics, directly to the tooth. Bite down on tea bag to stop bleeding. It is best to avoid eating, but if necessary eat only soft foods until patient can be seen by a dentist. To manage pain, apply ice to the face outside the lips or cheek at the location of the injured tooth. Do not apply ice directly to the tooth. Over-the-counter pain meds (Ibuprofen or Naproxen) if appropriate, are effective to minimize pain.

    First Aid for Tooth Avulsion- "Knocked out teeth"

    Best Choice: For professions around activities where teeth can be knocked out, such as athletic trainers, coaches, school nurses and emergency responders, Save-a-Tooth® is a proprietary product that should be carried to all events. This product keeps the tooth alive and nourishes cells until implantation occurs. About 90% success rate (versus 10%). If no one has this product available, (which is most likely) pick up tooth by crown, not the root. Rinse the affected tooth with water if dirty. Reposition into socket at once (if possible). Do NOT let the avulsed tooth dry-out! It is important to remember that time is extremely important here. After 30 minutes the success rate of tooth reimplantation drops sharply.
    • may hold in mouth next to cheek (Not recommended in cases where there is a fear of the patient swallowing their tooth)
    • drop into glass of milk (Best option if you don’t have Save-a-tooth)
    • see the dentist/endodontist within 30 minutes
    "Meth Mouth" is most commonly attributed to the abuse of methamphetamine (crystal meth, crank). This drug is made in meth labs, through the conversion of pseudoephedrine to methamphetamine. According to the American Dental Association, “meth mouth” is probably caused by a combination of drug-induced psychological and physiological changes including, xerostomia (dry mouth), extended periods of poor oral hygiene, frequent consumption of high-calorie carbonated beverages, teeth clenching and grinding (bruxism). The Pennsylvania Dental Association also contends the acidic nature of methamphetamine destroys enamel. (Due to highly corrosive nature of manufacturing process) “Meth mouth” is a misnomer. Not all patients with these blown away teeth are methamphetamine addicts. Meth mouth also describes any chronically using any amphetamine, or any opioid. This condition can also be seen in anorexia/bulimic patients.

    What the dentist sees: of the 28 teeth, most adults have (32 minus 4) most patients come in with at least 20 teeth blown away. The challenge is once these patients are in detox with the opioids withdrawn, the exposed nerves become very painful, and patients seek dental help. Generally speaking, dentures are the only viable treatment option.

    "We have spent the past thirteen columns meticulously going through all the products in our dental section, gaining a level of expertise that we didn’t have, thanks to the input of Dr. Rodney Messner. We have a lot of products to choose from to help our dental patients, but there are some complaints that we just can’t fix! This column is dedicated to what we can’t fix, and should be immediately referred to a dentist. Unfortunately many of our states do not reimburse dentists adequately and they will lose money seeing these patients that frequently come to our pharmacy with dental issues. A day doesn't go by when we get a prescription for Clindamycin and Ibuprofen from the Emergency Department from our local hospital. These patients are in pain and this is only a temporary fix. Only the expert care of a dentist will be able to remedy their dental problems. We as pharmacists like to help our patients, and sometimes the best advice we can give is to recommend our patients for appropriate dental care. Remember--"Dentistry isn't expensive...neglect is!" "

    Dr. Rodney Messner of CherryTree Dental Associates has been most helpful in providing expertise for these columns. His expertise in the treatment of tooth avulsion is most appreciated for this column. We wish him continued success in his practice.

    Dr. Rodney A. Messner, DMD

    Dry mouth complaints??... before heading to the dental section... check the med list!!!

    Treatment and Prevention of Xerostomia

    A healthy patient produces saliva at the rate of 0.5ml per minute, approximately 30 ml of (1 ounce) per hour. In a person with xerostomia, the rate is reduced to 0.1ml per minute, approximately 6ml (1 teaspoonful) per hour. Besides adding in chewing and digestion, saliva maintains the pH balance in the mouth by secreting bicarbonate ions, produced in the salivary ducts, which combine with and neutralize the H+ ions produced in the fermentation process. Inadequate production of saliva is a risk factor for dental caries.

    The Most Common Causes of Xerostomia:

    • Lesions in the salivary glands or duct obstruction
    • Radiation injury to the salivary glands
    • Sjogrens syndrome: 9:1 female: male ratio. Most common disease affecting salivary gland. These patients also experience dry eyes, dry skin, difficulty in swallowing and swollen inflamed joints
    • Hypertension, alcohol, tobacco, caffeine use
    • Cystic fibrosis
    • Lupus, Crohn's disease, Biliary cirrhosis, HIV

    Many Drugs are Commonly Implicated in Causing Xrostomia:

    • Numerous psychotherapeutic agents: benzodiazepines, buspirone, TriCyclic Antidepressants (Elavil), Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft), MAOI (Emsam), Effexor, Wellbutrin. Lithium, Valproic acid, numerous antipsychotics.
    • Antihypertensive agents: clonidine, enalapril, methyldopa, prazosin
    • Diuretics: HCTZ, Furosemide, Spironolactone
    • Anticholinergics: Benztropine, Trihexyphenidyl, Atropine, Dicyclomine, Hyoscyamine.
    • First generation antihistamines: Diphenhydramine, promethazine, hydroxyzine. This is primarily to their anticholinergic side effects.

    OTC treatment of Xerostomia: topical treatment of xerostomia is available as "Saliva substitutes".

    Saliva substitutes may be most useful before sleep, because viscosity of saliva changes at night; after waking at night with dry mouth symptoms, during telephone conversations, during social and workplace interactions, and in patients with dentures.

    • Contain carboxymethylcellulose and or mucins for lubrication and viscosity.
    • Contain xylitol or sorbitol as sweeteners. Remember sugar alcohols can cause diarrhea.
    • Trade names: MouthKote, Biotene Oralbalance gel, Biotene mouth spray, Salivart, Xero-lube

    Patient tips:

    • Sip water and sugar free drinks.Avoid sugary drinks and caffeine
    • Chew Sugarless gum or suck on sugarless hard candies
    • Use a humidifier
    • Breathe through the nose, not the mouth
    • Practice good oral hygiene: brush, floss, see dentist regularly.
    • Treat cracked lips with petroleum jelly or lip balm
    • Eat high moisture foods (Mashed potatoes instead of French fries). Avoid spicy foods

    RX Treatment:

    Includes the parasympathomimetics or the "cholinergic agonists": pilocarpine (Salagen), cevimeline (Evoxac). Patients may complain of excess sweating and gastrointestinal upset. Patients should be monitored for development of oral candidiasis (thrush).

    Special thanks to Dr. Rodney Messner from CherryTree Dental Associates for his review of this column:


    Dr. Rodney A. Messner, DMD

    Dr. Rod adds:

    • Biotene products seem to be the most popular with my patients.
    • Xerostomia is a very common problem among our older patients. I do see it a good bit in my dental practice
    • Don't forget to advise patients to avoid highly acidic foods/drinks as well due to their erosive effect on teeth. With limited saliva production, these drinks can quickly damage the protective enamel layer.


    Clenching teeth---our dentists can help!

    Bruxism--again we have to check the med list!!

    Bruxism refers to repetitive jaw-muscle activity characterized by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. stress and anxiety but by sleep disorders, an abnormal bite or teeth that are missing or crooked. The symptoms of teeth grinding include:
    • Clicking or popping jaw joints
    • Eating disorders
    • Enlarged jaw muscles
    • Earache because of proximity of ear canal to TMJ
    • Dull headaches
    • Jaw pain and stiffness on waking
    • Teeth that are painful or loose, due to wearing down of enamel and increasing sensitivity
    • Fractured teeth and excessive tooth wear
    Treatment may include mouth guards, and skeletal muscle relaxants.

    German researchers did a small study of 69 patients, and concluded that participants with high sleep bruxing activity tend to feel more stressed at work and in their daily life, and, according to the questionnaire, seem to deal with stress in a negative way. Bruxism is a dangerous dental problem that can not only wear down teeth, but also make them sensitive or loose or even fracture them. Besides worn tooth surfaces, which can lead to sensitivity, symptoms can include headaches and a sore jaw.

    Causes of Bruxism:

    Bruxism presents with multifactorial etiologies many of which remain unclear, but several factors may be involved which include, the use of psychoactive substances (tobacco, alcohol, caffeine, or medications for sleep and depression) increases arousal and leads to problems falling asleep, staying asleep and daytime sleepiness. Mental disorders, anxiety, stress and adverse psychosocial factors are significantly related to tooth grinding during sleep and it has been found that nearly 70% of bruxism occurs because of stress or anxiety.

    Pharmacotherapy may contribute to bruxism, believed to be due to lowering dopamine levels. Selective Serotonin Reuptake Inhibitors (SSRI) are most commonly implicated with Citalopram (Celexa), Fluoxetine (Prozac) and Paroxetine (Paxil) being the biggest culprits. Mirtazapine (Remeron) might be a better choice.


    TREATMENT (Pharmacotherapy) of BRUXISM
    • STOP the offending medication!
    • Buspirone (anxiolytic) may help with anxiety, without contributing to bruxism
    • Propranolol, Gabapentin, Botulism toxin have all been used.
    • Clonazepam has most evidence, and has the additional benefit of decreasing nighttime leg movements.
    Mechanical treatment of Bruxism: Mouth Guards
    • Premade Plastic Mouth Guards-flexible plastic- don’t always fit adequately over the teeth. May be an obstructive hazard
    • "Boil and Bite" Mouth Guards OTC fit better than the pre-made but are more uncomfortable to wear. May interfere with tongue movement.
    • CUSTOM FIT Mouth Guards: made by dental professionals, from soft rubber up to acrylic, for heavy grinding.
    • Occlusal splints (bite guards) have become first line therapy as they protect the teeth from premature wear, reduce jaw muscle activity and the noise of teeth grinding.


    Special thanks (once again) to Dr. Rod Messner for his expertise in reviewing this column for content.


    Dr. Rodney A. Messner, DMD

    April 2017

    Might want to grab a bottle of water after reading this column! (it is cheaper however if you drink it out of the faucet!)

    Have a soda...and a smile??

    Dr. Rod Messner has this to say about soda consumption: "When I was in Dental School at Temple University, one of the professors gave us first year dental students a most discouraging prediction: with every city fluoridating their water the upcoming generation will have teeth that will never dec... most of you will probably starve, as drilling and filling is our bread and butter" . "Since I first heard that statement 32 years ago, one thing has been made very clear to me: Human behavior always trumps good science! The science related to the deleterious effect of regular consumption of soft drinks is good science as well as the voluminous data related to systemic fluoride."

    "However, when our patients regularly ingest 6 liters of Mountain Dew per day, (yes 6 liters) no amount of flossing, tooth brushing, or fluoridated mouthrinse is going to help this patient! What we do know about the dental effects of soft drink consumption is that when compared with caries, dental erosion seems to have a much stronger relationship with soft drinks. In order to advise your patients on ways they can reduce dental caries risk, low-calorie and sugar-free foods should be recommended. However, sugar-free soft drinks often have as high an erosive potential as sugar-containing soft drinks."

    Dr. Messner provides these great insights, and 32 years since he heard that prediction we Americans are doing very little to decrease soda consumption. Consider the following: According to the New York Times 5% of the federal "food stamp" budget (SNAP) is spent on these soft drinks, while the category of "sweetened beverages" (energy drinks, fruit juices and teas) accounts for 10% of the grocery bill. The Department of Agriculture is coming under fire for "subsidizing the soda industry"

    https://www.nytimes.com/2017/01/13/well/eat/food-stamp-snap-soda.html?_r=1
    Here is the history of how much soda Americans consume:
    • 1970- Americans consumed 20 gallons soda per year (7-oz/day)
    • 1981- Americans consumed 32 gallons soda per year (11oz/day)
    • 2002- Americans consumed 54 gallons soda per year (20oz/day)
    • 2015- Americans consumed 41 gallons soda per year (14oz/day)
    It's called "pop" in the Midwest and most of Canada. It's "soda" in the Northeast. And it goes by a well-known brand name in much of the South. Where I live in Blair County, Pennsylvania is on the edge of the "pop versus soda" line. Folks to our west in Pittsburgh call it "pop" and the folks to our east call it "soda". Horry County, South Carolina, home of PharmCon it is called by a well-known "brand name". Yes there is a website: popvssoda.com !!

    • Larger serving sizes make the problem worse. From 6.5 ounces in the 1950s, the typical soft drink had grown to up to 20 ounces by the 1990s.

    Three ingredients in this delicious, fizzy drink cause the problems with our teeth:

    • Sugar: obvious contributor to dental caries. Note that this also includes corn syrup! This we see regularly as one of the top food additives to avoid in our diet for better health!!
    • Phosphoric acid: gives the "bite" to soft drinks. The pH of soda, and our mouths have a lot to do with the destruction of the enamel of our teeth.
    • pH of a soft drink ranges from 2.47-3.35
    • pH in our mouth is normally about 6.2 to 7.0
    • At a pH of 5.2 to 5.5 or below the acid begins to dissolve enamel on our teeth
    • Citric acid: Non-cola drinks contain citric acid which is also harmful to teeth
    As far as interprofessional interactions with dentists and pharmacists, Dr. Messner offers the flowing closing comments: "It is necessary to educate out patients about the harmful effects of excessive soft drink consumption and to advise them with the following tips to prevent dental erosion and caries: limiting soft drink intake, choosing low erosive soft drinks, improving their drinking habits, toothbrushing at least twice per day, and avoiding brushing teeth within 1 hour after consuming acidic food, and using a fluoride or a remineralizing toothpaste."
    I remember as a kid growing up, seldom was there soda in our house. We had to go to our Grandpa's house for a visit if we wanted such a treat. I remember well the 7 ounce soda bottles, and how there were judiciously passed out to us youngsters. As we discussed last week, about 2/3 of the municipal water supplies are fluoridated and with the large increases in consumption of sugared beverages and soda-pop, we are confident that our fellow health care clinicians in the dental profession will be plenty busy… for a long time! Once again, I want to express my sincere appreciation to Dr. Rodney Messner for his input on this column. With over 30 years of clinical experience, and an extremely busy schedule I'm delighted to have him contribute his expertise to this column. Have a great day on the bench!!

    "Keeping teeth strong with fluoride!
    Dr. Rod Messner is a huge fan too! "


    Fluoride---friend or foe??

    How fluoride works: The risk of dental caries is reduced due to the uptake of fluoride by enamel cystallites and formation of fluorhydroxyapatite which is resistant to acid solubilization. Fluoride is anticariogenic because it replaces the hydroxyl ion in hydroxyapatite with the fluoride ion to form fluorapatite on the outer surface of the enamel. Fluorapatite hardens the enamel and makes it more acid resistant. Fluoride also has demonstrated antibacterial activity. Fluoride is most beneficial from birth to age 12 because unerupted permanent teeth are mineralizing at that time. Whether a person receives fluoride supplementation depends on the concentration of the drinking water. Adding fluoride to the water reduces dental caries by 25%. Because of this contribution to public health, the CDC named community water fluoridation one of 10 great public health achievements of the 20th century. The American Dental Association, the American Academy of Pediatrics, the US Public Health Service and the World Health Organization all support fluoridation of water.

    Sources of fluoride:
    • Drinking water: About 66% of the US population lives in a municipality with a fluoridated water system. The United States Public Health Service recommends an optimal fluoride concentration of 0.7 milligrams/liter (mg/L). This concentration of fluoride in drinking water is the concentration that provides the best balance of protection from dental caries while limiting the risk of excess fluoride (dental fluorosis).
    • Dentist applied: fluoride based varnishes and gels can be applied directly to the teeth during a dental visit.
    • OTC mouthwashes: Children under the age of 6 years should not use mouthwash, unless directed by a dentist, because they may swallow large amounts of the liquid inadvertently.
    • Rx Gels and toothpastes such as Prevident 5000 and others. Rx products deliver about four times as much fluoride as do the OTC products.

    Does it work?

    The prevalence of dental caries in at least one permanent tooth (excluding wisdom teeth) decreased from 90% among those aged 12-17 years in the 1960s to 60% among those aged 12-19 years in 1999-2004. Obviously, people should drink municipal water to get the benefits of fluoride! And that includes the astronomical rise in soda consumption… which we can talk about next week... You can check your water supply, or the water supply where you practice at this website: https://nccd.cdc.gov/DOH_MWF/Default/Default.aspx

    How to supplement patients whose water supply is not fluoridated:

    Water concentration of Fluoride Age of patient Supplementation mg/day
    >0.6 ppm of fluoride 6 months - 3 years 0mg
    3 years - 16 years 0mg
    0.3 - 0.6ppm of fluoride 6 months - 3 years 0mg
    3 years - 6 years 0.25mg/day
    6 years - 16 years 0.5mg/day
    <0.3ppm of fluoride 6 months - 3 years 0.25mg/day
    3 years - 6 years 0.5mg/day
    6 years - 16 years 1.0mg/day

    Patient Care tips for Fluoride supplements
    • Fluoride supplements (oral) are prescription only.
    • All tablet formulations MUST BE CHEWED! Chewing "pulverizes" the fluoride into the enamel of the teeth
    • Milk and other dairy products may decrease absorption.
    • Available as Luride® (sodium fluoride) 0.25mg chew,0.5mg chew, 1mg chew, as well as Luride® solution 0.5mg / ml.
    • Sodium fluoride:2.2mg= yields 1mg active fluoride ion; 1.1mg= 0.5mg active fluoride ion
    • Most recommend fluoride be given at bedtime after kids brush their teeth.
    • Fluoride may be ingested from bottled water or juices that have been fluoridated

    Dr Rod Messner says: "Fluoride works! It is safe, and many water systems have been adding fluoride to the water system since the 1950's without any issues except for the decline in caries"


    Dr. Rodney A. Messner, DMD


    Where I live in Blair County Pennsylvania, we have 30 different water systems. ONLY the Tyrone water system is fluoridated.The major municipalities in our county of Hollidaysburg and Altoona do not fluoridate their water supply. There was a controversy back in 2013 about eliminating fluoride, where the Borough Council voted to eliminate fluoride supplementation. After many meetings, and our local dentists bringing evidence they had accumulated comparing the Tyrone patients to the patients who didn't have fluoridated water and the council reinstated the supplementation of fluoride to our water supply.

    "Keeping up the confidence of denture wearers...with safety in mind!"

    A look at Denture Adhesives... are they necessary? ...well sometimes

    Denture adhesives are pastes, powders or adhesive pads that may be placed in/on dentures to help them stay in place. In most cases, properly fitted and maintained dentures should not require the use of denture adhesives. Over time, shrinkage in the bone structure in the mouth causes dentures to gradually become loose. When this occurs, the dentures should be professionally relined or new dentures made that fit the aging mouth properly. Denture adhesives fill gaps caused by shrinking bone and give temporary relief from loosening dentures. They are effective; however, they are NOT a permanent solution!! If denture is ill-fitting, refer to a dentist.

    How they work: The denture adherent holds dentures in place while chewing or speaking. They also form a seal that keeps food particles from sticking between the dentures and gums, which can be a problem with whole grains, or even fiber laxatives like Metamucil.

    3 TYPES OF DENTURE ADHESIVES:

    • Paste Application: Most patients use too much! Just a "pea-sized" amount in 4-5 locations on denture is plenty. Examples: Fixodent, Polygrip, Effergrip
    • Powders: Easier to clean. Better initial retention but falls sharply within the first six hours. Examples: Fixodent, PolyGrip and Klutch
    • Thin Adhesive Liners are available as wafers or pads less messy or "gooey" to apply : Example: Sea-Bond.
    Remind patients to scrub off the adherent each time the dentures are cleaned.

    ZINC in Denture adhesives??

    • Active ingredients: polymethyl vinyl ether-maleic anhydride (PVM-MA) zinc and calcium salts with carboxymethylcellulose.
    • The problem becomes: Chronic, excessive ingestion of zinc can result in copper deficiency, which is an established and increasingly recognized cause of neurologic disease, causing weakness and numbness of the extremities.
    • Some marketed denture adhesive creams, including certain Fixodent and Poli-Grip formulations, contain zinc at levels of about 17 to 34 mg/g.

    WHAT does the ADA (American Dental Association have to say:

    To earn the ADA Seal: Clinical data demonstrating the effectiveness of the denture adherent in providing increased biting force, increased retention, and that the integrity of the dentures is not affected by the adherent. Effergrip®, is the only adherent that has the ADA seal. It has coloring agents, dispersal agents, wetting agents and adhesives: Polymethylvinylether maleic acid calcium, Polyethylene Oxide, Sodium Carboxymethylcellulose (also thickens). It is zinc free.

    Dr. Rod says: "I tell my patients that the selection of a denture adhesive is what works best for them. It's a vanilla or chocolate thing. I tell patients to use them, they do help! If they are doing some public speaking or going to a special event…..USE THEM!! Provides an extra level of confidence.”


    Dr. Rodney A. Messner, DMD


    Pharmacists Role: Remember, a film of saliva helps hold dentures in place. Inadequate saliva flow may cause dentures to be loose. Inadequate saliva flow may be due to prescription and OTC medications, such as anticholinergics (Bentyl®, Levsin®), tri-cyclic antidepressants (Elavil® is the worst), or first generation antihistamines (Benadryl). Treatment options could be changing to Pamelor® (nortriptyline) which is less anticholinergic and using the second or third generation antihistamines like Claritin or Allegra.

    Special thanks to Dr. Rodney Messner from Cherry Tree Dental Associates for his practical hints for this column!

    "Care and feeding of your dentures! Once again I had to consult an expert!"

    Daily care tips for denture wearers:

    Don't let dentures dry out...


    The teeth of a denture are typically made from various types of resin or porcelain. Place them in a denture cleanser soaking solution or in plain water when you're not wearing them. Never use hot water, which can cause dentures to warp. Dropping a porcelain denture might result in breakage. Most all dentures made today are plastic(acrylic), both the teeth and the pink denture base, very few have porcelain teeth. Many dentures are broken by dropping them in the sink. Also be careful with your beloved pet, dogs love to get a hold of dentures!

    Brushing the dentures...

    Brushing dentures daily will remove food and dental plaque, and help prevent them from becoming stained. Always brush dentures over a folded washcloth. If the dentures slip out of the wearers hand, a washcloth might prevent breakage. Patients can use special creams for dentures, or any toothpaste. Some sources recommend dishwashing liquid (Dawn works great) or hand soap to clean dentures.

    What NOT to do...

    Do not use any household abrasives. A regular or denture brush works fine, but patients should not rely solely on denture cleansers. Some dentures have a permanent soft liner, this material requires special care, a patient should not use conventional brushing methods for these. They are given a special solution to clean them with at the time they were given their denture.

    Take care of your mouth...

    Brush your gums, tongue and palate every morning with a soft-bristled brush before you insert dentures. This stimulates circulation in your tissues and helps remove plaque. Up to half of those wearing dentures will develop a fungal infection called oral stomatitis (candidiasis). But there are some tips you can follow to prevent this infection, as well as keep you smiling, eating, and speaking with confidence

    Give your dentures a rest...

    Remove dentures out for 6 to 8 hours a day to allow the tissues of your mouth to heal from any soreness or irritation that may have occurred throughout the day. Removing dentures while sleeping is a good way to give the mouth a rest.

    Consult your dentist...

    See your dentist if dentures break, chip, crack or become loose. Don't be tempted to adjust them yourself — this can damage them beyond repair. Never should a pharmacist recommend a “denture repair kit”, this is best left to the dental professionals to fix any damaged denture. Patients should NEVER super glue their dentures! Most of the time dentists are professionally unable to repair them after they have been glued.

    Adjust your eating habits...

    Cut foods into smaller pieces to allow better chewing or adding gravies or a pat of butter to soften up some foods for chewing. Chew on both sides of your mouth to avoid dislodging dentures while eating. Avoid chewy types of food like caramel and hard foods like nuts, which can loosen your dentures.

    Soaking the dentures...

    Alkaline peroxide cleaners are the most common. When dissolved in water become alkaline solutions of peroxides, releasing oxygen for mechanical cleaning. Soak 4-8 hours. Best for new stains and plaque. soaks are useful for inhibiting growth of Candida albicans, which can cause stomatitis. Examples are Polident and Efferdent.
    Hypochlorite: (bleach) removes stains, bacteria, fungi. Hypochlorite dissolves plaque, but not calculus when formed. Example: Dentural® Sodium Hypochlorite (0.5% NaOCl solution) is effective in decreasing microorganisms without changing the color of the denture resin.
    Avoid persulfate, it may cause allergic reactions. Acid containing solutions. Shorter soaking times recommended. May be used with ultrasonic cleaners. Usually contain citric acid, examples are: Polident®, Stain Away®.

    See your dentist...

    Just because a patient may not have all their natural teeth, they still have gums, and an oral cavity that needs to be routinely checked by their dentist. A dentist will also check the fit of the denture, which is extremely important as a patient ages, and has changes to the structure that holds the denture. Dr. Rod Messner recommends a once a year checkup. Pharmacists role in medication management: Please note that currently MANY medications, such as anticholinergics, cause varying degrees of xerostomia which adversely effects denture retention.

    "We’ve been discussing dentifrices for over a month now, all along the goal is to achieve stronger and healthier teeth. This week we will discuss what happens when things don’t go as planned, and our denture wearing patients come to us for advice. Nearly 69 percent of adults between 35 and 44 have lost one or more permanent teeth, and 26 percent of adults aged 74 are missing all of them. We have a lot of products in our dental aisle that caters to denture wearers, it is time we get familiar with them!"

    "Once again Dr. Rod Messner from CherryTree Dental Associates provided his expertise in writing this column."

    Dr. Rodney A. Messner, DMD


    "He shared with me many practical hints, especially with denture breakage and repair. Since we don't have any pets I never thought of dogs as being a danger to dentures! One of my local pharmacists told me of an elderly patient whose grandchildren hid her dentures, so she would stay for a longer visit!"

    March 2017

    "Brushing and flossing do the cleaning, but is your breath fresh and 'kissable'?"

    Mouthwashes - the finishing touch!

    Now that we have brushed our teeth for two minutes with an ADA approved soft toothbrush, with a pyrophosphate free fluoride ADA approved toothpaste, as well as cleaned our inter-dental spaces with appropriate ADA approved dental floss, the question becomes can we get “kiss-ably close”! The final class of dentifrices we can recommend to get more than a peck on the cheek is to try an ADA approved mouthwash!

    There are two distinct mouth washes. We have at our disposal those “cosmetic” mouthwashes that just freshen our breath, and the “therapeutic” mouthwashes that actually do something positive for our mouth. Let's briefly discuss “halitosis” and other mouthwashes.

    The major contributor to halitosis is the presence of “volatile sulfur compounds”. These volatile sulfur compounds arise from the breakdown of foods, as well as dental plaque and the bacteria associated with oral disease. Hydrogen sulfide (paper mill smell or rotten eggs) and dimethyl sulfide (smell of the ocean) account for about 90% of the volatile sulfur compounds found in breath and are produced by anaerobic bacteria. High protein foods, such as eggs, meat and fish when broken down by the anaerobic bacteria cause the highest concentration of volatile sulfur compounds. These bacteria can live in all of the corners of the mouth, between teeth and in the “nooks and crannies” of the tongue.

    Cosmetic mouthwashes: are best defined by what they don't do. They simply leave the mouth with a pleasant taste, but don't deal with the causes of bad breath, kill the bacteria that cause bad breath; or help reduce plaque, gingivitis or cavities.

    Therapeutic mouthwashes: rinse for at least 60 seconds, then spit out.
    • Control plaque and gingivitis (chlorhexidine, povidone iodine,cetylpyridium chloride -CPC- and essential oils) Using a mouthwash with povidone iodine, essential oil, CPC or chlorhexidine significantly reduced plaque and reduced bacterial indicators of gingivitis. Cetylpyridium chloride is an antiseptic that kills off the offending bacteria. CPC decreases dental plaque and gingivitis and remains in the oral cavity 3-5 hours. CPC was developed to control plaque and gingivitis without essential oils ie "medicine breath". Chlorhexidine products (Peridex) are prescription only. Chlorhexidine may cause staining of the teeth, which is easily removed by a dental hygienist.
    • Strengthen teeth (fluoride) For added protection against tooth decay, usually contains about 0.05% of Sodium Fluoride (NaF). Fluoride reduces demineralization by strengthening and protecting the enamel on teeth.
    • Whitener (peroxides) bleaching agent, usually hydrogen peroxide or carbamide peroxide. This helps to whiten teeth and remove stains over time. Products that contain 10 percent carbamide peroxide yield approximately 3.5 percent hydrogen peroxide. These products may also cause dentin hypersensitivity.
    • Alcohol levels can be as high as 20%. Best to avoid these with alcoholics as well as teenagers because of potential abuse. May also cause increase in tooth sensitivity by dissolving away the mucus layer that protects teeth.
    • Xerostomia “dry mouth”-- be sure to use sugar free products, as well as alcohol free dental rinses. Dental rinses containing alcohol may cause increased dryness. Because of reduced salivary flow, sugar free products are needed to decrease chance of tooth decay. (such as Biotene® or Oasis® mouth rinse).

    "So 1879 was a pretty amazing year, not only did Edison invent the light bulb, and Albert Einstein was born, but Dr. Joseph Lawrence and Pharmacist Jordan Lambert developed Listerine. One hundred years later, Professor Pete would be in Pharmacy School!.

    Special thanks to Dr. Rod Messner for reviewing the content of this article."

    "Dental floss...not just for corn-on-the-cob season!! We should use it every day!"

    Who would ever think DENTAL FLOSS could cause a controversy??

    We all have that spool of “nylon yarn” in our bathrooms. Some of us use it a lot more than others. Flossing helps remove plaque by reaching areas that a brush cannot reach, but reports show that as few as 3% to 18% of patients floss daily. By removing debris from these hard-to-reach tooth surfaces we may see a reduction in the likelihood of gum disease and tooth decay. Dental floss was formerly made of silk, today is made of nylon filaments or single strand plastic monofilaments. Look for the American Dental Association Seal of Approval before purchasing dental floss.

    To earn the ADA Seal of Approval…
    • The product components are safe for use in the mouth.
    • Unsupervised use of the product by the average patient will not harm hard or soft oral tissues or restorations
    • Tensile strength: high tenacity “nylon yarn” is best because:abrasion resistance of nylon, when drawn over rough surfaces. Elasticity of nylon is greater allowing it to pass through close places and over rough surfaces with less filament breakage.
    • Both Reach® (J&J) and Oral-B dental floss are ADA approved

    What floss should I buy:
    Simply stated it is the patients choice based on preference, waxed or unwaxed, flavored or not flavored..
    • Large gaps between teeth: Try dental tape or Super Floss, or JJ Reach® woven floss.
    • Tight spaces: recommend a waxed floss or Oral-B Glide®
    • Less mess: disposable flossers or floss in pre-measured strands.
    • Braces or bridges:A spongy floss is worthwhile, but any floss is OK with dental appliances, especially if you have a floss threader. Super floss is also a good choice.

    Is flossing worth the effort:
    Flossing Controversy: August 2, 2016- New York Times “There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries.”
    • ADA response: In this case, while the average benefit is small and the quality of the evidence is very low (meaning the true average benefit could be higher or lower), given that periodontal disease is estimated to affect half of all Americans, even a small benefit may be helpful. The other side of the benefit-risk analysis is an absence of documented harms as well as minimal cost to patients.
    • The Association also released a statement in response to the news story, reiterating its recommendations to maintain oral health, which include "brushing for two minutes, twice a day with a fluoride toothpaste, cleaning between teeth once a day with an interdental cleaner and regular dental visit advised by your dentist." The ADA also stated that interdental cleaners, including floss, "are an essential part of taking care of your teeth and gums.

    "Once again, I had to consult my friend the dentist for his input on this column. Dr Rodney Messner of Cherry Tree Dental in Wisconsin helped by making specific brand recommendations for all of the floss products I listed."

    Dr. Rodney A. Messner, DMD
    Dr. Rod advises: "There is reliable data correlating periodontal disease and heart disease. I have yet to find a dentist that has told their patients there is no need to floss. Flossing does more than just clean the spaces between the teeth-- it might even protect the heart!

    "So, this pharmacist will tell you...keep flossing… even when you are not eating corn-on the cob!"

    "My dentist friend guided me for this column. Lots of great information that was challenging for me to find! Special thanks to Dr. Rodney Messner."

    Hot tea or cold drinks bother your teeth??

    Last week we discussed in detail the characteristics of the toothpastes that we sell in our pharmacies. Sensitive teeth, known as “dentin” hypersensitivity occurs when stimulus (hot, cold, chemical or physical) is applied to tooth. Dentin becomes exposed by gingival recession or enamel loss.

    Enamel is the hardest surface in our body, which consists of 96% hydroxyapatite which is a combination of calcium and phosphate, the bones in our body contain 70% hydroxyapatite and the dentin in our teeth is also 70% hydroxyapatite. Dentin contains tubules which are an open pathway between pulp, and dentino-enamel junction.

    Hot, cold or mechanical stimulus causes increase in fluid flow through tubule, causing pain at the underlying nerve (or pulp). Dentin hypersensitivity is typically found in patients whose dentin has become exposed due to gingival recession, periodontal therapy and most commonly loss of tooth enamel.

    As we discussed, tooth abrasion from brushing and toothpaste selection can contribute to the wear and tear on the enamel, which exposes the dentin, and allows pain transmission through the tubules. 55-75% of patients may experience tooth sensitivity during professional whitening treatments.

    TREATMENT

    The most important step in treating dentin sensitivity is to STOP destructive habits such as aggressive or vigorous cross brushing.Use soft toothbrushes!! 50% of all damage occurs the first 20 seconds of brushing – lots of toothpaste, causes lots of abrasion. Review the “Modified Bass Brushing Technique”- a lot of dental professionals have a saying “It is not the brush, it is the brusher!”
    • Consult your dentist, dental hygienist, or pharmacist to recommend a toothpaste with a lower RDA (Relative Dentin Abrasivity).
    • Recommend twice-daily use of a desensitizing dentifrice. Active ingredients include stannous fluoride, strontium chloride hexahydrate, and aluminum, potassium or ferric oxalates and fluorides. While studies show improvement in patients’ perception of pain, the effectiveness of these products at reducing symptoms appears to increase with increased usage. Patients will experience more benefit the longer they use these products.
      • Fluoride dental paste: (Prevident-5000 plus®) written as a prescription, works by forming the precipitate calcium fluoride which plugs the tubules. Remind patients to brush on this dentifrice and do not swallow. Patients should not rinse and spit. Fluoride is an effective agent to control dentin hypersensitivity and to prevent root caries particularly when used in higher concentrations.
      • Potassium nitrate (5%) (KNO3) alters membrane potential along the dental nerves, after passing through dentino tubules. Also helps occlude the exposed dentino tubules, and decreases flow. Potassium nitrate lowers nerve sensitivity, by blocking the synapse between nerve cells, reducing nerve excitation and the associated pain.
      • Strontium chloride hexahydrate (10%) is an effective means for reducing the discomfort and pain caused by thermal and tactile stimuli in patients with dentinal hypersensitivity. Strontium works by exchanging calcium for strontium in biological processes. Strontium also impairs nerve stimulation by changing stimulus transmission. These treatments reduce flow into the dentin tubules by occluding or sclerosing the tubules.
      • Prevident® 5000 Sensitive teeth contains 5% potassium nitrate along with the Sodium Fluoride 1.1% (which is 4 times stronger than OTC toothpaste).
      • If no relief after twice daily brushing for 2 or 3 weeks, recommend a visit to dentist.

    "There is so much for us health care professionals to know, that is why we have 'specialties'! For this column, I struggled finding the mechanisms of action for the many ingredients in these toothpastes for dentin hypersensitivity. My dentist friend Dr Rod Messner came to the rescue again this week. His input, again this week was most valuable."

    Dr. Rodney A. Messner, DMD
    Dr. Rod says: I prefer using fluoride in my practice to desensitize the dentin. I try to stay away from the stannous fluorides because of the metallic taste, compliance usually becomes an issue at some point. Patients just quit using it at some point. Recently I began to prescribe products such as MI paste(GC America) and 3M’s Clinpro 5000, which contains sodium fluoride. Both these products possess regenerative capability. They taste good so compliance is improved.

    "Toothpaste-- how to select a dentifrice, and cause minimal problems. I even had a dentist help me with this column..."

    Toothpaste ...helping our patients select a product that won't harm their teeth!

    Every morning before heading to work, and every evening before going to bed, we put a dollop of this stuff called toothpaste on our toothbrush. Here is what is in it that amazing stuff that makes our teeth so white, and our mouths so sparkling clean:
    • Fluoride to strengthen tooth enamel and remineralize enamel.Fluoride is most commonly available as Sodium fluoride (NaF), stannous fluoride (SnF2), and sodium monofluorophosphate (Na2PO3F).
    • Humectants, such as glycerol, propylene glycol and sorbitol are added to prevent water loss in the toothpaste.
    • Flavoring agents, such as saccharin and other sweeteners improve taste.
    • Thickeners and binders stabilize the toothpaste formula. They include mineral colloids, natural gums, seaweed colloids or synthetic cellulose.
    • Detergents such as sodium lauryl sulfate, sodium N-Lauryl sarcosinate, cause foaming when contacted with water and manual brushing.

    The American Dental Association Seal means that:
    • The toothpaste must contain fluoride
    • Must not have any excipients (flavors, sweeteners) that can cause tooth decay
    • Must not be “too abrasive”

    “RDA” for toothpaste? We are familiar with the Recommended Daily Allowance for our vitamins, but there is an RDA for toothpaste, which refers to the Relative Dentin Abrasivity. This is a scale the industry uses to make sure the formulations are not too abrasive to the enamel and can expose the very sensitive dentin, either by wearing down the enamel or causing gingival recession.
    Pyrophosphate: Tartar control toothpastes cause more problems than good. The pyrophosphates work to decrease tartar formation by binding up the calcium and magnesium in saliva which blocks tartar formation on the teeth. Tetrasodium pyrophosphate is the most common pyrophosphate.
    • These pyrophosphates in the mouth can form an alkaline solution which can cause irritation.
    • Pyrophosphates have such a bitter taste more flavoring agents are used which can cause hypersensitivity.
    • More detergents are added to make the pyrophosphates soluble which also causes hypersensitivity.
    • Patients with reduced salivary flow are at highest risk for hypersensitivity reactions
    • The tartar control toothpaste might make our teeth mores sensitive to hot or cold temperatures.ns

    Chances are when any patient has a red ring around his lips or redness inside the mouth, I always ask what type of toothpaste, and most often it is a tartar control toothpaste. Tartar control toothpastes work on the surface of the teeth to block tartar buildup. However, the sub-gingival tartar (below the gums) is the problem! Tartar control tooth pastes cause a lot of hypersensitivity reactions, and only work above the gum line. That is why we must go to the dentist at least every six months to get the sub-gingival tartar removed- our brush and toothpaste doesn’t do the entire job. Do we even need toothpaste? According to the American Dental Hygienist the most important factor in plaque removal is the mechanical action of the toothbrush!

    "As a community pharmacist we all have our toothpaste sections. The ingredient panel lists all kinds of compounds, and some of those compounds can cause excess abrasion or even hypersensitivity reactions. Of all the available resources out there not one is more useful than a practicing dentist. One of my friends Dr Rod Messner, who practices in Wisconsin reviewed this newsletter for content. He also pointed out that the RDA numbers are rather proprietary in nature and most manufacturers are not willing to share this information. The RDA scale starts with just a toothbrush equals 4; toothbrush and baking soda=7 and the FDA upper limit is 200. Any number over 150 is considered to be at the "harmful limit." I suggest doing a google search of "RDA toothpastes" and there are several dentist sites with this information. Thanks to Dr. Messner, I will be switching my brand of toothpaste!"

    "Check out your toothbrush....might be due for a springtime replacement...I'll take the blue one!"

    Four minutes a day we should be grabbing this tool.

    Proper brushing twice daily and flossing at bedtime are preventative measures. Next week we can discuss the available toothpastes, so this week we can focus on the toothbrush, which really does all of the work.

    Toothbrushes should be soft, to decrease gingival irritation. Soft bristles are best, they can reach tighter spaces, and do less damage to gums. Brush teeth in a circular motion. Floss daily.

    REMIND patients to replace their toothbrush about every three months or sooner if the toothbrush bristles show signs of wear. Best to replace toothbrush after any illness. Bristles that are frayed or damaged are ineffective and may harbor harmful bacteria that could increase the risk of periodontal disease. As toothbrushes wear, they lose their effectiveness. Look for the American Dental Association (ADA) seal of approval, which governs sharpness of bristles, bristle retention and other safety parameters.

    Yuck! Here are some hygiene tips to consider when caring for your beloved toothbrush:
    • Store your toothbrush in an upright position after each use and allow them to air dry. Storing a moist toothbrush in a closed container promotes microbial growth more so than leaving it exposed to the open air.
    • We all store our toothbrushes on the sink in the bathroom. Toothbrushes do harbor bacteria including fecal coliform bacteria (like E. coli) that can be released into the air when the toilet is flushed or can be spread to the toothbrush when cross contaminated with another bathroom surface.
    • Although probably not necessary, you can disinfect your toothbrush by soaking in Listerine (26.9% alcohol) or hydrogen peroxide 3% solution.

    Powered toothbrushes

    Both manual and powered toothbrushes are effective at removing plaque. Remember as with manual toothbrushes, to replace the brush head every 3-4 months. Although the powered toothbrushes are more expensive, they might have the following advantages over the manual toothbrush:
    • People who have dexterity problems—like the elderly, people with disabilities, or children
    • Ease of use for patients with dental appliances such as braces
    • A variety of powered toothbrushes that use a different types of head movement (side-to-side, counter oscillation, rotation oscillation, circular, ultrasonic) are available.
    • People brush longer with the powered toothbrush.Most have a two-minute timer to insure brushing duration is adequate.

    "We Pharmacists and our Physician Assistants colleagues in the Emergency Department unfortunately see a lot of dental problems. Hardly a day goes by where we are not filling a Clindamycin and Ibuprofen prescription for someone with significant dental decay who was just seen in the ED. Unfortunately neither profession can adequately treat these "mechanical problems" and a trip to the dental office is the only effective resolution.We will spend the next couple of weeks exploring the dental sections in our pharmacies. Prevention of dental problems is truly the key to improving our patients dental health. It all starts with the toothbrush!

    The most important rule for toothbrush selection at the Kreckel house is this: I get the blue toothbrush. Mrs. Kreckel is free to buy any color toothbrushes that are on sale, as long as mine is blue!"

    February 2017

    "Canker sores, what to do when someone pulls down their lip and asks for your advice!"

    Canker sores (Aphthous ulcers)

    What: Aphthous ulcers are painful, round shallow lesions with a grayish base. Recurrent aphthous stomatitis (RAS) is the most common cause of mouth ulcers. Some patients may have only two to four outbreaks per year, while others may have almost continuous eruptions.

    Who: Aphthous ulcers are seen most frequently in childhood and adolescence and decrease in frequency in adulthood. There seems to be a familial tendency. It is not caused by any infectious agent (virus or bacteria).

    Why: There seems to be an association between recurrent cases of canker sores and an overactive immune system, so topical immunosuppressant medications (such as topical corticosteroids) are of benefit.
    • Exacerbated by: trauma, hormonal factors, and emotional stress. Avoid trauma to mouth when brushing teeth.Avoid eating “sharp” foods like nacho’s and chips to minimize oral trauma.Cover sharp edges of braces with dental wax.
    Over the counter treatment options include:
    • Benzocaine:Zilactin-B as we discussed last week forms a protective film over the lesion, and can be applied every 6 hours. Benzocaine helps decrease the pain, but should be avoided in kids under age 2 because of methemoglobinemia.
    • Peroxyl® rinse (peroxide) to cleanse the sores
    • Deficiency in the “blood building” supplements such as folate (folic acid), vitamin B-6, vitamin B-12 or zinc. Vitamin B-12 sublingual 1000mcg dissolved in the mouth may be effective in treatment/prevention of canker sores. (http://emedicine.medscape.com/article/867080-treatment)
    Home remedies include:
    • Applying ice chips directly to the ulcer
    • Rinsing mouth with a baking soda solution: 1 teaspoonful of baking soda to ½ cup of warm water.
    • Dab a small amount of milk of magnesia to the canker sore a few times per day.
    If all else fails, Rx treatment of canker sores: Because corticosteroids inhibits cell proliferation and is immunosuppressive, antiproliferative, and anti-inflammatory they are the mainstay for treatment of aphthous ulcers.
    • Dexamethasone elixir 0.5mg/5ml. Rinse and spit out.
    • Triamcinolone dental paste 0.1%
    • Magic Mouthwash: Benadryl/Maalox/lidocaine2% viscous—equal parts
    • Chlorhexidine gluconate mouth rinses reduce the severity and pain of ulceration but do not affect the frequency.
    "So we now know that the canker sores are NOT caused by viruses. There seems to be a connection between an "overactive" immune system that causes these to break out. Celiac and Crohn's patients are frequently plagued with canker sores. Patients with frequent complaints should be checked for vitamin deficiencies as well. Recurrent canker sores can be challenging."

    Is there any value in OTC cold sore remedies?

    "Are our patients throwing away good money on OTC cold sore treatment?..unfortunately the answer is probably "YES"."

    Cold sores are a quite common complaint year-round, but seems to become more prevalent this time of the year. Cold sores or herpes labialis are caused by the Herpes simplex virus Type-1 and is abbreviated as HSV-1. Recurrent herpes simplex labialis occurs in 20% - 40% of the US population. It is estimated that 67% of the population are affected by the virus. Although the disease is self-limiting in the immunocompetent, patients seek treatment because of the discomfort and visibility of a recurrent lesion.

    The virus: Reactivation of HSV-1 occurs in the trigeminal sensory ganglion. This leads to the occasional breakout of the virus where the site of infection is usually the border of the lips. Patients with oral herpes infection should be informed that HSV-1 can be transmitted through oral sex to their uninfected partner resulting in genital ulcers. 50% of new cases of genital lesions in the developed world are caused by HSV-1

    OVER THE COUNTER PRODUCTS

    Zilactin® (benzyl alcohol 10%) which is OTC contains hydroxypropyl cellulose which is a bioadhesive that adheres to mucus membranes and may be used to protect lesions from irritants for up to six hours. Remind patients not to peel off the adhesive film. Also, available at Zilactin-B which contains benzocaine 10% is for use inside the mouth to help numb the lesions.

    Abreva® contains docosanol needs to be applied five times daily for a maximum of 10 days. Complete treatment resulted in decreased duration of the lesion by only 18 hours.
    Mechanism: inhibiting fusion between the herpes virus and human cell plasma membrane. The end result is that the virus can’t enter into the host cells and multiply.

    Sunscreens: some patients will experience cold sores when they are exposed to large doses of ultraviolet light. Sunscreens are of great benefit to these patients. Sunscreen should be applied before direct UV exposure.

    Emollients/Protectants: white petrolatum, zinc oxide, cocoa butter relieve cracking and dryness. They do nothing to speed up healing. Many OTC products are seen in combination with camphor, thymol and benzocaine. Avoid any products that contain salicylic acid that can further break down the affected skin. Many of these products contain sunscreens as well.

    Lysine: dosed as 1000mg one to three times daily may show a decrease of frequency of recurrence and severity of the lesions. Is of minimal value.

    What does work: Rx antivirals
    I encourage my patients to have on hand (in their medicine cabinet) oral antivirals so they can take at the first sign of tingling (prodromal phase). The oral antivirals are very effective if taken during the prodromal phase. Here are the doses for cold sore prevention.

    Drug Name Brand Dispense Instructions
    Acyclovir 400mg Zovirax® #20 capsules Dose: Take one capsule five times a day
    Famciclovir 500mg Famvir® #3 tablets Dose: Take 3 tablets as a single dose
    Valacyclovir 1gm Valtrex® #4 tablets Dose: Take 2 tablets twice daily for one day

    "I give my patients a handout with the above chart, and tell them to have their physician or dentist write a prescription for two courses of any of these antivirals. My favorite is Valacyclovir. The patients can begin treatment as soon as they experience prodromal symptoms.

    Topical antivirals such as Acyclovir 5% (Zovirax) , Penciclovir 1% cream (Denavir), Acyclovir-5%/Hydrocort-1% (Xerese) must be applied five times daily. They are not as effective as the oral antivirals and cost more than $500 a tube. Do not recommend these products. "

    Nasal sprays - three drugs, three different mecanisms of action

    NASAL SALINE (Ocean):
    Sodium chloride 0.65% in purified water (USP), made isotonic with sodium phosphate/sodium hydroxide, with phenylcarbinol and benzalkonium chloride as preservatives.
    • Use: relief to dry, irritated nasal passages due to colds, allergies, dry air, pollution, smoke, air travel, and use of decongestant/steroidal sprays
    • Patients using saline irrigation show faster resolution of symptoms, less frequent reappearance of rhinitis, and reduced use antihistamines/decongestants.
    • Dosed on an as needed basis. No side effects

    CROMOLYN (Nasalcrom)
    • Mechanism: mast cell stabilizer. Mast cells release of histamine and other inflammatory mediators.
    • Dose: one to two sprays three to four times daily. Ages 2 to adult.
    • Adverse effects: minimal if any.
    • Efficacy: less effective than glucocorticoid nasal sprays like fluticasone (Flonase), may be ok for mild allergy.

    Administration:
    • Brief exposure (cat exposure) : 30 minutes before exposure. Efficacy: minutes to a couple of hours.
    • Prolonged exposures (seasonal allergies): four to seven days in advance. Should be used before pollen season.

    OXYMETAZOLINE (Afrin)
    • Mechanism: sympathomimetics (alpha adrenergic: vasoconstriction) that act on adrenergic receptors in the nasal mucosa creating vasoconstriction. They shrink swollen mucosa and improve ventilation.
    • Not recommended for kids under 6 years.
    • Dose every 10-12 hours. Maximum of 2 doses per day.
    • Maximum of three to five days to minimize risk of rebound congestion.

    Rebound congestion (rhinitis medicamentosa)
    • Cause: “overuse” of topical nasal decongestants, specifically α-adrenoceptor mediated down-regulation and desensitization of response.
    • Presentation: bright red, swollen nasal membranes
    • Treatment: gradually withdraw the nasal decongestant, one nostril at a time.Replace with saline nasal spray until completely withdrawn.Nasal corticosteroids are of great value
    • Oral decongestants, and topical nasal corticosteroids may be of some value. One study showed reversal of rebound congestion with fluticasone.

    "We covered corticosteroid nasal sprays last week. This will wrap up our topical nasal section."

    Best choice for allergic rhinitis if used correctly!

    Topical nasal corticosteroids have emerged as the MOST effective treatment of allergic rhinitis. Glucocorticoid nasal sprays are more effective than oral antihistamines for relief of total nasal symptoms, including blockage, sneezing, discharge, itch and postnasal drip, and. Currently two are available without prescription, with more to make the switch from Rx to OTC.

    The Rx product Veramyst (fluticasone furoate) will be making the switch to OTC in February 2017 and will be named Flonase® Sensimist. Although these drugs are extremely effective, and now very inexpensive, proper administration technique is necessary for optimal results. Pharmacist consultation is necessary to achieve patient satisfaction and symptom relief.
    • Mechanism: inhibits the activity of multiple cell types, such as mast cells, basophils, eosinophils, neutrophils, macrophages, lymphocytes, and mediators of the inflammatory response. Decreases capillary leakage and mucosal secretions.
    • Indications: management of nasal symptoms of seasonal and perennial allergic and non-allergic rhinitis.
    • Excellent for relief of pruritus, sneezing, congestion, rhinorrhea.

    Warnings/Precautions/Adverse effects
    • Local dryness & irritation.May cause stinging irritation, nosebleeds, sore throat & burning. May cause taste dysfunction.
    • Local infections with Candida have rarely occurred.
    • The growth rate of some children may be slower using these products. It should be used for the shortest amount of time necessary to achieve symptom relief.
    • Adult supervision if used in patients under age 12

    Patient counseling points: May feel better in 2 or 3 days, but peak response takes 2-3 weeks. This drug is not to be used “as needed”. It should be used for the entire allergy season.
    • Blow nose first
    • Remove cap
    • Prime bottle (if first use)
    • Shake bottle
    • Tilt head forward and exhale. (“It goes in your nose, look at your toes”)
    • Direct spray toward the ear on the same side. (Use the left hand to spray the right nostril, and the right hand for the left nostril)
    • Place pump into one nostril.Close other nostril with finger.
    • Administer spray in nostril while inhaling slowly and deeply.
    • Do not sneeze or blow the nose for 10-15 minutes after spray administered.

    What's available?

    Nasacort- Allergy 24 (triamcinolone)
    hours first approved 1957. Approved for OTC use in Fall 2013. The liquid vehicle of OTC triamcinolone acetonide nasal spray is alcohol and taste free.
    • Adults and children 12 years of age and older: 2 sprays each nostril while sniffing- once daily.Once improved may decrease to one spray each nostril.
    • Kids 6-12: one spray each nostril. May increase only if needed.
    • Kids 2-6 one spray each nostril daily.Under age-2 don’t use.


    Flonase (fluticasone) first available Rx in 1994. Approved for OTC use Summer 2014. First for relief of itchy watery eyes and nasal symptoms. The liquid vehicle of OTC fluticasone propionate contains phenylethyl alcohol.
    • Adults and children 12 years of age and older: 2 sprays each nostril while sniffing- once daily.Once improved may decrease to one spray each nostril.
    • Kids age 4-11: one spray each nostril. Do NOT use in children under age 4.

    Flonase Sensimist (fluticasone furoate) will be available soon as an alcohol free and scent free mist.

    January 2017

    So if a patient needs a humidifer what should I recommend?

    Most allergists feel that 30% room humidity is adequate. So, as we discussed last week, a humidity monitor should be purchased before any humidifier is purchased. I did buy one, and much to my surprise, even with all the cooking in our kitchen our winter humidity level is around 28%. Most allergists feel that setting pans of water on the radiators (and change them daily) will provide adequate moisture to a room without soaking carpets, ruining drapes, pictures, and encouraging dust mite growth.

    TYPES OF HUMIDIFIERS
    "Cool Mist" These two types of humidifers generally appear to produce the greatest dispersions of both microorganisms and minerals.
    • Ultrasonic, which create a cool mist by means of ultrasonic sound vibrations.
    • Impeller, or "cool mist", which produces a cool mist by means of a high-speed rotating disk.

    Two additional types of humidifiers can allow for growth of micro-organisms if they are equipped with a tank that holds standing water, but generally disperse less, if any, of these pollutants into the air. These are:
    • Evaporative: transmits moisture into the air invisibly by using a fan to blow air through a moistened absorbent material, such as a belt, wick, or filter.
    • Steam vaporizer: which create steam by heating water with an electrical heating element of electrodes. "Warm mist" humidifiers are a type of steam vaporizer humidifier in which the steam is cooled before exiting the machine.

    Humidifier Care:
    • Change the water in the portable humidifers EVERY day
    • Every 3 days thoroughly scrub out the reservoir. Rinse with Hydrogen peroxide or dilute bleach solution to decrease bacteria and fungi growth (1 part bleach / 9 parts water)
    • Little kids can get "scalded" with the warm steam vaporizers if they get too close. Pharmacists should never recommend a "warm mist" vaporizer especially if there are children in the home. The American Academy of Pediatrics (AAP) recommends the use of a cool mist humidifer. Vaporizers can cause burns if the child gets too close to the steam or accidentally knocks over a device filled with hot water.
    • There is no need to add anything to a warm steam vaporizer. Menthol, camphor (Vicks Vapo-Steam) or benzoin tincture makes the room smell better, but offers no advantage over the increased moisture.These essential oils will ruin a cool mist vaporizer.
    • Only recommend models with an automatic shut-off feature. Should the water reservoir run dry, the device should turn off automatically.
    • Recommend using distilled water in the humidifier. Tap water contains many minerals that can provide a breeding ground for microorganisms inside the humidifier.

    "Pharmacists frequently recommend humidifiers for children who are congested or have rhinorrhea. As we discussed in last week’s newsletter excessive humidity may make their allergies worse, especially if they are allergic to dust mites and mold. In this situation, you want to keep humidity levels low. An air conditioner or dehumidifier can help to keep humidity levels low below 50% if possible which is usually needed in the summer.

    Since 2001 The World Health Organization (WHO) suggests that neither steam nor cool mist therapy be encouraged in the management of a cough or cold. "

    DUST MITES They're everywhere!!!

    “Hey doc, what humidifier do you recommend?” We pharmacists get that question a lot especially during this time of year. This column will address “do we even want to recommend a humidifier.”
    • Every homeowner should own a hygrometer that measures temperature and relative humidity. The ideal relative humidity for health and comfort is about 40-50%. A local allergist told me at a presentation, “before you recommend a humidifier, recommend a hygrometer first!”
    • In the winter months, it may have to be lower than 40% relative humidity to avoid condensation on the windows
    • If a parent wants a cool mist humidifier for a child who is congested or has rhinorrhea, keep in mind that it may make their allergies worse, especially if they are allergic to dust mites and mold.
    • Dust mites and mold like high humidity levels, so a humidifier will increase humidity and make allergies worse. Mites contain about 70% to 75% water by weight and must maintain this to reproduce. Their primary source of water for dust mites is ambient water vapor
    • For dust mite control, you want to keep humidity levels low. An air conditioner or dehumidifier can help to keep humidity levels low -below 50% if possible. (30% is adequate)

    Meet your friendly dust mite: Dermatophagoides pteronyssinus and D. farinae
    • Adult Mite Lifespan: Up to 3 months; (3 larval stages)
    • Female mites lay about 25 to 50 eggs
    • Mites live in carpet, fabric upholstery, and mattresses.
    • Human skin scale, animal dander and trace nutrients. Mites need to absorb humidity, since they cannot drink water.
    • Dust mite fecal material. Dust mites do not bite, and they are microscopic.
    • Temperature Range: approx. 59°F to 95°F
    • Relative Humidity Range: approx. 55% to 85%

    Reducing exposure to dust mites:
    • Use bedding encasements that cover pillows and mattresses with zippered covers, which are impermeable to mites and mite allergens.
    • Wash sheets, pillowcases, and blankets in hot or warm water with detergent or dry in an electric dryer on the hot setting weekly.
    • Use washable, vinyl, or roll-type window covers.
    • Remove clutter, soft toys, and upholstered furniture.Limit stuffed animals to those that can be washed.
    • Where possible, carpets should be removed or replaced with area rugs that can be cleaned/washed.
    • Wash bed linens weekly
    • Avoid down fillings- encase comforters with fine mesh material
    • Reduce humidity level (between 30% and 50% relative humidity per EPR-3)

    Excess humidity can also cause:
    • Damage walls, paint, wallpaper, insulation and ceilings
    • Mold growth on household surfaces, which can cause health issues in sensitive individuals
    • Condensation or fog forming on walls or glass surfaces, such as mirrors, pictures or windowpanes.
    • Dampness around the humidifier.
    "When I was teaching about dust mite allergens to my class at St. Francis, the girls were "creeped out" when I told them about all of the dust mites that were inhabiting their pillow and mattress. According to Ohio State University , a typical used mattress may have 100,000 to 10 million dust mites inside. Ten percent of the weight of a two-year-old pillow can be composed of dead mites and their droppings. Dust mites are microscopic "garbagemen" that digest all the skin cells that slough off. When you see the "dust" in a sunbeam coming though the window, about 80% is said to be dead skin cells.

    Sleep tight tonight, with your newly discovered friends!"

    Pseudoephedrine and Phenylephrine

    Mechanism: Pseudoephedrine is an Alpha/Beta agonist that directly stimulates alpha-adrenergic receptors of the respiratory mucosa causing vasoconstriction and stimulates beta-adrenergic receptors causing bronchial relaxation. By constricting these swollen vessels in the nose and sinus region, tissue shrinks to allow the normal flow of air and mucus.

    Contraindications: breast feeding, bronchitis, closed angle glaucoma, hypertension (uncontrolled), coronary artery disease, MAOI therapy, urinary retention (BPH), peptic ulcer disease. Pseudoephedrine is classified as Pregnancy Category: C

    Illicit manufacturing of methamphetamine: Conversion of Pseudoephedrine (or ephedrine) involves hydrogenation of the hydroxyl group on the ephedrine or pseudoephedrine molecule.

    Combat Meth Act of 2005
    • Any products containing oral pseudoephedrine, require a signature, and valid photo ID to purchase.
    • The law limits such purchases to 3.6 grams base in any one day and 9 grams base in any 30 day period. Mail order maximum per month is 7.5grams.
    • 3.6gm Pseudoephedrine HCl146 x 30mg tablets
    • 9.0gm= Pseudoephedrine HCl 366 x 30mg tablets

    Nexafed® (pseudoephedrine HCl) Mechanism: significantly disrupts extraction and conversion of PSE to meth. Impede® technology’s inactive ingredients and unique polymer matrix form a thick gel that blocks the extraction. In the direct conversion (one-pot) method, Nexafed significantly disrupts the process, so that the meth yield is unsuitable. source: Nexafed.com

    Pseudoephredine with Hypertension
    • The effect in patients with controlled hypertension demonstrated an systolic blood pressure increase of similar magnitude (1.20 mm Hg). (probably OK if well controlled)
    • Higher doses and immediate-release preparations were associated with greater BP increases. Women showed less effect on BP or HR. Shorter duration of use was associated with greater increases in SBP and DBP. PSE exerts an indirect effect causing release of norepinephrine from storage sites which may contribute to its decongestant efficacy.
    • Increased heart rate around 3 beats per minute.
    • Arch Intern Med. 2005;165:1686-1694.

    What about Phenylephrine?
    • Phenylephrine (PE): direct alpha-adrenergic
    • PE half life: 2.5hrs. PSE half life: 9-16hr
    • Bickerman study showed no more effective than placebo at 10mg dose
    • Source: Pharmacist Letter: 240205

    "Any pharmacist working over the past 10 years remembers the legislation enacted on March 9, 2006, to regulate, among other things, retail over-the-counter sales of ephedrine and pseudoephedrine, because of their use in the manufacture of methamphetamine. Pseudoephedrine and ephedrine were moved behind pharmacy counter (BTC); positive identification was needed to purchase these products. Shortly thereafter phenylephrine became abundant out front as the nasal decongestant that didn’t require such restrictions. It has been over 10 years, and not a week goes by where some “meth lab” isn’t discovered."

    Lots of guaifenesin in the cough and cold aisle... is it worth recommending??

    Guaifenesin- lets look at the evidence...
    Expectorants work by increasing mucus hydration to a volume that is more easily expectorated by coughing. Guaifenesin (glyceryl guaiacolate) whose parent compound comes from the guaiac tree was first approved by the FDA in 1952. In 2002 the FDA approved only one extended release formula now made by Reckitt Benckiser to be marketed (Mucinex). Guaifenesin is also found frequently in cough syrups (Robitussin) and most often found in combination with dextromethorphan, antihistamines, decongestants and acetaminophen.

    Mechanism: Guaifenesin stimulates the gastric nerve and promotes increased in airway secretions via the vagal nerve. Guaifenesin also has emetic properties, and can cause GI upset and vomiting, especially in high doses. Other proposed mechanisms of action may include a reduction in mucus viscosity or an enhancement of the mucocilliary clearance.

    Guaifenesin for COPD: Excess mucus in COPD should focus on the treatment three major symptoms. First, underlying airways obstruction can be treated with both short and long acting beta agonists. Secondly, airway inflammation can be treated with inhaled corticosteroids or oral steroids if necessary. Cigarette smoking cessation is a must to decrease mucus production, as well as the occasional use of methylxanthines (Theophylline) or phosphodiesterase-4 inhibitors (Daliresp). Guaifenesin seems to lack clinical efficacy.

    The big picture: Guaifenesin has not been shown to work as an expectorant, as it does not increase the volume of sputum cleared, or as a mucolytic, as it does not alter thickness or stickiness of the sputum. I find that it does cause a fair amount of stomach upset and I usually just recommend adequate hydration.

    Water: adequate hydration is important for all patients, especially COPD patients, but over hydration is of no benefit.
    SSKI: (Saturated Solution of Potassium Iodide) may decrease the viscosity of mucus. Use limited due to side effects:
    • metallic taste
    • rash
    • hyperkalemia (especially if kidney dysfunction)
    • hypothyroidism if used more than six weeks

    "When we journey through our cough aisle we see a lot of single entity and combinations of products containing guaifenesin. Guaifenesin is the only FDA approved expectorant, and the efficacy for this drug is sketchy at best. The FDA is pushing drug companies to do further studies on the OTC products, and I doubt whether this product will stand up if it is intensely researched. In my past thirty-five years, I’ve seen other expectorants fall by the wayside, such as potassium iodide, and iodinated glycerol (remember Organidin?)"

    December 2016

    CAUTION with Rx ANTI-TUSSIVES

    BENZONATATE was first approved in 1958 as Tessalon® perles and is available in 100mg and 200mg capsules. Dosed three times daily for a maximum of 600mg per day
    MECHANISM OF ACTION: acts peripherally by anesthetizing the stretch receptors located in the respiratory passages, lungs and pleura by dampening their activity. It begins to work within 15 to 20 minutes and its effect lasts for 3 to 8 hours. Has NO inhibitory effect on the respiratory center in recommended dosages.

    WARNINGS/ PRECAUTIONS/ ADVERSE EFFECTS:
    SEVERE hypersensitivity reactions (bronchospasm, laryngospasm and cardiovascular collapse) have been reported when chewing the capsule instead of swallowing it whole! Choking can occur if capsule is bitten or chewed. I counsel my patients to swallow it whole with a cold glass of water. May cause sedation, headache, dizziness, constipation, nausea and GI upset.
    The Medical Letter back in February 2010 reported that of ingestion in children under 10 years of age may be fatal. One or two capsules in a 2-year-old or younger has caused fatalities. May cause seizures, cardiac arrhythmias and death. Remind patients to keep out of reach of small children.

    OPIOID DERIVATIVES
    (CODEINE & HYDROCODONE)

    Codeine ( 3-methylmorphine) is the “gold standard” for treating cough; all other anti-tussives are measured against codeine for effectiveness. The dose is 10-20mg every 4-6 hours which is ½ of analgesic dose. Some physicians will prescribe 30 to 60mg per dose due to lack of efficacy of the lower dose. Codeine is available OTC in 28 states, however Pennsylvania is not one of them.

    AVAILABLE AS: Guaifenesin/codeine; Promethazine/codeine; Promethazine VC/codeine each contains 10mg of codeine per teaspoonful. Clinicians should not prescribe more than 4-6 ounces at a time to prevent the potential of overdose. Pharmacists should offer to provide a measuring device and encourage patients to use it.

    MECHANISM: centrally mediated suppression of cough threshold. Binds to opiate receptors in the cough center. Codeine is a prodrug that is converted to morphine by the hepatic enzyme CYP2D6. However, genetic variability causes some patients to metabolize it too slowly, and others to metabolize it too quickly. Some patients, particularly children and individuals with obstructive sleep apnea, are "ultrarapid metabolizers," who experience sometimes fatal respiratory depression after taking therapeutic doses of the medication, because they convert the codeine to morphine too rapidly.

    Warnings: An FDA advisory committee recommended against the use of codeine for treatment of cough in children in December 2015. In September 2016, the American Academy of Pediatrics recommended against using codeine in children either for pain or as an antitussive. Is best not to prescribe codeine for any patient under age 18.
    HYDROCODONE: Hydrocodone gets metabolized to an active metabolite hydromorphone (Dilaudid) by CYP2D6 as well. Ultra-rapid metabolizers would expect to see an increase effect and increase in toxicities with hydrocodone.
    AVAILABLE AS Hydromet® (hydrocodone/homatropine 5/1.5 per 5ml)) and Tussionex® (hydrocodone/chlorpheniramine 10/8 per 5ml) Again, clinicians should be cautious when prescribing appropriate quantities. When prescribing Tussionex, keep in mind that the 4oz bottle has 24 doses (12-day supply) which most feel is an excessive duration.

    Pharmacists should provide a measuring device, and encourage its use.

    "We dispense a lot of cough suppressants this time of year, when the OTC preps are ineffective. We have two entirely different cough suppressants available by prescription only. Both are swallowed, but one works centrally and the other locally in the lungs. Remember that cough is only a symptom of an underlying problem, that can range from benign and self-resolving, to chronic or even life threatening, depending on the condition of the patient and comorbid illness. Effective treatment always addresses the underlying cause of the cough."

    We know how often this time of year our patients head to the cough and cold section to pick up a preparation with dextromethorphan to control their cough. The history of dextromethorphan (DXM) shows that abuse has always been a problem.

    HISTORY: The FDA approved DXM in 1958 and during the 1960s and 1970s, dextromethorphan became available in an over-the-counter tablet form by the brand name Romilar. In 1975, Romilar was taken off the shelves because of frequent misuse, and was replaced by cough syrup to cut down on abuse. Manufacturers began introducing refined DXM products (Robitussin-DM, Vicks-44, ) that were designed to limit recreational use by creating an unpleasant taste if consumed in large quantities. It wasn’t long we remember that the drug companies started marketing a higher concentration, and more pleasant tasting preparation (Delsym). Keep in mind when the recommended dose is taken, DXM has few adverse side effects, and has a long history of safety and effectiveness. Nine states (California, New York, Virginia, Arizona, Washington, Louisiana, Kentucky, Tennessee and New Jersey) now have legislation requiring a patient to be age 18 and show ID before purchasing DXM products.

    DXM ABUSE:
    • Most common abused: Coricidin HBP (DM-30mg + Chlorpheneramine-4mg), often referred to as “CC” or “triple C” or “Skittles”.Robitussin products can be used, called “Robo-tripping” or “Robo-shakes”.May lead to elevated body temperature and death.
    • Symptoms following ingestion of high doses (five to ten times the normal therapeutic dose) include euphoria, an altered sense of time, paranoia, and disorientation. In addition, tactile, visual, and auditory hallucinations may occur.
    • The effects seen with dextromethorphan abuse are like those seen after phencyclidine (PCP) use, another agent which blocks NMDA receptors.DXM is sometimes referred to as “Poor man’s PCP”.

    EFFECTS of EXCESSIVE DXM INTAKE:
    • Increased perceptual awareness
    • Altered time perception
    • Feelings of “floating” or dissociation of the body
    • Visual disturbances
    • Tactile, auditory, visual hallucinations
    • Paranoia
    • Disorientation and lack of coordination
    • Slurred speech
    • Impaired judgment and mental performance

    Below is a chart I prepared to illustrate the doses needed to cause all the levels of DXM intoxication. As you can see, just one bottle of Delsym (89ml) can get an abuser to dissociative sedation. I am much more concerned about the Delsym and the Coricidin products, because as we all know excess guaifenesin causes nausea and most likely vomiting.

    PlateauDose (mg)Behavior effectsRobitussin DMDelsymCoricidin HBP
    1st100-200Mild stimulation50-100ml17-34ml3-7 tabs
    2nd200-400Euphoria hallucinations100-200ml34-68ml7-14
    3rd300-600Distorted visual perception. Loss of coordination150-300ml50-100ml10-20
    4th500-1500Dissociative sedation250-750ml83- 250ml17-50