Monday, October 15, 2018

Flu Season is Coming ... with Some Updates

"When are flu shots coming in?" is the most frequently asked question at every community pharmacy counter once Thanksgiving weekend rolls around. Although pharmacies will have to brace themselves for the increased workload and disruption to normal prescription workflow, it's great to see that so many patients understand the importance of protecting themselves and the people around them against the flu and its complications.

While flu shots are slowly making their way into community pharmacies, pharmacy students are also preparing for the extra volume of patients flu season brings. For some of us, including myself, this year's influenza vaccine will be the first vaccination we've ever administered.

On top of remembering documentation requirements, the correct process for land-marking an injection site, and procedures for anaphylactic reactions, we should also keep in mind the important update for those 65 years and older as we're handing out influenza vaccination questionnaires to patients.

What's the update? 

The Canadian Immunization Guide created by the National Advisory Committee on Immunization (NACI) details current evidence-based recommendations on the use of vaccines for disease prevention in different populations. In an update for the 2018 flu season, NACI acknowledges evidence that the high-dose trivalent inactivated vaccine (TIV) provides better protection than the standard-dose TIV against flu-related complications and hospitalizations in those aged 65 and older.1

When considering the evidence for provincial and territorial funding, NACI recommends that any of the four influenza vaccines indicated of those 65 years and older - standard-dose TIV, high-dose TIV, adjuvanted TIV, and quadrivalent inactivated vaccine (QIV) - can be used.On the other hand for individuals 65 years and older seeking to get vaccinated and clinicians who are advising individual patients, NACI recommends the high-dose TIV be offered over the standard-dose TIV.3

How will this impact community pharmacy?

Currently in Canada, Ontario is the only province to publicly fund the high-dose TIV for all adults 65 years of age or older, while Nova Scotia, Manitoba, Saskatchewan, and Prince Edward Island are only funding the vaccine for elderly people living in long-term care facilities.Ontario pharmacies will not be receiving high-dose TIV as a part of the Universal Influenza Immunization Program (UIIP) and so the vaccination will only be publicly funded if received at a physician or nurse practitioner's office, retirement home, long-term care facility, or hospital.

While sharing the demands of flu season with other healthcare providers may relieve some of the burden on Ontario pharmacies, it leaves us with a question - what should we be doing with patients 65 years and older? There isn't enough evidence to make a comparative recommendation between the high-dose TIV, adjuvanted TIV, and QIV.So should we be vaccinating patients over 65 in community pharmacies or send them straight to their doctor's office? We can't possibly expect physicians and nurses to vaccinate all Ontarians aged 65 and older, so how do we decide which patients to refer? Would turning patients away significantly delay vaccination or even discourage them from getting vaccinated?


How will you apply NACI's recommendations to patients over 65 wishing to get vaccinated in your pharmacy? Please send me your comments and experiences using the form to the right.

For more information on influenza vaccinations in older adults and how to approach vaccine hesitancy, see the Influenza in Older Adults - Ensuring Optimal Protection course offered on rxBriefCase.

I look forward to reading your comments!




Chantel

References

  1. Government of Canada. (2018, May 1). Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2018-2019. Accessed October 9, 2018: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-statement-seasonal-influenza-vaccine-2018-2019.html#1.1
  2. Sanofi. (2018, October 1). Sanofi aims to topple the flu as it marks National Seniors Day with a Guinness World Record attempt. Accessed October 9, 2018: https://www.newswire.ca/news-releases/sanofi-aims-to-topple-the-flu-as-it-marks-national-seniors-day-with-a-guinness-world-record-attempt-694786581.html
  3. Ontario Ministry of Health and Long-Term Care. (Updated 2018, September 19). Universal Influenza Immunization Program (UIIP). Accessed October 9, 2018: http://www.health.gov.on.ca/en/pro/programs/publichealth/flu/uiip/

Saturday, October 6, 2018

WPD - The Significance behind the Abbreviation


In 2009, the International Pharmaceutical Federation (FIP) designated September 25th as World Pharmacist Day, commonly abbreviated as WPD.1 The theme for this year is "Pharmacists: Your medication experts".Although World Pharmacist Day shares the same date as other international holidays - World Dream Day, German Butterbrot Day, and One-Hit Wonder Day - the day has a great meaning to pharmacists and pharmacy students across the world.2

The Theme

The goal of World Pharmacist Day is to encourage pharmacists to advocate for their role in healthcare and to bring awareness to their unique knowledge base. Regardless of the differing scopes of pharmacists across the world, the most fundamental responsibility is to ensure that the right patient receives the right medication. This breaks down the perception of pharmacists as "pill counters" and emphasizes that pharmacists have a role in protecting health by using their expert medication knowledge to assess the appropriateness of medications for each patient. In keeping with the idea of pharmacists as one of the most trusted professionals, this year's theme also highlights that not only do we provide current and evidence-based information about medication to patients, but also to other healthcare professionals.1,3

Past World Pharmacist Day themes, such as last year's theme "From research to healthcare: Your pharmacist is at your service", have similarly countered other publicly-held opinions of pharmacists.4 The 2017 theme reflects that pharmacists contribute to patient health not only in patient-care settings like hospital or community pharmacy, but also in diverse settings like research, industry, and education.4

The 2018 Celebrations

The president of the International Pharmaceutical Federation, Dominique Jordan, invited pharmacists across the world to spread this year's message within their communities, at work, and on social media by decorating their profile pictures with a World Pharmacist Day Twibbon.

Pharmacy students at the University of Toronto embraced the theme by participating in a social media competition that involved completing the sentence "I am a future pharmacist and I am an expert in ____" and posting a photo on social media holding up the message. Outside of the University of Toronto pharmacy world, a simple search of "World Pharmacist Day 2018" or "WPD 2018" on Facebook, Twitter, or Instagram pulls up a long list of pharmacists, patients, and organizations from across the world celebrating the impact of pharmacists.


The Impact

Appreciation days, whether they are for bringing awareness to pharmacists or the best one-hit wonders, are meant to get the conversation started and serve as a platform for more questions and opportunities to advocate in the future. From my experience participating in Pharmacy Awareness Month last March where I spoke to patients about the expanded scope of Ontario pharmacists, many people were unaware of some of the things their pharmacists could do for them. Although I didn't have an extensive conversation about it with every patient, I'm sure I left the door open for them to ask their pharmacist about it at their next visit or ask their friends or family if they've had experience with it. 

Judging by the number of likes, comments, and shares of WPD 2018 social media posts and pictures, the campaign must be working to get people engaged and talking about the role of pharmacists.

Hope you had a happy World Pharmacist Day!

Chantel

References:
  1. International Pharmaceutical Federation. World Pharmacist Day. Accessed on October 2, 2018: https://www.fip.org/worldpharmacistsday
  2. Days of the Year. Browse all the weird holidays on ... 25th, September 2018. Accessed on October 2, 2018: https://www.daysoftheyear.com/days/2018/09/25/
  3. Marotta, Ryan. (2018, February 9). Pharmacists Remain Among Most Trust and Ethical Professionals. Accessed on October 2, 2018: https://www.pharmacytimes.com/news/pharmacists-remain-among-most-trusted-and-ethical-professionals
  4. International Pharmaceutical Federation. Diversity of profession to be focus of World Pharmacist Day 2017. Accessed on October 2, 2018: https://www.fip.org/www/index.php?page=news_publications&news=newsitem&newsitem=242

Friday, September 28, 2018

The New Pharmacy Student on the Block (Five)

Hi Everyone!

My name is Chantel Asamoah and I am 4th year Pharmacy Student doing block 5 of my APPE (Advanced Pharmacy Practice Experience) here at mdBriefCase.

APPE is a time for pharmacy students to put together everything we've learned over 3 years of school and apply it in real-life practice as a pharmacist. Although mdBriefCase will be my only non-direct patient care (NDPC) placement, I'm excited to learn about the impact that pharmacists can have in non-traditional settings. We all tend to envision the role of a pharmacist as binary - either a community pharmacist or a hospital pharmacist. Or at least that's how I saw it before I started pharmacy school. But there's so much more you can do with a PharmD degree - industry, education, consulting, public health, government, the list goes on!

Before coming to mdBriefCase, my placements included  Michael Garron Hospital (MGH) in general medicine, respirology and oncology, a community placement at a No Frills pharmacy, and a "study" block - which I used as an opportunity to visit Chicago with one of my best friends. I can say that there was at least one thing I learned from each of my previous blocks that has positively influenced the way I will practice as a pharmacist or how I think of the patients I will work with in the future.

  1. Block 1 General Medicine Unit at MGH - a common task for pharmacy students during a hospital setting is discharge prescription counseling. During this rotation at MGH, I was asked to provide discharge counseling to a deaf patient through a sign-language interpreter. It was such an eye-opening experience because I couldn't imagine how the patient would have dealt with all the changes to his medications and understood how/why he needed to start taking new medications. It really got me to start thinking about how language barriers can prevent people from accessing the health information that they need, and as a pharmacist, I should be mindful of these barriers and always have strategies to help. These can include providing written information or asking if I could call a family member that speaks English to translate.
  2. Block 2 Respirology and Oncology Unit at MGH - during my 5-weeks, one patient that I was interviewing was experiencing an excruciating migraine and didn't have any of her medications from home, which are usually effective. She had to resort to laying in her hospital bed with her eyes closed, lights off, and with an ice pack on her forehead. None of the medications she was getting in the hospital were helping, but she remembered receiving something in the emergency room years ago that helped, but she couldn't remember the name. Although it would have been easier and less time-consuming for me to give the Advil some more time to work, I looked through all the records of her previous hospital admissions to find the name of this specific medication that helped years ago. I didn't get to see her or find out if it was helpful because she was discharged over the weekend, but I'm glad I didn't just take the easy way out in the interest of time.
  3. Block 3 No Frills Pharmacy - being a familiar face in a community pharmacy allows you the opportunity to building lasting patient relationships. During this placement, I became involved in the care of a patient who was recently prescribed insulin for the first time. While he was very happy to have me review his medications and progress with him every week, he lacked the confidence to start an injectable medication that would get his diabetes under control, after years of struggling with it. It required a lot of motivational interviewing on my part before he was finally able to make that leap. Sometimes, people just need someone to take the time to listen to their fears and motivate them to reach their goals.
  4. Block 4 "Study" Block/Chicago Trip - if you've ever been to Chicago, you know that the city has a lot of culture (and good food)! Learning about the culture of the city made all of the tourist sitesand experiences much more meaningful. This reminded me why it is important for us to make an effort to at least try to understand our patient's culture or where they're coming from.

I'll be sure to share the experience at mdBriefCase that most greatly shaped who I am as a pharmacist and person by the end of this rotation. Stay tuned for my upcoming projects (a critical appraisal presentation, eNewsletter, MedSchoolForYou mini-module) and weekly blog posts! 

Chantel  

Tuesday, August 28, 2018

Heart Burn: Are we treating for too long?


Heart burn is a common phenomenon that can be characterized by a burning sensation in the throat, and chest. Heartburn is relatively easy to treat with a variety of OTC and prescription products. Proton Pump inhibitors (PPIs) are the premier drug class for treating heart burn, and have had a reputation for being benign drugs, until recently.

New evidence is emerging about long term use of PPIs showing correlations between opportunistic infections, pneumonia, and malabsorption of nutrients.1,2 The current recommendation for PPIs for heartburn is 8 weeks, but the reality is many patients surpass this time-frame.

Health care providers should be striving to limit PPI therapy duration in patients to avoid these complications until more information is available.

Difficulty Ceasing?

In patients that have surpassed the recommended 8-week therapy duration, there are two main barriers that make it difficult to terminate therapy.

One of the barriers stopping PPIs therapy cessation is patient preference. Most patients are not optimistic about stopping their PPI therapy, because of how well they work.

The second barrier that causes issues with cessation of PPI therapies is the perceptions of health care providers.  PPIs have been available since 1988, and many healthcare professionals view them as safe drugs. Since most health care professionals view them as harmless, they are less likely to intervene with patients using PPIs long term.


Who does this affect the most?

Although long durations of PPI therapy should be a concern for all patients, it is especially troublesome in older adults. Older adults are more prone to infection, and are more likely to suffer from nutritional deficiencies. Long term PPI use in older adults also adds an extra layer of issues due to drug interactions. To limit this potential harm, it is important to always address any PPI use in older adults.


What can we do?

The best way to decrease complications of long term PPI use in heartburn patients is to play a more active role in product selection, and therapy duration discussions.

Tips:

1) Recommend lifestyle interventions such as exercise, weight loss, and limiting meals before bed.3

2) Consider other drug classes first before PPIs when dealing with mild & moderate cases of heartburn.

3) Discuss with patient and prescribers expected duration of therapy prior to PPI initiation.

4) Investigate any patient prescribed PPIs for longer than 8 weeks and discuss possible taper options.

5) Attempt to taper patients on long term PPIs at least once a year using a combination of life style modifications and other drugs to help.

Quick Tip: Never stop a PPI abruptly due to risk of rebound hyperacidity.

Although PPIs are used mostly to treat minor ailments, it is important to remember the associated risk with long term use. 

Hopefully these tips will be helpful for everyone, because I am signing off.
I hope you have enjoyed my posts & are excited for the next student blogger.

Sincerely,

Derick Oduro

References:

1) Trifan, Anca, et al. “Proton Pump Inhibitors Therapy and Risk of Clostridium Difficile Infection: Systematic Review and Meta-Analysis.” Advances in Pediatrics., U.S. National Library of Medicine, 21 Sept. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5643276/. 

2) Heidelbaugh, Joel J. “Proton Pump Inhibitors and Risk of Vitamin and Mineral Deficiency: Evidence and Clinical Implications.” Advances in Pediatrics., U.S. National Library of Medicine, June 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC4110863/. 

3) Ness-Jensen E, Lindam A, Lagergren J et al. Weight loss and reduction in gastroesophageal reflux. A prospective population-based cohort study: the HUNT study. Am J Gastroenterol 2013;108(3):376-82.

Tuesday, August 14, 2018

Recalls and Shortages: Knowledge is Power

In today's digital age information is readily available quickly, which can be both positive and negative.  

Health Canada recently recalled Valsartan, a drug for hypertension due to carcinogenic contaminants. As one would expect, this caused a lot of panic among the public. Working in a community pharmacy at the time, I remember getting several frantic calls from frightened patients about this recall. Several patients were displeased that we did not contact them first. The most common calls however, were patients trying to confirm if any of their other medications were being recalled. This panic could have easily been avoided if patients were aware of the resources available to them. 

Health Canada provides updates on its website and app, both of which are underutilized by health care professionals and patients. The website and app provide updates on Health Canada’s decisions for recalls and shortages pertaining to food, consumer goods, vehicles, and drugs.  
Importance of Accuracy? 
Since information spreads quickly in the digital age, it is important to get accurate updates, especially in regards to drugs. 

A game of broken telephone often occurs when news breakscausing misinformation to spread. A great example would be the Valsartan recall. Health Canada had the entire list of Valsartan products being recalled along with their strengths, and manufacturers. Many news outlets simplified this to the drug name, Valsartan and its primary indication, blood pressure. Many patients simplified this to a medication for blood pressure when contacting their family and friends. This led several people down an emotional roller coaster only to find out their drug was not affected. 

Why does this matter? 
Providing patients with these resources provides a reputable source for information on drug recalls and shortages. Well-informed patients are less likely to make rash decisions or panic. The goal is not to stop patients from contacting their health care providers, but to provide better tools for self-care. Self-care is an integral part of health maintenance. Drug recalls and shortages are a common occurrence, and it is difficult to relay this information to patients. Arming patients with these tools for recalls and shortages promotes self-care and limits the harm that misinformation causes. Hopefully this is something that you will strongly consider for yourself and your patients. 

Thanks for your time & catch you next week, 

Thursday, August 2, 2018

Toenail Fungus: Wow, that's a lot on your plate

The issue?

Toenail fungus is not the most fun topic, but it is something we must talk about, especially when nail infections  currently effects 6.4% of Canadians.1 This is approximately 2.3 million cases of nail fungus in Canada, most of which are toenail infections. Toenail fungus is usually preceded by athlete's foot, but it can occur independently. Toenail infections can cause several complications and should be treated promptly. A common issue with toenail infections is the aftermath after a successful treatment.

There are two terms used to define a successful treatment for toenail fungal infections. A mycological cure refers to the eradication of the fungi at the nail. A complete cure is defined by the eradication of fungi at the nail and the appearance of a healthy-looking nail. Most successful treatments of toenail fungus end with mycological cure, leaving patients with discolored and thickened nails. 

The hard part?

Unfortunately, the medications available for treating toenail fungus are not great at achieving complete cures. Topical antifungals and oral antifungals are the preferred therapy for treating toenail infections.

Efinaconazole and Ciclopirox are the two available topical therapies for the treatment of toenail fungus and have a respective 17% and 8.5 % complete cure rate.2 Achieving these cure rates are difficult because it requires patient's to be compliant with once daily usage for 48 weeks. 

The oral therapies Itraconazole and Terbinafine have the advantage of a lower duration of therapy (12 weeks) but come with unwanted drug interactions. Oral antifungals are notorious for their plethora of drug interactions, which can effect people taking medications for:
  • Depression
  • Pain
  • Migraines
  • Blood Pressure
  • Heart rate
  • Cholesterol
  • Psychosis
  • Anxiety
  • Sleep Deprivation
  • Urinary Incontinence
  • Heart Burn

Since several drug interactions exist it is difficult to treat most patients without risk of interactions. All this extra risk coincides with a higher cure rate, but not much. Terbinafine has the highest complete cure rate for oral antifungals commonly used. When used optimally, it’s complete cure rate is 38%.2

Good hygiene:

Low complete cure rates are a reason for concern for fungal toenail infections. Good hygiene practices can decrease the risk of contracting a fungal infection.

Hygiene Practices:
  • Wearing shoes that minimize humidity. Preferable shoes made of canvas or leather.
  • Avoid sharing toe nail clippers, towels, and other foot care devices with individuals
  • Keep nails clean and short
  • Avoid being bare footed in publicly shared spaces such as swimming pools, nail salons, gym locker rooms.
  • Dry feet immediately after washing
  • Wash feet with soap and water every day
  • Change socks worn each day, and even more frequently for physically activity individuals or those with a propensity to sweat
  • Wear socks preferably made of acrylic, cotton, polypropylene or wool.

Quick Tip: All these hygiene practices are valid for preventing both nail and foot fungal infections.

Although the mycological cure rate is respectable for most antifungals, the complete cure rate is usually low. Hopefully this will keep you on your toes, and get you to make the appropriate changes to your daily routine to decrease your risk.

Thank you for your time, and have a nice long weekend!

Derick Oduro 

References:
1) Gupta AK, Gupta G, Jain HC et al. The prevalence of unsuspected onychomycosis and its causative organisms in a multicentre Canadian sample of 30,000 patients visiting physicians' offices. J Eur Acad Dermatol Venereol 2016;30(9):1567-72.

2) Gupta AK et al. J Cutan Med Surg. 2015 Sep-Oct;19(5):440-9. doi: 10.1177/1203475415581310. Epub 2015 Apr







Monday, July 30, 2018

Impacted Earwax: "I’m sorry, could you repeat that?"


We have all had congested nostrils before, but have we all experienced congested ears? The goal of this post is to explain how cumbersome ear congestion can be, and how to help anyone caught in this sticky situation.  

Common Reasons for Build-Up: 
Before we talk about what we can do for congested ears, let us first discuss what causes earwax build up. There are many factors that cause earwax build-up in a person including old age and anatomical anomalies.1 The most common cause of earwax buildup for younger individuals is ear hygiene practices, primarily the use of cotton swabs.2 Placing objects into your ear canal pushes earwax back and impedes the natural cleaning mechanism of the ear causing a build-up. Once enough ear wax has collected it can cause: 

    • Ear discomfort (mainly ear fullness & itchiness) 
    • Hearing loss 
    • Chronic Cough 
    • Ear infections 

What’s Next? 
These symptoms can affect one's ability to function in their daily activities, so it is important to treat for quick relief. Cerumenolytic products are the primary option for treating impacted earwax. Cerumenolytics work by either softening the impacted earwax or lubricating the ear canal. Currently there is no evidence suggesting any cerumenolytic product to be superior.2 Therefore, a recommendation based on practice experience or patient preference is the most suitable approach. Cerumenolytic products do not work instantly and may take up to 7 days to provide relief. For those who would prefer their hearing restored promptly, ear irrigation is an option. 

Quick Tip #1: Some cerumenolytic products contain peanut oils, always double check a patient's allergy status before recommending a product. 

Ear irrigation is the finishing move for removing troublesome earwax. It can be difficult to complete without assistance but the technique is relatively simple. Ear irrigation is not recommended for individuals with a current or past perforated tympanic membrane. Although pharmacist cannot view a patient's ear canal to confirm if the tympanic membrane is still intact, a perforated tympanic membrane presents differently than impacted earwax. 

Quick Tip #2Patients can use both cerumenolytic products and water irrigation together. For patient’s that opt for this it is recommended to use a water based cerumenolytic 10-30mins prior to water irrigation. 

Differentiating between the two1: 
Symptoms
Impacted Earwax
Perforated Tympanic Membrane
Pain
Unlikely, unless ear is also infected.
Yes.
Pain is sudden and sharp.
Itchiness
Yes
Refer if rash is present.
None.
Hearing status
Gradually fades, may become better through jaw movement.
Suddenly occurs.
Discharge
Unlikely, unless ear is also infected.
Yes.

If a patient presents with any of the signs favoring a perforated membrane or infection they should be referred.  Using cerumenolytic products and water irrigation should relive most patients' symptoms within 1-5 days. If relief is not obtained by this point a patient should be referred to a physician.  
  
Quick Tip #3: If, a patient already has lost their hearing in one ear prior to current circumstances refer patient immediately. 

Impacted earwax is a nuisance that can disturbs anyone’s ability to function in their daily life. Although physicians can clear out earwax for patients providing, this knowledge can help decrease those visits. 

Thank you & hope to see you next post, 

Derick Oduro 

References:
1) Ely JW, Hansen MR, Clark EC. Diagnosis of ear pain. Am Fam Physician 2008;77:621-8. 
2) Schwartz SR, Magit AE, Rosenfeld RM. Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Otolaryngology– Head and Neck Surgery. 2017. Vol 156: S1-S29.