Vitamin D

There are many people who are deficient in vitamin D and awareness of this has been increasing. To know you are deficient, you would need to have your  25-hydroxyvitamin D level drawn. Levels less than 20 ng/ml is commonly considered deficient and levels of 30-50 ng/ml are desired. It is thought that deficiency is growing globally and there are a number of theories as to why this is. The most common reasons include not taking in enough vitamin D and not enough sun exposure. It is recommended that people who do not have regular sun exposure intake 600-1000 IU's per day. Some patients will need much larger amounts, but this varies from person to person. Vitamin D3 is often preferred over D2 because the body naturally makes D3. Vitamin D is important for bone health, immune function, and aids in the absorption of other nutrients, like calcium. 

UpToDate: http://www-uptodate-com.proxy.lib.uiowa.edu/contents/vitamin-d-deficiency-in-adults-definition-clinical-manifestations-and-treatment?source=search_result&search=treatment+of+vitamin+d+deficiency&selectedTitle=1~150

Influenza vaccine in pregnancy and children

It is currently recommended by the CDC that all pregnant women get vaccinated for influenza. There is no preference for which flu shot they should receive. However, they are not to receive the nasal spray, which contains a live vaccine. Quadrivalent and trivalent forms of the vaccine are also available and pregnant women can receive either of these. Thimerosal is a preservative found in the multi-dose vials of the flu vaccine. There is no scientific evidence that shows this as unsafe and the ACIP does not indicate a preference for pregnant or non-pregnant individuals. There is a new recommendation for the 2014-2015 season about children. Kids age 2-8 are now recommended to receive the live vaccine in the nasal spray. Studies found that this was more effective at preventing the flu for children in this age group. However, they stress that if this is not readily available, they should not wait and they should get a flu shot anyway. There is no specific recommendation on quadrivalent vs trivalent in children, but the nasal spray is a quadrivalent vaccine.

Sources:
CDC: http://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm
Influenza Vaccination During Pregnancy. The American College of Obstetricians and Gynecologists. 2014 September.

Cough OTC

It’s the time of year where we get more questions on cold and cough. Usually coughs are treated with over the counter products and many patients don’t know which product to choose. There are a few reasons we should send these patients to the doctor. Some examples of exclusion criteria include: cough for more than 7 days, fever, production of green/thick mucus, or chest pain. Codeine is one of the most effective drugs at decreasing cough, but some pharmacies don’t readily offer these formulations over the counter. Dextromethorphan is in many combination products and is available OTC. This product is recommended for patients with a non-productive cough and works by suppressing the cough. Diphenhydramine can also be used to help with cough. This can especially benefit patients with other cold-like symptoms or if they are having trouble sleeping. Guaifenesin is an expectorant and should be used for patients with a productive cough. It loosens and thins secretions, making it easier to cough out the mucus and clear the lungs. Staying hydrated, using lozenges, and using a humidifier are some non-drug methods you can suggest to patients who have a cough. 

Reference: Handbook of Nonprescription Drugs 

Glaucoma

Glaucoma is a type of eye disease that involves damage to the optic nerve.  This can result in vision loss and blindness if not treated. An increase in intraocular pressure is one of the biggest risk factors and indicators of glaucoma, and many of the treatments are aimed at lowering this pressure. Treatment options include eye drops that increase aqueous outflow, such as prostaglandins, alpha adrenergic agonists, and cholinergic agonists. There are also eye drops that decrease aqueous production, such as alpha adrenergic agonists, beta blockers, and carbonic anhydrase inhibitors.

Examples:

Prostaglandins: Latanoprost, bimatoprost, travoprost, tafluprost, unoprostone

Beta blockers: timolol, betaxolol, carteolol, levobunolol

Alpha adrenergic Agonists: brimonidine

Carbonic anhydrase inhibitors: brinzolamide, dorzolamide, 

Source: Up To Date: http://www-uptodate-com.proxy.lib.uiowa.edu/contents/open-angle-glaucoma-treatment?source=search_result&search=glaucoma&selectedTitle=4~150

MS and prednisone

A prescription came to the pharmacy for prednisone 1250 mg for 5 days. It was being used for a patient with MS flare. MS is an inflammatory disease of the CNS. For patients experiencing a relapse or flare, it is fairly common to get IV methylprednisolone. Recently, high dose oral steroids have been used instead of IV therapy to help patients with convenience. There is not a lot of evidence supporting this, but a few studies have been done to justify the safety and efficacy of this method. Side effects are a concern, but the course is typically only 3-5 days and often a taper is not done. Some side effects include weight gain, insomnia, fluid retention, altered mood, and upset stomach. Long-term side effects should be monitored, but rare with short-term therapy.

Medscape: http://www.medscape.com/viewarticle/527706_7
http://dpic.org/article/professional/high-dose-oral-corticosteroids-relapses-multiple-sclerosis

Empagliflozin

Jardiance or empagliflozin was approved on August 1^st, 2014 for the treatment of type 2 diabetes. It is a SGLT2 inhibitor and in the same class as Invokana. The mechanism involves blocking the reabsorption of glucose by the kidney. This will cause more glucose to be excreted and therefore lower blood glucose levels. It can cause dehydration, low blood pressure, dizziness, yeast infections in women, and UTI’s. There is a risk of hypoglycemia with this medication and it may cause an increase in LDL. It is an expensive medication. A 30 day supply is around $360 according to lexicomp. The benefits of this medication include lowering A1C by 1%, weight reduction of 4-7 pounds, and lowering BP in patients with hypertension.  You should avoid using this in patients with severe renal impairment. In practice, this should be considered a 2^nd or 3^rd line option. Advise patients to take this in the morning as it can cause diuresis.

References: 

Pharmacist Letter: http://pharmacistsletter.therapeuticresearch.com/ce/ceNewsletter.aspx?nidchk=1&cs=STUDENT&s=PL&is=102014&ceid=CE4272634

Lexicomp: http://online.lexi.com.proxy.lib.uiowa.edu/lco/action/doc/retrieve/docid/patch_f/5279964

H. Pylori Treatment

A Helicobacter pylori, or H. pylori, infection is treated with multiple medications. Initial treatment is normally triple therapy with a proton pump inhibitor and two antibiotics. The most common prescribed treatment is with amoxicillin 1000mg twice daily, clarithromycin 500mg twice daily and a PPI, such as lansoprazole 30mg twice daily. Duration of treatment is ideally for 14 days. If a patient is sensitive to penicillins, then metronidazole 500mg twice daily can be substituted for the amoxicillin.

Crowe SE. Treatment Regimens for Helicobacter pylori. UpToDate 2014.

iGrow

The new iGrow isn't the latest Apple product, but instead is a hair growth system. The iGrow uses low-level light therapy to stimulate cellular activity which causes an increase in the natural function of hair follicles. Thicker and fuller hair can be seen in six months. 

This patented red light technology device is FDA cleared for the treatment of androgenetic alopecia, or male pattern hair loss. This system treats affected areas of the scalp and is the first hands-free low level laser therapy hair growth device cleared by the FDA for use at home. The device must be repeated at intervals to maintain results. The suggested treatment frequency is 3 to 4 sessions per week for about 25 minutes each. Results usually take 4 to 6 months. Once hair growth is achieved, an ongoing maintenance schedule of 1 to 2 sessions per week is strongly recommended to maintain new growth. It can be purchased without a prescription but the cost is about $700 currently.

http://www.igrowlaser.com/

Antibiotics Linked to Childhood Obesity

The study "Association of Antibiotics in Infancy With Early Childhood Obesity" published in JAMA Pediatrics stated that repeated exposure to broad spectrum antibiotics before the age of two years old is associated with early childhood (2-5 years old) obesity. Sixty-nine percent of the children in the study had taken antibiotics before the age of two. They averaged 2.3 antibiotic courses per child during that time. They also found that broad-spectrum antibiotics put kids at the highest risk compared to narrow-spectrum drugs. They believe that altering the gut microbes, alters digestion of food which changes the amount of calories and how energy gets extracted. Obesity in early childhood is a risk factor for obesity in adulthood, but it's still early enough to intervene and change the outcome. The authors state that using more specific antibiotics, and not broad spectrum antibiotics, might help lower the risk for childhood obesity. This was an observational cohort study so cause and effect can't be determined, but it is an interesting association that could help identify modifiable factors for the risk of obesity during childhood.

Bailey LC, et al. Association of Antibiotics in Infancy With Early Childhood Obesity. JAMA Pediatrics.  Published online September 29, 2014. doi:10.1001/jamapediatrics.2014.1539

http://time.com/3445232/antibiotics-children-obesity/

Essential Tremor

Essential tremor (ET) is a common neurological disorder with a prevalence estimated of 5% world wide. The incidence of ET increases with age and has a big genetic component to it. ET is treated most effectively by primidone and propranolol. Primidone should be taken 12.5-25 mg/day at bedtime to start out. It can then be titrated up to 250 mg/day in 1 to 2 divided doses.  Doses up to 750mg total per day may be beneficial in ET. Propranolol should be taken 40 mg twice daily to start out, but then increased to a usual maintenance dose of 120-320 mg/day in two divided doses. Common alternative treatments include atenolol, gabapentin, and topiramate.

Tarsy, Daniel. Overview of Tremor. UpToDate 2014.

NLA Cholesterol Guidelines

The National Lipid Association recently released their recommendations for the management of dyslipidemia. The NLA guidelines have a few different thoughts compared to the 2013 AHA/ACC guidelines. One major change is that the NLA has set specific treatment goals for both LDL-C and non-HDL-C based on risk categories and when to consider initiating therapy.

They stated that non-HDL-C is the cholesterol that is carried by all potentially atherogenic particles (root cause of atherosclerosis), which is total cholesterol minus HDL-C.

If a patient is in the desired range, labs and ASVD risk assessment should be repeated in 5 years (or sooner if clinically needed).

		Treatment goals	Consider drug therapy
Risk category	Criteria	Non-HDL-C mg/dL ------------------ LDL-C mg/dL	Non-HDL-C mg/dL -------------------- LDL-C mg/dL
Low	• 0–1 major ASCVD risk factors • Consider other risk indicators, if known	<130	≥190
		<100	≥160
Moderate	• 2 major ASCVD risk factors • Consider quantitative risk scoring • Consider other risk indicators	<130	≥160
		<100	≥130
High	• ≥3 major ASCVD risk factors • Diabetes mellitus (type 1 or 2) ○ 0–1 other major ASCVD risk factors and ○ No evidence of end organ damage • Chronic kidney disease stage 3B or 4 • LDL-C ≥190 mg/dL (severe hypercholesterolemia) • Quantitative risk score reaching the high-risk threshold‖‖	<130	≥130
		<100	≥100
Very high	• ASCVD • Diabetes mellitus (type 1 or 2) ○ ≥2 other major ASCVD risk factors or ○ Evidence of end-organ damage	<100	≥100
		<70	≥70

Jacobson TA, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia. Journal of Clinical Lipidology Volume 8, Issue 5, pages 473 - 488. 2014 National Lipid Association. 

Statin Intensity and Benefit Groups

The 2013 ACC/AHA Cholesterol Guidelines stated the different statin intensities, four statin benefit groups and which statin dose each group would benefit the most from.

Low-Intensity Statins	Moderate-Intensity Statins	High-Intensity Statins
daily dose lowers LDL by < 30%	lowers LDL by 30 – 50%	lowers LDL by ≥ 50%
Pravastatin 10 – 20 mg Lovastatin 20 mg Simvastatin 10 mg Fluvastatin 20 – 40 mg Pitavastatin 1 mg	Simvastatin 20 – 40 mg Lovastatin 40 mg Atorvastatin 10 (20) mg Rosuvastatin 10 (5) mg Pravastatin 40 (80) mg Fluvastatin 40 mg BID Pitavastatin 2 – 4 mg	Atorvastatin 40 – 80 mg Rosuvastatin 20 (40) mg
Bold = evaluated in RCT, Italics = FDA approved doses but not studied

Four Statin Benefit Groups:

1. Individuals with clinical ASCVD

    - Clinical ASCVD = acute coronary syndromes or history of MI, TIA, stroke, angina, coronary or other arterial revascularization, or peripheral arterial disease 

2. Individuals with primary elevations of LDL ≥190 mg/dL

3. Individuals 40 to 75 years of age with diabetes and LDL 70 to 189 mg/dL without clinical ASCVD

4. Individuals without clinical ASCVD or diabetes who are 40 to 75 years of age and have LDL 70 to 189 mg/dL and an estimated 10-year ASCVD risk of ≥7.5%. This requires a clinician-patient discussion.

Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline. Circulation. Published online 12 Nov 2013.

What's New for Cholesterol Guidelines

When the ACC/AHA Cholesterol Guidelines were released in November 2013, it changed the view on how to treat high cholesterol. Not everyone in the healthcare field is familiar with the changes in this newer guideline. I had to refresh my memory since it has been a long time since I last looked over it myself.

What's new:

• No randomized controlled trials that support specific LDL targets
• New equation used to estimate 10 year ASCVD (arteriosclerotic cardiovascular disease) risk 
• app for iPhone/Android ASCVD Risk Estimator from ACC/AHA
• Non-statin therapies do not provide acceptable ASCVD risk reduction benefits compared to their potential adverse effects in the routine prevention of ASCVD
• There is no data to show that adding a non-statin drug to high-intensity statin therapy will provide incremental ASCVD risk reduction benefit with an acceptable margin of safety
• 4 statin benefit groups which focus efforts to reduce ASCVD events

Stone NJ, et al. 2013 ACC/AHA Blood Cholesterol Guideline. Circulation. Published online 12 Nov 2013.

more information in the next post

Vivotif

The oral Typhoid Vaccine Vivotif for primary immunization should be taken one capsule on alternating days (day 1, 3, 5, 7) for 4 total doses. This should be completed at least one week prior to leaving on your trip. Capsules should be swallowed whole and taken with a glass of water one hour before a meal. Alcohol should be avoided one hour before or two hours after administration since it can disrupt the enteric coating. The capsules need to be stored in a refrigerator. If forgotten and left out of the fridge for less than 12 hours one time it is alright and can be taken regularly as long as they are kept in the fridge for the rest of the course. Once course is finished correctly, protection lasts for 5 years.

Vivotif (typhoid vaccine) [prescribing information]. Coral Gables, FL: Berna Products; August 2006

Severe Allergic Reactions to OTC Acne Products

The FDA is warning that certain topical acne products can cause rare serious allergic reactions or very severe irritation. You should stop using these products and seek medical help right away if a reaction occurs, such as trouble breathing or swelling of the face. These side effects are more severe than the adverse effect already listed on the products as warnings, such as irritation, minor swelling and redness of the skin. The FDA is not sure what the cause is yet. It could be from salicylic acid, benzoyl peroxide, the inactive ingredients, or a combination of the three.

www.fda.gov/Drugs/DrugSafety/ucm400923.htm

Invokana

Ivokana (canagliflozan) is a recently approved drug for the treatment of type two diabetes. Approved in the US in 2013. It is a subtype 2 sodium-glucose transport protein inhibitor, or more commonly referred to as a SGLT2 inhibitor. This medication increases urinary glucose excretion by lowering the reabsorption of filtered glucose. Initial dose is 100mg before the first meal of the day. The dose can be increased to 300mg once daily. It is important to drink plenty of fluids to prevent dehydration as more fluids will be excreted through the urine once starting this medication. Common adverse effects include UTI (in women) and an increase in serum potassium. Others include nausea and orthostatic hypotension.

Invokana (canagliflozin) [prescribing information]. Titusville, NJ: Janssen Pharmaceuticals, Inc; May 2014. Invokana (canagliflozin) [product monograph]. Toronto, Ontario, Canada: Janssen Inc; May 2014.

Growing Pains

When I hear the term "growing pains" the first thing I think of is the TV show from 1985-92. But there is condition commonly referred to as growing pains as well, which is usually described as aches or pains in the legs in growing children. There is no evidence that growth in kids hurts, but rather it could be due to a lower pain threshold or overuse of these muscles. Good news is this doesn't cause more severe problems or affects growth. Common treatments include rubbing/massaging legs, using heating pads or taking warm baths, using pain relievers (such as ibuprofen or acetaminophen), and stretching these muscles.

http://www.mayoclinic.org/diseases-conditions/growing-pains/basics/symptoms/con-20029782

Iron Supplements

For the treatment of iron deficiency, the recommended oral dose in adults is about 150 - 200 mg per day of elemental iron. The key thing to notice is elemental iron since iron supplements come in multiple formulations. A box of ferrous sulfate 325 mg might look like it could be your whole daily dose, but there is actually only 65 mg of elemental iron per tablet.

Treatment of the adult with iron deficiency anemia. UpToDate 2014

Influenza Vaccine

It is that time of year again. I gave my first flu shot of the season this afternoon. The flu vaccine is your best defense in preventing the flu. The vaccine can't prevent all cases of the flu since the viruses are always changing. Each year the flu vaccine is set to help against 3 or 4 strains of the virus. It also takes about 2 weeks after receiving the vaccine for protection to develop.


2014 - 2015 VIS from the CDC

Allegra

Some medications should be taken with food, some need to be on an empty stomach and other medications can be either way. Allegra, the allergy medication, shouldn't be taken with any fruit juices (such as apple, grapefruit, orange) because it can decrease the bioavailability of the medication by up to 36%.

Lexicomp

Nutritional Needs

When it comes to vitamins and minerals, the phrase Recommended Daily Allowance or RDA comes up quite often. What does this mean? The RDA is the amount needed to meet the requirements of 97.5% of healthy individuals. Basically enough to prevent deficiencies in almost all of the population. For optimal health, quantities higher than the RDA but lower than the tolerable upper limit may be needed.


Food and Nutrition Board, Institute of Medicine, National Academies, 2004, retrieved 2009-06-09

Hypomagnesium

There are many potential causes of hypomagnesium including diet, poor absorption and alcoholism. Medications such as loop and thiazide diuretics, some antibiotics, and long term use of proton pump inhibitors can also cause low magnesium. Diabetes is another common cause. If levels are low and you are exhibiting symptoms, such as weakness, muscle cramps, or confusion, your doctor might prescribe you Slow-Mag or something similar. If levels are low and symptoms are more severe than IV magnesium can be given.



Lexicomp 2014

Whang R, Hampton EM, Whang DD (1994). "Magnesium homeostasis and clinical disorders of magnesium deficiency". Ann Pharmacother 28 (2): 220–6. 

Hydrocodone containing products soon to be schedule II

Recently a new law passed to regulate hydrocodone combination products (such as Vicodin, Lortab and generics) as Schedule II controlled substances. This will go into effect on October 6^th, 2014. Starting on this date, prescriptions for these products will need a new written prescription for each 30 day supply. If you need a refill, your doctor will have to write a new prescription for you to take to the pharmacy. If needed, your doctor can write three separate prescriptions at the same time. These will have to have a "do not fill until after a certain date" written on them, for up to a potential 90 day supply. This is the same process for other current Schedule II controlled substances. 

http://www.pharmacist.com/hydrocodone-moved-schedule-ii-dea-final-rule

Sitavig

Sitavig (acyclovir buccal tablets) recently got released in North America for the treatment of recurrent cold sores. One tablet is placed on the upper lip at the first onset of symptoms and dissolves over a few hours. Sitavig is a potential alternative to current oral treatments (which usually last many doses over a few days) and other topical creams/ointments (which need to be reapplied several times a day).

http://sitavig.com/wp-content/uploads/2014/07/sitavig-prescribing-information_2014.pdf

Zostavax

Zostavax, or the shingles vaccination, is stored frozen and needs to be reconstituted immediately once removed from the freezer. Once it is reconstituted it can appear hazy and off-white or pale yellow in color. It is administered as a single 0.65ml dose subcutaneously in the deltoid region of the upper arm. It needs to be administered within 30 minutes of being removed from the freezer. As of now it is scheduled for only a one time dose.


 http://www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi2.pdf

Community Pharmacy Student Daily Blog

The purpose of this blog is to serve as a place for community pharmacy students to reflect daily about at least one thing they learn each day while on rotation. Every post will be reviewed by the pharmacy resident and discussed the next day.

Examples include, but are not limited to:
- New guidelines
- Mechanism of Action of medications
- Processes/Services
- Interactions with other healthcare providers
- Etc.

Rules:
Please cite all resources used.
All posts must not contain any individually identifying health information. Ex: No patient names