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.