Fungal treatment - Athlete’s foot, Jock itch, Ring worm

Available over the counter options
Brand	Generic/Strength	Form	Uses	Age	Directions
Lotrimin	Clotrimazole 1%	cream	athlete’s foot, jock itch, ring worm	Age 2+	Athletes foot/ringworm -          BID between toes for 4 weeks Jock itch -          BID between toes for 2 weeks
Lotrimin Ultra	Butenafine hydrochloride 1%	cream	athlete’s foot, jock itch, ring worm	Age 12+	Athletes foot between toes -          BID between toes for 1 week -          QD for 4 weeks Jock itch -          QD for 2 weeks
Tinactin	Tolnaftate 1%	cream	athlete’s foot, jock itch	age 2+	BID for 4 weeks
Lamisil	Terbinafine hydrochloride 1%	cream	athlete’s foot, jock itch, ring worm	age 12+	Athletes foot -          BID between toes for 1 week -          BID foot bottom or side for 2 weeks Jock itch and ringworm -          QD (AM or PM) for 1 week
Micatin	Miconazole nitrate 2%	cream	athlete’s foot, jock itch, ring worm	age 2+	Athletes foot/ringworm -          BID between toes for 4 weeks Jock itch -          BID between toes for 2 weeks
Counseling points
-          Wash and pat dry affected area daily or twice daily (morning and night) -          Do not share towels with others or use same towel on other parts of the body -          Wear protective footwear in areas with other family members or public -          Launder contaminated towel and clothing in hot water and dry on hot dry setting -          Avoid clothing or shoes that cause skin to stay wet such as wool and synthetic fabrics -          Dry shoes before wearing them again -          Dust shoes with medicated or nonmedicated foot powder to help dry -          Change insoles every 3 to 4 months for odor control -          Stop topical medications if causes irritation, sensitization or worsening -          Apply thin layer over affected area -          Apply to spaces between toes as well if affected -          Wear well-fitting ventilated shoes -          Change socks at least once a day -          Wash hands with soap and water after applying the cream, avoid getting cream in eye -          Creams and solutions are easier to get into skin than spray and powder dosage forms -          Consult doctor o   if last longer than 4 weeks o   cause unknown o   unsuccessful initial treatment or worsening o   nails or scalp involved o   face, mucous membranes, or genitalia involved o   secondary bacterial infection signs such as oozing purulent material o   excessive continuous exudation o   widespread, very inflamed, or debilitating o   diabetes, systemic infection, immune deficiency o   fever or malaise

Krinsky DL, Berardi RR, Ferreri SP, et al. Handbook of nonprescription drugs: An interactive approach to self-care. 18th ed. Washington, D.C.: American Pharmacists Association; 2015.

Asthma Guideline Review - GINA

Iron Supplementation Recommendations

Iron Supplementation Recommendations

Forms of Iron
Carbonyl	1 gram = 1 gram elemental iron (100% iron)
Fumarate	1 gram = 330 mg elemental iron (33% iron)	325 mg tablet contains 108 mg elemental iron
Sulfate	1 gram = 200 mg elemental iron (20% iron)	325 mg tablet contains 65 mg elemental iron
Citrate	1 gram = 180 mg elemental iron (18% iron)
Gluconate	1 gram = 120 mg elemental iron (12% iron)	325 mg tablet contains 36 mg elemental iron
Counseling points
·         The max amount of elemental iron that can be absorbed orally is 25 mg/day ·         Oral iron may 6 to 8 weeks to resolve anemia and up to 6 months to replete iron stores ·         Side effects include stomach upset, constipation or diarrhea, nausea, vomiting, and darkening stools ·         Consume iron two hours before, or four hours after, ingestion of antacids ·         Coffee, tea, dairy, food, calcium, zinc, manganese, or copper can decrease iron absorption ·         250 mg vitamin C (ascorbic acid) or a half-glass of orange juice helps to increase absorption of iron ·         Medications that decrease iron absorption: quinolones and tetracycline antibiotics, bisphonates, levodopa, levothyroxine, methyldopa, mycophenylate, penicillamine, chloramphenicol, histamine blockers, proton pump inhibitors ·         Ferrous iron is three times more absorbable than ferric iron
Iron in food
Non heme iron – plants, iron fortified foods Heme iron – meat, seafood, poultry

Iron: MedlinePlus Supplements (U.S National Library of Medicine)

http://www.nlm.nih.gov/medlineplus/druginfo/natural/912.html

Iron (Dietary Supplement Fact Sheet: — Health Professional Fact Sheet)

http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

The Importance of Iron and Use of Iron Supplements (The Importance of Iron and Use of Iron Supplements)

http://www.pharmacytimes.com/publications/issue/2013/June2013/R587_IronSupplement

Zoster Vaccine (Zostavax)

Zoster Vaccine (Zostavax)

What is Zostavax?

Zostavax is a live attenuated vaccine. 

Who can get Zostavax?

It is indicated for prevention of herpes zoster also known as shingles in patients ages 50 and older.  It can be utilized in patients regardless of prior herpes zoster.  Research has shown highest efficacy in patients ages 60-69; due to supply concerns, ACIP recommends the vaccine in ages 60 and older.

Who should not get Zostavax?

Contraindications to the vaccine include pregnancy, immunodeficiency, anaphylaxis, moderate illness (fever > 101.3F).

Also, it is also important to discontinue antivirals 24hrs prior to vaccination and till 14 days after vaccination.

How is Zostavax given?

0.65ml subcutaneous injection.

What are Zostavax side effects?

The most common side effects are injection site reactions and headache.

Can Zostavax be given with other vaccines?

Yes, CDC recommends that Zostavax can be administered with all other live and inactivated vaccines including the pneumococcal vaccine which is commonly given to older adults. According to the package insert, a Merck-sponsored, randomized clinical trial determined a reduced immune response to Zostavax when it co-administered with Pneumovax 23 compared to individuals who received these vaccines 4 weeks apart.

How effective is the Zostavax vaccine?

The vaccine helped reduce the incidence of shingles approximately 50% in patients who received the vaccine. 

How does Zostavax (shingles vaccine) compare to Varivax (chicken pox vaccine)?

They are both live subcutaneous injection vaccines of the same virus with Zostavax being 14 times more potent than Varivax. Zostavax is for older adults (age 60 and older) and Varivax is for children (1 year and older).  The two vaccines cannot be used in exchange for each other in adults and children. 

The dosing in children for Varivax is 0.5ml two doses subcutaneous.  

For children ages 1 to 12 years, there should be a minimum interval of 3 months between doses. 

For children ages 13 and older, there should be a minimum interval of 4 weeks between doses.

How is Zostavax stored?

Live vaccines such as (Zoster, Varicella, MMR, MMRV) should be stored in the freezer -58°F and +5°F (-50°C and -15°C).

Other live vaccines such that are refrigerated at 2° to 8°C (35° to 46°F) include:

rotavirus (Rotarix, RotaTeq)

yellow fever (YF-Vax)

polio (IPOL, KINRIX, Pediarix, Pentacel, Quadracel)

tuberculosis (BCG vaccine)

typhoid (Vivotif, TYPHIM Vi)

Where can I get more information?

Zostamax [package insert]. Whitehouse Station, NJ: Merck & Co., Inc.; 2015. Available at: https://www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi2.pdf

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/varicella.pdf

Webinar - Diabetes

Maximizing the Role of GLP-1 Agonists in Our Patients with Type 2 Diabetes 

Physiology

Consumption of food leads to a rise in a glucose levels. This rise in glucose leads to release of incretins from the intestines, specifically the duodenum to stimulate a decrease in blood glucose levels.  The two types of incretin are glucagon-like peptide (GLP) and glucose dependent insulinotropic polypeptide or gastric inhibitor polypeptide (GIP).  GLP1 acts on the brain to promote satiety and reduce appetite, acts on the pancreas alpha cells to decrease postprandial glucagon secretion, acts on the pancreas beta cells to increase glucose dependent insulin secretion, acts on the liver to decrease glycogenolycis (due to decrease glucagon secretion), acts on the gastro intestinal tract to slow gastric emptying. 

GLP1 agonists drugs

·         Short acting à lower postprandial glucose

Exenatide short acting BID

·         Long acting à lower postprandial glucose and fasting

Exentaide long acting weekly

Liraglutide

Albiglutide

Dulaglutide

Side effects of GLP1 agonists

Weight loss

Stomach upset – patients should eat smaller/frequents meals

Caution with pancreatitis

Storage of GLP1 pens

Refrigerate unopened pens

Room temperate pens sting less

GLP1 pens vs insulin pens

GLP1 pens should be primed initially

Insulin pens should be primed each time

GLP1 agonists vs DPP4 inhibitors

DPP4 inhibitors raise GLP1 to endogenous levels

GLP1 agonists raise GLP1 much higher

Pharmacotherapy options for diabetes treatment

·         Bolus insulin

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

Inhaled (Afrezza)

Regular (Humulin R, Novolin R)

·         Basal insulin

NPH (Humulin N, Novolin N)

Detemir (Levemir)

Glargine U100;U300 (Lantus, Toujeo)

·         Non-insulin injectables

Glucagon like peptide 1 agonists – exenatide, liraglutide, albaglutide, dulaglutide

Amylinomimetic – pramlintide

·         Oral

Alpha glucosidase inhibitors – acarbose, miglitol

Biguanides – metformin

Bile acid sequestrants – cholestyramine, colestipol, colesevelam

Dipeptidyl peptidase 4 inhibitors – sitagliptin, saxagliptin

Dopamine agonists – bromocriptine

Glinides – nateglinide, repaglinide

Sulfonylureas – glipizide, glimepiride

Sodium glucose co-transporter 2 inhibitors – canagliflozin, dapagliflozin

Thiazolidinediones – rosiglitazone, pioglitazone

Weight changes with antihyperglycemic agents added to metformin

Drugs causing weight gain Insulin* (most gain) Thiazolidinediones* Sulfonylureas* Glinides* Dipeptidyl peptidase 4 inhibitors (least gain)

Drugs causing weight loss Alpha glucosidase inhibitor (least loss) Glucagon like peptide 1 agonists Sodium glucose co-transporter 2 inhibitors (most loss)

*hypoglycemic risk