Drug Information Question

Patient asked whether her metformin interacted with an over-the-counter medication she was taking.  Based on researching the information in Micromedex, it was found that there was no interaction of concern.

To further understand possible over-the-counter medications interactions with Metformin, I read the journal article Drug Interactions of Medications Commonly Used in Diabetes and learned that the major OTC interaction of metformin is cimetidine.  Cimetidine causes a 60% increase in peak metformin plasma levels. The incidence metformin-induced lactic acidosis may reach 0.084 cases per 1000 patient-years, with 50% of the cases being fatal.  Other adverse effects associated with metformin are upset stomach, B12 deficiency, and headache.

References

Metformin.  Drug Interactions.  Micromedex Solutions.  Truven Health Analytics, Inc. Greenwood Village, CO.  Available at: http://www.micromedexsolutions.com.  Accessed May 22, 2015.

Triplitt, C. "Drug Interactions of Medications Commonly Used in Diabetes." Diabetes Spectrum (2006):19(4); 202-11.

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 ·         Medication 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

Asthma and COPD Review

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 - GLP1 agonists

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 

Drug Information - Lotemax Drug Supply

Drug Information Question

How long does Lotemax (loteprednol etabonate ophthalmic gel) 0.5% bottle containing 5 grams of gel last when taking four times a day for 1 week?

Answer

1 drop of water is 0.05ml which is 0.05g. 

0.05g per drop X 4 times daily X 2 eyes = 0.4g

5g per bottle / 0.4 g used per day = 12.5 days

The gel is likely more viscous than water so I estimate that at twice the viscosity a drop of gel would be 0.1g per drop

0.1g per drop X 4 times daily X 2 eyes = 0.8g

5g per bottle / 0.8 g used per day = 6.25 days

The bottle should last the patient approximately a week.  Since use of steroid eye drops long term is not recommended, this is appropriate for the patient. 

According to the package insert the directions for Lotemax use are follows: “Apply one to two drops of LOTEMAX into the conjunctival sac of the affected eye four times daily beginning the day after surgery and continuing throughout the first 2 weeks of the postoperative period.”

Other information    

Lotemax [package insert]. Tampa, FL: Bausch & Lomb Incorporated; 2015.

http://www.bausch.com/Portals/107/-/m/BL/United%20States/USFiles/Package%20Inserts/Pharma/lotemaxgel-package-insert.pdf

Drug Information - Birth Control and Antibiotics

Drug Information Question

How long is a secondary form of birth control needed for a patient on Quasense (0.15 mg of levonorgestrel and 0.03 mg of ethinyl estradiol) with the administration of cephalexin 10 day prescription? Quasense is an extended cycle 3 month pack birth control. 

Answer

Called Actavis at the phone number listed on the Quasense package insert.  Actavis response was that antibiotics may reduce the effectiveness of Quasense.  There are no current studies on this issue and Actavis recommends using a backup method until checking with doctor. 

We decided to call the patient and informed them on the limited information available on this topic.  We suggested that the patient talk to their physician and that the most conservative approach would be to use a back up method of birth control for the rest of the 3 month pack.  

Understanding Computer Systems

Understanding Computer Systems

There are several systems to be familiar with at CarePro Community Pharmacy.  The following list includes these systems and a brief explanation:

QS/1 is a pharmacy management software system that is needed for pharmacy workflow.  It is utilized to store patient information and bill for medications.

PQC (Pharmacy Quality Commitment) is a continuous quality improvement program that is a requirement of network contracts and Medicare Part D. The program tracks the various types of medication errors that can allow analysis on preventing medication errors.

MIRIXAPRO is a medication therapy management (MTM) provider.  Students and Pharmacists are able to perform complete medication review to analyze the patients current medications, indications, side effects, allergies, and labs to develop a personalized medication action plan.

OUTCOMES MTM  is also an MTM provider service that allows pharmacist to perform more clinical interventions and to be compensated for those services.

Publications - APhA/IPSF Public Health Newsletter May 2015

As the APhA-ASP National Project Coordinator on the International Standing Committee, I have the opportunity to inform pharmacy students around the country about public health topics.  Here is the recent newsletter compilation of the wonderful work pharmacy students are involved in around the country related to public health. Below is a pdf copy and a link to the newletter: