Vitamin D: No additional benefits in postmenopausal women

Many health professionals recommend that older postmenopausal women take a vitamin D supplement to help them avoid osteoporosis from developing and therefore preventing incidences of bone fractures, low bone density, etc. However, a recent study was conducted assessing different dosages of vitamin D supplements. Participants included postmenopausal women with no history of osteoporosis and were randomly either given high-dose cholecalciferol (50,000 IU) twice daily, low-dose cholecalciferol (800 IU) daily, or a daily placebo for one year. Patients in the high-dose group maintained vitamin D levels at 30 ng/mL or more by receiving extra doses if needed to reach this level. All groups of patients were counseled to consume between 600 mg and 1,400 mg of calcium every day.

The results showed that there were no significance differences in clinical outcomes between any of the groups, including the placebo group. This includes changes in bone mineral density, T-score, muscle mass and function, number of falls, physical activity, or functional status. Dr. Deborah Grady, MD, did acknowledge that the results may vary if the study is conducted for a longer period of time. However, it seems that there is no data to support the recommendation of keeping vitamin D levels at or above 30 ng/mL.


The take away from this study is that physicians’ recommendations may not always be valid. It is important for physicians and pharmacists to stay up to date on information such as this vitamin D study because it influences patient recommendations and health. I personally think it is important because keeping patients off of medications and supplements when possible is best – not only will they be happy to not have to take an additional pill every morning, but it also minimizes the chances for adverse effects with their drug therapy regimen. After reading this article, I am left wondering if there are any supplements that postmenopausal women can take in order to prevent onset of osteoporosis. If so, I would be interested to see if studies such as this one have been conducted to test their efficacy as well.

http://www.pharmacist.com/vitamin-d-no-additional-benefits-postmenopausal-women

Pucino F. “Vitamin D: No additional benefits in postmenopausal women.” Pharmacy Today. 22.1 (12 January 2016). 10. Web. 2 March 2016.

Liver injury caused by herbal and dietary supplements on the rise

Over the last ten years, liver injury caused by herbal and dietary supplements has almost tripled, raising from 7% of liver injury causes up to 20%. From these liver injuries, some have even resulted in liver transplant or death. In 2014, the Drug-Induced Liver Injury Network (DILIN) did an analysis evaluating cases of liver injury between the years of 2004 and 2013. Out of more than 800 cases, 85 were caused by nonbodybuilding supplements and 45 to bodybuilding supplements (709 due to medications). The study also showed that nonbodybuilding cases were more severe, with several of them resulting in liver transplantation or death.

Pharmacy Today’s article discussed how it is hard to monitor these liver injuries and failures because the supplements are often over the counter and can be purchased and used without a physician’s consent. Additionally, they are not as monitored by the FDA and do not go through the same efficacy and safety processes that prescription medications do. Some herbal and dietary supplements interact with medications if taken at the same time that will cause adverse effects, such as hepatotoxicity. Once the liver is experiencing injury, it is then hard to figure out what is causing the problems because most dietary and herbal supplements are composed of several vitamins and substances, making it hard to pinpoint the issue.

So what can pharmacists do for this problem? First off, they can inform patients and customers that they are not as highly monitored and regulated, so they should be more cautious taking the products. Going off of that, they should talk to their physicians about the safety of the products and should ask if the supplements are recommended to be taken with their current medications. I feel that this is an important issue when looking at how many livers are damaged by these products that are supposed to be used for improving health. The fact that the numbers are rising makes me feel that pharmacists and physicians should pay extra attention to the dietary and herbal supplements their patients are using. It does have me wondering though – could the FDA be doing more to regulate dietary and herbal supplements?

http://www.pharmacist.com/liver-injury-caused-herbal-and-dietary-supplements-rise

Navarro VJ et al. “Liver injury caused by herbal and dietary supplements on the rise.” Pharmacy Today. 20.11 (1 November 2014). 24. Web. 29 February 2016.

Health Literacy and Pharmacists: Language Barriers

While we learn all the medications you could possibly fit in your head during pharmacy school, along with their side effects and how to counsel patients, what we don’t learn is what happens if you cannot communicate with the patient. What happens when they don’t understand English? An article published in Pharmacy Today discussed how many pharmacies do have a plan for when this happens. CVS has telephones in the pharmacy for language interpretation for up to 150 languages. The University of Florida has a medication therapy management communication and care center (MTMCCC) that has a cultural competency training program for their students in place that teaches cultural sensitivity. And of course having bilingual pharmacists in the pharmacy can help with communication. The article also discussed financial barriers that may prevent pharmacies from having phones similar to those in CVS or other translation technology.

What really stuck out to me in this article was the fact that New York is the only state in the country that requires written and verbal instructions for medications in a foreign language upon request of the patient. Some community pharmacies can print medication labels in a few other languages, but what happens when the patient speaks a language not offered? The fact that it is not mandated to help patients with their medications, regardless of their language is frightening to me. If a patient does not understand how to use their medication and can’t get the help they need, it could lead to endless drug therapy problems and health problems. I hope that pharmacists do not send medications home with patients or customers who do not understand how to use it. I would love to see it become mandated across the country to provide instructions and counseling to every patient who requests it, regardless of language. I hope that translation resources become a more widespread implementation across our country, even for those pharmacies that cannot afford them on their own.

http://www.pharmacist.com/health-literacy-and-pharmacists-need-clear

Bonner, Loren. “Health literacy and pharmacists: the need is clear.” Pharmacy Today. 21.4 (1April 2015). 56. Web. 27 February 2016.

Adherence is Overrated

When a patient walks into a pharmacy and says they are having trouble remembering to take a medication, there are problems that arise when determining the degree of nonadherence. First of all, patients will undoubtedly underestimate the amount of times the have missed their medication. In addition, if a patient is not stating any issues with adherence, pharmacists can only truly observe refill behavior to monitor adherence. Only the date the prescription is filled can be recorded, so often monitoring adherence can be difficult.

But here is why Dr. Crowe, PharmD, is stating that adherence is “overrated” – patients can be perfectly adherent, never missing a single dose and still experience ineffective drug therapy. Dr. Crowe feels that the focus of pharmacists should lie on making sure the drug therapy regimen is efficacious, no matter the adherence of the patient. Because pharmacists see patients several times in between visits with their physician, they can be the one to monitor symptoms and side effects in between the visits. Dr. Crowe states that this is important because “when patients hold up their end of the adherence bargain, they [should be] doing so with an effective medication.” He uses the example of multiple sclerosis (MS) and how pharmacists can not only monitor the symptoms, but the relapse frequency. If this frequency becomes too high, they can recommend a switch in therapy.


This is a great concept that I have never thought of before in the way that was described by the article. It makes sense that if patients are doing everything they should be, they should be getting the best possible benefits from their medication. As far as monitoring symptoms to check for medication efficacy, I immediately thought of antidepressant medications. Because they take several weeks to work, it would be helpful for the pharmacist to check in on the patient when they are refilling a prescription to see how their mood has improved. If there is no improvement after one or two refills, they can contact the physician to recommend a change in therapy. I hope that this mentality is one that every pharmacist uses or is introduced to during their career, in addition to monitoring adherence.

http://www.pharmacist.com/adherence-overrated

Crowe, Michael. “Adherence is Overrated.” Pharmacy Today. 21.7 (1 July 2015). 63. Web. 17 February 2016.

Keeping the Kidneys Safe: The Pharmacists’ Role in NSAID Avoidance

While non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are very easy to purchase (in grocery stores and gas stations), they are one of the most common medications improperly prescribed, especially to older adults. If these are used at a high dose regularly and combined with the wrong medications, it can lead to acute kidney injury (AKI). NSAIDs inhibit the cyclooxygenase enzyme, preventing prostaglandin production. Prostaglandins help to autoregulate the dilation of arterioles in the kidney, controlling the amount of blood filtered. If AKI goes untreated long enough, self-prescribing NSAIDs can even lead to chronic kidney disease (CKD). Luckily, there are strategies that pharmacists can use to prevent patients from overusing NSAIDs at home and prevent these adverse effects.

Pharmacists can use bright stickers or post-it notes on the prescriptions of those who need medication counseling due to a high risk for AKI or CKD (patients with hypertension or diabetes). This will help the staff to remember to discuss the patient’s personal pain management system during consultations, blood pressure screenings, or when handing out the prescription. If the patient is in a rush, a handout could also be placed in with the prescription or on a pamphlet table so that the information is still available. They can also help to counsel on when to use ice or heat on a musculoskeletal issue, rather than taking an NSAID to relieve pain. This gives the patient other ways to manage their pain without taking an NSAID too frequently.

Acetaminophen could also be recommended as a pain reliever for those who are at high risk for AKI or CKD, as it is metabolized in the liver more than the kidney and is rarely seen to damage the kidney. However, this will then require that the pharmacist counsel on the maximum daily dose for acetaminophen in combination with other acetaminophen-containing medications the patient may have. This would be an optimal alternative if the patient is insistent on taking a pill for their pain, as long as the proper counseling regarding acetaminophen can be delivered.


I felt that this article had a lot of good options for educating patients with increased risk for kidney injuries against NSAID use. The repetition of seeing a helpful handout with the patient’s prescription would demonstrate the importance of the issue. The handout could serve as an additional reminder each time the patient has their prescription filled to steer clear of NSAIDs and use another pain-relieving method. This article also ties in nicely with what we are currently learning in anatomy and physiology and helped my understanding of kidney damage via non-steroidal anti-inflammatory drugs.

http://www.japha.org/article/S1544-3191(15)30021-2/fulltext

Pai, Amy B. “Keeping kidneys safe: The pharmacists’ role in NSAID avoidance in high-risk patients.” Journal of the American Pharmacists Association. 55.1 (2015) e15-e25. Web. 14 February 2016.

Pharmacists in the Community and Now Maybe in Your Homes

Mobile Pharmacy Services conducted a one-year study of home visits by pharmacists or pharmacy residents to the citizens of Buffalo, New York. This study was done to find the population who would request a home visit from a pharmacist, the average time a visit would take, and the cost to both the pharmacist and patient. What the study found was that there was a large majority of residents who requested a pharmacist home visit over 65 years of age. These seniors had an average of three chronic conditions, and were taking an average of ten medications. Each visit was about two hours in length, including travel time, and cost the home resident $147 for a pharmacist or $77 for a pharmacy resident.

 

The study was conducted to serve as a model for other pharmacies that may be considering setting up a home visit system. There are several suggested benefits of home visits, such as creating a better learning environment, not only for the patient but also for the family and/or caregiver. In addition, the pharmacist can have the best opportunity to assess what all prescriptions, over-the-counter medications, and herbal supplements are actually in the home, disposing properly of those that are expired. However, the main setback that was identified is the cost of the visits, when including medication costs and travel costs for the pharmacist. This is still a problem that will need to be addressed in later studies.

 

As a pharmacy student, I feel that home visits could be incredibly beneficial. First of all, the pharmacist becomes much more accessible to the community, especially for those who may not be able to travel. It also allows the pharmacist or pharmacy resident to see first hand some of the drug therapy problems that might be occurring. For instance, if medication management is an issue with the patient, the pharmacist can see exactly how the medicines are stored and managed and recommend improvements. Lastly, the pharmacist is much more capable of connecting with their community if they are willing to personally visit patients. I believe that having a good relationship with the community helps to establish trust and confidence.

 

http://www.japha.org/article/S1544-3191(15)00003-5/fulltext#sec6

 

Monte, Scott V. “Pharmacist home visits: A 1-year experience from a community pharmacy.” Journal of the American Pharmacists Association. 56.1 (2016): 67-72. Web. 11 February 2016.

The Pharmacist’s Role in Preventing Infant Mortality in the United States

Although a very advanced country, the United States has one of the worst infant mortality rates amongst the industrialized countries of the world. Infant mortality is defined as a child who is born alive but dies within its first year of life. The three main causes in the U.S. of infant mortality are congenital malformations, deformations, and chromosomal abnormalities. When including infant injuries and maternal complications with pregnancy, these problems account for 60% of all infant mortalities. Luckily, there is something pharmacists can do to help improve mother and infant health through all stages of pregnancy.

Improving healthcare access has proven to be a positive factor for infant mortality throughout all living environments and income levels. Because pharmacists are one of the most accessible healthcare providers, we can intervene and educate future parents. Whether it is a planned pregnancy or unplanned, pharmacists are able to promote healthy lifestyles for the preconception period, pregnancy, and the postpartum period of a woman’s life. With free resources such as the Affordable Care Act that provide patient education, pharmacists can reach out to women promote a healthy lifestyle in the preconception period.

Pharmacists can also be available to help expecting mothers with their disease states, figuring out ways to monitor the disease without using medications that may harm the fetus. The pharmacist should obtain an extensive medication list, current and past, including herbal supplements and over-the-counter medications to best identify potential hazards for the mom and the child. It is then important in the postpartum period to educate the mother on vaccines the infant can receive to avoid common illnesses. In addition, pharmacists should emphasize the importance of the mother’s health postpartum, as there will be many changes in her body and life during this time.

Finally, and in my opinion most importantly, pharmacists can educate on contraceptives. Over half of the pregnancies in the United States are unplanned pregnancies, with half of the couples with unintended pregnancies stating they used a form of contraception in the month prior to conception. Educating on the proper use of contraception forms could help to lower the unplanned pregnancies, and in turn lower infant mortality rate. It only takes a five minute explanation from a pharmacist to help teach how to avoid an unplanned pregnancy, and the more pharmacists educate, the more the public will turn to them with further questions.

http://www.japha.org/article/S1544-3191(15)00013-8/fulltext

Mager, Natalie A. “Preventing Infant Mortality: Pharmacists’ Call to Action.” Journal of the American Pharmacists Association. Elsevier Inc. 2016. Web. 8 February 2016.

The Outlook on a Zika Virus Vaccine

Over the past few months, there has been an outbreak of a new mosquito-born virus. This Zika virus is most prevalent in Latin America and Brazil and there have been thousands of cases just in the past few months alone. While the virus only causes the person infected to feel ill for a few days (fever, skin rash, vomiting, red eyes), the main concern is the birth defects it causes among pregnant women. The virus can lead to underdeveloped heads and brain damage in newborns. The virus has led to officials to urge pregnant women to avoid traveling to more than twenty countries in these areas. It has even led to some countries recommending women avoid getting pregnant for the next two years.

This article discusses the research that is being done to come up with a vaccine for the virus. Sanofi, a French drug company has stated they will begin their research with the newly-approved vaccine for the dengue fever (another mosquito-born virus in the same family as Zika). However, researchers fear that those who are immune to the dengue virus may not respond to a similarly-structured Zika vaccine. This will pose a challenge in the development of a vaccine, and it is predicted that a vaccine will not be available for a few years still.

This is relevant to pharmacists everywhere. As the numbers of those infected grows, there will be more questions about when vaccines will be available and it is important for pharmacist to advise pregnant women against visiting these countries during the outbreak. It will be important for pharmacist to stay up to date on the virus as more research is conducted to be able to best advise customers and patients on safety.

Loftus, Peter. Roland, Denise. (2 February 2016). Drug Industry Starts Race to Develop Zika Vaccine. The Wall Street Journal. Retrieved from http://www.wsj.com/articles/sanofi-to-launch-zika-vaccine-research-1454421279