Those Darn Allergies

Picture this: you see someone. They’re sneezing. Their nose is runny. Their eyes seem to be watery, and they keep rubbing them like they’re itchy. If you thought to yourself, “That person could use a hanky”, well you’re probably not wrong. But if you also thought, “Looks like they have allergies”, then you nailed it. Some people have had allergies for as long as they can remember. Some may not have ever had allergies then they moved someplace else and suddenly developed them. Others might be lucky enough to never develop them in the first place. The truth is that pesky allergies exist in many forms and arise from multiple allergens. We’ll investigate the why, what, and how when it comes to allergies.

Allergies occur because of the body’s immune system and its overreaction to a certain substance that it deems as an ‘intruder’ or ‘harmful’. This results in an allergic reaction. Any substance that causes such a reaction is labeled an ‘allergen’. Usually these allergens are relatively harmless, and what may trigger a reaction in one person may not cause the same reaction in another.

There are different kinds of allergies triggered by various allergens: food, pet, latex, mold, and drug, to name a few. Allergic rhinitis or ‘hay fever’ is used to describe the condition causing the symptoms previously described such as sneezing, runny nose, and itchy, watery eyes. Allergies may be seasonal or perennial meaning that it doesn’t just occur depending on the season but rather year-round. It is usually triggered by pollen. While sneezing and itching are milder and more common symptoms of an allergic reaction, hives and anaphylaxis are more severe symptoms that require prompt medical care.

Allergy Testing

It is important to figure out what triggers an allergy as sometimes the triggers may not be obvious. If allergies are suspected, an allergist would be the best healthcare provider to go to. Their roles involve performing allergy testing, identifying the trigger, and accurately diagnosing the condition. After a complete medical history and physical exam is done, an allergy test may be performed. Common allergy tests include:

● Skin testing – a tiny drop of allergen is pricked onto the skin or injected underneath
● Blood testing – involves a single needle prick and a sample is sent to a lab
● Patch testing – the allergen is applied to a patch which is then applied to the skin

Management and Treatment

If triggers are obvious and able to be anticipated, most patients can be treated completely with over the counter (OTC) medications. Some may still need prescriptions to alleviate their allergies. Regardless, pharmacists are in an important position for helping patients select the appropriate OTC options to help manage their symptoms. Pharmacists can help patients acquire the right oral antihistamine, decongestant, intranasal steroid, or eye drop based on the symptoms present. Patients should always consult with a doctor or pharmacist before taking any OTC drug. Some common treatment options for allergies include the following:

Allergies can be a nuisance, but dealing with them shouldn’t have to be. By understanding why they occur and recognizing the common triggers, patients can make informed decisions on what action to take to treat their condition as quickly as possible. In addition, patients can also come to recognize who to seek out for help (such as pharmacists) in selecting the most effective treatment option that is available.

Midrara Kashmari

RxPharmacist Team

References:

1. Types of Allergies. Asthma & Allergy Foundation of America. https://aafa.org/allergies/types-of-allergies/.
2. Allergy Treatments | AAFA.org. Asthma & Allergy Foundation of America. https://aafa.org/allergies/allergy-treatments/.
3. Allergic Conditions. ACAAI Public Website. https://acaai.org/allergies/allergic-conditions/.
4. Types of Allergies | Mount Sinai – New York. Mount Sinai Health System. https://www.mountsinai.org/care/allergy-immunology/allergy-types.
5. Mayo Clinic Staff. Allergy medications: Know your options. Mayo Clinic. Published 2017. https://www.mayoclinic.org/diseases-conditions/allergies/in-depth/allergy-medications/art-20047403.

Pharmacy Advice for Pregnancy and Lactation

Are you taking medication? Are you pregnant? Are you pregnant AND taking medication? These are important questions to consider especially for women of childbearing age as medication use during pregnancy is quite common. Per the CDC, 9 out of 10 women take some type of medication with 7 out of 10 women taking at least one prescription medication.¹

Women who are pregnant and/or lactating experience major physiological and psychological changes that require special attention to medication and healthcare. Pharmacists are in a unique position to offer additional advice in terms of medication safety, nutritional support, and general well-being in managing acute pregnancy issues. Not only does this ensure that the mother is provided with the safest and utmost care possible, but that the health of the baby is considered in equal measure as well.

Medication Safety

For all children and adults, it is important to speak to a doctor prior to using any medication, whether it’s a prescription drug or an over the counter (OTC) drug. During pregnancy and lactation, this warning is ever more critical to remember.

Taking inappropriate medication without proper consultation with a doctor may cause some undesirable effects in certain adults who are yet otherwise healthy. Women who are pregnant and/or lactating however, are more vulnerable for experiencing harm from certain kinds of medications, as is the baby.

Drugs that are considered toxic to the developing fetus during pregnancy (i.e., result in birth defects) are known as teratogenic drugs, and pose the most risk during the first trimester. Some medications may also decrease milk production during lactation. These drugs should be discontinued before pregnancy or once a woman is determined to be pregnant and safer options should be utilized instead.

Nutritional Support- Vitamin and Mineral Supplementation

A developing baby needs an appropriate amount of nutrients. Two vital examples of important nutritional support are folic acid and calcium and vitamin D. Deficiencies in folic acid (i.e., folate) causes birth defects of the brain and spinal cord known as neural tube defects, whereas deficiencies in calcium and vitamin D can hinder the development of the skeletal system.

Folic acid: Foods rich in folic acid include green leafy vegetables, dried beans, cereals, and orange juice. The recommended dietary folate equivalent (DFE) per day is 600 mcg DFE per day during pregnancy.

Calcium and Vitamin D: During pregnancy, 1000 mg per day of calcium and 600 IU per day of vitamin D are recommended. This can either be achieved through supplements or natural sources. Some foods rich in calcium include milk, cheese, yogurt, and green leafy vegetables.6 Good natural sources for Vitamin D include sunlight, milk, and fish/salmon.⁶

Common Pregnancy Discomforts and How to Treat Them

While not an all-inclusive list of all issues experienced during pregnancy, below are some drug treatments for common discomforts. Lifestyle measures or behavioral interventions will always be first line before implementation of drug therapy. These include eating smaller, more frequent meals while avoiding spicy food for morning sickness and GERD/heartburn. Drinking more water and increasing physical activity helps with constipation. Using hot/cold packs and relaxation/stress management techniques are useful in managing pain and headaches.

Enrolling in a pregnancy registry is also encouraged to help gather information on the use of a drug during pregnancy. For each woman, the journey will be unique, therefore personalized guidance from healthcare professionals remains paramount. Through collaboration and consultation with healthcare providers, making informed choices about medications and supplements, and focusing on proper nutrition, women can embrace pregnancy with confidence and optimal health. Some helpful resources for additional information are:

● LactMed
● March of Dimes
● Mother to Baby
● InfantRisk Center
● Office on Women’s Health

Midrara Kashmari

RxPharmacist Team

References:

1. CDC. Pregnant or thinking of getting pregnant? Centers for Disease Control and Prevention. Published July 19, 2018. https://www.cdc.gov/pregnancy/meds/treatingfortwo/facts.html.
2. DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod V, L. Michael Posey. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw Hill Professional; 2023.
3. Maryland SHL PharmD Primary Care Clinical Pharmacy Specialist Kaiser Permanente Mid-Atlantic States Clinical Pharmacy Services Silver Spring. OTC Medication Use in Pregnancy and Breastfeeding. www.uspharmacist.com. https://www.uspharmacist.com/article/otc-medication-use-in-pregnancy-and-breastfeeding.
4. Jin J. Safety of Medications Used During Pregnancy. JAMA. 2022;328(5):486. doi:https://doi.org/10.1001/jama.2022.8974.
5. American College of Obstetricians and Gynecologists. Nutrition During Pregnancy. www.acog.org. Published March 2022. https://www.acog.org/womens-health/faqs/nutrition-during-pregnancy.

Understanding Evidence Based Medicine

Currently, in a rapidly evolving healthcare landscape, the world of medicine relies heavily upon facts and evidence. As a healthcare professional, making informed decisions about medications, treatments, and interventions is crucial. What role does evidence-based medicine (EBM) play into all of this? Let’s investigate.

As a pioneer in EBM, Dr. David Sackett’s most recent definition of it is: “The integration of best available evidence with clinical expertise and patient values into the decision-making process for patient care.”¹ EBM serves to provide a scientific framework for being able to ask and provide answers to clinical questions while keeping in mind the needs of the patient in different clinical settings. The components of EBM fall into three categories: best available evidence, clinical expertise, and the values and preferences of the patient.

1. (Best Available) Evidence: refers to the findings from clinical research, from the best available resource that is relevant to patient care.2 These findings can be from systematic reviews, and clinical research from experimental and observational studies. It is the gathering of research information to help inform decision-making.
2. Clinical Expertise: involves using clinical skills and experience to evaluate evidence related to the patient’s current health status.2 Pharmacists have the skills and experience related to pharmacotherapy and clinical service. They can be valuable resources in both the access and translational aspects of pharmacotherapy evidence as this is relevant to patient care.
3. Patient Values and Preferences: refer to the goals, expectations, and beliefs that patients have for decisions and their outcomes.2 The values and preferences of a patient regarding the healthcare choices they make or decide upon are based on their beliefs, attitudes, cultural, and spiritual factors. It is vital to ensure that delivery of healthcare is mindful of all these factors and that they are used as a guide when it comes to clinical decisions.

Another way to view EBM is to look at it as a course of action: you receive a question, you search for the data to help answer the question, and then you end your search by relaying the information found. This course of action, in fact, can also be outlined in the 4 steps below.²

Step 1: Ask an Appropriate and Answerable Clinical Question
○ Make sure it is properly structured and guides the evidence search
○ What is the focus of the question? What type of information are you looking for?
Step 2: Find the Evidence
○ Search published literature from relevant resources
○ PubMed or Cochrane Library
Step 3: Appraise the Evidence Found
○ Review relevant information (all evidence ≠ each other) along with internal validity
○ Per the “Hierarchy of Evidence”, systematic reviews/meta-analyses are ranked the highest, then randomized controlled trials, and then cohort studies
Step 4: Apply the Evidence to Practice
○ External validity – can the results be applied to other populations, or more specifically, the patient in question?
○ Determine if the evidence is clinically significant, statistically significant, neither, or both

Through these steps, EBM incorporates interventions that work based on the high quality of evidence found, helps encourage communication among healthcare professionals, and facilitates the skill of research and keeping up with new information. However, that is not to say it is without its challenges or limitations. Individual patient factors must always be considered which may not always be synonymous with the evidence found, nor does EBM focus on explaining how the interventions are likely to work.

Making informed decisions in improving pharmacotherapy care is most effective through the utilization of EBM. Appropriate knowledge and skill are necessary to get the most out of it. EBM’s role in healthcare is inarguable, and it will continue to make an impact for years to come.

Midrara Kashmari

RxPharmacist Team

References:

1. Chant C. Evidence-Based Pharmacy Practice? The Canadian Journal of Hospital Pharmacy. 2017;70(4). doi:https://doi.org/10.4212/cjhp.v70i4.1673.
2. Aparasu RR, Bentley JP. Principles of Research Design and Drug Literature Evaluation. Jones & Bartlett Learning; 2015.
3. The Pharmacist’s Guide to Evidence-Based Medicine for Clinical Decision Making. ASHP. https://www.ashp.org/-/media/store-files/p1770-sample-chapter-1.
4. Wagner K. Research Guides: Introduction to Evidence-Based Practice: Overview. guides.lndlibrary.org. https://guides.lndlibrary.org/c.php?g=705624&p=5011032
5. Straus SE, Glasziou P, Warren Scott Richardson, R. Brian Haynes. Evidence-Based Medicine.; 2019.

Unraveling Diabetes: Type 1 vs Type 2

Diabetes as a health condition has become so prevalent that the number of cases are reported to be the highest that they have ever been. Per CDC, ~37 million people in the United States have diabetes and 1 in 5 people don’t even know that they have diabetes.¹ Moreover, prevalence, is projected to continue to rise in the coming years reaching almost 40 million by 2030.⁶

That doesn’t mean it’s all doom and gloom. Diabetes can be managed with medication treatment, and even better, prevented or delayed with achievable lifestyle changes. But there are different kinds of diabetes, and despite the name, they’re not all the same nor are they treated in the same manner. Here we’ll focus on type 1 and type 2 diabetes, what makes them different, their symptoms, and their management.

Overview of Diabetes

Diabetes mellitus (DM) is a chronic health condition where your blood glucose, or blood sugar, is too high. Insulin is a hormone produced by the pancreas that helps to control blood glucose by allowing glucose to enter cells and provide the body with energy. By affecting insulin, the blood glucose is also affected. The body is relying on its star player in this role to keep blood glucose in check. Without insulin, blood glucose will rise, leading to health problems over time with key organs such as the heart, kidneys, eyes, and nerves being damaged. There is no cure for diabetes.

Type 1 vs Type 2

Both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) have some sort of malfunction issue with insulin, causing it to become deficient.

In T1DM, the body cannot make insulin, stops making it, or it is not making enough of it because the cells in the pancreas that produce insulin are destroyed by the body’s own immune system. The primary cause is believed to be caused by genes and/or environmental causes. It can develop in early childhood/adolescence compared to later in adulthood in people with T2DM.

In T2DM, the body cannot use the insulin despite still making it. Insulin resistance is usually the primary cause of T2DM due to physical inactivity and obesity. Because of this resistance, the body is less able to absorb glucose over time which is why this condition is slow progressing. This contrasts with T1DM where the body is not able to absorb glucose at all and the condition can develop quite suddenly.

Management of Diabetes

There is a difference between how either condition is managed. Diet, exercise, drug therapy, and weight management (weight loss is more associated with T1DM whereas weight gain is more associated with T2DM) play critical roles in controlling blood sugar.

Understanding the difference between Type 1 and Type 2 diabetes is essential for effective management and improved health outcomes. Pharmacists as healthcare professionals can provide education, guidance, and support through helping individuals navigate the challenges of these conditions and work towards better health through a combination of lifestyle changes, medication management, and blood glucose monitoring.

Midrara Kashmari

RxPharmacist Team

References:

1. Centers for Disease Control and Prevention. What Is Diabetes? Centers for Disease Control and Prevention. Published April 24, 2023. https://www.cdc.gov/diabetes/basics/diabetes.html.
2. CDC. The Facts, Stats, and Impacts of Diabetes. Centers for Disease Control and Prevention. Published 2022. https://www.cdc.gov/diabetes/library/spotlights/diabetes-facts-stats.html.
3. Differences Between Type 1 and Type 2 Diabetes – DRC. Diabetes Research Connection. Published July 11, 2016. https://diabetesresearchconnection.org/differences-type-1-type-2-diabetes/?gclid=CjwKCAjwivemBhBhEiwAJxNWN4Hy-wLZ7LNw0yqLEzbHiQ21nhpBRs_0yeq16PHSc69ZPXkZkXhoAhoC5cMQAvD_BwE.
4. Type 1 Vs Type 2 Diabetes. DRIF. https://diabetesresearch.org/type-1-vs-type-2-diabetes/.
5. NIDDK. Symptoms & Causes of Diabetes | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. Published March 2019. https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms-causes
6. Lin J, Thompson TJ, Cheng YJ, et al. Projection of the future diabetes burden in the United States through 2060. Population Health Metrics. 2018;16(1). doi:https://doi.org/10.1186/s12963-018-0166-4.

Antibiotic Resistance: A Growing Concern in the Pharmacy World

“Now remember to complete the entire course of your antibiotic until it’s finished, even if you feel better.”

How often has a patient heard this from either their doctor or pharmacist? Hopefully every time. As vital drugs, antibiotics have saved countless lives. Akin to other drugs, they can also be misused or overused. However, what sets them apart as a class of drugs is the unique threat that comes with their use: antibiotic resistance. Why is that a threat?

Understanding Antibiotic Resistance

Antibiotic resistance refers to the ability of microorganisms such as bacteria to continue to grow and ultimately defeat the very drug (antibiotic) intended to limit their growth or kill them altogether.¹ In other words, the microorganism becomes resistant to the antibiotic treatment. Eventually, resistance of the microorganism to even one drug poses a risk to other drugs in the same class. When this occurs, infections become harder and harder to treat.

Now why this occurs is because bacteria can adapt and develop resistance through natural selection by the mere presence of antibiotics. The purpose of antibiotics is to kill bacteria, regardless of if they’re the bad bacteria that cause infection or the good bacteria that protect us from infection. Killing the good bacteria would cause loss of the protection that they normally provide allowing the bad bacteria to grow. What could make this worse?

Factors Contributing to Antibiotic Resistance

1. Incomplete courses of antibiotic treatment → by not finishing the entire course, bacteria that survived become resistant and multiply or pass on their resistant genes to other surviving bacteria
2. Inappropriate prescribing of an antibiotic → using an inappropriate antibiotic drug that wouldn’t effectively treat the infection or using antibiotics when not needed allows bacteria to spread and either worsen or cause an infection
3. Overprescribing of antibiotics → increased use of antibiotics gives bacteria more chances to grow, survive, and become resistant through multiple mechanisms of current and future antibiotics

The Consequences

If antibiotic resistance develops to the point of utilizing first-line treatment options, then use of second or third-line options may become necessary. However, they are not always ideal or as effective, and prolonged drug treatment use may cause serious side effects and may lead to a delay in recovery. In addition, some patients with chronic conditions may not have a strong immune system to fight off simple infections, much less infections from resistant bacteria. In addition, it is possible that in some cases there are not any more treatment options to continue. All these aspects contribute to increased healthcare costs, decreased effectiveness of interventions, and poor health outcomes for patients.

Pharmacists and Antibiotic Stewardship

Pharmacists play a vital role in promoting responsible, appropriate, and effective antibiotic use. Some interventions performed by pharmacists involve dose adjustments, dose optimization (increasing or decreasing the dose depending on patient’s health status), drug-interactions, stop orders that are time sensitive, changing IV antibiotics to oral formulation, and removing or discontinuing duplicate antibiotic therapy.³

Antibiotic resistance is a multifaceted challenge. Pharmacists have a vital role in educating patients, promoting responsible antibiotic use, and advocating for evidence-based prescribing practices. Their knowledge and skills allow them to provide education to both patients and other healthcare providers regarding adherence, drug dosing, and proper antibiotic use. Through collaboration with providers, proper and effective antibiotic use can improve and continue for all current and future generations.

Midrara Kashmari

RxPharmacist Team

References:

1. Centers for Disease Control and Prevention. About Antimicrobial Resistance. CDC. Published March 13, 2020. https://www.cdc.gov/drugresistance/about.html.
2. Centers for Disease Control and Prevention. How Antibiotic Resistance Happens. CDC. Published October 5, 2022. https://www.cdc.gov/drugresistance/about/how-resistance-happens.html.
3. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. CDC. Published 2019. https://www.cdc.gov/antibiotic-use/core-elements/hospital.html.
4. Chan AHY, Beyene K, Tuck C, Rutter V, Ashiru-Oredope D. Pharmacist beliefs about antimicrobial resistance and impacts on antibiotic supply: a multinational survey. JAC-Antimicrobial Resistance. 2022;4(4). doi:https://doi.org/10.1093/jacamr/dlac062.

Decoding Pharmacy Informatics

In today’s world, pharmacists are no longer limited to the traditional role of dispensing prescriptions and have decided to make use of the ever-expanding potential of information technology. Pharmacy informatics continues to be a dynamic field, combining the impact of pharmacy with the force of technology to transform the way that pharmacists manage patient care, streamline operations, and improve health outcomes. Let’s delve a little bit more into this topic.

What is Pharmacy Informatics?

Pharmacy informatics is defined as the application of clinical knowledge and expertise in combination with the use of health information technology (HIT) to improve the processes of medication management and drug delivery.¹ Pharmacists who work in this field, along with their knowledge and background in pharmacotherapy and pharmacy practice, have sufficient understanding of the discipline of informatics and health information technology.²

The Pharmacist’s Role

There are 5 basic responsibilities of pharmacists who work in pharmacy informatics.³ These have been defined by the American Society of Health-System Pharmacists (ASHP) as:

1. Information Management: overseeing medication management and sharing patient information to ensure patient safety
   • Bar code medication administration
   • Computerized provider order entry (CPOE)
   • Ease of information exchange among systems
2. Knowledge delivery: provision of knowledge and patient-specific information as clinical decision support
   • Clinical guidelines
   • Patient reports and summaries
   • Alerts and reminders
   • Optimizing electronic health records (EHR) to include mandatory indications and medication adjustments where appropriate
3. Data analytics: reviewing the data and analyzing it
   • Healthcare analytics- improving quality and efficiency of healthcare operations and processes by reviewing past performances
4. Clinical informatics: promoting the integration and application of information technology in healthcare settings for easier handoff and transition of care
   • Computerized medication reconciliation
   • Smart infusion pumps
5. Change management: the development, management, and continuous improvement of clinical information systems
   • Actively managing clinical decision support interventions to keep up with current and developing treatments

The Benefits and Challenges

Multiple advantages for adopting informatics exist in the form of reduced medication errors, improved medication adherence, and increased patient involvement. It is also important to highlight that decision making is being supported with data and facts to improve health outcomes for patients and contributes to evidence-based medicine (EBM) practices. As a result of using these systems and processes, pharmacists are able to identify potential drug-drug interactions, contraindications, and allergies with greater ease, safety, and efficiency.

That’s not to say that implementing pharmacy informatics systems comes without its challenges. One challenge lies in support training for all pharmacists so that there’s consistent quality of work and knowledge of using these systems across multiple settings. Another challenge includes maintaining proper safeguard measures and data security as more data is utilized in the healthcare setting. Some of these challenges can be overcome through continued education sessions, training and workshops, collaboration with IT for technology related developments, and staying open-minded to new technological innovations.

Closing Thoughts

Pharmacy informatics will continue to mold and reshape how pharmacy is being practiced. It has the ability to empower pharmacists in providing patient care that is safer and more efficient. Being more open-minded about the use of technology can open doors to embracing the optimization of medication management delivery so that the end result is improved patient health outcomes. Pharmacy informatics has the potential to change the future of healthcare and the future of pharmacy- let’s see where it will take us.

Midrara Kashmari

RxPharmacist Team

References:

1. Cortes D, Leung J, Ryl A, Lieu J. Pharmacy Informatics: Where Medication Use and Technology Meet. The Canadian journal of hospital pharmacy. 2019;72(4):320-326. Accessed January 25, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699873/#:~:text=Pharmacy%20informaticists%20are%20pharmacists%20with.
2. ASHP Statement on the Pharmacist’s Role in Clinical Informatics. ASHP. https://www.ashp.org/-/media/assets/policy-guidelines/docs/statements/pharmacists-role-clinical-informatics.ashx.
3. Pharmacy Informatics and Its Cross-Functional Role in Healthcare. www.himss.org. Published October 29, 2019. https://www.himss.org/resources/pharmacy-informatics-and-its-cross-functional-role-healthcare.