Overview

There is often negative stigma surrounding the idea of bariatric surgery as some may assume it is a shiftless intervention for weight loss in which the patient does not put effort into their weight loss goals. Therefore, some may find it interesting to learn that bariatric surgeries are vital procedures offered when all other options have been exhausted, and these procedures often require a great deal of work from the patient to maintain proper healthcare management post operation. In relation to general health and the maintenance of other comorbidities, bariatric procedures may limit the absorption of enteral products, including vitamins, minerals, and other necessary medications. Because of altering drug distribution patterns and the impact of weight reduction on chronic disease states, long-term medication regimens may need to be adjusted.

Background of Bariatric Surgeries

Body mass index (BMI) is used by the World Health Organization to classify obesity. The normal range is 18.5 to 24.9 kg/m2, overweight is 25 to 25.9 kg/m2, obese class I is 30 to 34.9 kg/m2, obese class II is 35 to 35.9 kg/m2, and obese class III is 40 to 49.9 kg/m2. There are many reasons as to why BMI may be high including lifestyle, genetics, age, medications, and other comorbidities. Obesity is a concern as the increase in fat tissue around organs can lead to dysregulation of body systems, and in attempt to address these problems, a number of therapy approaches have been developed including lifestyle changes, weight-loss drugs, and bariatric surgery. For the treatment of class III obesity, bariatric surgery is now more effective than lifestyle modifications. Between 50% and 75% of excess body weight can be lost with bariatric surgery, and some research indicates that weight maintenance can continue for up to 16 years following the procedure. 

Based on their functions, bariatric surgical techniques can be divided into three main classifications: malabsorptive, combination, and restrictive. Laparoscopic adjustable gastric banding, vertical banded gastroplasty, and sleeve gastrectomy are examples of restrictive surgeries. However, the vertical banded gastroplasty is no longer implemented because of significant complications. Roux-en-Y (RYGB) and biliopancreatic diversion with a duodenal switch are examples of combined restrictive and malabsorptive surgeries. Currently, the most popular bariatric operations carried out globally are RYGB and sleeve gastrectomy.

Source and Images: Original Artwork by Rogelio Avila. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9270090/ 

Gastric bypass patients who undergo a restrictive procedure involves separating a small pouch of their stomach from the rest of their stomach allowing them to feel fully satiated with little food. A malabsorptive procedure, where this pouch is then directly connected to the lower part of the jejunum, bypassing the whole duodenum and a part of the jejunum, causes the digestive system to absorb fewer calories, fat and nutrients.

Not all patients are candidates for bariatric surgery. Based on guidelines provided by American Society for Metabolic and Bariatric Surgery (ASMBS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), which rely on an individual’s BMI and comorbid conditions, most patients are qualified with a BMI ≥ 40 kg/m² with no comorbid conditions. A patient can qualify with a lower BMI if their health is compromised. This includes a BMI of 35-39.9 kg/m² having at least one severe obesity-related co-morbidity such as obstructive sleep apnea, MASH, or obesity-related cardiomyopathy or patients with a BMI of 30-34.9 kg/m² that suffer from metabolic syndrome or diabetes mellitus uncontrolled by medical therapy.

How Gastric Bypass May Affect Medications

• Increased gastric pH potentially influencing the solubility and/or dissolution of drugs
• The proximal small intestine is bypassed, reducing the drug transit time and potentially limiting absorption
• Substantial postoperative weight loss may reduce drug clearance of high-extraction-ratio drugs
• The volume of distribution for lipophilic medications that transfer to body fat may also be impacted by bariatric surgery (e.g. drug potency)
• Metabolic activity of certain enzymes may decrease after bariatric surgery (e.g. glucuronidation)

Examples of Some Medications Requiring Extra Attention

• Lithium: Due to decreased stomach surface area, increased gastric pH, or postoperative weight loss, lithium’s absorption and clearance can vary, which may increase the risk of lithium toxicity. Clinicians should closely evaluate serum lithium levels for the first six weeks following surgery, then every two weeks until six months afterwards, and then monthly for up to a year after surgery due to the lack of official guidelines.

• Lipophilic Medications: Bile acids serve as surfactants to increase the solubility of other medications, including lipophilic medications. The bypass procedure decreases bile acid secretion, which could result in lipophilic medications not fully dissolving and being absorbed.

• In General: Easy-to-digest medication formulations, such as liquids, oral dissolving, chewable, or immediate-release tablets, should be used post-bariatric surgery. Restarting diuretics should be handled carefully, particularly in the early postoperative period when fluid intake may be restricted. In addition, after restrictive and malabsorptive bariatric surgery, the absorption of oral contraceptives may be decreased, especially if diarrhea persists. Alternative non-oral forms of contraception should be tried.

Why Medication Safety Matters After Bariatric Surgery

Because of the associated bodily modifications and significant weight loss, bariatric surgery may have an impact on the pharmacokinetics of certain medications. Therefore, in order to obtain improved effectiveness while also preventing toxicity, it is vital to identify possible changes and adjust patients’ medication dosages.

Supplement and Lifelong Nutritional Considerations

Because of the significant risk of micronutrient deficiencies caused by decreased intake, altered digestion, and malabsorption following a gastric bypass, lifelong nutritional care is needed. In order to maintain lean mass, patients need continuous dietitian-guided care that emphasizes a sufficient protein intake (≥60 g/day, ideally ≥1.1 g/kg ideal weight/day) and regular physical activity. Since deficits in vitamin B1, B12, folate, vitamin D, calcium, iron, and zinc are common even despite normal supplementation, lifetime multivitamin and trace-element supplementation is strongly recommended. 

Immediate thiamine therapy for any patient experiencing persistent vomiting, systematic B12 supplementation with lifetime monitoring, daily vitamin D with calcium citrate when necessary to control PTH, aggressive screening and treatment of iron deficiency, particularly in menstruating women, and zinc replacement paired with copper due to competitive absorption are among the specific recommendations. To identify and treat deficiencies early and reduce risks including neuropathy, osteoporosis, anemia, and metabolic problems, routine laboratory monitoring is necessary (three times in the first year, then one or two times a year for the rest of one’s life).

Takeaway: Monitoring & Adaptation

Although bariatric surgeries can provide long-term health advantages, drug safety is a crucial aspect of long-term therapy due to physiological changes, and these must be considered when determining if treatment is appropriate for the patient. Certain medications, such as lithium, lipophilic medications, oral contraceptives, etc., require closer monitoring or alternate therapies since drug absorption, distribution, and clearance may differ significantly following surgery. In addition, maintaining general metabolic health and preventing continual micronutrient deficits need lifelong nutritional monitoring. Clinicians and patients can collaborate to maximize therapy, avoid toxicity, and ensure the positive outcomes of surgery are matched with safe and efficient medication administration by understanding how these procedures alter both nutrients and drug treatments.

Lauren T., APPE Student

References

1. Ayub S, Saboor S, Usmani S, Javed S, Tonpouwo GK, Ahmed S. Lithium toxicity following Roux-en-Y gastric bypass: Mini review and illustrative case. Ment Health Clin. 2022 Jun 10;12(3):214-218.
2. Alalwan AA, Friedman J, Alfayez O, Hartzema A. Drug absorption in bariatric surgery patients: A narrative review. Health Sci Rep. 2022 Apr 26;5(3):e605. 
3. Chacon D, Bernardino T, Geraghty F, Carrion Rodriguez A, Fiani B, Chadhaury A, Pierre-Louis M. Bariatric Surgery With Roux-En-Y Gastric Bypass or Sleeve Gastrectomy for Treatment of Obesity and Comorbidities: Current Evidence and Practice. Cureus. 2022 Jun 8;14(6):e25762.
4. Delaye, Matthieu et al. Management of Pain Medication in Patients With a History of Bariatric Surgery: A Systematic Review. Journal of Pain and Symptom Management, Volume 67, Issue 6, e859 – e868
5. D. Quilliot, M. Coupaye, C. Ciangura, S. Czernichow, A. Sallé, B. Gaborit, M. Alligier, P.-L. Nguyen-Thi, J. Dargent, S. Msika, L. Brunaud, Recommendations for nutritional care after bariatric surgery: Recommendations for best practice and SOFFCO-MM/AFERO/SFNCM/expert consensus, Journal of Visceral Surgery, Volume 158, Issue 1, 2021, Pages 51-61.
6. Heeyoung Lee, Brayden Kameg, Josua Palmer, Alice C. Cline, Pharmacokinetic Changes in Medications After Bariatric Surgery: A Scoping Review, The Journal for Nurse Practitioners, Volume 20, Issue 7, 2024.
7. Kingma JS, Burgers DMT, Monpellier VM, et al. Oral drug dosing following bariatric surgery: General concepts and specific dosing advice. Br J Clin Pharmacol. 2021; 87(12): 4560–4576.
8. Konstantinidou SK, Argyrakopoulou G, Dalamaga M, Kokkinos A. The Effects of Bariatric Surgery on Pharmacokinetics of Drugs: A Review of Current Evidence. Curr Nutr Rep. 2023 Dec;12(4):695-708. Epub 2023 Oct 20. 
9. Michael A. Edwards, Kinga Powers, R. Wesley Vosburg, Randal Zhou, Andrea Stroud, Nabeel R. Obeid, John Pilcher, Shauna Levy, Karina McArthur, Givi Basishvili, Amy Rosenbluth, Anthony Petrick, Henry Lin, Tammy Kindel, American Society for Metabolic and Bariatric Surgery: postoperative care pathway guidelines for Roux-en-Y gastric bypass, Surgery for Obesity and Related Diseases, Volume 21, Issue 5, 2025, Pages 523-536.
10. Mitchell BG, Collier SA, Gupta N. Roux-en-Y Gastric Bypass. [Updated 2024 Nov 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553157/
11. Porat D, Dahan A. Pharmacokinetics after bariatric surgery: adverse effects and drug safety issues in bariatric patients. Expert Rev Clin Pharmacol. 2025 Mar;18(3):101-108. Epub 2025 Feb 7. 

Overview

Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist. It is currently marketed under three different brand names: Ozempic®, Wegovy®, and Rybelsus®. With actions of lowering blood sugar, reducing the risk of cardiovascular disease, and suppressing appetite to facilitate weight loss, some may wonder, is this medication a solve all? Not all brand names of semaglutide have the same indications with the FDA nor the same formulations, and access due to cost differs between them. The right semaglutide formulation needs to be chosen with a full understanding of these differences to ensure the therapy selected will match the specific clinical needs of the patient and also align with the capabilities of the patient for ease of adherence to dosing instructions. With the growing patient and physician preference for GLP-1s, it is worth asking, when should it be used?

How Do Semaglutide Medications Differ?

While Ozempic, Wegovy, and Rybelsus contain the same active ingredient, their clinical characteristics differ. To better understand these differences, below are some informational tables that point out their differences with regards to their storage, dosage, FDA-approved Indications, and dosing schedules.

Choosing the Right Semaglutide for a Patient

Selecting the appropriate semaglutide product depends on the patient’s indication, preferred route of administration, comorbidities, and ability to adhere to required dosing instructions. For example, Rybelsus® is appropriate for patients who prefer an oral option and are willing to follow strict administration requirements (e.g. empty stomach).

Adverse Effects & Safety

Adverse Effects

• Gastrointestinal: The most common adverse effects of GLP-1RA therapies are gastrointestinal which include nausea, vomiting, constipation, diarrhea, and abdominal pain. In addition, decreased appetite, dysgeusia, and dyspepsia have also been reported. The majority of GLP-1RA treatment regimens reported nausea as the most frequent gastrointestinal side effect, particularly when beginning a GLP-1 or shortly following dose. To mitigate this, meal portioning can help lower the chance of this adverse effect. 

• Hypoglycemia: GLP-1 agonists can result in hypoglycemia by lowering blood glucose. When semaglutide is taken with other anti-hyperglycemic drugs such insulin, metformin, or sulfonylureas, the risk of hypoglycemia increases considerably. 

• Renal: Incidences of acute kidney injury more likely to occur in patients who had nausea, vomiting, diarrhea, or dehydration during therapy. It has been suspected to be linked with volume depletion or insufficient hydration.

• Gallbladder disorders: Semaglutide has been linked to biliary tract and gallbladder problems, such as cholecystitis and cholelithiasis. The mechanism is unclear exactly how this adverse effect occurs. 

• Risk of thyroid C-cell tumors: Animal trials using semaglutide during the early stages of drug development showed a risk of thyroid C-cell tumors. However, it is currently unknown whether semaglutide and thyroid malignancies in humans are related. People who have been diagnosed with multiple endocrine neoplasia type 2 (MEN2) syndrome or who have a personal or family history of medullary thyroid carcinoma (MTC) may be at higher risk.Other adverse reactions: Fatigue, headache, soreness at the injection site, and erythema at the injection site.

• Other adverse reactions: Fatigue, headache, soreness at the injection site, and erythema at the injection site.

Precautions/Warnings/Contraindications

• Semaglutide may affect the absorption of concurrently given oral drugs since it delays the emptying of the stomach. In research, semaglutide had no clinically significant impact on the absorption of drugs taken orally. However, when taking oral drugs along with semaglutide, caution should be used.

• To minimize the risk of transmitting infectious diseases, individuals shouldn’t share the multiple-dose injectable pen (Ozempic®).

• When using semaglutide, patients with a history of bariatric surgery are more likely to experience gastrointestinal issues. Regular monitoring in these individuals is recommended.

• Rebound weight gain has been seen with the discontinuation of GLP-1 RAs. Participants in the STEP 1 trial regained almost two-thirds of their original weight loss after stopping weekly subcutaneous semaglutide (Wegovy®) 2.4 mg and lifestyle modifications for a year.

• GLP-1 RAs are contraindicated with personal or family history of MTC or in patients with MEN2. Semaglutide is also contraindicated in patients with type 1 diabetes.

Cost Barriers

Insurance plans differ in their coverage of weight-loss drugs. Wegovy® and other prescription drugs used just for weight loss may not be covered by many insurance companies, or they may need prior authorization. Many individuals pay out of pocket monthly using manufacturer coupons, but paying high costs long-term may not be attainable. FDA-approved GLP-1 RAs such as Ozempic® and Rybelsus® may be covered by your insurance if you have T2DM.

Overall, semaglutide is available as Ozempic®, Wegovy®, and Rybelsus®, each designed for different therapeutic goals and delivered through distinct dosage forms and dosing schedules. Selecting the right formulation requires aligning the product with a patient’s clinical needs, preferred route of administration, and ability to adhere to specific instructions. While semaglutide offers significant benefits for diabetes, weight management, and cardiovascular health, it also carries important safety considerations and potential side effects that must be addressed prior to initiation. In addition, access and coverage can vary significantly, making these important factors in choosing the most appropriate therapy.

Lauren T., APPE Student

References

1. Calvarysky B, Dotan I, Shepshelovich D, Leader A, Cohen TD. Drug-Drug Interactions Between Glucagon-Like Peptide 1 Receptor Agonists and Oral Medications: A Systematic Review. Drug Saf. 2024 May;47(5):439-451.
2. Jialal I, Olatunbosun ST. Oral Semaglutide Therapy Reduces Cardiovascular Events in Patients with Type 2 Diabetes: Deciphering the Soul of the Study. J Clin Med. 2025 May 11;14(10):3335. 
3. Kommu S, Whitfield P. Semaglutide. [Updated 2024 Feb 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK603723/
4. Petralli, G., Zoppo, A.D., Rovera, C. et al. Different formulations of semaglutide and oxidative stress in subjects with type 2 diabetes and MASLD: an open-label, real-life study. Acta Diabetol 62, 1429–1437 (2025). 
5. Ryan DH, Lingvay I, Deanfield J, Kahn SE, Barros E, Burguera B, Colhoun HM, Cercato C, Dicker D, Horn DB, Hovingh GK, Jeppesen OK, Kokkinos A, Lincoff AM, Meyhöfer SM, Oral TK, Plutzky J, van Beek AP, Wilding JPH, Kushner RF. Long-term weight loss effects of semaglutide in obesity without diabetes in the SELECT trial. Nat Med. 2024 Jul;30(7):2049-2057.
6. Wilding JPH, Batterham RL, Davies M, Van Gaal LF, Kandler K, Konakli K, Lingvay I, McGowan BM, Oral TK, Rosenstock J, Wadden TA, Wharton S, Yokote K, Kushner RF; STEP 1 Study Group. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes Metab. 2022 Aug;24(8):1553-1564. 
7. Xie X, Yang S, Deng S, Liu Y, Xu Z, He B. Comparative gastrointestinal adverse effects of GLP-1 receptor agonists and multi-target analogs in type 2 diabetes: a Bayesian network meta-analysis. Front Pharmacol. 2025 Sep 19;16:1613610.

Overview

CKD is a life limiting diagnosis, and as kidney function declines, it can be the result of terminal illness. All of which to say, CKD is preventable, and the treatment regimen often targets the combination of factors that cause it, specifically HTN and T2DM. Clinical trials have shown that mineralocorticoid receptor antagonists, glucagon-like peptide 1 receptor agonists, and sodium-glucose co-transporter 2 inhibitors are beneficial in lowering adverse events in CKD, significantly increasing the options for effective treatment. These drug classes have been suggested as the four pillars of CKD, together with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. However, even in high-risk individuals, these medications are underutilized for therapy management.

Chronic Kidney Disease and its Intersection with Risk Factors

• T2DM is the primary leading cause of CKD and can serve as a predictor for kidney disease progression. Antiglycemic agents are an essential approach for lowering the risk of kidney disease irrespective of T2DM diagnosis. 

• Chronic hypertension is the second leading cause for CKD because it results in the long term increase of glomerular pressure which can damage the renal vasculature leading to the acceleration of kidney disease progression. Even mild blood pressure elevations can increase the risk of developing CKD and progressing toward ESRD. Blood pressure management in CKD patients should be considered irrespective of hypertension.
  • Per 2024 KDIGO guidelines, a standardized blood pressure of less than 120/80 mmHg is advised to lower the risk of cardiovascular disease and the onset and progression of chronic kidney disease. However, blood pressure targets should be customized based on life expectancy, frailty, and fall and fracture risk.

• AKI is becoming more widely acknowledged as a precursor to CKD. The vulnerable 7 to 90 day period following AKI when kidney function has not fully restored is known as AKD. During this timeframe, patients are at higher risk of transitioning to CKD, ESRD, cardiovascular complications, and mortality. Close monitoring is needed to ensure no further kidney damage occurs during AKD.

• T2DM, HTN, and AKI are all factors that contribute to CVD and strong indicators of CKD. As we dive into the treatment and management of CKD, it is important to recognize that optimization of these drug therapies for these indicators alone would serve as a preventative. 

Overall Prevalence in the Adult General Population

• Women are slightly more likely than men to have CKD (14.4% versus 11.8%)
• CKD affects about 20% of non-Hispanic Black adults
• CKD affects about 12% of non-Hispanic White adults
• CKD affects about 14% of non-Hispanic Asian adults
• CKD affects about 14% of Hispanic adults
• People 65 years of age or older had the highest prevalence of CKD (33.7%), followed by those 45 to 64 (12.3%), and those 18 to 44 (6.3%)

CKD: Trends in Adults with T2DM & HTN

The following charts and data below take a look at trends with respect to population and various disease states:

Source and Images: Centers for Disease Control. Available at: https://wwwn.cdc.gov/kdss/TopicHome/PrevalenceIncidence.aspx?topic=1

Without adjusting for age, sex, or other demographics (⋯ overall), the prevalence was 12.9% in 2001-2004 and 13.9% in 2017-2020. CKD was more common in women, individuals 70 years of age or older, non-Hispanic Black adults, and adults with diabetes or hypertension.

Albuminuria: Trends in Adults with T2DM & HTN

Source and Images: Centers for Disease Control. Available at: https://wwwn.cdc.gov/kdss/TopicHome/PrevalenceIncidence.aspx?topic=1

Without adjusting for age, sex, or other demographics (⋯ overall), the prevalence was 9.4% in 2001-2004 and 10.2% in 2017-2020. Albuminuria was more common in women, individuals 70 years of age or older, non-Hispanic Black adults, adults with diabetes, hypertension, and CKD Stages 4 and 5.

Note: UACR (measure of kidney damage) and eGFR (measure of renal function) are the two primary indicators of kidney disease that should be checked at least once a year in those with or at risk of CKD. The KDIGO 2024 guideline recommends repeat testing three months after the identification of an abnormal eGFR or UACR.

What are the Four Core Pillars of CKD?

RAS Inhibitors: Reduce Kidney Failure Risk

• When compared to placebo or other antihypertensive medications, ACEis or ARBs decreased the incidence of kidney failure requiring renal replacement therapy in individuals with CKD.

SGLT2 Inhibitors: Reduced CKD Progression Risk

• SGLT2 inhibitors are known to be effective in diabetes management, but studies are beginning to show that the benefits extend beyond blood glucose control. When compared to a placebo, treatment groups with SGLT2 inhibitor therapy had a 37% lower risk of kidney disease progression.

nsMRA (finerenone): Combination Therapy for UACR Reduction

• The 2024 KDIGO guidelines recommend combining finerenone with SGLT2 and RAS inhibitors. Finerenone has been demonstrated to lower composite kidney outcomes, heart failure hospitalizations, and all-cause mortality in those with CKD and T2DM. 

• The CONFIDENCE trial showed that starting empagliflozin and finerenone together resulted in significantly greater albuminuria reductions than either medication alone.
  • Combination therapy: Reduced UACR from baseline by 52%
  • Monotherapies: Finerenone or empagliflozin reduced UACR by 32% and 29%, respectively.

GLP-1 RA: Reduction in Kidney Composite Outcomes

• According to the 2024 KDIGO guidelines, individuals with T2DM and CKD who are unable to utilize metformin and a SGLT2 inhibitor or who do not achieve glycemic targets with both medications should also use a GLP-1 receptor agonist. 

• GLP-1 RAs reduce kidney composite outcomes by 21%.

The Bottom Line in CKD Management

CKD management involves a proactive and comprehensive treatment approach as incidence continues to rise. RAS inhibitors, SGLT2 inhibitors, nsMRAs, and GLP-1 RAs are the core pillars. This is a significant change in the way medical professionals manage kidney health. Blood pressure and glucose control are no longer the only ways to manage CKD; instead, these treatments are combined to delay the disease course, lower cardiovascular risk, and greatly improve long-term outcomes.

The four therapies are changing the standard of care with updated KDIGO recommendations and new evidence in support of combination therapy. In addition to refining medication regimens, pharmacists and other healthcare providers must stay up to date on these new medications in order to educate patients, detect care gaps, and promote timely screening with eGFR and UACR.

Ultimately, the best chance of influencing the course of CKD and improving quality of life for many individuals at risk is through early intervention, guideline-driven therapy, and coordinated care.

Lauren T., APPE Student

References

1. Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, Kolkhof P, Nowack C, Schloemer P, Joseph A, Filippatos G; FIDELIO-DKD Investigators. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. N Engl J Med. 2020 Dec 3;383(23):2219-2229. Epub 2020 Oct 23. 
2. Burnier, Michel and Damianaki, Aikaterini. Hypertension as Cardiovascular Risk Factor in Chronic Kidney Disease. Circulation Research, vol. 132, no. 8, 2023, pp 1050-1063. 
3. Cheng, A.Y.Y., Mottl, A. & Magwire, M. Pillar Risk-Based Treatment for Chronic Kidney Disease in People With Type 2 Diabetes: A Narrative Review. Diabetes Ther 16, 2083–2099 (2025).
4. Joana Gameiro, Beatriz Gouveia, José Agapito Fonseca, José António Lopes, The burden of acute kidney disease: an epidemiological review and importance of follow-up care, Clinical Kidney Journal, Volume 18, Issue 6, June 2025   
5. Kidney Disease Statistics for the United States – NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services, Sept. 2024, www.niddk.nih.gov/health-information/health-statistics/kidney-disease.  
6. Koh ES, Chung S. Recent Update on Acute Kidney Injury-to-Chronic Kidney Disease Transition. Yonsei Med J. 2024 May;65(5):247-256.
7. Treihaft A M, Parikh M A, Jackson K A, et al. (April 07, 2025) New Therapies for the Management of Chronic Kidney Disease. Cureus 17(4): e81824.

Skin Cancer Overview

While other types of cancers tend to receive more attention in the news, social media, or other outlets such as television commercials, the most common cancer type in the United States is skin cancer. Typically, a majority of skin cancer cases are caused by overexposure to ultraviolet (UV) light rays from the sun, tanning beds, or sunlamps. UV light in the short term is the cause of sunburn, while long-term exposure leads to damage build up, changes in skin texture, and potentially skin cancer. Currently, estimates state that roughly 1 in 5 Americans will develop skin cancer during their lifetime, and approximately 9,500 US citizens are diagnosed daily.

The average American has a 20% risk of developing skin cancer in their lifetime

Factors that Increase Skin Cancer Risk

Diving into the Skin

The skin has multiple layers, but the two main layers are the epidermis (upper and outer layer) and the dermis (lower and inner layer). 

The epidermis is composed of three different kinds of cells:

• Squamous cells: Thin, flat cells that form the top layer. Cancer that forms here is termed squamous cell carcinoma of the skin. 
• Basal cells: Round cells underneath the squamous cells. Cancer here is called basal cell carcinoma. 
• Melanocytes: Found within the lower part of the epidermis, where melanin is produced, which is the pigment that provides skin its natural color. When sun exposure is intensified, melanocytes make more pigment and cause skin tanning or darkening. Cancer in this location is called melanoma. 

The dermis consists of blood, lymph vessels, hair follicles, and glands. 

Nonmelanoma skin cancer (squamous cell carcinoma and basal cell carcinoma) sees new cases at an increasing rate year annually, and nonmelanoma skin cancer can typically be cured. Oppositely, melanoma type cancer is more likely to spread throughout the body into nearby tissues, which makes it more difficult to cure.

Image: Centers for Disease Control and Prevention (CDC). Available at: https://www.cdc.gov/skin-cancer/about/index.html

Early Skin Cancer Screening and Learning your ABCDE’s

It’s critically important to get yourself screened early for all types of cancer, of course. This is because if and when cancer is detected at an earlier stage, it is easier to treat. The earlier the detection occurs, the more likely chance that the cancer has not spread to other parts of the body. Additionally, it is crucial to remember that if a provider recommends a screening, it does not mean he/she thinks you have cancer, more so that this can be a precautionary measure. Most insurance plans will cover this service for patients at low or no cost. 

There are five key areas that are under investigation during an early screening, and the “ABCDE” acronym depicted above tries to keep this easier to remember. 

• A: Asymmetry: is one half of the area different from the other half?
• B: Border: are there any jagged edges or other irregularities on the outer ring of the mark?
• C: Color: is the mark a uniform, single color?
• D: Diameter: is the mark greater than 6 millimeters in size?
• E: Evolution: does the skin mark change at all over time (size, shape, color)?

If any of these domains are found to be concerning, a biopsy may be performed by the provider for further investigation into the skin.

Image: CDC. Available at: https://www.cdc.gov/skin-cancer/symptoms/index.html

Medication’s Role in Skin Cancer Treatment

The first line therapy for skin cancer cells is topical fluorouracil (5-FU, sold under brand names Efudex, Carac, or Tolak). It’s typically dosed every twelve hours for 3-6 weeks, up to a limit of 10-12 weeks. As a topical, patients are supposed to use enough to cover their lesions, so total application volume varies for all, but the dosing schedule stays the same. 5-FU is supported by randomized clinical trials in literature investigating patients with sun damaged skin and actinic keratosis. “The fluorouracil group had fewer actinic keratosis cases when compared with the control group at 6 months (3.0 vs. 8.1: P < 0.001) and for the overall study duration (P < 0.001). Topical 5-FU also reduced the risk of squamous cell carcinoma (SCC) requiring surgery at those sites for 1 year, but no effect was seen on basal cell carcinoma (BCC) in 1 year or on SCC or BCC over 4 years.” 

Some other interventions have been cited for use as treatment against skin cancer, with less evidence for their support. Some of the options are as follows.

Overall, it is important for physicians and pharmacists alike to be aware of the different levels of evidence supporting the use of different medications, or alternate therapies such as behavioral interventions. Additionally, it is crucial for patients to follow these safe skin practice recommendations, and if medications are prescribed to aid in these practices, it is important to adhere to the regimen to maximize potential benefits.

Collin B., APPE Student

References: 

1. CDC. Skin Cancer Basics. Skin Cancer. Published February 22, 2024. https://www.cdc.gov/skin-cancer/about/index.html
2. USCS Data Visualizations. Cdc.gov. Published 2025. https://gis.cdc.gov/Cancer/USCS/#/special-topic/demographics?datatype=1&cancer=58&indicator=value&timeperiod=1&sexes=1_2_3&races=1&ages=23&tab=2&view=chart&xaxis=sexes
3. National Cancer Institute. Skin Cancer Prevention (PDQ®)–Patient Version. National Cancer Institute. Published April 10, 2019. https://www.cancer.gov/types/skin/patient/skin-prevention-pdq
4. Skin Cancer Prevention. National Cancer Institute. Published 2012. https://www.cancer.gov/types/skin/hp/skin-prevention-pdq
5. Weinstock MA, Thwin SS, Siegel JA, et al; Veterans Affairs Keratinocyte Carcinoma Chemoprevention Trial (VAKCC) Group. Chemoprevention of Basal and Squamous Cell Carcinoma With a Single Course of Fluorouracil, 5%, Cream: A Randomized Clinical Trial. JAMA Dermatol. 2018 Feb 1;154(2):167-174. 
6. Rosenberg AR, Tabacchi M, Ngo KH, Wallendorf M, Rosman IS, Cornelius LA, Demehri S. Skin cancer precursor immunotherapy for squamous cell carcinoma prevention. JCI Insight. 2019 Mar 21;4(6).
7. American Academy of Dermatology Association. Skin Cancer. American Academy of Dermatology Association. Published April 22, 2022. https://www.aad.org/media/stats-skin-cancer

What’s Really Going on Inside the Gut?

Inside the gastrointestinal tract, there are two distinct disorders that commonly are lumped together as one, of course, referring to irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD). For most, it’s understandable to do this, as they do have some similar symptoms, but they are not the same condition. It’s uberly important to note what differences they have, because the treatments are very different and otherwise would not be managed correctly.

Irritable Bowel Syndrome Overview

IBS is a functional gastrointestinal disorder, headlining a disturbance in bowel function. It does not cause inflammation, and rarely requires hospitalization or surgery. Upon an exam of the colon, there is no sign of disease or abnormality present. With IBS, a patient does not have an increased risk for being diagnosed with colon cancer or IBD. IBS is broken up into two categories, IBS-constipation (IBS-C) and IBS-diarrhea (IBS-D). 

Symptoms can be triggered by ordinary stimuli, including foods, stress, hormonal shifts, and certain medications. Spasms can work in both ways, speeding up or slowing down gut motility, which could lead to either diarrhea or constipation. Here are some common symptoms of IBS:

Diagnosing IBS is difficult, since it’s unable to be found on a visual examination or with diagnostic procedure tools. A physician may use blood and stool tests, x-rays, endoscopies, and psychological tests to rule out any other diseases. Additional criteria for diagnosis includes having abdominal discomfort or pain for at least 12 weeks, even if non-consecutive, over the past 12 months, accompanied by at least two of the following:

It is not fully understood what the cause of IBS is, though those with IBS often have irregular colon motility patterns, meaning muscle contractions between the brain and the GI tract are working improperly.

Inflammatory Bowel Disease Overview

IBD is a chronic inflammatory disease of the GI tract, divided into Crohn’s disease (CD) and ulcerative colitis (UC). CD, resulting in transmural ulceration of any GI tract portion, most often affects the terminal ileum and colon while UC, involving diffuse inflammation, affects the rectum but may also extend into the sigmoid, beyond the sigmoid, or include the entire colon up to the cecum. Both are classified by extent and location, with CD also being categorized by phenotype: inflammatory, stricturing, or penetrating. 

IBD occurs in genetically susceptible individuals after an inappropriate immune response to the intestinal flora. Unfortunately, neither is a curable disease, and these can bring about serious morbidity risk, and a raised risk of colorectal cancer complications. A root cause, though, is not universally present in all patients. Smoking is an interesting conundrum, as it has a strong link to CD, but appears as a protectant against UC. Lastly, as far as a cause goes, the CARD15 gene has been connected to IBD, but because of its polymorphic features, it is not possible to determine which location(s) inside the GI tract will be affected. 

So, what are some signs and symptoms to look out for to diagnose a patient with IBD? Here are the most common symptoms, according to the World Gastroenterology Organization:

Image: CDC. Available at: https://www.cdc.gov/inflammatory-bowel-disease/about/crohns-disease-basics.html

IBS Treatment

Let’s look into how these two are treated. First, back to IBS. IBS treatment is targeted at symptom relief and improving overall quality of life. Split into IBS-C and IBS-D, as these have different treatments. 

To begin, describing some treatments for IBS-C include the following:

Image: Unsplash. Available at: https://unsplash.com/photos/fruit-lot-on-ceramic-plate-8manzosDSGM

Now, moving into IBS-D and the following treatments: 

For overall symptoms, there are some additional medication classes or lifestyle adjustments that can be implemented as well. Some of these options include antispasmodics, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), dietary modifications, probiotics, fecal microbiota transplant, behavioral therapies, complementary and alternative medicine (CAM). Simply put, IBS-C and IBS-D treatment comes in a multifactorial approach. They prioritize different mechanisms of action, but commonly see the opposite condition as a side effect, which can be minimized by other methods, such as taking IBS-C medications with food.

Image: Created on Google Docs

IBD Treatment

For Crohn’s Disease, the main goal of treatment is mucosal healing on endoscopy. Furthermore, treatment is based on severity level, outlined as follows.

Ulcerative Colitis (UC) treatment is centered around sustained and durable steroid-free remission, appropriate psychosocial support, normal quality of life and social functioning, prevention of morbidity including hospitalization and surgery, and lastly prevention of cancer. UC treatment options are complicated, featuring dozens of steps up in treatment depending on treatment failures, contraindications, disease severity level, etc. Treatment choices are based on the GRADED methodology per the American College of Gastroenterology (ACG). Featured drug classes include, but are not limited to:

Resealing our Divide

IBS and IBD at their core, seem very similar, though, they are not. While they share a few characteristics, it should now be more clear on where they differ, how to spot differences between the two, and why these differences are important. Both can very easily interrupt quality of life, patient comfort, trigger anxiety and depression symptoms, and much more. It’s imperative that each of these conditions are diagnosed correctly, treated appropriately with medications and lifestyle changes, monitored by providers, and follow ups are completed.

Image: CDC. Available at: https://www.cdc.gov/inflammatory-bowel-disease/about/#cdc_disease_basics_symptoms_mngmt-medication-and-managing-symptoms

Collin B., APPE Student

References: 

1. Crohn’s & Colitis Foundation. IBS vs IBD. Crohn’s & Colitis Foundation. Published 2025. https://www.crohnscolitisfoundation.org/patientsandcaregivers/what-is-ibd/ibs-vs-ibd
2. McDowell C, Farooq U, Haseeb M. Inflammatory Bowel Disease (IBD). PubMed. Published August 4, 2023. https://www.ncbi.nlm.nih.gov/books/NBK470312/
3. Tetali B, Suresh S. Management of irritable bowel syndrome: A narrative review. Translational Gastroenterology and Hepatology. 2024;9(9):26.
4. Updated 2025 ACG clinical guideline for the management of Crohn’s disease – American College of Gastroenterology. American College of Gastroenterology. Published 2025. https://gi.org/journals-publications/ebgi/zhai_dalal_sep2025/
5. The updated 2025 ACG guidelines to manage adult ulcerative colitis patients – American College of Gastroenterology. American College of Gastroenterology. Published August 20, 2025. https://gi.org/journals-publications/ebgi/alkazzi_aug2025/

As is everything in the modern world in 2025 and even leading up to 2026, technology plays an enormous role in services that consumers or patients receive in their daily lives. Think about it – you can order groceries, household toiletries, christmas gifts, clothing, etc, right to your front door all from an app or website on a cell phone or computer. On top of that, you can earn a college degree fully online, connect with friends and family over the phone across the globe, and so much more. Also, the rise of AI is opening new doors, and we’re just at the start of it. 
With that said, there have been many ways that one of the largest industries on the planet, healthcare, has been affected by technology and its advances. One of the biggest drivers has been the growth of telehealth. A 2022 study estimates that 38.8% (roughly 40%) of Americans have completed a telehealth visit within the previous year. Let’s dive into how this has happened.

40% of all Americans used telehealth in some form in a 2022 report. 

How did we get here?

Technology has evolved and enabled healthcare providers to be able to provide “telehealth”. What telehealth is at its core is simply the provision of healthcare by a health professional to a patient who is physically not in the same location as the health professional. This, on the surface, sounds basic, but it is a multi-layered dynamic between provider and patient. 

Looking into the past, one of the headlining beginnings of telemedicine in the United States was in the 1960s, when the National Aeronautics and Space Association (NASA) was monitoring astronauts in flight by physicians and medical teams during their mission Project Mercury. Teams of medical observers were positioned across 18 sites in North America, Europe, Africa, and Australia, with the task of observing by providing around the clock monitoring during travel. NASA demonstrated that using telecommunications to establish contact between providers and patients can allow for greater availability of, and access to, healthcare beyond what had previously been considered possible. After this potential was tapped into, in 1966, The U.S. National Library of Medicine designated $42 million towards multiple telemedicine projects spanning over 19 years which targeted medically isolated groups of patients, including rural, inner city, and even some suburban areas of the country. 

Teleradiology plays a significant role in neurology due to the shortage of providers, as nearly every radiology examination generates digital content. In 2014, teleradiology was reported to account for greater than half of all telemed services in the U.S. Even in psychiatry, a field that very heavily relied on in-person conversation, has been able to adapt to telemedicine methods as well. Roughly 85% of psychologists report using telehealth in some capacity within their practice scope, which is a 12-fold increase from previous reporting of only 20%. What was this drastic change in response to? You might be wondering. That would be the COVID-19 pandemic of 2020.

Image: Unsplash.com. Available at: https://unsplash.com/photos/visualization-of-the-coronavirus-causing-covid-19-rnr8D3FNUNY

Modern World

Telemedicine was such a critical part of the COVID-19 pandemic. So critical in fact, that a study looking at trends at NYU Langone Health, a hospital system in New York City, NY, showed that in-person visits declined by 80% and telemedicine visits saw a 683% increase between March 2nd and April 14th of 2020. 

A different aspect of telemedicine, can treat patients with at-home monitoring systems. Videoconferencing, medical data acquisition, sharing of collected data with physicians, web-based access to clinical data, and web access tailored to chronic conditions (diabetes, blood pressure, etc.) education. Units may be able to read glucose, monitor blood pressure, alert patients if any of their values are recorded as abnormal, and indicate whether physician contact is necessary. This at-home telehealth monitoring, especially for those with chronic diseases, has proven to be beneficial for both patients and hospitals. The Patient Protection and Affordable Care Act requires the US Centers for Medicare & Medicaid Services to penalize readmissions to hospitals that occur within 30 days after discharge. 

A study conducted by Partners Healthcare in 2014 provided in-home monitoring to over 3,000 patients with congestive heart failure (CHF). Their personal health data were recorded and uploaded daily to a monitoring system which alerted providers which patients needed attention.  Over six years of the study, hospital readmissions dropped by 44% for these patients, and the program generated savings of greater than $10 million. This is just another example of how telemedicine services benefit patients, providers, as well as lowering healthcare costs.

Image: Unsplash.com. Available at: https://unsplash.com/photos/white-and-black-digital-device-i1iqQRLULlg

Benefits versus Challenges of Telemedicine

Providers are always considering risk vs. benefit in their daily work, and it’s important to break those down here. 

To begin, the benefits of telehealth encompass the following:

Oppositely, the following displays some of the challenges seen in telehealth systems:

The benefits for both the patient and provider are evident, but with anything, these do not come without challenges and barriers to overcome. The biggest positive is access. Whether it be an elderly patient, someone from a super rural area, a single mom who cannot make it to a provider office, etc., or whatever the case may be, healthcare is only beneficial when you are able to access it! On top of that, it saves money for the healthcare system as a whole, which may not sound important, but this positively impacts all aspects of provided care down the line or at a later date, and also allows for potential improvements in the system itself as well. 

For challenges, the most important hurdle is patient information and privacy concerns. Patients are protected by HIPAA laws just as they are under regular in-person provider visits and consultations. There is concern, especially potentially with patients in older age about how they are being protected with more technological systems in place. Additionally, there are questions for the providers too, as they are the ones liable for recommendations and prescriptions. They have to ensure a patient-provider relationship, and be certain that they are comfortable with prescribing certain medications within the scope of their practice.

Provider Outlook: Regulations

It’s crucial to understand exactly how this process and service is regulated, what is allowed, and what is not. First off, it’s important to note that federal regulations generally pertain to use of telehealth in government-supported health care through the Department of Veteran Affairs and Medicare; while state laws are what govern the use of telehealth in Medicaid programs, licensing requirements for practicing telehealth within a specific state, and private insurance reimbursement for the services provided. It’s required for providers to not only follow federal regulation, but also to adhere to rules that are provided by their state jurisdictions in addition. Furthermore, states can decide where in the state it can be covered, how the service is provided/covered, what types of practitioners/providers may be reimbursed, and how reimbursement is conducted. 

All states do not operate the same, so it is necessary to be aware of the different rules of their area of practice. On top of that, if there is a situation where they are providing care to someone across state lines, be aware of those regulations as well. It sounds complex that there are multiple sets of law. Follow national first, then adhere to any state laws that are even more strict than federal. State laws are not allowed to be less stringent than federal rulings.

The Future of Telehealth

Overall, it is estimated that telehealth is saving the United States healthcare system more than $4 billion annually. So, it is not going away any time soon. It will continue to grow, making a continuous growth of healthcare access for patients all across the country. Legislation will continue to be adapted by federal and state lawmakers, protecting patients on either Medicare or through private insurance companies. Barriers will continue to be fought against, especially data/information privacy, as this is a key component of patient distrust with telehealth system operations. Back in 2000, it would have been very hard to predict what telehealth turned into in 2025 – a market with over $160 billion. That begs the question, what will it look like in 2050?

Image: Unsplash.com. Available at: https://unsplash.com/photos/latin-woman-patient-sit-on-couch-at-home-have-video-call-with-female-doctor-online-in-latin-america-IpwhZo5dhMQ

Collin B., APPE Student

References: 

1. Holčapek T, Šolc M, Šustek P. Telemedicine and the standard of care: a call for a new approach? Front Public Health. 2023 May 4;11. https://pmc.ncbi.nlm.nih.gov/articles/PMC10192621/
2. CDC. Research Anthology: Telehealth and Telemedicine. Public Health Law. Published May 13, 2024. https://www.cdc.gov/phlp/php/publications/research-anthology-telehealth-and-telemedicine.html
3. Spaulding EM, Fang M, Commodore-Mensah Y, Himmelfarb CR, Martin SS, Coresh J. Prevalence and Disparities in Telehealth Use Among US Adults Following the COVID-19 Pandemic: National Cross-Sectional Survey. J Med Internet Res. 2024 May 10;26. ​​https://pmc.ncbi.nlm.nih.gov/articles/PMC11127137/
4. Medicaid.gov. Reimbursement for Telehealth and Provider and Facility Guidelines | Medicaid. Medicaid.gov. Published 2022. https://www.medicaid.gov/medicaid/benefits/telehealth/reimbursement-for-telehealth-and-provider-and-facility-guidelines
5. Mechanic OJ, Kimball AB. Telehealth systems. National Library of Medicine. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK459384/

Overview:

The term “Acute Coronary Syndrome” or “ACS” is an umbrella term that describes cardiovascular conditions such as unstable angina (UA), non-ST-elevated myocardial infarction (NSTEMI), and ST-elevated myocardial infarction (STEMI). ACS and cardiovascular disease (CVD) are a prominent cause of death in the US. Based on 2022 data, someone in the US dies from cardiovascular disease every 34 seconds, which accounts for 2580 deaths each day.¹ Due to the high morbidity and mortality associated with ACS, prompt medical treatment is instrumental in survival for patients presenting to the hospital with myocardial infarction. This post will focus on NSTEMI and STEMI pharmacological management and the importance of the pharmacist’s role in the treatment of patients with these conditions.

STEMI/NSTEMI Pharmacotherapy

Analgesics

Patients presenting to the hospital with ACS often are experiencing a significant amount of chest pain due to the present ischemia and lack of oxygen flow to their heart. The most commonly used modes of treatment for pain in these situations are nitrates and opiates. Nitroglycerin is the first-line agent that is administered to patients presenting with chest pain and opiates are often used when the pain is not controlled with nitroglycerin.²

• Recommendation: use effective medications (nitrates and/or opiates) to manage chest pain associated with ACS.
• Nitroglycerin³
  • Dosing:
    • Oral: 0.3 mg or 0.4 mg SL every 5 minutes as needed, up to 3 doses
    • Intravenous: initiate if chest pain persists after max oral nitroglycerin
      • Initial infusion rate: 5-10 mcg/min
      • Do not exceed 400 mcg/min
  • Contraindications⁵:
    • Systolic BP <90 mmHg or ≥30 mmHg below baseline
    • Bradycardia: HR <50 bpm
    • Tachycardia: HR >100 bpm
    • Suspected or known right ventricular infarction
    • PDE5 within the last 24 hours (or 48 hours if tadalafil was used)
    • Hypertrophic cardiomyopathy
    • Severe aortic stenosis
• Morphine²
  • Dosing: 2-4 mg IV every 5-15 minutes as needed
    • Can consider doses up to 10 mg
  • Considerations
    • Reserved for use in patients whose pain is resistant to maximally tolerated nitroglycerin therapy
    • Potential to delay effects of oral PGY12 therapy

Antiplatelets

Antiplatelet therapy is an integral component of the treatment regimen for patients experiencing acute coronary events and reduces risk of death and major adverse cardiovascular events (MACE). The general mechanism by which antiplatelets work to reduce mortality in ACS events it to prevent further clotting by inhibiting platelet aggregation. This helps restore and maintain coronary blood flow and lowers the risk of recurrent ischemic events.²

• Recommendation: All patients with NSTEMI or STEMI should receive aspirin therapy and an oral PGY12 inhibitor (dual anti-platelet therapy or DAPT).
  • PGY12 choice based on clinical characteristics
• Aspirin
  • Dosing:
    • Loading: 162-325 mg PO once
    • Maintenance: 75-100 mg PO once daily
  • Considerations:
    • Loading dose should be administered as soon as possible in patients without an absolute contraindication
    • Chewable form is preferred

• PGY₁₂ Inhibitors (Oral)

Anticoagulation

Similar to antiplatelet therapy, anticoagulation therapy is a cornerstone treatment in patients experiencing ACS and further reduces risk of death and MACE. Anticoagulation therapy complements antiplatelet therapy by inhibiting the formation of fibrin; a protein in the coagulation cascade that is responsible for clot formation.²

• Recommendations:
  • Parenteral anticoagulation is recommended for all patients with NSTEMI or STEMI regardless of treatment strategy to treat the underlying cause of the infarction
  • STEMI patients treated with fibrinolytics should be continued on parenteral anticoagulation for the duration of the hospital stay (maximum of 8 days) or until revascularization

Fibrinolytics

Fibrinolytics, also known as thrombolytics, are powerful and high-risk medications that are used in STEMI, ischemic strokes, massive pulmonary embolisms and others. Fibrinolytic therapy has many risks associated with them such as major bleeding and intracranial hemorrhage. The decision to use these medications in STEMI relates to the availability for patients to have mechanical intervention within a given time frame.²

• Recommendations: Fibrinolytic therapy is indicated for ACS patients experiencing a STEMI, have a symptom onset of <12 hours, cannot receive a primary PCI within 120 minutes of first medical contact and do not have contraindications.
  • Administered in a non-PCI-capable hospital

Lipid Management

A large risk factor of infarction are high lipid levels as a high concentration of these molecules build plaques in blood vessels and increase the risk of occlusion. At the time of an ACS event, lipid management with the use of statins and other lipid lowering agents reduces the risk of recurrent ACS, stabilizes present atherosclerotic plaques, improves endothelial function, and supports secondary prevention. Lipid-lowering agents are often initiated upon hospitalization, continued indefinitely for secondary prevention, and used for long-term management.²

• Recommendations:
  • ACS patients are recommended to be initiated on high-intensity statin therapy
  • ACS patients already on maximally tolerated statin with LDL-C ≥70 mg/dL are recommended to be initiated on a non-statin lipid lowering therapy
  • ACS patients that are statin intolerant are recommended to be initiated on non-statin lipid lowering therapy
  • Lipid profile should be reassessed 4-8 weeks after hospital discharge and therapy should be adjusted as needed to achieve the targeted lipid levels
• Lipid Lowering Agents & LDL Reduction

Beta-Blockers

Beta-blockers play a crucial role in the management of ACS, and similar to lipid-lowering agents, are used both in the acute and long-term management setting post ACS event. These medications reduce the risk of reinfarction and lower early mortality by decreasing heart rate and contractility (lowers oxygen demand), decreasing blood pressure (reduces stress and ischemia), and decreases the risk for arrythmias which could lead to more issues.²

Recommendation: ACS patients are recommended to be initiated early (<24 hours) on oral beta-blocker therapy if not contraindicated.

Putting it All Together

Acute coronary events are prevalent causes of death in the US, and early and appropriate treatment is critical in ensuring patients have the best chance at survival; however, the fight does not end there. As pharmacists, we play critical roles in the treatment of patients post-ACS event. Such a role is ensuring patients are on appropriate therapy post-hospitalization to aid in preventing repeat events.

As discussed above, post-hospitalization, patients are likely to have new medications and therapy change. Common medication additions include aspirin, PGY12 inhibitors, beta-blockers, nitrates, statins, and others. It is our role as pharmacists to understand these medications, their use in a patient’s treatment plan, and, most importantly, be able to describe the importance of these medications to our patients to best be able to help prevent repeat ACS events and reduce morbidity and mortality.

Emily Heutmaker, APPE Student

References

1. Martin SS, Aday AW, Allen NB, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Bansal N, Beaton AZ, Commodore-Mensah Y, Currie ME, Elkind MSV, Fan W, Generoso G, Gibbs BB, Heard DG, Hiremath S, Johansen MC, Kazi DS, Ko D, Leppert MH, Magnani JW, Michos ED, Mussolino ME, Parikh NI, Perman SM, Rezk-Hanna M, Roth GA, Shah NS, Springer MV, St-Onge M-P, Thacker EL, Urbut SM, Van Spall HGC, Voeks JH, Whelton SP, Wong ND, Wong SS, Yaffe K, Palaniappan LP; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Committee. 2025 Heart disease and stroke statistics: a report of US and global data from the American Heart Association. Circulation. Published online January 27, 2025.
2. Rao, S. V., O’Donoghue, M. L., Ruel, M., Rab, T., Tamis-Holland, J. E., Alexander, J. H., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2024.11.009
3. Reeder, G. S., Kaski, J. C., & Dardas, T. F. (2023). Nitrates in the management of acute coronary syndrome. UpToDate. Wolters Kluwer. Available from https://www.uptodate.com/contents/nitrates-in-the-management-of-acute-coronary-syndrome?search=acute%20coronary%20syndrome&topicRef=66&source=see_link

Gender-Affirming Hormone Therapy Background

As pharmacists, we have the opportunity to experience a vast variety of patients with different cultures, social factors, and histories. In our education and practice, we have been trained to understand the science and mechanisms behind medication therapy, but our role in patient care is far-reaching reaching and extends beyond understanding complex medication regimens.

Gender-affirming hormone therapy, or GAHT, is a medically necessary treatment for many of our patients who are seeking to align their physical characteristics with their gender identity. However, access to compassionate and affirming care continues to be uneven throughout the population and healthcare system. For example, transgender individuals are often denied insurance coverage for GAHT treatment as well as experience significant barriers in access to quality healthcare.¹  In our role, we have the unique ability to help fill these gaps by supporting our patients through our pharmacological knowledge, understanding the experiences of our transgender and nonbinary patients, and most importantly, creating respectful and safe environments for all of our patients.

Throughout this post, we will examine the fundamentals of GAHT. This will include necessary distinctions between definitions used, common GAHT regimens, and how to best support your patients during an often very exciting and potentially nerve-wracking time in their transition journey.

Foundations of Gender-Affirming Hormone Therapy

Definitions

One of the first steps in understanding our patients who are seeking GAHT is to be able to distinguish the definitions used in this landscape and to use them properly. Proper use of language is essential in fostering a respectful and safe environment for our transgender and nonbinary patients. The following definition list is not comprehensive; however, a basic level of understanding of these concepts will go a long way.

Gender Identity and Related Terms

Gender-affirming hormone therapy is a pharmacological method for aligning a person’s physical characteristics with that of their gender identity and is supported by major medical organizations such as the Endocrine Society. The goal of therapy for GAHT is very individualized. Generally speaking, the goals of GAHT are to promote physical changes that align with the patient’s affirmed gender, reduction of gender dysphoria, and improve psychological well-being. The foundation of GAHT is routed in informed consent and with an emphasis on autonomy and shared decision-making between patients and medical professionals.¹

Types of Therapy

Gender-affirming hormone therapy is characterized by feminizing and masculinizing therapy. Feminizing therapy utilizes the use of estrogen and also often includes anti-androgens such as spironolactone, which promotes physical changes that are characteristically female. Some of these characteristics include breast development, redistribution of body fat, reduced body and facial hair, reduction in muscle mass, and many others. Masculinizing therapy utilizes testosterone to promote physical changes that are characteristically male. Examples of these characteristics include facial and body hair growth, increased muscle mass, voice deepening, and many others.¹

What Should Patients Expect with GAHT?

An important counseling point for patients who are beginning GAHT is the fact that the physical changes associated with the therapy often take months to years for maximal effect. For example, a transgender man who begins testosterone therapy may not see changes in their vocal pitch for 3-12 months, with the full effect around 1-2 years.¹ Of course, every patient is different, but it is incredibly important that as pharmacists we are realistic with our patients about the timeline of physical changes so our patients can be better prepared.   

Pharmacological Agents & Mechanisms

The following information describes the standard treatments for GAHT:

Feminizing Therapy

• Estrogen
  • Mechanism of action: binds to estrogen receptors which alters gene expression that drives feminizing effects, exerts negative feedback on the hypothalamus-pituitary-gonadal (HPG) axis resulting in decreased testosterone production, and competes with testosterone at receptor sites
  • Dosage forms and dosing: oral, transdermal patches and gel, parenteral
  • Dose adjustments: titrated to targeted 17-beta-estradiol levels of 100-200 pg/mL
  • Contraindications: cardiovascular disease, severe liver dysfunction, breast cancer, and VTE

• Spironolactone (anti-androgen)
  • Mechanism of action: a mineralocorticoid receptor antagonist that is a competitive inhibitor of testosterone at the androgen receptor and an inhibitor of testosterone biosynthesis
  • Dosing: 100-300 mg by mouth once daily
  • Considerations:
    • Often used in conjunction with estrogen therapy in transgender women due to further androgen suppression
    • Requires blood pressure and electrolyte monitoring

• Gonadotropin releasing hormone (GnRH) agonists
  • Mechanism of action: downregulation of GnRH receptors which suppresses gonadotropin hormone release and ultimately results in decrease in endogenous sex hormones
  • Dosing:
    • Leuprolide: 3.75-7.5 mg IM depot monthly or 11.25 mg IM depot every 3 months
    • Goserelin: 3.6 mg subQ implant monthly
  • Considerations:
    • Historically was second-line therapy due to cost, however they are becoming more popular
    • Very expensive, especially goserelin, and often not covered by insurance in the US²

Masculinizing Therapy

• Testosterone
  • Mechanism of action: binds to androgen receptors which alters gene expression that drives masculinizing effects and exerts negative feedback on the hypothalamus-pituitary-gonadal (HPG) axis resulting in decreased estrogen production
  • Dosage forms and dosing: transdermal and parenteral
  • Dose adjustments: dosing is titrated to a physiologically male serum testosterone level of 320-1000 ng/dL³

Cultural Competence, Affirming Practice, & Key Takeaways

Pharmacology aside, providing gender-affirming care extends far beyond understanding complex treatment regimens and requires a strong understanding of cultural competence. Cultural competence is the ability for someone to recognize and be able to respond to diverse values, needs, and values of individual people. In the setting of GAHT, this involves acknowledging previous healthcare experiences, not making assumptions, avoiding bias, and doing our best to tailor treatments to the patient’s experience.

A key component in delivering quality gender-affirming care is through respectful and effective communication with your patient. Ensure that you are using correct names and pronouns, and sincerely apologize if you made a mistake. Avoid assumptions about the purpose or goals of therapy, and ask open-ended questions when possible.⁴

Ultimately, as pharmacists, we have the opportunity to experience a vast variety of patients with differing cultures, social factors, and histories, and we play an important role in delivering quality and compassionate gender-affirming hormone therapy. We are often the ones who dispense a person’s first course of GAHT, so it is important that we not only know the pharmacology of the medications but also foster an environment of mutual respect and safety.

Emily Heutmaker, APPE Student

References

1. Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658
2. Deutsch, M. B. (2025). Transgender women: Evaluation and management. UpToDate. Wolters Kluwer. Available from https://www.uptodate.com/contents/transgender-women-evaluation-and-management
3. Safer, J. D. (2025). Transgender men: Evaluation and management. In J. E. Arbo (Ed.), UpToDate. Wolters Kluwer. Available from https://www.uptodate.com/contents/transgender-men-evaluation-and-management
4. Bass B, Nagy H. (2023). Cultural Competence in the Care of LGBTQ Patients. In: StatPearls. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563176/

Tobacco Background

The use of tobacco products, including electronic cigarettes (vapes/e-cigarettes), remains the leading cause of death and preventable diseases in the US. Smoking tobacco leads to many diseases including lung disease, cardiovascular disease, and many types of cancer. The smoking of combustible tobacco forms such as cigarettes, are responsible for the most tobacco-related diseases and deaths in the US.¹ Nicotine replacement therapy (NRT) is considered a first-line therapy for smoking cessation and nicotine dependence. NRT is often combined with other first-line agents such as varenicline and bupropion; however, NRT can also be used alone.³ Due to the prevalence, potential for disease burden, and difficulty in ceasing tobacco use, proper NRT pharmacotherapy is crucial for successful cessation. 

Adults who use tobacco products often have difficulties quitting due to dependence on the main addictive component of cigarettes: nicotine. Nicotine is an alkaloid that is produced in tobacco plants and can also be chemically synthesized as an additive in e-cigarettes and smokeless tobacco products. When nicotine is consumed, it diffuses into tissues and selectively binds to nicotinic cholinergic receptors that are located throughout the body. The binding of nicotine to these receptors ultimately results in a dopamine release, among other neurotransmitters, stimulating the reward pathway within the limbic system, which produces pleasure, stimulation, and mood modulation.

Long-term use tobacco products create nicotine dependence and quitting “cold turkey” can cause intense withdrawal symptoms such as increased urges, irritation, restlessness, difficulty concentrating, insomnia, increased appetite, anxiety, and depression among others. Because of this, the choice of therapy selection is crucial in increasing the chance of success in smoking cessation.²

NRT Pharmacotherapy Overview

As discussed above, the proper use of NRT greatly increases the likelihood for patient success in smoking cessation. There are many different dosage forms for NRT and choosing the one most suitable for individual patients is crucial for successful treatment. The following information examines the variety of treatment options available that can be tailored to patients based on their characteristics.

Goal of therapy: to minimize and relieve nicotine withdrawal symptoms through the use of nicotine without the use of tobacco or e-cigarettes.

Therapy Selection:

• Tailored to patient preference, accounting for contraindications and comorbidities
• Combination NRT: consists of the use of a long-acting agent (patch) and a short acting agent (lozenge, gum, nasal spray, etc.)

Nicotine Patches:

• Initial dose selection: based on how many cigarettes are smoked daily
  • >10 cigarettes/day: 21mg/day for 6 weeks (step 1), THEN 14 mg/day for 2 weeks (step 2), THEN 7 mg/day for 2 weeks (step 3)
  • ≤10 cigarettes/day: 14 mg/day for 6 weeks (step 2), THEN 7 mg/day for 2 weeks (step 3)
• Administration: remove backing and apply one patch to clean, dry, and hairless site on skin on the upper body in the morning
  • Remove the old patch prior to applicaon of a new one
  • Rotate administration sites to avoid skin irritation
• Dose titration: can increase to higher dose if experiencing withdrawal symptoms or decrease dose if experiencing side effects
• Dosage form related side effects: skin irritation, insomnia, vivid dreams
• Dose tapering: patches are marketed to be tapered over 12 weeks; however, dosing customization can be conducted with best clinical judgement

Nicotine Lozenges:

• Initial dose selection: based on how soon after waking the first cigarette is smoked and is used as needed for cravings
  • <30 minutes: begin with 4 mg lozenges
  • ≥30 minutes: begin with 2 mg lozenges
• Administration: place in mouth between gums and cheek, let dissolve over 30 minutes. Do not chew
  • Avoid acidic beverages (eg. carbonated drinks, coffee, etc.) before and during lozenge use as this reduces nicotine absorptionDo not eat or drink 15 minutes before using gum or when lozenge is in use
  • Minimize swallowing while dissolving, occasionally switch lozenge side to side in mouth
• Patient specific factors: may be better suited for patients with dentures, poor dentition, or temporomandibular joint (TMJ) disease as compared to gum formulations
• Dose titration: can increase to higher dose if still experiencing withdrawal symptoms
  • For best initial results, use at least 9 lozenges per day
• Dosage form related side effects: mouth ulcers or irritation
• Dose tapering: reduce number of lozenges used daily gradually over 6 weeks

Nicotine Gum:

• Initial dose selection: based on how soon after waking the first cigarette is smoked and is used as needed for cravings
  • <30 minutes: begin with 4 mg gum
  • ≥30 minutes: begin with 2 mg gum
• Administration: “Chew and park” – chew the gum until nicotine can be tasted (tingling sensation) then “park” gum in the side of the cheek until the taste goes away. Chew the gum again to release more nicotine. Repeat steps for 30 minutes, then spit gum out
  • Avoid acidic beverages (eg. carbonated drinks, coffee, etc.) before and during gum use as this reduces nicotine absorption
  • Do not eat or drink 15 minutes before using gum or when gum is in use
• Patient specific factors: may exacerbate TMJ, damage and/or adhere to dentures and other dental appliances
• Dose titration: can increase to higher dose if still experiencing withdrawal symptoms
  • For best initial results, use at least 9 pieces of gum per day
• Dosage form related side effects: sore jaw, mouth ulcers or irritation
  • Side effects of excess nicotine release due to over-chewing: constipation, headaches, hiccups, nausea, vomiting, abdominal pain, etc.
• Dose tapering: Use as needed and gradually reduce pieces chewed daily over 6 weeks for a minimum duration of treatment of 3 months  

Nicotine Nasal Spray

• Initial dose: 1 to 2 doses per hour, adjusted based on patient response
  • 1 dose is 1 spray per nostril (2 sprays total)
• Administration:
  • Prime pump before first use or if bottle has not been used for ≥24 hours
    • Pump bottle until fine mist appears (6-8 times usually)
    Blow nose prior to administrationSlightly tip head back, insert tip into nostril, breath through mouth and spray once into each nostrilDuring administration: do not swallow, sniff, or inhale through noseWait to blow nose until at least 2-3 minutes following administration
  • Avoid contact with mouth, eyes, and skin
• Dose titration: can increase up 5 doses per hour (10 sprays) with a maximum of 40 doses per day (80 sprays) based on patient response
  • For best initial results, use at least 8 doses (16 sprays) per day
• Dosage form related side effects: throat and nasal irritation (extremely common and limits tolerability), sneezing, tearing, and rhinitis
• Dose tapering/duration: Use beyond 6 months is not recommended, gradually reduce number of daily doses of 4-6 weeks

Duration of Therapy

As opposed to other treatments, NRT does not have a concrete recommendation for treatment duration and is very patient specific. Apart from the nasal spray, NRT can continue indefinitely as the use of NRT is safer than continued smoking. Ideally as NRT progresses, the dosage of the long-acting formulation (patch) is decreased and the dosage and frequency or short-acting formulations are gradually reduced as tolerated until NRT is no longer needed.

Key Takeaways & Tips for Success

Ensuring the appropriate initial doses of NRT is crucial in cessation success as well as proper administration techniques. Choosing the initial dose of long-acting patches based on the number of cigarettes smoked daily as well as the dosage of short-acting agents such as gum or lozenges based on first daily cigarette timing is very important in initiating proper NRT. Similarly, ensuring the patient uses enough short-acting NRT, such as a minimum of 9 pieces of gum daily, can drastically increase their chance of successfully quitting smoking.

Tobacco related complications are the leading cause of preventable disease and deaths in the US.¹ There are many potential pharmacological options for smoking cessation, with NRT being the first-line treatment.³ NRT can be tailored for individual patients for maximum efficacy and have been proven to aid in smoking cessation when initiated properly.

Emily Heutmaker, APPE Student

References

1. Centers for Disease Control and Prevention. (2024). Tobacco product use among adults — United States, 2022: 2022 National Health Interview Survey (NHIS) highlights (Publication No. OSH-NCIS-2024). U.S. Department of Health and Human Services. Available from https://www.cdc.gov/tobacco/media/pdfs/2024/09/cdc-osh-ncis-data-report-508.  
2. Sandhu A, Hosseini SA, Saadabadi A. (2023) Nicotine Replacement Therapy. In: StatPearls. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493148/
3. Rigotti, N. A. (2025). Pharmacotherapy for smoking cessation in adults. UpToDate. Wolters Kluwer. Available from https://www.uptodate.com/contents/pharmacotherapy-for-smoking-cessation-in-adults
4. UpToDate. (2025). Nicotine replacement therapy products: Drug information. Wolters Kluwer. Available from https://www.uptodate.com/contents/pharmacotherapy-for-smoking-cessation-in-adults