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Mentorship and Networking – Beyond a Job!

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Before my graduation in 2020, I was uncertain about my career and future with pharmacy being heavily saturated and the COVID-19 pandemic hit creating an ecomonic downturn. I first came across the summer internship at RxPharmacist because I recognized the opportunities that they offered including the flexibility of a remote work role, creating my own study guide, and achieving growth in medical technical writing and growing my professional network. Now as I complete the program, I am glad to share with you this incredible experience at RxPharmacist. 

My first project was to edit the CPJE guide, which aided me passing the exam on my first attempt. Besides providing feedback on my work performance, my inspiring mentor spent time discussing with me about entrepreneurship, marketing, and my career goal. There was a heavy emphasis on strategy to approach achieving my goals of attaining my dream fellowship program. For example, knowing my interest in the pharmaceutical industry, she introduced me to experts in the field and helped me on my CV, letter of intent, and practicing with mock interviews. Thanks to her unwavering support, I got accepted into my top choice fellowship program where I would practice as a clinical development fellow in oncology at Rutgers (2021-2023). Although I was already working as a full-time pharmacist, this remote job was so flexible that it allowed me to work on my own schedule. Needless to say, beyond a job, not only the internship offered a unique opportunity to expand my networks and writing skills, but it also was a good transition for me from a graduate student to a pharmacist. I’m incredibly thankful of being able to get into my top fellowship program with the unwavering support of RxPharmacist and also was able to gain the FDA ORISE fellowship as a backup opportunity should I not be able to get my top choice through their help.

Therefore, I highly recommend this internship to anyone who seeks for professional networks and experience in medical and scientific communications. The preceptors and team are highly supportive. If your willing to work hard, learn new skills, and try something new, this might be a wonderful opportunity for you.

Thi N., 2020-2021 RxPharmacist Graduate Intern

UC San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, Class of 2020

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The Fault in Our EGFRs

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The Fault in Our Stars is a novel written by John Green. Since its release in both print and film, the moving story has managed to strangle hearts around the world as it explores many colorful yet melancholic themes of life, cancer being among them. One example is a clever nod to Shakespeare’s Julius Caesar, specifically the following line by Caddius: “The fault, dear Brutus, is not in our stars, but in ourselves, that we are underlings”. 6

Of all the literary works I’ve read and enjoyed over the years, this line is especially memorable. Caddius implies fate (or stars for that matter) is a negligible force, for it is supposedly a person’s own fault alone if their life falls short of their expectations. By titling his book The Fault in Our Stars it is clear Green disagrees, at least as it pertains to cancer and our dear protagonists in the novel.

Although cancer can certainly be acquired through environmental means such as smoking or radiation, it can also be genetic. In fact, if we want to get a little more technical, for a select group of people their undoing could specifically be a fault in their epidermal growth factor receptor or EGFR (HER1/ErbB1) gene.2 EGFR positive lung cancer is most common in people who have adenocarcinoma, never/rarely smoked, women, young adults and people of asian or east asian heritage.2 Additionally, adenocarcinoma is a subtype of non-small cell lung cancer (NSCLC) which causes nearly 80-85% of all lung cancers.4 Risk of acquiring adenocarcinoma is increased for patients who smoke, inhale second hand smoke, and are exposed to radon gas, asbestos or other cancer-causing agents in their daily lives.4

If we are dealing with an EGFR positive case of lung cancer and wish to decide on a medication, it makes sense we would attempt targeted therapy as opposed to standard chemotherapy in order to directly inhibit the EGFR receptor. Therefore, NSCLC EGFR+ patients can typically be administered EGFR inhibitors as outlined above.

I have included some other potential mutations and their therapies as a bonus. Note they all end in -nib, as they are all tyrosine kinase inhibitors (TKIs) and the bolded drugs are preferred. Medications ending in ‘-mab’ denote monoclonal antibodies which are biologic type medications as they are usually therapeutic proteins and large structures chemically. Medications ending in ‘-nib’ are usually small molecules, think of this as a car versus an airplane which are ‘-mabs’ for size.

You should anticipate a rise in biosimilar oncology medications on the market. Overall, the Food and Drug Administration (FDA) has approved 29 biosimilar medications so far, and almost all of them have a role to play in oncology therapeutics. If you are interested in a much deeper dive into oncology and many more disease state topics, check out our CPJE Study Guide. Additionally, here are some useful resources on cancer you can also reference:

References

  1. American Cancer Society. What Causes Cancer? Accessed April 17, 2021. https://www.cancer.org/cancer/cancer-causes.html.
  2. Lung Cancer Foundation of America. EGFR Mutation and Lung Cancer: What is it and how is it treated? Accessed April 17, 2021. https://lcfamerica.org/lung-cancer-info/types-lung-cancer/egfr-mutation/.
  3. American Cancer Society. What Is Lung Cancer? Accessed April 17, 2021. https://www.cancer.org/cancer/lung-cancer/about/what-is.html.
  4. Harvard Health Publishing. Adenocarcinoma of the lung. Accessed April 17, 2021. https://www.health.harvard.edu/a_to_z/adenocarcinoma-of-the-lung-a-to-z.
  5. American Cancer Society. Non-Small Cell Lung Cancer Targeted Drug Therapy: Lung Cancer Drugs. Accessed April 17, 2021. https://www.cancer.org/cancer/lung-cancer/treating-non-small-cell/targeted-therapies.html.
  6. Shakespeare W, Mowat, BA, Werstine, P. The tragedy of Julius Caesar. New York: Washington Square Press; 2005.
  7. Green, J. The Fault in Our Stars. Penguin Books; 2013.

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Five Varieties of Insulin and Why We Need Them

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An estimated 34.2 million people in the United States have some form of diabetes (⅕ of which are entirely unaware), and in the last 20 years the number of diagnosed adults has more than doubled in size.1 The significance of this disease state is paramount from a public health perspective, especially as diabetes has been identified as the number one cause of kidney failure, lower limb amputations and microvascular complications.1 You can think of diabetes as a metabolic disease which is generally broken down into four categories: type one diabetes, type two diabetes, gestational diabetes (onset during pregnancy) and prediabetes (elevated blood glucose levels which are yet to be considered entirely diagnostic of active disease).1

The following video is an excellent visual resource for understanding diabetes and its associated consequences on the human body.6 Both type one and type two diabetes cause an accumulation of glucose in the bloodstream, however, it is the etiology that differentiates them. Type one diabetics essentially experience autoimmune destruction of their pancreatic beta cells which diminishes endogenous insulin production (type one is usually diagnosed in younger people and makes up 5-10% of diabetics).1 In comparison, type two diabetics can produce insulin just fine but their body is unresponsive due to built up insulin resistance over time (type two is usually diagnosed in adults and makes up 90-95% of diabetics).1

The tricky thing about insulin is it must be injected because it is easily broken down and digested in an oral form.2 All patients with type one diabetes will be dependent on exogenous insulin for survival, and some type two diabetics may also require insulin for adequate control. There is a highly interesting concern in type two diabetes management surrounding a delay in insulin initiation, typically dubbed clinical inertia. You can read more about clinical inertia in the following literature review: Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review.

Insulins can be deadly when used inappropriately. It is important to understand and be familiar with the onset, peak and duration of insulins as seen in the figures above so an appropriate personalized regimen or adjustment can be made for each patient’s needs and goals. Generally, rapid and short acting insulins are intended for bolus purposes, whereas intermediate and long acting insulins are intended for basal purposes. We can also categorize and identify insulins via the five categories above. Note that Afrezza is inhaled as opposed to injected and can be given at the start of each meal which may be a great option if a patient is looking for something non-injectable.

As an aside, one important public health issue as it relates to insulins is actually affordability. Supposedly one in four diabetic patients cannot afford their insulin altogether.4 The issue is complex and significant enough to have its own dedicated gofundme page as for many patients insulins are a non-negotiable lifeline. You can read more about the black market dedicated to the insulin trade here, but remember there are resources for patients who need them should you ever directly encounter this issue in the community. Some patients may also obtain over the counter insulin from Walmart’s ReliOn insulin program.

References

  1. Centers for Disease Control and Prevention. What is Diabetes? Accessed April 6, 2021. https://www.cdc.gov/diabetes/basics/diabetes.html.
  2. American Diabetes Association. Insulin Basics. Accessed April 6, 2021. https://www.diabetes.org/healthy-living/medication-treatments/insulin-other-injectables/insulin-basics.
  3. Insulin and diabetes. Accessed April 6, 2021. https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/treating-your-diabetes/insulin.
  4. About Mealtime Insulin. Accessed April 6, 2021. https://www.humalog.com/fast-acting-mealtime-insulin.
  5. Teare, K. One in four patients say they’ve skimped on insulin because of high cost. Accessed April 6, 2021. https://news.yale.edu/2018/12/03/one-four-patients-say-theyve-skimped-insulin-because-high-cost.
  6. Diabetes UK. Diabetes and the body | Diabetes UK. Published September 3, 2013. Accessed April 6, 2021. https://www.youtube.com/watch?v=X9ivR4y03DE.

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Why We Can’t Be Hasty When It Comes to Drug Safety

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To be, or not to be?

When it comes to drug safety, it is up to the U.S. Food and Drug Administration (FDA) to decide if a medication may be, or not be. The Risk Evaluation and Mitigation Strategy (REMS) requirement was set up by the FDA for select prescription medications which pose a high potential for serious adverse effects. As its name suggests, the REMS program is concerned with drug safety and in ensuring the benefits of a certain drug outweigh the risk.1

REMS does not only oversee adverse effects alone, but seeks to “prevent, monitor and manage” any medication the FDA expects could potentially violate safe medication practices.1 Although the FDA is in charge of determining whether REMS must be enforced for a medication, it is the manufacturer who is in charge of the program and submission of assessment reports for quality improvement or assurance efforts.2 Appendix 4 from A Framework for Benefit-Risk Counseling to Patients About Drugs with a REMS is a tool provided by the FDA which can be useful if you ever find yourself counselling a patient on a REMS classified drug.4

Drug safety efforts and their importance in public health can be seen as early as 1937. The antibiotic sulfonamide would result in hundreds of deaths due to the toxic excipient diethylene glycol supposedly claimed as being inert, you can read more about the incident via the June 1981 issue of the FDA Consumer magazine titled “sulfonamide disaster”.3 Later in the 1960s thalidomide was used for antiemetic effects in pregnant women, but resulted in severe teratogenic adverse effects made clear when babies were born with missing or deformed extremities.3

Science Museum Group. Thalomid (thalidomide) capsules. 2000-590 Science Museum Group Collection Online. Accessed March 13, 2021. https://collection.sciencemuseumgroup.org.uk/objects/co498098/thalomid-thalidomide-capsules-thalidomide.

Science Museum Group. Pair of artificial arms for a child, Roehampton, England, 1964. 1999-579 Science Museum Group Collection Online. Accessed March 13, 2021. https://collection.sciencemuseumgroup.org.uk/objects/co476754/pair-of-artificial-arms-for-a-child-roehampton-england-1964-artificial-arm.

The difference between these two events, however, is significant from the perspective of the United States. You see, after the sulfonamide tragedy the FDA mandated the 1938 Food, Drug, and Cosmetic Act (FDCA). At this point, pharmaceutical companies were required to conduct studies proving a drug is safe before becoming readily available to the general public.3 As such, thalidomide was never approved in the United States due to data suggesting deformities in animal models despite lobbying and immense political pressure against the clinical director at the time.3 

This brief dive into history barely scratches the surface on the importance of pharmacovigilance but is helpful in understanding what can happen if we get a little too hasty when it comes to drug safety, which brings us back to REMS. You can view a list of all current REMS medications on the FDA website alongside their associated goals, materials and a comprehensive timeline of program updates. Additionally, if you want to go really deep into the U.S. regulations for REMS, visit this helpful FDA slidedeck.

References

  1. Center for Drug Evaluation, Research. Risk Evaluation and Mitigation Strategies (REMS). Accessed March 13, 2021. https://www.fda.gov/drugs/drug-safety-and-availability/risk-evaluation-and-mitigation-strategies-rems.
  2. Center for Drug Evaluation, Research. FAQs about REMS. Accessed March 13, 2021. https://www.fda.gov/drugs/risk-evaluation-and-mitigation-strategies-rems/frequently-asked-questions-faqs-about-rems.
  3. Alshammari TM. Drug safety: The concept, inception and its importance in patients’ health. Saudi Pharmaceutical Journal. 2016;24(4):405-412.
  4. A Framework for Benefit-Risk Counseling to Patients About Drugs with a REMS. U.S. Food and Drug Administration https://www.fda.gov/files/about%20fda/published/A-Framework-for-Benefit-Risk-Counseling-to-Patients-About-Drugs-with-a-REMS.pdf.
  5. Science Museum Group. Thalomid (thalidomide) capsules. 2000-590 Science Museum Group Collection Online. Accessed March 13, 2021. https://collection.sciencemuseumgroup.org.uk/objects/co498098/thalomid-thalidomide-capsules-thalidomide.
  6. Science Museum Group. Pair of artificial arms for a child, Roehampton, England, 1964. 1999-579 Science Museum Group Collection Online. Accessed March 13, 2021. https://collection.sciencemuseumgroup.org.uk/objects/co476754/pair-of-artificial-arms-for-a-child-roehampton-england-1964-artificial-arm.
  7. Science Museum Group. Pair of artificial arms for a child, Roehampton, England, 1964. 1999-579 Science Museum Group Collection Online. Accessed March 13, 2021. https://collection.sciencemuseumgroup.org.uk/objects/co476754/pair-of-artificial-arms-for-a-child-roehampton-england-1964-artificial-arm.

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Contraceptive Options for Contraindicated Patients

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In 2015-2017, it was estimated 64.9% of women in the United States between the ages of 15-49 were using some form of contraception.1 The National Survey of Family Growth (NSFG) reported female sterilization (18.6%), oral contraceptive pills (12.6%), long-acting reversible contraceptives (10.3%) and male condoms (8.7%) were the most popular and common options, however, the degree of usage for each varied largely by age.1 Although some methods of contraception are far more efficacious than others, it is important to also take into consideration other factors such as demographics, side effects, duration, reversibility, and contraindications when offering contraceptive counseling. Likewise, dual protection should always be considered to prevent risks from HIV and STIs since even highly effective methods of contraception such as Intrauterine Device (IUDs) or surgical sterilization do not protect against these infections.2

Contraceptives can be grouped into hormonal and non-hormonal categories. See the interactive diagrams above which compare typical effectiveness per contraceptive method alongside their degree of hormonal properties. Although there are many options to choose from, some patients may find themselves contraindicated for hormonal contraceptives, specifically estrogen. The CDC provides a helpful summary chart (U.S. Medical Eligibility Criteria for Contraceptive Use) which outlines a comprehensive medical eligibility criteria across four categories of severity for several potential conditions and sub conditions.3 For women who find themselves in category 3, it would be wise to consider alternative birth control methods.

Women who find themselves in category 4 are completely contraindicated, typically due to hormonal therapy associated with estrogen releasing products. Patients contraindicated to hormone birth control methods can consider the above options which either circumvent hormones altogether or rely on progestin alone. Note when considering birth control methods, it is important to tailor the best option to the patient. For example, if a patient is looking to space their children out evenly across 3 years, a Nexplanon implant might be a good option. Likewise, a patient who is no longer interested in having children may be better suited for more permanent methods such as sterilization or a long-term IUD.

References

  1. Centers for Disease Control and Prevention. Current Contraceptive Status Among Women Aged 15–49: United States, 2015–2017. Accessed March 1, 2021. https://www.cdc.gov/nchs/products/databriefs/db327.htm.
  2. Centers for Disease Control and Prevention. Contraception. Accessed March 1, 2021. https://www.cdc.gov/reproductivehealth/contraception/index.htm.
  3. Centers for Disease Control and Prevention. US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016. Accessed March 1, 2021. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html.

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Opioids and Prescribing Patterns in Pain Management

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Imagine yourself for a moment walking through your home. You make your way across a table and then suddenly you feel a sharp insurmountable degree of pain in your foot. Is it a staple? Thumbtack? Are you dying? You can be relieved to know my story ends with you simply stepping on a LEGO, although anyone who has done so would tell you it’s no fun (just check out all these memes on the internet).

Pain management is a highly fascinating and challenging area of pharmacy practice. It is typically based on subjective information which can be difficult to quantify, after all one person’s pain tolerance may be vastly different from another. Analgesics like acetaminophen or non-steroidal anti-inflammatory drugs are considered relatively safe options which usually do the trick in helping relieve pain; however, they may not be enough. Many patients with moderate to severe pain will still find themselves needing additional therapy and may therefore end up being prescribed an opioid.

There are two patterns that may arise at this point when we consider opioid management: under prescribing to the point patients might remain in pain or overprescribing to the point patients might misuse. Interestingly, there is evidence variability in opioid prescribing can be traced back to a physician’s specialty and level of training. For example, emergency medicine residents and attending physicians were found to prescribe opioids to a lesser degree as compared to non-emergency medicine providers in an acute care setting.3 Among emergency trained providers, residents were found to prescribe opioids to an even lesser degree than attendings.3

The opioid epidemic is one of the most important health crises we currently have on our hands. Here is an interesting read on how Walmart is currently being sued for supposedly fueling America’s opioid crisis. Furthermore, stigma surrounding substance abuse disorders remains as relevant as ever within our society and is often a cause for patients feeling ostracized or reluctant to seek help should they need it.4

Public health experts have since voiced concerns the current coronavirus pandemic may also further exacerbate the opioid crisis. Vital healthcare services have become interrupted or flipped virtually and this does not even take into account the already extensive degree of isolation patients may feel from their support systems at this time.5 In the figure above you will find ten common non-analgesic effects and properties of opioids, counselling patients on what they can expect from their opioid is understandably vital in making sure these medications are not only used appropriately, but also in mitigating the fear that surrounds opioids as a whole.

References

  1. Portenoy RK, Zankhana M, Ebtesam A. Prevention and management of side effects in patients receiving opioids for chronic pain. UpToDate. UpToDate; 2021. Accessed February 22, 2021.
  2. Rauenzahn S, Del Fabbro E. Opioid management of pain: the impact of the prescription opioid abuse epidemic. Curr Opin Support Palliat Care. 2014;8(3):273-278. doi:10.1097/SPC.0000000000000065.
  3. Leventhal EL, Nathanson LA, Landry AM. Variations in Opioid Prescribing Behavior by Physician Training. West J Emerg Med. 2019;20(3):428-432. doi:10.5811/westjem.2019.3.39311.
  4. National Institute on Drug Abuse. Addressing the Stigma that Surrounds Addiction. Published April 22, 2020. Accessed February 22, 2021. https://www.drugabuse.gov/about-nida/noras-blog/2020/04/addressing-stigma-surrounds-addiction.
  5. Williams B. Expert Perspective: The Opioid Crisis and COVID-19. Published January 26, 2021. Accessed February 22, 2021. https://www.psychiatryadvisor.com/home/topics/addiction/opioid-related-disorder/expert-perspective-the-opioid-crisis-and-covid-19/.

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Renal Disorders: Why Dialysis Can Help Your Kidneys “Let It Go”

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Kidneys are a good example of the saying, “you don’t know what you’ve got ‘till it’s gone”. This is primarily because most people genuinely do not know they have reached an irreversible loss of kidney function until it is too late. You may be wondering how such a drastic decline in kidney function can silently progress under the radar. To answer why and how renal dysfunction typically goes undetected, it is important to first understand what makes the kidneys unique to other aspects of the body.

Your vital organs are all special with their own unique abilities and superpowers. For example, the liver is the only organ in your body with the capacity to regenerate itself. The key quality to remember when it comes to kidneys is they like to both work together as a team. Working together may not seem as much of a superpower, but it is incredibly useful when one kidney compensates for the impaired function of the other kidney. Even alone, a single kidney’s working nephrons can also compensate for the loss or degeneration of other nephrons within the organ itself.4 The kidneys are so highly adaptable they do a stellar job of making a sinking ship look like it is sailing, but this also means trying to identify declining renal function early to prevent progression of disease can be very challenging. Many patients will find themselves in this position and although we can screen for risk factors, a decline in renal function will likely remain silent and unrecoverable.

Outlined above are the differences between acute kidney injury (AKI) and chronic kidney disease (CKD). Since kidney damage is irreversible, prevention of AKI and CKD is paramount. For renal disorders, there is no real cure as therapy is typically supportive and dependent on the etiology.1 With this in mind, you may be wondering how we can go about being more proactive towards kidney disease. Clinical surveillance is an example of an effort that serves this very cause. If we take a look at the Nephrotoxic Injury Negated by Just-in-time Action (NINJA) project, we can see a 38% decrease in AKI exposure (estimated 633 cases avoided) and a 64% decrease in AKI (398 cases avoided) due to surveillance providing a timelier approach in identifying AKI.2

Although we have medications in place to treat the secondary complications and further progression of CKD, patients who do progress to end stage renal disease will find themselves dependent on dialysis in the absence of a kidney transplant.1 So, what happens to patients who officially progress to end stage renal disease and require dialysis? Well, the good news is there are some options. Patients can decide between hemodialysis (HD) or peritoneal dialysis (PD).1 HD requires several visits a week to a HD center and may cause further decline in residual renal function as compared to PD, which may be conveniently performed at home but has a higher risk of peritonitis.1

The title of this post references Frozen because that’s exactly how dialysis works: by letting all the toxins in your body go. When your kidneys are damaged, they cannot filter out all the toxins in your body as well so waste products and fluid can accumulate to a fatal degree.3 Dialysis helps prevent this accumulation by allowing toxins to essentially move from the blood to the dialysate, thereby filtering the blood and acting in place of the kidneys.1

References

  1. DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach. New York: McGraw-Hill Medical, 2020. Print.
  2. Goldstein SL, Mottes T, Simpson K, et al. A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury. Kidney Int. 2016;90(1):212-221. doi:10.1016/j.kint.2016.03.031.
  3. Dialysis. NHS. Accessed January 25, 2021. https://www.nhs.uk/conditions/dialysis/.
  4. Fattah H, Layton A, Vallon V. How Do Kidneys Adapt to a Deficit or Loss in Nephron Number?. Physiology (Bethesda). 2019;34(3):189-197. doi:10.1152/physiol.00052.2018.
  5. Bynum W. When kidneys fail. Lancet. 2014;383(9931):1798-1799.

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Thyroid Disorders: When Your Glands Go to the Dark Side

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If you are familiar with the Star Wars franchise, you know there is a light side and a dark side of the force. These sides represent either the selfless or the selfish and essentially act to hold the galaxy together. If you consider our galactic friends and their adventures for a second, you may be able to see there is a large parallel between the galaxy and the human body. After all, the goal for all Jedi is to keep the force within balance, or in the context of the human body and for our purposes, within homeostasis.

So then, what happens when the body is no longer in homeostasis? If you go back to our simplified analogy, you’ll find it suggests some aspect within the body has pulled a Darth Vader and gone to the dark side which can predictably have devastating consequences. This Star Wars analogy is also a stellar example for the pathogenesis of cancer as a cancerous cell is in essence simply a Darth Vader cell, but we will dive further into cancer a couple weeks from now (so stay tuned).

The thyroid gland is situated at the base of the neck and plays an important role in metabolism and development within the human body.1 The thyroid is glandular in nature meaning it secretes hormones and can therefore be categorized under dysfunctions of the endocrine system. Specifically, we can identify the type of thyroid dysfunction or disease by looking a little closer at where exactly regulation goes haywire. Regulation of the thyroid occurs through the hypothalamic-pituitary-thyroid (HPT) axis.1 It is important to understand the HPT axis encompasses the hypothalamus, anterior pituitary and thyroid gland which also stores the hormones T3 (triiodothyronine) and T4 (thyroxine).1 An appropriate feedback loop for the HPT axis is illustrated below:

As annotated in the figure, the hypothalamus releases thyrotropin-releasing hormone (TRH) allowing for positive feedback to the pituitary gland. The pituitary gland then produces thyroid-stimulating hormone (TSH) allowing for positive feedback to the thyroid gland. Lastly, the thyroid gland produces T3 and T4 allowing for negative feedback on hypothalamus and pituitary gland to decrease levels of TRH + TSH so homeostasis and balance is upheld within the body.

In the context of a thyroid gland, an appropriate regulation of homeostasis like the example above would be referred to as euthyroid, meaning everything is working as it should be and the force is in balance. When the force is unbalanced, we see cases of hypothyroidism and hyperthyroidism where your glands officially go to the dark side. The good thing about thyroid dysfunction is these processes are entirely predictable if you understand what goes wrong in what part of the loop.

I hope our little galactic journey through primary thyroid disorders has been informative and helpful. Notice how in both cases of primary hyperthyroidism and primary hypothyroidism, the negative feedback loop is still trying to work, it just does not matter because there is an autoimmune issue with the gland itself. Although the negative feedback loop is still there, the process fails due to either the destruction or dysfunction of the gland itself.

References

  1. DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 11th ed. McGraw-Hill; 2020.

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Hypertension: Why You Shouldn’t Take Your Stress With a Grain of Salt

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Although an estimated ~90% of high blood pressure cases are likely to be classified under the term “primary” or “essential” hypertension, we still have a very poor understanding of the etiology as a whole. As such, primary hypertension is often labeled as idiopathic, which is medical terminology for no identifiable cause that we are aware of at this time. We do, however, have an inkling for several risk factors which are associated with the development of hypertension.

In this post, we will attempt to break them down using a mnemonic that helps tie everything together. Can you think of what might be a good mnemonic for this cause? If you thought stress, you would be correct. We’ve all experienced stress at some point in our lives. Imagine yourself in peak rush hour traffic, the time is now 7:45 AM and your final starts at 8:00 AM. Can you feel your heart racing? The point stands that stress can exacerbate blood pressure and we think it is an excellent way to outline the following known risk factors:

As you soak in all these risk factors and suggested lifestyle changes, remember to consider the following: hypertension tends to be a disease state where adherence to therapy can be particularly troublesome. This is understandable as hypertensive patients generally feel no different but may still be expected to take several classes of medications, follow up routinely, and tolerate various adverse effects of medications that can interfere with their overall quality of life. Therefore, hypertension is known as a silent killer and as with any disease state, a solid line of communication is vital to ensuring appropriate therapy and patient satisfaction.

References

  1. Hypertension. IBM Micromedex. Truven Health Analytics/IBM Watson Health; 2020. Accessed December 26, 2020. http://www.micromedexsolutions.com.
  2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324.

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A Brief Review on Dyslipidemia for Pharmacists

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  • General information:
    • Dyslipidemia is defined as a condition in which an individual has elevated cholesterol or lipids in an individual’s blood such as the following:
      • HDL: “Good” cholesterol
      • LDL: “Bad” cholesterol
      • Triglycerides (TGs)
    • LDL cholesterol can form plaques in vessels
    • HDL cholesterol helps remove LDL
    • TGs are formed in fat cells when calories are not burned right away
  • Symptoms:
    • Regarded as a silent disease in which patients are unaware of having it
  • Types and causes:
    • Primary dyslipidemia:
      • Inherited through genetics
    • Secondary dyslipidemia
      • Caused by lifestyle factors such as the following:
        • Obesity
        • Diabetes
        • Hypothyroidism
        • Alcoholism
  • Risk factors:
  • Review of lab values**:
 Total cholesterolHDL  LDLTGs
Desirable< 200> 40 (men) > 50 (women)  < 100< 150
Borderline200 – 239   130-159150-199
High  > 240     160-189  200-499  
Very high      > 190> 500

**All units are in mg/dL

  • Treatment options:
Class and Mechanism of ActionGeneric (Brand) NamesSide EffectsBlack Box WarningsContraindications
Statins: Inhibits the rate-limiting step for cholesterol synthesis by inhibiting HMG-CoA reductase   **first-line**Atorvastatin (Lipitor) Rosuvastatin (Crestor) Simvastatin (Zocor) Pravastatin (Pravachol) Pitavastatin (Livalo) Fluvastatin (Lescol) Lovastatin (Mevacor) Simvastatin + Ezetimibe (Vytorin)  Myalgia Arthralgia Myopathy Diarrhea Cognitive impairmentSkeletal muscle effects  

Hepatotoxicity (increased LFTs)		Pregnancy Breastfeeding  

Use with cyclosporine  

Active liver disease
Bile Acid Sequestrants: Inhibits absorption of bile acids into blood which ultimately aids in reducing LDL  Cholestyramine (Questran) Colesvelam (Welchol) Colestipol (Colestid)  Abdominal pain Cramping Flatulence Constipation Increased TGs Increased LFTs   Esophageal obstruction   Cholestyramine: Biliary obstruction  
Colesvelam: Bowel obstruction and TGs > 500
Fibrates: PPAR-α agonist; inhibits TG synthesis and decreases VLDLGemfibrozil (Lopid) Fenofibrate (Tricor)  Abdominal pain Dyspepsia Increased LFTs  
Upper respiratory tract infection (URTI)  		Risk of myopathy with concurrent statin use   Increased serum creatinine   CholelithiasisLiver disease Renal disease Gallbladder disease  

Use with repaglinide
PCSK-9 Inhibitors: Monoclonal antibodies that decrease LDLAlirocumab (Oraluent) Evolocumab (Repatha)Flu Cold URTI Injection site reaction   Urinary tract infection (UTI)    
2-Azetidinones: Inhibits absorption of cholesterol at the small intestineEzetimibe (Zetia)Myalgia Arthralgia Diarrhea URTI  Skeletal muscle effectsAvoid in patients with hepatic impairment
Fish Oils: Unknown mechanism of action    Omega-3 Acid (Lovaza) Icosapent Ethyl (Vascepa)Dyspepsia Flatulence Burping Increased LDLCaution in those with a fish/shellfish allergy 
Nicotinic acid/Vitamin B3: Decreases synthesis of VLDL, LDL, and TGs  Niacin (Niacor, Niaspan)Flushing Pruritis Nausea Vomiting Diarrhea Cough

Hyperglycemia Hyperuricemia  
Orthostatic hypotension  		Hepatotoxicity  

Rhabdomyolysis with concurrent statin use		Liver disease  

Arterial bleed  

Peptic ulcer disease
High-Intensity Statin Therapy (Lowers LDL on average by > 50%)Moderate-Intensity Statin Therapy (Lowers LDL on average by 30-49%)  
Atorvastatin 40-80 mg Rosuvastatin 20-40 mgAtorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin 40 mg
Pitavastatin 2-4 mg  
  • Additional notes:
    • Statins
      • Patient must contact their doctor for any muscle symptoms or dark urine
      • Simvastatin, lovastatin, and fluvastatin must be taken at bedtime
      • Avoid gemfibrozil, niacin (> 1 gram), and colchicine
      • Simvastatin and lovastatin:
        • Avoid strong CYP3A4 inhibitors such as azoles, erythromycin, clarithromycin, HIV protease inhibitors, cobicistat, nefazodone, cyclosporine, grapefruit juice
    • Bile Acid Sequestrants
      • Take with food and water (colesevelam)
      • Space out with multivitamins
        • At least 4 hours of one another
      • ACC/AHA guidelines do not recommend use if TGs are > 300
    • Fibrates
      • Can increase LDL when TGs are high
      • Patient must contact their doctor for any muscle symptoms, dark urine, abdominal pain, nausea, or vomiting
    • PCSK-9 Inhibitors
      • Store in fridge
      • Prior to administration allow for syringe to warm up to room temperature for 30-45 minutes
        • Inspect for any particles and/or color changes
      • Rotate injection sites
        • Alirocumab and evolocumab: Subcutaneous injections given in the thigh, upper arm, or abdomen (except within 2 inches from belly button)
    • 2-Azetidinones (Zetia):
      • Avoid concurrent use with gemfibrozil
      • Monitor LFTs with concurrent statin or fibrate use
      • Give 2 hours before or 4 hours after bile acid sequestrants
      • Patient must contact their doctor for any muscle symptoms or dark urine
      • Concurrent use with cyclosporine may increase levels of both drugs
    • Nicotinic acid/Vitamin B3
      • Must be taken with food
      • Monitor LFTs
      • Niaspan:
        • IR: Flushing/itching
        • ER: Less flushing than IR; take at bedtime
      • Avoid spicy food and ethanol
      • Take 4-6 hours after bile sequestrant acids
  • Treatment algorithm:
Prevention type  SituationTreatment
        Primary preventionLDL > 190 mg/dLHigh-intensity statin  
Primary preventionAge 40-75LDL 70-189 mg/dLPatients with diabetesModerate-intensity statin, unless 10-year ASCVD risk > 7.5%  
Primary preventionEvaluating 10-year clinical atherosclerotic cardiovascular disease (ASCVD) score  ASCVD risk > 7.5%: high intensity statin
 
ASCVD risk > 5% but <7.5%: moderate-intensity statin  
Secondary preventionPatients with clinical ASCVD< 75 years old: high intensity statin 
> 75 years old: moderate-intensity statin  

We hope this review helped refresh your clinical knowledge on dyslipidemia!

Best of luck,

Sam Tamjidi

RxPharmacist Team

References:

  1. Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics. http://micromedex.com/. Accessed October 30, 2020.

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