Month: February 2018

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The Changing Role of Community Pharmacist

A recent article published in Forbes gives a possible future version of the shifting and expanding the role of Community Pharmacists. For over a decade now, Pharmacists have been trying to get provider status and recognition from the health care system and insurances for the evolving role of pharmacotherapy.

Most people still see Pharmacist as the traditional person who fills their prescriptions but in this new article in Forbes, the author envisions a larger role for the dispensing pharmacist. It states “pharmacists are in an excellent position to not only play a more primary role in treating illness, but also in preventive care. The information, or “Live Data,” that pharmacists gather while having routine human-to-human interactions” will make for better patient care.

The article also states, “Imagine a future health care system where you see your local pharmacist more than your primary care physician.” This already exists in more rural settings where access to health care close to home may not exist.
It is a very exciting time in the evolution of health care and the possibilities around the expandable role of the pharmacist.

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Diabetes Plate Method

The Diabetes Plate Method is a simple way to plan meals. Using the plate method “formula” encourages you to eat more healthy food and fewer unhealthy foods.

The Diabetes Plate Method helps you control portion sizes of starchy, carbohydrate-containing foods that have the most impact on blood glucose levels. It focuses on eating more non-starchy vegetables, which are low in carbohydrate and calories and high in vitamins, minerals, and fiber.

You can use the plate method for your specific health and nutrition goals including weight loss or maintenance, blood glucose management, and simple good nutrition. The plate method is also a useful tool for people with prediabetes and for those who simply want a healthy approach to eating.

Start by filling half your plate with non-starchy vegetables. Then fill one-quarter of your plate with whole grain or starchy foods and the remaining quarter with lean protein foods. The Diabetes Plate Method includes fruit and low-fat dairy on the side but is optional if you are trying to lose weight.

Healthful fats, which can be used in any section of the plate for food preparation or as condiments, are also key ingredients. The best part about the Diabetes Plate Method? It doesn’t require a lot of math and you can use it almost anywhere.

To create your own plate:

http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/#seven

The following healthy plate reflects the healthy fats that were omitted, thank you for the comments:

Healthy Eating Plate

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COMMON MEDICATION ERRORS AT HOME

Health care providers assume that patients will take medications as directed at home. A recent study found that the rate of out-of-hospital serious medication errors reported to U.S. poison control centers doubled between 2000 and 2012. These at-home medication errors often lead to one-third of these error cases in being hospitalized, (Nichole Hodges, Ph.D., lead author of the study and research scientist at Nationwide Children’s Hospital in Columbus, Ohio (J Clin Toxicol.).

Cardiovascular medications errors are the highest with 21% of serious adverse events, these events were associated with more serious medical complications. Additionally, cardiovascular and analgesic medications combined to account for 66% of all the deaths that occurred during the study period. The most commonly occurring errors involved patients taking or giving the wrong medication or incorrect dosage, and inadvertently taking or giving a medication twice.

The pharmacist can help ensure that patients understand how prescribed medications should be taken at home, especially for individuals who cannot read or write. Can patients or caregivers repeat back the correct dose and do they know when it should be taken or administered? How do they organize and store medications at home? Do they have a system in place for ensuring they take the right medication at the right time?

Pharmacist are easily accessible and can help the patient ensure correct medication Use

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Diabetes Action Plan

First Step:

To make any meaningful changes to your health, fitness, and diabetes you need to set goals and have positive motivation to accomplish those goals.

Goals can change the more you learn about healthy nutrition and exercise. Changing your goals means that you have a clearer idea about what you want and what’s possible. To start set small short-term goals that will help you get to long term goals. For example, set a 1-week goal, a 4-week goal, and a 6-month goal, once you set your goals to share them with family and friends, this will help you keep you on track to get to the goal.

Turn to positive motivation to reach your goals. Whenever you don’t feel like exercising, testing your blood sugar, or eating healthy food, try to remember how you feel on the days where your diabetes management is spot on, and imagine that being every day. Positive motivation can help you get to your short and long-term goals. Imagine how great you will feel when you reach your diabetes management and fitness goals, and let that be your motivation!

See the next steps: exercise and diet diabetes action plan.

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Diabetes Action Plan- Healthy Eating

This is one complex topic; many patients believe that having diabetes means you must give up your favorite foods or stop eating in restaurants.

There is no diabetic diet, only a healthy diet but you need to know that the foods you eat affect your blood sugar (also known as blood glucose).

Eating regular meals is very important, many patients mistakenly stop eating thinking that by not eating they can prevent blood sugars from going high. This is not true as your body stores sugar in the liver and when you don’t eat for prolonged periods of time it will release that sugar into the blood leading to high blood sugars. Instead, think about the amount of food you eat and make food choices to help control your diabetes and prevent other health problems.

Healthy eating should include Fiber, complex carbohydrates, protein, lots of vegetables and a limited amount of healthy fats. The three main nutrients are carbohydrates, proteins, and fats.

Carbohydrates – “Carbs” are found in all kinds of foods, including bread, pasta, fruits, dairy products and sugary foods such as desserts. “Complex” carbohydrates, such as whole-grain bread, provide more nutrition than others. Check labels for carbs and limit the amount you eat to the recommended serving.

Read food labels – Looking at food labels can give you a clue to just how healthy (or unhealthy) a food is. Look for foods with three or more grams of fiber per serving and avoid saturated and trans fats.

Measure each serving – It’s very easy to eat more food than you need or are even hungry for, without realizing it. For example, a serving of protein (such as chicken or fish) should be the size of a deck of cards.

Make an eating plan – Planning meals when you first start can help you make sure you are not overeating and that your meals are healthy.

Set goals for healthy eating – Changing your eating habits can seem overwhelming. Start with simple goals and a realistic plan to tackle them. The goals of a healthy diet plan are to prevent high or low blood sugar.

See low carb bread, the plate method, and carb counting.

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Diabetes Action Plan- Be More Active.

Make a goal to exercise or at least to be more active.

Exercise lowers blood sugars in several ways:

  • Insulin sensitivity is increased, so your muscle cells are better able to use any available insulin hormone that helps the body use sugar for energy.
  • When your muscles contract during activity, your cells are able to take up sugar and use it for energy whether insulin is available or not.

This is how exercise can help lower blood sugar in the short term. And when you are active on a regular basis, it can also lower your A1C, the A1C is a test that measures a person’s average blood sugar level over the past 2 to 3 months.

Here are some safety tips:

  • If you have never been active or haven’t been active for a while, start slowly. If you feel unsure about your health, talk to your doctor about which activities are safest for you.
  • Warm-up for 5 minutes before starting to exercise and cool down for 5 minutes after.
  • Avoid doing activity in extremely hot or cold temperatures. Choose indoor options when the weather is extreme,
  • Drink plenty of water before, during, and after activity to stay hydrated.
  • If you feel a low coming on, be ready to test for it and treat it. Always carry a source of carbohydrate Another word for sugars.
  • If exercising for an extended period (more than an hour or two), you may want to have a sports drink that provides carbohydrates.
  • Wear a medical identification bracelet, necklace, or a medical ID tag that identifies you as someone with diabetes in case of emergency.
  • Activities should be energizing but not overly difficult.
  • Take care of your feet by wearing shoes and clean socks that fit you well.
  • Carefully inspect your feet.
  • Stop doing an activity if you feel any pain, shortness of breath, or light-headedness. Talk to your doctor about any unusual symptoms that you experience.

See the ADA (American Diabetes Association) link: Walking – A Great Place to Start!

Walking – A Great Place to Start!

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Why We​ Overeat

Your brain is wired to make you eat more, first with cues such as the size of your plate, and the effects of sugar and fat on what’s known as the pleasure center of your brain. Eating is fun—especially when common foods are enhanced to tempt your taste buds. Willpower takes effort and it needs to be all day long. A study found that people who put fruit on their kitchen counter weighed 13 pounds less, on average than those who did not have visible fruit. And those with soda on the counter weighed 24 to 26 pounds more than those who had a soda-free counter.

Trick your brain into thinking you’re eating more by using an 8-inch plate. Your 3 ounces of pasta on an 8-inch plate looks like a full serving. But when it’s on a 10-inch plate, it looks like an appetizer size, so you end up adding more. A specific color that will help you not to overeat, is blue. The contrasting the color of your plate with the color of the food can lead you to eat about 30 percent more than if the plate is blue.

Food served from the stovetop encouraged people to eat 25 to 30 percent less than the same food served family-style at the table. People who ate while reading, watching TV or playing games were more likely to consume as much as 25 percent more food than if they were not distracted, according to a 2013 study published in The American Journal of Clinical Nutrition.

Creating a calming environment that encourages you to slow down and pay attention to your food can help decrease the amount of food consumed. Bright lights can push you to eat faster and eat more. Fast, loud music will prompt you to eat more food. Use calming and quiet background music, pay attention to what you’re eating.

Use tongs instead of a serving spoon. According to a 2011 study published in the journal Judgment and Decision Making, it’s harder to grab food with tongs, which means you put less on your plate. Dine with one friend, and you’ll likely consume about 35 percent more food than if you ate alone.

Your server’s appearance can influence how much you eat. If your waiter is overweight, you’re three times more likely to order dessert and alcohol than if you have an average-weight waiter. The reason? Comparing yourself to someone who is larger gives you a “license to eat. As many as 92 percents of restaurants exceeded recommended daily calories in a single meal. The average entrée plate is around 1,500 calories, and that doesn’t include the drinks, the appetizers, the sides, or the desserts.

The reason foods such as potato chips and ice cream tempt you. Humans are programmed to like sugar, fat, and salt. Our hunter-gatherer ancestors needed a lot of calories to survive, so our brains are hardwired to seek out high-calorie foods. It also doesn’t help that most of our foods and flavors have been enhanced by companies to hit this perfect balance of sugar, salt, and fat called “the bliss point”. Our foods have been modified so much many cannot and should not be call real food. While taste alone won’t cause you to overeat, high-sugar snacks might. There is evidence that foods with a lot of sugar can trigger an addictive-like pattern of eating, making you more likely to binge.

Your brain may pressure you to overeat, but you can push back.

  1. Don’t put fruits and veggies in your refrigerator’s crisper drawer. Cut them up, and place them in an easy-to-see spot in your fridge so your family is more likely to grab them.
  2. Ask your server to box up half or two-thirds of your meal before it ever touches your plate.
  3. At the grocery store, walk down the healthy aisles first.
  4. Use tall, slender glasses for beverages other than water. The tall glasses look fuller.
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The High Cost of Insulin

For the past few years, it has become very apparent that the cost of insulin is skyrocketing. The cost of insulin rose nearly 200% between 2002 and 2013, according to a new study (Expenditures and Prices of antihyperglycemic Medications in the United States: 2002-2013).

Patients who have been diabetic for decades this is the first time that they can’t afford their insulin. For Medicare patients with type 2 diabetes who fall into the “doughnut hole,” can’t afford their insulin. The newly insured patients who didn’t understand what it means to have a high deductible are struggling because they’re paying the full price. For other patients have seen their insulin copays increase to a level where they can’t even afford the copays.

The Pharmacy Benefit Managers (PBMs) get rebates from the insulin companies, so they’re the ones who control which insulin goes to the patient. It’s all based on what they can profit from with those rebates.

The insulin companies have had no choice but to increase the price of insulin so that they can at least keep their profit margin. Insulin companies try to maintain a high-profit margin and the Pharmacy Benefit Managers (PBMs) try to leverage prices in their favor but the only ones losing are the patients.

The United States has the most expensive insulin in the world. Even human insulin is expensive. It costs $2 per vial for neutral protamine Hagedorn (NPH) insulin in India, but if you go to Walgreens and pay cash, it’s $140. Lantus in India is $12 per vial, but here in the United States, it’s between $250 and $300 for the same insulin.

The ADA has spoken to all of the insulin companies in detail and has come out with a statement on the accessibility and affordability of diabetes medications (http://www.diabetes.org/newsroom/press-releases/2016/statement-on-accessibility-and-affordability-of-diabetes-medications.html).

Here other blogs/news about the high prices of insulin:

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Opioid-induced constipation (OIC)

As a Pharmacist in a primary care clinic with a family medicine residency program that is run out of our clinic, we get several drug information questions on a daily basis. Recently we received several inquiries about opioid-induced constipation and the drugs that treat it.

Patients were coming in asking for medications they had seen on TV commercials and the Residents wanted to know if there is a difference, is anyone drug better than others.

Opioids remain the most commonly used major pain-relieving medications for chronic noncancer pain.  Opioids are associated with several unwanted side effects, including feeling sleepy, respiratory depression, tolerance, nausea, vomiting, abdominal pain, and constipation. Unlike other gastrointestinal (GI) side effects constipation doesn’t get better and can interfere with pain treatment.

OIC is caused by the activation of receptors, which leads to reduced gastric, biliary, pancreatic, and intestinal secretions, increased absorption of water from bowel contents, and decreased gastric motility.

World Health Organization (WHO) guidelines for the treatment of cancer-related pain call for immediate oral administration of drugs beginning with non-opioids then move onto mild opioids such as codeine then “strong opioids such as morphine until the patient is free of pain.

To maintain patients free from pain, drugs should be given around the clock, every 3-6 hours”. The WHO notes that this approach, which focuses on administering the right drug at the right dose at the right time, is inexpensive and 80%-90% effective. Although initially developed to relieve cancer pain, the WHO “ladder of pain” has since been validated for other types of chronic pain.

Current guideline recommends daily ingestion of 25 to 30 g of dietary soluble fiber; adequate fluid ingestion (1.5-2 L daily); regular aerobic exercise (adjusted to individual physical fitness and preferences); balanced diet; regular meal pattern; and avoidance of heavy meals, fat, insoluble fiber, and flatulent foods.

Although these measures should be recommended to all patients during opioid initiation, it is unlikely that dietary and lifestyle changes alone will prevent or treat OIC.

OTC medications

  • Osmotic agents (e.g., lactulose [Rx in the U.S.], PEG 3350 [Miralax-U.S., RestoraLAX-Canada, others], sorbitol, and saline laxatives [see below]) promotes the secretion of water into the lumen of the colon and stimulate the movement of the bowel. The main side effect is diarrhea. Onset is typically from 12 to 96 hours. Glycerin suppository onset is usually within 15 to 60 minutes.
  • Fiber/Bulk agents (e.g., methylcellulose-U.S. only [Citrucel, etc], calcium polycarbophil [FiberCon-U.S., Prodiem Fibre Therapy-Canada, etc], psyllium [Metamucil, etc]) hold water in the stool, increase stool weight, increase colonic distension, and improve the frequency of bowel movements. The main side effects are bloating and cramping. Onset is typically from 12 to 72 hours.
  • Stimulant laxatives (e.g., bisacodyl [Dulcolax, etc], sennoside [Senokot, etc]) increase intestinal motility and colonic secretions. The usual onset with oral formulations is six to ten hours, possibly up to 24 hours. The onset with rectal suppositories is 15 to 60 minutes. The main side effect is cramping.
  • Stool softeners (e.g., docusate [Colace, etc]) improve the interaction of water and solid stool.
  • Saline laxatives, (a type of osmotic laxative; e.g., magnesium hydroxide, magnesium citrate, oral sodium phosphate liquid) draw water into intestines and colon by osmosis to increase motility. Major side effects are cramping dehydration and electrolyte disturbances.  Onset is 30 minutes to six hours (magnesium hydroxide) and 30 minutes to three hours (magnesium citrate, oral sodium phosphate). The onset of sodium phosphate enema (Fleet, etc) is usually within one to five minutes.

These products are available OTC and are appropriate to use in OIC therapy. The most common regimens involve the combination of a stimulant laxative, such as bisacodyl or senna, and a stool softener.

There are three types of stool softeners: surfactants, lubricants, and osmotic.

Surfactants such as docusate sodium are emulsifiers that facilitate the admixture of fat and water in the feces.

Lubricants such as mineral oil delay absorption of water from stools in the colon, thus softening the feces.

Osmotics draw water into the colon to hydrate the stools.  Bulk-forming laxatives such as psyllium should be avoided because they increase stool bulk and distend the colon, which can worsen abdominal pain and bowel obstruction when opioids prevent movement that pushes contents out of the canal.

Prescription medications

When the combination of diet, lifestyle, and OTC laxatives and stool softeners are insufficient to relieve OIC, most clinicians and patients turn to prescription medications.

Rx Therapy Cost* Indication (Adults Only) Therapeutic Considerations
Linaclotide

(Linzess [U.S.]; Constella [Canada])

 ~$12/day (U.S.)

~$4 to $6/day (Canada)

 Chronic idiopathic constipation

IBS with constipation

 Do not crush or chew; can sprinkle contents on applesauce or water (can give via nasogastric tube)

Give on an empty stomach, 30 minutes before first meal of the day

Minimal absorption, interactions unlikely

Expect improvement in week 1 for bowel symptoms; longer onset for abdominal symptoms. Keep this in mind if treatment delayed (e.g., during transitions of care).

No adjustments needed for renal or hepatic impairment

Protect from moisture; keep in original container with supplied desiccant
Lubiprostone

(Amitiza-U.S. only)

 ~$12/day Chronic idiopathic constipation

IBS (women) with constipation

Opioid-induced constipation in patients with chronic non-cancer pain

 Swallow whole, do not break or chew

No known drug interactions

Reduce dose for moderate and severe hepatic impairment

May not be effective in patients taking methadone. In vitro and preliminary data26 suggest methadone may interfere with lubiprostone’s activation of GI chloride channels.
Methylnaltrexone (Relistor) ~$55/day (oral; U.S.)

$109/12 mg (injectable, U.S.)

~$40/12 mg (injectable, Canada; oral not available in Canada)

 Opioid-induced constipation in patients with chronic non-cancer pain (U.S.) or with advanced illness, receiving palliative care
  • No known drug interactions
  • Reduce dose for moderate and severe hepatic impairment
  • Reduce oral (U.S.) and injectable dose for renal impairment
  • Adjust dose for under- or overweight
  • Stop other laxatives; can restart if needed after 3 days (U.S.)
  • May see less response in those on opioids for less than 4 weeks
  • Monitor for opioid withdrawal

Oral

  • Give on an empty stomach, at least
    30 minutes prior to the first meal

Subcutaneous Injection

  • Works within 4 hours of injection in up to 50% of patients (median 24 minutes); advise patients to stay close to the toilet
  • Give injection while seated or lying down
  • Protect from light
  • Consider stopping if no response after
    4 doses (Canada)
Naldemedine

(Symproic-U.S. only)

 ~$11/day Opioid-induced constipation in patients with chronic non-cancer pain Take with or without food

Avoid with strong CYP3A inducers and other opioid antagonists; monitor with moderate and strong CYP3A4 inhibitors and P-GP inhibitors

Avoid with severe hepatic impairment

May see less response in those on opioids for less than 4 weeks

Monitor for opioid withdrawal
Naloxegol

(Movantik)

 ~$11/day (U.S.)

~$7/day (Canada)

 Opioid-induced constipation in patients with chronic non-cancer pain Can crush tablet; mix the powder with water for oral or nasogastric tube use

Give on an empty stomach, 1 hour prior to a first meal or 2 hours after

Contraindicated with strong CYP3A4 inhibitors; avoid with moderate inhibitors (if possible) and grapefruit juice

Reduce dose for moderate to severe renal impairment, with weak CYP3A4 inhibitors (Canada), with moderate CYP3A4 inhibitors (if users can’t be avoided), or if not tolerated

Avoid with severe hepatic impairment

May see less response in those on opioids for less than 4 weeks

Stop other laxative therapy; may restart in 3 days if needed

Monitor for opioid withdrawal
Plecanatide

(Trulance-U.S. only)

 ~$12/day Chronic idiopathic constipation Swallow whole; can crush in applesauce or water (can give via nasogastric tube)

Give with or without food

Negligible absorption; no expected drug interactions

Protect from moisture; keep in the original bottle with desiccant

* Medication pricing by Elsevier, accessed November 2017 (for U.S. pricing). The cost listed is the wholesale acquisition cost (WAC) in the U.S. and Canada.

There is little published clinical evidence of the efficacy of complementary and alternative therapies in OIC or, in fact, any type of constipation. The greatest body of evidence attests to the benefits of hypnotherapy and relaxation techniques in patients with IBS. However, since IBS is strongly related to stress, it is doubtful that these approaches would have much effect on OIC, which, as noted earlier, primarily results from the specific mechanism of action of opioids.

Wenk et al evaluated the effects of baker’s yeast in an open-label study involving cancer patients upon opioid initiation, of whom were already constipated. Patients received an initial dose of 6g, doubled daily until laxation occurred. Eleven patients had bowel movements with no additional laxatives required. The authors hypothesize that brewer’s yeast triggers a fermentation process in the intestine leading to water absorption in the lumen.

Opioid-induced constipation significantly affects patients’ quality of life. Quite often, the effect is so debilitating that patients stop taking or refuse to take their medication. In effect, this means they choose pain over constipation.

When Bell et al surveyed 611 patients with non-cancer chronic pain who took opioids 2 or more days a week as well as laxatives, 81% reported constipation as a side effect of opioids and nearly all said it affected their quality of life. More than half said the effect on their quality of life was “moderate-to-great or great.” The condition also affected their activities of daily living.

To relieve their constipation, one-third reduced the dosage, skipped dosages, or stopped using their medication altogether. Of those who reduced their opioid dose or stopped taking their medication, 92% reported increased pain as a result, pain so severe it impacted their quality of life.

Opioid-induced constipation and bowel dysfunction affect up to 90% of patients who receive opioid therapy for chronic pain. Prophylactic bowel management combined with lifestyle approaches such as hydration, exercise, and regular toileting efforts may prevent OIC or reduce its severity.

If OIC occurs, stimulant laxatives combined with stool softener should be the first-line treatment. In patients who do not respond, an osmotic laxative may be added. Laxative-refractory patients may require a different opioid and/or the addition of lubiprostone or a peripherally acting opioid antagonist

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Low Carb Bread

For most of us, eating bread is part of our daily routine, for diabetes patients a healthy low carb diet seems to work best to control blood sugars. A lot of my patients’ report having a hard time finding low carbohydrate breads, a search was launched on the web to see if I could find products that are low carb but also taste good.
My first find was Diabetes Daily site, to my surprise they listed Joseph’s High Fiber Plus Pita Bread which I have tried and is not bad. Next The diet doctor site offers recipes for low carb breads that you can try. Linda’s diet delights site also mentions low carb bread alternatives, some are the same as Diabetes Daily, but she also has some that are different. Unfortunately, I have not been able to find many of the products mention but would love to hear from those of you have tried the low carb breads listed in the sites above or any of the low carb bread recipes.