does tamiflu help - scriptsave wellrx blog post image

by Terra Leon, PharmD Candidate 2019

Tamiflu (oseltamivir) is a prescription medication used in the treatment of influenza in patients 2 weeks and older. It can also be indicated as prophylaxis treatment from the flu and reduce the chances of getting the flu in patients 1 year and older1.

tamiflu package-flu shot image - scriptsave wellrx blog

How does Tamiflu work?

Tamiflu (oseltamivir) is a prodrug, meaning that the drug is metabolized into the active drug after it is administered. Prodrugs are beneficial when the active drug itself has low availability in circulation and is not absorbed well in the stomach. Prodrugs are designed to not only increase the amount active drug in circulation, improve elimination but they also can reduce adverse effects or unintended side effects. Once Tamiflu is metabolized into the active drug, the active drug blocks replication of the virus in the body3. Tamiflu stops the replication process of the influenza virus in your body, it does not cure you of the flu rather it shortens the duration of flu like symptoms in the body by about 1-2 days.

Can everyone use Tamiflu?

Tamiflu (oseltamivir) is recommended in patients for treatment of influenza who are 2 weeks and older and is to be initiated within 48 hours of influenza symptom onset2. Tamiflu may also be prescribed for patients who were exposed to a confirmed flu diagnosis within 48 hours of close contact with the infected individual2. Patients who use Tamiflu >48 hours of symptom onset or exposure may still benefit from the medication, specifically children4. A study was done in children indicating that if Tamiflu was administered within 5 days of symptom onset that overall flu symptoms were reduced by 1 day when compared to placebo4.

Tamiflu side effects

The main side effects patients experience while using Tamiflu are headache, nausea and vomiting3. Please seek medical attention if you have any serious skin and hypersensitivity reaction.

Misconceptions about Tamiflu

Tamiflu will cure me of the flu

Most patients have the misconception that Tamiflu will cure them of the flu, when in reality the medication works by reducing the number of days with flu like symptoms. There is not direct cure for the flu since it is a viral entity, like the common cold. All we can do is treat our symptoms to ease the burden of the virus on the body. The most effective way to protect yourself from the flu is to receive your flu vaccination annually.

Tamiflu is a replacement for the flu shot

Tamiflu or any antiviral medication is not a replacement treatment for the flu vaccine itself. Receiving the flu vaccine is the primary defense to protect yourself from the flu. Antiviral medications are second line when the flu vaccine is not available or contraindicated for the individual4. Most insurance companies will cover the flu vaccine at little to no cost at all where Tamiflu (oseltamivir) can cost anywhere from $50-$135 depending on insurance and quantity needed5. That being said, receiving the flu vaccine protects you from the unwanted flu symptoms as well as the unwanted cost of medication, doctor office visits, and valuable time off work and school.

When I take Tamiflu I cannot get sick

There is no evidence that Tamiflu has any effect on any other illness in the body that does not contain influenza viruses, including bacterial infections. Some bacterial infections can initially present as influenza, it is important to be tested for influenza before starting Tamiflu as the sole treatment2. Always follow up with your doctor if you suspect a secondary bacterial infection in order to be treated appropriately.

Resources:

  1. “Fever, aches, chills. Check your symptoms and learn more about a prescription flu treatment.” Tamiflu.havaswwsfdev.com. 2019. 15 Jan. 2019 <https://www.tamiflu.com/>.
  2. Tamiflu Prescribing Information. 2018. 15 Jan. 2019 <https://www.gene.com/download/pdf/tamiflu_prescribing.pdf>.
  3. “Tamiflu (oseltamivir).” Facts & Comparisons. 15 Jan. 2019 <https://fco.factsandcomparisons.com/lco/action/search?q=tamiflu&t=name&va=>.
  4. “Influenza (Flu).” Centers for Disease Control and Prevention. 22 Nov. 2013. Centers for Disease Control and Prevention. 15 Jan. 2019 <https://www.cdc.gov/flu/news/flu-antiviral-benefits.htm>.
  5. “Tamiflu (oseltamivir).” ScriptSave Wellrx.  Feb 2019 https://www.wellrx.com/prescriptions/tamiflu/

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alternatives toSudafed for HBP patients - allergy image - scriptsave wellrx

by Katie Tam
PharmD Candidate Class of 2019, University of Arizona

It’s allergy season and you can’t breathe the fresh air because your nose is congested and stuffed. You visit the pharmacy and purchase a box of Sudafed. Your pharmacist asks if you have a history of high blood pressure, and you answer “yes.” The pharmacist replies that she does not recommend Sudafed for you, but why?

What you need to know about Pseudoephedrine:

Brands of common over-the counter decongestants that contain pseudoephedrine: Allegra-D, Alka Seltzer Plus Cold Medicine Liqui-Gels, Aleve Cold and Sinus Caplets, Benadryl Allergy and Sinus Tablets, Claritin-D Non-Drowsy 24 Hour Tablets, Robitussin Cold Severe Congestion Capsules, Sudafed 24 Hour Tablets, SudoGest, Wal-phed 12 hour, Suphedrine.2

Indications: nasal congestion, sinus congestion, and Eustachian tube congestion

Adverse side effects of pseudoephedrine:

  • Common: insomnia, nervousness, excitability, dizziness, and anxiety
  • Infrequent: tachycardia (rapid heart beat) or palpitations
  • Rare: dilated pupils, hallucinations, arrythmias (irregular heartbeat), high blood pressure, seizures, inflammation of the large intestine, and severe skin reactions

Contraindications for pseudoephedrine:

  • Diabetes mellitus
  • Cardiovascular disease
  • Severe or uncontrolled high blood pressure
  • Severe coronary artery disease
  • Prostatic hypertrophy
  • Hyperthyroidism
  • Closed angle glaucoma
  • Pregnant women

Pseudoephedrine and High Blood Pressure Interaction

In 2005, a study showed that pseudoephedrine increased systolic blood pressure and heart rate, but had no effect on diastolic blood pressure.1 They also found that higher doses and immediate-release formulations of pseudoephedrine were associated with higher blood pressures.1 In addition, the study revealed that patients with well controlled hypertension had higher systolic and diastolic blood pressures after taking immediate release pseudoephedrine formulations.1

What are safe alternatives to pseudoephedrine in patients with high blood pressure?

There are a few safe and effective alternatives to pseudoephedrine in patients with high blood pressure that can relieve nasal or sinus congestion symptoms. Placing a humidifier in the bedroom keeps moisture in the air, which helps prevent your nasal passages from drying out. Humidifiers can also help break up mucus and soothe inflamed nasal passageways.3 In addition, propping your head up on 2 pillows may help the mucus flow out of your nose and relieve some congestion. Saline sprays are also another safe option that can loosen congestion and improve drainage.3 If a patient with high blood pressure insists on taking a medication that includes pseudoephedrine, their pharmacist or physician will recommend the patient to monitor their blood pressure and take a sustained-release formulation to reduce the risk of increasing blood pressure.3

Next time you have sinus or nasal congestion, ask your physician before using pseudoephedrine if you have high blood pressure. Your local pharmacist can also help manage nasal congestion symptoms, provide valuable information regarding safer alternatives, and ensure optimal drug selection in patients with high blood pressure.

Resources:

  1. Salerno SM, Jackson JL, Berbano EP. Effect of Oral Pseudoephedrine on Blood Pressure and Heart Rate: A Meta-analysis. Arch Intern Med. 2005;165(15):1686–1694. doi:10.1001/archinte.165.15.1686.
  2. Radack  KDeck  CC Are oral decongestants safe in hypertension? an evaluation of the evidence and a framework for assessing clinical trials.  Ann Allergy 1986;56396- 401.
  3. High Blood Pressure and Cold Remedies: Which Are Safe? Mayo Clinic.  https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/high-blood-pressure/faq-20058281. Published January 09, 2019. Accessed January 20, 2019.

 

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shingrix on backorder - scriptsave wellrx blog image

by Katy Winkel, PharmD Candidate Class of 2019
University of Kansas School of Pharmacy

Shingrix was approved in October 2017, nearly 10 years after Shingles Zostavax came to market. Shingrix is an inactivated, 2-dose series that anyone 50 years or older is eligible to receive. With the 2-dose series you will receive the first vaccine, then 2 to 6 months later you’ll receive the second vaccine. The Shingrix series is proven to be up to 90% effective unlike Shingles Zostavax, which is only 51% effective.

Shingrix is given intramuscularly, which means it will be given in your upper arm muscle much like where the flu vaccine is given. The most common side effects from Shingrix are pain, redness, and swelling at the injection site. Also, flu-like symptoms following the vaccine are common such as muscle pain, tiredness, fever, and upset stomach.1

The pharmacy tells me it’s on “backorder.” What does that mean?

The term “backorder” in terms of pharmacy simply means that the pharmacy went to place an order on a specific item and the wholesaler, or company that sells the item, cannot fulfill the order due to shortages. The manufacturer producing Shingrix is now experiencing shipping delays for their vaccine due to the high levels of demand putting it on “backorder.”3 Unfortunately, the Centers for Disease Control and Prevention (CDC), is unsure of the exact date when Shingrix will be available again, and they predict that the manufacturer will continue to only release small amounts through 2019.2

What if I’ve already received the first dose of Shingrix and I’m past the 6-month mark for the second vaccine?

Per the CDC, once the Shingrix vaccine becomes available again you will get the second dose and do not need to restart the series. If you have not received any of the Shingrix series, but are wanting immediate vaccination, the old vaccine, Shingles Zostavax, is still available for use per the CDC. You should wait a minimum of 8 weeks after getting Shingles Zostavax before you receive Shingrix.3

While you wait….

Many pharmacies have started a waiting list for the Shingrix vaccine and prioritize customers who have already had the first dose. Also, any time you are in your local pharmacy be sure and ask if there are any updates on the availability of Shingrix. Pharmacists are here to help!

 

References:

  1. “Healthcare Providers / Professionals.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 19 Nov. 2018, www.cdc.gov/vaccines/hcp/clinical-resources/shortages.html.
  2. “Shingles Vaccine.” SHINGRIX, Apr. 2018, www.shingrix.com/index.html.
  3. “Vaccines and Preventable Diseases.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Nov. 2018, www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/faqs.html.

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by Terra Leon, PharmD Candidate 2019

With all the new diet and detoxification trends arising from celebrities and the media, it’s hard to know harmful from helpful. Activated charcoal has been portrayed as the new “magic bullet” for multiple health issues. Activated charcoal’s popularity is quickly spreading and turning up in supplements, juices, hangover remedies, face masks and even toothpaste. The media and celebrities promise it will reduce bloating, clear skin, whiten your teeth, and detox your organs for a healthier life. But does it work?

What is Activated Charcoal

Charcoal is a fine black powder made from bone char, coal, saw dust, olive pits, coconut shells or petroleum coke4. The charcoal becomes activated when it is heated at a high enough temperature the structure changes and provides a higher surface area for substances to bind to4. Activated charcoal’s oldest use is in medical practice in the Emergency Room as a treatment to detox patients who over dose on certain medications. When a patient over doses on a medication like Tylenol or Aspirin, activated charcoal is utilized to help trap toxins and gases in the gut. Since activated charcoal is not absorbed by the body it carries the toxins bound to its surface area out of your body through feces like a big drug sponge. Due to its highly negatively charged surface, activated charcoal attracts positively charged molecules for excretion, like toxins and gases but it can also have an effect on other medication and lead to lower absorption4.

Alternative Options

An alternative to activated charcoal to reduce gas and bloating, is to stick to a whole food plant-based diet, avoid products with artificial sweeteners, avoid carbonated drinks, and beer, which can release carbon dioxide gas, Also, be sure to eat and drink slowly1. Taking your time eating and drinking can help you swallow less air and reduce gas. Consult your health care provider for other alternative over-the-counter options, such as Gas-X, if natural options still don’t provide relief.

For clear skin try over the counter or prescription products that help reduce oils and clear bacteria on the skin surface. Make sure you wash your face every day and avoid high in oil foods to reduce surface oil1. Consult your healthcare professional if blemishes continue to arise.

If its whiter teeth you seek, try over the counter whitening kits that have hydrogen peroxide. Rinse your mouth after consuming coffee, soda or teas. Activated charcoal lacks published studies on being beneficial for teeth whitening. In fact, the fine black charcoal powder can potentially become embedded into cracks or small holes in the teeth producing the opposite effect1. Consult your dentist for alternative whitening procedures.

Not So Harmless?

Using activated charcoal supplement as a detoxification method is not as harmless as some may think.  Activated charcoal does not have the ability to suck out toxic chemicals from your body, its effects are limited to the GI tract3. It does not discriminate against helpful chemicals in food you consume and can remove beneficial nutrients such as Vitamin C, B6, Thiamine, Biotin and Niacin from the body3. To “detox” or cleanse the body make sure to drink plenty of water each day and eat a high in fiber diet to help naturally remove waste from the body.

Medication Interactions

Activated charcoal can reduce the absorption and interrupt the circulation of certain medications and should only be used under the supervision of a health care professional2. If you are taking any prescription medication consult your doctor before using charcoal as a supplement or any other oral ingestible form. Due to its possibility of decreasing absorption of other medication it is recommended to take activated charcoal at least 1 hour before or 2 hours after taking other drugs if approved by your doctor2.

Bottom Line

With all the new health fads and trends offering a one supplement solve all solution or “magic bullet” it is easy to get sucked into the excitement of this new trend. When it comes to activated charcoal there are no strong studies supporting these benefits and weaker studies are not supported by science. Always consult your doctor or health care professional to gain all the information you need about a new product to determine if this product will be helpful or harmful to your personal health.

References:

  1. Calderone, Julia. “Activated Charcoal Isn’t a Magic Health Bullet.” Product Reviews and Ratings – Consumer Reports, Apr. 2017, consumerreports.org/dietary-supplements/activated-charcoal-fad-not-a-magic-health-bullet/.
  2. Charcoal Oral, Facts & Comparisons, 2018, https://fco.factsandcomparisons.com/lco/action/search?q=activated%2Bcharcoal&t=name&va=activated%2Bchar.
  3. Gavura, Scott. “Activated Charcoal: The Latest Detox Fad in an Obsessive Food Culture.” Science-Based Medicine, 28 Jan. 2016, sciencebasedmedicine.org/activated-charcoal-the-latest-detox-fad-in-an-obsessive-food-culture/. https://sciencebasedmedicine.org/activated-charcoal-the-latest-detox-fad-in-an-obsessive-food-culture/
  4. Petre, Alina. “What Is Activated Charcoal Good For? Benefits and Uses.” Healthline, Healthline Media, June 2017, www.healthline.com/nutrition/activated-charcoal#section10.

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searching online for health information - scriptsave wellrx - blog image

When it comes to health information on the internet, many patients are no longer sure what to believe. Just as important, patients often don’t know how to apply what they have read. Healthcare providers have the opportunity to help patients navigate through the vast variety of online health information.

Take the Practice Trends Today quiz (here) from the American Pharmacists Association (APhA) to learn more about helping patients understand the results of their online healthcare searches.

Click Here to take the quiz.


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drug recalls - patient guide - scriptsave wellrx - blog image

by Jenny Bingham, PharmD, BCACP
SinfoníaRx

Have you ever experienced the unsettling feeling when you hear a drug recall announcement for a prescription that you take every day? The United States Food & Drug Administration (FDA) recalled over seven different products in December 2018 due to impurities, mislabeling, or performance defects. The FDA works closely with drug manufacturers to recall and remove any defective medications from the consumer market.  They also have laws that require organizations to contact patients subject to the recall.

If you do find yourself not knowing what next steps to take after a drug recall, here are some useful tips to guide you throughout the process.

Step 1: Resources for Recalled Medications

The FDA publicly shares a current listing of all recalled products on their website. If you receive a phone call, email, mailer, or any type of communication from your dispensing pharmacy and/or organization that administers your medication to you, you can use this website to learn more information about the recall and the reason for it.

Patients can also contact their dispensing pharmacy to confirm whether their medication was subject to the recall. Most pharmacies keep a digital log of the lot number, expiration date, and NDC. They can compare it to the FDA’s drug recall tracking information (as shown below), along with product photos on their website.

NDC Manufacturer Product
Description
Lot/Batch Expiration
Date

The FDA classifies drug recalls based on their severity. Class I Recalls pose a risk for serious health problems and death. Class II Recalls pose a risk of temporary or reversible health problems. Class III Recalls are not likely to cause an adverse health problem, but it violated FDA laws. Only your provider can determine what is the best course of action to take in response to the recall.

Step 2: Contact Your Provider

Whether your provider is an ambulatory care pharmacist, nurse practitioner, or a medical doctor, it is imperative that you contact them once you learn about your drug’s recall. Do not abruptly stop therapy without consulting your provider. Some medications pose severe risks if you suddenly stop taking them.

Your provider can work with you to develop a plan. Your pharmacy might be able to refill the medication from a different manufacturer that is not related to the recall. If they are not able to substitute with a different manufacturer, your provider will work with you to determine what is an appropriate alternative therapeutic regimen.

Step 3: Disposing of Your Medication

If your medication is recalled and your provider advises you to discontinue therapy and stop taking it, it is important to properly dispose of your medicine. The Drug Enforcement Agency (DEA) announces National Prescription Drug Take-Back events on their website. The FDA also has a website that shares useful tips on how to safely dispose of medicine.

 

Resources:

https://www.fda.gov/Drugs/DrugSafety/DrugRecalls/default.htm

https://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html

https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm#1


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Do ARBs cause cancer - scriptsave wellrx - blog image

by Mitchell Welton, PharmD Candidate 2019
University of Arizona

As with all cause and effect scenarios it is always best to cover the basics. Before we ask if ARBs cause cancer let’s discuss what an ARB actually is. An ARB is a family of medications taken by mouth to lower blood pressure. The acronym stands for angiotensin II receptor blocker (ARB) and its name implies its function. This medication blocks angiotensin II from binding to its respective receptor. When angiotensin II binds to its receptor it causes the blood vessel to contract which increases the blood pressure.1 A patient taking an ARB would have less binding of the receptor and thus no contraction of the blood vessels causing lower blood pressure. Aside from its intended purpose, do ARBs also cause cancer?

Evaluation of Cancer Risk

In 2016 an analysis was done to evaluate the incidence of cancer in patients treated with ARBs for high blood pressure. The review concluded that ARBs had no effect in the incidence of cancer which was consistent with the findings of a similar study conducted in 2011.2 In other words, to say that ARBs as a drug class cause cancer would not be correct. However, in June of 2018 Valsartan, a commonly prescribed ARB, was recalled by the manufacturer citing an impurity found in the medication. The impurity, N-Nitrosodimethylamine (NDMA), is a probable cancer-causing agent.

Since then the United States Food and Drug Administration (FDA) launched an investigation into the affected Valsartan products. That investigation found a second impurity known as N-Nitrosodiethylamine (NDEA) also a probable human carcinogen. Further investigation and testing on other ARBs revealed that some irbesartan and losartan products contained NDEA as well. All affected products have been recalled. Not all ARBs are affected by this recall, however a list of all affected products can be found on the FDA website. It is also important to note that the drugs candesartan, eprosartan, olmesartan, and telmisartan belong to the ARB drug class and have not been identified as containing either of the previously mentioned impurities.3

The Impact of Impurities

The effect that these impurities have on cancer rates is difficult to assign a number to. Professionals at the FDA estimate that there would be one additional case of cancer out of 8,000 people taking valsartan contaminated by NDMA.3 This estimate assumes the patient was taking the highest daily valsartan dose of 320 mg over a period of 4 years. Prescribed dosages of valsartan range from 40 mg to 320 mg daily and lower strength tablets would contain less NDMA respectively than a higher strength tablet.3 This estimate also assumes that every tablet taken over the four-year period contained NDMA. Not all batches affected by the recall actually contained the impurities and over a four year period of refilling the prescription it is unlikely that a patient was exposed to the amount of NDMA calculated in the 1 in 8,000 risk.

With that being said, even if the risk of getting cancer is smaller than 1 in 8,000 it doesn’t take into account the emotional toll this recall can have on a patient that has taken a potentially affected blood pressure medication. NDEA was discovered after NDMA and the FDA does not yet have a risk estimate for the later impurity but will update the information as soon as it becomes available.3

What Should You Do?

If you or someone you know is taking an ARB for the treatment of high blood pressure, check the FDA website regularly. A list of affected medication with their lot and expiration dates can be found for all valsartan, irbesartan, and losartan included in the recall. Again, not all ARBs are affected, and if you are unsure how to match the lot and expiration dates on the medication you picked up from the pharmacy, call and talk to your pharmacist. If you are taking a medication affected in the recall, your pharmacist may be able to recommend or provide you with an unaffected medication by a different manufacturer. The FDA recommends you take your current medication as prescribed until you can get a replacement from your pharmacist or doctor.3

 

References

  1. Ogbru, O. (n.d.). Angiotensin II Receptor Blockers (ARBs) Drug Facts, Side Effects and Dosing. Retrieved from https://www.medicinenet.com/angiotensin_ii_receptor_blockers/article.htm
  2. Zhao, Y., Li, P., Zhang, J., Wang, L. and Yi, Z. (2018). Angiotensin II Receptor Blockers and Cancer Risk. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863811/
  3. Center for Drug Evaluation and Research. (n.d.). Drug Safety and Availability – Questions and Answers: Impurities found in certain generic angiotensin II receptor blocker (ARB) products. Retrieved from https://www.fda.gov/Drugs/DrugSafety/ucm626122.htm

 


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best-statin-prices - scriptsave wellrx - blog image

by Jenny Bingham, PharmD, BCACP; Heather Lee, PharmD Candidate; Mitchell Welton, PharmD Candidate

In such a competitive cholesterol medication market, manufacturers have been forced to make drastic cuts to their medication costs. Amgen lowered its product by 60%, followed by a 45-70% reduction from Regeneron. The price reductions occurred in response to the national consumer’s options to trial a multitude of more affordable options for cholesterol management, based on their clinical goals.

To better understand each product, a comparison should be made between each medication’s indication, effectiveness, and price.

Praluent

Praluent is an adjunct for patients who have uncontrolled cholesterol levels despite the presence of high intensity statin therapy.1 It is indicated for patients with atherosclerosic cardiovascular disease (ASCVD) who would benefit from an additional reduction of low-density lipoprotein (LDL) cholesterol. Praluent has been reported to reduce cholesterol levels by >=40% of patients who taking a maximally tolerated dose of statin.2 It was also reported to be effective at reducing cardiovascular outcomes and all-cause death by 15% in patients who have acute coronary syndrome.3 The primary patient population that would obtain the most benefit from Praluent are patients who have high LDL cholesterol levels.3 A recent price reduction by Regeneron and Sanofi occurred in May 2018. The price decreased from $14,600/year to a range of $4,500 to $8,000/year via rebate.4

Repatha

Repatha is indicated for the treatment of hyperlipidemia and has been reported to reduce the risk of heart attack and stroke.6 Evidence demonstrates the potential for plaque reduction if used with statin therapy. Amgen recently followed suit with lowering the price of Repatha after competitors Regeneron and Sanofi lowered the price of their competing product as mentioned above. Prior to the lowered cost in October the annual price of Repatha was $14,100/year. Amgen initially offered a prescription savings card for eligible patients, however patients with federal, state, or government-funded healthcare insurance were excluded. The new cost is $5,850/year, a nearly 60% decrease in cost. Amgen recently announced new opportunities for Medicare patients to benefit from therapy as the result of the price cut. 7

What to Ask Your Provider and/or Pharmacist

With the new, more affordable prices, you might be curious if these medications are best for your cholesterol management and cardiovascular health. It’s important to maintain routine appointments with your provider to ensure your cholesterol levels are monitored appropriately. Based upon your lab results and medication history, your provider and/or pharmacist may deem it appropriate to trial one of the above noted medications. However, it’s also important to adhere to provider recommendations about lifestyle changes, like diet and exercise.

References:

  1. Accessdata.fda.gov: https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/125559Orig1s000lbledt.pdf. Published 2018. (accessed 29 Nov 2018)
  2. Alirocumab (Praluent) to Lower LDL-Cholesterol. JAMA. 2015;314(12):1284. doi:10.1001/jama.2015.11372
  3. American College of Cardiology: https://www.acc.org/latest-in-cardiology/articles/2018/03/05/15/53/sat-9am-odyssey-outcomes-cv-outcomes-with-alirocumab-after-acs-acc-2018 (accessed 29 Nov 2018)
  4. CNBC. https://www.cnbc.com/2018/05/01/regeneron-sanofi-chop-cholesterol-drug-price-in-express-scripts-pact.html. Published 2018. (accessed 29 Nov 2018)
  5. Repatha (Evolocumab Injection, for Subcutaneous Injection): Side Effects, Interactions, Warning, Dosage & Uses. (n.d.): https://www.rxlist.com/repatha-drug.htm#indications.
  6. CBS News: https://www.cbsnews.com/news/drug-repatha-with-a-statin-could-help-reverse-heart-disease/ (accessed 4 Dec 2018)
  7. CNBC: https://www.cnbc.com/2018/10/24/amgen-cuts-price-of-cholesterol-drug-by-almost-60percent.html (accessed 4 Dec 2018).

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medical marijuana mmj - scriptsave wellrx - rx discounts -blog image

by Mitchell Welton, PharmD Candidate 2019
University of Arizona

The use of marijuana draws a wide range of strong opinions out of people. Its advocates will tout all of its potential benefits of medical marijuana, while its opponents try to draw from the negative stigma that surrounds it. As in all hotly contested topics, the truth usually falls somewhere in between the opposing viewpoints. While the use of marijuana still remains illegal at the federal level, there are many states that have approved its medical use for qualifying individuals to treat certain conditions, and even fewer states have approved its recreational use.

California was the first state to legalize marijuana for medical use in 1996 and since then many states have followed suit. About a dozen states have legalized marijuana for medical use. The difference between medical and recreational use warrants its own discussion and the disagreement can be seen at a legislative level with more leniency being extended to medical over recreational. This author would generalize medical marijuana in this article as containing a higher concentration of CBD over THC, for all intents and purposes, in order to discuss medical marijuana compared to FDA approved cannabinoids.

Medical Marijuana (MMJ) Uses

The two chemicals of interest found in marijuana are tetrahydrocannabinol (THC) and cannabidiol (CBD) although the plant itself may contain up to 400 different chemicals. A recreational smoker would be looking for a higher concentration of THC which is the psychoactive component delivering the “high” that users seek. 1 CBD is the cannabinoid that doesn’t produce the “high” and has recently been approved by the FDA as an oral solution, called Epidiolex, to treat seizures. There are currently only three FDA approved, cannabinoid medications on the market. 2

The first of these medications was approved in 1985 by the FDA known as Marinol or dronabinol. A synthetic form of THC first approved for the treatment of chemotherapy induced nausea and vomiting. Its indication was expanded to include the treatment of weight loss and anorexia in people with AIDS. Other studies have found efficacy in achieving pain relief in patients with multiple sclerosis (MS) and treating other neuropathic pain. 3 Cesamet, or nabilone, is another synthetic cannabinoid that mimics THC also approved in 1985 for the treatment of chemotherapy induced nausea and vomiting with off label use to treat fibromyalgia shown in a 2011 systematic review of cannabinoids for chronic pain. 4 The third, Epidiolex, has already been mentioned which is the first FDA approved drug derived from marijuana. The previous two drugs where synthetic. Epidiolex is used in the treatment of two rare, but severe forms of epilepsy. 2

MMJ Safety Factors

There are multiple factors to consider when thinking of safety between the two types of marijuana. First that comes to mind is the administration. Let’s take dronabinol for example as it has been around the longest from an FDA approval standpoint and such has been examined in multiple studies. This is a liquid filled capsule taken by mouth. Like many oral medications it may take some time for it to be absorbed which means a delay in its effect. This is something to keep in mind as a quick onset of action would be preferred when treating nausea and vomiting. Once the capsule is taken by mouth and absorbed the next consideration is its excretion from the body.

Dronabinol has an elimination half life of 19 to 36 hours meaning there will be a therapeutic level of the medication in the blood for a significant period of time. Other considerations I would bring to attention of the reader is the environment in which the medication is produced. Part of the FDA requirement is the manufacturing standard the medication is subjected to. Conditions must be controlled in its production which would allow us to assume there would be little tainting or contamination. Lastly, this synthetic medication is a pure isomer of THC meaning the end user is not consuming the potential 400 other chemicals found in the marijuana plant which could account for less of a “high” from any other psychoactive cannabinoids. 5

Marijuana in contrast when smoked has a much more rapid onset of action however may be inappropriate for use in patients with asthma or COPD. Ingesting marijuana will have a slower onset and more unpredictable absorption. Once in the system the body would eliminate marijuana faster than dronabinol. Though its production is not regulated like the FDA approved medications, each state has its own laws limiting the cultivating of your own marijuana and licensing of larger cannabis farms. 5

No matter where you might stand on the issue, there is a place in healthcare for the use of marijuana. The question lies in the best way to regulate and manage it. It is important to always evaluate safety and efficacy with any treatment used. Patients should always be treated with evidence-based methods and in accordance to state and federal laws. For better or for worse marijuana, and its use, continues to garner support and opposition in larger numbers. This is a landscape that will continue to change as we look for developments in the application of its use.

 

References:

  1. What Is the Difference Between Medical and Recreational Marijuana? (2018, September 10). Retrieved from https://docmj.com/2017/06/05/difference-medical-recreational-marijuana/
  2. Office of the Commissioner. (n.d.). Press Announcements – FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy. Retrieved from https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm611046.htm
  3. Dronabinol: Marinol. (n.d.). Retrieved November 19, 2018, from Micromedex.
  4. Nabilone: Cesamet. (n.d.). Retrieved November 19, 2018, from Micromedex.
  5. Morrow, A. (n.d.). Marinol or Marijuana: Which Is Better? Retrieved from https://www.verywellhealth.com/is-marinol-better-than-smoked-marijuana-1132483

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When winter rolls around, the holidays and the festivities that accompany the season follow suit. Turkey, the new year, and family, all of these jolly terms invoke the feeling of celebration and happiness. If you find yourself getting moody when the snow starts falling every year, do not fret. You are not alone. If you feel depressed during certain seasons, this is called seasonal affective disorder (SAD). About 5% of adults in the US experience SAD, and this usually lasts for approximately 40% of the year.1 This usually starts in the late fall and early winter and goes away during the spring and summer.2 This typically corresponds to when there is less sunlight, and symptoms improve with the returning sunlight that spring provides.1 The most challenging months for people tends to be January and February. It can even happen in the summer months, but this is less common.

Risk Factors

There are some characteristics that may increase your risk of getting SAD. If you are a female, you are four times more likely to develop this than men.2 In addition, where you live can play a role. If you live farther (north or south) from the equator, you are more likely to develop it. For example, it was seen that 1% of those who live in Florida can develop it versus 9% of those who live in Alaska.3 If your family has a history of other types of depression, this can play a role.2 Along with this, if you have been diagnosed with depression or bipolar disorder, your depression may worsen with the seasons. It has also been observed that younger adults have a higher risk. The age of onset is typically between 18 to 30 years of age.3

Seasonal Affective Disorder Signs And Symptoms

In order to be diagnosed with SAD, you must fulfill the criteria for major depression that occurs during specific seasons for at least 2 years. This may be more frequent than non-seasonal depressions.2 The symptoms of SAD typically look like those of major depressive disorder.

The typical symptoms of depression include:

  • Feeling depressed most of the day, nearly every day
  • Feeling hopeless/worthless
  • Having low energy or feeling sluggish
  • Losing interest in previously enjoyable activities
  • Trouble with sleep
  • Changes in appetite or weight
  • Difficulty concentrating
  • Frequent thoughts of suicide or death2

It is surprising that even the symptoms associated with winter SAD and summer SAD can differ. The typical winter SAD symptoms include:

  • Having low energy
  • Excessive sleepiness throughout the day (hypersomnia)
  • Overeating with possible weight gain
  • Craving for carbohydrates
  • Withdrawing from social activities (feels like “hibernating”)2

The typical summer SAD symptoms include:

  • Poor appetite with associated weight loss
  • Difficulty sleeping or staying asleep (insomnia)
  • Agitation, restlessness, or anxiety
  • Violent behavior2

Treatment and Therapies

There are a couple treatment options to help resolve the symptoms quicker and make you feel better, rather than just waiting it out. SAD is mainly treated through light therapy.4 Light therapy involves you sitting in front of a light box for 20-60 minutes daily in the mornings.2 The idea behind this is so you can replace your reduced intake of sunlight during the fall and winter months. However, this may not be enough and you may be treated through a different method, such as antidepressant medications, talk therapy, vitamin D supplementation, or a combination of the therapies. Medications include the selective serotonin reuptake inhibitors (SSRI) and bupropion, which are types of antidepressants. Common SSRI’s include sertraline (Zoloft), fluoxetine (Prozac), and citalopram (Celexa). You may have to follow up with your doctor whether this is an appropriate treatment for you, and you may have to switch antidepressants around to determine which is the right one that works for you. It may take several weeks for the medications to work, so your doctor may recommend to start taking it before your symptoms usually start every year.5

Another treatment option is talk therapy, which is also known as psychotherapy. A type of talk therapy that is used for SAD is cognitive behavioral therapy (CBT). CBT involves you talking with a mental health counselor to identify negative thoughts and replacing them with positive thoughts. They will help you identify activities that are enjoyable to help you cope with the winter and to help you manage stress. Vitamin D supplementation itself is not regarded as an effective treatment, but there have been some studies that suggest it may be as effective as light therapy.2 On the other hand, there are some studies that oppose that thought. The reason why you might be supplemented with this is that low levels of vitamin D were found in people with SAD.

Following up with your Doctor

If you find yourself nodding to these symptoms and thinking they sound like what you are experiencing, don’t worry. Schedule an appointment with your doctor to discuss your signs and symptoms. If you are taking any medications at home, such as prescription, over-the-counter, and herbals, be sure to update them with this information, because this may change what treatment you receive. From there, your doctor can discuss with you what treatment options may be appropriate. It may take a couple tries to figure out what treatment works best, but this is common. With treatment, you will soon be able to tackle the winter with renewed vigor.

 

References:

  1. Warning Signs of Mental Illness. https://www.psychiatry.org/patients-families/depression/seasonal-affective-disorder. Accessed November 9, 2018.
  2. Seasonal Affective Disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/seasonal-affective-disorder/index.shtml. Accessed November 9, 2018.
  3. Melrose S. Seasonal Affective Disorder: An Overview of Assessment and Treatment Approaches. Depress Res Treat. 2015;2015:1-6. doi:10.1155/2015/178564
  4. Seasonal Affective Disorder. MedlinePlus. https://medlineplus.gov/seasonalaffectivedisorder.html. Published March 6, 2018. Accessed November 9, 2018.
  5. Seasonal affective disorder (SAD). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/seasonal-affective-disorder/diagnosis-treatment/drc-20364722. Published October 25, 2017. Accessed November 9, 2018.

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In the world of prescription drug insurance, there are medications that are covered by a health plan and some medications that are not covered. The list of drugs that are covered is known as the Prescription Drug Formulary (or “Formulary” for short).

What is a Prescription Drug Formulary?

If you’ve ever visited a pharmacy with a prescription in one hand and your insurance card in the other, only to be told that your medication is not covered by your insurance … but if your doctor is willing to change the prescription to a similar drug used to treat the same condition … you have first-hand experience of a Prescription Drug Formulary.

The formulary is a list of approved medications for which an insurer has agreed to help cover the cost. However, there might be multiple manufacturers of numerous drugs designed to treat the same condition. This is an opportunity for the insurance company to trim costs by only agreeing to cover one drug for each health condition.

For pharmaceutical manufacturers, this can be a very big deal to be included or excluded from an insurer’s formulary list. Accordingly, each health plan generally reviews its coverage list on an annual basis. This helps ensure they continue to get the best possible price-points for the competing medications that are available to treat high-cost health conditions.

For patients, this can mean that, each year, they may discover the drug they had been taking is no longer covered. This may require them to switch to an alternative medication to continue receiving help paying for the medication from their insurance provider.

Prescription Formulary Changes for 2019

At the time of this write-up, the calendar is fast approaching year-end, and new insurance plan-years for 2019. Many formulary lists are likely to change. Two of the largest managers of prescription drug formularies in the U.S. are Express Scripts and CVS Caremark. Here are the details of the medications these two companies are REMOVING from their lists for 2019:

Acanya  Humatrope  Saizen 
Acticlate  Invokamet XR  Savaysa 
Alcortin A  Invokamet  Sorilux 
Alocril  Invokana  Sovaldi 
Alomide  Jentadueto XR  Synerderm 
Alprolix  Jentadueto  Targadox 
Altoprev  Lazanda  Tirosint 
Atripla  Levicyn  Topicort spray 
Avenova  Levorphanol  Tradjenta 
Benzaclin  Lupron Depot-Ped  Uroxatral 
Berinert  Mavyret  Vagifem 
Brisdelle  Maxidex  Vanatol LQ 
Brovana  Nalfon  Vanatol S 
Cambia  Namenda XR  Veltin 
Chorionic Gonadotropin Neupro patch  Verdeso foam 
Climara Pro  Norco  Viagra 
Contrave ER  Norditropin  Vivelle-Dot 
Cortifoam  Nutropin AQ Nuspin  Xadago 
Daklinza  Nuvigil  Xerese cream 
Duzallo  Olysio  Xyntha Solofuse 
Eloctate Omnitrope  Xyntha 
Emadine  Onexton  Yasmin 
Embeda  Oxycodone ER  Zemaira 
Extavia  Pradaxa  Ziana 
Fasenra  Praluent  Zolpimist 
Fenoprofen (capsule) Pred Mild  Zomacton 
Fenortho  Pregnyl  Zonegran 
Flarex  Prolastin-C  Zuplenz 
FML Forte  Qsymia  Zurampic 
FML S.O.P.  Recombinate  Zypitamag

If your medications are listed above (and if your insurer uses Express Scripts or CVS Caremark to manage their formulary) you can speak to your doctor or pharmacist about alternative medications designed to treat the same health condition. You can check these alternatives against your insurer’s new formulary list for 2019.

What If My Drugs Are Excluded?

It may also be worth double-checking the cash-price (i.e., the price without insurance) for your current medication. You can do this by clicking the drug name link in the list above. This can be a worthwhile effort, as the cash-price can often be lower than an insurance copay [Read more about Always Ask Cash Price]

What If I Can’t Switch to a Covered Alternative Drug?

If you’re unable to switch medications, you may be able to get some help from the FREE ScriptSave WellRx program. We negotiate savings on the cash-prices of medications at over 65,000 retail pharmacies across the United States. Patients can save up to 80% (relative to the cash price of their prescription).

Our price-check tool is available for free — no sign-up necessary. Go to www.wellrx.com or download the ScriptSave WellRx mobile app on iOS and Android to see how much you’ll save on your prescription costs!


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by Robert “Jed” Swackhammer, Ohio State University

The Patient Dilemma

A patient recently had a primary care follow-up appointment with her physician. She was concerned about waking up during the middle of the night sweaty, shaky, and dizzy. The patient’s physician decided to decrease, her insulin dosage of Lantus, a long-acting insulin.

A few weeks later, the patient received a phone call from her community pharmacist regarding a refill gap on her insulin. The patient stated that her doctor decreased her dosage of Lantus due to low blood sugars in the middle of night. The pharmacist then asked, what insulin where you injecting in the evening? The patient responded, “My Humalog,” a rapid acting insulin.

The patient had been mistakenly taking her Humalog before bed without eating, but her doctor assumed she was using the Lantus, as prescribed. It was at this time the pharmacist counseled the patient on the differences between her insulins and the appropriate time to inject them. After concluding the phone call, the pharmacist advised the patient to follow-up with her physician if her blood sugars remained uncontrolled within a week. A month later, the patient called her community pharmacist to report her symptoms resolved and her blood sugars were controlled!

Working With All Healthcare Providers

Currently, many healthcare professionals are having problems balancing the numerous responsibilities present in their day-to-day jobs. Consequently, this impacts patient care. A difficult and complicated question to ask is what should patients look for in a healthcare professional? The solution is to observe their willingness to work with all your healthcare providers. Consequently, it is important that your healthcare professional is an excellent communicator and prioritizes your needs.

Patient-focused Care

Recent studies by BioMed Central Health Services Research identified 25 different patient-centered care models. The main takeaway from the study was patient-care models consisted of communication, partnership, and health promotion to meet the needs of patients.[1] Similarly, the Nursing Clinics of North America states that in order to improve quality of care in the United States, there needs to be continued focus on 6 dimensions: safe, effective, patient-centered, timely, efficient, and equitable.[2]

It’s vital that healthcare professionals (i.e. physician, nurse practitioner, physician assistant, pharmacist, psychiatrist, psychologist, dentist, cardiologist, endocrinologist, oncologist, and many others) work with one another so that you, as a patient, receive optimal care. With this collaboration, your healthcare team will be able to appropriately share information, deliver compassionate and empowering care, and consider the sensitivity of you as an individual while addressing your needs.[3]

With the aging Baby Boomer population, all healthcare professionals should appropriately equip themselves to focus on taking care of each patient individually instead of just isolated conditions. In dealing with the rise in our elderly population, the American College of Clinical Pharmacy states that “multiple articles have been published in support of clinical pharmacists’ involvement in patient-centered medical homes (PCMH) to help complete team‐based care, enhance patient access, transitions of care, and improve the quality and safety of patient-care”.[4] All professions have a unique position on this team, including pharmacists, because we all bring a different perspective and lens with which to view and treat our patients.

It is vital that all healthcare professionals work together to help deliver optimal patient care. As a patient, you can ensure that this by observing current and future healthcare professional’s ability to communicate with one another. Remember, communication is vital, so that you can be treated as a patient and your needs are addressed.

References:

[1] Bmchealthservres.biomedcentral.com. (2018). [online] Available at: https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/1472-6963-14-271 [Accessed 27 Aug. 2018].

[2] Owens L, Koch R. Understanding Quality Patient Care and the Role of the Practicing Nurse. Science Direct. http://dx.doi.org/10.1016/j.cnur.2014.10.003. Published 2018. Accessed August 27, 2018.

[3] Bmchealthservres.biomedcentral.com. (2018). [online] Available at: https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/1472-6963-14-271 [Accessed 27 Aug. 2018].

[4] Onlinelibrary-wiley-com.proxy.lib.ohio-state.edu. (2018). Shibboleth Authentication Request. [online] Available at: https://onlinelibrary-wiley-com.proxy.lib.ohio-state.edu/doi/abs/10.1002/phar.1357 [Accessed 27 Aug. 2018].


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