immunization changes for 2018 - scriptsave wellrx blog image

by Samantha McKinnon, PharmD Candidate 2019
University of Arizona College of Pharmacy

With flu season right around the corner, what better time to talk about vaccines than right now?  We talk and hear about vaccines a lot, but what exactly is a vaccine, and which vaccine is right for you?

What is a vaccine?

In the simplest terms, a vaccine is medicine created from weakened or dead disease-causing germs given to you to help prevent you from getting sick or prepare your body in case you are infected.1 Vaccines can be created using different strategies, depending on who the vaccine is intended for and what disease is trying to be prevented.  There are live, inactivated, recombinant and toxoid vaccines; each serves a different purpose and treats a different germ.1 The way they work is to expose you to a small and safe amount of the germ so your body will recognize it in the future by creating antibodies.  Antibodies are what allow your body to fight off infections or you experience a much milder version of the illness.2   You may sometimes see terminology like “trivalent” or “quadrivalent” when you’re looking at different flu vaccines.3 Trivalent vaccines contain three different strains of virus whereas quadrivalent vaccines contain four different strains of virus.  There also “high-dose” flu vaccine formulations, these formulations contain extra amount of virus material to help people create more antibodies.1

Live vaccines

Live vaccines are also called sometimes called “attenuated” – which is a fancy term for “weakened”. Some examples of live vaccines you or children may have received would be measles, mumps, rubella (MMR), chickenpox or even smallpox.  Live vaccines take the entire virus and weaken it so that it can’t get you as sick as the regular beefed-up virus.  Imagine you have two runners getting ready to run a marathon, but one of the runners has 20-pound boots on, who will win the race?  It’s going to be much harder for the runner with boots to cross the finish line, this is essentially what attenuating viruses do.  Live vaccines do come with some risks, especially to people with weaker immune systems such as someone that had an organ transplant or someone with cancer.

Inactivated vaccines

Vaccines that inactivate the virus also use the entire virus but instead of being weakened like a live vaccine, it is completely dead.  Inactivated vaccines are the typical flu shots, polio and rabies.  Because these germs are completely dead you will not get sick, but this means you will also not be immune and need more frequent shots.3 This is one reason for an annual flu shot.

Recombinant vaccines

Recombinant is technical term that basically means mixed up, it would be like switching some letters around in the alphabet to be CBADEFG instead of ABCDEFG, it’s still the alphabet but not in the exact order it used to be.  These vaccines use only very specific pieces of the germ, a “target”, which will create a strong response in the person receiving the shot.  The bonus is that the vaccine does not have the entire germ, so you won’t get sick and they can be used on more people than live or inactivated vaccines – a big plus for patients with weaker immune systems.  Some recombinant vaccines currently used are for Hepatitis B, meningitis, shingles and whooping cough.

What changed for this year?

Now that you know about all the different kinds of vaccines we can talk about the new changes for this year.  Besides the World Health Organization (WHO) and the Centers for Disease Control (CDC) there is also another government body called The Advisory Committee on Immunization Practices (ACIP) that provides recommendations for what immunizations are needed and when.  Previous flu seasons did not have very good coverage against H1N1 so live viruses were not recommended for children.  That has changed this year, ACIP has recommended that eligible patients receive the FluMist intranasal spray, a live attenuated vaccine, this is good news for parents and kids as there is no needle and no shot.4 The recombinant flu shot called Flublok is recommended for pregnant women. For the older population there has been a change to the zoster vaccination recommendation.  ACIP recommends the recombinant Shingrix vaccine for prevention of shingles in adults over the age of 50.4 Shingrix is a two-dose vaccine just like the previous shingles vaccination Zostavax but has been found to be more effective than Zostavax, most especially in patients over the age of 80.5 The final changed recommendation is in regard to the live MMR vaccine.  Traditionally it has been a two-dose vaccine and that covered you for life.  With recent measles outbreaks, patients living in an area with an outbreak are recommended to receive a third dose of MMR.5

What vaccine is right for you?

The CDC releases an immunization schedule for all patient populations and revises it as new evidence comes to light.  The recommendations from ACIP have allowed the CDC to release a newly revised immunization schedule effective for 2018.  Based on your age and your health you may get different versions of vaccines or vaccinated at different times in your life than other people.  Your provider or pharmacist would be happy to let you know which vaccines are right for you and when, since some vaccines are age-specific.  It is especially important to let health professionals treating you know your health status and social history such as if you smoke tobacco or drink alcohol, if you’ve recently been sick or had a fever, what kind of environment you work in, if you’ll be around newborns or elderly people, your HIV status or if you have liver problems or blood factor issues as well as any allergies.  If you travel outside of the US, especially to an area that requires you to use antivirals, let your prescriber know as this may affect your vaccinations.  Some countries also require special immunizations before you may be allowed to enter, be sure to check these recommendations on the CDC website.

The importance of getting vaccinated

Diseases like polio, measles, whooping cough, flu can be prevented with vaccines.  Without vaccines people that caught these viruses could be paralyzed, blinded, lose their hearing, or even die.  In 2015 there were 710,000 people hospitalized for flu and over 56,000 of them died.  There are some patients that can not be vaccinated and depend on others to be vaccinated so they do not get sick.  This is called “herd immunity,” the more people that are vaccinated, the healthier everyone will be.  So don’t wait, get vaccinated today!

 

References

  1. www.vaccines.gov/basics
  2. www.newsinhealth.gov/nih/2016/07/safeguarding-our-health
  3. Felicilda-Reynaldo RF, “Types of flu vaccines for yearly immunization.” MedSurg Nursing, July-Aug. 2014, p. 256
  4. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices United States 2018-2019 influenza season. MMWR Morb Mortal Wkly Rep 2018.
  5. Kim DK, Riley LE, Hunter P. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older – United States, 2018. MMWR Morb Mortal Wkly Rep 2018; 67:158.

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imprtance of iodine - scriptsave wellrx blog image

by Marcus Harding
PharmD Candidate Class of 2019, University of Arizona

What is Iodine and why is it important?

You may be wondering, “Why do I need iodine in my salt or other food?” Iodine is an essential element our bodies need that we cannot produce on our own, and therefore need to get it from food sources1. Iodine is needed to produce the thyroid hormone, which is important for bodily functions related to metabolism and how our cells use the energy they are given1. Iodine is found in foods such as cheese, milk, eggs, ice cream, saltwater fish, iodized table salt and some multivitamins1. Most people get their daily intake of iodine from iodized table salt1. There is, however, a large population of people who have heart disease or high blood pressure, who are asked by their doctors to not consume as much salt as others.

Who should reduce their salt intake and by how much?

iodized salt - scriptsave wellrx blog image

Heart disease and high blood pressure afflict a large percent of the U.S. population today. The American Heart Association’s (AHA) Heart disease and Stroke Statistics of 2018 estimates that 31.1% of the world’s population has high blood pressure, and they predict that by 2035, more than 45% of the US population will have some form of cardiovascular disease2. It is because of these abnormally high numbers that the AHA has diet and lifestyle recommendations for being “heart healthy,” that they recommend to everyone, not just people who have heart disease or high blood pressure.

One such recommendation is to reduce the amount of sodium consumed each day. Sodium can cause water retention in your body, increasing blood pressure and making your heart work harder than it needs to3. The average American consumes more than 2,400 milligrams of sodium per day. The AHA recommends having less than 1,500 milligrams per day3. For reference, 1 teaspoon is about 2,300 mg of salt. The AHA reports that the body really only needs about 500 milligrams per day, so eating a heart healthy diet will still get you enough sodium to meet the daily requirements3.

How do I get enough Iodine on a low sodium diet?

So, what can you do to make sure you get enough iodine daily, while eating a heart healthy diet?  It is simple. The body needs 150 micrograms of iodine per day1. For reference, a teaspoon of iodized salt contains about 400 micrograms of iodine1. If you wanted to cut out salt in your diet and be under 1500 milligrams of salt per day, that is still at least 260 micrograms of iodine per day, which is greater than the 150 micrograms a day that your body needs. Keep in mind that the majority of people in the US are getting such large amounts of sodium through salty snacks, processed meats, and the typical “unhealthy foods” that the AHA is trying to help people avoid. Make sure that the sodium you do consume is iodized so that you are reaching that 150-microgram daily recommendation.

Overall, there is no need to fear not getting enough iodine while restricting sodium in your diet, as long as you make sure the salt you eat is iodized, and not coming from processed meats, potato chips and other salty snacks. Following the American Heart Association’s recommendations, you should still be getting more than the recommended daily amount of iodine. If you are concerned about the amount of iodine in your diet, there are multivitamins out there that contain 150 micrograms that can be taken daily.  As always, if you have any questions or concerns, your local pharmacist is well equipped to answer your questions and help guide you in the right direction.

 

References

  1. “Iodine Deficiency.” American Thyroid Association, http://thyroid.org/iodine-deficiency/.
  2. Benjamin, Emelia J, et all. “Heart Disease and Stroke Statistics— 2018 Update: A Report From the American Heart Association.” American Heart Association, 2 Mar. 2017, http://circ.ahajournals.org/content/137/12/e67.
  3. “How Much Sodium Should I Eat per Day?” Sodium Breakup, http://sodiumbreakup.heart.org/how_much_sodium_should_i_eat.

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Your child's medication during school hours - ScriptSave WellRx blog image

by Pattiya Wattananimitgul

How to Handle Your Child’s Medication During the School Year

In the United States, more than 263 million prescriptions are dispensed each year for pediatric patients.1 Chances are, your child may need to take their medications at school. If your child has a medication that they need to take during school hours, whether it is a long-term, short-term, or emergency medication, here are some helpful tips for parents and guardians:

Prior to the School Year1,2

  • Ask the pharmacist to put your child’s medications into two different bottles, each with its’ own label. One to be kept at home and one to be kept at school, if school policy allows.
  • Make sure all the prescription medications kept at school are in an original container (ie., no zip-top bags or foil) and labeled by a pharmacist.
  • Make sure all over-the-counter medications (including supplements) kept at school are in the original containers. Some states require a physician’s written consent and a parent written permission for over-the-counter medications. Be sure to check with your school.
  • It is also important for your child to play active roles in their medication. They should be educated about the effective and safe use of their medicine to help avoid improper administration, dosing errors, and non-adherence.

At the Beginning and During the School Year2,3

  • Provide the school with a full list of your child’s medications, including over-the-counter medicines and supplements. Be sure to update the school with any changes throughout the school year.
  • Talk to the school nurse or teacher ahead of time to make sure your child’s medication will be administered correctly (icorrect medication, dosage, route, frequency). Define who will administer the medication, and who will carry the medications during field trips.
  • School staff are not allowed to determine when to administer “as needed” medications. Be sure that your child’s medication includes specific instruction on when to administer and for what indication (ie., every 6 hours as needed for headache).
  • All medications should be transported by adults to adults. DO NOT let your child carry the medications unless they are capable and responsible to self-administer their medication to carry their own medications, especially for emergency medications that need immediate access, as deemed appropriate by the school.

Emergency Medications2

  • Be sure your child is able to get instantaneous access to emergency medications, like epinephrine injections for allergic reaction, glucagon for low blood sugar, or albuterol for an asthma attack.
  • Acetaminophen, ibuprofen, antihistamines are usually available at school in case your child experiences sudden pain or fever such as headaches, toothache, or menstrual cramps. It is important to sign a waiver granting the school permission to administer these medications in case your child experiences these symptoms.

Lastly, most schools and school districts have policies regarding student’s medication handling. It is important for you to check with your school for specific protocols that you need to follow to make sure that your child is getting the proper care.

 

References

  1. Abraham, O., Brothers, A., Alexander, D. S., & Carpenter, D. M. (2017). Pediatric medication use experiences and patient counseling in community pharmacies: Perspectives of children and parents. Journal of the American Pharmacists Association, 57(1), 38-46. doi:10.1016/j.japh.2016.08.019
  2. Administering Medication at School: Tips for Parents. (2016, December 19). Retrieved July 25, 2018, from https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Administering-Medication-at-Child-Care-or-School.aspx
  3. Guidelines for the Administration of Medication in School. (2003). American Academy of Pediatrics, 112(3), 697-699. doi:10.1542/peds.112.3.697

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Genomics impact on your medicine - ScriptSave WellRx blog image

by Sterling Harpst
2019 PharmD Candidate

Testing Your DNA May Actually Help Make Your Medicines Work Better

Many patients have heard of the personal genetic testing kits available for purchase from websites such as 23AndMe or AncestryDNA. There are currently over 250 Direct-to-Consumer (DTC) companies providing services to analyze saliva samples and create customized reports on what your genetic information says about you.1 Advertising for these companies often include claims that DNA testing can be used to determine an individual’s ancestry, risk for getting certain diseases, or even athletic ability.

What is of interest for many patients, however, is the claim that genetic information can be used to make their medicine more effective. With all of the information being presented, it can be easy for patients to become overwhelmed and unsure of how to make sense of it all. Here’s what consumers should know about the evolving field of Pharmacogenomics.

What are genes?

Inside your body there are millions of cells carrying chromosomes. Chromosomes makes up what is referred to as your “genetic blueprint.”  These are passed on to you from your parents and are made of unique information (genes) which code for specific traits. It is thought that there are nearly 30,000 genes in the human body which determine things like eye color, skin tone, height, and even the likelihood you may get a certain disease.2

What is Pharmacogenomics?

Pharmacogenomics is a relatively new field that looks at how a person’s unique genetic material affects their response to drugs. Imagine that three people get the same disease. Conventional medicine would often recommend they be prescribed the exact same medication. This may make one patient well again very quickly but have no impact on the other two. Essentially, pharmacogenomics aims to explain why changes in genetic information cause some drugs to work differently in different people. This new and exciting field hopes to make personalized medicine a reality, resulting in better diagnoses, earlier treatment decisions, more effective medication use, and customized therapy. By combining an understanding of drugs and genes, there is hope that one day all medicine can be personalized based on a patient’s DNA.

The Limitations of Genetic Tests

Although companies make a number of claims about what information their tests can provide, there are a few limitations to consider before completing any genetic test.

Interpretation

Perhaps the biggest limitation to pharmacogenomics is our ability to fully interpret what genetic information means. Modern technology allows us to analyze tens of thousands of genes, however truly understanding that information is another challenge entirely. Imagine a dictionary full of words, except only a few pages have a definition listed for each word. This dictionary could be used to describe where pharmacogenomics currently stands. Although we have advanced tremendously in recent years, we are still far from fully understanding of the meaning of every gene.

Ability to Make Changes

While there are certain therapies that require genetic testing before use, most do not. Many of the DTC genetic tests are designed to report only information related to drug metabolism. For example, if you do not make specific chemicals necessary to break down a drug, the drug may stay in your system longer and result in side effects. If you make those same chemicals in very high amounts, that drug may not reach the intended effect because your body removes it too quickly. For the purpose of making medication changes, this is often the only result tests can provide.

Minimal Regulation

Although there are many tests available today, there is little regulation when it comes to making sure companies are producing accurate results. Claims that you will know your chances for developing diseases such as Alzheimer’s are based on likelihood, not certainty. Many companies advertise tests that can be used to customize your diet and lifestyle as well. Without well documented clinical studies to provide evidence of these statements, the Centers for Disease Control and Intervention (CDC) and Food and Drug Administration (FDA) are often hesitant to agree.3

For some of the newer or less well-known companies, there are significant concerns with the privacy of your genetic information. The Genetic Information Nondiscrimination Act (GINA) was signed into law in 2008, preventing health insurances and employers from discriminating based on genetic information.4 However, with patient permission it is still legal to sell this data, making it very important to read the privacy policies on how they will use your information before taking a test.

If You’re Considering a DTC Genetic Test

It is important to know that the FDA and CDC do not approve genetic testing in place of traditional health care evaluation. The results may provide a likelihood regarding your chance to benefit from certain medications, but the tests are not final. Often the results may not be significant enough to change anything about your medicine. Here are a few points to keep in mind:

  • Talk with your doctor first before completing any genetic test. It is important to know what they would recommend based on your specific circumstance.
  • Ask your doctor if they would be able to interpret the test with you. Some reports can be complicated and very difficult for patients to understand. Genetic counselors are healthcare professionals that are specifically trained to help interpret the meaning of genetic testing results.
  • Before making any changes to medications or lifestyle, ask the opinion of your doctor. Since test results can be challenging to understand, changes could result in dangerous consequences if made incorrectly.
  • Understand your rights regarding privacy. Before sending your DNA to anyone, it is best to know what your information will be used for. Your genetic information is personal, and you may not want companies to share that information for personal gain.

References

  1. Phillips, Andelka M. “Only a Click Away – DTC Genetics for Ancestry, Health, Love and More: A View of the Business and Regulatory Landscape.” Applied & Translational Genomics, vol. 8, 2016, pp. 16–22., doi:10.1016/j.atg.2016.01.001.
  2. “Human Genome Project Completion: Frequently Asked Questions.” National Human Genome Research Institute (NHGRI), 30 Oct. 2010, genome.gov/11006943/human-genome-project-completion-frequently-asked-questions/.
  3. “Regulation of Genetic Tests.” National Human Genome Research Institute (NHGRI), 17 Jan. 2018, genome.gov/10002335/.
  4. Su P. Direct-to-Consumer Genetic Testing: A Comprehensive View. The Yale Journal of Biology and Medicine. 2013;86(3):359-365.

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Prescription options for allergy meds - scriptsave wellrx

by Marcus Harding
PharmD Candidate Class of 2019, University of Arizona

Seasonal allergies affect anywhere between 10-30% of people worldwide.1 Allergies to one or more common allergens are reaching upwards of 40-50% in school children.1 Allergies occur due to an immune response to something the body considers “foreign,” in other words, strange or unfamiliar. When in contact with the “allergen,” the body produces antibodies which release a chemical called histamine. Histamine and some other chemicals are what cause allergic reactions.1,3

Symptoms of a seasonal allergic response include but are not limited to:3

  • Sneezing and a runny nose
  • Itchy nose and throat
  • Itchy, watery eyes

Symptoms of a more severe allergic response include:

  • Shortness of breath
  • Rash
  • Welts
  • Swelling of mucous membranes

What to Do

When seasonal allergic symptoms occur, you should talk to your primary healthcare provider for help. While your physician can prescribe medications to minimize these symptoms, it is rare that they would be covered by your insurance. This is because most of the medications used for allergies are “over-the-counter” (OTC) medications. This means these medications can be purchased without a prescription, and can be easily found at your local drug store. If you are expecting a medication to be covered by your insurance, but find that it is not, there are options for you. Despite these medications being OTC, they can still be rather expensive, and if you need the medication consistently, the cost can add up. So, what are your options when it comes to these medications if your insurance won’t cover them?

There are many resources available to help you find the best price for OTC medications. The ScriptSave® WellRx app is free and can help you find the best price based on your location. If your physician writes a prescription for an OTC medication, you can use the ScriptSave WellRx app or discount card to get savings on that drug. You can visit www.WellRx.com to download a free card and find the cheapest cash price at a nearby pharmacy.

Lastly, your local pharmacist is a great resource when it comes to cost savings. They are a wealth of knowledge as it pertains to medication information and cost, and if they do not know the answer, they will know where and how to find the answer.

Allergy Medication Options

So now that you have the resources to find the best price, how can you decide which medication to choose? There are so many different types of medications for seasonal allergies, it is hard to know which is the best for you.

Antihistamines are the most common type of medication used for seasonal allergies.1 These are divided into two types, which are the first and second-generation antihistamines. The first-generation antihistamines are more likely to cause drowsiness and sedation compared to the second generation.2 The OTC first-generation antihistamines include:

The OTC second-generation antihistamines include

Second-generation antihistamines are not only less sedating, but also last longer, and are most often only needed once a day, whereas first-generation anti-histamines may need to be taken multiple times a day. All of these examples can be found as tablets, capsules, or suspensions.2

Some common side effects to look out for are:2

  • Dizziness/drowsiness (more common in first-generation)
  • Dry mouth
  • Blurred vision
  • Nausea/vomiting
  • Confusion

Another type of medication that can be used for seasonal allergies is nasal decongestants.1 These medications help to shrink the blood vessels in your nose to reduce the amount of leaking from your nose. These medications result in rapid relief of nasal congestion; however, they are only recommended for 3-5 days of use. Using these medications any longer than the recommendation can cause “rebound congestion,” basically making your symptoms worse. There are several different forms of these medications including topical, oral tablets and nasal sprays.4

Some of the side effects of these medications include:4

  • Rapid and irregular heartbeat
  • irritability
  • nasal dryness
  • high blood pressure
  • difficulty sleeping
  • loss of appetite
  • urinary retention
  • dizziness

Keep in mind that there are daily and monthly limits to the amount of Sudafed you can purchase based on state laws. Although these medications can act rapidly and help with symptoms right away, they should not be used for more than 5 days at a time.4

One last common type of OTC medication used for seasonal allergies is nasal corticosteroids1. These medications act to slow down the body’s immune response to the allergen, reducing the amount of inflammation. Although there are corticosteroids that work for the whole body, these are nasal sprays that are directed to the nose to help with symptoms that occur locally or in the general area, therefore, there are very few of the normal side effects of steroids because the medication is specifically targeted to the nose. Most of the side effects that can happen are in the nose/throat area, although they are not very common.4

The current nasal corticosteroids include:

The side effects of these medications can include:4

  • Nausea
  • Headache
  • Cough
  • Nose bleeds
  • Congestion
  • Throat swelling/irritation
  • Upper respiratory infection.

There are many options for treating your allergies with over the counter medications, including medications that are not antihistamines. If your doctor prescribes a medication and it is not covered by insurance, talk to your pharmacist about OTC alternatives and use the resources available to you to find the best price. That way you can treat your symptoms, feel better, and keep more money in your pocket.

 

References

  1. American Academy of Allergy, Asthma & Immunology. (2018). AAAA. Retrieved from http://www.aaaai.org/. Accessed on 5/16/2018.
  2. Carson S, Lee N, Thakurta S. Drug Class Review: Newer Antihistamines: Final Report Update 2 [Internet]. Portland (OR): Oregon Health & Science University; 2010 May. Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK50554/
  3. Jeffrey L. Kishiyama, M. (2014). Pathophysiology of Disease: An Introduction to Clinical Medicine, 7e. Gary D. Hammer, MD, PhD, Stephen J. McPhee, MD.
  4. Platt, Michael. International Forum of Allergy & Rhinology. Sep2014 Supplement, Vol. 4, pS35-S40. https://www.ncbi.nlm.nih.gov/pubmed/25182353

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Walmart Announces New Opioid Rules - pill image WellRx

On May 7, 2018, Walmart issued a press release to announce the pending introduction (within 60 days) of new restrictions on how it will fill prescriptions for opioid medications. These new initiatives will apply to all Walmart and Sam’s Club pharmacies and pharmacists in the United States and Puerto Rico.

Walmart indicated that these changes are “an effort to continue to be part of the solution to our nation’s opioid epidemic,” and it reflects a further expansion of the company’s Opioid Stewardship Initiative. The move from Walmart follows a similar initiative by CVS that went into effect in February. Increasingly, retail pharmacies are stepping up efforts to stem the spread of opioid addiction, prevent overdoses and curb over-prescribing by doctors.

What Doctors Need to know, and What it Means for Patients with Legitimate Prescriptions

Walmart is the fourth-largest pharmacy chain in the US and these changes (being introduced over the course of a 60-day period) are likely to touch a number of patients. The retailer will move to restrict initial acute opioid prescriptions to no more than a seven-day supply, while also limiting a day’s total dose to no more than the equivalent of 50 morphine milligrams. Meanwhile, in states where the law for fills on new acute opioid prescriptions is less than seven days, Walmart and Sam’s Club will follow state law.

In addition to these immediate-term changes, by January 1, 2020, Walmart and Sam’s Club will require e-prescriptions for controlled substances.

In terms of patients needing acute or short-time pain management, in the event that the pain lasts longer than a seven-day supply (and still warrants treatment with these medications), the patient will have to consult his/her physician in order to obtain a new prescription.

Such restrictions have prompted concern that requiring patients to obtain a new prescription after seven, or sometimes only three days (depending on the state), can become too costly due to mandatory co-pays. Dr. Steven Stanos, former president of the American Academy of Pain Medicine explained that the organization applauds “any action that seeks to limit the over-prescription of opioids,” but added, “That needs to be balanced with the very real need of patients.”

For this reason, doctors and patients should be engaging in dialog about current and alternative medications and possible savings options, as they formulate a strategy for effective pain management.


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by Derek Matlock
Pharm.D. Candidate 2017
Washington State University

Nearly one-quarter of all U.S. deaths in 2016 we­­­re linked to heart disease, which refers to conditions involved in narrowing or blocking blood vessels, potentially leading to things like heart attack, chest pain, or stroke.

A Steady Decline in Stroke Deaths

Despite the continued and steady decline of deaths due to strokes, they continue account for 1 of every 20 deaths in the US. The decline of deaths due to strokes can be attributed to early identification of strokes, primary prevention, and secondary prevention.

Signs of a Stroke

FAST stroke acronym explained - image - ScriptSave WellRx

As a patient or caregiver, is it important to be able to identify the signs of a stroke as early as possible, as it can influence a positive outcome in patients at risk. The FAST acronym can be a simple and easy tool for identifying a stroke.

 

Face: Does the face look uneven? Ask them to smile.

Arm: Does one arm hang down? Ask them to raise both arms.

Speech: Does their speech sound strange? Ask them to repeat a phrase.

Time: Every second brain cells die. If any of these signs are observed, call 911.

Primary Prevention of a Stroke

Primary prevention refers to the management or treatment of patients who have no prior history of stroke. It involves addressing modifiable risk factors a patient may have, which may include: high blood pressure, diabetes, dyslipidemia, atrial fibrillation, sickle cell disease, post-menopausal hormone replacement therapy, oral contraceptives, diet, weight and body fat.

 

Additionally, your doctor or pharmacist may calculate your Atherosclerotic Cardiovascular Disease (ASCVD) risk score, which estimates a 10-year risk of heart attack or stroke and helps determine the appropriateness of using medications to lower your risk. Some medications that may be added include: statins for cholesterol; thiazide diuretics, ACE inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs), or calcium-channel blockers (CCBs) for blood pressure; and aspirin to help prevent blood clot formation.

Secondary Prevention of a Stroke

Secondary prevention refers to the treatment of patients who have already had a stroke or “mini-stroke.” Interventions commonly prescribed for secondary prevention are summarized using the following ABCDE acronym:

Antiplatelets and Anticoagulants: Antiplatelet medications, like aspirin, clopidogrel, and dipyridamole, can prevent formation of clots. Anticoagulants like warfarin, apixaban, rivaroxaban, and dabigatran can also reduce the ability for the blood to clot and thus lower stroke risk.

Blood pressure-lowering medications: Thiazide diuretics, ACEIs/ARBs, and CCBs help patients control the number one risk factor for a recurrent stroke, high blood pressure.

Cessation of cigarette smoking and Cholesterol-lowering medications: Quitting smoking can significantly lower the risk of strokes, while cholesterol-lowering medications, like statins (e.g., simvastatin, rosuvastatin, atorvastatin), have been shown to lower bad cholesterol as well as decrease the risk of recurrent stroke and mortality.

Diet: In addition to helping weight loss, following a heart healthy diet, or a low-sodium “DASH diet”, may help lower cholesterol, triglycerides, or blood pressure, which decreases your risk of a stroke.

Exercise: For patients capable of exercising, it is recommended to exercise moderately to vigorously for 20 to 40 minutes 3-4 times per week. Be sure to stay within your limits. Good exercises can include walking or riding an exercise bike. Some community centers and gyms even host classes for older patients with physical limitations.

Strokes Still a Significant Cause of Death

Strokes continue to account for a significant amount of deaths in the United States. Your doctor or pharmacist may recommend lifestyle modifications and medications to help lower the possibility of experiencing a new or recurrent stroke. If you are being prescribed medications to lower your stroke risk, be sure to provide your doctor with a thorough medical history and medication list, as some conditions and medications may guide the recommendations your doctor makes. Your pharmacist can also be a valuable resource to any questions you may have.

 

References:

  1. American Heart Association: Heart Disease and Stroke Statistics 2017
  2. Mayo Clinic: Heart Disease
  3. MedicalNewsToday: Top 10 Causes of Death in the U.S.
  4. Medscape: Stroke Prevention
  5. UpToDate: Overview of Primary Prevention of Coronary Heart Disease and Stroke
  6. UpToDate: Overview of Secondary Prevention of Ischemic Stroke

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Prevent shingles - ScriptSave WellRx image

by Alyssa Kasher
PharmD Candidate of 2018

It’s likely you’ve heard about shingles, or may even know someone who has had the painful rash, but what exactly is shingles, and how can you prevent it? The varicella-zoster virus (VSV) causes two distinct forms of infection, chickenpox and shingles. It’s important to recognize how you can contract this virus and what you can do to protect against it.

If You’ve Ever had Chickenpox, You Can Develop Shingles

A primary VSV infection occurs when you’re first exposed to the virus, referred to as varicella or chickenpox. Chickenpox is a highly contagious condition spread through direct person-to-person contact, sneezing, or coughing. Most people recognize it from the itchy blisters or “pox” that appear all over the body.  In healthy people, the condition is mild and resolves within 5-10 days1.  As chickenpox resolves, the varicella-zoster virus retreats into the nerve cells and goes into hiding. The virus’s ability to evade the immune system allows it to lay dormant until future reactivation1. Although anyone previously infected with chickenpox will carry VSV in their system, not everyone will experience the virus’s reactivation.

According to the CDC, 1 in 3 Americans will experience the reactivation of the VSV. When this occurs, it manifests as a secondary infection called herpes zoster or shingles1. The virus travels down a nerve and produces a patch of painful lesions on the skin that may permanently scar or discolor the skin.

Shingles is More Dangerous Than Chickenpox

As the infection moves down the nerve, it causes inflammation resulting in damage or cell death2. This causes the most painful and lasting effect of the infection, called peripheral neuropathy or nerve pain. Inflammation may also occur in the eyes and the brain causing serious and potentially fatal complications1. Shingles is more dangerous than chickenpox, especially because it usually occurs in older people who may have weaker immune systems with less ability to fight off the infection.

How Can You Prevent Shingles? Vaccination

The first vaccine to prevent the primary VSV infection, or chickenpox, was not developed until 1995. This means much of the older population has been exposed to chickenpox. Zostavax, the first vaccine to prevent the reactivation of the virus (shingles), did not come out until 20064.  Many people may have already received the Zostavax vaccine. However, a better vaccine has taken its place.

Shingrix: A Better Way to Prevent Shingles

In the fall of 2017, Zostavax was replaced by Shingrix as the CDC recommended vaccine to best prevent shingles and related complications. Shingrix, unlike Zostavax, is not a live vaccine and cannot cause shingles. Shingrix is given in two doses, and is over 90% effective at preventing shingles3. The CDC recommends that everyone over the age of 50 of receive Shingrix. You should get the Shingrix vaccine if you have already had shingles, previously received Zostavax or if you’re not sure you had chickenpox as a child. Studies show that 99% of Americans over 40 have been exposed to the chickenpox virus whether they realize it or not3.

Patient populations at the highest risk of shingles include:

  • those over 50
  • immunocompromised patients
  • females
  • anyone with underlying chronic lung and kidney disease.

Facts About Shingrix3

  • After your first dose of Shingrix, you should receive the second dose within 2-6 months.
  • You can receive the vaccine at your community pharmacy without a prescription.
  • Shingrix is covered by Medicare Part D. Ask your pharmacist to see if your plan covers it.
  • Shingrix can cause injection site soreness and pain. Using ibuprofen or Tylenol can help.
  • Talk to your pharmacist or doctor to see if Shingrix is right for you.
  • Always discuss all conditions/medications with a doctor or pharmacist before getting a vaccine.

References

  1. Albrecht, MA. Clinical manifestations of the varicella-zoster virus infection: Herpes zoster. In: Basow DS, ed., UpToDate. Waltham (MA).: UpToDate; 2016.
  2. Albrecht, MA. Epidemiology and pathogenesis of varicella-zoster virus infection: Herpes zoster. In: Basow DS, ed., UpToDate. Waltham (MA).: UpToDate; 2016.
  3. Centers for Disease Control and Prevention. Vaccines & Preventable Diseases. Vaccines by Disease. Shingles. Retrieved at https://www.cdc.gov/vaccines/vpd/shingles/public/zostavax/index.html. Accessed 2018 Jan 22.
  4. Immunization Action Coalition. Chickenpox (Varicella): Questions and Answers. Retrieved at: https://www.immunize.org/catg.d/p4202.pdf. Accessed 2018 Jan 22.

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Medicine Chest Must Haves - image

Here are ten must-haves for every home medicine chest:

Plain soap

Good ol’ soap and water is still the best way to clean minor cuts and scrapes. It works just as well as antibacterial soap—and it’s less expensive!

A compression wrap

If you twist your ankle or wrist, remember the RICE treatment: Rest, Ice, Compression, Elevation. Elastic wraps, such as those made by ACE, are the compression component of the RICE equation. “These are excellent for giving support to a sprained joint,” says Jennifer Zimmer, MD, an internal medicine doctor at the Dallas Diagnostic Association and the Baylor Regional Medical Center in Plano, Texas.

Aspirin

Not only for headaches and hangovers, but if you’re at risk for something far more serious: “If you have chest pain, chew up 325 mg of uncoated aspirin,” advises Singh. “Heart attacks can happen any time and taking aspirin as soon as possible can help reduce the damage.” Aspirin can help break down the blood clot in your artery and limit the injury to your heart. Keep in mind, however, that there are many different types of chest pain and that aspirin is not the right treatment for many of them. Rare use is relatively safe but repeated aspirin use can cause harm. Talk to you doctor to learn about your heart-disease risk and what to do in an emergency.

Bandages (assorted sizes)

Not just for kids! You need these, as well, to keep your boo-boos and owies from becoming infected.

A thermometer

Experts recommend a digital thermometer over the mercury type (which are just as accurate but difficult to read). “A good thermometer can monitor for temperature elevation that could indicate infection in a wound or worsening of an illness,” says Zimmer.

Mild pain relievers

Stock acetaminophen or ibuprofen for minor pain and fever. “Remember to check doses, though, as children take a dose based on their weight,” advises Singh.

Antibacterial ointment

Apply after cleaning a wound to help reduce infection risk and increase healing time.

An antihistamine

Use to relieve minor allergy symptoms like sneezing, itching and swelling. Call 911 if you have a severe allergic reaction—such as difficulty breathing, or swelling of the tongue or lip—as an antihistamine won’t help.

Hydrocortisone cream

This is useful for taking itch out of rashes and insect bites.

Phone numbers

Inside the door of your medicine cabinet, adhere contact info for your family members, doctors, pharmacy, and your local poison control center. If there is an emergency, this cost-you-nothing strategy can prove to be priceless.

Remember to check the contents of your kit every 6 to 12 months to ensure that medicines haven’t expired, and that your contact numbers are still up-to-date.

Finally, it’s also handy to keep a first-aid kit in your car and your day-trip backpack. And think about other places a kit could be useful. Going on vacation? Remember to take one with you to the cabin, boat, or wherever else your road leads. Go well!

Nancy Gottesman, a health and nutrition writer in Santa Monica, CA, is stocking her first-aid kit now.

Copyright © 2018 Healthnotes, Inc. All rights reserved. www.healthnotes.com

Learn more about Healthnotes, the company.


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Treating and preventing osteoporosis - image - wellrx

by Tek Neopaney, University of Arizona College of Pharmacy Student

Each year, millions of Americans, who may otherwise feel fine, are diagnosed with Osteoporosis. Developing osteoporosis puts people at higher risk for fractures, especially in the hips, spine, and wrists. Women are at much higher risk, with 10 percent of women age 50 and older affected by osteoporosis, compared with just two percent of men that age.

What is Osteoporosis?

Osteoporosis is defined by low bone mass that results in decreased bone density, and bones become more prone to fracture. Osteoporosis often has no symptoms until there is a bone fracture. Bone strength decreases with the loss of bone mass, which is related to many factors such as, a decrease in bone mineral density, rate of bone formation and turnover, and the shape of the bones.

Postmenopausal women often have low bone density due to estrogen deficiency. With early diagnosis of bone loss and fracture risk, available therapies can slow or even reverse the progression of osteoporosis and help prevent bone fracture1. Vertebrae and hip fracture is common in osteoporosis patients. About two-thirds of the bone fractures are asymptomatic2, meaning patients won’t even be aware they have a fracture. Many patients without symptoms assume they don’t have osteoporosis, so it’s important for all post-menopausal women to get an osteoporosis evaluation.

Calcium Vitamin Supplements

If you are unable to achieve adequate amounts of calcium and vitamin D from diet alone, you should take supplements for bone growth and development. Children ages 9 to 18 should consume approximately 1300 mg of calcium per day from calcium rich food sources, and 600 mg of vitamin D from vitamin D-fortified food. Children who have a wide variety of foods in their diet, and are growing well, should not need calcium and vitamin D supplementation3. Calcium and vitamin D supplementation likely only benefits children with inadequate calcium and vitamin D intake3.

Most postmenopausal women with osteoporosis, 1200 mg calcium (total dietary and supplement) and 800 international units of vitamin D are recommended. Although optimal intake of calcium (diet plus supplement) for pre-menopausal women and men with osteoporosis is not established, generally suggested doses are 1000 mg of calcium (diet and supplement) and 600 international units of vitamin D4.

Exercise – It’s Important!

Exercise is strongly associated with a reduction in hip fractures in older women5. Regular exercise has shown to have positive effect on bone mineral density (BMD). BMD is the measure of calcium in your bone. In studies, a variety of exercises such as, jogging, resistance training, swimming, and walking were effective. Women with osteoporosis should exercise for at least 30 minutes a day, three days a week, to build bone strength and help prevent fractures. Exercise helps to increase muscle strength, reducing the risk of fracture from fall.

Pharmacological Therapy

In addition to lifestyle measures and calcium and vitamin D supplementation, patients at high risk for fractures should also receive drug therapy. Patients with a history of fragility fracture or osteoporosis based on BMD, benefit from medication. All patients treated with medication should have a normal calcium and vitamin D level prior to starting drug therapy, and should also receive vitamin D and calcium supplements if their dietary source is inadequate6.

Oral bisphosphonates such as, alendronate (Fosamax), ibandronate (Boniva) are the first line of therapy for postmenopausal women. These agents decrease the rate of bone breakdown leading indirectly to an increased BMD. Bisphosphonates are effective, inexpensive, and have long-term safety data on preventing hip and vertebrate fracture6. These drugs are usually taken once a weekly.

Putting it All Together

With so many Americans developing osteoporosis, it’s important to realize it could happen to you, so talk to your doctor about your risks. To help prevent, and possibly reverse Osteoporosis:

  • Bond density screening is important to detect osteoporosis
  • Get enough calcium and Vitamin D in your diet or take supplements to help prevent osteoporois
  • Exercise helps build bone mass and strengthen your bones
  • There are available drugs to treat osteoporosis that are inexpensive and have proven safe to take over time.

References:

  1. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int 2014; 25:2359.
  2. World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Geneva 1994. https://whqlibdoc.who.int/trs/WHO_TRS_843.pdf  (Accessed on March 09, 2012).
  3. Winzenberg TM, Shaw K, Fryer J, Jones G. Calcium supplementation for improving bone mineral density in children. Cochrane Database Syst Rev 2006; :CD005119.
  4. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int 2014; 25:2359.
  5. Gregg EW, Cauley JA, Seeley DG, et al. Physical activity and osteoporotic fracture risk in older women. Study of Osteoporotic Fractures Research Group. Ann Intern Med 1998; 129:81.
  6. Crandall CJ, Newberry SJ, Diamant A, et al. Comparative effectiveness of pharmacologic treatments to prevent fractures: an updated systematic review. Ann Intern Med 2014; 161:711.

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asthma inhaler image

by Tek Neopaney

What is Asthma?

Asthma is a chronic disease that affects the airway tubes of the lungs. During asthma attacks, the walls inside of the airway become sore, swollen, and red and produce mucus, making it harder to breathe. The airway tubes become very sensitive when they are inflamed and may react strongly to allergens. Air movement in and out of the lungs is constricted when inflammation is present, resulting in shortness of breath.

What Makes Asthma Worse?

There are many triggers of asthma. Common inhaled allergens that you may encounter at a daycare, home, school or work can trigger an asthma attack. Some avoidable allergens include mold, excretions from dust mites, cockroaches, and mice.

It’s common for many patients with high blood pressure to also have asthma. Some of the most effective and proven blood pressure medications are known to cause negative effects in people with asthma, so care is required in developing effective treatment plans.

Of the many different drugs available for treating hypertension, beta blockers and angiotensin-converting enzyme (ACE) inhibitors have the most potential to cause problems for asthma patients.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are medications commonly used for pain. However, NSAIDs, like naproxen (Aleve), and ibuprofen (Motrin) can sometimes make asthma symptoms worse. Other body reactions, including upper airway illness, hormonal fluctuation, and extreme emotions, can trigger asthma attacks.

How Can You Control Your Asthma?

Influenza can worsen asthma symptoms and cause complications, so it’s important to get a flu vaccine annually. The best way to treat asthma is identifying and avoiding triggers, taking medication regularly in order to prevent symptoms, and treating asthma episodes as they occur. Home monitoring of the peak expiratory flow rate (PEFR) can be very helpful, because it measures the airflow through airway and thus the degree of obstruction of airways. A peak flow meter is inexpensive and an easy way to assess asthma control.

Symptoms of Uncontrolled Asthma

If you have any of the following symptoms it’s considered uncontrolled asthma:

  • Coughing, wheezing, rapid breathing, or tightness of the chest experienced daily
  • Nighttime awakening more than twice a week
  • Need to use a short acting inhaler more than twice a week
  • If the asthma symptom is interfering with normal activities

Medications Used in Asthma Treatment

Long acting anticholinergic agents or beta agonists are the mainstay of asthma therapy. Common medications include:

These medications should be used regular for asthma control. Often, these medications can be combined. For example, in case of severe asthma, patients are often prescribed Acidinium and formoterol fumarate to use together on a regular basis.

Short acting inhalers, sometimes called rescue inhalers, are used for immediate symptomatic control:

How Do Asthma Medications Work?

Long acting anticholinergic agents work by competitively inhibiting the action of airway constriction. Short acting inhalers help to open up the airways by relaxing muscles of airway tubes.

Making an Asthma Action Plans

When you have asthma, your goal is to have a normal active life, and good control of your asthma. If your asthma is not well controlled, you may need to increase your medication and learn more about what triggers your asthma attacks. Your physician and pharmacist can provide you with information and an action plan to take care of your condition, so you can continue to be active and healthy.

References:

  1. Bateman, Eric D., et al. “Overall asthma control: the relationship between current control and future risk.” Journal of Allergy and Clinical Immunology 125.3 (2010): 600-608.
  2. Kew, K. M., & Dahri, K. (2016). Long-acting muscarinic antagonists (LAMA) added to combination long-acting beta2-agonists and inhaled corticosteroids (LABA/ICS) versus LABA/ICS for adults with asthma. Cochrane Database of Systematic Reviews, (1).
  3. Friedman, B. C., & Goldman, R. D. (2010). Influenza vaccination for children with asthma. Canadian Family Physician56(11), 1137-1139.
  4. Zheng, T., Yu, J., Oh, M. H., & Zhu, Z. (2011). The atopic march: progression from atopic dermatitis to allergic rhinitis and asthma. Allergy, asthma & immunology research3(2), 67-73.

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Medication for insomnia image

by Alyssa Kasher, PharmD Candidate 2018
University of Arizona College of Pharmacy

Sleep is a precious commodity that everyone needs to function. Individual sleep needs are different; some people need a few extra hours while others need less. Some people are light sleepers, while others “sleep like logs.” Sleep habits can also change temporarily, for example during college or after a baby is born. Despite varying needs, all people need adequate sleep to function. Sleep loss negatively affects work performance, mood and overall health. In light of this, it is important to identify factors that are causing you to lose sleep. It’s important to speak with your doctor to see if ongoing sleep problems are caused by clinical insomnia.

How do I know it’s clinical insomnia?

Clinical insomnia is diagnosed by having all of the following 3 conditions1:

  1.       Difficulty falling asleep, staying asleep, or waking up too early
  2.       The above difficulty occurs even with plenty of time to sleep in an ideal environment
  3.       Sleep loss causes decreased function during the daytime

What causes insomnia?

Historically, insomnia has been viewed as a condition that occurs secondary to another disease or condition. Recent studies show us that insomnia does occur by itself without any identifiable reasons1. You should still check with your doctor to see if another medication you take or condition you have is causing insomnia.

Treatment of insomnia

First line treatment for insomnia includes behavioral counseling and improving sleep hygiene. For information on non-drug therapies, check out our previous blog post written by Jenny Bingham, PharmDShould you and your doctor decide to use medication to treat insomnia, it is important to tell your doctor about other medication you are taking as well as any conditions you have.

Over the Counter Medications

  • Antihistamines purchased over the counter are commonly used to induce sleep as they can cause drowsiness1. While they are helpful, these medications should only be used short term. If your problems with sleep continue, you should consult with your doctor to ensure you get the appropriate treatment.

Prescription Medications

  • Non-benzodiazepines include other sleep drugs with varying mechanisms. They differ from benzodiazepines in that they usually have less anti-anxiety effects. Some of these drugs are approved only for short term use; while drugs formulated as extended release are better suited for long term use1.
  • Antidepressants can be used for sleep as many of them have a sedating effect. These are particularly useful in people who concurrently suffer from depression or anxiety, because the drug is also treating a potential cause of insomnia. The only antidepressant specifically FDA approved for insomnia is Silenor (doxepin) 1.
  • Other drugs are used for insomnia that have unique mechanisms
    • Rozerem (ramelteon) is a drug that encourages your body to release melatonin, which makes you sleepy. It has less side effects and less addiction potential than other drug types. It is also not a controlled substance.
    • Belsomra (suvorexant) is a first of its kind drug that blocks molecules in your brain that encourage wakefulness1. Because it has a long half-life, it can still cause day time drowsiness. It is a controlled substance due to abuse potential.

General Considerations

  • Sleep medications can make you drowsy, dizzy or experience day time sedation.
  • Many medications used to treat insomnia have a potential to be habit forming. They may also worsen insomnia if stopped suddenly. Use them exactly as directed by your doctor.
  • Sleep medications can impair your ability to perform tasks, so it is crucial to only take them once you are ready for bed. Do not use alcohol as impairment may be worsened.

Considerations in the Elderly

  • Since most sleep medications cause drowsiness to induce sleep, they can be especially dangerous when used in the elderly. This is true of both over the counter sleep medications (like diphenhydramine) as well as prescription drugs. This drowsiness can cause confusion, memory issues and serious falls. Consult your pharmacist or doctor before starting sleep medication.

 

References:

  1. Arand DL, Bonnet MH. Treatment of insomnia in adults. In: Basow DS, ed., UpToDate. Waltham (MA): UpToDate; 2016

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