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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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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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by Heather Lee, University of Arizona PharmD Candidate

With flu season upon us, make sure you pencil in a date to get your flu shot. You may wonder why this is so important, and why your healthcare providers are always asking whether you received it. Influenza (the flu) is a huge threat to public health. It has been shown that around 5 to 20 percent of the United States population get the flu during flu season.1 Hospitalization rates and death rates are quite high, with more than 200,000 people being hospitalized and around 36,000 deaths every year. Getting the flu vaccine not only lowers your risk of getting sick, but it also protects the people around you, too.2 With the risk of it turning into a serious and fatal threat, you should vaccinate against it to protect yourself and the ones you love.

What is the flu?

The flu is a disease that is caused by a virus. It is contagious, meaning it can be spread from person-to-person. It is spread when someone who has the flu sneezes, coughs, or talks and spread droplets. The droplets land on the noses or mouths of nearby people, or on surfaces that were near the sick person. If other people touch the surface and then touch their mouth, nose, or eyes, they can also get infected with the flu.2

Some common flu symptoms include:

  • Fever and chills
  • Cough
  • Sore throat
  • Runny/stuffy nose
  • Muscle/body aches
  • Headache
  • Feeling tired2

More serious complications of flu include:

  • Pneumonia
  • Inflammation of the brain or heart
  • Worsening of a health condition, such as asthma or heart failure
  • Sepsis (a life-threatening infection)2

Who Needs It?

It is recommended that everyone who is able to get the vaccine who is 6 months of age or older should receive the vaccine every season.3 There are some people who are at high risk of developing flu complications, so it is important to receive the vaccine if you fall into the following categories:

  • Children younger than 5 years, but especially children younger than 2 years
  • Adults 65 years and older
  • Pregnant women
  • Women up to 2 weeks postpartum
  • Residents of nursing homes and other long-term care facilities
  • American Indians and Alaska Natives
  • If you have certain medical conditions (asthma, heart disease, chronic lung disease, etc).4

Children who are between 6 months to 8 years require 2 doses of the vaccine if they are getting vaccinated for the first time or if they have only gotten one dose.5 Receiving two doses will provide children with a better immune response and more protection.5 The two doses should be separated by at least 28 days. For adults, only one dose per season is necessary. Research has shown no benefit in boosting immunity in adults who have received two doses in the same flu season, even in elderly people who have weakened immune systems.6

*There are some groups who should not get the vaccines. These include children younger than 6 months, if you have had a life-threatening allergic reaction to the flu vaccine or an ingredient it contains (eggs or gelatin), or if you have Guillain-Barrré Syndrome (an immune system disorder).2

Side Effects of Flu Shot

The most common side effects usually affect the area of injection, such as redness, pain, or swelling of where you received the shot.2 Other side effects are headaches, muscle aches, fever, or an upset stomach. These side effects usually go away in a few days. It is rare to get a serious side effect from the flu vaccine, but the person administering the vaccine can observe you for any serious side effects. The flu shot will not cause you to get the flu; it serves to boost your immune response to prevent the flu.

Sign Me Up

The benefits of getting the flu vaccines drastically outweigh the risks of the vaccine. Even though you may risk getting a sore arm or a headache, you still walk out with a lower chance of getting infected with the flu. Preventing the flu helps to keep you from developing the more serious complications, such as being in the hospital with pneumonia or even death. The best time to get vaccinated is usually the end of October, but you can still get vaccinated throughout the flu season.6

Receiving the flu shot in January or later is still better than nothing, since flu season can last as late as May. Your local pharmacy should have the flu vaccine available during flu season, and there is usually no appointment necessary. The next time you step into your local pharmacy, stop by and ask your pharmacist when you can get the flu vaccine so you can protect you and your loved ones.

Resources:

  1. NIH Fact Sheets – Influenza. National Institutes of Health. https://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=133. Accessed November 28, 2018.
  2. S. Department of Health and Human Services. Flu (Influenza). Vaccines.gov. https://www.vaccines.gov/diseases/flu/index.html. Published October 11, 2006. Accessed November 28, 2018.
  3. Influenza (Flu). Centers for Disease Control and Prevention. https://www.cdc.gov/flu/professionals/vaccination/vax-summary.htm. Published September 6, 2018. Accessed November 28, 2018.
  4. Influenza (Flu). Centers for Disease Control and Prevention. https://www.cdc.gov/flu/about/disease/high_risk.htm. Published August 27, 2018. Accessed November 28, 2018.
  5. Influenza (Flu). Centers for Disease Control and Prevention. https://www.cdc.gov/flu/protect/children.htm. Published November 8, 2018. Accessed November 28, 2018.
  6. Influenza (Flu). Centers for Disease Control and Prevention. https://www.cdc.gov/flu/about/qa/misconceptions.htm. Published September 25, 2018. Accessed November 28, 2018.

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

Diabetes, Cancer, HIV, seizures, pregnancy, organ transplant… chances are high that you or someone you know have experienced or are currently suffering from one of these conditions. But what do they all have in common? They’re all diagnosed or screened for with lab tests. Diagnostic lab test results influence approximately 60 to 70 percent of medical decisions. Without lab tests, we wouldn’t know what to do!1

What Are Lab Tests?

A lab test is searching for something specific in your body, and can use your blood, saliva, urine, feces, breath, or organ tissue (tissue biopsy). These tests can help you and your physician determine the presence, absence, or extent of disease or monitor the effectiveness of a treatment2. They are performed by having blood drawn, spitting into a cup, having your cheek swabbed, urinating into a cup, or breathing into a special device. Some examples of lab tests you may already be familiar with are a DNA test to determine if a man is the father of a child, a urine drug test for employment, an HIV screen to test if someone does or does not have HIV, a finger-prick blood sugar test, or an alcohol breath test (breathalyzer).

Why Should I Get a Lab Test?

If you’re experiencing any unusual symptoms, a lab test may help guide you toward a diagnosis. For example, if you’ve been feeling tired and fatigued lately a lab test may determine if your thyroid is underperforming, if you have anemia, if you have an electrolyte imbalance, or if you’re developing a chronic disease such as diabetes. Sometimes, lab tests are repeated to confirm a diagnosis. If you know you’re a carrier for a disease or have a close relative with a disease you should be screened regularly3.

Catching a condition or disease early gives you more treatment options, more opportunity for lifestyle modifications, and saves you time and money4. Screenings help establish a baseline that is unique to you, and some screenings (such as breast or colon cancer) become mandatory with age. A lab test can determine how well certain organs are working, and monitor their function – most especially the kidneys, liver, heart, thyroid, and pancreas, this is especially handy as you age.

Anyone needing an organ transplant or anyone wanting to donate an organ or blood will have blood typing and compatibility testing done. Certain medications, called narrow therapeutic index drugs, as well as antibiotics, are monitored to make sure those levels don’t get too high or too low and verify treatment is working. Lab tests also can be used to substantiate specific events; such as an exposure to heavy metals, or the administration of a rape kit.

What Lab Tests are Important?

Critical or required lab tests vary by individual and their current health levels. An 80-year-old man with diabetes and a foot infection is going to need different tests than a healthy 28-year-old pregnant woman. Some lab tests are precise and reliable, while others provide general clues to possible health problems. For a generally healthy individual, some common tests that are done at your routine checkup that establish your baseline are things like:

  • Complete Blood Count (CBC) which differentiates types of blood cells
  • Comprehensive Metabolic Panel (CMP) that determines your cholesterol, hormone levels, electrolytes, and enzymes;
  • Hemoglobin A1C (HbA1C or A1C) which measures how much sugar is attached to your hemoglobin (the stuff in your blood that carries oxygen) and determines your risk of developing diabetes.

If you have an infection, a culture and sensitivity test will be ordered so your physician knows what the offending bacteria is and the appropriate antibiotic to treat it. Participating in your own health care is paramount to your well-being, so ask your doctor what tests are right for you.

Important Questions to Ask Your Doctor Before Having a Lab Test5

  • What will this test measure? A patient on the “blood-thinner” warfarin would want to check their INR, a patient with diabetes would measure their A1C. Knowing what you’re measuring will ensure you get only the necessary tests.
  • Why is this test necessary? Someone that has seizures may need their medication levels monitored to ensure the levels are safe and appropriate. A person with an unsteady gait may need a test to rule in or rule out Huntington’s Disease. If it’s necessary, your doctor will be able to explain the test and why.
  • Are there risks or side effects to this test? Most lab tests are benign, but some do come with some risks or negative side effects. A biopsy patient may want to have someone else to drive them to and from their appointment. Ask your physician so you can prepare accordingly.
  • How do I prepare for this test? Some tests require fasting, others require drinking a special preparation beforehand, while some require no preparation at all. Every test is different, but it’s important to follow the directions so you don’t have to repeat the test.
  • What results should I expect from this test? Results can be confusing. Sometimes you want a positive, sometimes you want a negative, other tests you may want a high number or a low number. Understanding what a normal value is will help you to interpret your result.
  • How often will I need to do this test? As mentioned earlier, some tests will be repeated to ensure the diagnosis is correct. Some screenings are done annually to monitor any changes.  Some tests are daily or weekly. Other tests are only done once, so be sure to ask how often a test is needed.

If you don’t understand something, be sure to ask your doctor to explain it to you. Some additional factors that may influence your lab test results are:

  • age
  • sex
  • race
  • weight
  • diet
  • alcohol or tobacco use
  • caffeine intake
  • stress level, and,
  • hydration status

Always request a copy of your results, and retain it for your personal medical record. After all, it is your health!

References

  1. Ngo, Andy, et al. “Frequency That Laboratory Tests Influence Medical Decisions.” The Journal of Applied Laboratory Medicine, The Journal of Applied Laboratory Medicine, 1 Jan. 2017, jalm.aaccjnls.org/content/1/4/410.
  2. Kennedy, A G. “Evaluating Diagnostic Tests.” Journal of Evaluation in Clinical Practice., U.S. National Library of Medicine, Aug. 2016, ncbi.nlm.nih.gov/pubmed/27091221.
  3. Elmore, Joann G. “Screening for Breast Cancer.” JAMA Internal Medicine, American Medical Association, 9 Mar. 2005, jamanetwork.com/journals/jama/fullarticle/200479.
  4. Yong, PL. Saunders, R. and Olsen, L. (2018) Missed Prevention Opportunities from The Healthcare Imperative: Lowering Costs and Improving Outcomes Roundtable. Available at https://www.ncbi.nlm.nih.gov/books/NBK53914
  5. Talking with your doctor. No author. Available at https://www.nia.nih.gov/health/doctor-patient-communication

 


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by Randall Flores, PharmD Candidate 2019
University of Arizona

Bleeding can manifest itself in a variety of different ways which, at times, may not be easy to recognize. Some bleeds are also more serious than others and may require emergency medical attention. Bleeding frequency may also vary depending on a variety of factors such as underlying bleeding disorders or the use of certain medications.5

Potential Signs of Different Types of Bleeding

Gastrointestinal Bleeds5 
  • Bloody or black, tar-like stool
  • Weakness
  • Paleness
  • Swollen or firm abdomen
  • Vomiting or coughing blood
  • Abdominal or stomach pain
Urinary Tract Bleeds5  
  • Bright red or brown-colored urine
  • Pink urination
  • Frequent urination
  • Pain while urinating
  • Lower-back pain
Nosebleeds5  
  • Prolonged headache
  • Confusion, lethargy, and/or slurred speech
  • Discomfort to bright light
  • Double vision
  • Enlarged pupils or different size pupils
  • Dizziness and/or stumbling
  • Stiff neck or back
  • Seizures
  • Irritability
  • Loss of appetite
  • Sudden or forceful vomiting not due to upset stomach
Throat Bleeds5  
  • Choking
  • Vomiting or coughing up blood
  • Swelling or discoloration in the neck
  • Change in tone of voice
Eye Bleeds5  
  • Swelling or pain within or around the eye
  • Reddening of the white part of the eye
  • Double or blurred vision
  • Change in vision

Monitoring Lab Results While Taking Anticoagulants

Anticoagulation therapy is vital to the prevention and treatment of thromboembolic diseases; however, close monitoring is very important to treat and prevent harmful adverse effects. Lab monitoring is an important part of anticoagulation therapy to determine if it is necessary to counterbalance the anticoagulant effect of the drug4. Each drug has its own recommendations on lab monitoring depending on how it works in the body and possible adverse effects.

Coumadin (warfarin) remains the most prescribed oral anticoagulant medication worldwide despite the higher risk for bleeding compared to alternative anticoagulants1. The use of warfarin entails frequent blood tests and patient education about food and drug interactions4. The laboratory test that are most frequently monitored are prothrombin time (PT) and international normalized ratio (INR). PT is a test used to measure the number of seconds it takes for a clot to form3. INR on the other hand, is a more standardized PT measure so that it may serve as a reference value on how to adjust the dose depending on the result3. Higher INRs represent thinner blood, while lower INRs represent thicker blood.  [ Read more on our blog post, Losing the War With Warfarin? ]

New oral anticoagulants (NOACs) now formally known as direct oral anticoagulants (DOACs) have a few advantages over the use of warfarin. DOACs include dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis). One of the biggest advantages over warfarin is that DOACs typically do not require dose adjustments and routine monitoring4. There are however some recommendations of monitoring certain parameters in patients with specific circumstances and comorbidities. Kidney function is an important parameter to monitor because all DOACs are eliminated by the kidney and impairment is a risk factor for bleeding1.

Antidote Medications to Reverse the Effects of Anticoagulants?

There are several reversal agent options for warfarin, despite its challenging management. The reversal agents used for warfarin include phytonadione (vitamin K), fresh frozen plasma (FFP), and prothrombin complex concentrate (PCC)2. The availability of these agents makes warfarin a viable option for patients who are at increased risk of bleeding and enables it to still be recommended by guidelines2.

DOACs are becoming more popular due to safety and efficacy over other anticoagulants, however only one of these agents has an FDA-approved reversal agent. Praxbind (idarucizumab) received accelerated FDA approval due to its promising results in clinical trials as a reversal agent to dabigatran (Pradaxa)2.

Currently, there is one agent called andexanet alfa that in phase III clinical trials as a reversal agent to the remaining DOAC agents2. As the use of DOAC agents become more popular, the need for effective antidotes is demanded.

Whether a someone is on anticoagulant therapy or not, it is important for people to have a general understanding about bleeding risks and how to identify different types of bleeds. Patients on anticoagulant therapy should also have a general idea about the monitoring that their therapy entails, potential risks, and management of those risks. The more patients know, the lower their chance of hospitalization from bleeding.

References:

1 Conway, S. E., Hwang, A. Y., Ponte, C. D., & Gums, J. G. (2016). Laboratory and Clinical Monitoring of Direct Acting Oral Anticoagulants: What Clinicians Need to Know. Pharmacotherapy, 37(2), 236-248. doi:https://doi.org/10.1002/phar.1884

2 Griffiths, C., Vestal, M., Livengood, S. and Hicks, S. (2017). Reversal agents for oral anticoagulants. [online] The Nurse Practitioner. Available at: https://journals.lww.com/tnpj/fulltext/2017/11000/Reversal_agents_for_oral_anticoagulants.2.aspx [Accessed 21 Sep. 2018].

3 Hull , R., Garcia, D., Vazquez, S. (2018). Warfarin (Coumadin) Beyond the Basics. UpToDate. Retrieved from https://www.uptodate.com/contents/warfarin-coumadin-beyond-the-basics

4 Ramos-Esquivel, A. (2015). Monitoring anticoagulant therapy with new oral agents. World Journal of Methodology5(4), 212–215. http://doi.org/10.5662/wjm.v5.i4.212

5 The Basics of Bleeding Disorders. (2018). National Hemophilia Foundation. Retrieved September 19, 2018, from https://stepsforliving.hemophilia.org/basics-of-bleeding-disorders/identifying-types-of-bleeds


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by Randall Flores, PharmD Candidate 2019
University of Arizona

In the past few decades, there has been an alarming and steady increase in obesity rates in the U.S. This affects people of all races and ages. More Americans live with obesity than breast cancer, Alzheimer’s, Parkinson’s and HIV all together. The medical community has been aware of the rising epidemic for many years, yet its response has not been effective at addressing the problem.

What is a Healthy Weight (BMI)?

Obese or overweight is defined as weight that is higher than what is considered a healthy weight for a given height measured as Body Mass Index (BMI)1. The levels of weight measured by BMI are listed below:

  • BMI < 18.5 = underweight
  • BMI 18.5 to <25 = within normal weight
  • BMI 25 to <30 = overweight
  • BMI >30 = obese

The Facts About Obesity

With an estimated population of 328.73 million people in the U.S.,6 the prevalence of obesity was 39.8% between 2015-2016, affecting nearly 93.3 million people.1 The estimated health care cost of obesity was $147 billion in 2008 which was $1,429 higher than those of normal weight. Obesity seems to have a racial/genetic link as Hispanic and non-Hispanic blacks had the highest prevalence with 47% and 46.8% respectively.2 Much of the obesity seen in the U.S. starts at a younger age and transcends into adulthood with a prevalence of 18.5% (ages 2-19) nearly affecting 13.7 million children.2 Similar to adults, obesity in children is more common in certain populations; Hispanics having the highest prevalence (25.8%) followed by non-Hispanic blacks (22%).2

Obesity-Related Health Conditions

The most common obesity-related diseases that result in premature deaths include type 2 diabetes, heart disease, stroke, and certain types of cancers such as colorectal, pancreatic, and endometrial cancer.1,4 People who have obesity are also at increased risk for serious diseases including the following;3

High blood pressure Low quality of life
High levels of bad cholesterol &
low levels of good cholesterol
Sleep apnea & breathing problems
Gallbladder disease Mental illness, depression, anxiety, &
other mental disorders
Osteoarthritis Body pain & difficulty with physical functioning

A Push for Prevention

The epidemic of overweight and obese citizens in the nation is complex and has no simple solution. There are many factors that play a role in obesity. Due to its complexity, the epidemic of obesity needs to be approached through multiple outlets, with tactics in local, state, and federal organizations as well as professional health organizations.5 The long-term goal to decreasing obesity is shifting to norms of a healthy lifestyle, which include healthy eating and regular physical activity.5 Healthcare should also shift more of its efforts towards preventing obesity. Another key player in reversing the obesity epidemic is implementing community efforts that support a healthy lifestyle, such as food services, schools, childhood care, and clinics/hospitals.

Obesity and being overweight affects millions of people in our nation and worldwide. Obesity is associated with an increased risk of many serious diseases that are otherwise preventable. We must shift our efforts to the epidemic of obesity to halt its progression and strive towards a healthier future for younger generations to come.

 

References:

  1. Adult Obesity Facts | Overweight & Obesity | CDC. (2018). Retrieved from https://www.cdc.gov/obesity/data/adult.html
  2. Children Obesity Facts | Overweight & Obesity | CDC. (2018). Retrieved from https://www.cdc.gov/obesity/childhood/index.html
  3. Adult Obesity Causes & Consequences | Overweight & Obesity | CDC. (2018). Retrieved from https://www.cdc.gov/obesity/childhood/index.html
  4. Obesity and Cancer. (2018). Retrieved from https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet
  5. Strategies to Prevent Obesity. (2015). Retrieved from https://www.cdc.gov/obesity/strategies/index.html
  6. S. and World Population Clock. (2018). Retrieved from https://www.census.gov/popclock/

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by Heather Lee, PharmD Candidate
University of Arizona

A Guide to Medication Warnings

When you visit the dentist, you expect to answer typical questions regarding your oral health, such as how often you are brushing your teeth or the infamous question of whether or not you floss. It may surprise you when your dentist asks what medications you take at home. Why would it matter if the dentists knows what you’re taking? Many medications, which includes prescriptions, over-the-counter, and even herbal medications, can affect your oral health and it is important for the dentist to know what you take so they can determine the best course of action for your oral health.

Blood Thinners

Many patients are currently on blood thinners or antiplatelet therapy to prevent the risk of blood clots. Common examples of blood thinners include warfarin (Coumadin), dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto), and edoxaban (Savaysa). Common examples of antiplatelet medications include clopidogrel (Plavix), ticlopidine (Ticlid), prasugrel (Effient), ticagrelor (Brilinta), and/or aspirin. Taking these medications is important to prevent blood clots, but they can also increase the risk of bleeding, especially during a dental procedure. The risk increases if you are taking multiple medications to prevent clots.  It is important for the dentist to know if you are taking these medicines so they can take extra precautions to prevent bleeding, such as stopping the medication temporarily or controlling the bleeding through local measures. They can control the bleeding through various methods, such as mechanical pressure, agents that stop the bleeding, or suturing. The dentist can make a more informed decision with what they want to do with the medication when they have a better knowledge of the type of medication you’re taking, your bleeding risk, and what procedure you’re going in for.1

Dry Mouth

Having a dry mouth can be caused by a variety of different factors, such as a medication’s side effect, having a certain medical condition, or personal habits (mouth breathing and alcohol/tobacco use).

Saliva plays an important role in maintaining your oral health through multiple ways by:

  • Reducing the population of bacteria in the mouth
  • Neutralizing acid caused by bacteria, which damages your teeth
  • Repairing tooth enamel that may have been damaged by acid
  • Washing food particles away2

A lack of saliva can cause dry, cracked lips, bad breath, infections in your mouth, and cavities. Medications that can cause this include medications used to control allergies, asthma, blood pressure, pain, and depression.

Your dentist can help by:

  • Recommending a special gel or rinse to keep your mouth moist
  • Prescribing or applying a fluoride containing toothpaste or mouthwash to prevent cavities3

Other ways to relieve this symptom can include:

  • Chewing sugar-free gum or sucking on sugar-free hard candies to increase the flow of saliva
  • Sucking on ice chips
  • Drinking water with meals to help with chewing and swallowing food
  • Using alcohol-free mouthwash
  • Avoiding carbonated drinks, caffeine, tobacco, and alcohol
  • Using a lanolin-based lip balm to soothe dry lips3

Enlarged Gum Tissue

There are some medications that may increase your risk of getting enlarged gum tissue, which is also known as “gingival overgrowth”. This is usually associated with antiseizure medications (phenytoin), immunosuppressive drugs (cyclosporine), and calcium channel blockers (including nifedipine, verapamil, diltiazem, and amlodipine). If your dentist is aware you are taking these medications, they may encourage you to do professional cleaning more often throughout the year and educate you on how to improve your brushing technique.4

Jaw Pain

There have been some reports of individuals who had difficulty healing or jaw pain after going through invasive dental procedures or even a tooth extraction. This can be due to bone death caused by a lack of blood supply (osteonecrosis). The common factor in these individuals were that they were taking a medication from the bisphosphonate class. Bisphosphonates are usually used to prevent bone weakening or destruction and are commonly prescribed to treat osteoporosis. Examples include risedronate (Actonel), zoledronate (Zometa), alendronate (Fosamax), and ibandronate (Boniva).

Over 90% of cases were in patients receiving an IV form of the drug. The risk is thought to be less than 1% of patients receiving an IV form, but they were at least ten times more likely to be affected than those who took the oral form. If you are on this medication, your dentist can discuss ways to minimize the risk of needing invasive procedures, such as tooth extractions and surgery. They may consider more conservative treatments, such as a root canal procedure. They can provide preventative advice regarding whether you need professional cleaning more often, how to observe any changes in your mouth, and how to be more careful with taking care of your teeth and gums.5

The following may increase your risk of developing jaw pain:

  • Older age (greater than 65 years)
  • Treatment with chronic corticosteroids
  • Long-term use of bisphosphonates
  • Gum infection that damages the gum and can destroy the jawbone (periodontitis)6

Signs to watch out for:

  • Gum wounds that heal very slowly or do not heal for six weeks or more after a procedure
  • Exposed bone
  • ”Roughness” on gum tissue
  • Pain if the open wound becomes infected
    • Pus or swelling
    • Numbness, especially in the lower jaw, if the infection lasts long enough5

Current treatment options include:

  • Antiseptic rinses to help prevent the growth of bacteria
  • Antibiotics
  • Cleaning/removal of dead bone from the affected area
  • Possible referral to a specialist or a surgeon for further evaluation5

Updating Your Dentist Regarding Medications

These are just a few of the reasons of why it is important to inform your dentist regarding what medications, over-the-counters, and herbal supplements you take. Your dentist can take extra precaution when you come in and educate you as to the best way to maintain your oral health when they are aware of what medications may be affecting it. The next time you go in, bring an updated medication list so your dentist is on the same page as to what you are taking at home.

References:

  1. Anticoagulant and Antiplatelet Medications and Dental Procedures. https://www.ada.org/en/member-center/oral-health-topics/anticoagulant-antiplatelet-medications-and-dental-. Accessed October 31, 2018.
  2. Department of Health & Human Services. Teeth and drug use. Better Health Channel. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/teeth-and-drug-use. Published June 30, 2014. Accessed November 1, 2018.
  3. Managing dry mouth. The Journal of the American Dental Association , Volume 146 , Issue 2 , A40
  4. Staff SBI. Gingival Enlargement. The American Academy of Oral Medicine. http://www.aaom.com/index.php?option=com_content&view=article&id=132:gingival-enlargement&catid=22:patient-condition-information&Itemid=120. Accessed November 2, 2018.
  5. Staff SBI. Bisphosphonate Therapy. The American Academy of Oral Medicine. http://www.aaom.com/index.php?option=com_content&view=article&id=78:bisphosphonate-. Accessed November 2, 2018.
  6. Dental management of patients receiving oral bisphosphonate therapy. The Journal of the American Dental Association. 2006;137(8):1144-1150. doi:10.14219/jada.archive.2006.0355.

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by Eli Kengerlinski, PharmD Candidate 2019
University of Florida, College of Pharmacy

Congestive Heart Failure (CHF), occurs when your heart muscle doesn’t work as well as it should to pump blood. Some conditions, like narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to pump efficiently. Most patients struggling with CHF usually present to the hospital with shortness of breath, the most frequent symptom in patients with deteriorating CHF.1 It is crucial to be able to identify if your CHF is worsening. Early management of CHF can prevent hospitalization and equip you with the proper knowledge to identify trigger factors, improve the signs and symptoms of heart failure, and help you live longer.

Presenting CHF Symptoms

Usually CHF patients present to the hospital with worsening symptoms of:

  • Shortness of breath and/or difficulty breathing while lying down
  • Weight gain (over 2 kg), usually due to leg or ankle swelling caused by fluid retention.

However, there are major medical conditions reported in literature that can occur simultaneously in a patient with CHF, such as Chronic Obstructive Pulmonary Disease (COPD) and Coronary Heart Disease (CHD).1 Therefore, patients hospitalized with worsening CHF can be admitted for more than one reason such as pneumonia (respiratory infection due to COPD worsening), pulmonary edema (fluid built up in lungs due to CHF), or CHD event (heart attack or stroke).

Hospital Readmissions

Patients readmitted following COPD exacerbation have 10-20% readmission rate within 30 days post hospital discharge, especially during May to November compared to January indicating seasonal admissions.4 Accordingly, it is crucial to use your inhalers, as prescribed with proper technique throughout the year, and inform your doctor if your symptoms are getting worse during seasonal changes. Also, management of other conditions like CHF, high blood pressure and cholesterol, can help reduce COPD readmission rates, as one condition can worsen another if not properly managed.

How to Tell if  Your Condition is Worsening

Congestive Heart Failure Chronic Obstructive Pulmonary Disease
Shortness of breath when active or at rest Shortness of breath, especially when active or during exercise
Shortness of breath when lying down or at night Chronic cough (dry or productive) with clear white, yellow, or greenish mucus
Wheezing & coughing Wheezing
Rapid or irregular heartbeat Chest congestion, tightness, discomfort
Swelling in your ankles & feet Unintended weight loss
Frequent urination especially at night Increased usage of short acting inhalers
Weight gain of 2-3 lbs/day or 5 lbs/week Frequent respiratory infections
Feeling fatigued or weak Feeling fatigued or weak

Preventing Emergency Room Visits and Hospitalizations

While you may not be able to prevent every return trip to the emergency room or hospital, there are some steps you can take to help minimize the possibility:

  • Patient Centered care: Effective communication and rapport between healthcare professionals and patients are crucial in preventing hospitalizations. Patients can have precipitating factors due to their other health conditions therefore reporting on signs and symptoms of worsening conditions are important as it would enable the health care provider to practice preventive medicine and construct appropriate treatment strategy after an effective patient assessment.
  • Medication Adherence: Being adherent to your medication therapy will prevent disease progression, hospitalizations, as well as additional health care costs.2 There are multiple tools and resources to help patients overcome barriers such as access to medicine, forgetfulness, improper administration technique, perceived side effects, cost, as well as understanding of their disease state and how to appropriately manage their condition. If you have any issues with adherence, make sure to inform your provider as effective communication will provide you optimal treatment.
  • Vaccines: COPD admissions are seasonal as studies show strong association with the flu season, however every patient is unique and can have worsened symptoms during seasonal changes, therefore it is highly recommended to get your flu and pneumonia vaccines to decrease chances of readmission.
  • Diet & Lifestyle Modifications:
    • CHF: Limit your salt and fluid intake, as increase in salt intake can pull water into your body and cause you to swell up. Therefore, it is crucial to weigh yourself every morning to ensure you do not gain more than 2-3 pounds in a day or 5 pounds in a week. If your medication or limited salt intake is not helping you control your fluids, seek your provider immediately as this is a sign for deteriorating CHF.
    • COPD: Current smokers should seek smoking cessation as it is the most effective in minimizing symptoms and risk for respiratory infections. Furthermore, COPD patients should avoid dust as well as indoor and outdoor air pollutants. Make sure to follow up with primary care provider within 7 days after discharge for lab tests and assessment to ensure
    • CHD: Controlling your blood pressure as well as your cholesterol will reduce the risk for heart attacks as well as stroke. For patients at a higher risk for heart attacks should have NTG sublingual tablets at hand and report to their provider if they start to experience chest pains more than usual as this can indicate a risk for another heart attack. Obesity is also associated with worsened cholesterol and high blood pressure therefore managing your weight as well as your disease states can put you at a lower risk for heart attacks and stroke.

If you’re having trouble managing your disease states, talk to your doctor for a referral to a dietician and/or lifestyle coach who can aid in minimizing your risk for readmissions.

 

References:

  1. Shafazand, Masoud et al. “Patients with Worsening Chronic Heart Failure Who Present to a Hospital Emergency Department Require Hospital Care.” BMC Research Notes5 (2012): 132. PMC. Web. 12 Oct. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315737/
  2. Jimmy, Beena, and Jimmy Jose. “Patient Medication Adherence: Measures in Daily Practice.” Oman Medical Journal3 (2011): 155–159. PMC. Web. 12 Oct. 2018.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191684/
  3. Ziaeian, Boback, and Gregg C. Fonarow. “The Prevention of Hospital Readmissions in Heart Failure.” Progress in cardiovascular diseases4 (2016): 379–385. PMC. Web. 12 Oct. 2018.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4783289/
  4. Simmering JE, Polgreen LA, Comellas AP, Cavanaugh JE, Polgreen PM. Identifying patients with COPD at high risk of readmission. Chronic Obstr Pulm Dis. 2016; 3(4): 729-738. doi: http://doi.org/10.15326/jcopdf.3.4.2016.0136

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by Pawel F. Kojs
University of Arizona College of Pharmacy

Living with diabetes is not an easy task, however, you are not alone. Roughly 415 million people across the world are affected with this disease. If you have diabetes, you should consider several things, such as lifestyle, medication adherence, and check-ups with your healthcare provider. These are important to make sure that your diabetes is controlled and doesn’t lead to a deterioration in your overall health. Keeping blood sugars controlled can prevent serious problems like diabetic cardiomyopathy, stroke, and atherosclerosis4. An ounce of prevention is worth a pound a cure.

Tests to Keep Your Diabetes in Check

According to Kaiser Permanente, there are several exams that a person living with Diabetes should consider1:

Weight and blood pressure: checked at every doctor’s visit.1

A1C (Glycosylated hemoglobin): This is a test that is meant to be done every three months. Blood test that shows your average blood sugar for the past two to three months. This is done by measuring the amount of glucose attached to your blood cells1.

The A1c target is usually less than 7% for people with diabetes. However, your provider will decide the ideal A1c target for you3.

Urine check: This annual test is done to look for small proteins which show signs of early kidney damage1.

Lipid blood test: This test performed once every two years checks the level of your triglycerides, total ( “good” and “bad” cholesterol)1.

The following tests are recommended to be checked every 2 years if you have Type 2 Diabetes with no symptoms, or had Type 1 Diabetes for more than 5 years1

Eye Exam: Diabetes can affect your vision. Exams checks for any nerve damage of the eye. If you have nerve damage of the eye then it is recommended to see the doctor yearly1.

According to the American Diabetes Association (ADA) guidelines, pregnant women with preexisting type 1 or type 2 diabetes, the exam should be done in the first trimester. Patients should then be monitored at every trimester and for 1 year after giving birth2.

Foot Exam: Diabetes can affect your feet. This test performed at least annually is to examine the feet. Tests are done more often if you have any positive findings1. This checks for any numbness, sores, infections, and calluses1,3.

Vaccines: According to the ADA, vaccines are recommended for diabetic patients. The flu vaccine is recommended for all people greater than 6 months of age. A 3-dose series of Hepatitis B vaccine should be given to people ages 19-59. People over the age of 60 should be considered for a 3 dose Hepatitis B vaccine. A PPSV23 Vaccine is recommended for people between the ages of 2-64 years of age and after age 65, the PPSV23 vaccine is necessary even if you had a vaccine in the past2.

Diabetes management does not end in the doctor’s office. It all starts with the goals that you have set out for yourself. Whether it’s controlling your blood pressure or reducing your weight, this requires small and achievable goals. Set a goal too big and you will become overwhelmed. Talk over your goals with your healthcare provider. Putting in a consistent effort to maintain or achieve your diabetic goals will produce worthy results.

 

References:


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

Nearly 20% of Americans have self reported an allergy to a medication and roughly 4% of the nation suffers from some form of food allergy.1 While it would seem obvious to avoid something if you’re allergic to it, you’d first have to know you’re allergic. When it comes to medications this can be challenging.

There are different grades to an allergic reaction. It could be as mild as some pesky itching or a cough; a more serious fever, rash or painful blisters; or very serious blood irregularities, difficulty breathing or death.2,3 Allergic reactions can occur within many different classes of medications such as antibiotics, antidepressants, anesthetics, narcotics, nonsteroidal anti-inflammatory drugs (NSAIDs), among others.1

Excipients – Crucial for Drug Delivery

When you take medication, there is more than just an active drug inside the tablet, capsule, spray or syrup; these additional “inert” products are called excipients4. Excipients play a variety of roles in medications. They are used to stabilize the active drug, bind the active drug(s), increase the solubility, enhance or delay absorption (such as enteric coated tablets), and provide flavor or sweetness.4 Some excipients come from foods that people have an allergy to. The most common food allergies in the United States are milk, egg, peanut, soy, fish, and gluten.5 The Food Allergen Labeling and Consumer Protection Act (FALCPA) was enacted to inform patients if a major allergen was in their food, even in trace amounts. This carries over to medications, however, this information comes and stays with the original bottle, it will not be transferred to the prescription label. These food and drug allergies are why the pharmacy will ask for your allergy information when creating your profile and before dispensing any medications. Different manufacturers use different excipients in their preparations, so you may be allergic to one brand and okay to take a different brand. If you would like to know if an allergen is in your prescription, ask your pharmacist.

Milk: Milk allergy, sometimes called lactose intolerance causes discomfort in the digestive tract whenever dairy products are consumed. There are other enzymes in milk that people may be allergic to such as casein. Lactose is used as a stabilizer in some asthma inhalers and as a filler (excipient) in some tablets. Other milk products can be found in TUMS smoothies, as well as some vaccines, so be sure to ask your doctor or pharmacist to avoid an allergic reaction.5,6

Egg: Those with an egg allergy should be cautious of vaccines that use egg as a stabilizer and certain hospital drugs for intravenous use as some patients have had an anaphylactic reaction. The CDC has said that the Flu vaccine is safe, even in people with an egg allergy but there are egg-free versions of the vaccine available. IV Benadryl and the sedative propofol are two medications that contain egg. Again, make sure any health care professional that considers you a patient knows your allergy history as it is important for your safety.5,6

Peanut: Peanut is a well-recognized allergy alert and as such is not found in many medications. The package inserts for progesterone capsules and valproic acid capsules have peanut as an ingredient. Dimercaprol lists peanut oil and there is peanut oil in some asthma inhalers and the topical medication fluocinolone.6  There are alternatives to any of these medications for anyone with a peanut allergy that would also need one of these medicines.

Soy: Soy can be listed as soy or as one of its derivatives – lecithin. Again, it can be found in some inhalers and propofol5. Some over the counter products I’ve discovered that have soy are Advil liquid-gels, TUMS smoothies, and black cohosh (an herb sometimes used to treat perimenopause and menopause symptoms). Be sure to read the ingredient list when choosing an over the counter medication or ask your pharmacist if you are unsure if an allergen is in a product.

Fish: Fish products can be found in some (not all) multi-vitamins and supplements, which highlights the importance of reading labels. A reversal agent for the anti-coagulant heparin called protamine contains some derived fish products. NPH insulin also contains some fish oil, so diabetic patients with a fish allergy needing a short acting insulin could choose a different insulin.3,5 There are case reports of patients with a fish allergy trying fish oil and not experiencing a reaction, if you would like to try the fish oil test then ask your doctor.

Dyes: One final excipient that causes a reaction in some patients is medical dye. Most specifically FD&C Blue 1, Blue 2, Red 4, and FD&C Yellow 5. These colors can be used in many different medications, your doctor or pharmacist would need to check to ensure these dyes aren’t in any of your medications7.

This is not a complete list of possible allergens or medications that may contain allergens. If you have ever experienced a reaction to a food, medicine, or dye be sure to inform your primary care doctor, pharmacist, and any specialists that you see. Document your reaction so that you can remember what happened if a health professional asks you about your allergy. Questions about possible allergens can be answered by your prescriber, pharmacist, poison control center, or manufacturer of your medication so never hesitate to call and ask. Any patient that has ever experienced an anaphylactic reaction should wear a bracelet advertising the allergy.

 

References

  1. Macy E, Ho NJ. Multiple drug intolerance syndrome: Prevalence, clinical characteristics, and management. Ann Allergy Asthma Immunol2012; 108:88–93
  2. Stevenson, DD. Sanchez-Borges M. Szczeklik, A. Classification of allergic and pseudoallergic reactions to drugs that inhibit cyclooxygenase enzymes. Ann Allergy Asthma Immunology 2001; 87:177
  3. Demoly P, Adkinson NR, Brockow K, et al. International Consensus on Drug Allergy. Allergy 69:420-437, 2014
  4. Lesney, Mark S. More than just the sugar in the pillToday’s Chemist at Work. 10(1): 30–6, 2001
  5. Kelso JM, Davis C. Food Allergy Management. Immunology and Allergy Clinics of North America 2018; 38:53-64
  6. Kelso JM. Potential food allergens in medications. Journal of Allergy and Clinical Immunology. Jun 2013; 133(6):1509-18
  7. Swerlick RA, Campbell CF. Medication dyes as a source of drug allergy. Journal of Drugs in Dermatology. Jan 2013; 12(1):99-102

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