Drew Boxler

Pharmacy students looking for a unique internship experience should look no further than Colonial Williamsburg living history museum in Virginia. 

In 2018, Colonial Williamsburg’s apothecary store launched its first ever official internship for fourth-year pharmacy students. Having relied on history graduate students for years, this was the first time the museum opened an opportunity for pharmacists. 

Typically, pharmacy students might choose a professional internship in places one might reasonably expect to find a pharmacist (ie hospitals, community retail settings, etc); however, at Colonial Williamsburg, pharmacy students don 18

 century attire and interact with and educate tour guests. 

The apothecary shop in which pharmacy students are stationed, according to 

, stands as a reconstructed version of the original shop owned by 2 Virginian apothecaries, Dr William Pasteur and Dr John Minson Gault. 

In the 1770s, the 2 competing apothecaries decided to partner up. Colonial Williamsburg posits that the move was to simultaneously increase each other’s revenue while decreasing overhead costs. The partnership lasted until Pasteur’s retirement in 1778, but the shop remained open until Gault’s death in 1808. 

Today, the reconstructed shop is staffed by 2 full-time interpreters, Sharon Cotner and Robin Kipps. 

“We actually compound drugs from the original pharmacy books,” said Kipps. “When you walk into the shop, it’s like stepping back in time.” 

Throughout any given day, Kipps said tours can include anyone from lay public individuals to medical specialists like orthopedic surgeons and pharmacists. 

“We try to customize the presentation to what [the guests] are interested in,” she said. “If we have pharmacists come in, we can talk about some of the medicines from the 18

 century that are still in use today.” 

 century medicinal treatments with tour guests was one of the core experiences of the apothecary’s latest intern, Dena Kota. As a fourth-year student at the Virginia Commonwealth University (VCU), Kona chose to fulfill her experiential requirements to grow closer to her roots at Colonial Williamsburg. 

“I’ve grown up in Williamsburg most of my life,” she said, “and went to elementary school down the street from Colonial Williamsburg. The community is a part of something I’ve grown up in and [the internship] sounded like a unique way to gain a further appreciation of pharmacy history and how far the profession has come.” 

 published by VCU, Kota had to learn things like archaic measurements (drams and grains), interpret old textbook instructions for medicinal production, and build her public contact and speaking skills by describing her work to the tours that passed through the shop. 

VCU also describes how Kota dried foxglove flowers from the apothecary’s garden to make a treatment for edema, as well as her preparation of concoctions like a “tincture of Peruvian bark” that was used to treat malaria. 

Beyond the apothecary, Kipps says that the Colonial Williamsburg program specializes in other areas as well. “We have retired physicians, two retired pharmacists, and one naval officer who specialized in public health issues in the navy,” she said. 

The wide range of historical and medical experiences gives participating students the opportunity to interact with and learn from modern professionals as well as historians, Kipps said. 

“It’s cool to put yourself in [the apothecaries’] shoes, see the things they thought were important to document and how that compares to our approach today,” said Kota.

Feature and sidbar images courtesy of Colonial Williamsburg and Bill Munroe.

Articles

See how some students have opted for a unique conclusion to their studies.

Apothecary Offers Historical Internship for Pharmacy Students

Grifols, a global producer of plasma-derived medicines, announced the official launch of their new 20% subcutaneous immunoglobulin therapy, Xembify (immune globulin subcutaneous human-klhw), for the treatment of patients 2 years of age and older suffering from primary humoral immunodeficiency (PI). 

Originally approved in July, Xembify is Grifol’s first 20% subcutaneous immunoglobulin therapy. 

Xembify is contraindicated in patients with known anaphylactic or severe systemic reactions to human immunoglobulin or inactive ingredients of Xembify (ie polysorbate 80). Xembify is also contraindicated in patients deficient in immunoglobulin A (IgA), those with IgA antibodies, and a history or hypersensitivity. 

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A boxed warning issued with Xembify warns of the potential for thrombosis to occur in patients using immunoglobulin products. Risk factors listed in the warning include advanced age, prolonged immobilization, hyper coagulable conditions, history of venous or arterial thrombosis, use of estrogens, indwelling vascular catheters, hyperviscosity, and other cardiovascular risk factors. 

For patients at risk for thrombosis, Xembify should only be administered at the most practicable minimum doses and infusion rates. 

Other warnings and precautions issued with the use of Xembify include aseptic meningitis’s syndrome, which may occur within 2 days of treatment; hemolysis; pulmonary adverse reactions; infectious disease transmission due to human plasma origins; passive transfer of antibodies. 

Adverse reactions reported with the use of Xembify include infusion site erythema (redness), infusion site pain, infusion site swelling (puffiness), infusion site bruising, infusion site nodule, infusion site pruritus (itching), infusion site induration (firmness), infusion site scab, infusion site edema, and systemic reactions including cough and diarrhea.

Grifols launches Xembify 20% subcutaneous immunoglobulin, a new Primary Immunodeficiency treatment [news release]. Grifols’ website. https://intranet.grifols.com/documents/38081080/89399853/np-20191212-en.pdf/2a829e8e-9efe-48f8-aa7c-b01956b9520b. Accessed December 16, 2019.

Xembify Prescribing Information. Xembify’s website. https://www.xembify.com/documents/90180901/0/xembify+prescribing+information+-+2019+-++3054808/9ff0e9a4-1249-4cd7-8b10-3ce50a8fad5d. Accessed December 16 2019.

Grifols Launches Xembify, A New Primary Immunodeficiency Treatment

The Institute for Safe Medication Practices (ISMP) announced new additions and several modifications to their best safety practices at the 2019 Annual American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting & Exposition. 

ISMP’s best practices were initiated in 2014 to identify, inspire, and mobilize adoption of consensus-based best practices for specific medication safety issues (ie events that continue to cause harmful and fatal errors in patients despite repeated warnings). Reviewed and updated every other year, the practices provide a focus for medication safety efforts and strategic plans for both hospitals and other health care settings. 

For 2020-2021, ISMP has updated 5 best practices, added a new classification, and introduced 2 new best practices. 

: Verify and document patient’s opioid status and type of pain before prescribing and dispensing extended-release and long-acting opioids. 

: Restrict medications available using override in automated dispensing cabinets (ADC) to those that would be needed emergently (as defined by the organization). Sub rules include the limitations of the amount of medications that can be removed using the override function; requiring medication order prior to removing medication from ADC, including the override function; monitoring the ADC overrides; and listing the medications available using override functions. 

: Ensure that all oral liquid medication that are not commercially available in unit dose packaging are dispensed by the pharmacy in an oral or ENFit syringe. 

The best practice has been updated to include an enteral syringe that meets the International Organization for Standardization (ISO) 80369, such as ENFit.

: Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale. In addition, if patients are taking an oral liquid medication after discharge, supply them with (or provide a prescription for) oral syringes, to enable them to measure oral liquid volumes in milliliters (mL).

Now includes the suggestion to educate patients to request appropriate oral dosing devices to measure oral liquid volumes in milliliters only. 

: Administer high-alert intravenous (IV) medication infusions via a

programmable infusion pump utilizing dose error-reduction software.

This best practice has been generalized to include all “medication infusions” instead of “high-alert IVs”. 

8b: Maintain a compliance rate of greater than 95% for infusions administered using dose error-reduction software.

8c: Monitor compliance with use of smart pump dose error-reduction software on a monthly basis. 

8d:  If your organization allows for the administration of an IV bolus or a loading dose from a continuous medication infusion, use a smart pump that allows programming of the bolus (or loading dose) and continuous infusion rate with separate limits for each.

: Independent verifications should be performmd and directed at all sterile preparations. 

The previous version of this best practice directed independent verification at high-alert, high-risk medications. 

: Eliminate injectable promethazine from the formulary. 

The previous version directed this rule toward hospitals

: glacial acetic acid removal from the hospital is now archived due to high levels of compliance. 

Two new best practices, a new classification, and 5 updated existing rules.

ISMP Unveils 2020-2021 Best Safety Practice Updates at ASHP Midyear

As the use of both medical and recreational use of cannabis become more common with increased legalization of these products across the United States, new challenges continue to emerge, including relating to use of medical marijuana within health systems.

Pharmacists at the 2019 Annual American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting & Exposition gathered for a roundtable discussion on this subject, touching on an array of issues including policy confusions, the best practices to reduce stigma, and how to have discussions with primary care providers. 

One pharmacist from the University of Las Vegas Medical Center said that some confusion exists at her hospital about defining those patients who are uing products that meet standards set for legal products. Herbal medications, she said, are not allowed. 

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Another pharmacist brought up the issue of responsibility for potential interactions with cannabidiol (CBD) use. At his health system, he said patients are allowed to use CBD, but it has to be pure, 100% CBD. If the product doesn’t meet that standard and the patient tests positive for THC, the clinician can be held accountable, since CBD and THC can effect patients differently.  

Stigma regarding marijuana use was one of the most prominent issues the panel discussed at the roundtable. 

A pharmacist that works in an outpatient clinic at the VA said that she, the VA’s practitioners, and pharmacists always ask about other complementary therapies that the patients may be taking. Although she noted that she couldn’t be certain that people were telling the complete truth about their marijuana use, she said patients will often be open to the discussion of their cannabis and CBD use. She noted that she doesn’t necessarily tell her patients to stop using marijuana, but she does inform them that the healthcare industry does not have enough information on the contents of the products and that patients consequently need to use caution when using the products. 

As an example of the lack of awareness of interactions, she provided a case-based experience from her medical center, specifically, a patient prescribed an opioid who had tested positive for marijuana. The patient swore he was not taking marijuana, but indicated that he was using CBD oil. “Was it possible that the patient could test positive for THC while using CBD,” the physician asked? The pharmacist responded: yes. She then advised the physician and told the patient that the opioid prescription would stop. To resume treatment, the patient would need to return in a month after suspending use of CBD. 

The roundtable panel agreed that patient education was needed on this topic.

One pharmacist said that his health system had developed an FAQ brochure that addressed basic things patients should look out for such as drug interactions and adverse events. The brochure covers pharmacist and protects patients by ensuring that pharmacists are taking care of patients as best as they can, given the little amount of information currently available. 

The ASHP moderator said that they might look into developing a similar education leaflet and will possibly work to provide something similar on their website in the future. 

Controversy in Cannabis: Cannabidiol Products and Health-System Approaches. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8-12, 2019. Las Vegas, Nevada.

Takeaways from a roundtable at ASHP 2019.

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Sponsored in cooperation with Amgen, the ASHP Best Practice Award Winners have been recognizing pharmacists who demonstrate leadership and innovation in enhancing patient care and other areas of pharmacy practice since 1999. 

“These pharmacist-led teams applied bold thinking and creative approaches to address critical medication-use issues,” said ASHP CEO Paul W. Abramowitz, Pharm.D., Sc.D. (Hon.), FASHP in a statement. “This award is a fitting recognition of their inspiring work to improve the quality of care patients receive in all healthcare settings and expand the pharmacist’s role on the healthcare team.”

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, Kaiser Permanente, Northern California Region, Oakland, Calif.

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, Wake Forest Baptist Health, Winston-Salem, N.C.

Candace M. Dixon, Pharm.D., BCACP, CPP, MSCR

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Interdisciplinary health care teams that incorporate pharmacists, physicians, and nursing staff into diabetes care, as well as increased use of continuous glucose monitoring systems are likely to improve outcomes for these patients as evidenced by results presented at the American Society of Health-System Pharmacists Midyear Clinical Meeting & Exposition being held in Las Vegas this week.

 at the meeting, Maj. Jacob Mock, PharmD, of Eielson Air Force Base in Alaska noted his team routinely received complaints about their predominately military dependent and retiree diabetic population’s need to conduct blood glucose fingerstick measurements multiple times per day. 

From the spring of 2018 into the summer of 2019, the team started 61 patients on a continuous glucose monitoring (CGM) system. The patients were monitored by a collaborative care team that included physicians, nurses, and pharmacists.  The physicians on the team would use glucose data from the CGMs to alter medications as needed and provide patient-specific recommendations, nurses on the team provided initial patient education and phone triage for needed supplies, and pharmacy staff dispensed the supplies and provided ongoing patient and provider support. 

Patients were treated by medical staff based upon current guidelines appropriate to comorbidities, blood glucose, and hemoglobin A1c levels, regardless of whether or not the patient received CGM or continued their regular fingerstick measurements. 

Maj Mock said that he was “blown away” but the number of patients whose hemoglobin A1c values dropped below 7% and 8% from baseline, with about 10 patients showing dramatic declines using the CGM system. 

Since the majority of the patients in the study were type 2 diabetics, the researchers noted that further research is needed to confirm the benefits of an intervention like this in patients with other types of diabetes. 

Mock J, Worthington B, Willett A. Use of Continuous Glucose Monitoring (CGM) in a Military Outpatient Clinic Setting. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8, 2019. Las Vegas, Nevada.

Based upon results from a military population study presented at ASHP 2019.