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A deep dive for pharmacists into this frequently debilitating disorder

Cannabinoid Hyperemesis Syndrome: Diagnosis and Management

journal explores issues within pharmacy, from the impact advocacy can have in community pharmacies to staffing shortages across multiple sectors within pharmacy. This month’s issue also explored the importance of disease awareness months and how they are opportunities to maximize valued care. Check out a preview of this month’s issue here.

download the PDF of the Total Pharmacy August 2024 issue here

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See what’s trending in pharmacy with a preview of the Total Pharmacy August issue.

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In This Issue: Total Pharmacy August 2024

Combining sodium glucose co-transporter 2 inhibitors (SGLT2is) with glucagon-like peptide-1 receptor agonists (GLP-1RAs) may offer additional protection against cardiovascular and kidney disease in patients with type 2 diabetes (T2D), according to the results of a new meta-analysis published in 

 and presented at the 61st European Renal Association Congress in Stockholm, Sweden.

Separately, SGLT2is and GLP-1RAs have demonstrated cardiovascular benefits. However, little clinical literature has focused on outcomes associated with using the medicines together. Due to the growing prevalence of GLP-1RAs in the 

 and obesity landscape, accelerated by an increasing number of indications for the agent class, this is a crucial area for further study.

The SGLT2 Inhibitor Meta-analysis Cardio-Renal Trialists’ Consortium (SMART-C) is the largest assessment of outcomes for the combined therapeutic use of SGLT2is and GLP-1RAs. The study gathered data from 12 large-scale, placebo-controlled trials of SGLT2is involving 73,238 patients with diabetes. Of these, 3065 were already receiving GLP-1RAs.

Overall, SGLT2is lowered the risk of major adverse cardiovascular events by 11% and hospitalization for heart failure or cardiovascular death by 23% compared to placebo. Notably, this benefit was seen regardless of whether patients were also taking GLP-1RAs.

When used together with GLP-1RAs, SGLT2is reduced the risk of chronic kidney disease progression by 33% and slowed the annual loss of kidney function by nearly 60%.

The study found no additional safety concerns when SGLT2is were used in combination with GLP-1RAs.

Study Reveals Robust Benefits of Semaglutide in Protecting Against Kidney, CV Events in Patients With T2D

Current meta-analysis results build off positive results of the landmark FLOW trial (

). Published earlier in May, results of the international, double-blind, randomized, placebo-controlled phase 3 trial spotlighted semaglutide’s effectiveness in lowering the risk of kidney failure, decelerating worsening kidney function, and protecting against the risk of cardiovascular events and death, in patients with T2D.

“SGLT2 inhibitors have clear protective effects against heart failure and chronic kidney disease, while GLP-1 receptor agonists can reduce the risk of heart attack, stroke, and also kidney disease—as recently demonstrated in the landmark FLOW trial,” said Brendon Neuen, lead author, clinical associate professor, senior research fellow at The George Institute for Global Health, and director of kidney trials at Sydney’s Royal North Shore Hospital, in a news release.

 “Our findings support using this combination to further improve outcomes in patients with type 2 diabetes who meet guideline recommendations for both therapies.”

Elevated glucose from diabetes can damage blood vessels in the heart and kidneys, increasing the risk of 

 and kidney disease. In fact, diabetes is the most common cause of chronic kidney disease.

Moreover, estimates predicting that T2D prevalence will more than double in the next 30 years, surpassing 1 billion global cases by 2050, further strengthen the need for research into diabetes care.

 According to Neuen in an interview with 

 conducted over email, the current study offers valuable insights for developing global treatment strategies for the condition.

"These findings, which represent the largest and most comprehensive evaluation of the combined use of SGLT2i and GLP-1RA, provides the clearest evidence yet that combined use of both medicines can further reduce cardiovascular and kidney disease," said Neuen. "We anticipate that these findings will inform how people with diabetes are treated worldwide, including influencing major clinical practice guidelines.

Although current results suggest that using SGLT2is and GLP-1RAs in tandem may offer robust protection against cardiovascular and kidney disease, further research is needed to fully understand the long-term effects of the combination therapy.

Pharmacy practice is always changing. Stay ahead of the curve: Sign up for our 

 and get the latest drug information, industry trends, and patient care tips, straight to your inbox.

1. Apperloo E, Neuen BL et al. Efficacy and safety of sodium glucose co-transporter 2 inhibitors with and without glucagon-like peptide-1 receptor agonists: A SMART-C collaborative meta-analysis of randomised controlled trials. 

. 2024. doi: 10.1016/S2213-8587(24)00183-9

2. Massaro L. Study reveals robust benefits of semaglutide in protecting against kidney, CV events in patients with T2D. 

https://www.drugtopics.com/view/study-reveals-robust-benefits-of-semaglutide-in-protecting-against-kidney-cv-events-in-patients-with-t2d

3. Combining popular diabetes drugs offers complementary heart and kidney benefits. News release. The George Institute for Global Health. July 9, 2024. Accessed July 10, 2024. 

https://www.georgeinstitute.org/media-releases/combining-popular-diabetes-drugs-offers-complementary-heart-and-kidney-benefits

4. Mayo Clinic Staff. Chronic kidney disease. Fact sheet. Accessed July 8, 2024. 

https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521

5. Klein HE. Diabetes prevalence expected to double globally by 2050. 

https://www.ajmc.com/view/diabetes-prevalence-expected-to-double-globally-by-2050

When used together, sodium glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) were able to lower the risk of major adverse cardiovascular events and kidney disease by 11% and 33%, respectively.

Clinical

SGLT2i, GLP-1RA Combination Therapy Offers Robust Protection Against Cardiovascular, Kidney Disease

Measles, a highly contagious viral disease,  recently emerged as a significant public health concern in the United States, challenging the progress made through decades of vaccination efforts. Once considered eliminated in the country by 2000, measles is now experiencing a resurgence that highlights the critical importance of maintaining high vaccination rates. As of April 2025, the Centers for Disease Control and Prevention (CDC) reported 712 cases across more than 20 states, with Texas and New Mexico bearing the brunt of the outbreak, accounting for approximately 90% of all cases, according to Crystal Hodge, PharmD, associate professor of pharmacotherapy at The University of North Texas Health Science Center at Fort Worth.

The current outbreak serves as a stark reminder of the disease's potential severity and transmissibility. Before widespread vaccination in the 1960s, measles caused approximately 500,000 annual cases in the United States, leading to 500 deaths, 50,000 hospitalizations, and 1,000 instances of permanent brain damage. Today, with 97% of current cases occurring in unvaccinated individuals, the outbreak underscores the vital role of immunization in protecting public health. The virus's extraordinary contagiousness—with the ability to infect 12 to 18 people per infected individual in a vulnerable population—makes vaccination not just a personal health choice, but a critical community responsibility.

"For measles, this has one of the highest R naughts that we have ever studied, with an R naught of 12 to 18," Hodge said. "For every 1 person who has an active measles case, they are expected to infect 12 to 18 other people, assuming, again, a vulnerable, naive population, which is one of the reasons why vaccines are so important."

What is the current landscape of measles in the United States?

So I think it's important to think about this in the context of prevaccine versus what we're currently experiencing. The prevaccine era, generally, this is about before the 60s or so, the 1900s. We had about 500,000 cases of measles per year that led to actually about 500 deaths from measles per year, roughly 50,000 hospitalizations, and about 1000 people every year who ended up with permanent brain damage from encephalitis, which is a potential complication for measles. So that's the historical context. Thankfully, we are not at that point right now. Because of vaccines, we actually for a long time, like between 2000 and roughly 2019 [to] 2024, we really only had about 63 cases per year, roughly 4 outbreaks. An outbreak is 3 or more cases in a year. So, we really were able to eliminate measles from the US; in 2000 we actually did eliminate measles from the US. This year what we are seeing, and last year we actually also saw a big outbreak, but this year, we currently have about 712 cases, so nowhere near where we were in the prevaccine era, but still more than what we normally see. These numbers are as of April 11 from the CDC, so about 712 cases, and that's total. So that's across 20+ states. Now, not all 20 states have a current outbreak. There are about 6 or 7 active outbreaks that are currently ongoing, and of those, the highest counts are in Texas and New Mexico. They account for about 90% of the current outbreak or cases, and most of the current case counts are in our kids, unfortunately. About a third of the cases are in kids less than 5 years old, so probably haven't finished the MMR vaccine series. We do have almost 40% that are between 5 and 19 [years.] But even of the cases that we're seeing, the 712 cases, about 97% of them are in people who are either unvaccinated—maybe they're not eligible yet, because I mentioned that there are some that are really young—or they have unknown vaccine status, and of the cases that we've seen, about 12% of them are being hospitalized, and we've had 3 deaths so far. That's where it currently stands.

Which states are most affected by the current measles outbreak, and what are the reported case numbers?

So, this is a little bit hard to tell, because all of the health departments have a different date that they're reporting. Some of them report on Fridays, and some of them report on Tuesdays and Thursdays. So it kind of changes depending on when you [view it,] and that's why you're seeing so many differences in the numbers of what people are reporting is because it depends on when people are when the health departments are reporting to the national registry into the CDC. The current outbreak is largely based in Texas, with some spillover into New Mexico. That counts for about 90% of cases. In Texas alone, and this updated April 15, there have been 561 cases in Texas, and the vast, vast majority of those have been associated with the ongoing outbreak in West Texas. Only about 7 cases so far are not associated with the outbreak in West Texas, and the majority of the cases that are occurring are in those who are unvaccinated or have an unknown vaccination status. About 175 of those are, again, in our kids that are 0 to 4 [years], so really not able to complete the vaccine series, or right around the age that they should be completing the series. We have had 56 people that are been hospitalized in Texas, and we've had 2 kids who are not vaccinated and had no underlying conditions who, unfortunately, did pass away. The second highest outbreak has been in New Mexico, and as of [April] 12, they had 58 cases, and their epidemiology is a little bit different. About half of their cases are actually in adults, and the 1 death that they had was in an unvaccinated adult, so a little bit of a different makeup, but it does seem to be largely related to that outbreak in West Texas; geographically, they're close by each other. We've got some other states with ongoing outbreaks, Kansas [and] Ohio, for example, and then other states are also seeing active outbreaks, but nowhere near the same numbers as what we're seeing in Texas and in New Mexico.

What are your biggest concerns regarding the recent measles outbreak in Texas?

One of the biggest concerns in Texas is that the reason why it was able to become such an outbreak is because of the low vaccination rates in that in that particular community where it was imported, and unfortunately, I think that one of the things that the COVID pandemic highlighted is that there tends to be a lack of trust and goodwill in health care, and so there is concern that there are going to be growing numbers of larger communities that are unvaccinated or have below the threshold of vaccination needed for herd immunity, and that's going to potentially leave people. Vulnerable to ongoing outbreaks, and one of the reasons why it's been difficult to get this current outbreak under control. So we really need to be thinking about herd immunity. The current vaccination rate that's recommended in order to kind of stop measles in its tracks is through the vaccination rates of greater than 95% or higher, and in some communities in West Texas, the vaccination rates were as low as 50%. I have heard some reports that have been a little bit lower. So that's one of the reasons why you have so many people who are vulnerable to measles and one of the reasons why that outbreak has been difficult to contain. Other things that I'm worried about are some of the social consequences from this degradation in societal trust, right? Like we're trusting our communities to be able to protect people who don't have the option to get vaccinated. Not everyone is eligible for the vaccine, and so I have a lot of sympathy for those people. I work with a very large immunocompromised patient population, for example, and they're not eligible for a live vaccine like MMR. Other things to think about, or to at least have on your radar, are that sometimes measles can have very rare but serious [adverse] effects like the like encephalitis, which is a type of brain infection, and sometimes that can occur 7 [to] 10 years later, after the initial infection. So this is not only the acute infection but the potential downstream effects, and something that we're still investigating is something called immune amnesia. So after having an active measles infection, you can wipe out prior immunity that's been built up through other exposures. Now that's not to say that you can't build that back up, but you don't want to get sick, right? So, that's something that we're actively trying to investigate is what is the impact of immune amnesia from a measles infection.

How does the contagiousness of measles compare to other common infectious diseases?

Yeah, this one's interesting, because how do you measure contagiousness? Well, in the public health literature, we have a value called R naught. You may have heard this because there was a lot of discussion around it when COVID first came out, but R naught is really the reproduction number. So it's the average number of people who will contract the disease in a naive population. So we're assuming that everyone is vulnerable. There's no vaccination, something like that. To give you a frame of context for something like tuberculosis, which is known worldwide for causing significant harm mortality, it's in all the history books that are not for that is about 0.5 to 1. So for every one person who is infected, they're expected to infect another person. For the Spanish flu, the 1918 Spanish flu, that was an epidemic the R naught was around 2 to 3, so every one person that came down with the Spanish flu, they would infect about 2 to 3 other people. For smallpox, that was about 5 to 7. For another vaccine preventable infection, like chicken pox that we all probably got before the vaccine came out, this is a vaccine preventable condition, the R naught is about 10 to 12. So for every 1 person that got chicken pox, another 10 to 12 people that were susceptible to chicken pox would come down with chicken pox. For measles, this has got one of the highest R naughts that we have ever studied, with a R naught of 12 to 18. So for every 1 person who has an active measles case, they are expected to infect 12 to 18 other people, assuming, again, a vulnerable, naive population, which is one of the reasons why vaccines are so important. Other things to think about with the contagiousness of measles is that this is an airborne infection. So it can actually hang around in the air for about 2 hours, and it can live on surfaces for about 2 hours. The incubation period is about 2 weeks, and so you could be exposed and not know it for several weeks, and you actually can spread the disease from 4 days before you have the classic rash like symptoms to 4 days after the rash appears. So you've got about 8 days where you are able to infect other people, and about 4 days where you may not even know that you are infected with it. So it's very, very contagious., and to the point where there are some statistics that say that 90% of people who are nonimmune, if they're exposed, will come down with the infection.

What are the appropriate steps a pharmacist should take if they suspect a patient has measles?

Well, first, before you potentially run into that scenario, I would recommend getting vaccinated so that you can protect yourself. So, try to make sure that that you are protected, first and foremost, and then second, it depends on what the situation is. So if someone is calling in and saying, "Hey, I think I've been exposed to measles," or "I think I have measles, what should I do?" Please, please, please, recommend them to get tested, whether that is at an emergency room or an urgent care, but before they show up anywhere, at any health care facility, they need to call and let them know, because, again, this is an airborne transmitted infection. It's highly contagious. There need to be proper precautions put in place, such as a negative pressure broom, appropriate air filters, all sorts of things. So they need to know ahead of time. So if someone's calling in, that's kind of the best scenario. You can tell them, don't show up anywhere without telling them. If the person is already there, and if they're a pharmacist and maybe they're face-to-face with them, try to isolate them as soon as possible. One of the interim recommendations is to go to a closed-off room so you could try to decrease the amount that it's spreading. There's not a whole lot of data behind this. It's just an interim recommendation, but really make sure that you're isolating them. Do not let them sit in waiting rooms and infecting other people. Contact your local health department. This is an immediately notifiable condition. I will say, the Texas Department of Health and Human Services actually do have a template script for triaging measles contacts for prophylaxis, for vaccinations, and whatnot. So there's some great resources with the Texas Health Department that are available online, but then you also want to make sure that you're asking people about their timing, so whether or not their last measles was exposure, if they happen to know within 72 hours, that's the ideal scenario. If it's been within 6 days, you need to know a little bit more about the exposure and about the patient to see whether or not we're talking about potentially using the vaccine or immunoglobulin, for example, but those are some of the things I would think about if you're a pharmacist in running into potential patients with with measles.

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Crystal Hodge discusses R naughts and the measures of how contagious measles is.

Expert: For Every 1 Measles Case, There Are Expected to Be 12 to 18 More

LucyRx’s Role in Supporting the Pharmacist Profession

Between a primary care shortage persisting in the US and the pharmacist’s positioning within their respective communities, the pharmacy profession has separated itself apart from other provider roles. However, David Blair, CEO of 

, a new-wave independent pharmacy benefit manager (PBM), still believes pharmacists are being underutilized because of declining reimbursement and antiquated provider regulations.

“We need to do a better job leveraging their experience because they're a trusted resource. Particularly, when you start thinking about the shortage in primary care physicians that we're facing as a country, we need to better benefit from what a pharmacist can offer,” he said.

In part 3 of our interview with Blair, he focused on the utmost importance of pharmacists within the drug supply chain. With their perspective as patient-facing providers interacting with the community, Blair believes prescription drug benefits should not be distributed without pharmacists in mind.

He discussed new initiatives designed to improve challenges within pharmacy deserts and ultimately improve the bottom lines of pharmacies struggling the most. Not only is LucyRx set out to revolutionize how pharmacies are paid for dispensing, but they’re also benefiting patient outcomes with their increased focus on pharmacists’ capabilities.

Watch the full video to find out about LucyRx’s mission to support pharmacies and the employees that support their efforts. Also, stay tuned for the full-length podcast version of our conversation with Blair, releasing on Drug Topics’ Over the Counter podcast channel this coming Thursday afternoon.

Pharmacists’ Expertise Can Improve Patient Outcomes in Transitions of Care

David Blair, CEO of LucyRx, joined Drug Topics to discuss the initiatives his company is conducting in support of a struggling pharmacy profession.

The use of medications for treating acute or chronic pain has become a taboo subject in the US as of recent history. Amid a nationwide opioid crisis and the potential rescheduling of drugs like cannabis, the options patients have for treating their pain are vast but not standardized—whether they are prescription drugs or over-the-counter (OTC) products.

In other words, there is a plethora of options for treating pain, but no one option is significantly preferred over others.

“When it comes to the OTCs, the over-the-counter pain management options, we really do have a decent amount of them,” said Mark Garofoli, PharmD, BCGP, CPE. “An individual scenario is going to come down to what a patient has going on, and as health care professionals, we're patients too, so whatever is in our head.”

Garofoli, a certified pain expert, recently joined 

 to discuss common trends in OTC medication use for pain as he’s been working in the pharmacy industry since 2001.

What Pharmacists Should Know About Psychedelic Medicine | APhA 2025

“Most folks, if not all, don't really think about this, but analgesia, where'd that come from?” he continued. “The name just rolls off the tongue now, after [about] a century of experience, but it's derived from Greek to mean ‘without pain.’ So, we literally put out in the aisle a sign that says, ‘Without Pain,’ making that the goal.”

In part 1 of our interview with Garofoli, he delved into current understandings of the OTC space in treating pain. He also discussed emerging OTC options, specifically topicals, that have potential to make waves in the marketplace but are still lacking in efficacy and safety research.

: In your experience as a pharmacist, what are the most common and effective OTC medications that have been used to treat acute pain?

When it comes to the OTCs, the over-the-counter pain management options, we really do have a decent amount of them. An individual scenario is going to come down to what a patient has going on, and as health care professionals, we're patients too, so whatever is in our head. We have those biases based on direct-to-consumer advertising, word of mouth, you name it. Usually we're talking about a pharmacy, but it could also be a grocery store, convenience store, gas station, dollar store, whatever type. [In those places,] we have that analgesics aisle. Most folks, if not all, don't really think about this, but analgesia, where'd that come from? The name just rolls off the tongue now, after [about] a century of experience, but it's derived from Greek to mean “without pain.” So, we literally put out in the aisle a sign that says, “Without Pain,” making that the goal. We have to keep that in mind with folks too. Is that the goal? We certainly want to be compassionate here but is it always the goal is a really good conversation question, of course.

When we're thinking about what people are looking for, it's typically the pill formulations. We have OTC non-steroidal anti-inflammatory drugs (NSAIDs), our most common being ibuprofen, naproxen, and, of course, aspirin in there as well, too. Then [there’s] acetaminophen, or as the entire rest of the world calls it, paracetamol. Good golly, it's like the metric system, but with a pain medicine. We're the only ones. We drive our own truck here in that regard. But those are a lot of the common ones. Topicals: It seems like a new frontier; takes up a lot of the aisles, lots of options out there. And boy, it gets confusing really quick, because it's like, which one, when there's 15 different versions, maybe 10, of each individual product. At least in our society, our culture, it's typically the pill formulations, but our horizons are expanding these days.

: What are the most notable trends you’ve seen in patient preferences for specific over-the-counter pain relief products?

I alluded to the idea of, we typically go to the pill formulations, sometimes liquid as well, too; it depends on the scenario. When our kiddos are in pain or having fevers, oh my goodness, it's like we make it Calc 3 for dosing and we don't even put it on the label. As far as trends overall, you have pill formulations, oral formulations. But then there's a growing trend, and this is observational, don't necessarily have a study, they're out there, but what about topical formulations? It's growing. That being said, are we catching up with the rest of the planet? I mean, when you go to a different continent—not necessarily just outside of our country—it's a very different landscape. The preference, the trends in many other continents would be topical first. Is that right, wrong? It depends on the scenario, of course, too, but we're starting to see some of that shift overall, because there's more education. Yes, there's more marketing out there too, but there's more education as to how to go about pain management when you, I, as the patient, are in charge over the counter.

I think it remains to be said, of course, cannabis and CBD, everything these days, on the tips of everyone's tongue. So topical CBD seems to be a thing. We've had some interesting recent articles with that. Probably one of the most in-our-faces titles and headlines I've seen, a study came out, and literally, the title was like, “Hey, topical CBD, not really working out for pain,” and boy, that catches headlines. It's like the media didn't even have to change the headline; the title was right there. Again, that's one study; there are many others. We have to stop that insanity of going by one study, unless it's quite the profound one. So, those are some of the big-picture trends overall, I'd say.

Stay tuned for more from our conversation with 

, as he further explains OTC medications used for treating pain and the importance of pharmacist counseling among patients using these products.

Ready to impress your pharmacy colleagues with the latest drug information, industry trends, and patient care tips? Sign up today for our 

Expert on pain medicine, Mark Garofoli, PharmD, BCGP, CPE, CTTS, joined Drug Topics to discuss trends in the safety and efficacy of OTC pain medications and what products patients often seek at the pharmacy.

Q&A: What are the Current, Emerging Trends in OTC Pain Management?

Navigating Legal and Billing Challenges in Pharmacists’ Clinical Services

The legal and billing challenges within the business of pharmacy have historically served as road blocks for independents looking to maximize revenue. While the end goal of independent pharmacy business is to bring valued care to the community, navigating these challenges is almost just as important in order to financially support a pharmacy’s ability to deliver care.

 Solutions Summit Spring 2025 event, Dae Lee, PharmD, Esq, CPBS, and shareholder at Buchanan, Ingersoll & Rooney PC, hosted a session titled Navigating Legal and Billing Challenges in Pharmacists’ Clinical Services: Compliance, Reimbursement, and Opportunities.

During the session, Lee went into detail about compliance, credentialing, and provider status of pharmacists. With his background in law, he provided a unique perspective, offering real-world evidence of the success, challenges, and opportunities often presented to community pharmacies.

“Pharmacies delivered millions of vaccines, testing services, [and] clinical consultation during [the COVID-19 pandemic]. Several states are qualifying that expanded scope and letting pharmacists initiate treatment, order labs, [and] bill insurers directly,” said Lee. “I think this is a chance to redefine our role of community pharmacies in care delivery, especially in the underserved area. We all need to take advantage of that [and] put a lot of pressure on those positive movements.”

Check out Lee’s full presentation from the 

Total Pharmacy Solutions Summit Spring 2025: Clinical Practice Expansion

Dae Lee, PharmD, Esq, CPBS, discusses the legal and billing challenges hindering pharmacy practices and opportunities to overcome them.

Jessica Calihan, MD

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