Karen Appold

As the COVID-19 pandemic drags on, the pharmaceutical industry continues to face uncertainty regarding the stability and quality of the drug supply chain. The American Society of Health-System Pharmacists (ASHP) provided both insight into and recommendations on how to combat supply chain issues in its 2021 ASHP Foundation Pharmacy Forecast.

 Now—nearly a year later—the report’s authors and other experts have come together to discuss what progress has been made to address supply chain issues.

Of the 272 forecast panelists surveyed, 90% thought that at least 75% of health systems would develop guidelines through ethics committees or similar processes to allocate finite resources during a disease pandemic. 

Although Erin R. Fox, PharmD, senior pharmacy director at University of Utah Health in Salt Lake City and an author of the ASHP report, said there isn’t a tracking mechanism to determine how many health systems have developed allocation guidance, the Centers for Medicare & Medicaid Services requires that all hospitals have policies in place regarding drug shortages. 

“The pandemic forced most hospitals to develop strategies for using limited resources,” said Fox. For example, when remdesivir (Veklury) first became available through an FDA emergency use authorization (EUA), no hospital received the amount it needed to treat all patients who could qualify under that EUA.

Paige Clark, RPh, vice president of pharmacy programs and policy at  Prescryptive Health, Inc in Redmond, Washington, said that health care systems have been preparing for a COVID-19 scenario since 2009 when the influenza A virus emerged globally. These preparations, she noted, were made with the understanding that an influx of infected patients would strain all parts of the health care ecosystem.

But even with these preparations in place, COVID-19—more specifically, the Delta variant surge in July and August—considerably strained numerous health systems, including those in Florida, Oregon, and Texas. From a national perspective, Michael Ganio, PharmD, MS, BCPS, FASHP, senior director of pharmacy practice and quality at ASHP in Bethesda, Maryland, said that the federal government, medical corporations, and other organizations have been able to identify vulnerabilities in the supply chain and the ability of the United States health care system to respond to emergencies.

“Since the start of the pandemic, both [the] public and private sectors have taken steps to address vulnerabilities—such as addressing limitations of the strategic national stockpile or building more redundancy in supply chains—which should improve our nation’s ability to maintain access to necessary supplies and medications,” he said.

One key recommendation from a recent report by the FDA’s Drug Shortages Task Force2 was to develop a manufacturing quality rating system to provide incentives for drug manufacturers to invest in improving their facilities. Forecast panelists were almost evenly split on whether this would come to fruition. According to Fox, the FDA has recommended a ratings system since 2013 when Janet Woodcock, who headed the FDA’s pharmaceutical division at that time, first wrote how such a system could improve quality and shortages.

However, the FDA has yet to implement a ratings system, and the private sector cannot implement one without the necessary transparency. For example, pharmaceutical companies aren’t required to disclose the name of the company that made a particular product or the factory in which it was made. “Unless the United States Congress requires improved transparency from pharmaceutical companies, I don’t think the FDA will create a ratings system,” Fox said.

The ASHP report mentioned that congressional representatives have introduced multiple bills related to moving drug manufacturing back to the United States, but, Ganio said, there has not been much movement on these bills. There have, however, been executive orders from both current and previous administrations to increase domestic manufacturing. Similarly, the Biomedical Advanced Research and Development Authority, a division of the US Department of Health & Human Services, has made investments in increasing domestic production of some essential medications and their active ingredients.


But according to Ganio, moving drug manufacturing back to the United States alone is not a solution. “There are still some raw materials and precursor chemicals that are not made domestically,” he said. “The domestic pharmaceutical supply chain is also vulnerable to disruption, as we experienced with small-volume saline bags after Hurricane Maria in September 2017.


“Although these products are manufactured domestically, there were still severe, critical shortages of essential medications. Investments in supply chain resiliency, including redundancy and in new manufacturing technologies that can quickly scale up production, are also important strategies to ensure the United States maintains access to essential medications during an emergency.”

Regarding international markets as a source of lower drug pricing, most pharmacy panelists (68%) expected the United States to adopt rules to import prescription drugs from other countries as a way to help lower drug prices.

“Importation of prescription drugs has been proposed for decades, but prior presidential administrations were reluctant to push for more vigorous implementation of importation in the face of opposition by the pharmaceutical industry,” wrote the authors of the ASHP report. “While importation of single-source brandname drugs may not be feasible, FDA may develop pathways for responding to generic drug shortages (or price hikes) by facilitating the regulatory approval of overseas manufacturers of those products.”

Both the current and previous administrations have included importation in their plans to lower prescription drug prices, but progress has been slow, Ganio said, and there are some concerns with these potential plans. Ganio noted that importation may conflict with attempts to guarantee the pedigree of prescription drugs

that are required in the FDA’s Drug Supply Chain Security Act.3 Importation also requires a willingness of manufacturers and wholesalers to sell products from Canada to the United States; however, Canada —concerned with ensuring its own supply of medications—has repeatedly signaled that it may move to block the export of pharmaceuticals if the United States implements a drug importation program.

According to Clark, multiple factors need to be in place for the successful import of prescription drugs, including quality control and the supply chain to ensure the safety of United States citizens. “The process would need to have measures in place to ensure that drugs are made to US quality standards. The US has extremely stringent standards to protect the safety of its citizens,” she said. “Similarly, all aspects of the supply chain must be monitored so that there aren’t any delays, breakdowns, or any other activity that could compromise the security, quality, and delivery of drugs to the US.”

New manufacturing technologies can help improve the quality and reliability of pharmaceutical manufacturing, Ganio said. Continuous manufacturing is more agile than traditional batch manufacturing and can quickly scale up production in response to demand or shift production from one medication to another. “This type of scalable end-to-end manufacturing is a promising advancement in pharmaceutical manufacturing, but it’s expensive to adopt and will take years to implement,” he said.

Joseph T. DiPiro, PharmD, dean of the School of Pharmacy, Archie O. McCalley Chair and associate vice president for health sciences, faculty affairs, at Virginia Commonwealth University in Richmond, who is also an author of the ASHP report, noted that the United States has taken steps to develop a more secure domestic supply chain for generic drugs.

In May 2020, the federal government allocated $354 million to build a national stockpile of essential medications. Phlow Corp, a new company in Richmond, Virginia, is working with Civica Rx in Petersburg, Virginia, and AMPAC Fine Chemicals in Las Vegas, Nevada, on this effort.

According to Ganio, the prescription drug supply chain outlook for 2022 is anticipated to be the same as in 2021. “There are very big issues to address, and solutions will not be implemented overnight,” he said. “Barring any worsening of the pandemic or other geopolitical challenges or natural disasters, we will continue to manage drug shortages that mostly occur as a result of quality problems in manufacturing facilities.”

Recent escalation in shipping issues at ports and with trucking companies is alarming and also a threat to drug supply chains. “Trade restrictions, pandemics, and climate change continue to threaten the drug supply chain, posing an increased potential for drug shortages, and its future impact is unknown,” DiPiro said.

The 2022 ASHP Foundation Pharmacy Forecast is scheduled to publish in early December.

DiPiro JT, Fox ER, Kesselheim AS, et al. ASHP Foundation Pharmacy Forecast 2021: strategic planning advice for pharmacy departments in hospitals and health systems. Am J Health Syst Pharm. 2021;78(6):472-497. doi:10.1093/ajhp/zxaa429

FDA. Drug shortages: Root causes and potential solutions. Updated February 21, 2020. Accessed November 3, 2021. 

https://www.fda.gov/media/131130/download

Drug supply chain security act (DSCSA). FDA. Updated October 25, 2021. Accessed November 3, 2021. 

https://www.fda.gov/drugs/drug-supply-chain-integrity/drug-supply-chain-security-act-dscsa

Articles

As we head into 2022, the pharmaceutical industry still faces uncertainty
stemming from supply chain challenges.


Slow Going: Progress to Resolve Drug Supply Chain Issues Is Minimal

From home health monitoring devices to fitness tracking wearables, technology use in healthcare settings has significantly increased since the onset of the COVID-19 pandemic.

Because the pandemic necessitated a switch to virtual care, patients and providers alike embraced digital tools—like those that facilitate at-home self-monitoring, improve medication adherence, or help manage lifestyle habits like diet and exercise.

“Pharmacists can guide patients on the most appropriate tech tools to use based on patient-specific factors to ensure optimal management of their medical conditions,” said Briann Fischetti, PharmD, MBA, BCACP, AAHIVP, an assistant professor of pharmacy practice at The Arnold & Marie Schwartz College of Pharmacy and Health Sciences (LIU Pharmacy) at Long Island University in Brooklyn, New York.


Electronic Health Record Platforms Patients can use portals like Epic’s MyChart on their phone or computer, putting a tremendous amount of health information at their fingertips.


They can schedule appointments, receive test results, manage prescriptions, and review medical records. “I encourage every patient, even if they’re not comfortable with technology, to try out their health care providers’ patient portal. It’s a great way to engage with their care team and be an active part of their health care,” said Elizabeth Hall, PharmD, informatics pharmacist in outpatient pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio. Brooke Fidler, PharmD, associate professor of pharmacy practice at Long Island University’s LIU Pharmacy, is also a proponent of MyChart. 

“Many health systems use Epic as their electronic medical record system. It’s one of the more user-friendly portals,” she said. “[It] allows patients to message their provider for medication-related questions or refills.”

Hundreds of phone applications are geared toward monitoring medication adherence and managing chronic diseases like diabetes. “I recommend discussing a patient’s wants and needs for an application while also considering how technologically savvy they are,” said Maria Sorbera, PharmD, AAHIVP, BCACP, assistant professor of pharmacy practice at Long Island University’s LIU Pharmacy. Many applications are free or have tiered access. These applications are also great tools to assist motivated patients with improving their medication adherence and disease control, Sorbera added. 

In many cases, an app can also serve as a medication list for patients to bring to new providers or to refer to if they’re hospitalized. 

 helps users organize medications and improve medication adherence.
Users can enter all their medications, including the drug name, dosage, frequency, and indication, and set up reminders to take medication at certain times each day.

The Medifriend feature allows users to sync their app with that of a family member, letting others stay informed in case a dose is missed, according to Amanda Phoenix, PharmD, BCACP, CDE, an assistant professor of pharmacy practice at Touro College of Pharmacy and ambulatory care clinical pharmacist at BronxCare Health System in New York, New York. 

 can provide customized health plans based on individual user health goals, sex, age, and weight. Users can enter the foods they eat each day, then track calorie intake against a daily allowance, Phoenix explained.

This app uses the smartphone accelerometer to track steps and provides helpful workout and meal prep tips. 

 is for those who want to watch what they eat. Users can check nutrition labels and find the calories, carbohydrates, sugars, fat, sodium, and protein per serving.


“This app is ideal for patients who count carbs for diabetes management or for people who count calories to help lose weight,” Phoenix said. 

allows providers to access patient health information remotely. Users can manually add their blood glucose and message providers with questions if their blood glucose is out of range. This is a great tool for patient health information remotely. Users can manually add their blood glucose and message providers with questions if their blood glucose is out of range.

“This is a great tool for patients who require touch points between visits and appreciate a collaborative approach to their care,” Fischetti said.

Notifications and Reminders The simplest way to track medication reminders is by setting an alarm or calendar notification using the apps on a mobile phone.


“This can be a good option for patients with poor health literacy or for [older] patients who aren’t technologically savvy,” Fidler said. A daily alarm can also be set on most glucometers to remind patients to check their glucose. For those more comfortable with technology, some free phone apps give reminders for medication refills and medication dosing at a prescheduled time. Pill Reminder and MyTherapy can also be used to remind patients to take medications.

Messaging-based Platforms Messaging-based platforms provide ways for pharmacies and other health care providers to communicate with their patients.


“We encourage patients to take advantage of these messaging systems because sometimes it can be difficult to contact a health care provider by phone,” Sorbera said. Most of these platforms require a pharmacy or clinic to pay for the service but are usually free to patients. 

 is an all-in-one platform that allows patients to communicate with health care providers. Communications sent to patients are received as text messages with a confidential link that, when clicked, brings the patient to the messaging portal; patients don’t have to download an application.

MyChart also includes a messaging component for patients to contact providers, make appointments, and request medication refills.

For motivated patients, wearable monitors can be a great adjunct to medication therapy and can assist with lifestyle modifications, Fischetti said. Basic health tracking tools include fitness-specific wearables like Fitbit and more general devices like the Apple Watch. These wearable fitness trackers can help patients set realistic goals. “You can ask patients to track their activity for 1 or 2 weeks [and] then review their baseline activity,” Fischetti said. 

“From there, goals for the number of steps, calories burnt, and so forth can be set and monitored. Monitors also assist with accountability because patients know that we’ll review trackers when we meet.”

In general, Fiddler doesn’t recommend social media sites to patients.

“Due to the abundance of medical and medication misinformation on social media platforms, I have found that it’s best to avoid steering patients to social media for medication management,” she said. “Patients may want to independently use social media for support groups and social support; however, I may caution them to ask their health care provider before implementing [the] recommendations discovered on social media.”

Pharmacists can direct patients who are looking for updates—or notifications on specific medical-related issues in the news—to reputable social media sources, Sorbera said. For example, pharmacists can direct patients who want current information on COVID-19 to the CDC’s social media pages. 

Patients should ask their health care providers for suggestions before committing to any paid application subscriptions, Fischetti noted.

“It may be tempting to have advanced features, but many patients may not need these features and it’s best to learn how to navigate an application prior to buying a subscription,” she said. The most important factors to consider before recommending one of these tools is the patient’s level of health literacy, how tech savvy they are, their insurance situation, and their financial means.

“Unfortunately, insurers can hinder the use of many advanced tools for home monitoring,” Fidler said. “However...a number of free applications and simple tools [are available] to aid in medication adherence and disease state management.”

1. Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: aquarter-trillion-dollar post-COVID-19 reality? McKinsey& Company. July 9, 2021. Accessed November 10, 2021. 

https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality

Mobile apps and fitness trackers predate the COVID-19 pandemic but are being utilized more ever before. 

In the Era of Virtual Care, Tech Tools Facilitate Patient Provider Engagement 

Medications used to treat stroke are complex and their preparations are complicated. Pharmacists’ knowledge and familiarity with these brain-saving medications is crucial in the typically narrow time windows to effectively treat stroke patients, according to Deborah Sadowski, RPh, BSPharm, MHA, director of pharmacy services at Deborah Heart and Lung Center in Browns Mills, New Jersey.

“The pharmacist is uniquely positioned to assess the safety and appropriateness of these medications for each patient as well as dose and prepare them in a safe and expedient manner,” Sadowski said.

As a result, including pharmacists in stroke care teams can greatly improve patient outcomes. They can be incorporated into a stroke patient care team in a variety of practice settings, including inpatient units, outpatient clinics, and community pharmacies, in addition to emergency departments.

At Mount Sinai Hospital in New York, New York, clinical pharmacist Nicole Davis, PharmD, BCCCP, an assistant professor in the Department of Pharmacy Practice at Touro College of Pharmacy, also in New York, said the pharmacy team is alerted when a stroke patient arrives in the emergency department. When this occurs, a pharmacist will bring a thrombolytic directly to the bedside to assess eligibility as well as to compound the medication. The patient is then transferred to the neurology intensive care unit (ICU) or to a step-down unit or floor bed depending upon their condition, where they are followed by an ICU-trained pharmacist or inpatient pharmacist.

Kristina Stein, PharmD, a neurology clinical pharmacist at the University of Alabama at Birmingham Hospital, is part of a multidisciplinary team that responds to “code strokes.” She receives an alert when a patient has a neurologic change or event that could be concerning for a stroke. “Pharmacists can identify candidates for thrombolytic therapy and reduce time to thrombolytic therapy,” she said. Furthermore, they can facilitate adjunctive therapy, such as blood pressure control or reversing anticoagulation therapy in the case of hemorrhagic strokes.

Pharmacists can also participate in medication reconciliation, secondary stroke prevention, risk reduction, patient counseling and education, and transitions of care initiatives. Stein attends transition-of-care rounds, where she meets with an interdisciplinary group to review each patient with stroke. She also counsels patients who start oral anticoagulants during their hospitalization or who will start one after discharge, works with providers to choose the best agent for patients, and helps monitor heparin, enoxaparin, and warfarin.

Stein would advise smaller organizations to train some inpatient pharmacists in stroke care. First gauge staff interest, then have that group develop a continuing education presentation or other training session. Choose someone who is interested in this effort to take ownership and be responsible for developing house-wide education. The 2019 update to the 

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

 is a great place to start when developing education.

If an institution is looking for other ways to incorporate pharmacists into stroke care, opportunities exist with developing or reviewing stroke electronic order sets; completing competencies in stroke identification, management, and thrombolytic therapy administration; participating in stroke simulation education experiences; and serving on stroke committees, Stein added.

When looking to make a change, such as adding a pharmacist to a stroke care team, it’s helpful to have a physician promote it. After a pharmacist has joined the team, Alyssa Bernard, PharmD, a patient care pharmacist in the stroke unit and neurosensory ICU at Jefferson Hospital for Neuroscience in Philadelphia, Pennsylvania, recommends a few first steps. To begin with, she said, it’s important to review team- and unit-specific policies and procedures, as well as team- and unit-specific disease states and guidelines.

Bernard’s stroke unit and intermediate neurosensory step-down units are the hospital’s only non-ICU units in which IV push administration of labetalol and hydralazine is permitted. “Having some baseline knowledge about disease states that a pharmacist will focus on and the workings of a new unit will allow a pharmacist to make more targeted and useful recommendations to their team,” she said.

Bernard also advises establishing the best point of contact for recommendations and other messages, as well as obtaining other team members’ communication preferences. Her usual go-to individual is a junior resident, but the entire team should be informed of interventions that involve radically changing a patient’s therapy.

Pharmacists can facilitate appropriate medication use by familiarizing themselves with the latest acute ischemic stroke guidelines from the American Heart Association and American Stroke Association, including secondary prevention strategies (ie, antiplatelets, statin therapy, blood pressure management, glucose control, and vasospasm prevention after subarachnoid hemorrhage). This will enable them to intervene throughout a patient’s hospital stay and encourage optimal pharmacotherapy, according to Doug Humber, PharmD, a health sciences clinical professor and clinical pharmacist specialist at Skaggs School of Pharmacy and Pharmaceutical Sciences Department of Pharmacy at the University of California, San Diego.

Humber also noted that pharmacists can be involved in developing computerized prescriber order sets for alteplase to ensure that appropriate decision pathways are followed and that medication orders are entered and viewed in a timely manner. Moreover, hospitals can incorporate pharmacists into the development of an acute stroke care pathway. This would include all aspects of the alteplase process, such as indications and contraindications for alteplase, dosing and administering alteplase, and monitoring patients after giving alteplase, explained Humber.

Further, Bernard noted there are many ways in which a pharmacist can assist in proper medication usage in an inpatient setting, but one that is often overlooked is route of administration. Many patients with stroke experience difficulty swallowing as one of their major presenting symptoms. These patients require nutritional support and medication administration via tubes. “It is vital, therefore, that a pharmacist know which medications can be crushed and which interact with tube feedings,” she said. This can also extend to which medications can be given rectally or converted to IV formulations if a patient does not yet have other access to their gastrointestinal system.

Pharmacists also need to be aware of the different outcome measures for preventing future strokes. Ensuring that patients have good outpatient poststroke discharge plans is important to make sure they are monitored for high blood pressure, high cholesterol, diabetes management, smoking cessation, and other health maintenance concerns, according to Sarah Clark, PharmD, BCPS, a senior pharmacy manager for neurology, psychiatry, and emergency medicine, at Mayo Clinic in Rochester, Minnesota. Outpatient pharmacists can play a role in the ongoing medication management of these patients.

By working collaboratively with providers, pharmacists can build mutual trust and confidence with them, making providers more open to accepting recommendations from pharmacists on medication use. This partnership will benefit patients and provide them with optimum care through team collaboration, Sadowski said.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.

Pharmacist inclusion in stroke interventions improves patient outcomes. 

Integrating Pharmacists Into Stroke Care Teams

Seasonal allergies can cause a myriad of physical reactions to environmental allergens, such as eyes becoming red, puffy, itchy, and watery; a runny nose; nasal congestion; throat irritation; and mild fatigue. Common triggers include pollen from trees and flowers, pet dander, and mold. With allergy season upon us, pharmacists may encounter questions from patients about how to best manage symptoms of allergic rhinitis.

An arsenal of medications exists for symptomatic relief. In recent years, pharmaceuticals that were previously limited to prescriptions became available as over-the-counter (OTC) products, according to Kathy Campbell, PharmD, CEO, and clinical community pharmacist at DrKathy Health, LLC, and owner and CEO of Medicap Pharmacy in Owasso, Oklahoma.

When pharmacists are looking to guide patients with allergic rhinitis on which OTC medication will be best for them, their choices should be based on a patient’s goals of treatment, safety, efficacy, adherence, severity, and preferences, saidSuzanne G. Bollmeier, PharmD, FCCP, BCPS, AE-C, professor of pharmacy practice at St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis, Missouri. 

According to Bollmeier, pharmacists should ask for details about a patient’s symptoms including:

onset (eg, if symptoms are year-round or worse during a certain season), type, frequency, duration, and severity of symptoms;

what, if anything, provokes or relieves these symptoms;

whether they or any family members have a history of asthma or allergies;

sleep problems, such as snoring or repeated sniffling; and

presence of an allergic salute or shiner.

An allergic salute is a crease that forms across the nose’s bridge. It is caused by repeatedly rubbing the nose upward with the palm of the hand to reduce itching or to wipe secretions. An allergic shiner is a discoloration under the lower eyelids due to vasodilation or venous congestion, Bollmeier said. Chronic mouth breathing because of nasal obstruction can cause dental and orthodontic issues. Many patients with chronic rhinitis have a decreased sense of smell or taste and may also experience ear popping and pressure due to eustachian tube dysfunction. The presence of an allergic salute or shiner, orthodontic issues, or loss of smell and taste indicates moderate to severe allergic rhinitis.

In addition, Laura A. Hart, PharmD, MS, BCPS, BCGP, health sciences assistant clinical professor, Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, said it is crucial for pharmacists to ask about a patient’s underlying health conditions, medication allergies, and other medications they take to ensure a selected medication will be safe and appropriate.

Ferkhanda Najib, PharmD, pharmacy manager at Community Care RX, a long-term care pharmacy in Hempstead, New York, asks patients if they’re pregnant or breastfeeding or if they have any renal or liver impairment that may necessitate altered dosage.

Pharmacists should also ask a patient’s age, whether they have already tried any medications to relieve their symptoms, and if they are already on any medications that cause drowsiness or dehydration. In addition, it is important to find out if they’re looking to treat active symptoms or if premedication may be beneficial before coming into contact with allergens, Najib said.

Pharmacists should also consider a patient’s preference for route of administration. For example, some patients may not tolerate nasal sprays and would prefer an oral medication.

Antihistamines, nasal steroids, decongestions, corticosteroids, ophthalmic antihistamines, decongestants, and eye drops are among the options for treating allergic rhinitis. Typically, they are either taken by mouth or administered topically and are used either on an as-needed basis or regularly.

Patients with intermittent allergic rhinitis have several OTC options. An OTC intranasal steroid will most likely have the greatest effect. Examples include fluticasone propionate (Flonase Allergy Relief; GlaxoSmithKline), budesonide(Rhinocort Allergy; AstraZeneca), and triamcinolone acetonide (Nasacort AQ; Sanofi). Other OTC options for seasonal allergies include intranasal cromolyn, oral and ocular antihistamines, and topical decongestants for short-term use.

Intranasal cromolyn acts to prevent an allergic reaction from happening after exposure to a trigger. “Although safe, it’s less efficacious than other therapies, has to be administered multiple times per day, and can require several weeks to be fully effective,” Bollmeier said. It is wise to reserve cromolyn for prophylaxis before exposure to a known allergen. Children and pregnant women can use it.

Antihistamines are available over the counter in both oral and ocular formulations. Bollmeier recommends second-generation oral antihistamines, which have fewer adverse effects (AEs) of sedation. Examples include desloratadine, fexofenadine, loratadine, and levocetirizine. Counsel patients with seasonal allergies to choose an OTC antihistamine if symptoms include nasal itching, rhinitis, or postnasal drip, but not congestion. Olopatadine, an ocular antihistamine/mast cell stabilizer, can be recommended in patients at least 2 years old but should be reserved for patients who exhibit only eye symptoms such as itching, redness, and drainage.

Oral and topical decongestants are also options for patients with intermittent symptoms as they can reduce congestion. Oral decongestants include phenylephrine and pseudoephedrine. Topical decongestants are advised for short-term use only.

If patients know the season their symptoms always appear, for example when a certain flower or tree blooms in the spring, encourage them to start on an anti-inflammatory (intranasal steroid or cromolyn) 1 month prior to help prevent symptom onset, Bollmeier said.

For patients with persistent or perennial allergies, intranasal steroids are most effective. This is especially true if congestion or troublesome symptoms are present. An oral antihistamine is ideal for patients with mild nasal itching.

Each medication option for treating allergic rhinitis symptoms is associated with different AEs, so it is important to tailor counseling to the specific medication you recommend, according to Hart.

AEs associated with OTC intranasal steroids triamcinolone, fluticasone propionate, budesonide, and fluticasone furoate are typically limited to local irritation, burning, stinging, and dryness, with minor nose bleeding as the most commonly reported AE, Bollmeier said. By using the proper technique to administer nasal corticosteroid products, patients can reduce the risk for adverse reactions. 

Tell patients to gently blow their nose before using a nasal spray and directly spray away from the nasal septum. Severe local effects such as septal ulceration are rarely seen but can be prevented with this technique, Bollmeier said.

First-generation antihistamines such as diphenhydramine, brompheniramine, chlorpheniramine, and clemastine can cause significant sedation, which may be desirable for aiding in sleep. However, they can also cause cognitive impairment. Second-generation antihistamines such as loratadine, fexofenadine, cetirizine, desloratadine, and levocetirizine are typically recommended because they don’t have sedation effects when taken at recommended doses, Bollmeier said. They are safe for small children and elderly patients.

Advise patients not to use topical decongestants for more than 3 days or rebound congestion can occur. “This lessens a drug’s effects, causing patients to use a drug more frequently and use more of it,” Bollmeier said. “This will perpetuate their problem and congestion will worsen.”

Pharmacists should recommend reducing and removing allergy instigators. Patients can get rid of seasonal pollens from the environment and body by using artificial tears or saline sinus flush, or by immediately taking off clothing and showering after being outside, Campbell said. High-quality HEPA filtration can remove environmental pollens from indoor living spaces.

To decrease exposure to pollens, Bollmeier said it is best to keep windows and doors shut even in the spring and run the air conditioner instead. “This reduces the amount of pollen that can enter a home through the air,” Bollmeier explained. Also, limit outdoor exercise and activities during high pollen count days.

Don’t allow pets in bedrooms, especially at night. Hardwood floors, frequent vacuuming, and washing sheets can reduce pet dander. If visiting a home with a pet that is a known trigger, pretreating with an antihistamine can reduce symptoms as can handwashing after touching a pet, Bollmeier said.

Noncaffeinated teas, in particular ginger, work as a natural antihistamine and can alleviate nasal congestion and headaches, Najib said. When the patient inhales the steam from the tea, it can soothe nasal passages. Acupuncture has also been used as a nonpharmacologic means to treat allergic rhinitis.

Pharmacists can also ask if a patient had skin-prick or puncture testing. These tests identify what patients are sensitive to and are helpful in educating patients about allergen avoidance, Bollmeier said. 

Pharmacists can guide patients to the best OTC product selections for their symptoms. 

Counseling Points for Allergic Rhinitis Management

When patients with cancer leave the hospital, they’re usually overwhelmed with multiple items demanding their attention. Chief among them is filling their outpatient prescriptions, according to Nelly G. Adel, PharmD, BCOP, BCPS, chair of pharmacy practice and associate professor of oncology at Touro College of Pharmacy in New York, New York.

Community pharmacists play an important role in helping oncology patients manage their prescriptions. First and foremost, because these patients often take many medications, it’s important to have a medication expert review them for appropriateness. “Pharmacists can review medication lists to ensure that prescribed regimens are cost-effective, safe, efficacious, and being used for the proper indication,” said Roxane L. Took, PharmD, BCACP, clinical pharmacist at Gateway Apothecary in St Louis, Missouri, and assistant professor of pharmacy practice at St Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis. Although other health care providers are capable of fulfilling these roles, research has shown that pharmacist-provided services can reduce physician visits, emergency department visits, hospital stays, and overall health care costs.

Another reason why community pharmacists are in a prime position to assist transitions of care for patients with cancer is because they’re the most accessible health care providers to the public. “Patients can call or walk in to see them without an appointment and receive professional medical advice about their medications or get referrals to appropriate higher levels of care if needed,” said Roman Fazylov, PharmD, BCPS, clinical pharmacist for internal medicine and assistant professor of pharmacy practice at Touro College of Pharmacy.

When patients with cancer have questions about treatment plans or a medication’s adverse effects (AEs), community pharmacists are well-equipped to offer 1-on-1, in-person counseling. In addition, these patients may try self-care practices, such as taking vitamins, minerals, and herbal supplements. “While some of these may help certain ailments, some also have serious risks,” Fazylov said.“Pharmacists can advise patients on self-care strategies that are effective and carry a low risk of adverse [effects].”

Community pharmacists also can provide access to hard-to-find medications, and they work with physicians and insurance companies to provide expedited drug coverage and access to novel therapies, said Kavel Bhathela, PharmD, a community pharmacist at Carolina Pharmacy in Charlotte, North Carolina. They can offer medication delivery as well as medical and household supplies needed for managing disease, making it convenient for transitioning patients. Furthermore, pharmacists can collaborate with other health care providers and monitor and optimize drug therapy for complex disease states.

Here’s a closer look at the specific roles community pharmacists can play in transitions of care for patients with cancer.

Before a patient even leaves the hospital, community-based specialty pharmacists work with the discharge team to reconcile all prescribed 

medications, troubleshoot prior authorizations for prescriptions, and enroll patients in copay assistance programs, said Vivianne K. Celario, PharmD, a registered community-based specialty pharmacy manager at Walgreens in New Brunswick, New Jersey. Additionally, pharmacists conduct initial consultations with patients to assess their understanding of therapy goals and potential AEs. Patients are enrolled in the pharmacy’s clinical care program, where pharmacists monitor their treatment, adherence, and AEs, and address barriers that may arise between hospital and clinic visits.

It is important for community-based specialty pharmacists to work with the discharge team to establish that any medications a patient took prior to admission, including OTC medications and supplements, continue to be safe and effective with a patient’s newly discharged medication list, Celario said. For example, newly prescribed oncology medications often have the potential for drug interactions and AEs. Pharmacists can perform drug utilization reviews and address the need for dose changes or recommend drugs to alleviate AEs to increase treatment efficacy and adherence.

Due to a rise in the use of oral and self-administered oncology prescriptions, the success of a treatment greatly depends upon the patient, which is why it’s important for patients to understand their therapy goals and potential AEs.

Community pharmacists also can review patients’ OTC and prescription medications to improve patient 

safety and adherence. Carolina Pharmacy offers medication strip packaging and medication synchronization services, which help patients keep up with taking all of their medications on time and appropriately. “Through these services, we can check and see how patients are doing, and address any questions or concerns they may have regarding their drug therapy and overall well-being, which helps to builds trust and strong relation

Community-based specialty pharmacists receive advanced training specific to oncology to effectively educate patients about their medications and the challenges they may face during their cancer journey, Celario said. These pharmacists can perform initial patient consultations, reassessments, and cycle dosing education to monitor patient adherence. In addition to onsite counseling tools, pharmacists work with manufacturers and professional and patient cancer organizations to provide patients with medication education kits, seminars, workshops, and advocacy support.

Due to the complexity of cancer treatments, a patient’s list of prescribed medications can be extensive. Consequently, multiple drug therapies are quite common. Known as polypharmacy, this can become problematic if patients end up with medications they don’t need, Adel said. Therefore, it’s essential for pharmacists to carefully review these patients’ medication lists and counsel them accordingly.

Comorbidities are common among patients with cancer. In addition to cardiovascular conditions and diabetes, these patients may experience mental health conditions and chronic pain. This leads to patients taking multiple prescriptions and visiting multiple providers. “Community pharmacists are essential in maintaining a patient’s most accurate drug profile, as well as bridging any communication gaps between the patient, hospital discharge team, cancer care team, and the specialists and primary care prescribers patients see,” Celario said. “Furthermore, due to their accessibility, pharmacists are great resources to assist patients in managing chronic conditions and [adverse] effects that come with having cancer and getting treatment.”

Fazylov said that pharmacists also can play roles in managing insomnia, changes in bowel habits, decreases in appetite, and other comorbidities. “Many of these issues can be managed with over-the-counter therapies,” he said. Pharmacists are trained to monitor pain medications by keeping track of total dose requirements and monitoring AEs. In turn, they can make recommendations to prescribers regarding the right dose and frequency of pain medications to help optimize pain control while keeping AEs at bay.

Many oncology medications are costly; community pharmacists can address any cost issues that patients may have. Pharmacists can relay concerns to the appropriate physician, and suggest cost-effective alternatives.

Community pharmacists also can provide delivery services through a “meds-to-beds” program in which the pharmacy brings a patient’s medications to them before hospital discharge. “These programs help identify and resolve barriers to adherence sooner than a typical community workflow process,” Took said. “By identifying medications that cannot be filled due to formulary restrictions or medication cost, this program also helps to decrease readmission rates.”

Resources are available to assist pharmacists who are looking to implement a transitions of care program. For example, the American Pharmacists Association’s Transitions of Care Toolkit was developed to help pharmacists implement or enhance their transitions of care programs in order to improve patient care, reduce health care costs, and optimize medication therapy, Took said.

Took would also encourage community pharmacies to initiate a pilot transitions of care program with patients recently discharged from the hospital, and to offer it free of charge initially. During this early phase, pharmacists can identify common characteristics of patients who are discharged, a patient populations’ needs, and a hospital’s receptiveness to working with them.

To take the program a step further, Took would advise pharmacists to work with a local hospital near their pharmacy and engage with management to develop a proposal to present to hospital leadership.

As pharmacists go through the process, they should have realistic expectations.

“Although it’s ideal to follow up with patients within 48 hours of discharge, it may not be ideal for your pharmacy’s workflow,” Took said. “You may find that it’s best to limit your service to a certain patient population, such as those aged 65 and older or patients with diabetes.”

Lastly, don’t be afraid to outsource a service or even partner with another pharmacy such as a specialty pharmacy, Bhathela said. The more services and access to care and products you provide, the more your community will rely on you for their health care needs.


How community pharmacists can advance care as patients come home.

Cancer Care In Transition

Pharmacy errors occur for many reasons. Some can be avoided by simply improving how staff function within a pharmacy, since multitasking and distractions during work are the leading causes of dispensing errors.

“Take steps to minimize distractions as much as possible when pharmacists are working on orders,” said Deborah Sadowski, RPh, MHA, director of pharmacy services at Deborah Heart and Lung Center in Browns Mills, New Jersey. This includes having sufficient staffing to allow pharmacists to work without routine multitasking and interruptions. Adding barriers to work stations can help pharmacists improve concentration without outside distractions.

Hossam Maksoud, PharmD, chief executive officer at Community Care Rx, Hempstead, New York, said that optimum organization of one’s work space, work environment, and workflow has also been shown to markedly reduce dispensing errors. Proper lighting, adequate counter space, and comfortable temperature and humidity can help facilitate a smooth flow from 1 task to the next, which reduces the chances of dispensing errors.

 Developing a routine for entering, filling, and checking prescriptions helps in organizing workflow. In addition, working with 1 drug product at a time and affixing the label to a patient’s prescription container before working on the next prescription can help prevent mix-ups.

Approximately 83% of errors are discovered during counseling and are corrected before a patient leaves the pharmacy.

 “Therefore, it’s important to go beyond offering to counsel and actually provide counseling for every patient,” Maksoud said. “Open a container and show the actual medication to the patient during counseling, rather than handing it to a patient in a sealed bag.” Completing this process provides an opportunity for the patient to see the medication and ask questions if it looks different from what they’re used to getting.

Counseling should also include instructions on how to take a medication and the appropriate route of administration, because many dispensing errors are attributed to misunderstood directions for use.

 Educating patients about safe and effective medication use promotes patient involvement in their health care, which will likely reduce medication errors, Maksoud added.

Now that you’re equipped with some general information on how to avoid prescription errors, here’s a look at 7 common mistakes and advice on how to avoid them.

Dispensed a similar, but incorrect medication.

 Using barcode technology at all touchpoints can reduce the risk of dispensing an incorrect medication, Sadowski said. Build barcode technology into the receiving process, as well as at points of dispensing and at bedside administration in hospitals. Physically separate medications that look or sound alike when storing them on shelves.

Keith Veltri, BPharm, PharmD, associate professor at Touro College of Pharmacy, New York, New York, and clinical pharmacy manager of family medicine at Montefiore Medical Center, Bronx, New York, suggests employing Tall Man Lettering (TML) to differentiate drug names that look and sound similar. TML, a term dubbed by The Institute for Safe Medication Practices (ISMP) in 1999, indicates a portion of a drug’s name in uppercase letters (eg, on stock bottles and electronic medication orders) to help distinguish lookalike drugs from one another and avoid medication errors. For example, in TML, “hydralazine” and “hydroxyzine” are written “hydrALAzine” and “hydroxyzine,” respectively.

Common mistake #2: Dispensed the wrong quantity or dosage.

 Using barcode technology is a key strategy to avoiding these types of errors as well, Sadowski said. Other strategies include storing different dosages in different physical spaces, such as a 200 mg strength on 1 shelf and a 400 mg strength 2 shelves lower on the opposite side. Most importantly, regardless of other technologies used, always read labels 3 times.

Recheck prescriptions whenever possible, ideally by another person and preferably by a pharmacist, Maksoud said, because confirmation bias and preconceived notions make self-checking a poor method to reduce errors. If another pharmacist is not available, delay self-checking. This will allow a pharmacist to study the prescription from a fresh perspective, which will help identify an error that they may have missed the first time.

Common mistake #3: Incorrectly entered data.

 Pharmacists shouldn’t second guess illegible or ambiguous prescriptions, nonstandard abbreviations, acronyms, decimals, and call-in prescriptions, which are frequently associated with medication errors.

When in doubt, call the prescriber for clarification and promptly document it, Maksoud said. Immediately transcribe all verbal prescriptions to a blank prescription pad and read it back to the prescriber to ensure that you have correctly transcribed it.

Sadowski has found that using computerized physician order entry is the key to reducing errors from handwriting and incomplete information in medication orders. Minimizing the amount of free-text information required for order entry by providing pre-built drop-down menu choices with complete information helps ensure that providers accurately complete order entry.

Common mistake #4: Improperly stored a medication.

 Refer to package inserts and drug information references to ensure familiarity with proper storage requirements for all drugs. Using robust temperature and humidity monitoring systems for all storage areas including room temperature monitoring, freezers, refrigerators, and warmers are best practices, Sadowski said. These systems should provide continuous monitoring, providing real-time as well as historical data, and can send multi-level alerts when temperatures are out-of-range and allow documentation of actionable interventions that were taken when alerts were triggered.

Veltri recommends displaying a chart of common medications that require either refrigeration or freezing in the pharmacy. Routinely checking all medications on shelves and discarding any expired medications, regardless of where they’re kept, is also key.

In order to avoid mix-ups among lookalike drugs, Maksoud advises storing them away from each other. Medication bottles should be properly organized with labels facing forward. Routinely check all medications on shelves and discard any expired ones. Using storage bins, cabinets, or drawers can result in misplacing lookalike drugs. Lock up or sequester drugs with a high potential of causing errors.


Common mistake #5: Forgot to fully inform a patient about side serious effects or drug interactions.

 Jitu Patel, BPharm, MS, head pharmacist and chief compliance officer at 

, Brooklyn, New York, advises pharmacists to build systems and technology that make it easy to communicate drug interactions and adverse effects to patients. During the first fill, build rapport with a customer by talking about the importance of adhering to their therapy and encouraging dialogue to build a personal connection.

When a patient receives their prescription from 

, the patient is offered pharmacy consultation for their medication. “With any medication we dispense, whether we’re filling it for the first time or not, we include a small leaflet about a drug’s uses and [adverse] effects,” Patel said. “Counseling is also available via our mobile app or in-person at our pharmacy.”

When doing patient counseling at discharge from a hospital, review medications in advance and prepare important information ahead of time to ensure that no vital information is missed if a discussion gets side-tracked or other questions arise at the time, Sadowski said. If important information is missed, follow up with the patient as soon as possible to relay the information and answer any further questions.

Common mistake #6: Communication issues, particularly during transitions of care from one level to another.

 One of the most common causes of medical errors in general is failure to communicate effectively between caregivers, particularly as patients transition from 1 level of care to another, Sadowski said. Efficient hand-off strategies between care team members is crucial to preventing these avoidable errors. This includes creating a culture where 1 team member is comfortable questioning another at any level when clarity is needed or questions regarding orders or procedures arise. Having well-defined policies and procedures around communication is essential.

Common mistake #7: Making typos related to zeros and abbreviations.

 Misplaced zeros, decimal points, and faulty units are common causes of medication errors due to misinterpretation.

 A transcription or interpretation error involving a zero or a decimal point could result in a patient receiving at least 10 times more medication than indicated, which could result in serious consequences if the medication was levothyroxine or warfarin, for example.

Prevent such errors by using computer alerts or by only stocking a single strength of a medication, Maksoud said. These errors may be detected when reviewing label directions during patient counseling. ISMP offers a list of error-prone abbreviations, symbols, and dose designations. Being familiar with this information may also help prevent dispensing errors.

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Multitasking and distractions during work are the leading cause of dispensing errors. 