Karen Berger, PharmD

According to a Council for Responsible Nutrition 2019 

, 77% of adults in the United States take dietary supplements, the highest number reported to date.1 This places pharmacists in a unique position to offer both products and educational advice. What are patients looking for, and how can pharmacists help? 

Neal Smoller, PharmD, is a holistic pharmacist, founder of Supplement School, and owner of Village Apothecary in Woodstock, New York. Smoller shared what he sees as the biggest trends in supplements: collagen and cannabidiol (CBD). According to Smoller, collagen is a “trendy protein supplement that we use as a cornerstone of holistic care.” He noted that his patients who are protein-deficient often take collagen, and praises its unique amino acid profile and structure. “People aren’t getting enough collagen-rich foods like organ meats or bone broth in their diets, so it’s my protein of choice for omnivores who want to supplement. It supports a healthy [gastrointestinal] tract, healthy joints, and optimal protein levels.” Smoller said that CBD is popular in his patients for anxiety, sleep, and pain.

Jennifer Burch, PharmD, CDCES, is the pharmacist and owner of Central Pharmacy/Central Compounding Center South in Durham, North Carolina. She sees a high demand for supplements pertaining to the immune system and stress, especially during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Some popular supplements include vitamin A, vitamin D, vitamin C, N-acetylcysteine, glutathione, zinc, theanine, melatonin, probiotics, digestive enzymes, and CBD oil.

With all the products out there, what should pharmacists look for when deciding what to stock? Smoller recommends that no matter what brands pharmacists decide to keep in their pharmacies, the products should meet high quality standards, “this includes not just GMP compliance and cleanliness, but therapeutic requirements, and ethics of the brand in question.” For example, with collagen, Smoller looks for products with excellent farming standards that are proven to be low in heavy metals, and ensures the manufacturing process has no dilution or spiking of the protein. With CBD, Smoller noted that there are “too many products with poor quality.” He deals with transparent brands, or “those that give us full access to their production flow and a certificate of analysis on each lot (third party verified),” he said.

During COVID-19, Smoller saw an uptick in demand for immune blends, zinc, and vitamin C among patients looking to boost their immune system. Smoller stocks and recommends zinc lozenges “but we give people honest advice—no supplement will protect you as the charlatans are advising. Be healthy and well, but don't get a false sense of security or the illusion of control from a supplement.”

Burch recommended that pharmacists stock “high-quality multivitamins—not ‘one-a-day’ vitamins.” She recommends offering brands that are labeled “pharmaceutical grade or professional grade,” and contain activated nutrients like methylcobalamin instead of cyanocobalamin. Some of her preferred brands include Xymogen, Ortho Molecular, and Thorne.

In terms of probiotics, Burch recommended Enterobiotic SBO by Natural Creations. “I have been using it with great results for over 20 years, long before many others were on the market. It contains 14 organisms including Saccharomyces boulardii which has an antagonistic effect against Candida albicans. It also contains fructo-oligosaccharides, a prebiotic which helps feed good bacteria in the gut.” Burch noted it has worked well for her patients, and local gastroenterologists recommend it as well.

Burch also suggested stocking a high-quality chelated magnesium. The advantage of chelated magnesium, she explained, is to help with absorption and delivery to the tissue.

“Magnesium oxide is a common magnesium patients pick up at the pharmacy, but it cannot be absorbed, so it causes diarrhea. When using magnesium for leg cramps or headache, we need to get the magnesium into the tissue, so the chelated form does this best.”

Both Smoller and Burch emphasized that, as the most accessible and trusted health professionals, pharmacists can use their drug and supplement expertise to help patients find the right products.

Dietary Supplement Use Reaches All Time High. News Release. Council for Responsible Nutrition; September 30, 2019. Accessed July 5, 2020. https://www.crnusa.org/newsroom/dietary-supplement-use-reaches-all-time-high

Articles

What supplements are patients looking for the most, and how can pharmacists help?

Stay Ahead of Trends in Dietary Supplements 

Ashley Gulyas, PharmD, a clinical pharmacist and pharmacist in charge at Spartanburg Regional Healthcare System in South Carolina and owner/editor of Academy & Apothecary, advises noting each patient’s preferred method of communication; although many appreciate in-person counseling, not all do. “Some patients prefer texting, so a secure, HIPAA [Health Insurance Portability and Accountability Act]–compliant text is the easiest way,” Gulyas said. Telepharmacy and videoconferencing can work, too. “Be flexible and creative,” she said.

Gulyas also recommends introducing oneself, if necessary, and setting time expectations by asking if the patient has several minutes to talk. Ask open-ended questions to ensure a better understanding and dialogue, she suggests. For example, instead of telling the patient to take a medication at night, ask, “Can you tell me what time of day you take this medication?”

Leah Nunez, PharmD, MS, director of pharmacy at Rio Grande State Center in Harlingen, Texas, noted that a patient may need explanations in basic terms. “Even highly educated people may have very little medical literacy,” she said. Like Gulyas, Nunez uses open-ended questions to determine how to adapt the conversation to the patient. 

Nunez acknowledges the struggle of working in a busy pharmacy. “Getting information across in a timely manner is important when pharmacies are busy and the staff is pushed to do more with less,” she said. Using or creating a counseling area that allows private conversations with patients, without the distraction of other patients, shoppers, and staff, can be helpful. “A patient may be less willing to speak at a cash register where there is a long line,” she said.

Because providing detailed education can be difficult in a community pharmacy, Nunez recommends that pharmacists familiarize themselves with local community services, such as classes offered at a hospital or nearby support groups. Patients who are strapped for time may appreciate a pharmacist’s recommendation for reputable educational websites, such as that of the American Heart Association, as opposed to relying on Google for finding important information. “If we don’t have the time to tell the patient all we wish we could, we can give them the tools to increase their knowledge and improve their health,” she said.

Anne Henriksen, PharmD, owner of and pharmacist in charge at Malley’s Compounding Pharmacy in Richland, Washington, added that although it is important for the pharmacist to ask open-ended questions, a yes-or-no question from a patient should be addressed with caution. “There are very few yes/no questions when it comes to medicine,” she said. She recalled a patient if 2 medications were the same; a technician answered no, but Henriksen knew she needed to dig deeper. A conversation revealed that the patient was not supposed to take either medication. “If the patient had left the pharmacy with the simple answer of no, she would have continued to take both medications, which could have been dangerous,” Henriksen said.

What about a patient who takes a personal call when you need to convey important counseling points? Make clear that their full attention is needed, but be kind about it, Henriksen recommends. She said, “I will not perform a medication consultation with a patient who is on the phone. I kindly state that I am happy to complete the medication consultation when the patient is available and walk away, and ask them to please let my staff know when the patient is ready.” 

Patients retain very few of the details provided, Henriksen said, so she highlights important points on written materials and recommends that patients read the information at home: “I always emphasize that patients can call anytime if they have any further questions after they get home.”

With pharmacists stretched thinner than ever, counseling patients efficiently but effectively has become a top concern. Drug Topics® asked 3 experienced pharmacists to share how they accomplish this important goal.  

Pharmacists Share Tips to Streamline Patient Communication in Busy Pharmacy

 that in 2019, 9 out of 10 prescriptions filled in the United States were for generic drugs.1 This places pharmacists in a unique position to recommend cost-saving generics and counsel patients on generic substitution. 

Jennifer Palazzolo, RPh, pharmacist-in-charge and owner of Flatirons Family Pharmacy in Longmont, Colorado, feels that pharmacists can play an important role in helping patients with generics. “In the day of electronic prescriptions, patients often have no idea what is sent to the pharmacy and often have sticker shock when the prescription is not covered or has a high copay.” Palazzolo recommended that “the best thing to do in this case is to reach out to the patient before proceeding with filling an expensive brand-name prescription. There are often acceptable generics available that are cost-saving to the patient and health care as a whole, and the pharmacist can teach patients to advocate for themselves if the cost of medication is an issue.”

Palazzolo often educates patients on generics, beginning with OTC products. For example, if a patient is asking for a recommendation and reaching for the brand-name product, Palazzolo will explain to the patient how the generic contains the same active ingredient and will have the same therapeutic outcome. Palazzolo said, “sure, there are times the patient can't get past the pretty packaging, but 9 times out of 10, once explained, the patient will opt for the cost-saving option.”

Palazzolo finds that in conversation, patients will sometimes share the economic burden of copays. If a patient is requesting a brand-name product when a generic is available, she asks why in a non-confrontational way, and explains that it may not be covered or may be very expensive. Often, the patient simply doesn’t want medication from another country. Palazzolo takes the opportunity to educate patients on the manufacturing processes and quality assurance practices, as well as the standards generics have to follow. Once she does this, the patient often feels more comfortable trying the generic, as long as they know they can still switch back to brand if need be (which they rarely do).

Wendi Medved, PharmD, pharmacist-in-charge and owner of Coast to Coast Compounding in Golden, Colorado, takes the time to look for opportunities to save patients money with generics. She recommends pharmacists review patient profiles to look for possible generic substitutions, and reach out to patients and their prescribers for a new prescription, “keeping in mind federal and state laws, and which medications are listed in the Orange Book as Narrow Therapeutic Index (NTI) medications.” She also looks for opportunities to bypass the insurance and save the patient even more money.

Medved stressed the importance of keeping an open line of communication with patients, and letting the patient be involved in the decision-making process. This way, she said, the patient is not surprised or taken aback by a medication that appears different.

Medved also noted that pharmacists should recognize the difference between generic substitution and therapeutic interchange, as a therapeutic interchange using a generic product in place of a brand can save a significant amount of money. “Drugs in therapeutic interchange programs should be targeted based on scientific evidence for similar levels of clinical effectiveness and positive medical outcomes,” she said. For example, the physician may prescribe a newer, brand-name hypertension drug, but a drug in the same class that is available in generic form may work just as well for treating the patient’s hypertension. In the community pharmacy setting, Medved suggests initiating a conversation with both the patient and prescriber about the possibility of a therapeutic interchange.

By helping patients save money, pharmacists can help them improve adherence and outcomes, and avoid complications and hospitalizations.

1. FDA. Generic Drugs. Accessed July 10, 2020. Last updated November 21, 2019. 

https://www.fda.gov/drugs/buying-using-medicine-safely/generic-drugs

Pharmacists are in a unique position to recommend cost-saving generics and counsel patients on generic substitution. 

The Pharmacist’s Role in Generic Substitution

Gastroesophageal reflux disease (GERD) occurs when stomach acid flows through the esophagus to the mouth. Patients with GERD may experience a variety of symptoms, including:

Having occasional reflux symptoms is common, but reflux that occurs more than twice a week for several weeks may be GERD.

GERD affects approximately 20% of adults in the United States.

Patients are more likely to develop GERD if they are over age 40, overweight or obese, pregnant, a smoker, or taking certain medications, which include:

Asthma medications (prednisone, albuterol, and other bronchodilators)

Pharmacists can counsel patients on lifestyle changes that may help GERD symptoms:

Keep a food diary. Limit trigger foods and beverages such as chocolate, fried food, peppermint, spicy foods, pizza, processed foods, fatty meats or cheese, tomato-based sauces, citrus fruits, chocolate, coffee, and carbonated beverages.

Sit up straight while eating. Eat smaller, more frequent meals instead of a few large meals. Do not lay down for at least 2 to 3 hours after a meal or an acidic or caffeinated beverage.

Elevate the head while sleeping. Raise the head of the bed 6 to 8 inches by safely putting blocks under the bedposts. Patients can use extra pillows in addition to this.

Wear loose-fitting clothing to limit pressure on the stomach.

Antacids work by neutralizing stomach acid.

Examples include Tums, Mylanta, and Rolaids.

H2 blockers compete with histamine for H2 receptors in the stomach, decreasing acid production.

OTC H2 blockers include cimetidine (Tagamet HB), famotidine (Pepcid AC), and famotidine/antacid (Pepcid Complete).

In April 2020, the FDA requested removal of all ranitidine (Zantac) products, both OTC and prescription, due to contamination with N-Nitrosodimethylamine (NDMA).

PPIs work by preventing or reducing heartburn.

OTC PPIs include OTC esomeprazole Nexium 24 HR, OTC lansoprazole (Prevacid 24 HR), OTC omeprazole (Prilosec), and OTC omeprazole/sodium bicarbonate (Zegerid).

OTC PPIs should only be used for 2 weeks at a time.

What prescription products are available?

Counseling points for H2 receptor antagonists

The most common adverse effects (AEs) of H2 blockers include diarrhea, constipation, fatigue, drowsiness, headache, and muscle aches.

Rare instances of liver injury may occur.

H2 antagonists may be associated with rare CNS AEs such as delirium, confusion, hallucinations, or slurred speech. These AEs are more common in patients with renal or hepatic impairment or patients over 50 years old.

Cimetidine is a potent CYP450 inhibitor and has many drug interactions. Cimetidine inhibits the metabolism ofwarfarin, phenytoin, propranolol, nifedipine, chlordiazepoxide, diazepam, certain tricyclic antidepressants, lidocaine, theophylline, and metronidazole.

 Patients should consult their health care provider to ensure no drug interactions are present before taking cimetidine.

PPIs’ most common AEs include diarrhea, headache, nausea, constipation, flatulence, and abdominal pain.

Response to therapy does not rule out a gastric malignancy. Patients should consult their health care provider about the need for additional testing.

PPIs have been associated with Clostridium difficile diarrhea, especially in hospitalized patients.

PPIs may be associated with an increased risk of bone fractures (of the hip, wrist, or spine). The risk increases with higher doses or duration of treatment over 1 year.

Daily long-term PPI treatment (more than 3 years) can cause B12 deficiency.

Gastroesophageal Reflux Disease: A Focus on Management and Patient Education

Low magnesium levels may occur, usually after 1 year of PPI treatment. Symptoms may include muscle cramps, arrhythmia, and seizures.

Daily treatment with a PPI for more than 1 year is associated with an increased risk of fundic gland polyps.

Acute interstitial nephritis may occur at any point in therapy, usually due to a hypersensitivity reaction.

Symptoms include fever, blood in the urine, change in urine output, mental status changes, nausea, vomiting, rash, swelling, and weight gain.

Cutaneous lupus erythematosus and systemic lupus erythematosus have been reported in patients taking PPIs.

When should patients see a gastroenterologist?

Patients who experience frequent or severe symptoms (projectile vomiting; vomiting large amounts; breathing problems; pain; or bloody, green, or coffee-ground vomit) should consult a gastroenterologist for treatment and testing.

With their knowledge and experience, pharmacists can be quite helpful to patients with GERD. Pharmacists can review the patient’s medication list and identify any drugs that may be contributing to GERD symptoms. Pharmacists can also recommend appropriate OTC medications or counsel on prescription drugs, encourage lifestyle changes, and refer patients to a gastroenterologist if needed.

1. GERD (Chronic Acid Reflux) Cleveland Clinic. 

https://my.clevelandclinic.org/health/diseases/17019-gerd-or-acid-reflux-or-heartburn-overview

2. Symptoms & Causes of GER and GERD. National Institute of Diabetes and Digestive and Kidney Diseases. 

https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/symptoms-causes

3. Asthma and Gastroesophageal Reflux Disease. Asthma and Allergy Foundation of America. 

https://asthmaandallergies.org/asthma-allergies/asthma-and-gastroesophageal-reflux-disease/

4. GERD Diet: Foods that help with Acid Reflux. Johns Hopkins Medicine. 

https://www.hopkinsmedicine.org/health/wellness-and-prevention/gerd-diet-foods-that-help-with-acid-reflux-heartburn

5. Lifestyle changes for Gastroesophageal Reflux Disease. NYU Langone Health. 

https://nyulangone.org/conditions/gastroesophageal-reflux-disease-in-adults/treatments/lifestyle-changes-for-gastroesophageal-reflux-disease

6. Over-the-Counter (OTC) Heartburn Treatment. United States Food and Drug Administration. 

https://www.fda.gov/drugs/drug-information-consumers/over-counter-otc-heartburn-treatment

7. FDA Requests Removal of All Ranitidine Products (Zantac) from the Market. United States Food and Drug Administration. 

https://www.fda.gov/news-events/press-announcements/fda-requests-removal-all-ranitidine-products-zantac-market

8. Treatment for GER and GERD. National Institute of Diabetes and Digestive and Kidney Diseases. 

https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/treatment

8. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Histamine Type-2 Receptor Antagonists (H2 Blockers) [Updated 2018 Jan 25]. Available from: 

https://www.ncbi.nlm.nih.gov/books/NBK547929/

9. Nugent CC, Falkson SR, Terrell JM. H2 Blockers. [Updated 2020 Mar 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: 

https://www.ncbi.nlm.nih.gov/books/NBK525994/

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=06c0a509-026f-44e0-9975-a94a8de51d43

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6b9c60e9-b0d2-4aec-a04b-ccc7a62c822b

12. Interstitial nephritis. Medline Plus. US National Library of Medicine. 

https://medlineplus.gov/ency/article/000464.htm

https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c6c22be1-659d-4e71-b292-701e27da201b

With their knowledge and experience, pharmacists can be quite helpful to patients with GERD. 

Author | Karen Berger, PharmD

Articles

Stay Ahead of Trends in Dietary Supplements

Pharmacists Share Tips to Streamline Patient Communication in Busy Pharmacy

The Pharmacist’s Role in Generic Substitution

How Pharmacists Can Help Patients with GERD