Tzipora Lieder, RPh

Over 80 autoimmune diseases affect an estimated 14.7 million to 23.5 million people in the United States.

The mainstays of therapy consist of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and anti–tumor necrosis factor (TNF)–Î± biologics, but various products over the counter also help relieve symptoms. Pharmacists can help patients select the appropriate OTC medications in light of special considerations related to their conditions.

For rheumatoid arthritis (RA) and other autoimmune diseases, NSAIDs can be a good starting point for relieving pain and inflammation, said Wendy Ramey, BSPharm,RPh,CSP,clinicalpharmacist with a specialty in inflammatory conditions at University of Kentucky’s specialty pharmacy and infusion services in Lexington. For some conditions, such as ankylosing spondylitis, most insurance companies require that patients try OTC or prescription NSAIDs before being approved to move on to biologics, she said.

Ramey recommends that patients limit OTC NSAID use to short periods. “If they need to go beyond 2 or 3 weeks of everyday use, then they’re going to need to talk to us about some other kind of treatment to take care of their pain,” she said.

Community pharmacists who notice patients with autoimmune diseases consistently buying these OTC products should initiate a discussion regarding use, said Jessica Farrell, PharmD, clinical pharmacist at the Center for Rheumatology at the Albany College of Pharmacy and Health Sciences in New York. “If [patients are] using lots of NSAIDs consistently with a DMARD-methotrexate, hydroxychloroquine, sulfasalazine-or a TNF inhibitor...then maybe that DMARD or biologic is not adequate,” Farrell said. Patients should be advised to speak with their provider about trying a different therapy. Patients also should take a histamine-2 receptor blocker or proton pump inhibitor (PPI) because of gastrointestinal toxicities related to NSAIDs, she advised.

Pharmacists can recommend other OTC products to manage symptoms. For patients with inflammatory arthritis, Farrell encourages use of OTC topical pain-relief prod- ucts such as lidocaine patches and diclofenac gel. “These are great options for patients who have more mild disease or in smaller joints or for small flares that don’t require systemic therapy,” she said.

Pharmacists also can guide patients toward OTC products to treat the dry mouth and eyes associated with SjÃ¶gren syndrome. “Many of our patients [with] other au- toimmune diseases have overlap SjÃ¶gren syndrome,” Farrell reported. Various products treat dry mouth, including mouthwashes, gums, and toothpastes, and it often takes trial and error to find what works best for each patient, she said. Patients with SjÃ¶gren may need help finding the right eye drops, whether they need a preservative-free product or one for sensitive eyes. Gel-like drops can be particularly helpful for patients with severe nighttime dryness that interferes with sleep, Farrell said.

Mild injection site reactions in patients on injectable therapies can be treated with OTC topical steroids or antihistamines, according to Farrell.

For patients who complain of insomnia, which can be caused by an autoimmune disease or its treatment, Ramey recommends melatonin products rather than antihistamines, which can have other unwanted effects.

Various nutritional supplements also play a role in managing autoimmune diseases. Folic acid supplementation is crucial to reduce the gastrointestinal and liver toxicities of methotrexate therapy in patients with RA. Although most patients take prescription folic acid, Farrell said, some use the OTC version. Recommendations on amounts vary, but common regimens consist of 1 mg daily or 5 mg once weekly.

Some data suggest that cherries and cherry extract products have antioxidant properties and reduce inflammation in patients with gout. Farrell commonly adds those products as an adjunct for patients taking uric acid–lowering therapies, such as allopurinol and febuxostat, who need additional urate-lowering therapy but for whom adverse effects preclude increased doses.

Patients taking NSAIDs should be taught to carefully check labels of OTC combination products to prevent overdosing on NSAIDs, Farrell said. “That’s one of the things that I teach my patients a lot about: reading labels and how to recognize if they’re taking products that have multiple drugs in them, so they’re not double dosing on ibuprofen or taking ibuprofen and naproxen at the same time,” she said.

Patients with SjÃ¶gren should be ad- vised to avoid OTC products containing decongestants and first-generation antihistamines, which can exacerbate dryness, Farrell said: “Sometimes patients take Tylenol PM; they don’t realize that it has diphenhydramine, so it’s drying them out even more.” For relief from seasonal allergy symptoms, second-generation antihistamines are preferable, she said.

Patients with RA who are looking for immune-boosting supplements also need to scrutinize labels. Ingredients such as zinc and vitamin C are fine to take, Farrell said, but pharmacists should warn patients to steer clear of products that contain astragalus, an herb that increases TNF-É.

An important drug interaction in this population occurs between immuno-suppressant mycophenolate mofetil and PPIs, Farrell noted. PPIs can reduce absorption of mycophenolate mofetil, which requires an acidic environment for optimal absorption, so patients should take mycophenolate mofetil at least 90 minutes before the PPI. Pharmacists are in an ideal position to alert patients about this interaction, she said, because physicians might not be aware that their patients are taking OTC PPIs.

To avoid toxicity, acetaminophen use should be limited to 2 g per day in patients taking drugs that are metabolized by the liver, Ramey said. Farrell noted that in patients taking hydroxy- chloroquine, any OTC product potentially associated with increased risk of QTc prolongation, such as pseudo-ephedrine, could be problematic.

“For the most part, we [in the field of rheumatology] are very lucky to have drugs that don’t cause us very many [drug interaction] problems,” Ramey said.

Pharmacy software might flag an interaction between methotrexate and NSAIDs, but that is not clinically relevant in this patient population, Farrell said. NSAIDS can prevent excretion of methotrexate, which is used in high doses in oncology, and result in toxicity, but that is not an issue at the doses used in autoimmune diseases, she said.

Because so many patients with autoimmune disease take immunosuppressants, pharmacists counseling them should be on the lookout for infections.

“If a patient with an autoimmune disease is coming in looking for something to treat a possible infection, like [OTC] bactericidal ointments or creams, that would be the first clue that something needs to be addressed with their doctor,” Ramey said. “Because most of our medications increase the risk of infection, we always want to know if a patient has a cut or a bug bite that is starting to look infected; that is our biggest concern.”

Patients on immunosuppressants who want to buy OTC cough or cold products should be reminded that their current treatments prevent them from fighting infections. “If they’re on methotrexate, sometimes, if it’s a very mild infection, we might not have to hold it, but if they’re on biologics, they definitely should hold during an infection.”

Articles

The right products can help manage symptoms of autoimmune diseases.

Offer Patients OTC Pointers

In the ever-changing world of diabetes devices, pharmacists need to stay on top of developments so that they can answer patients’ questions about what is available.

Continuous glucose monitors (CGMs) are used increasingly to help patients with diabetes monitor and treat blood sugar levels, said Panteha Kelly, RPh, BCACP, APh, CDE, a clinical pharmacist specialist and clinic coordinator at the University of California, San Diego, Health Diabetes Self-Management Clinic in La Jolla, California.

Continuous scanning, or real-time, CGMs provide a constant reading of interstitial glucose to a receiver or smart device, and alarms alert the wearer when glucose is approaching patient thresholds for hyper- or hypoglycemia. In contrast, intermittently scanning, or flash, CGMs require the user to swipe the transmitter over the sensor to display data from the previous 15 minutes, including trend arrows showing whether blood sugar is rising or dropping and how quickly; they do not have alarms or alerts.

The most popular CGM on the market is the Dexcom G6 system. Unlike earlier Dexcom models and the other real-time CGMs, Guardian Connect and Eversense, Dexcom G6 does not require finger sticks for calibration. Eversense requires implant and removal every 3 months in office by a provider.

Jennifer Trujillo, PharmD, FCCP, BCPS, CDE, BCADM, believes that once it has been on the market for a while longer and gets approval for longer wear (6 or 12 months), it will likely be used more. Trujillo is an ambulatory care pharmacist and certified diabetes care and education specialist at the University of Colorado Anschutz Medical Campus Center for Adult Diabetes Care and Research in Aurora.

Freestyle Libre is the only flash CGM; it costs less than the Dexcom G6 and is easier to use, Trujillo said. Kelly cautioned that it must be scanned at least once every 8 hours to save the data for review later.

Real-time CGMs are usually preferred for patients with type 1 diabetes, who need close monitoring of their blood glucose and alerts, whereas flash CGMs are appropriate for patients with type 2 diabetes. The alarms on a real-time CGM can be lifesaving by, for example, alerting patients with hypoglycemic unawareness when their blood sugar is dropping, so they know not to drive, Kelly said.

“Real-time CGMs also allow data sharing, so it’s a great option for kids so that their parents can have the CGM data on their phones, as well,” Trujillo said.

About half of Trujillo’s patients with type 1 diabetes use insulin pumps. “The evidence at this point indicates that patients can achieve good glucose control in a variety of different ways, either through injection therapy or through insulin pump therapy, so I think it requires a thoughtful conversation between the patient and the provider,” she said.

Hybrid closed-loop systems combine the functionality of a CGM with a pump to automate insulin delivery based on real time glucose values. The first hybrid closed-loop system, Medtronic’s MiniMed 670G, was approved in 2016. This CGM communicates with an insulin pump designed to decrease or stop insulin when glucose is low and increase insulin delivery when glucose is high, without input from the user.

Tandem’s t:slim X2 Insulin Pump with Basal-IQ technology was approved in 2018 as an insulin pump and CGM: The pump suspends insulin delivery if the CGM detects glucose falling below a predefined threshold.

Tandem’s next advance, approved in December 2019, is Control-IQ technology, which automatically increases, decreases, or suspends delivery of basal insulin based on insulin delivery history, CGM data, and predicted glucose values. Control-IQ uses the Dexcom G6 CGM with the t:slim pump.

For patients who have traditional insulin pumps, Trujillo said, providers track glucose trends over 3 or 6 months and work with the patients to adjust basal insulin rates for different times of day. “[This is as] opposed to the hybrid closed-loop insulin pumps, where the basal rates are constantly changing based on the glucose readings from the CGM,” she explained. “There is encouraging evidence that the hybrid closed-loop systems can improve glucose variability, particularly overnight.”

Patients are slowly transitioning to newer models but still represent a small percentage of patients with type 1 diabetes, Trujillo said.

Patients should be carefully selected, according to Kelly. “I can’t give a closed-loop system to just anybody at this time, because if it malfunctions [or] if someone has a low health literacy, it can be dangerous.”

Medicare typically covers CGMs for patients with diabetes who test their blood sugar at least 4 times a day and take multiple daily doses of insulin, Trujillo said. She believes that almost all patients with type 2 diabetes can benefit from a flash CGM. “Knowledge is very powerful,” she said, “and when you’re able to see your glucose values all day long without sticking your finger, that information can create important behavioral changes and can create more understanding of how medications are working and how different behaviors are influencing glucose.”

Patients can observe how stress, lack of sleep, and lack of exercise negatively affect their blood glucose control, whereas exercise and healthy eating improve glucose control, she said: “Seeing that over time can certainly improve glucose management overall.”

The 2 most popular CGMs can be dispensed in pharmacies, which places pharmacists in an ideal position to counsel patients about these devices, especially because most patients with type 2 diabetes are managed by primary care providers who may be less familiar with diabetes technology advances, Trujillo said.

Kelly emphasized that patients need to understand that when starting to use a CGM, they cannot draw conclusions regarding diabetes management until they have collected 10 to 14 days of data. To capture nighttime data, she noted that patients starting to use the Freestyle Libre should scan their device both right before going to bed at night and upon waking up in the morning.

Trujillo encourages pharmacists to learn more about CGMs by taking continuing education courses and watching tutorials on the manufacturers’ websites. “It’s challenging to keep up on the latest and greatest but certainly important for a frontline health care provider like a pharmacist to do so,” she said.

Pharmacists must be tuned in to the latest technology for patients who monitor blood glucose.

Get Educated on Diabetes Devices 

It’s been 20 years since the Institute of Medicine released its landmark To Err is Human report, but medication errors remain a serious problem in our health care system. Pharmacists are positioned to play a key role in preventing or catching errors that can occur at the various stages of the drug-use process: prescribing, dispensing, and administration. Here are some strategies that can help.

The pharmacy environment is often fast-paced and intense, with high prescription volume, insufficient staffing, and demanding patients. Keeping pharmacy counters clear and clutter free can be challenging, but it is an important part of reducing risk for dispensing errors, said Matthew Grissinger, RPh, director of error reporting programs at the Institute for Safe Medication Practices (ISMP) in Horsham, Pennsylvania. He advises pharmacies to use a basket system to keep different patients’ prescriptions and drugs separate, as well as to clear away the bottles from prescriptions that have been completed. Ideally, he said, pharmacists should take phone calls in a quiet, distraction-free area.

For prescriptions called in by phone, it’s important to write down and then repeat the order to verify that it was heard correctly; ISMP recommends spelling drug names during read back.

E-prescribing comes with its own pitfalls, according to Dixie Leikach, RPh, vice president of Catonsville and Paradise Professional Pharmacies in Catonsville, Maryland. Her pharmacy often deals with problems caused by improper use of the technology. For example, sometimes prescribers can’t find the correct drug strength or dosage form on the e-prescribing dropdown menu, so they select a similar drug from the list and then write the intended product in notes in other areas of the prescription, which can be missed during order entry. “We’ve learned over time that we have to read all the information and clarify if something really doesn’t make sense,” Leikach said.

Scanning barcodes plays an important role in checking that the correct drug, dosage form, and strength has been selected, Grissinger said, ensuring that the most common dispensing errors are avoided. But he cautions that in the retail environ- ment, this will only work if orders are entered in the system before selecting the drug bottle; if pharmacists pull the wrong drug off the shelf and enter its NDC number, barcoding will not catch that error because the incorrect barcode will appear on the prescription label.

At Boulder Community Health (BCH) in Boulder, Colorado, where Christopher Zielenski, PharmD, is pharmacy clinical coordinator, the use of barcoding throughout the system, from dispensing through administration, has resulted in a huge reduction in errors. Since they began requiring barcode scanning for medications being placed in automatic dispensing cabinets, the rate of mistakes in filling medications has been reduced to nearly zero, he reported.

4. BE AWARE OF LOOK-ALIKE SOUND-ALIKE (LASA) DRUGS

ISMP maintains a long list of drugs with similar names that may be confused, which it recommends printing in bolded tall man (uppercase) letters (eg buPROPion/busPIRone).

 It is imperative for pharmacists to stay informed about what those drugs are, experts said. Grissinger advised that every pharmacy choose 5 common LASA pairs and develop strategies to avoid errors with them, such as separating them. If drugs are separated, he cautioned, pharmacists and techs need to know where they are located.

Leikach said that LASA lists grow as more drugs become available in generic formulations. She gave risperidone and ropinirole as an example. “When those were brand names they weren’t a problem, but once they both went generic and they’re both available in the same strength... and they’re sitting next to each other on the shelf, all of a sudden you’ve got a huge potential for pretty severe med errors and adverse drug effects.”

5. HAVE A SECOND PAIR OF EYES CHECK PRESCRIPTIONS

One way to prevent human error is by involving a second human-a pharmacist or technician (as permitted by state law)-in the dispensing process. “If I’m the one taking the prescription and entering it, then I’m not pulling the drug and counting it, because I know I have to final check it,” Leikach said. “Someone else, a tech or another pharmacist, will look at it.... We check each other.” When she worked in environments where there was no one else there to check, she would walk away from prescriptions once she’d reached a certain point in the dispensing process, so that she could come back with “a fresh set of eyes.”

Grissinger cautioned that final checks should always include verification of the original order entry, whether by keeping the paper prescription with the label and medicine bottle until completion or by pulling up the scanned prescription on the computer screen.

Various alert strategies can be helpful, but human nature is to overlook the familiar. That’s why Leikach moves around shelf talkers alerting staff about LASA drugs so they continue to catch the attention of staff members. She has also requested that the pharmacy software system change some alerts to hard stops, so that the pharmacist or technician is required stop, read the alert, and type a response-thus ensuring that they pay attention.

Patients are their own last line of defense when it comes to medication errors, and investing a minute or 2 in speaking to them can reap huge dividends in catching medication errors. Grissinger advises asking the patient when they pick up the prescription: “Open the bag; is this what you were expecting? Look at the label, look at the name of the drug, look inside the bottle if it’s a refill to make sure it’s what you got last time.”

Basic counseling can help ensure that patients understand what their prescription is for and how to take it properly; it sometimes helps catch errors as well. Leikach recalled situations where she could tell that her explanation did not make sense to the patients. “They said, ‘That’s not why I went to the doctor, that’s not what he told me!’” This enabled her to catch medication errors made by the prescriber or the dispensing pharmacist, she said.

Speaking to patients is also valuable in obtaining an accurate medication reconciliation, Zielenski noted, which is why BCH has instituted training in active listening for staff involved in medication reconciliation.

"Pharmacists need to recognize their role to the patient,” Leikach said. “When you receive a prescription-especially if you get to know your patients-then if something doesn’t make sense don’t just let it go.” Question the patient and call prescribers to verify, she advised, and if necessary, dig deeper to obtain clarification on why something was prescribed as it was and whether it was a mistake. After enough occasions of being thanked by prescribers for catching their errors, Leikach realized that “you really do need to push when you feel that something isn’t right,” she said.

“Let’s not keep waiting for things to go wrong and fix them,” Grissinger said. Experienced pharmacists can sense when things are not going right and should address those concerns, he said. “Otherwise something’s going to go wrong and the pharmacist is going to get blamed for that when we saw it coming a mile away.”

ISMP has free self-assessment tools that pharmacists in different practice settings can use to evaluate how well they are maintaining patient safety. Its Medication Safety Self Assessment® for Community/Ambulatory. Pharmacy includes over 200 items in 10 elements important for safe medication use.

Sometimes, Zielenski said, simple changes can have a big impact. For example, BCH started stocking batteries on the floors after pharmacists realized that barcode medication administration rates were dropping due to scanner batteries running out. Similarly, BCH includes dosing and administration instructions with emergency kits.

“Those types of tools can be implemented anywhere,” he noted. “Frontline staff can develop them; it doesn’t have to come from a manager.”

“I believe in reporting safety events-which are classified as near-misses and errors-even if they are your own, to allow a big picture to develop so we can identify trends at the system level and then address those issues and encourage peer-to-peer feedback,” said Zielenski. He recently published an article describing how BCH developed several interdisciplinary committees that used medication safety events reported through its voluntary electronic safety event reporting system to perform continuous quality improvement throughout the hospital.

Over the course of 3 years, there was a significant drop in rates of medication errors and concomitant increase in the rate of near misses, while reporting rates remained the same.

Open discussion of medication errors is most helpful when an institution has a just culture perspective, Zielenski added. “As soon as it becomes part of a normal conversation, I think that’s where you really start to gain traction on reducing medication errors,” he said.

1. Cohen M, Hanson A, Shah N. Top medication errors reported to ISMP in 2019. Webinar presentation. December 18, 2019. 

2. List of Confused Drug Names. Institute for Safe Medication Practices. 

https://www.ismp.org/recommendations/confused-drug-names-list

3. Hanifin R, Zielenski C. Reducing medication error through a collaborative committee structure: an effort to implement change in a community-based health system. 

 2020;29(1):40-45. doi: 10.1097/QMH.0000000000000240.

Pharmacists are positioned to play a key role in preventing or catching errors that can occur at the various stages of the drug-use process: prescribing, dispensing, and administration.

10 Strategies to Reduce Medication Errors

Pain is a very common and dreaded symptom in oncology patients, reportedly occurring in more than half of patients with active cancer and one-third of cancer survivors.

“Unrelieved pain impacts patients’ quality of life and comfort,” said Alison Duffy, PharmD, oncology clinical specialist at the University of Maryland Medical Center and associate professor in the department of pharmacy practice and science at the University of Maryland School of Pharmacy in Baltimore. “Ultimately, their survival outcomes are definitely linked to early and effective palliative care, which includes pain management,” she said.

Erica Rhein, PharmD, clinical pharmacist at UCHealth Anschutz Cancer Pavilion’s outpatient palliative care and oncology urgent care clinics and assistant professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences categorizes pain as directly cancer-related or iatrogenic (Fig. 1).

Determining the source of the pain can be tricky and involves listening closely to the patient and using imaging studies when appropriate. Duffy recommends PQRST pain assessment (questioning the patient about Provoking factors, Quality, Region/Radiation, Severity, and Time). The patient’s description of the pain can provide important clues, Rhein said. “Neuropathic pain tends to be hard for patients to localize and has descriptors like burning and shooting,” she explained, “while somatic pain is a lot of times easier for a patient to pinpoint.” There are often multiple sources for the pain requiring treatment with multiple modalities.

In this patient population, the usual go-to non-opioid options are fraught with complications.

Although nonsteroidal anti-inflammatory drugs (NSAIDs) should theoretically be ideal, since cancer-related pain frequently has an inflammatory component, they have many potential contraindications, said Rhein. NSAID use is problematic in patients with renal dysfunction due to their cancer (for example, multiple myeloma) or advanced age, Duffy added. In patients undergoing active treatment, Rhein said, NSAIDs can interact with chemotherapeutic agents by increasing cumulative renal toxicity or by decreasing renal clearance of the chemotherapeutic agent so its toxicities are increased. Additionally, the increased risk of bleeding associated with NSAIDs is problematic for patients whose cancer increases bleeding risk (eg, gastrointestinal cancers) or who have chemotherapy-related thrombocytopenia, Rhein added.

Acetaminophen also has its concerns. Its dose is limited in patients with liver impairment due to cancer location, liver metastases, or chemotherapy, Duffy said. It can only be used sparingly in neutropenic patients with hematologic malignancies since acetaminophen can mask fevers. If pain requirements are high, she said she prefers to use another agent. Even when acetaminophen is a safe option, it often is not enough for effective pain relief, Rhein said, so it is often used in conjunction with opioids as an opioid-sparing agent.

Rhein and Duffy agree that in oncology patients, opioids are often the best and safest option.

The most commonly used opioids in oncology patients are morphine, oxycodone, and hydromorphone. For patients with liver dysfunction, Duffy said, morphine is preferred over oxycodone, and vice versa for patients with kidney dysfunction.

Opioid choice, however, is often dictated by cost and insurance formularies.

“Once patients are getting higher doses of opioids, even medications like morphine that are considered to be more affordable can become very expensive, so the cost is definitely something that we have to consider for our patients,” Rhein noted.

Before patients are started on opioids, they must be screened for risk factors for opioid misuse and addiction. All the information in the media about the opioid epidemic has made some patients wary of taking opioids, Rhein said, and these patients must be educated. “There are certainly patients that have their pain sub-optimally managed because of their concerns about addiction, and some of those challenges are based on the hyperawareness in this country,” Duffy said. Oncology patients with a history of substance use disorder can be very challenging to manage, Rhein said.

This is particularly for opioid naÃ¯ve patients, who are then usually started at low doses of opioids, said Duffy. Patients with chronic or advanced cancer pain may require long-acting opioids such as extended-release morphine (MS Contin) or oxycodone (OxyContin). Fentanyl patches are also an option, according to Duffy, particularly for patients who have compliance issues or have swallowing difficulties due to head and neck or gastrointestinal cancers.

Rhein reported that she also uses methadone quite a bit in her clinical practice, as it has benefits for both neuropathic and somatic pain and is often better tolerated than very high doses of the opioids. Patients must usually be hospitalized during methadone up-titration, and Duffy cautions that clinicians must be on the lookout for QTC prolongation, particularly in patients taking other drugs that affect the QTC interval.

Counseling Points for Patients with Cancer

When counseling patients being treated for cancer pain, particularly with opioids, pharmacists should realize that these patients are often legitimately taking other sedating drugs such as benzodiazepines, Duffy said. These patients must be screened for falling risk and cautioned about the risks of driving while sedated.

Many patients on high doses of opioids also have multiple risk factors for constipation, such as chemotherapy, radiation, and hypercalcemia due to bone metastases. Since constipation increases risk for bowel obstructions, she said, pharmacists should counsel these patients about constipation and ensure that they are on appropriate bowel regimens.

For patients on more than 1 opioid, Duffy said, “make sure they understand the maintenance basal rate of their long-acting control and the bolus nature of the short-acting one.”

Clinicians should understand that drug therapy alone may not be adequate for pain management.

“There is a huge psychosocial component of the pain experienced in patients with cancer, and you often have to address that to have any hope of controlling the pain,” Rhein said.

Special consideration for pain management in patients with cancer. 

Author | Tzipora Lieder, RPh

Articles

Offer Patients OTC Pointers

Get Educated on Diabetes Devices

10 Strategies to Reduce Medication Errors

Conquering Cancer Pain