It’s no secret that the United States is facing an obesity epidemic: Over 40% of the adult population is living with obesity, which can increase the risk for a multitude of health conditions including heart disease, stroke, and type 2 diabetes.

 Besides its impact on quality of life, obesity can be a burden on both individual finances and the health care system. Can pharmacists—positioned as trusted health care professionals in the communities they serve—play a role in bringing weight loss programs to the public?


Meagen M. Rosenthal, PhD, associate professor, Department of Pharmacy Administration, University of Mississippi School of Pharmacy, has taken part in research investigating the role of pharmacists in weight loss programs, including a scoping review of literature on the topic and research into pharmacists’ and patients’ attitudes toward pharmacy-based weight loss programs. “We have community pharmacists who are interested in doing this kind of work, and we have patients who are willing to see community pharmacists to make this work happen, which to me is the perfect storm of opportunity to do more of this work,” she said. In small rural communities dealing with recent hospital closures, Rosenthal noted, community pharmacists can play an important role in improving health outcomes.


In a review of 9 studies of pharmacist-run weight loss programs published between 2010 and 2017, Rosenthal and her colleagues found that patients in these programs lost a mean 3.8 kg over the course of the programs

 which, she said, “translates to important clinical reductions in...glucose levels for people who have diabetes and blood pressure levels for folks who have hypertension.”


Kathy M. Campbell, PharmD, owner of Medicap Pharmacy in Owasso, Oklahoma, who has had over 300 patients complete her pharmacy-based weight loss program over the past 6 years, reported dramatic results over the course of the 12-week program in some patients, including reductions in glycated hemoglobin A1c from 13.5 to 6.5 and a 107-point reduction in low-density lipoprotein cholesterol.

In focus group interviews with potential participants, many highlighted their desire for programs that are tailored to their individual needs, with a mix of one-on-one and group counseling sessions.

 Instead of a program with a specific defined curriculum, Rosenthal noted, they wanted opportunities to say things like “I can exercise fine on my own, but what I really need to know more about is how to cook for myself.”

Campbell’s 12-week pharmacy-based weight loss program typically includes 6 half-hour individual counseling sessions, but also offers group activities such as cooking demonstrations. Some pharmacy-based weight loss programs feature pharmacists working in conjunction with other providers to manage patients who are taking weight loss drugs. Campbell takes a more biochemical view of weight loss, and incorporates a Mediterranean diet–based meal plan, pharmaceutical-grade supplementation with multivitamins, omega-3 fatty acids, and vitamin D, as needed, and counseling on movement (“It doesn’t have to be formal exercise,” she emphasized), stress management, and sleep. “The biggest secret is that it’s not a weight loss program. It’s a health program; it’s a lifestyle program,” Campbell said. “The by-product of a healthy body is a healthy weight.”


In sessions with patients, Campbell assesses whether they have drug- or disease-induced nutrient deficiencies that may cause weight gain and can be corrected by diet and supplementation. In some cases, she may recommend that a patient switch to a different drug.


Desiree Gaines, PharmD, health and wellness director at Avant Pharmacy and Wellness Center in Charlotte, North Carolina, does lab work before and after her 12-week weight loss program, examining patients’ lipid panels as well as vitamin D, magnesium, vitamin B12, and folate levels to identify potential chronic conditions that require further evaluation by a medical provider. Gaines also uses these data to give patients recommendations on supplements and nutrition education outside counseling sessions, and she offers an app that allows patients to contact the pharmacist with questions at any time.


Pharmacists have a unique perspective on weight loss, as they recognize not only the effects of prescription drugs on weight, but also the effects of weight on prescription drugs. Most of the patients Campbell works with are taking between 3 and 5 medications.She coaches patients on communicating with their providers so they can, for example, adjust the dose of their antihypertensive medications.


“Many supplements actually enhance the effects of our traditional medications. Eventually, these patients are able to either lower their doses, or…come off some of their medications,” Gaines said.

As in so many areas of pharmacy practice, lack of insurance reimbursement for services is a major impediment. Campbell’s motto is “no margin, no mission,” and she has moved beyond the dispensing fee model to charge patients for counseling services. After a great deal of market research, she introduced her weight loss program with a price tag of $1000—which patients were willing to pay. She also offers related products for sale in her pharmacy, such as cast-iron cookware and microgreens, and has even started her own line of supplements.


Gaines offers weight-loss counseling packages tailored to patients’ needs for cash prices that can range from $199 to $1500. “We are working on trying to find grants that will cover the cost of this program for our community so that we can make this accessible to everyone,” she said.


There is room for pharmacy advocacy in this area, Rosenthal added, to convince payers that reimbursement for health and weight management education will yield tremendous savings in health care costs.


Gaines advises pharmacists who want to start a weight loss program to focus on their goals and training. Education on topics related to health and weight loss is important. One such source is a course that Campbell teaches through the National Community Pharmacists Association, but there are other avenues of education as well.


One major challenge is figuring out how to fit weight loss counseling into pharmacy workflow. Gaines began by offering these classes in the evenings and on weekends and, once she had built up enough business, designated 1 day a week when she does only counseling while another pharmacist handles dispensing.


Promotion can be done through a combination of word-of-mouth, point-of-sale, print, and online advertising. Gaines’ pharmacy uses social media and hosts free events where it gives out products and showcases its offerings to specific demographic groups.


“I think that the biggest thing with marketing is telling people what you can do for them and then doing it,” Campbell said.


“Reach out to other pharmacists who may be doing similar programs,” Gaines advised. As an individual who struggled with her own weight challenges before establishing a program to help others, she added, “Start your program with yourself, family members, and close patients that you feel comfortable with. This is a great way for you to tweak your program the way you feel is best for you and your patients.”


Adult obesity facts. CDC. Reviewed September 30, 2021. Accessed January 4, 2022. 

https://www.cdc.gov/obesity/data/adult.html

Rosenthal M, Ward LM, Teng J, Haines S. Weight management counselling among community pharmacists: a scoping review. 

 2018;26(6):475-484. doi:10.1111/ijpp.12453

Arnold A, Holmes E, Rosenthal M. Building a patient-centered weight management program: a mixed methods project to obtain patients’ information needs and ideas for program structure. 

. 2019;7(4):165. doi:10.3390/pharmacy7040165

Articles

As some of the most accessible health care professionals, pharmacists are uniquely positioned to help patients manage their weight

Lose Weight, Gain Health: How Pharmacy-Based Weight Loss Programs Can Fight the Obesity Epidemic

Navigating a cancer diagnosis is hard. Navigating a cancer diagnosis as a transgender patient is even harder, according to Don S. Dizon, MD, medical oncologist, director of women’s cancers at Lifespan Cancer Institute in Rhode Island and associate professor of medicine at The Warren Alpert Medical School at Brown University.


“I think what people may not realize, particularly my colleagues, is that any person who identifies as gay or bisexual or trans…[e]very single time they meet a new doctor, there’s that moment of anxiety of: Do I need to come out to this person? Are they going to ask me, and what’s going to be the repercussions if I do?” Dizon said.


Dizon sat down with Hayley Virgil, senior editor of 

 sister publication, for a recent episode of 

 covering a wide range of topics, from the importance of society-published guidelines to how patients can be their own advocate.


“If a patient is not being cared for in an environment that they consider friendly, supportive, [and] equal—if it’s hostile, and they’re going in with increased anxiety—then I would encourage them…to state [their] experience,” Dizon said, adding that “I” statements—such as “I felt,” “I was,” and “I heard”­—are powerful, “because no one can take that away from you.”
Even outside the oncology space, pharmacists play an important role on the multidisciplinary care team.


Providing “comprehensive, respectful, and gender-affirming support” to patients, as well as improving the physical pharmacy space and environment, can position pharmacists as trustworthy health care providers for transgender patients, wrote the authors of a 2019 study published in 

 Keeping principles of cultural competence—the ability to “understand, appreciate, and interact with people from cultures or belief systems different from one’s own”

—in mind can go a long way toward ensuring that transgender patients are receiving the highest quality of care.


In 2021, the Human Rights Campaign and the American Pharmacists Association (APhA) partnered to create a guide for pharmacists on providing inclusive services for patients in the transgender and gender-diverse communities.

 Released on March 31 to mark International Transgender Day of Visibility, the guide is “an educational tool and a resource…on how to be inclusive to transgender, nonbinary, and gender-diverse patients,” said the organizations in a press release.


“The pharmacy profession holds itself to the highest standards of conduct,” said Ilisa Bernstein, PharmD, JD, FAPhA, senior vice president, pharmacy practice and government affairs, at APhA,4 adding that the guide promotes “treating patients that identify as transgender and gender-diverse with the utmost care and respect.”

To watch the full episode, visit medicalworldnews.com.

Redfern JS, Jann MW. The evolving role of pharmacists in transgender health care. 

2019;11;4(1):118-130. Doi:10.1089/trgh.2018.0038

DeAngelis T. In search of cultural competence. American Psychological Association.

https://www.apa.org/monitor/2015/03/cultural-competence

Transgender and gender diverse pharmacy resource guide. Human Rights Campaign Foundation. March 31, 2021. Accessed January 28, 2022. 

https://www.thehrcfoundation.org/professional-resources/transgender-pharmacy-guide

Human Rights Campaign and American Pharmacists Association release new guide on trans inclusion for pharmacies on trans day of visibility. News release. Human Rights Campaign. March 31, 2021. Accessed January 28, 2022. 

https://www.hrc.org/press-releases/human-rights-campaign-and-american-pharmacists-association-release-new-guide-on-trans-inclusion-for-pharmacies-on-trans-day-of-visibility

A recent episode of Medical World News' Deep Dive shared best practices for caring for transgender patients.


Navigating Health Care as a Transgender Patient 

 The information provided in this month’s New Drug Review column is based on the FDA’s emergency use authorization (EUA).

 “Paxlovid has not been approved, but has been authorized for emergency use by FDA under an EUA, for the treatment of mild to moderate COVID-19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death; and the emergency use of Paxlovid is only authorized for the duration of the declaration that circumstances exist justifying the authorization of the emergency use of drugs and biological products during the COVID- 19 pandemic under Section 564(b)(1) of the Act, 21 U.S.C. § 360bbb- 3(b)(1), unless the declaration is terminated or authorization revoked sooner.”

On December 22, 2021, the FDA issued an EUA for nirmatrelvir copackaged with ritonavir (Paxlovid; Pfizer).

 Paxlovid is the first oral pill indicated for the treatment of mild to moderate COVID-19 for certain adult and pediatric patients 12 years and older, weighing at least 40 kg, who have a positive SARS-CoV-2 viral test, whose symptoms have been present for at least 5 days, and who are at high risk for progression to severe disease, including hospitalization or death. 

Paxlovid is not indicated for treatment in those requiring hospitalization for severe disease, as exposure prophylaxis, or for those with symptoms that have been present for more than 5 days.

The Paxlovid EUA came from a planned interim analysis of the EPIC-HR Trial (NCT04960202), a phase 2/3 randomized, double-blind, placebo-controlled trial.

 At randomization, the trial enrolled 2246 nonhospitalized, symptomatic (< 5 days) adult patients 60 years or older with at least 1 risk factor for progression to severe disease. Patients with a history of COVID-19 infection or evidence of vaccination against the virus were not included.


The primary efficacy end point was the proportion of patients with COVID-19–related hospitalization or death from any cause through day 28. In a modified intention-to-treat analysis (n = 2085) of patients whose symptom onset was within 5 days and who were not expected to receive monoclonal antibody therapy, 8 patients in the Paxlovid group (n = 1039; 0.8%) and 66 patients (n = 1046; 6.3%) in the placebo group were hospitalized or died.2 This represented an 88% decreased risk of hospitalization or death in those treated with Paxlovid vs placebo (–5.62 reduction relative to placebo; 95% CI –7.21 to –4.03). This is an interim analysis; effectiveness continues to
be evaluated.

Initial safety data also come from the EPIC-HR Trial. Notable adverse effects in the Paxlovid group vs placebo included dysgeusia, diarrhea, hypertension, and myalgia.

 As stated in the EUA, rates of reactions observed may not reflect the rates observed in clinical practice and may become more apparent with widespread use. Health care providers and/or facilities are required to track all serious medication errors and adverse events that are considered related to the drug and must report them to both the FDA and Pfizer.


Paxlovid is supplied as two 150-mg tablets of nirmatrelvir copackaged with one 100-mg tablet of ritonavir. The current dosing recommendation is 300 mg/100 mg every 12 hours for 5 days. A dose adjustment to 1 tablet of nirmatrelvir (150 mg) plus ritonavir (100 mg) is recommended in moderate renal impairment (eGFR 30-60 mL/min). Pharmacokinetic or safety data are not available for severe renal or hepatic impairment and pregnancy; therefore, use is not recommended in these populations.

Paxlovid (ritonavir component) inhibits cytochrome P450 3A4 metabolism pathways, and many potentially significant drug interactions may exist. Contraindications to use are any clinically significant hypersensitivity reactions to active drug components of Paxlovid. 

The Paxlovid Fact Sheet for Healthcare Providers provides an extensive and comprehensive list of potential drug interactions.

 Given the significant potential for many drug interactions, pharmacists should review all concomitant medications and monitor for any adverse events that may be associated.

Cassandra R. Doyno, PharmD, BCPS, BCCCP, is an assistant clinical professor at the University of Connecticut School of Pharmacy in Storrs.

O’Shaughnessy JA. Re: Emergency Use Authorization 105. FDA. December 22, 2021. Accessed January 12, 2022. 

https://www.fda.gov/media/155049/download

Coronavirus (COVID-19) update: FDA authorizes first oral antiviral for treatment of COVID-19. News release. FDA. December 22, 2021. Accessed January 7, 2022. 

https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-first-oral-antiviral-treatment-covid-19

Paxlovid. Prescribing information. Pfizer; 2021. Accessed January 7, 2022. https://www.pfizer.com/products/product-detail/paxlovidtm

EPIC-HR: Study of oral PF-07321332/ritonavir compared with placebo in nonhospitalized high risk adults with COVID-19. ClinicalTrials.gov. Updated January 12, 2022. Accessed January 7, 2022. 

https://clinicaltrials.gov/ct2/show/NCT04960202

Pfizer received an emergency use authorization (EUA) for Paxlovid, an oral pill for the treatment of mild to moderate COVID-19 in certain adult and pediatric populations. 

Paxlovid: Oral Antiviral for the Treatment of COVID-19 

The most valuable advice pharmacists can give to women with autoimmune conditions who want to get pregnant is simple: Participate in preconception planning.


Beyond that general advice, understanding a woman’s “head-to-toe” health is important, explained Susan Lanni, MD, a professor in the Division of Maternal-Fetal medicine at Virginia Commonwealth University (VCU) School of Medicine’s Department of Obstetrics and Gynecology. Women with type 1 diabetes (T1D), for example, might have another autoimmune condition present, she explained.


Conditions such as a history of heart attack; underlying vascular disease, nephropathy, or retinopathy; or other autoimmune disorders can make the care of a woman with T1D more complex, said Lanni, who is also a women’s health provider at VCU Health in Richmond, Virginia.


It makes a big difference if a woman’s T1D is well managed, and the general rule with such patients is “no alteration whatsoever,” Lanni said. The only reason to change the woman’s insulin is to get her blood sugar level under control, she added, noting that surveillance for vascular disease is also important if the woman’s condition isn’t well managed.


For other autoimmune diseases, study results have shown that hydroxychloroquine, sulfasalazine, and azathioprine are safe for pregnant women, said Mary Temple-Cooper, PharmD, MS, BCPS, a clinical coordinator at Cleveland Clinic’s Hillcrest Hospital in Ohio who specializes in obstetrics. It is safe to use azathioprine in pregnant women who have rheumatoid arthritis (RA) or lupus, she said, but dosage is important: Try to maintain it at 2 mg/kg per day or less.


Hydroxychloroquine can be prescribed safely in pregnancy to treat RA, lupus, and other autoimmune diseases.

 Sulfasalazine, a disease-modifying antirheumatic drug, is used to treat RA, inflammatory bowel disease, and other autoimmune conditions.

OTC treatments like nonsteroidal anti-inflammatory drugs may cause the fetus to experience kidney problems, which can result in low levels of the amniotic fluid that supports the development of their lungs, digestive system, and muscles.

 According to Temple-Cooper, other treatments to steer clear of include methotrexate, which can take 4 months to clear from the body, and mycophenolate mofetil, which a woman should stop taking a minimum of 4 weeks before conception.


Methotrexate can result in miscarriage or birth defects affecting the brain and bones,

 while mycophenolate mofetil can cause miscarriage and have teratogenic effects.

 During the first 3 to 5 weeks of pregnancy, teratogens can lead to neural tube defects, such as spina bifida.

For those prescribed steroids, appropriate use of those treatments is another consideration. “Many women [with autoimmune disease] will have major flares during pregnancy. The goal is to get them treated,” said Temple-Cooper. “You may have to use a high-dose steroid for the shortest possible [time] and then get them on the lowest dose possible to control them. What [we] find is that if you don’t keep [women] controlled, the outcomes are usually a lot worse if you pull them off the steroids.”


Hydroxychloroquine (Plaquenil). American College of Rheumatology. Updated April 2020. Accessed January 14, 2022. 

https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/Hydroxychloroquine-Plaquenil

Sulfasalazine (Azulfidine). American College of Rheumatology. Updated December 2020. Accessed January 14, 2022. 

https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Treatments/Sulfasalazine-Azulfidine

FDA recommends avoiding use of NSAIDs in pregnancy at 20 weeks or later because they can result in low amniotic fluid. FDA. Reviewed November 3, 2020. Accessed January 14, 2022. 

https://www.fda.gov/drugs/drug-safety-and-availability/fda-recommends-avoiding-use-nsaids-pregnancy-20-weeks-or-later-because-they-can-result-low-amniotic

Rheumatoid arthritis medications: dangerous during pregnancy? Mayo Clinic. April 4, 2020. Accessed January 14, 2022. 

https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/in-depth/rheumatoid-arthritis-pregnancy/art-20091856

Coscia LA, Armenti DP, King RW, Sifontis NM, Constantinescu S, Moritz MJ. Update on the teratogenicity of maternal mycophenolate mofetil. 

 2015;4(2):42-55. doi:10.1055/s-0035-1556743

Medical genetics: teratogens. Stanford Children’s Health. Accessed January 14, 2022. 

https://www.stanfordchildrens.org/en/topic/default?id=teratogens-overview-90-P09519

Managing autoimmune conditions like type 1 diabetes, rheumatoid arthritis, and lupus during pregnancy can present challenges for patients and physicians.

Tips for Managing Autoimmune Disease During Pregnancy 

As more research is completed, COVID-19 treatment recommendations evolve. Guidance has been published by several institutions for treatment of patients hospitalized with COVID-19, and their basic recommendations are very similar. Although a standard of care has been offered, treatment of patients severely ill with COVID-19 is heavily dependent on a patient’s health condition and comorbidities. Clinical judgment should be used on a case-by-case basis.

Corticosteroids, remdesivir, tocilizumab, and baricitinib are pharmaceutical agents commonly recommended for treatment of patients hospitalized with COVID-19.

Systemic corticosteroid use can reduce 28-day mortality in patients receiving respiratory support through oxygen supplementation and invasive or noninvasive mechanical ventilation, but not among those not receiving respiratory support.

The immune response in patients with severe COVID-19 symptoms can cause lung injury and significant organ damage. Corticosteroids inhibit the inflammatory response, reducing cytokine release. This weakens the intensity of the immune response and lowers the severity of organ damage.

Common adverse effects (AEs) of steroid use include hyperglycemia, adrenal suppression, and myopathy, if given in high doses for long periods of time. Psychiatric disturbances may also occur, and steroids may also cause perforation risk in patients with gastrointestinal disease.

Dexamethasone is the recommended corticosteroid. Other steroid equivalents can be substituted.

Dosing regimen: Dexamethasone 6 mg intravenously (IV) or orally, once daily for up to 10 days or until hospital discharge.2


As of press time, remdesivir (Veklury)—a nucleotide analogue RNA polymerase inhibitor

—is the only FDA-approved agent indicated for patients in this setting. It was approved in October 2020 for the treatment of adults and pediatric patients 12 years and older who weigh more than 40 kg and who require hospitalization for COVID-19. Remdesivir has an emergency use authorization (EUA) for hospitalized pediatric patients younger than 12 years, weighing between 3.5 kg and 40 kg with suspected or laboratory-confirmed COVID-19.

Common AEs include nausea and increased liver enzymes.

Dosing regimen: 200 mg IV once, then remdesivir 100 mg IV once daily for 5 days or until hospital discharge.

Originally approved in 2010 for rheumatoid arthritis (RA), tocilizumab was issued an EUA for the treatment of COVID-19 in hospitalized adults and pediatric patients age 2 years and older who are receiving systemic corticosteroids and who require supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).

Tocilizumab, a monoclonal antibody to the IL-6 receptor, is administered by IV infusion. Tocilizumab may affect the expression of multiple cytochrome P450 enzymes. The precise effects are unknown, but they may last for several weeks after stopping therapy.

Severe AEs include serious infections, gastrointestinal perforation, and hepatotoxicity. The most common AEs include upper respiratory tract infections, nasopharyngitis, headache, hypertension, increased alanine transaminase level, and injection site reactions.

Dosing regimen: Tocilizumab 8 mg/kg actual body weight (up to a maximum of 800 mg) is administered as a single IV dose. In clinical trials, one-third of participants received a second dose of tocilizumab 8 hours after the first if no clinical improvement was observed.

Another drug originally approved for RA, baricitinib has additional use in treating patients with COVID-19, and—at press time—is also under EUA in combination with remdesivir for those hospitalized with COVID-19.

Baricitinib is an oral Janus kinase inhibitor known to have anti-inflammatory effects. In the COV-BARRIER study (NCT04421027), baricitinib was found to have a safety profile similar to that of standard of care alone and was associated with reduced mortality in hospitalized adults with COVID-19. However, it did not show a significant reduction in the frequency of disease progression overall.

Dose reductions should be considered when coadministered with strong OAT3 inhibitors (eg, probenecid).

Serious AEs include serious infections or worsening of active infections; increased risk of cancers; and increased risk of major cardiovascular events, blood clots, and tears in the stomach or intestines (especially with concomitant use of NSAIDs, corticosteroids, or methotrexate). The most common AEs include upper respiratory tract infections, nausea, cold sores, and shingles.

Dosing regimen: Baricitinib dose is dependent on estimated glomerular filtration rate (eGFR). Duration of therapy is up to 14 days or until hospital discharge.

eGFR at least 60 mL/min/1.73 m2: baricitinib 4 mg orally once daily

eGFR 30 to less than 60 mL/min/1.73 m2: baricitinib 2 mg orally once daily

eGFR 15 to less than 30 mL/min/1.73 m2: baricitinib 1 mg orally once daily

eGFR less than 15 mL/min/1.73 m2: baricitinib is not recommended.

COVID-19 treatment is differentiated based on illness severity, determined by oxygen requirements. Prior to beginning therapy, patients severely ill with COVID-19 should be assessed for possible organ dysfunction and other comorbidities that could complicate potential therapy.

Tocilizumab may be preferred to baricitinib in patients who cannot take anything orally. However, baricitinib can also be administered via oral dispersion, gastrostomy tube, or nasogastric tube.

Acetaminophen is recommended for fever reduction for all patients with COVID-19, rather than NSAIDs. However, patients on chronic NSAIDs for other conditions should not discontinue use.

Patients Who Do Not Require Oxygen Supplementation

Patients who have an oxygen saturation greater than 95% on room air and who do not require oxygen supplementation above their baseline should receive supportive care and oxygen monitoring.

 They should be closely monitored for disease progression.

 In the case of high risk for disease progression, remdesivir may be appropriate.

The National Institutes of Health COVID-19 Treatment Panel recommends against the use of corticosteroids in these patients.1

For Patients Requiring Oxygen Supplementation

Therapy for patients who are severely ill with COVID-19 with oxygen requirements above their baseline depends on the level of oxygen.

For these patients, low-dose dexamethasone and remdesivir are recommended. Baricitinib or tocilizumab therapy is recommended as an adjuvant to be added based on different conditions, such as elevation of inflammatory marker C-reactive protein level (≥75 mg/L), increased oxygen requirements despite dexamethasone, and being within 96 hours of hospitalization.

For patients requiring noninvasive high-flow oxygen, low-dose dexamethasone is recommended within 24 to 48 hours of patient admission to an ICU. Baricitinib or tocilizumab should be considered in addition to dexamethasone; the addition of remdesivir should be made if supplies are available. Remdesivir is prioritized for patients who are on low-flow oxygen supplementation at baseline.

Patients Requiring Mechanical Ventilation or ECMO

Low-dose dexamethasone is recommended within 24 to 48 hours of admission to an ICU and within 96 hours of hospitalization. Tocilizumab can be added to dexamethasone therapy. If tocilizumab is not available, baricitinib is a reasonable alternative.

Corticosteroids, remdesivir, tocilizumab, and baricitinib are not the only pharmaceutical agents available for treatment of hospitalized patients. Numerous other agents are under investigation, or are used on a case-by-case basis. Treating hospitalized patients with COVID-19 requires professional clinical judgment, as COVID-19 treatment guidelines are constantly evolving and can change based on evidence from studies and clinical trials.

Betsy Adegborioye is a PharmD candidate at South College School of Pharmacy, anticipated to graduate in spring 2022. Debra Lee, MBA, BA, is a PharmD candidate at Duquesne University School of Pharmacy, anticipated to graduate in spring 2022.

Jonathan Ogurchak, PharmD, CSP, is CEO and cofounder of STACK, a professional information management platform. He also serves as a preceptor at more than 15 schools of pharmacy for a virtual advanced pharmacy practice experiential rotation for specialty pharmacy, technology, and entrepreneurship.

Coronavirus disease 2019 (COVID-19) treatment guidelines. National Institutes of Health. Updated January 14, 2022. Accessed January 17 2022. 

https://www.covid19treatmentguidelines.nih.gov/

YNHHS initial treatment algorithm for hospitalized adults with non-severe* COVID-19. Yale New Haven Health System. April 3, 2020. Accessed January 13, 2022. 

https://files-profile.medicine.yale.edu/documents/7801c631-3dcc-48fc-a438-3aa18f3b7130

Veklury (remdesivir). Veklury. Accessed January 13, 2022. 

Emergency Use Authorization (EUA) for use of actemra for the treatment of COVID-19. Genentech. Accessed January 13, 2022. 

Marconi VC, Ramanan AV, de Bono S, et al; COV-BARRIER Study Group. Efficacy and safety of baricitinib for the treatment of hospitalised adults with COVID-19 (COV-BARRIER): a randomized, double-blind, parallel-group, placebo-controlled phase 3 trial. 

2021;9(12):1407-1418. doi:10.1016/S2213-2600(21)00331-3

Olumiant could be right for you. Olumiant. 

Olumiant—baricitinib tablet, film coated. Boxed warning (prescribing information). Lilly; revised December 2021. Accessed January 13, 2022. 

https://uspl.lilly.com/olumiant/olumiant.html#s14

Several institutions have published guidance on how to treat patients hospitalized with COVID-19. 

Practice Update: Treating Patients Hospitalized With COVID-19

"Breaks were nonexistent. I would have to try to use the bathroom at the most convenient time to step away from the pharmacy. Often I would find myself saying, ‘I’m going to the bathroom,’ and 2 hours later still needing to go.” This is the story that one former employee at a major retail pharmacy chain told 


The lack of breaks, hiring of new staff, organization of staff schedules, and managerial support was a problem at the pharmacy even before the COVID-19 pandemic began, the pharmacist said.


After community pharmacists began administering COVID-19 vaccines, pharmacy staff workloads increased, but help was not available “due to staff quitting and not being replaced,” the pharmacist added.
She is now working for an independent pharmacy and said her work experience is “much better.”


But that former retail pharmacist is not alone. Many pharmacists and pharmacy staff have told Drug Topics® and other national news outlets that they are leaving retail pharmacy or have plans to make a change.
“Community pharmacy is hemorrhaging pharmacists currently,” said another PharmD who recently left their role another retail pharmacy chain at after 11 years.


The lack of well-trained staff was the pharmacist’s biggest challenge. “I had not had enough staff for 7 months. Having to do the work of multiple people for so long really took its toll,” she said.


“People come and go because they get overwhelmed without adequate training,” she added. “The job does not pay enough for the level of stress that technicians endure.”


Stress and burnout among pharmacists and pharmacy technicians are not new issues, nor are they limited to retail pharmacy. Some pharmacists and technicians are leaving the profession and encouraging high school graduates not to go into pharmacy, said Lucinda L. Maine, PhD, RPh, executive vice president and CEO of the American Association of Colleges of Pharmacy (AACP).


Still, chain pharmacy practices have the highest percentage of pharmacists whose scores indicate the risk of high distress in the American Pharmacists Association’s (APhA) Well-Being Index for pharmacy personnel,

 an online self-assessment tool measuring well-being and suicidal ideation, and other factors. Last July, the national distress percentage for pharmacists had reached 33.68%.


Initial findings from APhA and the National Alliance of State Pharmacy Association’s (NASPA) 2022 National Pharmacy Workplace Survey2 “validate the many anecdotal stories heard through national and state pharmacy association members and pharmacy-specific social media,” the organizations said in a news release.

“The responses to this survey indicate that work environment factors contribute to pharmacy personnel’s difficulty in performing their clinical and nonclinical duties effectively,” the organizations said.

 “There is no open mechanism for pharmacists and pharmacy personnel to discuss workplace issues with supervisors and management; if they try, the discussion is not welcomed or heard. This is concerning because feelings of not being listened to or valued are risk factors that can cause stress leading to occupational burnout.”


The APhA/NASPA survey identified a number of factors that contribute to stress—and may lead to medication errors or near misses—a list that includes increased demands on pharmacy staff; harassment, and bullying by patients/consumers; insufficient and ill-trained staff; employer focus on production results; constant interruptions or calls to insurance companies; and the addition of services with inadequate support for these services.

Additional comments from pharmacy staff included complaints about management’s focus on metrics. “Quotas always increase,” said one commenter.

 “This year, our region’s flu shot goal is 500% larger than last year. It’s ridiculous.”

According to survey respondents, other issues that impact the ability of pharmacy staff to provide optimal patient care include the following

“Not caring that employees are at their breaking points mentally and emotionally while still asking for us to
do more.”

“Imposing unrealistic workload by increasing COVID-19 vaccines while we try to maintain good and safe service to our customers.”

“Employers are solely focused on the bottom line. Eliminating technician hours and pushing salaried pharmacists to work 60 to 80 hours weekly without paying overtime. The money is not what matters, but the detriment to patient care and well-being of the pharmacist is evident for every pharmacy you walk into."

“Conflicting messaging: Go as slow as you need to avoid errors/get the prescriptions done and out faster, you slow down the discharge process.”

Many pharmacy organizations are supporting the Pharmacist’s Fundamental Responsibilities and Rights,

 developed by APhA and NASPA, which outlines the fundamental principles enabling pharmacists to fulfill their professional obligations to patients.


The National Association of Boards of Pharmacy (NABP) recently pledged its support5 of the document. “NABP recognizes that pharmacists have a primary role in the protection of public health and the provision of quality health care,” NABP said in a statement

 adding that “In support of this role, pharmacists must be given the opportunity to understand their rights and responsibilities and preserve patient safety without fear of intimidation or retaliation.”

“We greatly appreciate and value our pharmacists and technicians who have been working diligently on the front lines during the pandemic,” said a spokesperson for Albertsons Companies. “[We are] committed to supporting their work and well-being, and we have several initiatives in place to provide additional staff, reduce workload, and provide access to training.”


Meanwhile, spokespersons for Walgreens—another retail chain at the center of the movement to improve pharmacist working conditions—and CVS told 

 that their organizations are committed to hiring additional staff and improving working conditions.


“We are taking several steps to mitigate current pharmacy staffing pressures, including hiring thousands of new pharmacy team members, offering bonuses for vaccination certifications, and adjusting our appointment availability and store hours as needed,” Fraser Engerman, senior director of external relations at Walgreens, told 

.
The company also increased shift breaks for team members to “provide needed rest,” Engerman said.


Walgreens has “continued to offer new roles to allow our pharmacists more time to spend with our patients,” Engerman added. For example, the company created a pharmacy operations manager position to reduce the administrative burden on the retail chain’s pharmacy managers.
In May 2021, Walgreens gave a bonus of $1000 to full-time pharmacists and $700 to part-time pharmacists. In September 2021, the company gave additional bonuses of $1250 to full-time pharmacists and $1000 to part-time pharmacists.


As of October 2021, all Walgreens pharmacy technicians receive a starting salary of $15 per hour, which will be increased to $16 per hour later this year. In addition, new pharmacy technician hires receive a $1250 signing bonus.


At CVS, many stores have teams dedicated to administering vaccines and are not filling prescriptions or counseling patients, Matt Blanchette, manager of retail communications for CVS Pharmacy, told 

“At pharmacies without vaccination teams, we’ve adjusted workflows, processes, and vaccine scheduling to provide pharmacists and other vaccinators with predictability and structure for their day-to-day activities,” Blanchette said. “Also, we’re rolling out an additional prescheduled daily break time to create a predictable and consistent daily pause while minimizing disruption to our patients.”



Well-being during COVID-19. American Pharmacists Association. Accessed January 17, 2022. 

https://www.pharmacist.com/Practice/COVID-19/Well-being

APhA/NASPA National state-based pharmacy workplace survey. Report of initial findings. American Pharmacists Association. December 2021. Accessed January 17, 2022. 

https://www.pharmacist.com/DNNGlobalStorageRedirector.ashx?egsfid=Zofb6PIvYhs=

APhA and NASPA release initial findings from the 2022 National Pharmacy Workplace Survey. News release. American Pharmacists Association. January 13, 2022. Accessed January 17, 2022. 

https://www.pharmacist.com/APhA-Press-Releases/apha-and-naspa-release-initial-findings-from-the-2022-national-pharmacy-workplace-survey

Pharmacist’s fundamental responsibilities and rights. American Pharmacists Association. Accessed January 17, 2021. 

https://www.pharmacist.com/pharmacistsresponsibilities

NABP supports efforts to improve pharmacist workplace safety and well-being. National Association of Boards of Pharmacy. January 13, 2022. Accessed January 17, 2022. 

https://nabp.pharmacy/wp-content/uploads/2022/01/NABP-Statement-Workplace-Safety-and-Well-Being-2022.pdf

Pharmacy workloads, corporate demands, and customer behavior have stretched an already thin pharmacy workforce to the breaking point.

Drug Topics February 2022

Lose Weight, Gain Health: How Pharmacy-Based Weight Loss Programs Can Fight the Obesity Epidemic

Navigating Health Care as a Transgender Patient

Paxlovid: Oral Antiviral for the Treatment of COVID-19

Tips for Managing Autoimmune Disease During Pregnancy

Practice Update: Treating Patients Hospitalized With COVID-19

Retail Pharmacy Has Reached the Breaking Point

Managing Migraine: From Acute Treatment to CGRPs

Lean Methodology and Technology Can Support Clinical Services

Review: Vaccine Guidelines for Older Adults

OTC Update: Asthma Medications

Become A Champion for Heart Health