Health care providers play an important role in adolescent sex education, including in discussions on contraceptive use.1,2 Adolescents may start engaging in sexual activity while undergoing the numerous physical and emotional changes that occur during their transformative period.3 By the age of 20 years, approximately 80% of young women have had sexual intercourse; however, adolescents (aged 15 to 19 years) have limited understanding of the various contraceptive methods available to them, and the lowest rates of contraceptive use.1,2 Counseling individuals about the various methods of contraception and increasing access to care can help address unplanned pregnancies and sexually transmitted diseases.3 As most women prefer oral contraceptives over other forms, such as injections, transdermal patch, and vaginal rings, familiarizing themselves with the safest and most effective use of all these products is good practice.1,2 (Table 13). This article delves into the contraceptives available for adolescents and discusses their efficacy and safety.

Various methods of contraception are available for adolescents3 (Table 22,3,7). Medical providers should counsel them on the efficacy, safety, and adverse effects of contraception,1 informing them about the most effective options. Contraceptive options from most effective to least effective are as follows: intrauterine devices/ progestin implants, progestin injections, and combined oral contraception (pills, patch, vaginal ring).2 Regarding efficacy, discussing aspects of “typical” use and “perfect” use is also recommended. Perfect use is when a contraceptive is used correctly all the time, whereas typical use takes human error into account1,2,3; this includes missing pills or forgetting to change a patch, as well as using a con- dom.1,2 Common adverse effects are listed in Table 2.2,3,7

Intrauterine devices (IUDs) are small, T shaped, and flexible. Currently, 3 are approved in the United States: levonorgestrel (Mirena) 52 mg, levonorgestrel (Skyla) 13.5 mg, and a cop- per-containing device (Paragard). Levonorgestrel 52 mg is approved for use for 3 years, levonorgestrel 13.5 mg for 5 years, and the copper IUD for 10 years.2,3 These devices are highly effective with a failure rate of less than 1%.2,3 Multiple data articles support the safety of these devices in adolescents.3,4,5 The one-time insertion of an IUD into the uterus reduces the risk of nonadherence,6 and thus the responsibility of maintaining effectiveness. This can make IUDs an ideal choice for a young woman who has not yet reached adulthood. The success rate for insertion is reported at 96%, but there is a risk of pelvic infection for the initial period (~21 days) after implantation. Choosing between the 2 different types of IUD can be challenging, but counseling patients about the risks and benefits with each option can help facilitate their decision. Counseling points include the misconception of infertility with IUDs and safety in nulliparous females.1-3

A progestin implant is a thin, flexible, single rod containing etonogestrel, which is placed under the skin of the upper arm. Etonogestrel 68 mg (Nexplanon) has 3 years of effectiveness. Implants are highly effective with a failure rate of less than 1%. These exert their action by thickening cervical mucous, thinning the endometrial lining, and inhibiting ovulation. Implants do not seem to have a high impact on bone mineral density, as higher levels of estradiol are seen in females using implants vs a progestin injection. Implants are an option for adolescents who prefer not to take scheduled medication daily or who prefer longer-term protection.1-3,7

Depot medroxyprogesterone acetate (DMPA; Depo-Provera) is an injection administered every 3 months with a 96% efficacy rate in pregnancy prevention. DMPA causes anovulation and thickening of the cervical mu- cous by inhibiting pituitary gonadotropins. Advantages of this product include infrequent dosing, discrete- ness, improvement in dysmenorrhea, and protection against iron-deficiency anemia and endometrial cancer. Dis- advantages include having to access a health care provider for injections, menstrual cycle irregularities, delayed fertility return, weight gain, headache, and hair loss. Weight gain is a concern for adolescents who gain more than 5% of body weight after 6 months of use. A black box warning exists for the drug’s potential to cause bone mineral density loss in the first 2 years of use; however, the American College of Obstetricians and Gynecologists states no restriction on the length of time that DMPA can be used.1,2 During this time, adolescents should be counseled on adequate daily intake of calcium and vitamin D (1300 mg calcium; 600 IU vitamin D), weight-bearing exercises, and smoking cessation.1-3,7

Three different methods exist that contain both an estrogen and pro-gestin: pill, patch, and vaginal ring. The 4- to 7-day hormonal-free interval can be used monthly or extended to once every several months. Data have shown safety with the extended approach. Hormonal contraception needs to be taken for at least 21 consecutive days for efficacy against un-planned pregnancy. The timing of contraception use varies and should be taken into consideration when choosing between the pill form, injectable form, patch, or vaginal ring. Adolescents can start these products immediately or can wait until their next menstrual cycle. Preferring a Sunday start or starting on the first day of the next menstrual cycle is common. This will ensure the adolescent is not pregnant before starting contraceptives. Current data, however, do not support evidence of any adverse effects of contraceptive hormone exposure on fetal development.1-3,6

Combined oral contraceptive pills are the most commonly prescribed hormonal contraception and contain various amounts of ethinyl estradiol. Providers should suggest strategies such as using cell phone alarms, maintaining a regular schedule, and getting family member support. Discussion of missed doses is very important, as taking 7 consecutive hormone pills is required to prevent pregnancy. Many different formulations exist (monophasic and in-phasic) and choosing an appropri- ate pill that is covered under the adolescent’s insurance is preferred. Experts recommend starting with a monopha- sic formulation and transitioning over to an in-phasic regimen to alleviate ad- verse effects and/or correspond with the adolescent’s preference.1-3,7

Contraceptive patches (Xulane, Zafemy) contain 150 μg norelgestromin and 35 μg ethinyl estradiol. The patch is worn weekly for 3 weeks and removed for 1 week to induce a withdrawal bleed. The abdomen, upper torso, upper arm, and buttocks are safe places on which to place

The vaginal ring (NuvaRing) is a round, flexible device that is inserted into the vagina weekly for 3 weeks that contains 15 μg ethinyl estradiol and 120 μg etonogestrel. During the doctor visit, patients should be shown a pelvic model to help explain where the vaginal ring will be; they should be reassured the ring will not fall out and that it can remain in during sexual intercourse.1-3,7

Best practices on discussing birth control for adolescents

Danielle m. Alm, PHARMD, BCPS, BCPPS, Reina Puri, Christine Payne

Contemporary PEDS Journal, June 2022, Volume 40, Issue 5

Counseling patients about methods of contraception and increasing access to care can help address unplanned pregnancies and sexually transmitted diseases.

Health care providers play an important role in adolescent sex education, including in discussions on contraceptive use.

 Adolescents may start engaging in sexual activity while undergoing the numerous physical and emotional changes that occur during their transformative period.

 By the age of 20 years, approximately 80% of young women have had sexual intercourse; however, adolescents (aged 15 to 19 years) have limited understanding of the various contraceptive methods available to them, and the lowest rates of contraceptive use.

 Counseling individuals about the various methods of contraception and increasing access to care can help address unplanned pregnancies and sexually transmitted diseases.

 As most females prefer oral contraceptives over other forms, such as injections, transdermal patch, and vaginal rings, familiarizing themselves with the safest and most effective use of all these products is good practice

). This article delves into the contraceptives available for adolescents and discusses their efficacy and safety.

Various methods of contraception are available for adolescents

). Medical providers should counsel them on the efficacy, safety, and adverse effects of contraception,

 informing them about the most effective options. Contraceptive options from most effective to least effective are as follows: intrauterine devices/progestin implants, progestin injections, and combined oral contraception (pills, patch, vaginal ring).

 Regarding efficacy, discussing aspects of “typical” use and “perfect” use is also recommended. Perfect use is when a contraceptive is used correctly all the time, whereas typical use takes human error into account;

 this includes missing pills or forgetting to change a patch, as well as using a condom.

 Common adverse effects are listed in Table 2.

Intrauterine devices (IUDs) are small, T shaped, and flexible. Currently, 3 are approved in the United States: levonorgestrel (Mirena) 52 mg, levonorgestrel (Skyla) 13.5 mg, and a copper-containing device (Paragard). Levonorgestrel 52 mg is approved for use for 3 years, levonorgestrel 13.5 mg for 5 years, and the copper IUD for 10 years.

 These devices are highly effective with a failure rate of less than 1%.

 Multiple data articles support the safety of these devices in adolescents.

 The one-time insertion of an IUD into the uterus reduces the risk of nonadherence,

 and thus the responsibility of maintaining effectiveness. This can make IUDs an ideal choice for a young woman who has not yet reached adulthood. The success rate for insertion is reported at 96%, but there is a risk of pelvic infection for the initial period (~21 days) after implantation. Choosing between the 2 different types of IUD can be challenging, but counseling patients about the risks and benefits with each option can help facilitate their decision. Counseling points to consider include the misconception of infertility with IUDs and safety in nulliparous females.

A progestin implant is a thin, flexible, single rod containing etonogestrel, which is placed under the skin of the upper arm. Etonogestrel 68 mg (Nexplanon) is available and has 3 years of effectiveness. Implants are highly effective with a failure rate of less than 1%. These exert their action by thickening cervical mucous, thinning the endometrial lining, and inhibiting ovulation. Implants do not seem to have a high impact on bone mineral density as higher levels of estradiol are seen in females using implants versus a progestin injection. Implants are a great option for adolescents who prefer not to take scheduled medication daily or who prefer a longer length of protection.

Depot medroxyprogesterone acetate (DMPA; Depo-Provera) is an injection administered every 3 months with a 96% efficacy rate in pregnancy prevention. DMPA causes anovulation and thickening of the cervical mucous by inhibiting pituitary gonadotropins. Advantages of this product include infrequent dosing, discreteness, improvement in dysmenorrhea, and protection against iron-deficiency anemia and endometrial cancer. Disadvantages include having to access a health care provider for injections, menstrual cycle irregularities, delayed fertility return, weight gain, headache, and hair loss. Weight gain is a concern for adolescents who gain more than 5% of body weight after 6 months of use. A black box warning exists for the drug’s potential to cause bone mineral density loss in the first 2 years of use; however, the American College of Obstetricians and Gynecologists states no restriction on the length of time that DMPA can be used.

 During this time, adolescents should be counseled on adequate daily intake of calcium and vitamin D (1300 mg calcium; 600 IU vitamin D), weight-bearing exercises, and smoking cessation.

Three different methods exist which contain both an estrogen and progestin: pill, patch, and vaginal ring. The 4- to 7-day hormonal-free interval can be used monthly or extended to once every several months. Data have shown safety with the extended approach. Hormonal contraception needs to be taken for at least 21 consecutive days for efficacy against unplanned pregnancy. The timing of contraception use varies and should be taken into consideration when choosing between the pill form, injectable form, patch, or vaginal ring. Adolescents can start these products immediately or can wait until their next menstrual cycle. Preferring a Sunday start or starting on the first day of the next menstrual cycle is common. This will ensure the adolescent is not pregnant before starting contraceptives. Current data, however, do not support evidence of any adverse effects of contraceptive hormone exposure on fetal development.

Combined oral contraceptive pills are the most commonly prescribed hormonal contraception and contain various amounts of ethinyl estradiol. Providers should suggest strategies such as using cell phone alarms, maintaining a regular schedule, and getting family member support. Discussion of missed doses is very important, as taking 7 consecutive hormone pills is required to prevent pregnancy. Many different formulations exist (monophasic and in-phasic) and choosing an appropriate pill that is covered under the adolescent’s insurance is preferred. Experts recommend starting with a monophasic formulation and transitioning over to an in-phasic regimen to alleviate adverse effects and/or correspond with the adolescent’s preference.

Contraceptive patches (Xulane, Zafemy) contain 150 mcg norelgestromin and 35 mcg ethinyl estradiol. The patch is worn weekly for 3 weeks and removed for 1 week to induce a withdrawal bleed. The abdomen, upper torso, upper arm, and buttocks are safe places on which to place the patch.

The vaginal ring (NuvaRing) is a round, flexible device that is inserted into the vagina weekly for 3 weeks that contains 15 mcg ethinyl estradiol and 120 mcg etonogestrel. During the doctor visit, patients should be shown a pelvic model to help explain where the vaginal ring will be; they should be reassured the ring will not fall out and that it can remain in with sexual intercourse.

Ott MA, Sucato GS; Committee on Adolescence. Contraception for adolescents. 

. 2014;134(4):e1257-e1281. doi:10.1542/peds.2014-2300

Committee on Adolescence. Contraception for adolescents. 

 2014;134(4):e1244-e1256. doi:10.1542/peds.2014-2299

Todd N, Black A. Contraception for adolescents. 

. 2020;12(suppl 1):28-40. doi:10.4274/jcrpe.galenos.2019.2019.S0003

Committee on Adolescent Health Care. Committee Opinion No 699: adolescent pregnancy, contraception, and sexual activity. 

. 2017;129(5):e142-e149. doi:10.1097/AOG.0000000000002045

Di Meglio G, Crowther C, Simms J. Contraceptive care for Canadian youth. 

 2018;23(4):271-277. doi:10.1093/pch/pxx192

Kumar N, Brown JD. Access barriers to long-acting reversible contraceptives for adolescents. 

. 2016;59(3):248-253. doi:10.1016/j.jadohealth.2016.03.039

Contraception explained: options for teens and adolescents. American Academy of Pediatrics. Updated July 20, 2020. Accessed April 27, 2022. 

https://www.healthychildren.org/English/ages-stages/teen/dating-sex/Pages/Birth-Control-for-Sexually-Active-Teens.aspx

Articles

There are numerous methods of contraception available for adolescents.

Best Practices on Discussing Birth Control for Adolescents

According to Erin O’Connor Prange, MSN, CRNP, of Chil dren’s Hospital of Philadelphia in Pennsylvania, drugs for attention-deficit/hyperactivity disorder (ADHD) have been on the market for more than 45 years, beginning with methylphenidate (Ritalin), which was approved in 1955. [

Editor’s note: Although not included in the 

Diagnostic and Statistical Manual of Mental Disorders

 until 1968, methylphenidate was originally prescribed for fatigue and depression.

] According to a 2016 study, roughly 6 million children in the United States have ADHD, said Prange. Boys receive a diagnosis twice as frequently as girls, but overall, 77% of these children were receiving treatment, with roughly 32% of them having both behavioral and medication treatment.

What is a snapshot look at a child with ADHD? Prange, who was speaking at the 43rd National Conference on Pediatric Health Care in Dallas, Texas,

 in March 2022, explained that the main component of this developmental learning disorder is poor executive functioning in tasks. These include planning, time management, attention, organization, and self-control. Additionally, during the months that children were learning remotely due to the COVID-19 pandemic, impaired communication, eye strain, distractions, and anxiety were also reported, largely as a result of the struggle with virtual and hybrid learning.

Nonmedication treatment for ADHD includes cognitive behavioral therapy, extra time on test taking, creating lists (eg, what to put in the school backpack), and bouncy bands and wiggle seats for desks. The newest (those that have become available over the past 5 years) and most commonly prescribed drugs for the disorder include the nonstimulant viloxazine (Qelbree); for stimulants, there are now several methylphenidates (Cotempla, Adhansia, Aptensio, Jornay) and amphetamines (Dyanavel, Adzenys, and Mydayis).

Before starting a patient on stimulants, the American Academy of Pediatrics recommends a thorough cardiovascular assessment, including patient and family health histories; evaluation of all medications being used; and a physical exam focused on cardiovascular disease risk factors. Prange also reviewed the adverse effects for stimulant medications, which include, but are not limited to, decreased appetite, trouble sleeping, headache, weight loss, and mood swings. She also encouraged audience members to seek out a copy of the ADHD medication guide, available at addwarehouse.com, which provides books, assessment products, and training programs for ADHD and related conditions.

Stay tuned for the August issue of Drug Topics®, featuring an in-depth look at the latest in managing pediatric and adult ADHD.

1. Epstein JN, Loren REA. Changes in the definition of DSM-5: subtle but important. 

. 2013;35(5):455-458. doi:10.2217/npy.13.59

2. Prange EO. ADHD treatment explosion: new meds are here! Presented at: 43rd National Conference on Pediatric Health Care; March 23,2022; Dallas, TX.

Nonstimulant drugs and even nonmedication options are available for use.

Quick Look: The Newest Drugs for ADHD

Pediatric patients in need of infusion therapy face the same access barriers as their adult counterparts. But they also deal with the added challenges of finding sites of care and infusion providers that are accustomed to caring for children.

Robert Dracker, MD, MHA, MBA, CPI, medical director of Summerwood Pediatrics & Infusacare Medical Services in Liverpool, New York, spoke on these issues at the 2022 National Infusion Center Association (NICA) Annual Conference, held June 17 and 18, 2022, in New Orleans, Louisiana.

Dracker discussed considerations and developmentally appropriate interventions to promote high-quality, patient-centered pediatric infusion care. Dracker started with a question: “What is infusion medicine?” There is no standard definition, he said, so he crafted his own, drawing on his decades of experience in the field. Dracker defined this growing sector as, “the health care specialty involved with the clinical science and practice of administering parenteral fluids, medications, biologic, and cellular therapies to adults and children.”

Dracker also touched on the unique needs of children who will be receiving intravenous (IV) or parenteral medications. Compared with an emergency department visit or for a hospitalized child, outpatient infusion therapy is semielective and scheduled, allowing time to prepare the child for the therapy.

“This is a very difficult thing to do for a child in general,” he said. “A [provider] should explain the need for the therapy and obtain an informed consent in some cases, particularly with regards to some of the newer biologic therapies for diagnoses like eczema and psoriasis.”

He compared general therapy considerations with important concerns specific to dealing with pediatric patients, reminding health care professionals that children are not just tiny adults. Things to know and factor into the care include the age of the child and any developmental issues, how ill the child is (acute vs chronic), who is with the child at the visit, any preexisting conditions that could complicate the therapeutic intervention, and the child’s understanding of the treatment and informed consent.

Dracker spoke about the importance of establishing a relationship between a provider and the infusion site team; there must be open communication between both to address issues such as special needs of a particular patient, who will be monitoring the response and follow up labs, and how to partner medically with regards to new emerging therapies.

Dracker also noted that treating a child may raise the anxiety of the medical team, so a collaborative approach is helpful, especially at the start of the therapy. He stressed that an open, interactive relationship between the provider's practice and the therapy site is critical for care.

“There should obviously be communication between both regarding currently available and emerging therapies, the needs for prior authorization, follow-up lab work required, and the fact that the infusion center staff will commonly see the patient during treatment more often than the dermatologist, which means that the response to treatment, or lack thereof, should also be conveyed back to the referring office,” he said.

Providers can take steps to prepare children for treatment in this environment by familiarizing the child with the environment, explaining each step of the process, and surrounding them with love, affection, and even “bribes” such as cartoons, books, and snacks.

In general, parents are fairly motivated to ensure that their child receives their therapy on a scheduled basis. It is important to provide a reminder to parents for an upcoming appointment with regards to date and time. Dracker also urged infusion providers to make an attempt to accommodate a child’s needs, especially related to school and activities.

Dracker also touched on vascular access issues in pediatric patients, the importance of being honest with children, and steps the FDA is taking to ensure access to safe and effective medical products for children.

At the conclusion of his talk, Dracker shared his hope that attendees could walk away with the understanding that children have special needs when it comes to infusion therapy treatments and that in many ways, these providers are treating a whole family—an experience that can be positive or negative depending upon the efforts made and the accommodations provided.

1. Dracker R. Not just tiny adults: considerations for a pediatric population. Presented at: 2022 National Infusion Center Association Annual Conference; June 17-18, 2022; New Orleans, LA.

An expert offers considerations and developmentally appropriate interventions to promote high-quality, patient-centered pediatric infusion care.

Optimizing Outcomes for Pediatric Infusion Therapy

The COVID-19 pandemic has upended the world of respiratory diseases. Every cough and sniffle raises red flags in a clinical area that already was a drain on health care resources. Roughly 12% of adults in the United States have chronic sinusitis, and about 2.7 million physician and 234,000 emergency department visits are attributed to this diagnosis each year.

Drawing the line between acute sinusitis and other respiratory bugs can be difficult, though. As with many other conditions driven by viral infection, there is little clinicians can really offer patients for sinusitis other than supportive care and calls for patience.

As COVID-19 transmissions are lessening, patients and providers are equally concerned about respiratory symptoms, but experts say the pandemic isn’t really changing the game plan for sinusitis.

“I think the biggest thing I try to explain to patients is the disease process,” said Jane Carnazzo, MD, of Children’s Hospital and Medical Center in Omaha, Nebraska.

Observing mucus changes can help patients determine where they are in a bout with sinusitis, she explained; green mucus is common for about a week after infection and doesn’t signal a severe infection.

“When it comes to sinusitis, your acute sinusitis is going to be someone who is sick for 10 to 14 days. You have to give a cold a good week to get better,” she added.

A high fever or copious amounts of mucus right away is a different story, she said, but this level of infection isn’t common.

COVID-19 isn’t the only worry when it comes to respiratory symptoms, Carnazzo added. Antibiotic resistance is a real problem and one she said she tries to educate her patients about. Prescribing antibiotics may give patients a peace of mind regarding their symptoms, but Carnazzo said 75% of her patients don’t return for a prescription after a bit of education about what to expect and what is normal in terms of symptoms and progression of sinusitis.

Besides education, she says offering patients an alternative for symptom management can help. People like to turn to OTC remedies that dry out mucus at the first sign of illness— but, she explained, this is the opposite of how sinusitis should be managed.

“You want the nose to drain. When it comes to preventing a sinus infection, it’s the best you can do,” she said.

Saline rinses have become a popular choice among her patient population, Carnazzo added, but lavage can sometimes make symptoms worse. Instead, things like promoting crying, exposure to cold weather, and anything else that can help make the nose run work well.

The exception, she explained, is children who have issues that could increase mucus retention, immune deficiencies, and conditions including Down syndrome that may predispose a child to smaller sinus cavities. Even with these patients, though, Carnazzo explained that providers should use caution about jumping to antimicrobial treatments.

Time is an important tool in the provider’s arsenal, and many patients will improve in about a week with little intervention. It’s also to be expected that some children will appear to have chronic sinus problems, but constant antibiotic therapy isn’t an option, she noted.

“Kids in day care have runny noses all the time but you can’t just keep them on antibiotics,” she said. “It’s just a matter of trying to sort it out. Give it some time and try to get them to clear their nasal passages. Don’t try to dry it up too much.”

Pushing OTC medications isn’t much help, she added, and imaging studies like x-ray and computed tomography scans are not generally recommended for diagnosis.

The best thing health care providers can do is to get a good history and description of how symptoms developed, what they feel like, and when they are worse.

“History, symptoms, and presentation are key,” Carnazzo said, to management. “Chronic sinus issues may need imaging, but lab work and imaging are really not necessary. Just because the sinuses are plugged doesn’t mean they are infected.”

Purulent drainage is the key symptom in diagnosing an infection that needs more intervention, she said. Providers also need to remember a less common differential diagnosis: foreign objects.

Foul or smelly drainage—especially on just 1 side of the nose—is a red flag that something may be stuck in the nasal cavity, Carnazzo said.

Overall, the best practice for sinusitis is to stress patience and exercis- ing restraint when it comes to antibiotics and medications that dry mucus. Mucus is an annoying symptom, but drainage is what sinusitis needs.

“We’re always looking for a quick and easy fix, even if there isn’t one,” Carnazzo added.

For symptom relief, Carnazzo tends to point parents to menthol products, hydration, and humidifiers rather than OTC medications. If antibiotics are needed, Carnazzo says amoxicillin is the first choice, while zithromax is not recommended because of resistance. The lowest-spectrum antibiotic is always best to use first, she added.

“Just telling them it will take time and offering comfort is key,” she said

This article originally appeared in the June issue of our sister publication Contemporary Pediatrics®.

1. Centers for Disease Control and Prevention. Chronic sinusitis. Updated January 27, 2022. Accessed May 2, 2022. 

https://www.cdc.gov/nchs/fastats/sinuses.htm

Patience and antimicrobial stewardship are the keys to treating sinusitis

What to Consider with Sinusitis in 2022

When my daughter received a type 1 diabetes (T1D) diagnosis about 18 months ago, I could not even express how devastated I felt. I have been a pharmacist for about 20 years and even with my background, it was overwhelming. Managing diabetes is a constant job. Whether the patient has T1D or T2D, the condition can be very stressful. As I joined various online support groups, I noticed a lot of discussions about diabetes burnout.

The CDC acknowledges that diabetes burnout is real,

 noting that “over time, the emotional burden of managing diabetes can cause burnout.” 

® interviewed several experts about how pharmacists can help patients or caregivers who are experiencing diabetes burnout.

Amanda Lane, MS, RD, LDN, CDCES, is the founder of Healthful Lane Nutrition, LLC. “Diabetes distress or burnout can look different for everyone,” she said. “Some patients may be angry about their medications or checking [blood glucose]; others may brush it off with vague terms like ‘it’s all good,’ avoiding appointments, and not refilling medications on time.”

Stephanie Redmond, PharmD, CDCES, BC-ADM, cofounder and vice president of the Diabetes Doctor is a clinical pharmacist and diabetes educator. When ascertaining whether a patient has diabetes burnout, she looks for the following signs:

• The patient is not refilling prescriptions on time, indicating they are not taking medication.

• The patient does not bring in their meter, which is a sign they are not checking blood glucose as directed.

• The patient has not followed up in a long time or does not want to talk about their diabetes.

According to Lane, patients who need more medications or higher doses feel like they are doing something wrong. In these cases, “helping the patient or a caregiver learn how to fill a pillbox can be a super helpful way to combat diabetes distress,” she explained. “Seeing all the pill bottles multiple times per day can be overwhelming, but having a box that has the right medications portioned out can be less overwhelming.”

For certain patients, Lane recommends continuous glucose monitoring (CGM). However, she noted that first there should be a conversation about comfort level with new technology. “Some patients are more stressed by managing the increased technology that CGM requires, whereas others find the decreased finger sticks and increased glucose readings to be incredibly helpful,” she added.

“Pharmacists are more involved than ever in CGM dispensing and education,” Redmond added.“ Wearing a CGM can have a huge real-time impact and teach lessons that checking blood glucose never can. [Patients can] see the benefits immediately of taking a medication, going on a walk, or eating nuts vs chips for a snack.”

Lane noted that Medicare covers CGM in patients meeting specific criteria. Those with T1D or T2D with multiple daily injections or other qualifying criteria can typically get CGM through their insurance. However, the insurance may dictate the brand of CGM that is covered.

Redmond suggested that pharmacists use motivational interviewing techniques, such as asking open- ended questions and giving the patient time to respond. “I love restating what they told me, to give them a chance to react in a positive way— [for example], ‘You feel like nothing you do helps your blood sugars.’ This gives the patient a chance to respond: ‘Well, when I walk on Saturday, I noticed Sundays are my best day,’” she explained.

Redmond also encouraged pharmacists to focus on the patient’s good blood glucose days, rather than the bad, and to brainstorm together on what makes the difference. “This helps encourage self-reflection,” she said.

Pharmacists can also give patients hope and encouragement. “They are not alone,” Redmond said. “It is helpful to find a support community— even online—of other individuals living with diabetes who have ideas or diet/exercise/lifestyle tips that have worked for them.” Pharmacists can remind patients to seek support—but not medical advice—from their peers.

Pharmacists should also help patients with a plan of action when they check blood glucose. “If you are checking blood [glucose] but not doing anything with that information, it really seems pointless to check,” Redmond noted. Pharmacists can ensure that the patient has a plan for how to treat highs and lows, as well as a glucagon prescription—and, crucially, knows how to use it and can train loved ones or caregivers to administer it during a hypoglycemic emergency.

Redmond tells her patients, “Focus on how to make your next decision a good one. Even if you ate chocolate cookies all day and feel like the day is wasted, you don’t have to commit to going to the gym for the next week or eating zero carbs. Just make your next decision, whether it’s dinner or a snack at bedtime, a healthier one. Or maybe it’s taking a 10-minute walk after dinner. One decision at a time seems easier than trying to undo a whole year’s worth of bad lifestyle habits. Small changes have a big impact in the end.”

Redmond also reminds pharmacists to counsel patients on their medications. “Often, patients take different medications for their diabetes and don’t understand why they would take more than 1. But if they understand that they work in different ways or have different benefits, they are more likely to take them,” she says.

She also offers information about adverse effects (AEs) and solutions, so patients know that certain AEs do not mean failure. “For example, metformin tells your liver to stop making so much [glucose] because you don’t need it. If you notice any loose stools, let me know; we can change to a long-acting tablet that can help, or reduce your dose. Your other medication, dapagliflozin [Farxiga], helps your kidneys urinate out extra [glucose] that the body doesn’t need. This means you are also losing calories, so it can help with weight loss. Most individuals notice an increase in urinary frequency for the first week or so, but this does get better with time.”

“When [a treatment plan] makes sense, patients want to take it and want to be healthier,” Redmond said.

1. Dealing with diabetes burnout. CDC. Updated January 26, 2022. Accessed June 20, 2022. https://www.cdc.gov/ diabetes/library/spotlights/diabetes-burnout.html

Over time, the emotional burden of managing the disease can become overwhelming. 

Helping Patients Manage Diabetes Burnout

Three years ago, my wife, Denise, planned another vacation of a lifetime.

 In 2001 and 2013, we had traveled, with our parish priest and our kids, to Italy on a pilgrimage to various religious sites. We had a marvelous time. This trip, though, would be different: We were going to Germany, where all of my grandparents are from. My dream to see the Passion Play in Oberammergau would become a reality in May 2020.

The Passion Play was performed there first in 1634 and every 10 years thereafter as a thanksgiving offering for the village being spared from the plague. The Passion Play deviated from every 10-year schedule only twice: in 1940, during World War II, and again in 2020 for the COVID-19 plague. The Germans seemed to know that COVID-19 would last longer than 1 year and rescheduled the performance for 2022. We were excited to get tickets to the second performance on May 15.

Whenever I travel to a different locale, I like to stop by the pharmacy for a quick visit. In Germany, it is easy to find a pharmacy. Each store is designated by a big, red A for apotheke.

Pharmacies, by German law, are owned and operated by a pharmacist who has graduated from an accredited school of pharmacy. It is a strange experience when you walk in. The employees, technicians, and pharmacists are sharply dressed in white lab coats with name tags. Throughout the country, pharmacies had the same vibe: calm, quiet, and professional—unlike the chaos in some American pharmacies. Each pharmacist we talked to happened to be a woman and spoke English with proficiency.

Prescription products were available only in unit-of-use blister packs. I asked one pharmacist if they ever split the boxes and received a firm no in response. These boxes were dispensed as a single unit, QR-coded with the lot and expiration date entered on the patient’s profile. There are absolutely no stock bottles and no prescription vials.

German pharmacists do not frequently receive electronic prescriptions. Instead, patients carry a pink and white prescription blank from their physician. There are no directions or drug names on the blank; there is a serial number that, when entered, populates the drug name, quantity, and directions for use. This information is contained in a central database and it is virtually impossible for a pharmacist to enter data incorrectly. There is no chance the pharmacist will enter amitriptyline 100 mg for an order written for amitriptyline 10 mg.

All pharmacies in Germany utilize the same formulary. Patients pays 10% of the cost of the prescription: between €5 and €10, maximum. Can you imagine a prescription in your pharmacy having a maximum co-pay of $10? Best of all, there are no prior authorizations in the pharmacy; everything is approved.

Of all the wonderful experiences Denise and I had interacting with our fellow pharmacists, our encounter in Oberammergau stands out. It was Sunday afternoon and I went to the apotheke to buy a box of ibuprofen 400 mg. When she rang up the sale, she warned me that there would be a €2.5 inconvenience fee because it was a Sunday purchase. I told her I would be honored to pay a surcharge; I’ve always been annoyed with Sunday shoppers. Of the prescriptions we fill on a Sunday, seldom are there more than a few true emergencies.

The German population is covered by a national insurance, which seems satisfactory to most of the citizens there. They have had national health insurance since 1883 thanks to Otto Von Bismarck’s social legislation. Today, the German government spends $685 for health care for the average citizen. Compare that with the United States, which spends over $1000. When it comes to providing drugs to our patients, we could learn a lot from the Germans about safety, cost containment, and satisfaction of its pharmacists.

Kreckel PA. A lesson from the friendly skies. 

https://www.drugtopics.com/view/a-lesson-from-the-friendly-skies

American pharmacies can learn a lot from the Germans about safety, cost containment, and pharmacist satisfaction.

Welcome to the Apotheke

On May 13, 2022, the FDA approved tirzepatide (Mounjaro) for the treatment of type 2 diabetes (T2D) in conjunction with diet and exercise.

 Tirzepatide has a dual mechanism of action as an agonist to glucose-dependent insulinotropic polypeptide (GIP) receptors and to glucagon-like peptide-1 (GLP-1) receptors. As such, tirzepatide acts to modulate insulin and glucagon release, which can improve blood glucose control.

Tirzepatide efficacy was demonstrated in a series of trials (SURPASS-1 through SURPASS-5) aimed at improving glycemic control in participants with T2D in addition to diet and exercise. SURPASS-1 (NCT03954834) compared tirzepatide monotherapy to placebo, while SURPASS-2 through SURPASS-5 allowed participants to use additional background therapy.

SURPASS-2 (NCT03987919) compared tirzepatide with semaglutide in addition to metformin. Participants were allowed to use metformin or metformin plus a sodium/glucose cotransporter 2 inhibitor (SGLT2I); SURPASS-3 (NCT03882970) compared tirzepatide with long-acting insulin degludec; SURPASS-4 (NCT03730662) compared tirzepatide to long-acting insulin glargine in participants concomitantly taking a background therapy regimen of up to 3 of the following medications: metformin, an SGLT2I, and/or a sulfonylurea; and SURPASS-5 (NCT04039503) evaluated patients who administered insulin glargine with or without metformin who were randomly assigned to tirzepatide or placebo.

The trials included a total of 5870 participants and studied tirzepatide 5-mg, 10-mg, and 15-mg doses for a duration of either 40 or 52 weeks.

Gastrointestinal adverse events (AEs) were most common with tirzepatide and included nausea, diarrhea, decreased appetite, vomiting, constipation, dyspepsia, and abdominal pain. These AEs were more common during dose escalation but tended to decrease with time. Concomitant use of sulfonylureas or insulin can increase the risk of hypoglycemia.

Tirzepatide carries a boxed warning. In rats, tirzepatide causes thyroid C-cell tumors in a dose- and duration-dependent exposure. The risk of thyroid tumors in humans is currently not known, but tirzepatide it is contraindicated in patients with a family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2. All patients should be informed of the potential risk for MTC and of the presenting symptoms of such tumors in order to self-monitor.

Pancreatitis and acute gallbladder disease are associated with use of GLP-1 receptor agonists. Tirzepatide has not been studied in patients with a history of pancreatitis and the effect on lactation or infant exposure is unknown. Patients using oral contraceptives should switch to or add a nonoral contraceptive method for 4 weeks after initiation and after each dose escalation because of the resultant delay in gastric emptying. Tirzepatide is not indicated for use in patients with type 1 diabetes.

The approved starting dosage of tirzepatide is 2.5 mg once weekly as a subcutaneous injection to the abdomen, thigh, or upper arm. Injection sites should be rotated weekly. As needed for glycemic control, the dosage may be increased by 2.5 mg every 4 weeks, with a maximum dose of 15 mg injected subcutaneously weekly Tirzepatide may be administered without regard to meals. Tirzepatide is supplied as a package of 4 prefilled, single-dose pens. The medication can be stored in the refrigerator but is stable at room temperature for up to 21 days.

FDA approves novel, dual-targeted treatment for type 2 diabetes. News release. FDA. May 13, 2022. Accessed June 17, 2022. 

https://www.fda.gov/news-events/press-announcements/fda-approves-novel-dual-targeted-treatment-type-2-diabetes

Mounjaro. Prescribing information. Eli Lilly; 2022. 

https://pi.lilly.com/us/mounjaro-uspi.pdf

Tirzepatide is a once-weekly subcutaneous injection to treat type 2 diabetes in conjunction with diet and exercise.