At the beginning of 2020, we provided a look into the upcoming trends that will shape how the profession moves forward in the year ahead. But what if we dig even deeper? What new gaps will pharmacists need to fill?

Walk into a pharmacy in 2030 and you may find that the pharmacist’s role has completely transformed. Our 

 for this issue explores what the future will bring as pharmacists move beyond their dispensing duties and continue to step out from behind the counter, exploring the evolution of new roles and specialized niches emerging in the profession.

March is National Autoimmune Disease Awareness Month, and this issue provides an 

treatment options, management tips, and what’s in the pipeline. Approximately 1 million individuals are living with MS in the United States. Pharmacists can play an integral role in managing the disease in their patients.

In preparation for allergy season, in this issue Frieda Wiley, PharmD, 

 for patients looking to relieve their allergy-related symptoms, as well as counseling tips and techniques for optimizing these treatments. In addition, pharmacists looking to add diabetes care to their expertise will find advice on how to turn their pharmacy into a place where patients seek out care and counseling for their disease.

Feeling like you could use a change in your profession or you’re just not the right fit for a current job? This issue also features an article on 

 to explore a different path in pharmacy. Pharmacy managers and educators offer expert advice on transitioning into different areas of the field–sharing knowledge that is applicable to both graduating students and established pharmacists.

It’s easy to get caught up in the stresses of the job; sometimes you just need to reflect on what motivated you to join the profession in the first place. Karen Berger, PharmD, asked pharmacists from across the country, and a variety of settings, 

. Their answers are refreshing and motivating.

As Laura Dee, PharmD, clinical pharmacist, said in the article, “pharmacy as a profession is very versatile-–you can do research, or work in a hospital, industry, or retail. You are also learning something new every day-–as our society evolves, so does our profession.”

Thank you for reading and continue to follow us on DrugTopics.com for more.

Articles

What new gaps will pharmacists need to fill?

Preparing for Evolving Pharmacist Roles

Back in the late 1980s, the pharmacy profession gave so much away. We gave up reasonable dispensing fees in the name of increasing volume.

We had computers; we could do more with less. We didn’t have to fill out those 3-part carbon copy claim forms with a pen, as our computers could print those out for us to mail in. Then Prescription Card Services (PCS) had us install those electronic terminals in our pharmacy, we didn’t have any paper to deal with. We then got our computers to interface directly with those insurance companies. At that time, one of my most quotable pharmacists Dick Treese said, “Once you leave those black boxes (modems) into your store, you will kiss your profession goodbye!”

Pharmacists got bamboozled for sure. As if the hassles with the insurance companies were not enough, we then got the DUR messages from the Omnibus Budget Reconciliation Act of 1990 (OBRA 90) to assure that prescriptions for covered outpatient drugs are appropriate, medically necessary, and not likely to result in adverse reactions. We had to review (at no charge!) all of these messages and call physician offices if necessary. No problem, however, lots of jobs were available and salaries increased by leaps and bounds. My starting salary of $12.35 per hour in 1981 had tripled in less than 20 years.

Salaries like that attract interest in high school kids looking for a financially rewarding career. Universities answered the demand by creating more slots for these students. In 1981 when I graduated there were 72 schools of pharmacy, 40 years later there are 143 schools. Now I’m seeing job offers for new graduates about 2/3 of my current salary. Tuition is at least 17 to 20 times higher than when I graduated pharmacy school. Minimum wage midway through pharmacy school in 1978 was $2.65 per hour. A student would need to earn $52 per hour doing a minimum wage job to keep up with college pharmacy school inflation. Don’t forget to add an extra year of tuition for the PharmD program. We’ve sold out this profession to the pharmacy schools.

It’s my hope that 2020 is a profession changing year, starting with the schools of pharmacy. The average family size in my baby boomer generation was 3.67. Today’s family size is 1.9, nearly half of the family size when I was growing up. Half of the available kids as when I was growing up, with twice as many pharmacy school, has resulted in lower overall quality of graduating pharmacists. We need to be graduating a lot less student pharmacists. Wages have indeed stabilized, and I’m sure by the time I hang up my white lab coat, they will further decline. Again, we’ll be haggling about the price of the pharmacist.

Let’s take a clue from our fellow health care professionals: the physicians and dentists. We need to fix the “glut” of pharmacists. By selling out this profession, we will see a further depression in wages and benefits. We will also see an increase in the misery in the profession, by reduction in staffing, more responsibilities, and decreased job satisfaction.

I love this profession; I am so appreciative of the excellent academians that trained me and those training the future generation of pharmacists. Although there is a “glut” of pharmacists, there will never be an excess of excellent pharmacists that come from excellent schools of pharmacy. We need to stop the deluge of pharmacists who will never see the job satisfaction that I’ve seen throughout my career. We need to keep our excellent schools of pharmacy producing those excellent pharmacists.

It’s my hope that 2020 is a profession changing year, starting with the schools of pharmacy.

Addressing the ‘Glut’ of Pharmacists

This article was originally published on 

According to the National Institutes of Health (NIH), nonalcoholic steatohepatitis (NASH) is a form of non-alcoholic fatty liver disease (NAFLD). The NIH defines NAFLD as a condition in which a buildup of fat-not caused by heavy alcohol consumption-occurs in the liver. Patients with NASH also have inflammation of the liver, known has hepatitis, and resultant liver cell damage.

 NASH currently affects between 6.5 million to 16.3 million Americans.

Current Management and NASH Pipeline Drugs 

According to the American Association for the Study of Liver Diseases, the management of NASH consists of treating liver disease as well as the associated metabolic comorbidities such as obesity, hyperlipidemia, insulin resistance, and type 2 diabetes.

There are currently no FDA-approved medications for the treatment of NASH, but the guidelines recommend lifestyle modifications like weight loss, pioglitazone (biopsy-proven NASH), and vitamin E as treatment options.

Empagliflozin ( Jardiance) is showing promise for patients with type 2 diabetes and NAFLD based on positive results from the E-LIFT trial and study demonstrating the medication reduces liver fat.

 Intercept has submitted the new drug application for obeticholic acid (Ocaliva) for the treatment of liver fibrosis due to NASH and was granted priority review by the FDA, with a target approval date of March 26, 2020.

Obeticholic acid has a unique mechanism of action as an oral farnesoid X receptor (FXR) agonist. It’s the only therapy the FDA has designated as a Breakthrough Therapy for NASH with fibrosis, according to results from the phase 3 REGENERATE study.

"If approved, obeticholic acid would be the first FDA-approved product for NASH, and it would likely have a year or more marketing head start over the rest of the pipeline," said David Calabrese, RPh, MHP, senior vice president and chief pharmacy officer, OptumRx.

GENFIT is studying elafibranor, an oral medication currently in a phase 3 trial RESOLVE-IT for the treatment of NASH. After a favorable safety review, the study is continuing and expected to be completed in 2021.

 Elafibranor is a dual agonist of PPAR-alpha and PPAR- delta receptors, which both play an important role in numerous processes involved in the development of NASH and its comorbidities. The FDA has granted elafibranor fast track designation for the treatment of NASH.

"Allergan's cenicriviroc and Madrigal Pharmaceutical's resmetirom are in phase 3 trials and are anticipated to be approved in 2021-2022,” said Nicole Kjesbo, PharmD, BCPS, principal clinical program pharmacist, Prime Therapeutics.

The phase 3 study AURORA is currently recruiting an estimated 2000 participants to evaluate cenicriviroc for the treatment of NASH, with topline results expected in the fourth quarter of 2020.

 Resmetirom would be a first- in-class oral thyroid hormone receptor-beta selective agonist, and the phase 3 study MAESTRO-NASH began March 2019.

 The endpoint is resolution of NASH after 1 year of treatment. In addition to the drugs mentioned, Kjesbo revealed there are at least 10 other drugs for the treatment of NASH that are in Phase 2/3 trials and are anticipated to be approved in 2021 and beyond.

"Many of the pipeline drugs are being developed by different manufacturers and some manufacturers are developing multiple drugs for NASH," said Calabrese. "Therefore, there may be potential for combination therapy down the road which would further increase the future cost of treatment."

"This is going to be an emerging category in the coming years," said Kjesbo. "Currently, pharmacotherapy is reserved for NASH patients with fibrosis; it will be interesting to see if lifestyle changes will continue to be the first-line treatment over medications." According to Kjesbo, analysts have forecasted the market for NASH drugs could reach $20 billion by 2025.

1. National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts of NAFLD & NASH. National Institute of Health. 

https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash/definition-facts

2. American Liver Foundation. The Silent Liver Diseases You Need to Know About: NAFLD and NASH [infographic]. American Liver Foundation’s website. 

https://liverfoundation.org/wp-content/uploads/2018/04/ALF-NAFLD-NASH-Infographic.pdf

3. Kuchay MS, Krishan S, Mishra SK, et al. Effect of empagliflozin on liver fat in patients with type 2 diabetes and nonalcoholic fatty liver disease: a randomized controlled trial (E-LIFT trial). Diabetes Care. 2018. Doi: 

4. Sattar N, Fitchett D, Hantel S, et al. Empagliflozin is associated with improvements in liver enzymes potentially consistent with reductions in liver fat: results from randomized trials including the EMPA-REG OUTCOME® trial. 

https://doi.org/10.1007/s00125-018-4702-3

5. FDA Accepts Intercept’s NDA for OCA for the Treatment of Liver Fibrosis due to NASH and Grants Priority Review [news release]. Intercept’s website. 

http://ir.interceptpharma.com/news-releases/news-release-details/fda-accepts-intercepts-nda-oca-treatment-liver-fibrosis-due-nash

6. GENFIT: Positive 42-month DSMB recommendation for continuation of phase 3 RESOLVE-IT study of elafibranor in NASH. GENFIT’s website. 

https://ir.genfit.com/news-releases/news-release-details/genfit-positive-42-month-dsmb-recommendation-continuation-phase

7. Tobira Therapeutics. AURORA: Phase 3 Study for the Efficacy and Safety of CVC for the Treatment of Liver Fibrosis in Adults With NASH. ClinicalTrials.gov. 

https://clinicaltrials.gov/ct2/show/NCT03028740

8. Madrigal Pharmaceuticals Announces First Patient Dosed in MAESTRO-NAFLD-1, a Second Phase 3 Multi-Center, Double-Blind, Randomized, Placebo-Controlled Study of Resmetirom (MGL-3196) in Patients With Non-Alcoholic Steatohepatitis (NASH) and Presumed NASH (NASH/NAFLD (non-alcoholic fatty liver disease)) [news release]. Madrigal’s website. 

https://www.madrigalpharma.com/wp-content/uploads/2019/12/Madrigal-Pharmaceuticals-Announces-Second-Phase-3_NAFLD-1-12-18-2019.FINAL_.pdf

Analysts have forecasted the market for NASH drugs could reach $20 billion by 2025.

NASH Drug Pipeline Shows Promise

We asked pharmacists from various settings around the country: “Why did you become a pharmacist, and what keeps you motivated?" Their answers are refreshing and motivating, and a reminder of why we all chose pharmacy.

Larry Riggi, PharmD, Pharmacy Manager                                                                                                        

“I chose to pursue a career in pharmacy because the medical field has always interested me. When it came time to decide, I had heard the rumors about a lucrative pharmacy career back in the early 2000s, and had added that as an option. I was really interested in becoming an ER doctor as well, so I decided to shadow a pharmacist for a day. The pharmacist said one thing that really stuck with me: ‘If you want to have a family later in life, choose pharmacy over ER doctor.’ I chose pharmacy after that day and haven’t looked back. Whether or not that still stands true today with the direction pharmacy is going is still to be determined.

There are a few things that keep me motivated on a regular basis–my kids being the biggest thing. Looking. forward to days off with my kids is what can get me through a long stretch of work every time. I also enjoy seeing my store excel with corporate metrics and comparing how we stack up to other stores. I’d be lying if I didn’t say that the desire to be the best in the district wasn’t a motivating factor.”

Laura Dee, PharmD, Clinical Pharmacist                                                                                                                      Crusader Community Health, Rockford, IL

“I started a part-time job at a retail pharmacy and my pharmacy manager’s compassion and enthusiasm inspired me to become a pharmacist.

As an ambulatory care pharmacist, my coworkers and my patients keep me inspired. I manage a hepatitis C clinic, and just hearing my patients’ stories of all the obstacles they’ve overcome, I’m honored that they entrust their medical care to myself and my team.”

Elaine K. Richer, RPh, CEO                                                                                                                                      MyCureAll, Fair Lawn, NJ

“I always knew that I wanted to work in the medical field, and as pharmacy school was shorter than medical school, it was a no brainer.

As a newly licensed pharmacist, I loved working in a retail setting, interacting with people, helping with their questions, advising on interactions with food or medicine. It was a very fulfilling experience, and I looked forward to going to work every morning.

As the years passed, and I had my daughter, I also realized that working as a pharmacist was a great job for a female because I was able to design my schedule around my family’s needs. Pharmacy as a profession is very versatile–you can do research, or work in a hospital, industry, or retail. You are also learning something new everyday–as our society evolves, so does our profession. When I started out as a pharmacist, I would never imagine vaccinating a patient or administering Narcan, but alas, that is what pharmacists are doing now. And I really enjoy it.

Now that I am in the middle of my career and I decided to completely shift my focus and work in a med/tech start up world, everything I’ve learned as a pharmacist is here to support me, and my knowledge leads the way to new and exciting opportunities.”

Arun Tandon, RPh                                                                                                                                                      Advanced Health Pharmacy, Portage, Michigan

“I became a pharmacist as I was very much interested in human health.

What keeps me going is the ability to understand health at a much deeper level and translating it to my patients. Seeing them healthier and happier drives my passion.”

Gunda Siska, PharmD                                                                                                                                              Presbyterian Hospital, Albuquerque, New Mexico

“Even as a kid, I always knew I would work in a hospital. I went to LPN (licensed practical nurse) nursing school concurrently while in high school. Then I automatically went to college to pursue an RN degree, but at the last minute, I decided to pursue pharmacy school. I did retail and mail order work right out of pharmacy school, but felt restless until I got a hospital job. It thrills me to be involved in acute and critical care. I often think of my time as retail pharmacist, and now I write pharmaceutical articles to pass on the knowledge that I acquire in the hospital setting to the retail pharmacists. I think it takes a village to keep the general public safe, and the retail pharmacists are the most accessible. They are on the front lines and I admire their contributions. Iwant to support them the best I can. I think making the world a healthier place is my destiny and life mission.”

Jennifer Gershman, PharmD, CPH
						Fort Lauderdale, Florida

“I’ve always looked up to my father, who is a pharmacist, and wanted to follow in his footsteps and make a positive impact on patient care. Educating pharmacists and patients about vaccines, new drug approvals, and hot topics in health care through writing is a true passion of mine. I enjoy helping pharmacists stay up-to-date with the ever-changing profession through drug information updates.”

Andrea Levin, PharmD, BCACP, Assistant Professor, Department of Pharmacy Practice                                                Nova Southeastern University College of Pharmacy

“I became a pharmacist because of my love and passion for medicine paired with the opportunity to make an impact in patient care. Pairing this with my love of teaching made being a pharmacist faculty the perfect path for me. This is also why I specialized in ambulatory care, as it allows for more longitudinal patient care, often times in an interprofessional setting. Ambulatory care is truly unique since you have the opportunity to interact with both other health care providers and patients equally and work as a team to provide the highest quality of care for a patient.

My motivation as a pharmacist and faculty comes from my students and patients. Seeing how proud and accomplished my students are when they make a difference in a patient’s life reminds me everyday why I love teaching. Also, seeing my patients’ HbA1c or blood pressure or some other laboratory markers either decrease or get to goal and seeing that same sense of accomplishment and knowing that their health will improve keeps me going as a pharmacist.”

We asked pharmacists from various settings around the country: “Why did you become a pharmacist, and what keeps you motivated?"

Why Did You Become A Pharmacist?

We all check in with our smartphones more than a few times throughout the day. Whether we’re responding to texts or scrolling through our social feeds, it can be difficult to refrain from the distraction of our mobile devices. But what if there was a way to make your phone actually useful at work?

From drug information to patient education, these apps can help you be better at everything that you do.

Epocrates, a point-of-care medical application, is widely regarded as a useful tool for pharmacists. The app itself provides clinical reference information on drugs and has a variety of features such as a drug interaction checker, pill identifier, and drug coverage information for insurance plans. Most of the app’s offerings are free of charge, although additional features may be included for a monthly fee. This includes medicine monographs, peer-reviewed disease content from the BMJ, and labs, ICD-10 codes, and more.

The Pocket Pharmacist app provides pharmacist-curated drug information that can be useful if you need to look something up quickly. According to the company’s description, it “feels like you’re talking to a live pharmacist versus reading through an encyclopedia.” The tool is good for drug information, searching for drug interactions, and testing your own knowledge through medication quizzes.

Here’s a way to have the latest recommended immunization schedules at your fingertips. The CDC’s Vaccine Schedules app visually mimics the printed schedules which are reviewed and published annually, including the most current version of the schedules for children and adolescents, catch-up schedule for children, adult schedule (as recommended by age group and medical conditions), and an adult contraindications and precautions table. Any changes in the schedule are released through app updates.

Drugs.com offers a comprehensive app filled with information that allows you to check drug interactions, identify pills, and create custom lists and reports. The app also offers in-depth consumer information, FDA alerts, and a complete A-to-Z database of drug information.

The Merck Manual has long been the go-to source for medical knowledge, and now you can put all that in your pocket-without having to lug around a 20-pound book and flip endlessly through thousands of pages. The app contains thousands of regularly-updated articles, drug reference information, illustrations, and much more-all available for free.

this tool has unique features such as pharmacogenomics databases, IV compatibility data, patient education leaflets, drug shortage information, and the ability to reorder databases and monograph fields to customize displays.

According to the company, the content is also stored directly on the device, making it feasible to quickly answer questions while on the go even if there’s no internet connection.

The FDA's Drugs@FDA Express app is a free mobile version of the agency’s online database of information on approved drugs. Users can search and browse by drug name, active ingredient, or application number. A list of recent approvals, organized by date, can also be viewed in the ‘Last 7 Days’ Approvals’ option

7 Pharmacist-Friendly Apps You Should Be Using

Americans are desperate to be well. Being well, however, is not the business model of modern medicine, according to Kathy Campbell, PharmD, clinical community pharmacist and CEO/owner of Dr Kathy Health, LLC, and Medicap Pharmacy in Owasso, Oklahoma. The American health care system is structured to respond to a patient’s diagnosis, not prevent disease.

The $40 billion supplement industry,1 which includes vitamins and nutraceuticals, represents Americans’ willingness to spend money to be healthy. “Pharmacists are perfectly positioned and trained to understand the chemistry of supplements and foods, and as well as drugs and diseases,” Campbell said. “They can assist customers by recommending appropriate supplements. Sales of these products can also benefit a pharmacy’s bottom line.”

Bowe Craine, PharmD, co-owner and pharmacist in charge at Okie’s Pharmacy II Inc., in Blaine, Tennessee, agreed, and said that pharmacists should be at the forefront of not only selling supplements, but that they should also educate patients on OTC products that may not be FDA approved.

When looking to grow business with supplement sales, pharmacists should first educate themselves. “Research the most common products in various categories, and then analyze which ones fit your community’s needs,” Craine said. For example, if you have a large patient population with inflammatory conditions, such as irritable bowel disease or arthritis, then you should start with products like turmeric, fish oil, or cannabidiol (CBD) oil.

“Get out from behind the counter and talk to customers,” Craine said. “Ask how they feel about their current therapies and if they’re sufficient. Be confident in your ability to make recommendations about products that can improve quality of life. Not only will you increase your sales and profit margins, but you will also create loyal customers and build trusting relationships.”

Campbell recommended attending an 8-hour continuing education course from the National Community Pharmacists Association and Dr Kathy Health, Creating Health-Pharmacist-led Lifestyle and Weight Management, which teaches supplementation basics and foundational training in assisting patients with health.

When researching supplements, Craine uses UpToDate, PubMed, or the Dietary Supplements Labels Database to study their safety, efficacy, and various uses. National Center for Complementary and Integrative Health’s website is also recommended to get a better understanding of the usefulness and safety of supplements with evidenced-based research, advises Dipan B. Ray, MPharm, MS, PhD, RPh, senior director of experiential education at Touro College of Pharmacy in New York, New York.

Nina Chhabra, PharmD, a natural medicines specialist at Northwell Health/Vivo Health Pharmacy in New Hyde Park, New York, subscribes to reputable databases, such as the Natural Medicine Database, which provides detailed information regarding supplements like their level of effectiveness, safety information, dosing information, and possible drug interactions. ConsumerLab.com provides third-party testing results. The National Institute of Health’s website shows if any clinical trials were conducted to support a particular product’s usage, she said.

By far, the most popular supplement Craine sells are multivitamins. “Consumers take them mainly to avoid vitamin deficiencies which can lead to problems such as osteoporosis, muscle cramps, and fatigue,” he said.

Hemp-derived CBD topped Chhabra’s list in 2019. Patients use this product to help manage anxiety and stress, for insomnia or to support sleep, and for different types of pain related to fibromyalgia, headaches and migraines, and muscle and joint pain.

Vitamin D is the most popular supplement currently used. It helps the body absorb calcium in order to increase bone density and therefore reduces the risk of developing osteoporosis, especially in women and the elderly, he said.

In addition to serving as a resource on which supplements to take, pharmacists should make customers aware of possible adverse drug reactions.

A general myth is that most supplements are safe because they’re derived from natural sources. “The truth is that a majority of herbal supplements interact with other drugs and can have significant adverse effects,” Ray said.
	
	For example, Chhabra noted that turmeric, curcumin, and fish oil supplements can thin blood. If a patient takes a blood-thinning agent such as aspirin or warfarin, she warns them to stop taking these supplements before surgery or any medical procedure that could affect their clotting time.

Chamomile, often used as a sleep aid, interacts with birth control, Craine pointed out. Ginger, which prevents nausea and vomiting, can lower blood sugar and interact with blood thinners if high doses are taken. Yohimbe may aid with erectile dysfunction, but it can raise blood pressure and heart rate and cause tremors.

Consumers should understand the importance of selecting the most appropriate products depending on their medical histories and current medication use. “Before using any such products, patients should share their current medications and over-the-counter products with their physicians and pharmacists so they can counsel them about any potential risks and benefits,” Ray said. “I encourage patients to report any side effects to physicians or pharmacists immediately.”

Because the kidneys and liver break down supplements just as they do prescription drugs, Chhabra asks customers if they have any issues with these organs. “Supplements can cause interactions for patients who take prescription drugs because they can compete with the same pathway,” she said.

Craine aims to ensure that customers buy products from reputable companies. For example, he’ll recommend a multivitamin with the United States Pharmacopeia (USP) seal of approval. “This seal means you can trust that the bottle’s contents contain exactly what the label states,” he noted.

Craine asks patients for feedback as well. “I want to know if a product helped or if it had side effects, so I can relay that to other patients,” he said.

The most frequent questions Chhabra gets from patients is if a product is safe and if it works. “I emphasize that safety is our primary concern, however it is hard to find robust clinical evidence about efficacy,” Chhabra said. “This is simply because large trials that can show this are rarely performed. Unlike prescription drugs, supplements are considered safe unless proven otherwise.”

Currently, Chhabra also receives many questions about hemp-based CBD products. “Although CBD appears to be safe, it is relatively new and we’re still learning its exact uses,” she said. “I recommend patients start taking low doses and slowly increase the dosage every 2 to 3 days until they feel an effect. But I caution them to only use products that provide third-party testing results, which can help ensure it’s a quality product and reveal its CBD content as well as any contaminants such as heavy metals, pesticides, and bacterial growth.”

The most frequently asked question consumers ask Ray is, “How much should I take?” He pointed out that all vitamins need to meet a certain Recommended Daily Allowance (RDA) as stated on the label to achieve desired benefits.

Supplements, Vitamins, and Nutraceuticals: What’s the Difference?

The best way to describe the differences between vitamins, supplements, and nutraceuticals is to consider supplements as the main category that these agents fall into.

The Dietary Supplement Health and Education Act of 1994 (DSHEA) defines dietary supplements as “a product intended to supplement the diet that bears or contains 1 or more dietary ingredients, including a vitamin, mineral, herb or other botanical, an amino acid, a dietary substance for use by man to supplement the diet by increasing the total dietary intake, or a concentrate, metabolite, constituent, extract, or combination of any of the aforementioned ingredients.”2

Nutraceutical products are generally derived from food sources intended to be used for health benefits, whereas vitamins are organic compounds that are needed from external sources, such as food, because the body can’t make them, explained Chhabra.

“If someone can’t obtain enough of a necessary vitamin from a food source alone, they may use a supplement that contains that specific vitamin,” Chhabra said. “Vitamins are essential for bodily functions, whereas nutraceuticals are used to supplement the diet and are typically food or food sources and are used for a specific health benefit.”

1. Statista. Total US dietary supplements market size from 2016 to 2024. https://www.statista.com/statistics/828481/total-dietary-supplements-market-size-in-the-us/.
	2. National Institutes of Health, Office of Dietary Supplements. Dietary Supplement Health and Education Act of 1994 Public Law 103-417 103rd Congress. https://ods.od.nih.gov/About/DSHEA_Wording.aspx#sec3

When looking to grow business with supplement sales, pharmacists should first educate themselves.

Growing Your Business With Supplements

The advent of spring represents new life and rebirth of nature. Unfortunately for many, the budding plants come with consequences in the form of watery eyes, stuffy or runny nose, scratchy throat, and sneezing. So bothersome are these signs and symptoms of allergic rhinitis, in fact, that America spends more than $18 billion treating allergies each year, according to the American College of Allergy, Asthma, and Immunology.

Corticosteroids are first-line therapy for seasonal allergic rhinitis in patients who are 12 years of age and older. They do not provide acute relief and are the most effective medications to curtail allergic complaints, according to Elizabeth Richardson, PharmD, BCPS, assistant professor of pharmacy practice at Butler University and clinical pharmacy specialist in internal medicine at Indiana University Health Methodist Hospital.

To optimize benefit and limit allergic symptoms, proper adherence to corticosteroid therapy is critical, said Gary Gross, MD, an allergist on the medical staff at Texas Health Presbyterian Hospital Dallas. Patients often expect that intranasal corticosteroids  (ie, budesonide, triamcinolone, and fluticasone) will provide instant relief and become discouraged when they do not. Many patients either give up too quickly on using intranasal corticosteroids, or they stop using the medication once symptoms improve, so their complaints return.

Gross also encourages patients to begin using intranasal corticosteroids either when allergy seasons starts or a week prior.

While intranasal corticosteroids keep allergic symptoms at bay, patients have other options. Depending on their symptoms, antihistamines and decongestants can give additional or alternative relief.

However, as Gross noted, one common pitfall occurs when patients seeking relief from nasal congestion erroneously select an antihistamine instead of a decongestant.

“Some people pick the wrong medicine,” he said. “Patients need to be educated that antihistamines provide relief from sneezing, itching, and runny nose and that decongestants reduce congestion.”

Another important differentiating point between antihistamines and decongestants is that decongestants elevate the blood pressure, whereas antihistamines do not.

Pharmacists should consider the adverse effect profile when recommending antihistamines. Although effective, the first-generation antihistamine diphenhydramine has strong sedating effects. For this reason, as well as the overall lower adverse effect profile,  Richardson recommends second-generation antihistamines. Her top choices for second-generation antihistamines are loratadine and cetirizine because they tend to be cheaper than their cousin, fexofenadine.

For patients who require a decongestant, Gross recommends pseudoephedrine, cautioning that its stimulating effects may interfere with sleep if taken late in the day. He also encourages patients to rinse their nares daily with saline solution

“People like it because it is natural and can be used often,” he said.

On a final note, pharmacists should also advise patients against using allergy medicine when they have conditions where the signs and symptoms are not allergy-related. For example, individuals with a cold sometimes try to treat their illness with antihistamines. The same holds true for patients who have dry eye. Some of these patients tend to use allergy eye drops, which Gross cautions is the wrong use for the medicine. They may resolve the redness, but they do little to moisturize the eyes.

1. American College of Asthma, Allergy, and Immunology (ACAAI). Allergy Facts. AACI’s website. Updated January 9, 2018. https://acaai.org/news/facts-statistics/allergies

Relieving symptoms and optimizing therapies for allergic rhinitis

Prepare for Allergy Season

Obtaining a PharmD has such broad value when it comes to career offerings, and those offerings can best align with not only one’s personal strengths, but professional goals. Sure, you can look to practice as a pharmacist in the community setting or within the hospital setting- where the majority of jobs still reside- but there are non-traditional roles that pharmacists play as well.

“Serving in the long-term care market, the specialty pharmacy market, or even the ambulatory care setting, pharmacists can use their clinical expertise to directly impact the patient’s utilization and response to taking medications,” said Jonathan Ogurchak, PharmD, CSP, founder and CEO of STACK, a compliance management software company for pharmacists. “Beyond that, pharmacists can be looked upon as educators, frequently being hired as medical science liaisons within the pharmaceutical industry and tasked with teaching providers about disease processes and the medications used to treat them.”

Pharmacy schools are tasked with a huge responsibility–not only training pharmacists to understand the complexities of disease states and the drugs to manage, but also with educating about career opportunities.

“The experiential education component of the curriculum plays a huge part in understanding what types of roles might be available, since it’s often one of the closest steps to direct practice that student pharmacists would have prior to graduation,” Ogurchak said.

Pharmacy students regularly do rotations during their last year of schooling, which places them in different industries and shows them how different segments of pharmacy operate. But just because they decide to go in one direction initially does not mean they are stuck in that area for their entire career.

Jeannie K Lee, PharmD, BCPS, BCGP, FASHP, associate professor for pharmacy practice and science at the University of Arizona College of Pharmacy, said that often students know about community pharmacy work, but not much more.

“Pharmacy is a broad and interesting field with many possibilities and opportunities in general and specialized practices, managed care, industry, research, academia, etc,” she said.

That’s why, at the University of Arizona College of Pharmacy, one of the courses students participate in their first semester is Pharmacy Practice, where students take a survey of their interest areas and learn how to explore and pursue those fields through resources that have been gathered for them.

“At the same time, practitioners from various pharmacy careers come into class to present their journey and engage students in a question and answer session,” Lee said. “Our students are surveyed each year to help them explore as many career paths in pharmacy as they wish.”

It’s not unusual for someone in the pharmacy field to want to find something new and pivot to a different career path in pharmacy, and it’s not as hard to do as some may think.

Lee noted that the best way to start a possible switch is to first explore the field of pharmacy they are passionate about and identify details-training needed, procedures, types of patients, niche opportunity, collaborators, settings, salary, benefits, etc.

“For each possible position, they may want to create a pro and con list to think about the choice deeply and to help with decision making,” she said. “It will help tremendously to talk with a pharmacist who is currently in the position to learn about their path and others they know of."

Nonye Uddoh, PharmD, BCACP, clinical pharmacist at CHC Health, pivoted from retail to managed care 5 years ago by gaining additional certifications and experience outside of her 9-to-5 schedule, and by networking with other pharmacists. She believes others can make a smooth transition.

“What I’m noticing in the field is the focus on developing yourself with certifications and/or residency, consider gaining more than 1 state license, connect with your colleagues and add value as much as possible,” Uddoh said.

Conrad Dhing, PhD, assistant dean of student academic affairs at Husson University’s School of Pharmacy, noted that many hospitals and pharmacy chains have internal career development programs to help someone learn of other opportunities.

Ogurchak added that demonstrating an understanding of the profession, based on practice experience, carries a huge weight when looking to shift career opportunities.

“Often times, the ability to relate prior situations into more broad terms can highlight your ability to perform in new scenarios-especially if you're looking to move into a new setting for practice,” he said. “Demonstrating a desire to learn is also critical-either through highlighting continuing education that you’ve completed in a particular practice area, additional trainings, or certifications that you may have achieved as well.”

Lee believes a silo-thinking approach to different areas of pharmacy might make it more challenging, where people think that they are “stuck” in an area of pharmacy they started with. But the knowledge and skill sets are transferable.

For example, over a 20-year career in pharmacy, Lee has worked in community pharmacy (as a student); ambulatory care clinics in internal medicine/primary care, cardiology and geriatrics; home-based primary care and interprofessional home visits; hospital work in pain management and rehab, adult acute care and critical care; and academia, research, and administration.

Those wanting a similar career path can achieve it.

“I think engagement is key-seek out pharmacists in different areas of pharmacy to receive mentorship and guidance. Pharmacists are by and large kind and generous people, and you can benefit from their experiences and wisdom,” Lee said. “Also, advocate for the pharmacy profession so that our paths continue to enlarge and not become stagnant or narrow.”

Kelley D. Carlstrom, PharmD, BCOP, a clinical oncology pharmacist, is contacted often by pharmacists who want to pivot into oncology.

“It is rare to be handed an opportunity in oncology with no prior experience, although I’ve talked to a few pharmacists that were in the right place at the right time and recognized the opportunity,” she said. “So, keep your eyes/ears open for any opportunity to get exposure to oncology drugs, patients, or systems in any capacity.”

For example, if your site has a cancer center, she recommended volunteering to cross-train.

“Most pharmacists shy away from chemotherapy so that provides an opportunity for you,” Carlstrom said. “If you work in retail, spend extra time with patients that are filling supportive care medications; you may even dispense some oral chemotherapy.”

Furthermore, if your site doesn’t have a cancer or infusion center, Carlstrom suggested looking for one local to you that does and follow them on LinkedIn, and connect with others that work there.

“Build and grow your professional network-this is said a lot these days but can’t be overstated,” she said. “Don’t blindly grow your network, but be proactive by interacting with people regularly. I highly recommend LinkedIn but networking in person at local events is very impactful. There is also a great online community at the Pharmacist’s Slack."

For students or current pharmacists looking to learn about the many opportunities, there are plenty of easy ways to discover these on the web. Thankfully, students can learn about pharmacy career choices through the American Pharmacist Association (APhA) and many pharmacy programs encourage students to explore all options.

Pharmacyforme is geared toward students thinking about pharmacy as a career; the APhA site is for students and professionals exploring different areas of pharmacy. Pharmacists can also review the APhA career center information.

“A career as a pharmacist is so much more than 1 job-it’s a combination of all of one’s experiences from the time they enter school through the time they retire,” Ogurchak said. “Finding ways to utilize each one of those experiences across the course of a career helps one to practice as a better, well-rounded practitioner.”

It’s also important to keep in mind that pharmacy is a very small world.

“It is like ‘6 Degrees of Kevin Bacon.’ Someone is bound to know someone, who knows someone, who you’ve worked with,” Dhing said.“Being an engaged, professional employee who helps your organization reach its goals is always valued. When you help your organization reach their goals, you’re more likely to develop a positive reputation and reach your own personal goals.”

Pharmacy managers and educators offer career advice.

Making A Career Pivot

On December 23, 2019, the FDA approved ubrogepant for the acute treatment of migraine with and without aura in adult patients.

 Ubrogepant is a calcitonin gene-related peptide (CGRP) receptor antagonist. CGRP is a protein released when the trigeminal nerve is activated. Binding of CGRP to its receptor is associated with blood vessel dilation, inflammatory mediator release, and transmission of pain stimulus to the central nervous system–mechanisms involved with migraine pathology. Blocking CGRP from binding to its receptor is a novel mechanism for migraine treatment.

Ubrogepant was approved based on the results of 2 randomized, double-blind, placebo-controlled trials. In these trials,
		1439 participants were randomized to placebo, or 50mg of ubrogepant in both trials. Some patients (23%) were taking preventive migraine therapies, but none were on medications affecting CGRP. In study 1, participants were randomized
		to an additional 100-mg arm. In both trials, participants were instructed to treat a migraine of moderate-to-severe intensity with the study drug. A second dose of study drug or the participant’s usual acute migraine therapy could be administered 2 to 48 hours after the initial dose as needed. 

In both studies, a comparison of pain and most bothersome symptom (MBS) at 2 hours post-dose for ubrogepant versus placebo serves as the primary outcome.Both studies showed that participants taking ubrogepant demonstrated greater rates of absence of pain or MBS at 2 hours post dose compared with placebo. In study 1, both doses of ubrogepant were associated with reduced occurrence of photophobia or phonophobia compared with placebo.

The most common adverse effects seen in studies with ubrogepant are nausea and somnolence. Ubrogepant is primarily eliminated via metabolism by cytochrome P450 3A4 (CYP3A4). Administration of ubrogepant is contraindicated in patients taking a concomitant strong CYP3A4 inhibitor, as this will significantly increase exposure to ubrogepant. Patients taking concomitant moderate 3A4 inhibitors should administer a lower dose (50 mg) and avoid a second dose within 24 hours of the first dose.

Ubrogepant is also a substrate for BCRP and P-gp transporters. Based on the findings of clinical interaction studies, patients taking concomitant BCRP and/or P-gp inhibitors should utilize a lower dose of ubrogepant to limit exposure. Patients with severe hepatic impairment (Child- Pugh class C) should administer the reduced dose. Patients taking strong CYP3A4 inducers, or who have end stage renal disease (CrCl <15 mL/min) should avoid taking ubrogepant. There are no data regarding the safety of treating more than 8 migraines in a 30-day period or on the effect of ubrogepant on a breastfed infant.

Ubrogepant is approved for use in adult patients as both 50-mg and 100-mg tablets to be administered as a single dose as needed for migraine symptoms. It can be administered with or without food. A second dose may be administered no sooner than 2 hours after the initial dose, with a maximum dose of 200 mg per 24 hours. Administration of ubrogepant with a high-fat meal may reduce peak drug concentration by 22% and delay the peak drug concentrations by 2 hours without an overall change in the AUC.

1. Ubrelvy [package insert]. Madison, NJ: Allergan USA, Inc., December 2019

2. Durham PL. Calcitonin Gene-Regulated Peptide (CGRP) and Migraine.Headache. 2006;46(1):S3-S8.

On December 23, 2019, the FDA approved ubrogepant for the acute treatment of migraine with and without aura in adult patients.

Ubrogepant: A Novel Drug Mechanism for Migraine Treatment

Approximately 1 million individuals are living with multiple sclerosis (MS) in the United States, according to the National MS Society.

 The condition is caused by the immune system attacking the protective sheath (myelin) that covers nerve fibers and can result in a wide range of symptoms such as the inability to walk.

 Most patients with MS experience a relapsing-remitting disease course, which involves periods of new symptoms or relapses that occur over days or weeks and usually improves partially or completely.

 There is no cure for MS, so treatment usually involves therapies that improve recovery from attacks, slow disease progression, and manage symptoms.

Treatments for MS include pharmacotherapy and physical therapy. Corticosteroids can help to treat MS attacks by reducing nerve inflammation. Adverse effects include increased blood pressure and blood glucose, mood changes, and fluid retention.

  The American Academy of Neurology (AAN) recommends a careful evaluation of the risks/benefits of disease-modifying therapies (DMTs).

 The DMTs can help to slow the disease process and assist with keeping the condition stable by decreasing the number of new lesions that can form, preventing existing ones from becoming larger, and decreasing the number of relapses.

Approximately 1 million individuals are living with multiple sclerosis in the United States, according to the National MS Society.

Drug Topics March 2020

Preparing for Evolving Pharmacist Roles

Addressing the ‘Glut’ of Pharmacists

NASH Drug Pipeline Shows Promise

Why Did You Become A Pharmacist?

7 Pharmacist-Friendly Apps You Should Be Using

Growing Your Business With Supplements

Prepare for Allergy Season

Making A Career Pivot

Ubrogepant: A Novel Drug Mechanism for Migraine Treatment

What Pharmacists Should Know About Multiple Sclerosis

Going Beyond Dispensing: The Future of Pharmacist Roles

How To Turn Into A ‘Diabetes Pharmacy’

Top 5 Things to Know About COVID-19

Harmons Pharmacies Are Special

Massachusetts Hospital Uses Telehealth to Increase Access to Opioid Treatment

The Impact of Patents and Exclusivities on FDA’s Approval of Generic Drugs