In the United States, there were over 67,000 drug overdose deaths in 2018.

 Of these, about 70% were due to opioids.

 According to the CDC, from 2006 to 2017, there was a greater than 19% decrease in annual opioid prescribing, suggesting that “health care providers have become more cautious in their opioid prescribing practices.” 

As the most accessible health care providers, pharmacists are in a unique position to help patients find ways to treat pain without opioids.

As pharmacists, we may immediately start thinking about pharmaceuticals when a patient asks for a recommendation. However, pharmacists can counsel on both OTC and prescription medications, as well as other nonpharmacologic measures. When appropriate, encourage the patient to see a specialist to discuss nonopioid alternatives such as massage, physical therapy, acupuncture, injections, or nerve blocks, or even surgery.

When recommending medication for an adult aged 65 or older, it is prudent to check the 

 to ensure the medication is safe and appropriate.

 Checking a drug interaction database is also prudent in ensuring safety at any age. 

In terms of nonopioid medication for pain relief, acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) is a good starting point.

: Acetaminophen can help patients with mild to moderate pain. Counsel patients on maximum dosage, avoiding alcohol, and liver toxicity. Caution against combining products that contain acetaminophen, such as cough and cold products.

: NSAIDs are available in many OTC and prescription products and can help patients with mild to moderate pain and inflammation from various conditions. Those with gastrointestinal (GI) concerns may fare better with prescription celecoxib, a COX-2 inhibitor, which has fewer GI adverse effects (AEs). Patient counseling can include the risk of GI bleeds, perforation, and ulcers; hypertension; kidney problems; and cardiac thrombotic events.

 Medications such as gabapentin and pregabalin are often prescribed for nerve pain. Counsel patients on the risk of sedation, the possibility of suicidal thoughts and behavior, and the risk of misuse.

 Patient counseling on antidepressants should always include the risk of 

. In addition to reviewing the drug’s AEs with the patient, it is prudent to mention withdrawal symptoms due to abrupt discontinuation, and the importance of a tapering schedule when the drug will eventually be discontinued.

 and drugs that can interact with antidepressants (eg, triptans, opioids, muscle relaxants, St. John’s Wort, and dextromethorphan) can help prevent a life-threatening serotonin buildup.

: TCAs can be useful in chronic pain and nerve pain. In addition to the counseling points above, pharmacists can also counsel patients on the anticholinergic AEs: dry mouth, dizziness, sedation, memory problems, orthostatic hypotension, urinary retention, and cardiac conduction abnormalities.

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

: SNRIs such as duloxetine or venlafaxine can help various pain conditions, like nerve pain or fibromyalgia, and have fewer side effects than TCAs.

Selective serotonin reuptake inhibitors (SSRIs)

: SSRIs such as fluoxetine or escitalopram are effective as antidepressants but have less of an effect on pain relief than other classes of antidepressants.

 are sometimes used for muscle pain and spasms. In these patients, counseling on AEs and drug interactions is essential, as well as the importance of short-term use.

Several community pharmacists shared their experiences in talking to patients about pain relief. Trisha Winroth, PharmD, pharmacy manager at Walgreens in Lowell, Massachusetts, has plenty of recommendations she shares with her patients. “In community pharmacy, there aren’t many things that top the satisfaction of helping a patient in pain. Pain can and does affect a patient’s life in every way, from productivity to personal relationships, from sleep to work capacity. Helping a patient resolve pain will ensure you a trusted patient-pharmacist relationship forever,” she explained.

Winroth finds it helpful to offer solutions that she has personally tried, which adds more trust to the recommendation. Winroth noted that chronic pain patients “often dislike pharmacies and pharmacists because we've been put in the position to police narcotics and pain medications for years. Through corresponding responsibility, good faith dispensing, and a plethora of lawsuits and board of pharmacy cases, pharmacists must act judiciously to ensure prescriptions meet a number of requirements that often remove of us from a true patient care role.”

She reminds pharmacists to remember that caring for patients is of utmost importance. “Spending a few minutes listening and offering suggestions can be the difference between true patient care and merely a dispensing gatekeeper role,” Winroth said.

Some of the go-to products she recommends include:

ice packs, eye masks, and MigreLief supplements for headache and migraine,

lidocaine patches (remind patients to remove for 12 hours) or roll-on for sciatica or back pain.

Anne Henriksen, PharmD, is the pharmacist and owner of Malley’s Compounding Pharmacy in Richland, Washington. For nerve pain, Henriksen recommends a supplement that contains the methylated and active forms of B vitamins. She noted that “since opiates do not work for nerve pain, patients with nerve pain are typically very willing to try alternatives to alleviate their pain,” and this product helps a great deal with nerve pain. “Our pharmacists often recommend this supplement even before a prescription medication is started,” she said, noting that a local neurologist puts all of his patients on the supplement before starting any prescription medication for nerve pain.

Henriksen finds that many of her patients who take opioids are eager to learn more about OTC options for pain management. “As a compounding pharmacist, I often recommend low-dose naltrexone (LDN) for pain,” Henriksen said. “Naltrexone works with the body's inflammatory system to reduce pain levels. There is a growing body of evidence to support the use of LDN in pain and other disease states, and a conversation about LDN is worth having with any chronic pain patient.” Henriksen also recommends that her patients try cannabidiol (CBD) products, especially topicals with menthol, that “provide the familiar cooling relief of menthol but has the added healing and anti-inflammatory benefits of the CBD and herbs.”

Elaine Richer, RPh and CEO of MyCureAll, has 25 years of community pharmacy experience and now focuses her practice on CBD and medical cannabis. “Because cannabinoid receptors, unlike opioid receptors, are not located in the brainstem areas controlling respiration, lethal overdoses from cannabis and cannabinoids do not occur,” she explained. Richer noted that medical cannabis is becoming a popular alternative for patients who do not want to take opioids or cannot tolerate them. Richer advises talking to patients about CBD or medical cannabis. “Studies show that medical cannabis is effective for pain. In combination with opioids, medical cannabis can enhance pain relief and lower the incidence of side effects and overdoses from opioids. Patients are often able to lower opioid doses or taper to discontinuation.” She indicated that CBD or cannabis can help the patient reduce opioid use without the risk of overdose and relapse, providing a safe alternative treatment for pain and other conditions. 

With many treatment options, pharmacists can be a valuable resource to patients who require pain relief. By listening, understanding, and counseling, pharmacists can make a meaningful difference.

CDC. Drug Overdose Deaths. Last updated March 19, 2019. Accessed February 11, 2021.

https://www.cdc.gov/drugoverdose/data/statedeaths.html

CDC. Changes in Opioid Prescribing Practices. Last updated August 13, 2019. Accessed February 11, 2021. 

https://www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html

American Geriatrics Society. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate medication use in older adults. Last updated November 2015. Accessed February 11, 2021. 

https://www.guidelinecentral.com/summaries/american-geriatrics-society-2015-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-older-adults/

US Department of Health and Human Services. Pain Management Best Practices Inter-Agency Task Force Report. Last updated May 9, 2019. Accessed February 11, 2021. 

https://painmed.org/wp-content/uploads/2021/01/pmtf-final-report-2019-05-23.pdf

Articles

Pharmacists can counsel on prescription and OTC options, as well as nonpharmacologic measures. 

Discussing Pain Management Options With Patients

Heart failure with reduced ejection fraction (HFrEF) is characterized by dyspnea or exertional limitation and occurs when the left ventricular ejection fraction (LVEF) is 40% or less.

 Treatment for patients with HFrEF includes a diuretic, a beta blocker, and either an angiotensin receptor-neprilysin inhibitor, an angiotensin-converting enzyme inhibitor, or an angiotensin receptor blocker. Ivabridine, hydralazine/ isosorbide, and sodium-glucose cotransporter 2 inhibitors have also been shown to provide additional benefit in patients with persistent symptoms. On January 20, 2021, the FDA approved vericiguat (Verquvo; Merck) for use in adults with symptomatic HF and an ejection fraction less than 45% to reduce the risk of cardiovascular death and HF hospitalization following a hospitalization for HF or need for outpatient intravenous diuretics.

 HF is characterized by myocardial and vascular dysfunction, which may be due to impaired synthesis of nitric oxide (NO) and decreased activity of soluble guanylate cyclase (sGC).

 Vericiguat stimulates sGC, an enzyme that, when it binds to NO, catalyzes the synthesis of intracellular cyclic guanosine monophosphate (cGMP). The increased intracellular levels of cGMP lead to smooth muscle relaxation and vasodilation.

The efficacy and safety of vericiguat are based on the results of the VICTORIA trial.4 This was a phase 3, randomized, double-blind, placebo-controlled trial that randomized 5050 patients with chronic HF (New York Heart Association (NYHA class II-IV)) and an ejection fraction less than 45% to receive either vericiguat 10 mg daily (n = 2526) or placebo (n = 2524), in addition to guideline-based medical therapy. The primary outcome was a composite of death from cardiovascular causes or first hospitalization for HF and occurred in 35.5% of patients in the vericiguat group and 38.5% of patients in the placebo group. The secondary end points were cardiovascular death and HF hospitalization. Cardiovascular death occurred in 12.9% and 13.9% of patients given vericiguat and placebo, respectively. HF hospitalization was reported at 25.9% and 29.1% of patients in the vericiguat and placebo group, respectively. The study investigators concluded based on the efficacy data from this study, that vericiguat reduced the incidence of death from cardiovascular causes or hospitalizations for HF compared with placebo.

The prescribing information for vericiguat contains a warning for embryo-fetal toxicity and is contraindicated in pregnant females.

 Females of reproductive potential must use effective forms of contraception during treatment and for 1 month after stopping the treatment to prevent pregnancy. Vericiguat is also contraindicated in patients taking other sGC stimulators and is not recommended to be used in patients also taking phosphodiesterase-5 inhibitors due to the potential for hypotension. The most common adverse events seen in the VICTORIA trial were hypotension (16% vs 15% in the vericiguat and placebo group, respectively) and anemia (10% vs 7% in the vericiguat and placebo group, respectively).

Vericiguat is available as 2.5, 5, and 10 mg tablets.

 The initial dose is 2.5 mg orally once daily with food. The dose may be doubled about every 2 weeks until the target maintenance dose of 10 mg once daily is achieved, as tolerated by the patient. The tablets may be crushed and mixed with water immediately before administration in patients who are unable to swallow whole tablets. Vericiguat does not need to be dose-adjusted in patients with an estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 min2 or with mild or moderate hepatic impairment. Vericiguat has not been studied in patients with an eGFR < 15 mL/min/1.73m2, patients on dialysis, or patients with severe hepatic impairment (eg, Child-Pugh C). If a dose is missed, the patient should take the dose as soon as the patient remembers on the same day of the missed dose. Patients should not take 2 doses on the same day.

Katelyn Yamartino, PharmD, is a PGY-1 pharmacy resident at UConn John Dempsey Hospital at UConn Health, Farmington, Connecticut.

Kevin W. Chamberlin, PharmD, FASCP, is university director of pharmacy residency programs at UConn Health.

Murphy SP, Ibrahim NE, Januzzi JL Jr. Heart failure with reduced ejection fraction: a review. JAMA. 2020;324(5):488-504. Published correction appears in JAMA. 2020;324(20):2107. doi:10.1001/jama.2020.10262

Merck Announces U.S. FDA Approval of VERQUVO® (vericiguat). News release. Merck. January 20, 2021. Accessed February 3, 2021. https://www.merck.com/news/merck-announces-u-s-fda-approval-of-verquvo-vericiguat/

Verquovo. Prescribing Information. Merck; 2021. Accessed February 3, 2021. https://www.merck.com/product/usa/pi_circulars/v/verquvo/verquvo_pi.pdf

Armstrong PW, Pieske B, Anstrom KJ, et al. Vericiguat in patients with heart failure and reduced ejection fraction. N Engl J Med. 2020;382(20):1883-1893. doi:10.1056/NEJMoa1915928


A new drug review for vericiguat, indicated for heart failure, reports efficacy and safety data. 

Vericiguat (Verquvo) for Heart Failure With Reduced Ejection Fraction 

Due to a variety of new communication and technology advances, pharmacists now are much better armed to prevent drug shortages. During the initial surge of the COVID-19 pandemic in April 2020, severe drug shortages plagued health systems. Particularly affected was the supply of sedation medications. However, this was not the case during the second surge this winter, according to Emily Pherson, PharmD, assistant director of medication use policy and clinical informatics at The Johns Hopkins Hospital in Baltimore, Maryland. “In this second surge, we are doing much better than back in the spring,” Pherson told 

Chronic drug shortages have become a much bigger issue in recent years. However, Michael Ganio, PharmD, MS, BCPS, FASHP, senior director of pharmacy practice and quality for the American Society of Health-System Pharmacists (ASHP) in Bethesda, Maryland, said pharmacists now have better software technology for managing inventory control. Typically in hospitals there are seasonal changes, with more respiratory infections in the winter and a greater need for antibiotics. However, centralized inventory allows a pharmacist to better keep track of how specific drugs are being prescribed. This can allow for an immediate alert if a drug is in short supply or headed that way. “The most major thing is communication,” Ganio said, “everything from the purchasers, who may have an early signal that a shortage is going to occur, and then notifying the clinical pharmacist and the providers.”

The COVID-19 pandemic created drug shortages that had not been anticipated. Ganio said in April and May 2020, pharmacists experienced a 300% to 500% increase in the use of intensive care drugs and agents for patients on ventilators. “So the whole country was affected because wholesalers made big shifts,” Ganio said. “That was a very scary time for the pharmacists.”

Artificial intelligence (AI) could be potentially useful in helping prevent drug shortages. However, limitations exist due to the inability of AI to predict a problem at a manufacturing plant or other links in the system. “When it comes down to it, there is not a lot of transparency,” Ganio said.

Most drug shortages are caused by manufacturing quality issues.

 There may be a quality issue identified during an FDA inspection, but the citation may not be posted in a timely matter. “It could be glass, the raw material, or a supply chain issue,” Ganio said. Warning letters can be delayed for months, he noted. AI use may be limited due to these factors and the fact that third parties are involved and often masked.

New drug shortages in general are declining, but the concern among pharmacists is that hundreds of drugs remain in chronic shortage. To address this issue at The Johns Hopkins Hospital, there are weekly task force meetings looking at all drug inventories and stocking practices. One task force examines weekly inventories and the areas of highest need. A second task force is dedicated solely to COVID-19–related treatments. Combined with other strategies, such as analytics solutions, pharmacists work with the providers to restrict drugs to those who are in the most need so each agent can be used the most optimally. “The keys are good management and use of dashboards that can allow for easily pulling data for monitoring and predicting shortages,” Pherson said. “It lets you be more proactive.” 

Woodcock J. To help reduce drug shortages, we need manufacturers to sell quality—not just medicine. Food and Drug Administration. Updated October 24, 2019. Accessed January 31, 2021. 

https://www.fda.gov/news-events/fda-voices/help-reduce-drug-shortages-we-need-manufacturers-sell-quality-not-just-medicine

Hospitals employ several strategies for a proactive approach to shortages. 

Leveraging New Technologies to Prevent Drug Shortages

Complementary and alternative medicine (CAM) has grown steadily over the last decade but surged in popularity in 2020—likely due to the coronavirus disease 2019 (COVID-19) pandemic.1 According to the results of a survey conducted by the Council for Responsible Nutrition, users cited overall immune support (57%) and health/wellness benefits (53%) as the most common reasons for increasing their supplement intake.1 With many individuals seeking additional ways to stay healthy, pharmacists are ideally positioned to help educate patients on the appropriate use of these products.

Despite the uptick in CAM use, misconceptions abound among health care professionals, including pharmacists. Two integrative pharmacists seek to dispel these myths and offer their colleagues tips to improve their ability to assist their patients in navigating complementary and integrative care.

"The biggest myth about CAM I keep hearing from medical professionals is that CAM and herbal products don't have evidence behind clinical use," said Marina Buksov, PharmD, health coach, nutritionist, and clinical herbalist based in Brooklyn, New York. "I think because of the lack of education, health care professionals and patients alike are wary of herbal medicine, and there's a general consensus that it's potentially dangerous to use—guilty until proven innocent."

For Hossein Ejtemai, RPh, owner of Brookville Pharmacy and Wellness Center in Chevy Chase, Maryland, the misconceptions surrounding CIM seem to be demographic- and geographic-based.

"People often think there's a [cultural] gap with CAM because people from overseas—especially from the Asian culture—are more likely to use supplements, natural products, and natural remedies," he said. "The younger generation in this country is also changing to CAM because of access to information [via the internet].”



Pharmacists Offer Key Counseling Points for CAM

To optimize their patients' experience with CAM, Ejtemai said pharmacists should seek training.

"Health care professionals are [generally] aware of CAM but most medical professionals, including pharmacists, lack sufficient training in CAM,” he said. "The 3 credits you get in pharmacy school is not enough to assist your patients."

Pharmacists looking to expand their knowledge can choose from numerous certifications, many that are available online and take 6 to 18 months to complete. "Get certified to better educate your patients," Ejtemai said. The Institute for Integrative Nutrition, Duke University, and The George Washington University are among the institutions that offer programs.

After developing their CAM skills, pharmacists should keep several key concepts front of mind when counseling patients on CAM. Most importantly, pharmacists should take the time to ensure patients understand when and how to use these products.

"Natural products have a place in both Eastern and Western medicine, but you have to keep in mind that natural products are generally better for prevention than treatment," Ejtemai explained. "You cannot treat a disease with natural products in the late stages."

Ensure patients understand that, unlike many conventional medicines that often show results in a few days or weeks, natural products can take several weeks to months to work.

Below are more recommendations for pharmacists seeking to educate their patients on CAM use.

Use trustworthy sources to conduct your research.

"It's important to look to reputable resources on topics that we don't have enough education on," Buksov said. She recommends Lexicomp, the Natural Medicines database, and 

 by Memorial Sloan Kettering Cancer Center.

Educate patients taking nutrient-depleting medications on the importance of supplementation.

For example, Ejtemai recommended counseling patients taking metformin on the importance of vitamin B12supplementation to potentially ward off diabetic neuropathy.

Consult with a practitioner, educator, or

researcher who is an expert in the topic about which you are seeking information.

Conventional medicine has exchanged peer reviews for evidence-based medicine, but the sometimes nebulous nature of CAM sometimes warrants peer consultations.

Dietary supplement usage up dramatically during pandemic, new Ipsos-CRN survey shows. News release. Council for Responsible Nutrition. August 20, 2020. Accessed February 6, 2021. https://www.crnusa.org/newsroom/dietary-supplement-usage-dramatically-during-pandemic-new-ipsos-crn-survey-shows

Alternative healing approaches and therapies become increasingly popular among consumers. 

Pharmacists and Patients Navigating Complementary and Integrative Medicine 

Numerous COVID-19 relief funding programs in 2020 gave pharmacies access to extra cash flow but added uncertainty in an already tumultuous year. With most independent pharmacies receiving Paycheck Protection Program (PPP) relief loans, Congress granted these pharmacies a last-minute gift, and some certainty, with the passage of the Consolidated Appropriations Act, 2021 (CAA) on December 27, 2020. This bill changed how the PPP would be taxed and essentially made it nontaxable. Add in other taxpayer-friendly provisions from the CAA, such as the nontaxability of Small Business Administration (SBA) debt relief and Economic Injury Disaster Loan (EIDL) grants, among others, and pharmacies ended the year with thousands in tax savings potential with the stroke of a pen.

Consequently, many pharmacies optimized their taxes, and cash flow, without having to do anything. For those who may still face a tax liability for 2020, there is little room to limit that tax liability after the tax year has concluded. However, there is one last-minute planning idea that, surprisingly, I often see not being used. This strategy can still be implemented before you file your taxes for 2020.

The Tax Cuts and Jobs Act of 2017 allows pharmacies to report, for tax purposes, on the cash method of accounting instead of the accrual method of accounting beginning in tax years after December 31, 2017. Many pharmacies already take advantage of these new rules but we often see pharmacies still not optimizing this generally easy tax-planning tool. 

Owners can use the cash accounting method to optimize tax savings. 

Tips for Optimizing Pharmacy Taxes

Multiple sclerosis (MS) is a disease of the central nervous system (CNS) that affects almost 1 million individuals in the United States, according to the National Multiple Sclerosis Society.

 It is an autoimmune disease in which the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between the brain and the rest of the body.

Unfortunately, there is no cure for MS but there are medications that can modify the disease course, treat relapses, and manage symptoms. Nonpharmacologic therapies including lifestyle modifications and physical therapy also are an important part of comprehensive care for MS. 

The cause of MS remains unknown but evidence suggests it is triggered by a combination of environmental and genetic risk factors (eg, family history).

 Most individuals are diagnosed between the ages of 20 and 50 years, and women are 2 to 3 times more likely than men to have MS.

 Infections such as Epstein-Barr virus and certain autoimmune diseases (eg, type 1 diabetes) may increase the risk of developing MS.

 Other risk factors that may contribute to an increased risk of MS include living farther from the equator, low vitamin D levels, and smoking.

Signs and symptoms of MS can vary from individual to individual and throughout the disease course.

Exacerbations of MS caused by an inflammation of the CNS that lasts at least 24 hours and are separated from a previous attack by at least 30 days are typically treated with high-dose corticosteroids (eg, prednisone, methylprednisolone).

Pharmacists can educate patients that corticosteroids may cause insomnia, hypertension, increased blood glucose levels, psychiatric issues, and weight gain.

 Exacerbations can range from mild to severe enough to affect daily activities.

Disease-modifying therapies (DMTs) reduce the frequency and severity of relapses, and evidence demonstrates these medications also reduce the development of new areas of damage in the brain and spinal cord and delay disability progression.

 Treatment options include oral medications, injectables, and infusions. The Multiple Sclerosis Coalition recommends early and ongoing treatment with DMTs.

 There are a variety of FDA-approved DMTs available and pharmacists can counsel patients about the different options and potential adverse effects. 

Ozanimod (Zeposia; Bristol Myers Squibb) is an oral medication approved in 2020, and it is the only DMT that is a sphingosine-1 phosphate receptor modulator that offers patients an initiation with no genetic test and no label-based first-dose observation required.

 It is also approved for active secondary progressive disease (worsening condition).

Additionally, evidence demonstrates that ozanimod was more effective at reducing the risk of disease relapse compared with interferon beta-1a.

 Fingolimod (Gilenya; Novartis) is an oral medication and it is the only DMT approved for use in children 10 years and older.

 Other oral treatment options include dimethyl fumarate (Tecfidera; Biogen) and diroximel fumarate (Vumerity; Biogen), teriflunomide (Aubagio; Sanofi), cladribine (Mavenclad; Merck), and siponimod (Mayzent; Novartis).

Ocrelizumab (Ocrevus; Genentech) is a monoclonal antibody and intravenous (IV) infusion therapy that is the first and only DMT approved to treat both the relapse-remitting and primary progressive forms of MS in adults.

 Other IV infusion treatments include alemtuzumab (Lemtrada; Sanofi Genzyme), generic mitoxantrone, and natalizumab (Tysabri; Biogen).

Injectable DMT treatment options include interferon beta-1a (Avonex; Biogen), interferon beta-1b (Betaseron; Bayer), glatiramer acetate (Copaxone; Teva Neuroscience), interferon beta-1b (Extavia; Novartis), glatiramer acetate (Glatopa; Sandoz), peginterferon beta-1a (Plegridy; Biogen), and interferon beta-1a (Rebif; EMD Serono and Pfizer). On February 1, 2021, the FDA approved a new route of administration for peginterferon beta-1a as an intramuscular injection for the treatment of relapsing forms of MS, with evidence demonstrating fewer injection site reactions than the subcutaneous formulation approved in 2014.

 There are promising MS drugs in the pipeline (

Pharmacists should educate patients about the black box warnings associated with DMTs. Avonex, Rebif, Plegridy, Betaseron, and Extavia include warnings about depression, suicide, cardiovascular problems, hepatotoxicity, and allergic reactions.

 Injection site reactions including skin infections have been reported with Rebif and Plegridy so it is important to rotate injection sites regularly.

 Aubagio can cause hepatotoxicity, and it is important to have blood tests performed 6 months before initiating therapy and once a month for 6 months after starting treatment.

 Patients taking Aubagio should also use effective birth control and receive a pregnancy test before starting treatment since it can cause birth defects.

 Gilenya, Mayzent, and Zeposia can cause bradycardia, so it is important for patients to have an electrocardiogram before starting the first dose of these medications.

 Certain DMTs (eg, Tecfidera, Vumerity, and Tysabri) may increase the risk of a rare brain infection called progressive multifocal leukoencephalopathy, which usually occurs in patients who are immunocompromised.

Other medications used to manage the signs and symptoms of MS may include antidepressants (eg, citalopram), pain management therapies (eg, duloxetine), and bowel dysfunction treatments (eg, docusate).

 Physical and occupational therapy can play an important role with stretching and strengthening exercises, and various devices can help patients perform daily tasks more easily.

There is little evidence to support a specific diet for patients with MS but it is important to eat a well-balanced diet.

 Since evidence suggests vitamin D deficiency may be associated with MS, it is important to ensure that patients have appropriate vitamin D levels.

 Food sources that contain vitamin D include oily fish, beef liver, egg yolks, pork, and fortified foods such as milk and juices. However, most individuals are unable to obtain sufficient vitamin D from diet so supplementation is usually needed.

 Exercise and physical activity are beneficial in patients with MS and can improve strength, bladder and bowel function, fatigue, mood, cognitive function, bone density, and flexibility. Physical activity can include gardening, household chores, cooking, walking the dog, and taking the stairs. Patients can consult with a physical therapist to help develop an individualized exercise program.

 Since smoking can cause worsening disease progression in patients with MS, pharmacists can play an important role in educating patients about smoking cessation therapy options.

Pharmacists can counsel patients about the following healthy sleep habits that can help improve MS symptoms: developing a bedtime routine; avoiding caffeine in the afternoon and evening; avoiding screen time before sleep; limiting fluids close to bedtime; practicing relaxation techniques; and making sure the bedroom is cool, dark, and quiet.

Individuals with MS can experience temporary worsening of symptoms when the weather is very hot or humid, and certain activities such as sunbathing, exercise, and hot showers can also have these effects.

National Multiple Sclerosis Society. Definition of MS. Accessed January 31, 2021. 

https://www.nationalmssociety.org/What-is-MS/Definition-of-MS

Wallin MT, Culpepper WJ, Campbell JD, et al. The prevalence of MS in the United States: a population-based estimate using health claims data. 

. 2019;92(10):e1029-e1040. doi:10.1212/WNL.0000000000007035 

Mayo Clinic. Multiple sclerosis. Updated June 12, 2020. Accessed January 31, 2021. 

https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/symptoms-causes/syc-20350269

National Multiple Sclerosis Society. Diagnosing MS. Accessed February 1, 2021. 

https://www.nationalmssociety.org/Symptoms-Diagnosis/Diagnosing-MS

MS symptoms. National Multiple Sclerosis Society. Accessed February 1, 2021. 

https://www.nationalmssociety.org/Symptoms-Diagnosis/MS-Symptoms

Comprehensive care. National Multiple Sclerosis Society. Accessed February 1, 2021. 

https://www.nationalmssociety.org/Treating-MS/Comprehensive-Care

Disease-modifying therapies for MS. National Multiple Sclerosis Society Updated June 2020. Accessed February 1, 2021. 

http://www.nationalmssociety.org/nationalmssociety/media/msnationalfiles/brochures/brochure-the-ms-disease-modifying-medications.pdf

The use of disease-modifying therapies in multiple sclerosis: Principles and current evidence. Multiple Sclerosis Coalition. Updated September 2019. Accessed February 1, 2021. 

https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/DMT_Consensus_MS_Coalition.pdf

Drug trial snapshots: Zeposia. Food and Drug Administration. Updated April 1, 2020.Accessed February 2, 2021. 

https://www.fda.gov/drugs/development-approval-process-drugs/drug-trials-snapshots-zeposia

Biogen announces FDA approval of Plegridy (peginterferon beta-1a) intramuscular administration for multiple sclerosis. News release. Biogen. February 1, 2021. Accessed February 2, 2021. 

https://www.globenewswire.com/news-release/2021/02/01/2167195/0/en/Biogen-Announces-FDA-Approval-of-PLEGRIDY-peginterferon-beta-1a-Intramuscular-Administration-for-Multiple-Sclerosis.html

Janssen submits Ponesimod new drug application to the U.S. FDA for treatment of adults with relapsing multiple sclerosis. News release. Janssen. June 1, 2020. Accessed February 2, 2021. 

https://www.janssen.com/janssen-submits-ponesimod-new-drug-application-us-fda-treatment-adults-relapsing-multiple-sclerosis

TG Therapeutics announces positive topline results from the ULTIMATE 1 and II phase 3 studies evaluating Ublituximab monotherapy for the treatment of patients with multiple sclerosis. News release. TG Therapeutics. December 10, 2020. Accessed February 2, 2021. 

https://ir.tgtherapeutics.com/news-releases/news-release-details/tg-therapeutics-announces-positive-topline-results-ultimate-i-ii

Diet, exercise, & healthy behaviors. National Multiple Sclerosis Society. Accessed February 2, 2021. 

https://www.nationalmssociety.org/Living-Well-With-MS/Diet-Exercise-Healthy-Behaviors

Multiple sclerosis and smoking. Cleveland Clinic. Accessed February 2, 2021. 

https://my.clevelandclinic.org/departments/neurological/depts/multiple-sclerosis/ms-approaches/ms-and-smoking

Pharmacists can play an important role as part of the interdisciplinary care team.

Multiple Sclerosis: Treatment Options and Counseling Tips

In the late 1970s, I worked at a paper mill for 3 summers while I was in pharmacy school. Of all my lessons learned running jackhammers in steel tanks, shoveling bark in the woodyard, and muscling cast iron boiler parts, I can still see a sign in the personnel director’s office. It was a sheet of paper that read, “Don’t start vast projects with half-vast ideas.” Say it quickly and it really makes sense.

I can’t think of a more lucid example of a vast project that has been implemented with “half-vast” ideas and implementation than the COVID-19 vaccine rollout. There isn’t a community pharmacist whose day-to-day activities has not been altered by this historic event. Patients call incessantly asking when it is their turn to get their dose of the precious vaccine. Even the leadership in Washington and our state capitals see the community pharmacist as the answer.

The news, whether on the internet or television or in your local newspaper, is chock-full of vaccine stories. Patients read the headlines and pick up the phone and call the pharmacy for information. Small community pharmacies can field 100 phone calls or more a day for patients to be put on the “list.” Forget the internet; most patients, especially the elderly, want to speak to a human, a human who can get them this life-preserving shot in the arm.

We’ve all seen the colossal success in West Virginia, one of the few states to use independent pharmacists to administer vaccines in the nursing homes. In my home state of Pennsylvania, we were ranked in the very bottom of percentage of shots administered versus received in the initial rollout. West Virginia, early on under the leadership of Gov James “Big Jim” Justice, deployed small, independent pharmacies as the best option. My daughter Gretchen Garofoli, PharmD, BCACP, CTTS, and her team of pharmacists, Krista Capehart, Pharm D, MSPharm, BCACP, AE-C; Betsy Elswick, PharmD; Ashleigh Barrickman, PharmD, BCACP; Heather Johnson, PharmD; Ashlee McMillan, PharmD; and Angela Goodhart, PharmD, are mostly responsible for West Virginia’s success. Gretchen was featured on local news channels, NPR, PBS, and even the British Broadcasting Corporation’s (BBC) World News. Capehart has been featured on many news outlets as well and was featured giving Justice his vaccine.

Notice that all 7 leaders from the West Virginia’s School of Pharmacy are women. At the end of the day, they go home and manage their households and take care of Ethan, Luke, Gwyn, Ainslee, Connor, Macy, Lila, and Ava. These amazing women saw a vast project and used their leadership skills and connections to implement the rollout of vaccines to the long-term care facility residents.

Two other women I’m familiar with are Pennsylvania residents and pharmacists. Molly Beimel, PharmD, from my birthplace of St. Marys, Pennsylvania, spearheaded her independent pharmacy’s efforts and pulled off a 1200-dose clinic at the local Catholic high school. Even closer to me is my wife, Denise Kreckel, RPh, who, along with her colleagues at Centre Volunteers in Medicine in State College, Pennsylvania, conducted the same 1200-dose clinic, however, with the Pfizer vaccine. With such precision, my wife handled the numerous storage requirements of this delicate vaccine from dry ice to thawing, reconstitution, and administration. I was amazed to see this 5-foot, 2-inch powerhouse impact the lives of so many in our community. 

Women make up about a quarter of Congress and of Pennsylvania’s state representatives in Harrisburg. On the national and state levels, the rollout of the vaccine has been abysmal. Is there any wonder the amazing success of West Virginia and the clinic success in Pennsylvania are led by women pharmacists? There is no doubt their vast ideas are making up for the “half-vast” vaccine rollout on the federal level. 

In an opinion piece, pharmacist Pete Kreckel highlights the ways that women have been leading the COVID-19 vaccination effort.

Women Pharmacists Are Leading Successful COVID-19 Vaccination Programs

As the United States surpasses 26 million COVID-19 infections, immunization against the disease is critical. President Biden has pledged to increase the vaccine supply so that 100 million doses can be distributed during his first 100 days in office, and that means that community pharmacies should prepare to do their share.

But pharmacists still need to oer other immunizations as well, so the addition of these expected COVID-19 vaccinations will only add to the pharmacy’s workload. That’s why pharmacists need to think about how to improve workflow eciencies and create a stronger system management. Technology is often the answer.

Technology allows for faster counting and better record keeping, and for those pharmacies that can invest in automation, the impact can be exponential in improving eciencies, both in vial dispensing and in medication adherence packaging.

Peter Saad, PharmD, MBA, director of product strategy at pharmacy automation company Parata Systems, noted that the COVID-19 vaccine efforts will be new waters for retail pharmacy, as much of the process will be dierent, including, but not limited to, billing and tracking.

“Technology and automation will be key in streamlining processes for these pharmacies by freeing up time for pharmacists and technicians to focus on the clinical initiative of vaccine efforts and understanding the new waters,” Saad said.

More than ever, pharmacists are seen as frontline medical providers for the vaccine, and as such, they need to be front of house counseling patients. That’s why we are seeing retail pharmacies invest in technology, whether new to automation, or scaling their existing automation.

“Tactically, there are a variety of ways pharmacists can rely on technology for workflow and system management,” Saad said.

These include syncing patient medication regimens to monthly cycles to limit time to dispense/sell in the pharmacy, allowing more time for vaccine discussion and distribution; using Health Insurance Portability and Accountability Act compliant online form submission and preemptively inputting patients before arrival to streamline the vaccination process; and automating the filling process or hiring an additional pharmacy technician, as at least 1 technician will likely be occupied with receiving and inputting patient and vaccine information.

“If possible, have all refills filled via central fill, which allows for the ability to fill prescriptions quickly without using new resources, as this supports the bottom line and returns pharmacists and techs to activities that support patient care,” Saad said.

Jason Turner, PharmD, owner of Moundsville Pharmacy in Moundsville, West Virginia, said a great way to create a strong foundation of efficiencies in a pharmacy is to initiate a medication synchronization program.

“Medication synchronization changes your workflow from being ‘on demand’ workflow, meaning when the patient calls in the prescription, you begin to work on it in a way where your pharmacy team is in control of when you process a large percentage of your prescription volume,” he said.

For example, there are 1800 patients enrolled in Moundsville Pharmacy’s SyncRx program—73% of monthly prescription volume.

“We are able to schedule the work with a strategy to be most efficient in our prescription processing and most available to our patients for clinical services, such as immunization,” Turner said.

Jason Ausili, PharmD, chief clinical officer for FDS, a provider of pharmacy technology solutions for independent pharmacists, noted that tech can help drive immunization efficiencies in numerous ways.

“It can be used for billing the medical benefit for vaccine and/or administration fees in a way that is streamlined with workflow, provide automated reporting to state registries for reportable vaccine events, and allow a pharmacist to query state registries for vaccine eligibility at the patient level,” Ausili said. “Tech makes clinical documentation easy and efficient and makes the patient scheduling process a more automated and organized experience.”

At Moundsville Pharmacy, there are 2 Kirby Lester units, a ScriptPro SP 200, and a Parata PASS 300VP to increase efficiencies in the sta, workflow, and programs.

Turner recommends using dierent colored paper for each immunization record, which allows the staff to access and recognize vaccines in the workflow quickly, from billing to vaccinating, documenting, and record storage.

“For larger pharmacy teams, I would create a workflow for your immunization prescriptions,” he said. “This way, if a patient comes in and requests a vaccine, everyone knows how that clipboard is to flow to maximize your eciency and not disrupt existing workflow.”

Because vaccine billing can be challenging, Turner suggests directing vaccine billing to 1 or 2 vaccine specialists to make sure they are processed timely and identify quickly if you are unable to bill a payer through your pharmacy management system.

Maximizing the features of pharmacy software is no longer an option, as many pharmacies continue to use their software the way they did 5 or even 10 years ago, either not detecting the upgrades in their pharmacy management systems or not knowing how to incorporate them into their workflow.

Too often pharmacies invest in automation, counting technology, or a fancy new bell or whistle for their pharmacy management system, only to find that it doesn’t change the outcome.

“Over the years, in working with and training pharmacy owners in medication synchronization, it has become clear that the physical workflow of the pharmacy—how the prescription moves about the pharmacy—and the processes that support pharmacy workflow really dictate the eciency of a pharmacy,” Turner said.

The expense of automation technology and lack of cash flow for retail pharmacies are no question the largest barriers for adoption. But Saad said the best way to increase efficiencies with existing staff is by incorporating automation.

“Not only will it allow pharmacists to move to the front of the pharmacy and practice at the top of their license, but it will allow for value-adding activities for patients, all the while technology is handling routine prescription fills quietly in the back of the pharmacy,” he said. “When pharmacies start to hit 200 scripts a day, there will already be ROI from the technology, helping to fix that cash flow problem and making the cost worth it almost instantaneously.”


In 2021, there will be a lot of buzz around the approved COVID-19 vaccines and their availability, and although these vaccines have given pharmacists opportunities, they also have added pressure.

Pharmacies can leverage technology for their workflow and system management. Here’s how.

Drug Topics March 2021