Pharmacy Practice+Business - April 2017

INSPIRING CANADIAN PHARMACISTS TO BE THEIR BEST

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APRIL 2017

OUR

23RD ANNUAL

PM 42940023

LOOK AT THE NONPRESCRIPTION ASPECT OF COMMUNITY PHARMACY IN CANADA

INCLUDES THE MOSTRECOMMENDED OTC BRANDS

AND MORE

PLUS: DRUGS AND COLOSTOMY/ ILEOSTOMY PATIENTS

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APRIL 2017

Contents 40-68

17 ON THE COVER

SPECIAL REPORT 23RD ANNUAL OTC MARKET REPORT 40

Introduction: About this year’s report

41

Pharmacists’ advice steers OTC Market

FEATURE

43

17

Report on the top OTC categories

COLOSTOMIES AND ILEOSTOMIES:

48

Minor ailments authority reshapes OTC counselling

COVER ILLUSTRATION: ZIGOR SAMANIEGO, COLAGENE.COM

Key considerations for medication use in ostomy patients

50

Pharmacists’ most-recommended brands

FIND IT

31-38

ONLINE

CE LESSON:

Iron deficiency anemia 1.0 CEU

HOT TOPIC Christina Alarcon’s latest blog has broken our record for reader comments! What’s everyone talking about? Find out in the Discussions section.

us: the The Zika vir t’s role in pharmacis ction n and dete preventio -I-P 29-2016-1916 CCCEP #13 1, 2018 Approved for .

Expires Feb

1.25 CEUs

CONTINUING EDUCATION GALORE Did you know that there are dozens of accredited CE lessons on our site? Go to eCortex.ca to update your knowledge and earn credits.

WHERE DID I READ THAT? Articles from Pharmacy Practice+ (and predecessors Pharmacy Practice and Drugstore Canada) going back to 2008 are archived on our website. Click on the magazine logo to review back issues, or use the search box to look for topics of interest.

DEPARTMENTS

OPINIONS 5

Editorial You’re ready for minor ailments

YOUR PRACTICE

12

Drug News

Ethics and Issues, Medication Forum

7

Launches, new indications, Health Canada advisories, new dosage forms

11

Clinical Notes Antimicrobial stewardship, managing croup; asgthma in adults, new Zika recommendations

Practice Experts

5 TIPS 28

Pearls for your practice

SELF-CARE AND WELLNESS 25

OTC Issues New standards for nonprescription health claims and labels

Communicating effectively and respectfully with transgender patients

+ Classified section: page 70 [Vol.4 No.3] April 2017

3

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© 2015 Pfizer Canada Inc. Kirkland, Quebec H9J 2M5

® GENMED is a trademark of Pfizer Canada Inc. GenMed, a division of Pfizer Canada Inc. ® Pfizer Inc., used under license

Visit genmed.ca today

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Learn how our programs and services can help you grow your business.

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Minor ailments? You’re ready!

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Editorial

For almost as long as we’ve been fielding the Survey on OTC Counselling and Recommendations—and that’s 23 years—we’ve made a point of publicizing and promoting pharmacists as experts in over-the-counter (OTC) products and their use.

That claim is, of course, based on what pharmacists have long told us about how they perceive their role (99% believe counselling on OTCs is an important part of their job) and their influence on patient behavior (90% say patients will purchase the product they recommend).

With the advent of minor/common ailment assessment and prescribing (now in place in all but three provinces), we’ve been asking about this new authority, which, although often more complex, is a natural next step for healthcare professionals experienced in helping people to manage their own minor health issues and stay well.

As you’ll read in our feature on page 48, pharmacists who embrace this new role tend to find it rewarding. And our survey respondents seem to agree. Virtually all are keen to use their skills, with 98% agreeing that “responsibility for primary care of minor self-limiting ailments is an appropriate role for community pharmacists.” Like our profile subject, Saskatchewan pharmacist/ owner Roderick Amaya and his staff, 95% are “personally enthusiastic about the opportunity to add minor ailment assessment to my practice.”

But how do patients feel? In a February 2017 Abacus survey of more than 4,000 Canadians, 70% of patients trust their pharmacist for the management of common ailments.

Pharmacists seem to want this new role. At the Annual General Meeting of the College of Pharmacists of Manitoba in early April, pharmacist Cary Lai asked the College to review the province’s pharmacy regulations with the goal of expanding prescribing authorityin that province to include immunizations, minor ailments and travel health.

If it eventually comes about, the new authority would bring Manitoba into alignment with pharmacist prescribing authority as it exists in Alberta, Saskatchewan, New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland/Labrador.

So far, both B.C.and Ontario (which has committed to fees to new pharmacy professional services), have held back on adding minor ailment assessment/prescribing to their menu of paid pharmacy services. Creating a documentation and fee structure framework for minor ailments will be complex. (Of the other provinces with minor ailments assessment, only Saskatchewan ties a fee to the service—and that fee only applies if a prescription is issued.)

Should pharmacists still seek to grow into their new role primary minor ailment advisors? If it’s all about the money, perhaps not. But for others, as Amaya says: “This is where pharmacy gets fun and we get to make a difference to patients.”

vwood@ensembleiq.com @Ppr_plus

[Vol.4 No.3] April 2017

5

CLINICAL AND PROFESSIONAL NEWS, ADVICE, EDUCATION

Your

Practice Drug News

Lu-Ann Murdoch RPh, BScPhm, ACPR Lu-Ann Murdoch is a consulting clinical editor for Pharmacy Practice+ and drug information consultant for Pharmacist’s Letter and Prescriber’s Letter.

A review of launches, new indications, Health Canada advisories and new dosage forms

Lancora: first “funny” current inhibitor for heart failure ivabradine 5 mg and 7.5 mg film-coated tablets (as ivabradine hydrochloride), Servier.

INDICATIONS Treatment of stable chron-

ic heart failure in adults, to reduce the incidence of cardiovascular mortality and hospitalization for worsening heart failure. Intended for adults with reduced left ventricular ejection fraction (≤ 35%) with NYHA Class II or III heart failure who are in sinus rhythm with a resting heart rate ≥ 77 beats per minute. Should be administered in combination with standard chronic heart failure therapies.

Not indicated for treatment of patients with stable coronary artery disease; clinical trials failed to show clinical benefit in these patients.

ACTION Selectively inhibits the “funny” channel (If) pacemaker current in the sinoatrial node, which slows conduction through the AV node, resulting in a lower heart rate and greater blood flow to the myocardium. Can also inhibit the Ih current in the retina, which may be responsible for the phosphenes (i.e., transient enhanced brightness in certain areas of the visual field) experienced by some patients.

DOSAGE Recommended starting dose is 5 mg twice daily for patients with stable chronic heart failure who are in sinus rhythm with a resting heart rate ≥ 77 beats per minute. A starting dose of 2.5 mg twice daily is recommended in patients with arrhythmias, patients ≥ 75 years of age and those taking moderate CYP3A4 inhibitors. After two weeks, dose is adjusted based on the patient’s resting heart rate (see dosage table provided in the product monograph).

Maximum dose is 7.5 mg twice daily.

No dose adjustment is required in patients with renal impairment or mild to pharmacy practice+

moderate hepatic impairment; contraindicated in severe hepatic impairment.

ADMINISTRATION Must be taken orally twice daily with food at approximately 12-hour intervals (e.g., with morning and evening meal).

ADVERSE EFFECTS Most common: Atrial fibrillation, inadequate blood pressure control, bradycardia, ventricular extrasystoles and intermittent visual effects (phosphenes, blurred vision).

Most serious: Atrial fibrillation, sudden cardiac death, pneumonia, myocardial infarction, conduction disturbances (e.g., atrioventricular block, bundle branch block). Contraindicated in patients with existing prolonged QT interval.

DRUG INTERACTIONS Exclusively metabolized by CYP3A4. Ivabradine concentrations are increased by CYP3A4 inhibitors, which may worsen bradycardia and conduction disturbances.

Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin, ritonavir) or with moderate CYP3A4 inhibitors that also reduce heart rate (e.g., diltiazem, verapamil) is contraindicated. Caution is also recommended with moderate CYP3A4 inhibitors without heart rate lowering effects because ivabradine concentrations will be increased; use a lower starting dose of ivabradine and monitor heart rate. Avoid grapefruit juice and St. John’s wort. Use caution when co-administered with CYP3A4 inducers (e.g., rifampin, phenytoin) as ivabradine concentrations may be reduced. Avoid concomitant use with QT prolonging drugs, if possible; ivabradine’s heart rate lowering effect may exacerbate QT prolongation.

Kevzara for moderate to severe RA sarilumab 150 mg/1.14 mL and 200 mg/1.14 mL solution for subcutaneous (SC) injection in single-dose prefilled syringes, Sanofi Genzyme.

INDICATIONS Treatment of adults with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response or intolerance to one or more biologic or nonbiologic disease-modifying antirheumatic drugs (DMARDs). Should be used in combination with methotrexate or other traditional DMARDs; may be given as monotherapy if methotrexate or DMARDs are contraindicated or not tolerated.

ACTION Interleukin-6 (IL-6) receptor antagonist monoclonal antibody. Binds to both soluble and membrane-bound IL-6 receptors and inhibits IL-6-mediated signalling. IL-6 is produced locally by synovial and endothelial cells in joints affected by RA; it is believed to play an important role in the development of inflammation.

DOSAGE 200 mg SC every two weeks.

Dose may need to be reduced to 150 mg SC every two weeks (or the drug discontinued) to manage neutropenia, thrombocytopenia and elevated liver enzymes. If a serious infection develops, hold sarilumab treatment until the infection is controlled. No dose adjustment is required in patients with mild to moderate renal impairment; has not been studied in severe renal impairment. Not recommended in hepatic impairment.

Reconsider therapy if patient does not respond within 16 weeks.

ADMINISTRATION Allow prefilled syringe to sit at room temperature for 30 minutes before injection. Syringe must

[Vol.4 No.3] April 2017

7

Your Practice 8

be used within 14 days after removal from the refrigerator. Inject the full amount in the syringe (1.14 mL) SC into the thigh or abdomen (but not within 5 cm of the navel). Rotate injection site with each injection. Do not inject into skin that is tender, damaged, bruised or scarred. Patients may be taught to self-inject the drug.

ADVERSE EFFECTS Most common: Neutropenia, increased liver transaminases, injection site erythema, upper respiratory tract infections, urinary tract infections, nasopharyngitis. May cause thrombocytopenia and may increase plasma lipids. Most serious: Increased risk for developing serious infections (e.g., pneumonia, cellulitis, opportunistic infections) that may lead to hospitalization or death; do not administer to patients with an active infection. Consider risks and benefits before starting therapy in patients with chronic or recurrent infection. Evaluate patients for tuberculosis prior to initiating treatment. Possible hypersensitivity reactions.

DRUG INTERACTIONS Avoid use of live vaccines during sarilumab treatment. Avoid use with other biological DMARDs, as such combinations have not been studied. Sarilumab may affect CYP substrates that have a narrow therapeutic index and require individual dose adjustment; when starting or discontinuing sarilumab perform therapeutic monitoring of effect (e.g., warfarin) or drug concentration (e.g., theophylline) and adjust the dose of these drugs as needed. Use caution when co-administered with CYP3A4 substrates (e.g., oral contraceptives, statins); sarilumab may reduce their exposure and lead to a reduction in their activity.

COMMENTS Patients can be enrolled in the Mobilize patient support program to receive assistance with sarilumab reimbursement and self-injection training (1-888-972-6634; info@mobilizeRA.ca).

Sarilumab is the second IL-6 inhibitor to be marketed in Canada. Actemra (tocilizumab) was introduced in Canada

by Hoffmann-La Roche in 2010; it is available in intravenous and SC dosage forms for use in the management of RA in adults and juvenile forms of arthritis.

April 2017 [Vol.4 No.3]

Mictoryl/Mictoryl Pediatric for overactive bladder propiverine hydrochloride 30 mg and 45 mg modified-release capsules/propiverine hydrochloride 5 mg tablets, Duchesnay.

INDICATIONS Symptomatic treatment of urinary incontinence and/or increased urinary frequency and urgency in patients with overactive bladder. The 30 mg and 45 mg tablets are intended for adults including those > 65 years of age. The 5 mg tablets are intended for children five years of age or older, up to a body weight of 35 kg (see weight-based dosing below). Only limited efficacy and safety data are available for children and adolescents with a body weight ≥ 35 kg.

ACTION Propiverine has anticholinergic action, which results in relaxation of bladder smooth muscle. It also has calcium-modulating properties that reduce urinary bladder smooth muscle spasm.

DOSAGE Adults: One 30 mg capsule once daily. If well tolerated, may be increased to 45 mg once daily, if needed. Maximum recommended daily dose is 45 mg.

Children: 0.8 mg/kg body weight per day administered in two doses. Children 12–16 kg: one 5 mg tablet twice daily; 17–22 kg: one 5 mg tablet for first dose and two 5 mg tablets for second dose each day; 23–28 kg: two 5 mg tablets twice daily; 29–34 kg: two

New generics • Apo-Rosiglitazone (rosiglitazone 2 mg, 4 mg and 8 mg tablets), Apotex. Generic alternative to Avandia.

• Apo-Tryptophan (tryptophan 750 mg tablets), Apotex. New midstrength tablet join the existing 500 mg and 1 g tablets.

• pms-Amphetamines XR (mixed salts amphetamine 5 mg, 10 mg, 15 mg, 20 mg, 25 mg and 30 mg extended-release capsules).

Pharmascience. Generic alternative to Adderall XR.

5 mg tablets for first dose and three 5 mg tablets for second dose each day; ≥ 35 kg: three 5 mg tablets twice daily. No dose adjustment is required in patients with mild or moderate renal impairment; maximum daily dose is 30 mg in severe renal impairment. No dose adjustment needed in mild hepatic impairment; not recommended in moderate to severe hepatic impairment.

ADMINISTRATION The modifiedrelease capsules can be taken with or without food, but should not be crushed or chewed. A high-fat meal increases the bioavailability of propiverine from the 5 mg tablets; the tablets should be taken at least one hour before meals, especially in patients with renal or mild hepatic impairment.

ADVERSE EFFECTS Most common: Dry mouth, headache, visual impairment and accommodation disorder, constipation, abdominal pain, dyspepsia, fatigue. Decreased appetite, sleep disorder and disturbance in attention have also been reported in children. Most serious: Rare cases of tachycardia, palpitations, urinary retention.

• pms-Zopiclone (zopiclone 3.75 mg tablet), Pharmascience.

New lower-strength tablet complements the existing 5 mg and 7.5 mg tablets, which are generic alternatives to Imovane. First 3.75 mg strength of zopiclone to be marketed in Canada.

• Sandoz Amphetamine XR (mixed salts amphetamine 5 mg, 10 mg, 15 mg, 20 mg, 25 mg and 30 mg extended-release capsules).

Sandoz. Generic alternative to Adderall XR.

• Bortezomib for Injection (bortezomib 3.5 mg/vial), Teva.

Generic alternative to Velcade.

pharmacy practice+

Other new products insulin aspart 100 U/mL solution for injection, Novo Nordisk.

INDICATIONS Treatment of diabe-

tes in adults who require mealtime insulin for the control of hyperglycemia. Should generally be used in a regimen with intermediate- or long-acting insulin (plus metformin in patients with type 2 diabetes) to maintain adequate glucose control.

ACTION A mealtime fast-acting insulin aspart formulation; the presence of niacinamide (vitamin B3) in the formulation results in a faster initial absorption of insulin, leading to an earlier onset and greater early insulin exposure. The onset of action is about five minutes earlier with Fiasp than with NovoRapid (insulin aspart) and the peak effect occurs approximately 11 minutes earlier.

Therefore, if hypoglycemia occurs, it may occur earlier after an injection of Fiasp compared with other mealtime insulins.

DOSAGE Must be individualized. Consult product monograph for details.

ADMINISTRATION Should be injected SC up to two minutes before the start of a meal. When necessary, it may be administered up to 20 minutes after starting a meal.

SUPPLIED Clear and colourless solution supplied in 10 mL vials, 3 mL Penfill cartridges, and 3 mL Fiasp FlexTouch disposable pens.

contractions in the myometrium, relaxation of the uterine cervix and evacuation of the uterine contents.

DOSAGE One mifepristone 200 mg tablet taken orally. This is followed by misoprostol 800 µg (4 tablets) administered buccally 24–48 hours later.

ADMINISTRATION Mifepristone should be administered under the supervision of the prescriber. The four misoprostol tablets should be taken as a single dose by the buccal route. Tell patient to keep tablets between the cheek and the gum for 30 minutes before any remaining fragments are swallowed with water.

No data are available on the effect of food intake on the absorption of mifepristone or misoprostol.

SUPPLIED One mifepristone tablet (in a green box) and four misoprostol tablets (in an orange box), packaged together.

COMMENT Currently, only a trained certified prescriber or pharmacist (https://sogc.org/online-courses/ courses.html) can purchase Mifegymiso. A prescriber can order Mifegymiso and provide it directly to the patient (some provincial differences) or send the patient to the pharmacy to fill the prescription from a certified pharmacist.

Odefsey

emtricitabine 200 mg/rilpivirine 25 mg (as rilpivirine HCl)/tenofovir alafenamide 25 mg (as tenofovir alafenamide hemifumarate) tablets, Gilead Sciences.

Mifegymiso

mifepristone 200 mg tablet and misoprostol 200 µg tablets, Celopharma (1-877-2304227).

INDICATIONS Medical termination of

a developing intrauterine pregnancy with a gestational age up to 49 days.

ACTION Mifepristone blocks progesterone receptors. As a result, the endometrium can no longer sustain the growing embryo, the lining of the uterus breaks down and bleeding begins. Mifepristone also triggers an increase in prostaglandin levels and dilates the cervix, facilitating abortion. Misoprostol, a prostaglandin E1 analog, induces smooth muscle pharmacy practice+

Your Practice

Fiasp

and Descovy (emtricitabine/tenofovir alafenamide). Gilead will continue to market Complera (emtricitabine/ rilpivirine/tenofovir disoproxil fumarate), which was introduced in Canada in 2011.

Otixal

ciprofloxacin 0.3% (as ciprofloxacin hydrochloride) and fluocinolone acetonide 0.025% otic solution; preservative-free, 0.25 mL single-use polyethylene vials; 15 vials per pouch, Pediapharm.

INDICATIONS Treatment of acute otitis media with tympanostomy tubes (AOMT) in children six months of age or older, caused by Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis or Pseudomonas aeruginosa.

DOSAGE Instill the contents of one single-use vial (0.25 mL) into the affected ear canal twice daily (approximately every 12 hours) for seven days.

ADMINISTRATION Before administration, warm the solution by holding the vial in the hand for one to two minutes (to avoid dizziness, which may occur with instillation of a cold solution). Instill the medication while the patient is lying down with the affected ear upward. Pump the tragus four times by pushing inward to help the medication penetrate into the middle ear. Maintain lying position for one minute. Repeat procedure for opposite ear, if necessary.

INDICATIONS A complete regimen for

the treatment of adults with HIV-1 infection. Intended for patients with no known mutations associated with resistance to the non-nucleoside reverse transcriptase inhibitor class, tenofovir or emtricitabine, and a viral load ≤ 100,000 copies/mL. DOSAGE One tablet orally once daily.

Must be taken with a meal to obtain optimal absorption of rilpivirine.

COMMENT Odefsey is the third tenofovir alafenamide-based regimen to be introduced in Canada, following Genvoya (elvitegravir/cobicistat/ emtricitabine/tenofovir alafenamide)

New dosage forms Humira

(adalimumab solution for subcutaneous injection), AbbVie.

New 40 mg/0.4 mL single-use pen and 40 mg/0.4 mL single-use prefilled syringe join the existing 40 mg/0.8 mL vial, pen and prefilled syringe.

[Vol.4 No.3] April 2017

9

Your Practice

New indications Ilaris

(canakinumab subcutaneous injection), Novartis.

NEW INDICATIONS Treatment of

tumor necrosis factor receptorassociated periodic syndrome (TRAPS) in adults and children.

Treatment of hyperimmunoglobulin D syndrome (HIDS)/mevalonate kinase deficiency (MKD) in adults and children. Treatment of familial Mediterranean fever (FMF) in adults and children.

(Originally indicated only for use in the ongoing management of cryopyrin-associated periodic syndromes and for the treatment of active systemic juvenile idiopathic arthritis.)

DOSAGE TRAPS, HIDS/MKD and FMF: 150 mg SC every four weeks for body weight > 40 kg; 2 mg/ kg SC every four weeks for body weight ≤ 40 kg. Intensified dosing regimen of 300 mg or 4 mg/kg SC every four weeks may be needed, based on clinical response.

Imbruvica

(ibrutinib capsules), Janssen.

EXPANDED INDICATION Indicated in combination with bendamustine and rituximab for the treatment of patients with chronic lymphocytic leukemia (CLL) who have received at least one prior therapy. (Formerly only indicated for use in the treatment of previously untreated CLL or CLL in patients who have received at least one prior therapy.

Also has a Notice of Compliance with conditions for the treatment of patients with relapsed or refractory mantle cell lymphoma and for the treatment of patients with Waldenström’s macroglobulinemia.)

DOSAGE CLL in combination with bendamustine and rituximab: 420 mg (three 140 mg capsules) once daily until disease progression or no longer tolerated by the patient. Take with or without food at about the same time each day.

Swallow capsules whole with water; do not open, break or chew.

10

April 2017 [Vol.4 No.3]

Health Canada advisories Fluoroquinolones: persistent, disabling adverse effects Oral or parenteral fluoroquinolone antibiotics (ciprofloxacin, moxifloxacin, levofloxacin, norfloxacin, ofloxacin) can cause rare but severe, persistent and disabling adverse effects, including tendonitis or tendinopathy, peripheral neuropathy and central nervous system disorders. Patients should be counselled to consult a healthcare professional if they experience side effects such as joint and muscle pain, numbness, tingling or confusion during fluoroquinolone therapy. hCG: not approved as weight loss aid Human chorionic gonadotropin (hCG) is not authorized in Canada for use as a weight-loss aid. It has not been proven effective for this use and could pose serious health risks. Health Canada has received several complaints that clinics across Canada are promoting hCG for weight loss (an unauthorized use), often as part of a severe caloriereduced diet.

Evidence does not show that hCG is effective for weight-loss, that it redistributes fat, or that it reduces appetite or the hunger and discomfort associated with calorierestricted diets. Risks associated with hCG use include blood clots; depression; hyperstimulation of the ovaries, multiple pregnancy and false pregnancy tests in women; and fluid retention and gynecomastia in men.

prevent blood clots while undergoing spinal/epidural anesthesia or spinal puncture are known to be at rare risk of developing bleeding in or around the spinal cord (spinal/epidural hematoma).

The risk of bleeding may increase if the spinal procedure is carried out soon after injection of LWMH. The product information for LMWH products is being updated to include the recommended duration of time to wait between LMWH injection and spinal/ epidural anesthesia or spinal puncture. Consult the individual product monographs for Fragmin (dalteparin sodium), Fraxiparine/ Fraxiparine Forte (nadroparin calcium), Innohep (tinzaparin sodium) and Lovenox/Lovenox HP (enoxaparin sodium).

Topical menthol-containing pain relievers: severe burns A Health Canada review has established a link between the use of OTC topical pain relievers containing menthol and the rare risk of serious skin burns. Labelling standards for OTC topical pain relievers containing menthol alone or in combination are being updated to note this risk. Information was insufficient to link products containing methyl salicylate or capsaicin alone with the development of serious burns.

Further details about these advisories and safety reviews can be obtained from the MedEffect Canada website: www.hc-sc.gc.ca/dhp-mps/medeff/

LMWH: spinal/epidural hematoma Patients receiving low-molecularweight heparin (LMWH) to

!

advisories-avis/index-eng.php and www. hc-sc.gc.ca/dhp-mps/medeff/reviewsexamens/index-eng.php .

Discontinued product

RETIN-A MICRO (tretinoin 0.1% gel; 20 g and 45 g tubes), Valeant.

Retin-A Micro 0.1% continues to be available in a 50 g gel pump format. pharmacy practice+

Your Practice

Lu-Ann Murdoch

Clinical Notes

RPh, BScPhm, ACPR

MANAGING CROUP IN YOUNG CHILDREN Customizable business case document for antimicrobial stewardship programs AMMI Canada (Association of Medical Microbiology and Infectious Disease Canada) is introducing a customizable business case document to help healthcare professionals acquire the necessary resources from healthcare administrators to launch or improve inpatient antimicrobial stewardship programs. The document, which uses Canadian data, can be customized to reflect the situation in specific institutions (acute care, cancer care, rehabilitation or complex continuing care).

The business case consists of two complementary files: a Microsoft Word document and a Microsoft Excel spreadsheet. The Word document includes an executive summary of the issue and well-referenced discussions of antimicrobial benefits, harms and resistance trends; burden and costs of antimicrobial-resistant organisms; and evidence supporting antimicrobial stewardship programs. Local data can be input into both the document (e.g., number of isolation bed-days, number of C. difficile infections) and the spreadsheet (personnel, startup and support costs). Core team members of an antimicrobial stewardship program should include the following minimum staffing per 1,000 acute care beds: 1.0 FTE physician, 3.0 FTE pharmacists, 0.5 FTE project/program administrative and coordination support, and 0.4 FTE data analyst.

Association of Medical Microbiology and Infectious Diseases (AMMI) Canada Antimicrobial Stewardship and Resistance Committee. Business case for inpatient antimicrobial stewardship programs in acute care, cancer care, rehabilitation, and complex continuing care. December 2016.

Available at https://www.ammi.ca/?ID=126. (accessed February 21, 2017).

pharmacy practice+

The Canadian Paediatric Society’s new practice point outlines the evidence-based management of typical croup. It includes an algorithm for the outpatient management of croup in children, including when to consider hospitalization.

Management is based on the severity of the child’s respiratory distress. Children should be made comfortable. Antipyretics can be used to reduce fever and discomfort. A corticosteroid (e.g., single dose of oral dexamethasone [0.6 mg/kg]) should be considered for all children with mild to severe symptoms. Improvement generally begins within two to three hours and persists for 24–48 hours. The dose may be repeated once in children with severe croup.

Nebulized epinephrine (in addition to oral dexamethasone) is recommended for moderate to severe croup. It improves signs of respiratory distress within 10–30 minutes and effects last for at least one hour. One trial demonstrated that 5 mL of nebulized 1:1000 L-epinephrine is comparable in safety and efficacy to 0.5 mL of nebulized racemic epinephrine (which is not currently available in Canada). These standard doses can be used in all children regardless of age and weight.

Antibiotics and short-acting beta-2-agonist bronchodilators are rarely indicated in children with typical croup because of the low incidence of bacterial infection (< 1 in 1,000 cases of croup).

Ortiz-Alvarez O; Canadian Paediatric Society, Acute Care Committee. Practice point. Acute management of croup in the emergency department. www.cps.ca/en/documents/position/acute-management-of-croup (accessed February 21, 2017).

ASTHMA OFTEN MISDIAGNOSED OR IN REMISSION IN ADULTS A new Canadian study shows that about onethird of adults with recently diagnosed asthma (within the past five years) can be safely tapered off asthma meds.

The study also showed that failure to consistently use objective testing at the time of initial asthma diagnosis was associated with failure to confirm current asthma. Whenever possible, physicians should order objective tests (e.g., pre-bronchodilator and post-bronchodilator spirometry, serial peak flow measurements, or bronchial challenge tests) to confirm asthma at the time of initial diagnosis. Approximately 4% of the participants without current asthma had been originally diagnosed with asthma based on pulmonary function testing in the community; these patients presumably experienced spontaneous remission of their asthma since their original diagnosis.

Asthma symptoms and treatment should be periodically reviewed. Global asthma guidelines suggest stepping down asthma treatment once good control has been achieved and maintained for three months.

Aaron SD, Vandemheen KL, FitzGerald JM, et al; Canadian Respiratory Research Network. Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA 2017;317:269-79.

ZIKA VIRUS: UPDATED RECOMMENDATIONS The third update of the Canadian recommendations for the prevention and treatment of Zika virus infection summarizes current evidence related to epidemiology, transmission, clinical symptoms and areas of risk. It also provides guidance regarding the prevention and management of Zika virus infection, with a focus on Canadians travelling to or returning from Zika virusaffected areas. Specific recommendations are provided for pregnant women and those planning a pregnancy.

Committee to Advise on Tropical Medicine and Travel (CATMAT). Recommendations on the prevention and treatment of Zika virus for Canadian health care professionals. An Advisory Committee Statement (ACS). January 16, 2017. http://healthycanadians.gc.ca/publications/ diseases-conditions-maladies-affections/committee-statement-treatment-prevention-zika-declaration-comite-traitement-prevention/ index-eng.php (accessed February 21, 2017).

[Vol.4 No.3] April 2017

11

Your Practice

Practice Experts

Ethics and Issues Derek Jorgenson BSP, PharmD Associate Professor, College of Pharmacy and Nutrition, University of Saskatchewan; West Winds Primary Health Centre, Saskatoon.

Q Should pharmacists be cynical about the motives behind corporate pharmacy’s interest in patient adherence initiatives?

A This is a good example of how pharmacist’s efforts to improve patient outcomes can be facilitated by corporate pharmacy’s requirement to maximize profits for shareholders. We have to stop expecting large corporations to suddenly develop a moral conscience and place patient care ahead of profits.

That is not their job. These companies answer to shareholders, not patients or pharmacists. It’s not wrong; it’s simply how our economy runs.

Perhaps it would be better if large corporations did not exert such an influence over the direction of our profession, but I am afraid that ship has sailed long ago. We have no choice but to work within this system to find opportunities to improve patient care, while keeping corporate executives happy.

Unfortunately, many of our profession’s previous efforts to offer new patient care services have resulted in an epic incompatibility between the goals of large corporations and practising pharmacists. For example, the potential health system impact of medication assessment programs has likely been significantly hampered by corporate pharmacy’s focus on volume and the imposition of quotas, making it difficult for pharmacists to provide high-quality services.

12

April 2017 [Vol.4 No.3]

However, I am confident that patient adherence initiatives may reverse this trend and lead to positive outcomes for pharmacists and their patients, along with large corporations and their shareholders.

Recent estimates suggest that nonadherence costs the health system up to $20 billion annually (not to mention the preventable patient morbidity that is linked to this figure), which could be prevented if people actually took their medications (at an estimated cost of $10 billion annually).

Now that is a win-win-win if I’ve ever seen one. If we spend $10 billion on prescriptions (making corporate pharmacy happy), we can save $20 billion in health expenditures (making governments happy), and improve patient outcomes (making both patients and pharmacists happy). Everyone wins.

As always, however, the devil is in the details. This house of cards is built on the premise that effective patient adherence initiatives can be developed that are feasible to implement into the existing pharmacy workflow—not an easy task. Luckily we have researchers across the country, such as Dr. David Blackburn at the University of Saskatchewan, who are testing new adherence initiatives as you read this column.

Pharmacists should perhaps be cynical about the motives of large corporations when programs promoted as adherence initiatives actually have weak evidence regarding their impact

on patient outcomes. Such programs are likely implemented only to increase profits.

One example is dispensary software systems that synchronize patient’s chronic prescriptions to be “autorefilled” at the same time every month.

Patients do not call when their bottles are empty, their prescriptions are refilled automatically and the patient receives a phone call that they are ready.

These synchronization and auto-refill systems may only create a perception of better adherence and may lead to patients stockpiling unused medications. It’s just not plausible that these programs could improve adherence in the absence of a co-administered intervention by the pharmacist. They likely exist only to increase corporate profits. I would question the ethics of a pharmacy processing a prescription without the patient personally requesting the refill.

At the end of the day, I believe that patient adherence is an area where practising pharmacists may find that their motivations are (finally) complementary with those of corporate pharmacy. This is an opportunity that should be embraced; however, the specific patient adherence programs that are implemented should be based on sound research and evidence that demonstrate improved patient outcomes.

Please continue to submit your Ethics and Issues questions to derek.jorgenson@usask.ca. pharmacy practice+

Your Practice

Medication Forum Glen Schoepp BSP Glenn Schoepp is manager, St. Anthony’s Clinic Pharmacy, Victoria, BC; and clinical instructor, University of British Columbia

Q What are the primary clinical considerations for oral anticoagulant prophylaxis in venous thromboembolism?

A Venous thromboembolism (VTE)

Prophylactic Therapy Choices

includes both deep venous thrombosis (DVT) and pulmonary embolism (PE).

It is one of the most common cardiovascular diseases, occurring in about 1:1000 of the general population and in up to 7:1,000 people > 70 years of age.(1,2) PE occurs in one-third of patients with DVT, and has a mortality rate of 16% at three months.(3,4) Significant risk factors for VTE include a family history of thrombosis; stroke, hip, pelvis or leg fracture in the past month; immobility; morbid obesity and a history of VTE.(5) After the first VTE episode, the 10-year cumulative rate of recurrence is about 25% if a patient is not given anticoagulant therapy.(6) The risk of a second event peaks in the first six months, stabilizes after three years, and remains at 2% for up to 10 years.(7) VTE provoked by surgery, trauma or pregnancy has a lower rate of recurrence than unprovoked (spontaneous) VTE.(2) In addition, a DVT occurring distally has a 50% lower risk of recurrence compared to a proximal embolism.(2)

A meta-analysis of large, good-quality trials examined the efficacy of the new oral anticoagulants (NOACs) rivaroxaban, apixaban and dabigatran compared to warfarin. It found no statistically significant difference in VTE recurrence rate or all-cause mortality in studies lasting six to 18 months.(4) No direct comparisons of NOACs in VTE treatment are available.(7) Patients may prefer NOACs versus warfarin, since they do not require dosage adjustments, laboratory monitoring or dietary modifications.(8) For these reasons and their generally superior safety versus warfarin, 2016 expert guidelines now largely recommend NOACs over warfarin for VTE prevention.(11) Prophylactic doses of NOACs generally differ from those used immediately after a VTE episode. For apixaban, initial therapy is 10 mg bid for seven days, then 5 mg bid for at least three months.(12) After six months, prevention in high-risk individuals can be achieved with apixaban 2.5 mg bid.(12,13) Immediately after a VTE, rivaroxaban 15 mg bid is given for three weeks, then 20 mg daily thereafter.(14) The standard dose for dabigatran is 110 or 150 mg bid ongoing, and as with other NOACs, is dependent on the age and/or co-morbidities of the patient.(15) For cancer patients, whose risk of VTE is four to seven times higher than noncancer patients, a low molecular weight heparin continues to be the drug of choice because of proven superiority over warfarin.(11) NOACs are being investigated in this patient subgroup and results are awaited with interest.(3) The risk of bleeding due to anticoagulant therapy must always be balanced against the risk of VTE in each patient.(2,3) High-

Prophylaxis and duration of treatment

Individuals with provoked or unprovoked VTE should receive anticoagulant treatment for at least three months to prevent further episodes.(8) The recurrence rate at 90 days in patients who are well-anticoagulated is about 2%, and the major bleeding rate is 2.2%.(9) Prophylaxis may be life-long in patients with unprovoked DVT or PE, if the bleeding risk is low or moderate.(2) In addition, DVT recurs more frequently in men (20%) than women (6%), necessitating more long-term therapy in males.(10)

pharmacy practice+

risk factors for bleeding include severe renal disease and diabetes (see reference 16 for a more comprehensive summary of predisposing factors and predictive tools for bleeding).(16) Switching anticoagulants

Rivaroxaban and apixaban can increase the International Normalized Ratio (INR). Therefore, when switching from these NOACs to warfarin, continue both drugs for two days, then check the INR just prior to the next dose of NOAC to minimize confounding the result.(13) Stop factor Xa inhibitors (apixaban, rivaroxaban) when the INR is > 2. If changing from dabigatran to warfarin, start warfarin three, two or one day(s) before discontinuing dabigatran, if creatinine clearance is > 50, 30–50 or 15–30 mL/ min, respectively.(13) If changing from warfarin to a NOAC, stop warfarin; before starting the NOAC, the INR should be < 2 for dabigatran or apixaban, and < 2.5 for rivaroxaban.(13) NOAC reversal

The monoclonal antibody, idarucizumab (Praxbind), was approved in July 2016 for reversing the action of dabigatran prior to emergency surgery or in situations of uncontrolled bleeding.

Given intravenously (IV), it reverses dabigatran’s anticoagulant effect within four hours and stops bleeding in 11 hours. Thrombosis has occurred between the time of idarucizumab administration and the restart of dabigatran, which can be done as soon as 24 hours after the idarucizumab dose.(17,18) TO SEE REFERENCES, GO ONLINE Visit CanadianHealthcareNetwork.ca and click on the Pharmacy Practice+ logo.

[Vol.4 No.3] April 2017

13

Key considerations for medication use in ostomy patients eople living with an ostomy are referred to as ostomates. An ostomy is created through a surgical procedure and is used to treat a wide variety of conditions that affect the gastrointestinal (GI) tract. In the United States, 120,000–130,000 ostomy surgeries are performed annually and an estimated 450,000–800,000 Americans are currently living with an ostomy.(1-3) Rates in Canada could be expected to be proportionately similar.

The most common indications for ostomy surgery are Crohn’s disease, ulcerative colitis, colon cancer, intestinal obstruction, fecal incontinence, diverticulitis and trauma.(4,5) Many of these conditions require ongoing management with medications and these patients may also have co-morbidities that require treatment. Therefore, pharmacists may be asked to provide advice on a wide variety of medications for patients with ostomies. To do so, pharmacists require an understanding of the alterations to the GI tract in ostomy patients and the impact these changes have on medication efficacy and safety. It is also important for pharmacists to be knowledgeable about the medications required to treat issues specific to ostomates. To help pharmacists provide optimal care, this article briefly reviews the two main types of ostomies and the main factors to consider when providing advice on medication administration to ostomates.

It also outlines the general suitability of various routes of administration and 14

April 2017 [Vol.4 No.3]

dosage forms, as well as considerations in administering specific drug classes to patients with an ostomy. Information on the safe and effective use of medications in ostomates is lacking; if pharmacists identify ostomy patients in their practice, they can use their pharmaceutical knowledge to provide tailored counselling and follow-up to ensure that medications are having the desired therapeutic effects while minimizing adverse effects.

Ostomy basics An intestinal ostomy is a surgicallycreated opening connecting the bowel to the abdominal wall for the elimination of fecal waste. An ostomy is indicated when the bowel cannot be re-anastomosed (i.e., surgically reconnected) after removal of the disease or damaged section. Ostomates wear an appliance with pouch over the opening (stoma) to collect fecal waste. The exact portion and length of intestine removed varies depending on the condition being treated and the extent of disease in the bowel. An ostomy can be created at any point along the GI tract.(4) An ileostomy is formed when the entire colon is removed and the small intestine is used to create a stoma (Figure 1).(6) If only a portion of the colon is removed, it is referred to as a colostomy (Figure 2).(6) Ostomies can also be created to temporarily divert waste to allow the bowel distal to the stoma to heal secondary to perforations, fistulas, ob-

by Brenda Rosenthal, BScPharm

structions or inflammation. These temporary ostomies may be required for several months or longer before they can be surgically reversed. Patients with temporary ostomies should follow the same advice regarding medication use as patients with permanent ostomies.(4) Ostomies are not always required after surgical removal of a segment of bowel.

Surgical techniques to create an internal pouch called an ileoanal reservoir (Figure 3)(6) or reanastomosis of the remaining bowel can obviate the need for an external stoma. Since these patients have a shortened bowel length, recommendations for medication use are similar to patients with ileostomies or colostomies.

Factors to consider when providing advice on medication administration When pharmacists are asked to provide advice on medication administration in patients who have had surgical removal of a portion of the intestine, it is important to first determine the site of the ostomy, the length and health of remaining bowel and whether the ostomy is permanent or temporary. An enterostomal therapy nurse or wound, ostomy and continence nurse involved in the patient’s care can be a valuable source of information. The Canadian Association of Enterostomal Therapy website (https://members.caet.ca/etfinder) allows users to search for nurses who specialize in enterostomal care in their city or province.(7) Additional resources on ostomy care can be found in Box 1. pharmacy practice+

Feature

Other important factors to consider when providing advice on medication administration to ostomates are discussed below.

Routes of medication administration Outside of a hospital environment, medications are most commonly administered orally. A healthy intact GI tract is important for oral medications to be absorbed and exert their desired effects. Patients with an ostomy have a shortened intestinal length and the remaining bowel may contain residual disease (e.g., Crohn’s disease) or be damaged secondary to nondrug treatments (e.g., radiation-induced enteritis). Therefore, oral drug absorption may not be optimal in many ostomates and individualized treatments may be needed, including consideration of alternate routes of administration.

Table 1 outlines the general suitability of various routes of medication administration and dosage forms for ostomates.(11-14) Not all medications are commercially available for administration via nonoral routes; therefore, Table 1 should be used in conjunction with references listing product availability and dosage forms (e.g., the Compendium of Pharmaceuticals and Specialties or Health Canada’s Drug Product Database).

Oral medication absorption in ostomy patients Box 2 lists factors affecting oral drug pharmacy practice+

absorption in ostomy patients. After swallowing an orally administered solid dosage form, the tablet or capsule must disintegrate and dissolve in the stomach and intestine in order to be absorbed into the systemic circulation.(6) Drug absorption can occur at all points along the GI tract, but the proximal small intestine including the duodenum and jejunum are generally the sites of highest drug absorption due to the large surface area, generous blood supply, optimal pH and permeable mucous membrane.(15) The distal portion of the small intestine (ileum) is also an important site of drug absorption. When portions of the duodenum and jejunum are removed intestinal adaptation in the ileum can often occur, with the remaining portion of small bowel increasing the number of microvilli and effectively increasing the surface area available for nutrient and medication absorption.(16) Colostomy patients can take most medications with little concern for malabsorption since the large intestine plays a minimal role in drug absorption except when sustainedrelease or certain enteric-coated formulations are administered.

Unfortunately, the precise location for absorption has not been eludicated for many drugs. Standard pharmacy references often do not specify the site of drug absorption and may only provide a general statement that the medication is “rapidly absorbed” or “absorbed in the small intestine.”

Box 1 General Resources on Ostomy Care Berry M. Ostomy care. In: Jovaisas B, ed. Therapeutics [Internet].

Ottawa (ON): Canadian Pharmacists Association; 2015 [updated June 2016]. www.e-therapeutics.ca (by subscription). Also available in hardcopy from the publisher.(8) Ostomy products. In: Jovaisas B, ed. Therapeutics [Internet].

Ottawa (ON): Canadian Pharmacists Association; 2015 [updated June 2016]. www.e-therapeutics.ca (by subscription) Also available in hardcopy from the publisher.(9) The Canadian Association of Enterostomal Therapy.(7) https://caet.ca/ United Ostomy Association of America.(2) www.ostomy.org/Home.html National Institute on Diabetes and Digestive and Kidney Disease.

Ostomy surgery of the bowel.(6) https://www.niddk.nih.gov/ health-information/health-topics/ digestive-diseases/ostomysurgery-bowel/Pages/ez.aspx U.S. Library of Medicine. Medline Plus. Ostomy (information for patients).(10) https://medlineplus.gov/ ostomy.html

[Vol.4 No.3] April 2017

15

* Nielsen MarketTrack, Scar Treatments, Specialty Creams & Lotions Closed Grouping, National Grocery + Drug + Mass, 52 weeks ending February 6, 2016.

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ture, but it is difficult to extrapolate these data to all patients with ostomies as there can be significant variation in length and health of the remaining bowel.(13,17-20) Case reports are also more likely to report negative outcomes, such as malabsorption and ineffectiveness, and can provide conflicting conclusions. For digoxin and warfarin, for example, some case reports indicate malabsorption, while others report effective therapeutic levels; this makes it difficult to confidently predict drug absorption for future patients.(21-28) Table 2 reviews aspects to consider before using common classes of medications in ileostomy and colostomy patients.(3,13,29-33)

Feature

This may be insufficient to provide an accurate assessment of drug absorption to ostomates who have had a portion of their small intestine removed. It is important to review detailed pharmacokinetic data beyond what standard references may provide.

Clinical trials generally do not include patients with ostomies and alterations to pharmacokinetics secondary to GI disease or surgery have not been well studied; therefore, evidence-based recommendations for administering specific drugs to ostomates are often not available.(15) Case reports of malabsorption of medications are available in the litera-

(Cont’d on page 21)

Table 1

Suitability of Routes of Administration and Dosage Forms for Ostomy Patients

Liquids

OK

OK

Chewable tablets

OK

OK

Regular or film-coated tablets and capsules

OK

OK

Patient should report if regular tablets or capsules appear in their pouch; this may indicate malabsorption and an alternate formulation or route may need to be considered

Orally-disintegrating tablets

OK

OK

Does not avoid the GI tract; disintegrated tablet must be swallowed

Enteric coated

Maybe

OK

Enteric coatings are intended to protect a medication from stomach acid and generally start to disintegrate in the small intestine, therefore, enteric coated medications could be considered in ileostomy patients. If the enteric coating is intended to delay the release of the medication to more distal portions of the intestine the product may not be effective in ileostomy patients.

Sustained release or long acting

AVOID

Maybe

Transdermal patches

OK

OK

Topical creams, ointments or gels

OK

OK

OK

OK

OK

OK

OK

OK

OK

OK

Sublingual Buccal

Few liquid medications are available and most are designed for children; therefore, adults may need a large volume. Artificial sweeteners, high osmolality or alcohol in liquids may cause GI upset, diarrhea or increase stoma output.

May be used in colostomy patients with close monitoring; duration of action may be shorter than expected. Patients should be informed that tablets may appear in the ostomy pouch as “ghost tablets” when tablet matrix is not digested.

OK

OK

Suppositories

AVOID

AVOID

Insertion of suppositories into stoma openings is not recommended. Patients with an intact rectum may use the rectal route for systemic effects if no other options are available.

Enemas

AVOID

Maybe

Enemas or irrigation of colostomies should only be done if recommended by a specialist who is familiar with ostomy care.

Intravenous

OK

OK

Long-term use of this route requires ongoing intravenous access, with a risk of infections and catheter occlusions.

Intramuscular

OK

OK

Subcutaneous

OK

OK

GI–gastrointestinal; Maybe–might be acceptable in selected patients with monitoring for efficacy and adverse events; No–do not use; OK–generally acceptable to use pharmacy practice+

[Vol.4 No.3] April 2017

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Feature

Table 2

Considerations in administering specific drug classes to patients with ostomies

Antacids

Calcium- or aluminum-based antacids generally okay.

Magnesium-containing antacids can increase stoma output.

Calcium- or aluminum-based antacids can cause constipation. Magnesium-based antacids generally well tolerated, but can cause diarrhea.

Antibiotics

Risk of decreased absorption and efficacy depending on length of remaining small intestine. May alter bacterial flora leading to increased stoma output.

No specific concerns

Anticholinergic agents (antihistamines, tricyclic antidepressants, antipsychotics, antiparkinson agents, antispasmodics)

Counsel patients to monitor for decreased stoma output due to decreased intestinal peristaltic activity.

May cause constipation, especially when anticholinergic agents are used in combination

Antidiarrheals

Loperamide can be used on a regularly scheduled basis to decrease output from a high output stoma. Does not cause central nervous system side effects.

May cause constipation and possible obstruction

Antiflatulence agents

Simethicone and alpha-galactosidase (Beano) can be used to decrease gas output from stoma.

No specific concerns

Bile acid sequestrants (e.g., cholestyramine)

Bile salt malabsorption due to ileostomy may cause diarrhea; treatment with cholestyramine may be required in some patients.

No specific concerns

Diuretics

Avoid. Can cause dehydration and electrolyte abnormalities.

No specific concerns

Medications that may discolour feces

Iron (black), bismuth (greenish black), amitriptyline (blue or green), phenothiazines (pink-red), vitamin B12 (yellow), salicylates (pink to red or black), senna (yellow), aluminum-containing antacids (whitish or speckled), rifampin (orange-red). Warn patients of this possibility.

Enteric-coated medications

Avoid.

Exceptions: • enteric-coated proton pump inhibitors are used to decrease excessive gastric fluid production in ostomates with high stoma output.

• Enteric-coated 5-aminosalicylic acid may be used to treat Crohn’s disease in the remaining small bowel

No specific concerns

Laxatives

Avoid. Bulk forming laxatives (psyllium) can cause obstruction. Stimulant (senna, bisacodyl) or osmotic laxatives (PEG 3350) can cause dehydration and electrolyte abnormalities.

Bulk forming laxatives are generally safe.

Use oral stimulant or osmotic laxatives only if other treatments fail. Enemas or irrigation of colostomies should only be done if recommended by a specialist who is familiar with ostomy care.

Long-acting or sustained-release medications

Avoid

May be used in patients with a significant portion of colon remaining. Monitor for shortened duration of action. Counsel patients that “ghost tablet” may appear in ostomy pouch as some longacting medications are formulated in a nonabsorbable matrix or shell.

Medications active in the colon (sulfasalazine, sodium polystyrene sulfonate, lactulose)

Avoid

May be less effective depending on remaining colon length.

Natural products (e.g., herbal remedies)

No information on efficacy or safety.

No information on efficacy or safety.

Opioids

Codeine and diphenoxylate/atropine slow GI transit time and decrease stoma output.

May cause constipation. Sustainedrelease tablets/capsules may not be fully absorbed due to shortened colon.

Oral Contraceptives

Absorbed in the small intestine and undergo enterohepatic recirculation. Consider alternate route or method in patients with a significant portion of small bowel removed.

No specific concerns

Potassium supplements

Supplements may be required for patients with high stoma output. Liquid formulations may cause GI upset and increased stoma output. Wax matrix or slow-release formulations may not be well absorbed.

No specific concerns

Prokinetic agents (metoclopramide, domperidone)

Avoid. Can increase stoma output causing dehydration and electrolyte abnormalities.

No specific concerns

Vitamins & mineral supplements

May be required to treat nutritional deficiencies. Vitamin B12 is absorbed in the terminal ileum. B vitamins can cause pouch odour.

No specific concerns

GI–gastrointestinal

18

April 2017 [Vol.4 No.3]

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“It clicked when my doctor and I discussed Trulicity .” ®

• • •

*

Once-weekly dosing Ready-to-use pen† Preattached, hidden needle†

*Fictitious patient. May not be representative of all patients.

Trulicity 1.5 mg demonstrated A1c reduction comparable to liraglutide in a non-inferiority, open-label study. ठChange from baseline in A1c at 26 weeks: Trulicity 1.5 mg + metformin, -1.4, liraglutide + metformin, -1.4; p<0.001 for non-inferiority.

Trulicity is indicated for the once-weekly treatment of adult patients with type 2 diabetes mellitus to improve glycemic control, in combination with: • diet and exercise in patients for whom metformin is inappropriate due to contraindication or intolerance.

• metformin, when diet and exercise plus maximal tolerated dose of metformin do not achieve adequate glycemic control.

• metformin and a sulfonylurea, when diet and exercise plus dual therapy with metformin and a sulfonylurea do not achieve adequate glycemic control.

• prandial insulin with metformin, when diet and exercise plus basal or basal-bolus insulin therapy (up to two injections of basal or basal plus prandial insulin per day) with or without oral antihyperglycemic medications, do not achieve adequate glycemic control.

Clinical use:

Contraindications: • Patients with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) • Pregnant and nursing women Most serious warnings and precautions: Risk of thyroid C-cell tumours: In male and female rats, dulaglutide causes dose-dependent and treatment duration-dependent thyroid C-cell tumors after lifetime exposure. Patients should be counseled regarding the risk and symptoms of thyroid tumors.

Other relevant warnings and precautions: Heart rate increase • Prolongation of PR interval • Hypoglycemia (in combination with a secretagogue or prandial insulin) • Severe gastrointestinal disease • Pancreatitis • Systematic hypersensitivity • Not studied in pediatric patients • No dose adjustment required in patients over 65 years of age • Hepatic or renal impairment • Recent myocardial infarction, unstable angina and congestive heart failure •

For more information: Please consult the product monograph at www.lilly.ca/ TrulicityPM/en for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling us at 1-888-545-5972.

Reference: 1. Trulicity Product Monograph. Eli Lilly Canada Inc., August 4, 2016. †

Clinical significance has not been established.

‡

The recommended starting dose for Trulicity is 0.75 mg once-weekly.

§

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Treatment was added to background therapy with metformin (≥1500 mg/day). All n-values refer to intent-to-treat population.

Primary endpoint was change in A1c from baseline to week 26 between once-weekly Trulicity and once-daily liraglutide.

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PP-DG-CA-0016

Feature

Trulicity has not been studied in combination with basal insulin. Trulicity is not a substitute for insulin.

Trulicity should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.

Box 2 Factors affecting oral drug absorption in ostomy patients(13,14) • Drug formulation (liquid, tablet, etc.)

• Site of drug absorption • Length of remaining intestine • Health of remaining intestine • Gastrointestinal transit time • Gastric and intestinal pH • Stomal output

BOX 3

Special considerations for oral medication use in ostomy patients(11-15, 31-33)

• Delayed-release and sustained-release medications may not be suitable for all ostomates (see Tables 1 & 2).

• May need to consider alternate (nonoral) routes of administration.

• Counsel the patient about potential gastrointestinal (GI) side effects of medications (e.g., diarrhea, constipation, GI bleeding) as these side effects may affect stomal output. Bleeding from the stoma or into the pouch should be reported to a healthcare provider.

• Advise patient to report intact tablets in their pouch.

• Inform patients of drugs that may alter the colour or odour of ostomy output (see Table 2 and references 3 and 33).

• How can drug efficacy and safety be monitored?

Short bowel syndrome Patients with short bowel syndrome form a subset of ostomy patients that require special consideration. They have rapid GI transit time and high ostomy output due to significant loss of small intestinal length. The American Gastroenterological Association defines short bowel syndrome as patients with less than 200 cm of functional small intestine.(34) High ileostomy outputs (> 2 L/day) can also indicate the presence of short bowel syndrome.(35) For some patients, short bowel syndrome develops over the course of several surgeries when additional bowel is removed.

Patients with short bowel syndrome are at high risk of malabsorption of orally-administered nutrition, vitamins, minerals and medications. In the immediate postoperative period, some ostomy patients have high output that improves as intestinal adaptation occurs.(16) However, adaptation can be difficult or impossible when a significant amount of intestine has been removed or is not functional.

[Vol.4 No.3] April 2017

21

2017 COMMUNITY PHARMACY TRENDS & INSIGHTS REPORT GET AN INSIDER’S LOOK AT PHARMACY IN CANADA TODAY

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This is an era of unprecedented change–even transformation— for both the profession and business of community pharmacy in Canada.

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Figure 1

An ileostomy(6)

Stoma Ileum Anus

Figure 2

A colostomy(6)

Feature

Colon

If intestinal adaptation does not decrease ostomy output, patients often require long-term intravenous hydration and nutrition to prevent dehydration, malnutrition and electrolyte abnormalities. They will also be prescribed medications to slow GI transit time, including high-dose, regularly-scheduled loperamide, codeine or diphenoxylate/atropine. Medications to decrease gastric acid production (e.g., ranitidine or omeprazole) may also be prescribed to decrease gastric fluid output. In severe cases, octreotide injection may be used to decrease intestinal secretions and control ostomy output. These patients may require more than one medication to control ostomy output.(36-39) Absorption of all orally-administered medications is compromised in patients with short bowel syndrome.(13) These patients should receive medications via alternate routes whenever possible. They require experienced clinicians to closely monitor medication effectiveness, nutritional status, hydration and overall health.

Pharmacistâ&#x20AC;&#x2122;s role Small intestine

Colon

Rectum (may be removed) Anus

Figure 3

Stoma Colon section (removed)

An ileoanal reservoir(6)

Colon (removed)

Ileoanal reservoir Anus

pharmacy practice+

Ileum

Patients may not disclose that they have an ostomy when they fill a new prescription and pharmacists may not ask about past surgical history. Identifying patients with an ileostomy or colostomy can help the pharmacist provide appropriate therapeutic recommendations and counselling. It may be appropriate to suggest an alternate route of drug administration or close monitoring for these patients. Box 3 lists other factors pharmacists may need to consider when using oral medications in ostomates.

Summary Oral medication use in patients with an ileostomy or colostomy can be affected by decreased drug absorption, shortened intestinal length and increased GI transit time. Information on the safe and effective use of oral medications in ostomates is lacking; therefore, close monitoring and follow-up may be required to ensure that medications are having the desired therapeutic effects while minimizing adverse effects.

Patients with short bowel syndrome are at highest risk of malabsorption of nutrients and medications; alternate routes of administration should be considered when feasible. Identification of patients who have an ostomy will allow pharmacists to provide tailored counselling and follow-up.

Brenda Rosenthal (brosenthal@hsc.mb.ca) is a clinical resource pharmacist for drug information and drug use management with the Winnipeg Regional Health Authority. She has been an invited speaker on this topic for a nursing Ostomy Education Day. She also recently presented at the Ostomy Canada Society Conference for patients interested in learning more about medication use in ostomies.

TO SEE REFERENCES, GO ONLINE Visit CanadianHealthcareNetwork.ca and click on the Pharmacy Practice+ logo.

[Vol.4 No.3] April 2017

23

Advanced Digital Ovulation Test The first and only ovulation test to typically identify a woman’s four or more best days to get pregnant1 Accurately identifies more of the fertile window for more opportunities to get pregnant naturally: The Clearblue Advanced Digital Ovulation Test tracks two key fertility hormones in urine, estrone-3-glucuronide (E3G*, a urinary metabolite of estradiol) and luteinizing hormone (LH), to adapt to a woman’s personal menstrual cycle and identify a wider fertile window than any other home ovulation test.

A recent study demonstrated that the use of digital ovulation tests neither increases nor decreases the levels of stress in users, and importantly, may potentially shorten the time to conception.2

Provides couples with more flexibility to plan intercourse around their busy lifestyles:

Additional benefits

Other home ovulation tests only provide 1-2 days’ advance warning of ovulation through identification of the LH surge. Clearblue Advanced Digital Ovulation Test also measures rising E3G levels to typically identify two additional days of high fertility during each cycle, thereby maximizing the chance of conception.

The Clearblue Advanced Digital Ovulation Test is suitable for all women whatever their length of cycle.1

The only digital ovulation test that can adapt to a woman’s unique hormone profile every time she tests: Each menstrual cycle has a unique hormone profile. The Product Holder contains software with a sophisticated algorithm that adapts to a woman’s individual hormone levels every time she tests, in order to accurately identify her fertile window. Days of ‘High Fertility’ are detected by a sustained rise above baseline in the level of E3G a few days prior to ovulation. ‘Peak Fertility’ is displayed when the LH surge is detected.

Clear circle Low Fertility

Flashing Smiley Face High Fertility

No impact on stress levels among couples trying to conceive:

For some women studied, there was value in knowing early whether they had a surge in LH or not, as it was a trigger for them to seek medical advice sooner and gave them more confidence in discussing their reproductive health with their healthcare providers.

Digital format for unmistakably clear results: In a recent study, over 97% of volunteers correctly read the result of a Clearblue Advanced Digital Ovulation Test.3

More accurate than other commonly-used home methods for fertile phase detection: The Clearblue Advanced Digital Ovulation Test is more than 99% accurate at detecting the LH surge.4 This is significantly better than other methods, with accuracy reported to vary between 57-70% for the basal body temperature method and 48-76% for the cervical mucus evaluation method.5 Calendar methods are also inaccurate: many women have a lack of awareness of their own menstrual cycle characteristics with a significant proportion incorrectly estimating their fertile days.6

Smiley Face Peak Fertility

References * Estrone-3-glucuronide, E3G, is recognized by the World Health Organization as a principal metabolite of estradiol7 that can be used to identify the onset of the fertile phase.

The urinary levels of E3G correspond to the serum levels of estradiol.

1. Data on file. In a study of 87 women, four or more fertile days were identified in 80% of cycles using actual cycle length (2012).

2. Tiplady S., et al. Home ovulation tests and stress in women trying to conceive: a randomized controlled trial. Hum Reprod (2012) 27 (suppl 2): ii9-ii11. doi: 10.1093/humrep/27.s2.5 3. Data on file.

4. Data on file. Study found >99% agreement with AutoDELFIA reference method in 100 cycles (all cycles had LH surge >40mIU/ml).

5. Brezina PR., et al. At home testing: optimizing management for the infertility physician. Fertil Steril (2011) 95: 1867-1878.

6. Zinaman, M., et al., Accuracy of perception of ovulation day in women trying to conceive. Curr Med Res Opin (2012) 28: 749-754.

HCP-0087.2.CA

Nardine Nakhla PharmD

New standards for nonprescription health claims and labels

Self-care and Wellness

OTC issues

Pharmacists should be aware of three key pending changes to labelling standards for nonprescription drugs

1

Health claims based on scientific proof

Health Canada, the regulator of all prescription and nonprescription drugs sold in Canada, considers self-care products to consist of three different product types: cosmetics, natural health products and nonprescription drugs.(1) Currently, not all self-care products require that the company provide Health Canada with scientific evidence to support the claims made on the label.(1) This means that patients may be selecting products without the information required to make an informed decision. In fact, public opinion research conducted in April 2016 revealed that only 19% of Canadians considered themselves well-informed when purchasing natural health products, followed by 29% for cosmetics and 37% for nonprescription drugs.(1) Because of this, Health Canada is examining new approaches to the regulation of self-care products, including product classification based on risk level (proposed risk classification system is presented in reference 1) and refocusing the approval of health claims to those based on scientific proof, so that Canadians can trust that these products are safe and do what they claim to do.(1)

pharmacy practice+

2

Updated nonprescription drug labels

Health Canada also recognizes that labels are integral to communicating information about self-care products. As part of the Plain Language Labelling (PLL) initiative, new regulations will improve the safe use of drugs by making nonprescription drug labels easier to read and understand.(2,3) Label information required by these regulations must be prominently displayed on the label, readily discernible to the purchaser or consumer under the customary conditions of purchase and use, and expressed in plain language. In addition, the label format, including text display and graphics, must not impede the comprehension of the information on the label. New nonprescription drugs will also be required to undergo a brand name assessment to ensure the drug is not confused with another drug because of similar names.(2) This will help minimize errors due to brand-line extensions.

3

New drug facts table for nonprescription drugs

The new PLL regulations require all nonprescription drugs, excluding those “obtained only through health professionals,” to display a bilingual Canadian Drug Facts Table (CDFT) on the product’s outer packaging. The CDFT (Figure 1) will convey the most important information about the drug in a standardized, easy-to-read format, to enhance safe and effective use of the drug. The concept and format is modelled after Canada’s Nutrition Facts table on foods and the Drug Facts box required for nonprescription drugs in the United States.

The CDFT will enable consumers to compare different products (particularly when there may be similarities in name, packaging and ingredients) to aid in selecting the product most suitable for their needs or symptoms. It will also help consumers identify the same medicinal ingredient in multiple products (to avoid the potential for unintentional overdose), quickly locate the directions for safe use and associated warnings, and quickly locate the list of product ingredients (to avoid the potential for allergic reactions).(2) These new labelling rules will apply to all new nonprescription drug applications filed after June 2017, and will be applied to all other nonprescription drugs over the next few years.

[Vol.4 No.3] April 2017

25

Help them target the pain where it hurts.

1

The #1 Topical Analgesic recommended by physicians.*

*The Medical Post and Profession SantŽ 2017 Survey on OTC Counselling and Recommendations.

1. Voltaren® Emulgel™ and Voltaren® Emulgel™ ExtraStrength Product Monograph. GlaxoSmithKline Consumer Healthcare Inc. January 18, 2016.

Voltaren Emulgel® 1.16% and Voltaren Emulgel® Extra Strength 2.32% are indicated for relief of pain associated with recent (acute), localized muscle or joint injuries such as

sprains, strains or sports injuries (e.g., ankle sprain, shoulder strain or back muscle pain). This is typically as an adjunct to other measures, such as rest, for the relief of discomfort associated with such injuries.

Please consult the product monograph at http://webprod5. hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for more information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

The product monograph is also published in the CPS. GlaxoSmithKline Consumer Healthcare Inc., Mississauga, Ontario L5N 6L4 © 2017 GSK group of companies.

All rights reserved.

Self-care and Wellness

FIGURE 1 FORMAT SPECIFICATIONS: DRUG FACTS TABLE(2) Box frame 1.5 pt line weight

Left Justified Titles: Drug Facts 8 pt Helvetica Bold* Headings: 7 pt Helvetica Bold*

Rules: 1.5 pt line weight, extend from one edge of frame to other Hairlines: 0.375 pt line weight, gap of 2 character spaces on either end between hairline and frame sides

Subheadings: 6 pt Helvetica Bold*

Bullet: 3 pt solid square or circle

Body text: 6 pt Helvetica Regular with 6.5 pt leading

Insert graphic (arrow or similar) leading to next panel when applicable

Lines and characters do not touch

Drug Facts Active ingredient (in each tablet)

Purpose

Ingredient A xxx mg............................................................Xxxxxxxxxxxxx

Uses Relief of

•xxxxxxxxxxx •xxxxx xxxxxxxxxxx •xxxxxxxxx

Warnings

Allergy alert: May cause a severe allergic reaction.

•xxxxxxx •xxxxxxx •xxxxxxx •xxxxxxxxxxxxxx •xxxxxxx •xxxxxxx • • • •xxxxxxx Ask a doctor or pharmacist before use if you take •xxxxxxx •xxxxxxx •xxxxxxx •xxxxxxx •xxxxxxxxxxxx Do not use if

Ask a doctor before use if you have xxxxxxx xxxxxxx xxxxxxxxxxxx

When using this product do not drive a motor vehicle operate machinery. This product may cause dorwsiness or excitability.

•

•

Stop use and ask a doctor if xxxxxxx xxxxxxx xxxxxxx xxxxxxxxxxxx xxxxxxx xxxxxxxxxxxx

•

•

•

•

•xxxxxxx

If pregnant or breast feeding ask a healthcare practitioner before use.

Keep out of the reach of children. In case of an overdose, call a poison control centre or a healthcare professional immediately.

▼

Drug Facts (continued) Directions Do not chew tablets.

Children under 6 years

Ask a doctor

Children 6-12 years

x tablet(s) every y hours as needed

Do not take more than Z tablets in 24 hours

Children over 12 years, and adults

x tablet(s) every y hours as needed

Do not take more than Z tablets in 24 hours

Impact on pharmacists Pharmacists have a critical role in educating patients to ensure they fully understand the new regulations.

The standardized label format can assist patients in quickly and easily zeroing in on the information they need. However, pharmacists must continue to strive to provide objective advice and product education to inform self-care decisions.

Pharmacists also have to be cognizant of the potential unintended consequences of these regulations. The principal display panel (the brand side of the carton facing the consumer) where the new information is presented will be more cluttered; this may affect product selection and/or lead to patient confusion and subsequent seeking of assistance from the pharmacist. The labelling standards include conformance to text sizes for enhanced readability, as illegibility of printed information is a documented contributing factor in health product errors; this heavy emphasis on legibility may come at the price of comprehension. Product costs to the consumer may also increase, as many products will resort to more costly peel-back labels and other more expensive packaging configurations. Costs to the industry may also increase, as many products will require larger packages (which also affects pharmacy shelving space and raises environmental concerns).

Nardine Nakhla is a practising community pharmacist, Adjunct Clinical Assistant Professor at the University of Waterloo School of Pharmacy, Lecturer & CPD Education Coordinator at the University of Toronto Leslie Dan Faculty of Pharmacy.

Other information Store at room temperature (15-30° C).

Inactive ingredients List of NMIs List of NMIs List of NMIs

List of NMIs

Questions? Call 1-8XX-XXX-XXXX

Title for "continued" panel: 7 pt Helvetica Bold* except for "continued" which is not bold * or other sans serif font of comparible size.

Source: Health Canada. The reproduced image is a copy of the version available at: www.hc-sc.gc.ca/dhp-mps/pubs/medeff/_guide/2016-labelpackage-practices-pratiques-etiquetage-emballage-non/index-eng.php

pharmacy practice+

References 1. Government of Canada. Consulting Canadians on the regulation of self-care products in Canada. Updated November 25, 2016. http://healthycanadians. gc.ca/health-system-systeme-sante/consultations/selfcare-autosoins/document-eng.php?_ga=1.213868567.2064167766.1469488879 (accessed January 3, 2017).

2. Health Canada. Good label and package practices guide for non-prescription drugs and natural health products. Updated June 30, 2016. www.hc-sc.gc.ca/ dhp-mps/pubs/medeff/_guide/2016-label-package-practices-pratiques-etiquetage-emballage-non/index-eng.php (accessed January 3, 2017).

3. Health Canada. Guidance document questions and answers: plain language labelling regulations. Updated September 8, 2016. www.hc-sc.gc.ca/dhp-mps/ prodpharma/applic-demande/guide-ld/pll_qa_fin_qr_elc-eng.php (accessed January 3, 2017).

[Vol.4 No.3] April 2017

27

Pearls you can use in your practice now

Communicating effectively and respectfully with transgender patients

by Christine Elliott, BScPhm, RPh Recognition and acceptance of transgender (trans) people is a relatively recent phenomenon.

Based on survey data, it is estimated that 0.5% of the adult population identifies as being transgender.(1,2) A survey of 433 transgender people in Ontario found that these patients were more comfortable talking with family physicians when they perceived that their physician had a greater knowledge of transgender health issues. Furthermore, at least one trans-related negative experience with a family physician was reported by 37.2% of trans men and 38.1% of trans women.(2) Pharmacists have an opportunity, in their discussions with patients, to build stronger relationships by communicating respectfully and understanding transgender health issues. This article provides 5 tips for communicating effectively with transgender people.

#1

Mirror the language that your transgender clients use to express their own identity When communicating with trans individuals, it is important to use respectful language that reflects their gender identity.(3) Use the same language that your transgender patients use to express their identity. If you make a mistake with the language or preferred personal pronoun, apologize sincerely and move on.(4) Use the personal pronoun that reflects the gender that your patient identifies with, or the gender neutral singular pronoun “they/them/their.” Many languages do not have gender neutral pronouns.

New pronouns such as “zie” (he/she) and “zir” (him/ her) are being created and used by some people.

See the link in Box 1 for a more comprehensive list of gender pronouns. In addition, some common gender identity terminology is defined in Table 1.

28

February April 2017 2017 [Vol.4 [Vo1.4 No.3]No.1]

TABLE 1 GLOSSARY OF GENDER IDENTITY TERMS(3,5) Cis

Having a non-trans identity. This term is preferred over "bio," "genetic" or "real." Thus, “cis woman” and “cis man” are preferred terms to “woman” and “man” for those who identify with the sex they were assigned at birth.

Gender nonconformity

The extent to which a person's gender identity, role or expression differs from the prescribed cultural norms for a particular sex.

Transgender

A person who identifies with a different gender from what is typically associated with their assigned sex at birth.

Transsexual

A person who has changed, or intends to change, his or her body to a different gender permanently through surgery or hormone therapy.

Trans man

An assigned female at birth who transitions to live as a man/boy or somewhere on the masculine spectrum.

Trans woman

An assigned male at birth who transitions to live as a woman/girl or somewhere on the feminine spectrum.

Trans

Umbrella term for non-cis people, including transgender, transsexual, and those who may identify with multiple or changing genders or no gender at all.

#2

Understand that each transgender patient has unique healthcare needs Gender dysphoria (being uncomfortable in one’s biologic sex) can present at any age. A transgender person may not identify with a static binary sex, or may identify with multiple genders, or none. Some will seek multiple interventions (social, hormonal, surgical); others will seek none. The timeline and steps for transition will be unique to each individual. All will have healthcare needs that are unrelated to their transition status.(4) Pharmacists should be familiar with gender reaffirming hormonal therapy and be prepared to discuss the efficacy and safety of the medications listed in Table 2. Patients may be prescribed antiandrogens to reduce endogenous hormones and the characteristics

of their biologic sex.(3) They may also receive feminizing or masculinizing hormones that are associated with their gender identity.(3)

#3

Be familiar with feminizing therapy and counselling points for trans women The effect of hormones on sperm is variable. It is important to understand options for contraception and reproduction before initiating drug treatment(3,5): • Consider cryopreserving sperm before starting hormone therapy if a trans woman wishes to have children.

• Use a contraceptive if having sexual intercourse with someone who could become pregnant.

Estrogen therapy is associated with some risks, similar to those for a postmenopausal cis-woman(3,5): • Consider smoking cessation therapy for smokers. pharmacy practice+

TABLE 2 HORMONE THERAPY AVAILABLE IN CANADA(3,6,7) MEDICATION

DOSAGE

Antiandrogens Spironolactone

100–200 mg daily

Cyproterone

25–100 mg daily

GnRH agonist (leuprolide)

3.75 mg subcutaneously monthly

Finasteride

1–5 mg daily

Dutasteride

0.5 mg daily

Male to Female Individuals (estrogens) Conjugated estrogen

0.625–1.25 mg daily

Estradiol (oral)

2–6 mg daily

Estradiol (transdermal)

0.1–0.4 mg twice weekly

Estradiol valerate (parenteral)

10 mg intramuscularly every 2 weeks or weekly

Female to Male Individuals (testosterone) • Consider recommending a lower estrogen dose or the transdermal route for patients with risk factors for estrogen therapy (e.g., cardiovascular disease, family history of genetic breast cancer, clotting disorder, uncontrolled diabetes or hypertension, migraine or cerebrovascular disease).

Explain that breast cancer can occur in transgender women taking hormone therapy; the exact risk is not known.

#4

Be familiar with masculinizing therapy and counselling points for trans men Prior to starting therapy, the pharmacist should ensure that a trans man has a contraceptive plan in place since testosterone is contraindicated in pregnancy. Effective contraceptive options include a progestin-only contraceptive or an intrauterine device.(3) Fertility can be permanently affected by testosterone therapy. If reproduction is desired, testosterone therapy can be postponed, or in some cases, it may be possible to harvest and preserve eggs for future use.(3) For all hormonal therapy, help set realistic expectations for your patients.

Hormones will not change bone structure, height, or with feminizing hormones, voice pitch.(3,6) Changes may be very gradual and sometimes take months or years to become apparent or to reach maximum effect.(3,6) This information should be conveyed with pharmacy practice+

Testosterone cypionate or enanthate (parenteral)

100–200 mg intramuscularly every 2 weeks OR 50–100 mg intramuscularly every week

Testosterone gel 1% (transdermal)

2.5–10 mg daily

Testosterone patch (transdermal)

2.5–7.5 mg daily

compassion, as it can be very difficult for the transgender person when his or her body does not reflect who he or she is.

#5

Admit what you don’t know and prepare yourself with education and training Even if you are unable to answer questions about transgender health, a willingness to learn and find answers can relieve an anxious patient.(4) In addition to the references used to prepare this article, the resources in Box 1 provide comprehensive information about transgender health and issues.

Summary It can be difficult for a transgender individual to engage in dialogue with a healthcare professional. Pharmacists have an opportunity to make a meaningful positive contribution to that discussion and gain trust by educating themselves and demonstrating sensitivity and humility.

Christine Elliott (celliott@opatoday.com) is a drug information pharmacist at the Drug Information and Resource Centre, Ontario Pharmacists Association.

BOX 1 RESOURCES FOR TRANSGENDER HEALTH AND ISSUES Center of Excellence for Transgender Health www.transhealth.ucsf.edu/ My Guide to Caring for Trans and Gender Diverse Clients www.rainbowhealthontario. ca/TransHealthGuide/ Creating Authentic Spaces: A Gender Identity and Gender Expression Toolkit www.the519.org/educationtraining/training-resources/ trans-inclusion-matters/ creating-authentic-spaces Gender pronouns https://uwm.edu/lgbtrc/ support/gender-pronouns/

TO SEE REFERENCES, GO ONLINE Visit CanadianHealthcare Network.ca and click on the Pharmacy Practice+ logo.

[Vol.4 No.3] April 2017

29

ur o y k r! r a M e nda c al

VANCOUVER

TORONTO

VANCOUVER CONVENTION CENTRE

THE INTERNATIONAL CENTRE

NOVEMBER 25, 2017

FEBRUARY 3, 2018

FIND MORE DETAILS AT

PharmacyU.ca Inspiring business learning

ce April 2017

Approved for

Answer online at eCortex.ca

Continuing Education L E S S O N

1.0

CEU

Approved for 1 CE unit by the Canadian Council on Continuing Education in Pharmacy • CCCEP #1065-2016-1723-I-P • Not valid for CE credits after April 10, 2018

TOPIC

Learning Objectives

Upon successful completion of the lesson, the pharmacist will be able to do the following: 1. Understand the prevalence and etiology of iron deficiency anemia 2. Understand and apply diagnostic tools to detect iron deficiency anemia 3. Identify symptoms and risk factors for iron deficiency anemia 4. Apply evidence-based treatment options to manage iron deficiency anemia 5. Discuss the pharmacist’s role in managing anemia

Iron Deficiency Anemia

By Victor Wong, Bsc(Pharm), PharmD and Lucy Wang, MPharm The author, expert reviewers and EnsembleIQ have each declared that there is no real or potential conflict of interest with the sponsor of this CE lesson.

Instructions 1. After carefully reading this lesson, study each question and select the one answer you believe to be correct. Answer online at eCortex.ca 2. To pass this lesson, a grade of at least 75% (6 out of 8) is required.

If you pass, your CEU(s) will be recorded with the relevant provincial authority(ies). (Note: some provinces require individual pharmacists to notify them.)

Answer online at eCortex.ca

·ca

Background Anemia is defined as a “reduced concentration of hemoglobin in the blood.”(1) Hemoglobin is a vital protein in red blood cells that helps to carry oxygen from the lungs to tissues and organs throughout the body.

Individuals with anemia have inadequate levels of hemoglobin resulting in insufficient distribution of oxygen and higher risk of associated morbidity and mortality. Iron is an essential component of hemoglobin, necessary for growth, development and normal cellular functioning. Most of the 3 to 4 grams of elemental iron in the body is found in hemoglobin. Iron deficiency anemia is an insufficiency in hemoglobin secondary to low iron stores.(2) More than one quarter of the world’s population is anemic, with one half of that burden being iron deficiency anemia.

Currently, iron deficiency anemia is the most common nutritional disorder in the

world, being most prevalent among women of reproductive age and growing children.

Furthermore, iron deficiency anemia in the elderly significantly increases morbidity and mortality, while anemia itself is found to be an independent risk factor for mortality in patients with chronic kidney disease and heart failure.(3) The dangers of iron deficiency anemia are not just present in the elderly or chronically ill, but in infants and adolescents as well. In growing children and adolescents, iron deficiency has been linked to irreversibly poor growth of both stature and brain function.(4–7) In pregnancy, iron deficiency anemia has been linked to premature delivery, low birth weight, and an increased risk of perinatal infant mortality.(5) From a socioeconomic perspective, iron deficiency anemia impairs workplace productivity and quality of life, with recent studies drawing strong correlations between low iron and depression.(8) The prevalence and comorbidities of iron deficiency anemia warrants heightened awareness by pharmacists to identify symptoms of the disease, recommend appropriate therapy, monitor for therapeutic efficacy, and monitor for undesirable side effects that may increase non-adherence and therapeutic failure.

Pathophysiology Iron deficiency anemia occurs when iron intake can no longer adequately support iron expenditure or loss.(1) Iron homeostasis is particularly unique because the body

Supported by an educational grant from Aralez Pharmaceuticals Inc.

ce

Continuing Education L E S S O N

Iron Deficiency Anemia

CE2

has no mechanism to actively excrete iron, with the balance of iron stores being solely dependent on iron absorption.(1) In most clinical settings, restricted erythropoiesis is the most important cause of anemia secondary to reduced availability of iron. There are two main causes of iron-restricted erythropoiesis: absolute iron deficiency, and functional iron deficiency.(2) In absolute iron deficiency, iron stores in the bone marrow, liver and spleen are absent and thus unavailable for normal rates of erythropoiesis.(2) This results in the reduced production of hemoglobin. Absolute iron deficiency is usually caused by poor intake of dietary iron, decreased iron absorption, and/or increased blood loss.(2) In functional iron deficiency, anemia occurs despite having normal or increased body iron stores due to insufficient iron available for erythroid precursors.(2) This is most common during situations of inflammation such as infection, inflammation or malignancy.(2) In these situations, iron is released back into circulation by macrophages, making iron less available for red cell production.(2) Alternatively, individuals being treated with erythropoiesis-stimulating agents may also have functional iron deficiency

F I G U R E 1 Iron input and output from the body

Iron absorption 1-2 mg

30 mg

30 mg

Plasma

April 2017

since iron stores may not be released quickly enough to meet the increased demands of erythropoiesis.(2) CAUSES OF IRON DEFICIENCY

Iron loss due to natural desquamation of mucosal cells, including the natural shedding of GI lining, and excretion via urine and feces, accounts minimally to the daily loss of iron (~1 g/day), and an additional 2 mg of iron is lost per day due to menstruation.(1) In fact, the human body is so efficient at preserving iron stores that the daily requirement for iron in a normal, healthy individual is 5 mg for males, 15 mg for growing children, and 15 mg for menstruating women.(1) Hence, the body of a regular, healthy individual is able to replenish iron stores through dietary iron alone.(1,9) In contrast, abnormal decreases in iron stores leading to iron deficiency are generally a result of blood loss, decreased iron absorption and ingestion, food and medications.

Blood loss is the most common cause of iron deficiency in developed countries and may be overt (visible by the patient or physician) or occult (not visible by patient or physican, such as gastrointestinal bleeding).(2) Furthermore, drugs that may increase gastrointestinal bleeding risk should be suspected in cases of occult blood loss.(2) These include agents such as NSAIDS, anti-coagulants, antiplatelets, and SSRIs. Decreased ingestion of iron leading to deficiency is observed in individuals with dietary restrictions, such as vegetarians and vegans or other meat-restricted diets. Situations of malabsorption include gastritis, Celiac disease and gastric bypass surgery.(2) FIGURE 2

Tissues

Finally, food and medications (e.g. PPIs which impair absorption) may impair the absorption of iron, particularly nonheme iron salts.(10) Specifically, the content of calcium in a meal reduces absorption of iron, and the content of phytate in bran, oats and rye fiber, polyphenols in tea and some cereals, and soy protein reduce the absorption of iron salts.(2,11–13) Less commonly, individuals may have a genetic predisposition to low iron.(2)

Presentation and Diagnosis Iron deficiency commonly presents with symptoms including fatigue, weakness, headache, tachycardia and decreased immunity. Signs may include pallor, smooth tongue, angular cheilitis and koilonychia.(2) However, many individuals are asymptomatic or may not identify that their symptoms are secondary to anemia. As a result, anemia is insidious and often presents with symptoms related to exacerbation of an underlying co-morbidity, such as increasing angina from coronary artery disease, dyspnea in patients with congestive heart failure, or are discovered during routine blood tests.(2) In children and infants, there may be symptoms of neurodevelopmental delay.(4,5,7,14) Studies on long-term anemic patients have suggested cognitive and motor impairment specifically in language and coordination.(4,5,7,14) It is still unknown if there can be reversal of these symptoms with treatment.

DIAGNOSIS

An examination of a patient’s history and analysis of red blood indices are used to make a diagnosis of iron deficiency

Detailing the multiple signs and symptoms of anemia Nausea

Anorexia

Depression

Bone marrow: in red blood cell precursors

24 mg

6 mg

Hemoglobin in red blood cells

Gastrointestinal system

Fatigue

Loss 1-2 mg

Storage in mononuclear phagocytes

24 mg

Central nervous system

Impaired cognitive function

Impaired T-cell and macrophage function

Chest pain Risk of life threatening cardiac failure

Cardiovascular system

Tachycardia palpitations Cardiac enlargement hypertrophy

Vascular system

Immune system

Increased pulse pressure, systolic ejection murmur

Exertional dyspnea

Signs and symptoms of anemia

Low skin tempertaure

Genital tract Loss of libido

Adapted from Rang and Dale’s Pharmacology(1)

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Adapted from Therapeutic Choices: Common Anemias(15)

Menstrual problems

Pallor of skin, mucous membranes, and conjunctiva

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TA B L E 1

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Causes of iron deficiency anemia.

Increased Requirements

Decreased Intake

• Growing infants and children • Menstruating women • Pregnancy • Lactation • Multiparity • Parturition

• Low socioeconomic status • Vegetarian diet • Lack of balanced diet or poor intake • Alcoholism • Elderly • High risk ethnic groups (First Nations, Indo-Canadians*)

Increased Loss

Decreased Absorption

• Menorrhagia • GI bleeding • Regular blood donors • Post-operative patients with significant blood loss • Hematuria • Intestinal parasites (travel or immigration from an endemic area) • Intravascular hemolysis: hemoglobinuria • Extreme physical exercise (endurance athletes) • Pathological (hemolytic anemias)

• Dietary factors (tannins, phytates in fiber, calcium in milk, tea, coffee, carbonated drinks) • Upper GI Pathology: - Chronic gastritis - Gastric lymphoma - Celiac disease - Crohn’s disease • Medications that decrease gastric acidity or bind iron • Gastrectomy or intestinal bypass • Duodenal pathology • Chronic renal failure patients

Taken directly from British Columbia Ministry of Health guidelines for iron deficiency anemia.(11)

anemia. There are different benefits and limitations to some of the commonly used lab values.

Hemoglobin Count

Hemoglobin count is a measure of the amount of hemoglobin in grams per liter unit of blood. Since anemia is defined as a reduction in hemoglobin concentration, hemoglobin count is a direct, defining measurement for the diagnosis of anemia.(16) Current Canadian standards state that a patient is anemic if their hemoglobin count is less than 135g/L in men and less than 120g/L in women.(15) Currently, hemoglobin count is not recommended as the sole diagnostic measurement for the diagnosis of iron deficiency anemia due to its low specificity.(16) Instead, hemoglobin count is only seen as a “red flag” to begin further investigation.

Mean Corpuscular Volume

Mean corpuscular volume (MCV) is the average volume of red blood cells expressed in femtoliters.(3) Superior to hemoglobin count in terms of specificity, MCV is typically the second test that would be performed in the differential diagnosis of anemias.(16) Iron deficiency anemia present with microcytic cells (smaller than normal cells yielding low MCV values).(3) Patients with iron deficiency anemia commonly have MCV values fall below 80 fl.(9) This is a relatively late change in lab values and limits our opportunity for early detection.

Ferritin Concentration

Ferritin is a form that iron takes when being stored intracellularly.(13,17) Therefore, ferritin concentration is a direct

measure of the body’s iron stores. A vast majority of iron deficiency anemia guidelines around the globe recommend the measurement of serum ferritin concentrations as the primary diagnostic tool for iron deficiency anemia.(8) Though guidelines around the world cite differing threshold values, a serum ferritin of below 30ug/L is generally accepted as an indicator for true iron deficiency.(15) The benefits to measuring serum ferritin include its universal accessibility and its high standardization and specificity, making it highly reliable.(16) The only drawback to measuring ferritin serum levels is false negatives due to the presence of inf lammatory disorders. (18,19) It is well documented that ferritin levels rise in patients with inf lammatory conditions. Therefore, patients with active infections or experiencing active inf lammation could be anemic despite having ferritin levels as high as 100µg/L. (19) To date, there is no universal conversion factor that accurately accounts for higher ferritin levels in this patient population. (18) Transferrin Saturation

Transferrin saturation can be seen as an alternative or complementary measurement for the diagnosis of iron deficiency anemia.(8) It is expressed as a ratio of plasma iron to total iron binding capacity.

Though sub-optimal due to its large diurnal variation and low specificity, transferrin saturation proves to be particularly useful in diagnosing iron deficiency anemia in patients with inflammatory disorders or infection.(16) Thresholds of transferrin saturation to determine iron deficiency range between 15-20%.(8)

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TA B L E 2 Health Canada recommended daily intake of elemental iron.

Recommended Dietary Allowance (mg per day)

Infants 0-6 months

0.27

7-12 months

11

Children 1-3 years

7

4-8 years

10

Males 9-13 years

8

14-18 years

11

Greater than 18 years

8

Females 9-13 years

8

14-18 years

15

19-50 years

18

Greater than 50 years

8

Pregnant

27

Breastfeeding 14 – 18 years

10

19 – 50 years

9

Taken directly from the CPhA monograph for oral iron preparations.(22)

Treatment Regardless of the presence or absence of symptoms, all patients with iron deficiency anemia should be treated because the risk of associated morbidity and progression of anemia will continue until adequate iron stores are replenished.

Current standard of care suggests a twopart treatment protocol. The first step is to find and alleviate the underlying cause of anemia.(20) Once the underlying cause of the iron loss has been established and addressed, the second step is to replenish the patient’s iron stores via supplementation.(20) Only patients with severely symptomatic iron deficient anemia (e.g., symptoms of myocardial ischemia) should be treated with red blood cell infusion.(21) DIETARY IRON AND IRON HOMEOSTASIS

A typical western diet provides approximately 15-20 mg of iron.(1) It is encouraged that individuals consume enough dietary iron daily to replenish low iron stores.

See Table 2 for Health Canada’s recommended daily allowance of elemental iron in healthy individuals. Many food sources have good sources of iron.

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Dietary iron exists in two forms: heme iron and non-heme iron. Heme iron is derived from the hemoglobin and myoglobin of animals and is obtained through meat products. The richest sources of heme iron are found in lean meats and seafood.(17) Heme iron is more efficiently absorbed (15-35%) than non-heme iron and thus contributes to greater than 40% of total absorbed iron in a non-vegetarian diet.(24,25) Conversely, non-heme iron can be found from plant and animal byproducts, such as milk, and much more difficult to absorb in the body (2-20%).(26) Nuts, beans, vegetables and fortified grain products contain the most non-heme iron.

In general, more iron is absorbed when iron stores are low, and less when stores are high.

Absorption mechanisms for heme iron vs. non-heme iron differ greatly. In order to fully understand both the pathophysiology and treatment of iron deficiency anemia, we must first understand the mechanisms responsible for iron absorption. The current up to date absorption mechanisms for non-heme and heme iron are depicted in figures 2 and 3, respectively. It is recommended that the learner reviews these pathways extensively in order to grasp a full understanding of the risk and benefits of available iron preparations, as discussed below.

Though the mechanism by which heme-iron is absorbed into circulation is still being studied, the bottom line is clear: heme iron is absorbed more efficiently into circulation via an alternate pathway compared to non-heme iron.(13,17,26) IRON SUPPLEMENTS

Currently, there are several types of iron preparations available on the market: heme and non-heme oral iron products, and IV iron. The choice between these supplements depends upon the cost and availability of the products, tolerability of the patient to the oral preparation, and any functional restrictions that the patient may have that may alter absorption of iron.

Oral Iron Salts

The current mainstay of therapy comes in the form of oral iron salts.(15,19) Recommended iron salt preparations include ferrous gluconate, ferrous sulfate and ferrous fumarate. Of these three salts, their elemental iron contents are depicted in Table 4.

Current guidelines recommend 105200 mg of elemental iron per day, divided

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TA B L E 3

Amount of iron found in common foods.

Food

Milligrams per serving

Percent DV*

Breakfast cereals, fortified with 100% of the DV for iron, 1 serving

18

100

Oysters, eastern, cooked with moist heat, 3 ounces

8

44

White beans, canned, 1 cup

8

44

Chocolate, dark, 45%–69% cacao solids, 3 ounces

7

39

Beef liver, pan fried, 3 ounces

5

28

Lentils, boiled and drained, ½ cup

3

17

Spinach, boiled and drained, ½ cup

3

17

Tofu, firm, ½ cup

3

17

Kidney beans, canned, ½ cup

2

11

Sardines, Atlantic, canned in oil, drained solids with bone, 3 ounces

2

11

Chickpeas, boiled and drained, ½ cup

2

11

Tomatoes, canned, stewed, ½ cup

2

11

Beef, braised bottom round, trimmed to 1/8” fat, 3 ounces

2

11

Potato, baked, flesh and skin, 1 medium potato

2

11

Cashew nuts, oil roasted, 1 ounce (18 nuts)

2

11

Green peas, boiled, ½ cup

1

6

Chicken, roasted, meat and skin, 3 ounces

1

6

Rice, white, long grain, enriched, parboiled, drained, ½ cup

1

6

Bread, whole wheat, 1 slice

1

6

Bread, white, 1 slice

1

6

Raisins, seedless, ¼ cup

1

6

Spaghetti, whole wheat, cooked, 1 cup

1

6

Tuna, Bluefin, fresh, cooked with dry heat, 3 ounces

1

6

Turkey, roasted, breast meat and skin, 3 ounces

1

6

Nuts, pistachio, dry roasted, 1 ounce (49 nuts)

1

6

Broccoli, boiled and drained, ½ cup

1

6

Egg, hard boiled, 1 large

1

6

Rice, brown, long or medium grain, cooked, 1 cup

1

6

Cheese, cheddar, 1.5 ounces

0

0

Cantaloupe, diced, ½ cup

0

0

Mushrooms, white, sliced and stir-fried, ½ cup

0

0

Cheese, cottage, 2% milk fat, ½ cup

0

0

Milk, 1 cup

0

0

Taken directly from the U.S. Department of Health and Human Services’ fact sheet on iron.(23) * DV = Daily Value. The DV for adults and children 4 and above is 18 mg.

into three daily doses.(15) Patients are to be treated until three months after they reach a hemoglobin count of greater than 135 g/L for men and greater than 120 g/L in women in order to replenish iron stores.(29) The benefits of oral iron salts include their accessibility, low cost, general efficacy and safety.(21) In addition, having been used for several decades in the treatment of iron deficiency anemia, safety and efficacy data pertaining to oral iron salts are well known and documented.

Drawbacks of oral iron salt therapy include low tolerability and absorption.(9,15,16,19,30) Gastric adverse reactions

such as nausea, dyspepsia and constipation are most commonly seen with the use of oral iron salts. Some individuals may require additional management of constipation using high-fiber diet or laxatives. Though these adverse reactions are typically dose related, the resulting consequence is a high rate of patient discontinuation and non-adherence to therapy.(26) Up to 70 percent of patients who are prescribed iron salts, especially ferrous sulfate, report gastrointestinal side effects.(26) Another major disadvantage of oral iron salts is their low oral bioavailability. This unfavorable absorption profi le is due to the fact that non-heme iron is

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TA B L E 4

April 2017

Content of elemental iron in common oral iron salt preparations.

Iron Salt

Percent of Elemental Iron (%)

Salt Strength (mg)

Elemental Iron Content (mg)

33 11.6 20 30

300 300 300 300

99 36 60 90

Ferrous fumarate Ferrous gluconate Ferrous sulfate Ferrous sulfate, dried

Taken directly from the CPhA monograph for oral iron preparations.

F I G U R E 3 Proposed absorption mechanism for non-heme iron.13,17,27,28

Non-heme iron is ingested, usually in ferric form

Ferric iron enters the duodenum

Duodenum cytochrome b (DcytB), ferrous reductase, and potentially ascorbic acid reduces ferric iron to ferrous iron

Divalent ion transporter (DMT1) on the microvillus membrane transports ferrous iron from the intestinal lumen to the enterocyte.

Ferrous iron is in the enterocyte

Ferrous iron stored in enterocyte as ferritin

Ferrous iron transported into circulation by ferroportin 1 (FPN1) which interacts with hephaestin to oxidize ferrous iron back to ferric form

absorbed via a far more complex pathway in comparison to heme iron.(13,17,26) Furthermore, iron salts are subject to many food and drug interactions. They are easily chelated by surrounding ions such as calcium, and by common foods such as phytates in bran, oats and rye fiber, soy proteins, polyphenols found in tea and some vegetables and cereals.(11,13,30) As such, it is generally recommended that iron salts be consumed on an empty stomach if tolerated to maximize absorption.(11,26,30)

Non-heme iron is also best absorbed as the ferrous salt in a mildly acidic medium. (11,30) Gastric acidity is helpful, and medications that reduce acid such as antacids, histamine receptor blockers, and proton pump inhibitors may impair iron salt absorption. (10) Though absorption can be increased with the co-ingestion of ascorbic acid in the absence of food, the estimated absorption efficiency remains approximately 10-20%. (9) Iron Polysaccharide Complex

The iron polysaccharide complex (IPC) is an iron supplement containing 150 mg of elemental iron formulated with a slow release profile to decrease incidents of GI intolerance that are common with iron salts. The theory behind IPC is that the majority of gastric intolerance caused by iron salts is a result of rapid iron release in the GI tract. IPC, however, stores iron atoms in an inner core and slowly releases iron in a controlled fashion, much like the endogenous ferritin protein.(31,32) One multi-center randomized controlled trial done by Ortiz et al. concluded that the oral iron(III) polymaltose complex was at least equally efficacious when compared to ferrous sulfate, while offering a more agreeable safety profile.(33) Therefore, the benefits of IPC include decreased adverse drug reactions as well as pill burden (onea-day dosing).

One major critique of IPC therapy is that the long acting release profi le of IPC is not compatible with the nature of iron absorption. Recall that iron absorption is mainly achieved in the duodenum.

Therefore, absorption of iron from IPC is limited to the duration of time the formulation can stay within that absorption “sweet spot.”(15) This, of course, is limited by gastric emptying and passage, which results in less iron present at the duodenum villi for absorption. Consequently, sustained-release capsules are less efficient for oral absorption because they release iron too far distally in the intestine, hence reducing the amount of iron present for absorption at the duodenal villi.(30)

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TA B L E 5 Estimated total dose of absorbed iron needed for anemia correction based on hemoglobin values.

Hemoglobin (g/dL)

Absorbed iron total dose (mg)

Greater than 11 9-11 Less than 9

500 1000 1500

Note that these values were based on and taken from the paper Individualized Treatment for Iron-deficiency Anemia in Adults done by Allenye et al. which are based on studies done on elemental iron only.9

Bovine Heme Iron

Bovine heme iron is iron in the heme form, extracted from cows available on the Canadian market as an oral formulation containing 11 mg tablets of heme iron.

Due to its specialized absorption pathway, studies on healthy volunteers have shown bovine heme iron to be better absorbed than non-heme iron salts, (i.e., up to 20 times better than an equivalent dose of ferrous fumerate.)(12,34, 27) In addition, supplementation with bovine heme iron in regular blood donors was shown in early studies to have less intolerance issues such as less constipation, nausea, cramping and reduced GI distress.(35) It should also be noted that, as opposed to iron salts which are better absorbed on an empty stomach, heme iron absorption is not affected by the presence of food and therefore more convenient to take since they can be consumed with or without meals.(12) In comparison to IV iron therapy, which has long been considered the gold standard for iron supplementation in the highest risk anemic patient population of chronic kidney disease patients, heme iron supplements have demonstrated equivalence in several studies.

In one study, heme iron supplements (11 mg 3 times daily) were shown to have similar efficacy to IV iron sucrose (200 mg monthly) in maintaining hemoglobin in non-dialysis chronic kidney disease patients, with no differences in adverse events over six months.(36) In another open prospective study, heme iron supplements (21 mg or 36 mg per day) were able to replace the use of IV iron and not only sustain response to rHuEPO in the majority of hemodialysis patients, but was able to significantly increase rHuEPO efficiency (p=0.04).(37) A similar trial showed similar achievement in maintaining rHuEPO response while having a reduction in GI side effects and significant reduction of gas (p=0.3) suggesting better patient compliance.(38) These studies indicate that oral heme iron

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FIGURE 4

April 2017

Proposed absorption mechanism for heme iron.(13,17,27,28)

Though it is well known that heme iron is absorbed more efficiently than nonheme iron, the mechanism by which this happens is still poorly understood. The depicted pathway is an up to date summary of the hypothesis for heme iron absorption.

Heme iron is ingetsed and goes into the duodenum

Heme iron is uptaken into the enterocyte by receptor mediated endocytosis (likely via HCP1) at the luminal brush border membrane

Heme iron is catabolized into non-heme iron and biliverdin at the endoplasmic reticulum by heme-oxygenase 1

Intact heme could possibly be transported directly across basolateral membrane by FLVCR into circulation where it binds to hemopexin

Non-heme iron possibly transported to cytoplasm via DMT1

Non-heme iron in the cytoplasm follows the non-heme iron release pathway into circulation to bind onto transferrin

supplementation is a viable, efficient and safe iron delivery method for treatment of iron deficiency anemia equivalent to the traditional gold standard.

A drawback of bovine heme iron is its animal protein origin, making it unsuitable for patients with dietary restrictions to animal products. Furthermore, a secondary drawback to bovine heme iron is it’s cost. Current retail value of bovine heme iron is approximately $1.01 per tablet at Canadian pharmacies such as Shoppers Drug Mart®, making it the most expensive oral iron tablet formulation on the market. Therefore, pharmacists must consider the patient’s own financial budget during product selection.

PARENTERAL IRON

Parenteral iron is typically appropriate for patients who are unable to tolerate gastrointestinal side effects of oral iron supplementation, or where oral iron

iron is still the mainstay of iron replacement therapy for patients with chronic kidney disease undergoing dialysis or conditions that result in iron malabsorption.(3,16) Doses vary between preparations but typically range between 100 mg to 510 mg, once to thrice per week.(15) INDIVIDUALIZING TREATMENT

Heme iron is in the enterocyte

Heme iron is engulfed into endosomes or lysosomes within 2-3 hours of heme uptake and subsequently catabolized into non-heme iron and biliverdin by heme-oxygenase 2

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therapy is contraindicated or ineffective.

IV iron may also be given to individuals with severe and active blood loss, gastric surgery, coexisting inflammatory states that interfere with iron homeostasis, or malabsorption conditions like Celiac disease which may limit absorption of oral iron.(3) There are currently several different forms of parenteral iron on the market including ferumoxytol, iron dextran, iron sucrose and sodium ferric.(15) The main benefit of parenteral iron is the avoidance of the need for GI absorption, making it 100% bioavailable. IV iron allows administration of nearly full replacement doses in one or two infusions rather than over the course of several months with oral iron.(30) Drawbacks of parenteral iron include the possibility for anaphylactic reactions, although this risk is exceedingly low. IV iron is also significantly more expensive than oral iron.(15) Though not commonly used, parenteral

As noted earlier, the duration of iron replacement therapy typically continues for three months after the patient has reached a normal hemoglobin count. A new study, however, done by Alleyne et al. suggests that patients who are intolerant to the traditional therapy of 105-200 mg of iron per day in divided doses should follow a cycled therapeutic regimen.(9) The premise of cycled dosing is based on the concept that decreasing daily iron doses requires an increase in the duration of therapy. Since iron intolerance is mostly dose related, cycled therapy would allow patients to choose a smaller daily dose at the expense of increasing their duration of therapy with a set total dose of iron as the target.(9) The research suggests that patients should aim to complete their iron replacement therapy in cycles of 500 mg of absorbed iron. Assuming a 10% absorption for iron salts, a total dose of 5000 mg of elemental iron will yield 500 mg of absorbed iron, which is enough to replenish iron stores in moderately deficient patients.(9) By this method, patients who are intolerant can take a smaller dose of daily iron (e.g. 50 mg of iron per day, yielding 5 mg of absorbed iron) for a longer duration of therapy. By following the above exampled regimen, the patient would reach target hemoglobin levels by approximately 100 days of therapy.

By using this dosing method, patients are not only more involved with their care, but can calculate the theoretical amount they need to take of other iron preparations. Take, for instance, the example of heme iron. With the absorption of heme iron ranging between 15-35%, assuming an absorption rate of 25%, the manufacture recommended dosing of three 11 mg tablets per day will yield 8.25 mg of iron per day. Following this regimen, a moderately iron deficient patient will need to take three tablets per day for only 61 days to replenish their iron stores completely.

An additional benefit to dosing with heme iron would be less variation secondary to dietary practices. Of course, one limitation to this dosing “rule” is that the conclusions are tentative and extrapolated based on studies done with iron salts. Nevertheless,

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with no clear “rule of thumb” for the dosing of heme iron, this estimation will have to suffice until further studies are done in the field.

Role of the Pharmacist In a community setting, pharmacists have the unique role of educator and clinical advisor. With respect to iron deficiency anemia, a vast majority of cases that are presented to the pharmacy involve patients who have already been diagnosed with iron deficiency and are looking for a product to use.

In this scenario, pharmacists should understand the advantages and disadvantages of each form of iron therapy before selecting an appropriate product for the patient. In brief, treatment with an iron salt is cost effective, accessible and well documented in literature pertaining to efficacy, dosing, and adverse effects. Conversely, disadvantages of iron salts include gastric intolerance resulting in poor compliance, which incidentally is the number one reason for poor treatment response.(21,20) Pertaining to other oral iron preparations, advantages of the polysaccharide iron complex formulation include decreased adverse drug reactions and pill burden whereas its disadvantage lies in its release profi le which compromises iron absorption in the duodenum. In addition, other than being the only available oral iron preparation that is comparable to IV iron therapy, bovine heme iron offers both a more agreeable drug safety and absorption profi le in comparison to iron salts. Drawbacks of treatment with bovine heme iron would include its high cost and incompatibility in patients with dietary restrictions to beef.

Concerning parenteral iron, the most attractive benefit is its 100% bioavailability resulting in the replenished iron stores within one to two doses. However, the high cost and potential for anaphylaxis often warrants serious consideration of the risks versus benefits of using parenteral iron therapy.

Using knowledge of all the above advantages and disadvantages, it is the pharmacist’s role to use his or her professional judgment when selecting iron replacement therapy for the patient.

To do so, the pharmacist must assess the patient for any existing or previous iron use, paying particular interest to any adverse reactions that might have occurred. Furthermore, after product selection and counseling on appropriate

use, pharmacists should make use of follow-ups to determine the existence of adverse drug reactions secondary to the initiation of the chosen drug therapy.

Pertaining to nutrition, pharmacists should be promoting adequate iron intake in the infant and pregnant population. For mothers that choose to use formula, pharmacists should advise against using cow milk and instead advise caregivers to choose age appropriate and iron fortified formula. For pregnant women, pharmacists should be knowledgeable about nutritional iron needs during pregnancy and suggest frequent iron monitoring followed by the appropriate supplementation.

Finally, pharmacists are often approached daily with queries about chronic fatigue or “low energy”. It is important that pharmacists recognize signs and symptoms of iron deficiency anemia such as fatigue and refer appropriately.

Conclusion Though iron deficiency anemia is common, it is in no way a silent bystander.

Due to the ease of treatment, it is easy for the healthcare practitioner to overlook its significant impact on both quality and duration of life. At present, there are several available treatment options on the market, making it the pharmacist’s role to educate and help choose the most appropriate treatment option for each patient’s individual need.

References

1. Rang HP, Dale MM, Ritter JM, Flower RJ, Henderson G. Haemopoietic system and treatment of anaemia. In: Rang and Dale’s Pharmacology. 2012. p. 309–17.

2. Schrier SL, Mentzer WC, Tirnauer JS. Causes and diagnosis of iron deficiency anemia in the adult [Internet]. UpToDate.

2015 [cited 2016 Apr 20]. Available from: http://www. uptodate.com.myaccess.library.utoronto.ca/contents/ causes-and-diagnosis-of-iron-deficiency-anemia-in-theadult?source=search_result&search=iron+deficiency+ane mia&selectedTitle=1~150 3. Cook K, Inneck BA, Lyons WL. Anemias. In: Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors.

Pharmacotherapy: A Pathophysiologic Approach. 8th ed. 2011.

4. Gordon N. Iron deficiency and the intellect. Brain Dev. 2003;25:3–8.

5. Harris RJ. Iron deficiency anaemia : does it really matter?

Paediatr Child Health (Oxford). 2007;17(4):143–6.

6. Lozoff B, Clark KM, Jing Y, Armony-Sivan R, Angelilli ML, Jacobson SW. Dose-Response Relationships between Iron Deficiency with or without Anemia and Infant Social-Emotional Behavior. J Pediatr. 2008;152(5):696–702.

7. Lozoff B, Georgieff MK. Iron Deficiency and Brain Development.

Semin Pediatr Neurol. 2006;158–65.

8. Peyrin-biroulet L, Williet N, Cacoub P. Guidelines on the diagnosis and treatment of iron deficiency across indications: a systematic review. Am J Clin Nutr. 2015;102:1585–94.

9. Alleyne M, Horne MK, Miller JL. Individualized Treatment for Iron-deficiency Anemia in Adults. Am J Med. 2008;121:943–8.

10. Heidelbaugh JJ. Proton pump inhibitors and risk of vitamin and mineral deficiency: evidence and clinical implications. Ther Adv drug Saf. 2013;4(3):125–33.

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11. Guidelines and Protocols Advisory Committee. Iron Deficiency - Investigation and Management. 2010.

12. Nam T, Shim JY, Kim B, Rah SY, Park K, Kim S-Y, et al. Clinical Study on the Iron Absorption from Heme-Iron Polypeptide and Nonheme-Iron *. Nutr Sci. 2006;9(4):295–300.

13. Waldvogel-abramowski S, Waeber G, Gassner C, Buser A, Frey BM, Favrat B, et al. Physiology of Iron Metabolism. Transfus Med Hemotherapy. 2014;41:213–21.

14. Shafir T, Angulo-Barroso R, Calatroni A, Jimenez E, Lozoff B. Effects of iron deficiency in infancy on patterns of motor development over time. Hum Mov Sci. 2006;25:821–38.

15. Lim W. Common Anemias. In: Association CP, editor.

Therapeutic Choices. 7th ed. Ottawa; 2014.

16. Cook JD. Diagnosis and management of iron-deficiency anaemia. Best Pract Res Clin Haemotology. 2005;18(2):319–32.

17. West AR, Oates PS. Mechanisms of heme iron absorption : Current questions and controversies. World J Gastroenterol.

2008;14(26):4101–10.

18. Thurnham DI, Mccabe LD, Haldar S, Wieringa FT, NorthropClewes CA, Mccabe GP. Adjusting plasma ferritin concentrations to remove the effects of subclinical inflammation in the assessment of iron deficiency: a meta-analysis. Am J Clin Nutr.

2010;92:546–55.

19. Nielsen OH, Coskun M, Weiss G. Iron replacement therapy: do we need new guidelines? Curr Opin Gastroenterol.

2016;32(2):128–35.

20. Pettit K, Rowley J, Brown N. Iron deficiency. Paediatr Child Health (Oxford). Elsevier Ltd; 2011;21(8):339–43.

21. Camaschella C. Iron-Deficiency Anemia. N Engl J Med. 2015;372(19):1832–43.

22. Canadian Pharmacist’s Association. Iron Preparations: Oral.

CPhA Monogr. 2011; 23. National Institutes of Health - Office of Dietary Supplements.

Iron: Dietary Supplement Fact Sheet [Internet]. U.S. Department of Health and Human Services. 2016 [cited 2016 Mar 25]. Available from: https://ods.od.nih.gov/factsheets/ Iron-HealthProfessional/#en17 24. Hurrell R, Egli I. Iron bioavailability and dietary reference values. Am J Clin Nutr. 2010;91:1461–7.

25. Rang HP, Dale MM, Ritter JM, Flower RJ, Henderson G. Hemostasis and Thrombosis. In: Hyde M, editor. Rang and Dale’s Pharmacology. 7th ed. London; 2012. p. 294–308.

26. Zimmermann MB, Hurrell RF. Nutritional iron deficiency.

Lancet. 2007;370:511–20.

27. Shayeghi M, Latunde-dada GO, Oakhill JS, Laftah AH, Takeuchi K, Halliday N, et al. Identification of an Intestinal Heme Transporter. Cell. 2005;122:789–801.

28. Olivares M, Figueroa C, Pizarro F. Acute Copper and Ascorbic Acid Supplementation Inhibits Non-heme Iron Absorption in Humans. Biol Trace Elem Res. 2015;1–5.

29. Short M, Domagalski J. Iron deficiency anemia Evaluation and management. Am Fam Physician. 2013;87(2):98–104.

30. Killip S, Bennett JM, Chambers MD. Iron Deficiency Anemia.

Am Fam Physician. 2007;75(5):671–8.

31. Coe EM, Bowen LH, Speer JA, Bereman RD. Comparison of Polysaccharide Iron Complexes Used as Iron Supplements.

292(1095):287–92.

32. Coe EM, Bowen LH, Speer JA, Sayers DE, Bereman RD. The Recharacterization of a Polysaccharide Iron Complex (Niferex).

278(1995):269–78.

33. Ortiz R, Toblli JE, Romero JD, Monterrosa B, Frer C, Macagno E, et al. Efficacy and safety of oral iron ( III ) polymaltose complex versus ferrous sulfate in pregnant women with iron-deficiency anemia : a multicenter , randomized , controlled study Efficacy and safety of oral iron ( III ) polymaltose complex versus ferrous s. J Matern Neonatal Med ISSN. 2011;24(11):1347–52.

34. Seligman PA, Moore GM, Schleicher RB. Clinical Studies of HIP: An Oral Heme-Iron Product. Nutr Res. 2000;20(9):1279–86.

35. Frykman E, Bystrom M, Jansson U, Edberg A, Hansen T. Side effects of iron supplements in blood donors: superior tolerance of heme iron. J Labratory Clin Med. 1994;123(4):561–4.

36. Nagaraju SP, Cohn A, Akbari A, Davis JL, Zimmerman DL. Heme iron polypeptide for the treatment of iron deficiency anemia in non-dialysis chronic kidney disease patients: a randomized controlled trial. BMC Nephrol. 2013;14(1):64.

37. Nissenson AR, Berns JS, Sakiewicz P, Ghaddar S, Moore GM, Schleicher RB, et al. Clinical Evaluation of Heme Iron Polypeptide: Sustaining a Response to rHuEPO in Hemodialysis Patients. Am J Kidney Dis. 2003;42(2):325–30.

38. Ghaddar S, Moor GM. Evaluation of the Ability of Heme Iron Polypeptide to Sustain Response to rHuEPO in Peritoneal Dialysis Patients: A Prospective Clinical Evaluation. 2003.

ce

Continuing Education L E S S O N

Iron Deficiency Anemia

CE8

Questions

April 2017

Answer online at eCortex.ca

Answer online at eCortex.ca. Quick Search CCCEP #1065-2016-1723-I-P

1. Which of the following statements is false: a) Blood loss is a significant contributor for iron deficiency anemia b) Iron deficiency anemia is commonly a congenital disease c) Vegetarians are at high risk of iron deficiency anemia d) Iron deficiency anemia is prevalent among women of child bearing age e) Growing children and at increased risk of iron deficiency anemia 2. Choose the statement that ranks diagnostic for iron deficiency from least to most specific. a) Ferritin, MCV, hemoglobin count b) MCV, ferritin, hemoglobin count c) Hemoglobin count, ferritin MCV d) Hemoglobin count, MCV, ferritin e) MCV, hemoglobin count, ferritin 3. Which of the following is NOT a sign or symptom of anemia? a) Decreased blood pressure

b) Fatigue c) Decreased immunity d) Koilonychia e) Pallor 4. Choose the statement that ranks the percentage of elemental iron in iron salts from highest to lowest a) Ferrous fumarate, dried ferrous sulfate, ferrous sulfate, ferrous gluconate b) Dried ferrous sulfate, ferrous gluconate, ferrous sulfate, ferrous fumarate c) Ferrous fumarate, ferrous sulfate, dried ferrous sulfate, ferrous gluconate d) Ferrous gluconate, ferrous fumarate, ferrous sulfate, dried ferrous sulfate e) Ferrous sulfate, ferrous gluconate, ferrous fumarate, dried ferrous sulfate 5. In studies on hemodialysis patients comparing heme iron supplementation to IV iron, researchers found: a) Heme iron was as equally effective as IV iron in supporting rHuEPO response b) IV iron was significantly superior to heme iron in rHuEPO response c) Neither supplementation

was effective in rHuEPO response d) Iron salts were superior to both heme and IV iron supplementation 6. ID is a 33 year old female who is asking for an over-thecounter product for fatigue.

You learn that ID has been experiencing fatigue on and off for the past 6 months and has difficulty concentrating at work.

In addition, ID has shared that she typically feels fatigued during her menstrual period.

Which of the following would you recommend? a) More sleep and counsel her on sleep hygiene b) An iron tablet as she could possibly be low on iron c) A b-complex OTC item advertised for “stress” d) Refer her to her family physician to get a full blood test e) Tell her that fatigue is not a real medical problem and there is nothing you can offer 7. A few weeks later, ID comes to your pharmacy with a prescription for an “iron supplement.” ID explains that she was diagnosed with iron deficiency anemia and that her physician

told her to “ask the pharmacist for an appropriate iron supplement.” Which of the following would you recommend for ID? a) Iron salts b) Polysaccharide iron complex c) Heme iron d) Parenteral iron e) None of the above; you need to see her hemoglobin count before making a clinical decision 8. ID is started on ferrous sulfate, 1 tablet TID. You follow up with her in 2 weeks and discover she has been experiencing gastric upset since starting the tablets.

Upon further investigation, you learn that she has already tried taking her iron tablets at meals with no alleviation of symptoms. You also learn that ID is has no dietary or monetary restrictions. What would you recommend? a) Stop the iron salts, start on a polysaccharide iron complex b) Stop the iron salts, start on a heme iron preparation c) Switch to a different iron salt d) Stop the iron salts, start on parenteral iron e) Stop the iron salts and seek the physician’s advice

Answer online at eCortex.ca

Faculty: Iron Deficiency Anemia ABOUT THE AUTHORS

Victor Wong is pharmacist-owner of two Shoppers Drug Mart pharmacies, as well as a teaching associate at the University of Toronto’s Faculty of Pharmacy. He is a Chief Examiner at the Pharmacy Examining Board of Canada.

Lucy Wang received her Master of Pharmacy degree in the UK and has an extensive research background in the field of nanotechnology. She is currently Ontario licenced pharmacist practising at Shoppers Drug Mart.

REVIEWERS All lessons are reviewed by pharmacists for accuracy, currency and relevance to current pharmacy practice.

This lesson is valid until April 10, 2018.

Information about iron deficiency anemia may change over the course of this time.

Readers are responsible for determining the most current aspects of this topic.

CONTINUING EDUCATION PROJECT MANAGER Rosalind Stefanac, Toronto, Ont.

canadianhealthcarenetwork.ca. No part of this CE lesson may be reproduced, in whole or in part, without the written permission of the publisher. ©2017

CE DESIGNER Shawn Samson, TwoCreative.ca This lesson is published by EnsembleIQ, One Mount Pleasant Rd, 7th floor, Toronto, ON M4Y 2Y5. Editorial office: Tel: 416-764-3926, Fax: 416-7643931. CE queries: Tel: 416-764-3879, Fax: 416-764-3937, email education@

Answer online at eCortex.ca Over 100 FREE CCCEP-approved CE lessons online.

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OTC REPORT

MARKET

Pharmacists’ advice steers OTC market

By Sonya Felix

Canada’s OTC (over-the-counter) category continues to chug along with moderate sales growth for many major product groupings. Total OTC dollar sales, including adult mouth care, analgesics, cough, cold and allergy remedies, dermatologicals, digestive remedies, emergency contraception, eye care, NRT smoking cessation aids, sleep aids and wound care rose 2.6% in 2016 to reach nearly C$3.2 billion, according to Euromonitor International.

Sales performance was positive for analgesics (up 2.9%), cough, cold and allergies (up 2%), dermatologicals (up 3.1%), digestive remedies (up 2.3%), eye care (up 2.2%) and sleep aids (up 5.7%) in 2016.

But Euromonitor forecasts stagnant growth ahead for both OTC and vitamins and dietary supplements in Canada. Any gains going forward will likely come from Rx-to-OTC switches, new ingredient approvals, new product launches and growing awareness of self-care.

Year after year, the aging population gets much of the credit for OTC growth trends and that insight hasn’t changed. As a result of a low birth rate and longevity, seniors make up a bigger segment of the population and that reality will continue to drive demand and product development to help older folk manage aches and pains, dry eyes, sensitive skin, stomach upsets and sleep problems.

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April 2017 [Vol.4 No.3]

Minor ailment programs, now in many provinces, is a more recent development that could potentially have an impact on OTC sales if pharmacists recommend prescriptions over non-prescription treatments. Phil Emberley, director of professional affairs at the Canadian Pharmacists Association (CPhA), suggests that minor ailment prescribing could drive OTC sales down slightly. But, he adds, the impact isn’t measured well.

“As pharmacists, we need to do what’s right for the patient,” Emberley says. “It is not up to the pharmacist to choose whether a patient gets an OTC or a prescription medicine. Rather, that’s based on the assessment of the patient— just because you can prescribe for a minor ailment doesn’t prevent you from counselling on OTCs. It is very important to help patients choose the most effective and safest option.”

With the increasing breadth of OTC offerings on drugstore shelves, pharmacist counselling is more important than ever to help patients cut through the noise and confusion to choose a product that is safe and effective. To assist pharmacists in counselling on non-prescription products, CPhA offers the Compendium of Products for Minor Ailments and the Compendium of Therapeutics for Minor Ailments in print and online formats.

As pharmacists, we need to do what’s right for the patient... it is very important to help patients choose the most effective and safest option.

In this year’s OTC issue: P. 37

OTC Market Report

P. 39-43

Category reports

P. 44-45

Counselling & Recommendations Survey

P. 48-64

Most-recommended brands

pharmacy practice+

OTC

MARKET REPORT

A flurry of switches, new regulations

By Sonya Felix

W

hile many major OTC categories have seen scant innovation in recent years—other than numerous “me too” line extensions and combination products— Rx-to-OTC switches is favoured to add excitement and boost sales going forward. In 2016, three switches made it to Canadian drugstore shelves: fluticasone propionate (Flonase Allergy Relief), esomperazole (Nexium) and a 12-hour formula of ibuprofen (Advil). Although it is too early to assess the effect on the market, the new non-prescription drugs give consumers over-the-counter options for treating allergic rhinitis, GERD and pain.

Gerry Harrington, vice-president of policy and regulatory affairs at Consumer Health Products (CHP) Canada, expects more switches to come based on what’s happening elsewhere. But he laments the slow

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[Vol.4 No.3] April 2017

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MARKET REPORT

process of getting switches to market in this country. Once Health Canada approves a switch, it passes through NAPRA (National Association of Pharmacy Regulatory Authorities) for scheduling before hitting retail in most provinces.

“Canada’s Rx-to-OTC switches lag behind countries like the U.S., the U.K. and Australia by six to seven years,” says Harrington. “For example, the first OTC proton pump inhibitor (PPI) was approved in Canada two years ago but it’s been available in the U.S. since 2003. Oral contraceptives are now available OTC in some U.S. states. Canada hasn’t switched any prescription migraine treatments to OTC yet although a lot of other markets have. But I think we’ll see some interesting switches going forward given our ongoing primary care challenges.”

In the U.S., recent switches include Differin Gel 0.1% for acne— the first retinoid approved for over-the-counter use. In 2016, the FDA also approved OTC hearing aids for sale without consultation of a credentialed dispenser. Most of the Rx-to-OTC switches in the U.S. over recent years have been for allergy treatments. The FDA approved the switch of Flonase Allergy Relief, to OTC in 2014 and a line extension, Flonase Sensimist Allergy Relief got the green light in 2016. Approvals for OTC Xyzal Allergy 24HR (levocetirizine dihydrochloride) in tablets were granted in early 2017.

Reverse switch on way for codeine Meanwhile back at home, Health Canada is planning an unusual reverse switch from OTC to prescription status for low-dose codeine products sold behind the pharmacy counter in most provinces. The change is meant to restrict access to low-dose codeine products in light 42

April 2017 [Vol.4 No.3]

Regulatory changes

of the current opioid crisis sweeping the country.

For the most part, however, switches are intended to increase consumer access to medications.

A report from the Conference Board of Canada on the impact of switching prescription drugs to OTC was released in March 2017. The research evaluates the economic value of Rx-to-OTC switches for three separate drug classes: proton pump inhibitors, oral contraceptives and erectile dysfunction drugs. Just for these three drug classes, the annual savings are estimated at $1 billion.

The report notes the positive and negative impacts that Rx-toOTC switches have on pharmacies—OTC sales may go up while revenue is missing from drug markups and dispensing fees.

Switches also increase pharmacists’ role in providing OTC medications for a broader range of conditions and heighten the need for thorough assessments and counselling to ensure patients can safely self-treat. All of this intervention requires more time and resources.

A second Conference Board report, focused on barriers to Rxto-OTC switching, is coming later this spring. The report will include recommendations for key stakeholders including government, manufacturers, pharmacists/pharmacy, researchers and all Canadians.

Several new regulatory initiatives are aimed at improving the safety and efficacy of OTC products on the Canadian market. Coming soon is the new standardized drug fact table that’s intended to make it easier for consumers to understand directions of use, ingredients, warnings, where to call for information and how to report adverse drug reactions. All new products must display the facts table by June 2017 and existing products must comply by June 30, 2021.

In September 2016, Health Canada announced updated labelling standards for OTC acetaminophen in response to a review of the risk of acetaminophen and liver damage.

All new acetaminophen products on the Canadian market must have updated product labels within 18 months. Packages of acetaminophen must display clearer instructions that emphasize the importance of using the lowest effective maximum (4,000 mg for adults) in a 24 hour period. To address the issue of multi-ingredient formulations, the words “contain acetaminophen” must appear in bold, red text in the top right corner of packaging when a product includes acetaminophen.

This spring, Health Canada will conduct a second round of consultations on its new proposal to regulate OTC medicines, natural health products and cosmetics. “CHP Canada welcomes the stem to stern overhaul of the self-care regulations,” says Harrington. “We’ll see single regulations for all self-care products, based on risk, in a consistent framework.

The regulators are very focused on not removing consumers’ choices but propose a way to distinguish whether a product’s claims are based on scientific evidence versus traditional products. We need to do this but it is still about three years away.”

pharmacy practice+

OTC

MARKET REPORT

All category reports written by Sonya Felix

Analgesics make gains amidst safety warnings

RECOMMENDATIONS PER MONTH: Adult oral analgesic ........................ 30 Adult toothache .................................5 Children’s oral analgesic................ 14 Heat analgesic (patch/wrap/rub) ..5 ANALGESICS

$1,014M +2.9%

Topical analgesic (overall) ............. 16 Source: Pharmacy Practice+ 2016 Survey on OTC Counselling & Recommendations.

Euromonitor Passport, 2016 full year sales.

Analgesics—which includes both systemic and topical pain relievers—is a massive OTC category in Canada where most consumers are used to treating minor aches and pains over-the-counter. Euromonitor International reports dollar sales of analgesics rose nearly 3% to reach over $1 billion last year, a sum almost equal to half of the total dollar value of the OTC category in 2016.

This huge category is dominated by three top brand owners: Wyeth Consumer Healthcare (30% share), McNeil Consumer Healthcare (21% share) and Bayer (15% share). Product development in this highly competitive category where brands tend to follow each other’s lead has flooded the shelves with line extensions. Tylenol, for example, recently introduced liquid pharmacy practice+

gel caps, a format Advil has offered for years. Meanwhile, like Advil and Tylenol, Aleve now has a nighttime formula said to promote sleep and control pain for 12 hours. Advil is now available in a 12-hour format, as well.

Safety concerns, however, could potentially limit growth in some analgesic segments. For example, Health Canada issued new labelling standards to address the risk of liver injury from misuse of acetaminophen. Beginning in 2018, all acetaminophen products will display clearer instructions and maximum dosage. It will be interesting to see if highlighting the potential danger of acetaminophen will have an impact on OTC sales.

Health Canada also advises consumers that certain OTC topical pain relievers containing menthol may cause

mild irritation or inflammation, as well as more serious side effects such as skin burns, pain, blistering or other severe skin damage. An updated labelling standard for all menthol-containing topical pain relievers will be published later this year to better inform consumers of the risks.

Analysts from Euromonitor International suggest that, despite strong demand for analgesics, the impact from prescription pain killers and consumers’ aversion to the side effects of standard OTC products is likely to negatively affect sales in the short and medium term.

For pharmacists’ most recommended brands of children’s oral analgesic, heat analgesic (patch/wrap/rub) and topical analgesic, turn to pages 56, 61 and 67.

[Vol.4 No.3] April 2017

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Cough/cold & allergy sales stall Sales in OTC cough and cold are often cyclical depending on the level of cold and flu activity. Last year’s flu season got a late start, running from February to May in 2016, but a new virus hit again with a vengeance in the fall, causing misery all across the country. With so much coughing, nasal congestion and the accompanying aches and pains, it’s no surprise that consumers flocked to the OTC aisles to seek relief of symptoms.

Euromonitor International, which tracks cough, cold and allergy (hay fever) together, reports category sales rose 2% in 2016, to reach nearly C$867 million. But the category is forecast to follow a slow growth trajectory, reaching only C$871 million by 2021. Euromonitor analysts suggest no significant driver is likely to lead to any pronounced growth and performance is expected to stay in line with population growth of 1% annually in the medium and long term.

Cough remedies grew slightly owing to a mixed performance, says Andrew Bishop at Nicholas Hall’s Insight North America.

“Buckley’s continued to perform well, overtaking its competitors Benylin and Robitussin, both of which declined. Smaller brands like

homeopathic Stodal (Boiron) also enjoyed growth. Systemic cold & flu remedies declined slightly despite the strong performance of No.1 brand Tylenol Cold (J&J), which generates a quarter of sales.

No. 2 brand Advil Cold & Sinus (Pfizer) did not perform as well.”

As for allergy relief, Bishop notes that sales were driven by the strong growth of Nasacort Allergy 24HR. “Store brands are particularly strong, accounting for more than a quarter of sales and outperforming branded entries. J&J fields the two leading brands, Reactine and Benadryl, while Bayer markets No. 3 and No. 4 brands Claritin and Aerius. Reactine was supported by an innovative smart phone app that has been popular with consumers.”

The arrival of OTC Flonase Allergy Relief (GSK) in Canada for treating symptoms associated with allergic rhinitis should help to expand the market. In the U.S., several Rx-to-OTC switches for treating allergic rhinitis followed the launch of OTC fluticasone propionate.

For pharmacists’ most recommended brands of adult antihistamine, children’s antihistamine and natural cold remedy, turn to pages 52, 56 and 64.

Slow growth for eye care despite array of products Products for treating dry eye and allergic symptoms gained 2.2% in dollar sales to reach $123 million in 2016, according to data from Euromonitor International. But the retail analyst forecasts flat growth in Canada going forward to 2021.

Polysporin, a well-known first aid brand, remains a major driver in the Canadian OTC eye care market. The J&J brand, targeted at treating pink eye, grew by 20% to take 15% share and third place in the category, reports Nicholas Hall’s OTC Insights. Dry eye treatments lead the overall category with the top brand, Novartis’ Alcon, growing dollar sales by 15% to garner 33% share. With 17% share, Allergan’s Refresh was in number two spot but saw only modest 4% growth.

Other eye care brands had mixed performances last year. J&J’s Visine, available in several SKUs aimed at dry eye, red eye, allergy and multi-symptom relief, lost 7%. Meanwhile Nicholas Hall reports 3% growth for Clear Eyes from Prestige Brands.

For pharmacists’ most recommended brands of dry eye drops, turn to page 60.

RECOMMENDATIONS PER MONTH: Dry eye drops .................................. 11

RECOMMENDATIONS PER MONTH: Adult antihistamine ........................ 21 Adult cold preparation ................... 23 Adult sinus remedy......................... 17 Children’s antihistamine ................ 11 Children’s cough and cold ............. 13 Nasal decongestant....................... 12 Natural cold remedy..........................5 Source: Pharmacy Practice+ 2016 Survey on OTC Counselling & Recommendations.

44

April 2017 [Vol.4 No.3]

COUGH/COLD/ ALLERGY

$866.7M +2% Euromonitor Passport, Canadian nonprescription sales, year-end2016.

Source: Pharmacy Practice+ 2016 Survey on OTC Counselling & Recommendations.

EYE CARE SALES

$123.1M +2.2% Euromonitor Passport Canadian nonprescription sales, full year 2016.

pharmacy practice+

OTC

MARKET REPORT

Technology revolutionizes diabetes care Over one in four Canadians lives with diabetes or prediabetes, according to the Canadian Diabetes Association. But if current trends continue, the number is expected to rise to one in three by 2020. The staggeringly high incidence of the disease is projected to cost our healthcare system and economy $16 billion annually by 2020.

OTC products targeted at managing diabetes run the gamut from socks, sweeteners and nutritional meal replacements to high tech shoe insoles, glucose monitors, syringes, strips and lancets. While public and private drug plans pick up the tab for some diabetes supplies, coverage varies by jurisdiction.

Most people still pay more than $1,500 outof-pocket annually, states a report from the Canadian Diabetes Association.

Despite growing demand for OTC diabetes products, retail analysts don’t seem to track sales for diabetes care. But given the trends, it’s likely a booming category—and there is lots of innovation in response to demand and evolving technology. New developments in the works that could improve care for people with diabetes include wearable, on-demand delivery systems for insulin; glucose monitors that get software updates like smartphones; wireless glucose monitors that can send blood sugar data to smartphones; and insulin pens that track when the last dose was given; subscriptionbased blood glucose monitoring programs; and Bluetooth-capable glucose meters with apps that log data, track diet and exercise and create reports.

For pharmacists’ most recommended brands of blood glucose monitor, turn to page 55.

RECOMMENDATIONS PER MONTH: Blood glucose monitors....................7 Source: Pharmacy Practice+ 2016 Survey on OTC Counselling & Recommendations.

pharmacy practice+

SLEEP AIDS

$97.4M +5.7% Euromonitor Passport, 2016 Canadian nonprescription sales data.

Sleep aids still buzzing along In the medicated segment, Worth about $97M in Canada, sales of Sleep-Eze (Prestige the sleep aids category continues Brands) grew by 8%, Nytol (also to make strong gains with a 6% Prestige Brands) jumped 25%, increase in dollars during 2016, reports Euromonitor International. ZzzQuil grew by 3%, and Unison (Paladin for Sanofi) shone Considering that two-thirds brilliantly with a 45% gain, ac(67%) of Canadians wish they cording to Nicholas Hall’s OTC got more sleep, according to the Insights. Sales of private labels 2016 Canadian Sleep Review, the dropped 20%. potential market for sleep aids is Other OTC products, howhuge. But Nicholas Hall’s OTC ever, compete for sleep troubled Insights shows Canadians spent consumers’ dollars. Leading only $1.06 per capita on sleep analgesic brands now offer nightaids and sedatives last year. time versions to aid sleep and Strong competition among the natural health segment has a medicated entries, heightened by range of sleep inducing products, the launch of P&G’s ZzzQuill in including melatonin and valerian Canada, helped add life to the in various formats. category. But while medicated sleep aids gained, the non-medicated Breathe Right—the top brand in the category—lost RECOMMENDATIONS PER MONTH: sales and market share despite line extensions including a smartphone app to analyze snoring patterns.

Sleep aid...............................................8 Source: Pharmacy Practice+ 2016 Survey on OTC Counselling & Recommendations.

[Vol.4 No.3] April 2017

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MARKET REPORT

New options in dermatologicals and sun care Sales of topical products used to alleviate symptoms or treat skin or hair ailments rose 3% to total $403 million in 2016, according to Euromonitor International. However, sales in this broad category, which includes everything from antifungals and hair loss treatments to products for treating diaper rash, cold sores and hair loss, is expected to remain flat over the next few years.

Health Canada’s recent approval of OTC hydrocortisone cream 1.0% for topical could have a positive impact on the category. The stronger formula is now showing up on drugstore shelves under brands such as Polysporin, which offers a 1% hydrocortisone anti-itch creams for treating eczema and allergic reactions. Taking a different approach, Glysomed Eczema Control adds 2% colloidal oatmeal to the classic Glysomed formula.

Sales of acne remedies, a $58 million category in Canada, also grew 3% last year, reports Nicholas Hall’s OTC Insight. While much innovation in acne care is focused on the prescription side of the market, last July the FDA approved an Rx-to-OTC switch for Differin Gel 0.1%. Time will tell if a similar switch will occur in Canada.

Meanwhile, retail analysts are forecasting slow growth for the sun care market, which includes after sun, self-tanning and sunscreen products. Sun protection is the biggest skincare segment, driven primarily by concern about overexposure to the sun, and innovation is focused on multi-function products, convenient formats such as wipes and sticks, and higher SPF formulas. Last year, La Roche-Posay introduced a digital element to sun care with My UV Patch, a wearable product that connects to a mobile app to show the wearer’s sun exposure.

DERMATOLOGICALS

$403.2 M +3% Euromonitor Passport, 2016 Canadian OTC sales data

RECOMMENDATIONS PER MONTH: Acne treatment ..................................4 Dermatological skin care .................7 Diaper rash treatment ......................4 Eczema treatment.......................... 10 Lip care .................................................4 Moisturizer/dry skin product ....... 10

For pharmacists’ most recommended brands of acne treatment, dermatological skin care, diaper rash treatment, lip care, moisturizer/dry skin product, scar/stretch mark therapy and sunscreen, turn to pages 52, 59, 64 , 66 and 67..

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April 2017 [Vol.4 No.3]

Scar/stretch mark therapy .............2 Sunscreen ............................................7 Source: Pharmacy Practice+ 2016 Survey on OTC Counselling & Recommendations.

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OTC

MARKET REPORT

Lots of competitive activity in upset stomach remedies UPSET STOMACH/ DIGESTIVE REMEDIES

$399.7M +2% Euromonitor Passport, 2016 Canadian sales data.

RECOMMENDATIONS PER MONTH: Aging consumers, consumption of unhealthy processed foods and beverages, and busy lifestyles all contribute to growing demand for upset stomach remedies, an OTC category that includes products for diarrhea, constipation, motion sickness, and indigestion and heartburn. Euromonitor International data pegs sales of digestive remedies at nearly $400 million in Canada last year, a 2.3% increase over 2015.

Nicholas Hall’s OTC Insights breaks down the segments by brand performance and shows significant give and take in market shares. The laxative category, worth $109 million, jumped 5% in dollars. But top brand Metamucil actually lost 1% despite introducing snack bars to its lineup. Meanwhile, RestoraLAX, the number three-selling brand, led overall growth with a 23% increase in sales. Senokot and Pico-Salax each grew 3% during the 12 months to September 2016.

Antidiarrheals climbed 4% to $42 million, driven primarily by growth in private labels and Pedialyte ORT (Abbott), which went up 5%. Immodium, the category leader, had flat sales and lost market share.

During the same period, sales of antacids and antiflatulents rose 3% to $116 million. “Three antacid brands—Gaviscon (Prestige Brands), J&J’s Zantac and Tums (GSK)—compete closely, creating a stifling effect on sales,” says Andrew Bishop at Nicholas Hall’s Insight North America. “Together with [private label brands] they account for 90% of sales. Zantac [the market leader] was outperformed by its competitors.”

It is unclear if the recent entry of Nexium, the first OTC proton-pump inhibitor since Health Canada approved esomperazole’s Rx-to-OTC switch, has yet had an impact on the digestives category.

For pharmacists’ most recommended brands of antiflatulent, antinauseant, laxative and probiotic, turn to pages 54, 63 and 66. pharmacy practice+

Antidiarreal ..........................................8 Antiflatulent .......................................4 Antinauseant ................................... 11 Laxative ............................................. 16 Probiotic ...............................................9 Source: Pharmacy Practice+ 2016 Survey on OTC Counselling & Recommendations.

ce

FREE! Approved for Answer online at ·ca www.eCortex.ca 1.0 Continuing Education CEU L E S S O N CCCEP #1065-2016-1723-I-P • Not valid for CE credits after April 10, 2018

Look for it in this issue!

Iron Deficiency Anemia

By Victor Wong, Bsc(Pharm), PharmD and Lucy Wang, MPharm

Upon successful completion of the lesson, the pharmacist will be able to do the following: 1. Understand the prevalence and etiology of iron deficiency anemia 2. Understand and apply diagnostic tools to detect iron deficiency anemia 3. Identify symptoms and risk factors for iron deficiency anemia 4. Apply evidence-based treatment options to manage iron deficiency anemia 5. Discuss the pharmacist’s role in managing anemia

Supported by an educational grant from Aralez Pharmaceuticals Inc.

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Minor ailments authority reshapes OTC counselling

By Brett Ruffell

S

askatoon’s Roderick Amaya is a big proponent of providing expanded services. So when his province unveiled its pharmacist-led minor ailments program a few years ago the Shoppers Drug Mart associate owner made sure his team was prepared to grasp the opportunity.

“I introduced it by saying you’re not a pharmacist just to check prescriptions,” he recalls telling staff. “This is where pharmacy becomes fun and we get to make a difference to patients.”

First, they identified the biggest barriers to offering the service, which reimburses pharmacies $18 when an assessment leads to a prescription. Time management would obviously be an issue. They’d also have to train pharmacists and assistants if the program was to be a success. And the biggest challenge, they concluded, would be marketing the service to patients.

Amaya found simple steps—such as leaving assessment forms at the drop-off counter—helped raise awareness with customers. He also used role plays, for two purposes: to train assistants on inviting patients to have an assessment done, and to train pharmacists on how to properly conduct those assessments.

“We made it easier for customers and ourselves to walk into that new world,” says Amaya.

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April 2017 [Vol.4 No.3]

His vision came to fruition. Amaya’s pharmacy has conducted more minor ailments assessments than any other Shoppers Drug Mart in Saskatchewan.

That said, he isn’t the only pharmacist passionate about treating self-limiting conditions, as this year’s Survey of OTC Counselling & Recommendations shows.

For the first time in the annual questionnaire’s history, Pharmacy Practice+ asked pharmacists their thoughts on their burgeoning role assessing and advising on minor, self-limiting ailments.

The results show strong enthusiasm for the growing service.

Respondents were nearly unanimous (94%) in agreeing that they’re personally enthusiastic about the opportunity to add minor ailments assessments to their practice with 66% saying that they strongly agree. Even more respondents (97%) agreed that it’s appropriate for community pharmacists to take responsibility for primary care of such conditions, with 76% strongly agreeing.

Clearly, many have done just that.

One-third (33%) of respondents answer questions related to minor, selflimiting ailments one to five times per day. Another third (31%) said they’re approached six to 10 times per day.

All this said, many (81%) agree pharmacists need more education before taking on responsibility for primary care of these conditions. More than half (43%) of those pharmacists strongly agree.

How many times per day (on average) are you approached by

9

patients who have questions related to minor, selflimiting ailments? * Katherine DeMong, a University of Saskatchewan pharmacy student, feels comfortable conducting assessments. One reason for that is that her school—like a growing number of pharmacy schools these days—includes a heavy dose of minor ailments education throughout the program. Another factor is the valuable on-the-job experience she’s gained working at Amaya’s pharmacy.

When she’s on duty there, if a patient needs to have a common ailment like a cold sore treated, the pharmacist will tap DeMong to look after it. When she’s done, the pharmacist will then check everything over and address any concerns. If she’s less experienced with the condition, she’ll observe as another pharmacist conducts the assessment.

DeMong finds the experience hugely rewarding. “I love it,” she says. “Minor ailments is an exciting avenue and will give us more opportunities.”

Amaya’s team not only trains students; they leverage each other’s strengths as well. When a pharmacist isn’t comfortpharmacy practice+

OTC able counselling around a particular minor ailment they’ll refer the patient to an eager colleague. Afterwards the team meets to debrief and share any insights.

Local doctors have been supportive of the program—or at least they haven’t complained about it. “We have a good relationship with doctors who are aware of what we can do and how we do it,” he says.

Pharmacy Practice+ found the same.

Physicians in the 2016 Survey on Counselling and Recommendations are fairly supportive of pharmacist-led minor ailments services. Seventy-seven per cent of physicians agreed that the primary care of minor, self-limiting ailments is an appropriate role for community pharmacists—23% strongly agreed.

But 81% of all physicians who responded felt that pharmacists need more training on these conditions. Half of those respondents strongly agreed.

Jeff Taylor, a pharmacy researcher from the University of Saskatchewan, has taken a more in-depth look at doctors’ views on pharmacist minor ailments programs. In general, he says they’re nervous. “They think it’s an infringement on their world,” he says.

Some conditions raise concerns Taylor says it’s important to break minor ailments research down according to the condition. For instance, he says physicians are particularly concerned

97% of pharmacists agree that responsibility for primary care of minor self-limiting ailments is an appropriate role for community pharmacists* about pharmacists handling migraines and hemorrhoids. Pharmacists, he’s found, share the exact same discomfort.

Taylor views these shared concerns positively. “That suggests we’re both healthcare professionals, and speaks to the reasonable approach pharmacists take to these conditions,” he says. “It shows we’re conservative.”

Amaya agrees pharmacists shouldn’t be afraid to refer for ailments they’re uncomfortable with—even if it’s to a pharmacist colleague. For example, assessing acne isn’t Amaya’s area of expertise, so he refers patients with the condition to another pharmacist on staff.

While most other provinces (all except for B.C., Ontario and the territories) have minor ailments programs, Saskatchewan is the only one that reimburses pharmacies for the service.

However, they only receive the $18 when the consult leads to a prescrip-

COUNSELLING & RECOMMENDATIONS SURVEY

tion. Gerry Harrington, vice president, policy & regulatory affairs, thinks the arrangement sends a bad message. “It says to the pharmacist: your assessment is of no value unless it results in a drug being prescribed,” he says. “That runs the risk of perverting the practice.”

While Amaya says he’s pleased with the success of his minor ailments program and the revenue it generates, he stresses to his team it’s not about that. “Unfortunately, we don’t get a fee if the session ends with nonprescription items,” he says. “But I tell them that’s not the goal—the goal is to treat the patient with the best possible solution.”

He says that traditional OTC counseling built the foundation for minor ailments programs sprouting up across the country. Amaya also believes these assessments have helped improved his nonprescription consults as well.

“You become more aware of the whole condition,” he says, adding that opening up the pharmacist’s repertoire means critical decision making is more important. “Pharmacists now have to look at all the possibilities we have under our umbrella to help that patient.”

Patients consider me a source of information on self-care and OTC products: 99% agreed* *Source: 2016 Survey on OTC Counselling & Recommendations.

Switching priorities Another trend reshaping pharmacists’ front-store consults is the rise of OTC switches. Last year alone, several prescription drugs were rescheduled. And a recently released report from the Conference Board of Canada makes the case for even more switches. It found that Canada could save $1 billion by making proton pump inhibitors, oral contraceptives and erectile dysfunction drugs OTC.

pharmacy practice+

Nardine Nakhla, an OTC expert with the University of Waterloo and University of Toronto’s pharmacy schools (and author of this magazine’s OTC Issues column) says the trend means pharmacists will be relied upon even more for their expertise. “It highlights their role even more,” she says. “It will make it imperative that pharmacists have a more in-depth discussion with patients.”

On that note, her biggest piece of advice for pharmacists is to keep abreast of OTC switches. From discussions she’s had, Nakhla senses many of her peers are unaware of recent switches and, thus, unprepared for them. “That awareness piece is missing, and I’ve heard of pharmacists recommending alternatives when there’s a first-line OTC available.”

[Vol.4 No.3] April 2017

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COUNSELLING & RECOMMENDATIONS SURVEY

OTC counselling: not an afterthought Remember the days when pharmacists practised partially obscured behind a tall dispensary wall, looking down on patients who waited a couple of steps below for a moment of their time?

More and more, the “new normal” for community pharmacy is an open environment that encourages patients to ask questions, not just about their prescriptions, but also about the products sold just in front of the dispensary, or even about common ailments and conditions. Pharmacists are growing more comfortable with stepping out from behind the counter, actively making themselves available to help with product recommendations and wellness information.

In the Pharmacy Practice+ 2016 Survey on OTC Counselling and Recommendations, virtually all (99%) pharmacists told us that “OTC product counselling is an important part of my job.” And 94% wish more patients would ask their advice before selecting OTC products. The most common question they’re asked, said 89% of respondents, is which product they recommend for a specific need. And nine times in 10, when a pharmacist makes a product recommendation, the consumer makes the purchase.

Not surprisingly, what’s raising the profile of pharmacists as primary health advisors is their new authority in many Canadian provinces as minor ailment assessors and prescribers. It’s an idea long overdue. Almost all (98%) respondents agreed that “responsibility for primary care of minor self-limiting ailments is an appropriate role for pharmacists.” And 95% are personally enthusiastic about the opportunity to add minor ailment assessment to their practice.

Long known as the drug experts, pharmacists are now easing comfortably into this exciting new practice area. In fact, 98% believe that counselling on self-care and wellness is an important part of their role as a pharmacist.

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April 2017 [Vol.4 No.3]

Pharmacists’ most-recommended products Canadian pharmacists told us how many times per month they make a recommendation on popular nonprescription products.

Product

Recos/month

Adult oral analgesic

30

Eczema care

10

Adult cold preparation

23

Moisturizer/dry skin

10

Adult antihistamine

21

Topical anti-infective

10

Adult sinus remedy

17

Probiotic

9

Laxative

16

Sleep aids

8

Topical analgesic

16

Antidiarrheal

9

Children’s oral analgesic

14

Topical anti-infective

9

Antinauseant

11

Cold sore remedy

8

Children’s antihistamine

11

Iron supplement

8

Children’s cough and cold13

12

Sleep aids

8

Nasal decongestant

12

Antibiotic eye and ear drops

8

Dry eye drops

11

Blood pressure monitor

8

Source: Pharmacy Practice+ 2017 Survey on OTC Counselling and Recommendations.

pharmacy practice+

SURVEY METHODOLOGY The 2016 Survey on OTC Counselling & Recommendations was an online survey fielded between July and September, 2016 by Rogers Insights Custom Research Group. A total of 2,610 Canadian retail pharmacists responded to the survey. All respondents completed the counselling questions for the survey, then each respondent was initially asked about a random block of 5-7 product categories. Once they had completed the initial block, respondents were then asked if they would complete another block of categories. In total 52 product categories were presented to the overall sample of pharmacists. To establish the OTC brand rankings, respondents were asked two openended questions: 1) how often do you make recommendations on this product category? And 2) What brand(s) do you usually recommend? Store brands, prescription drugs, products not belonging in a category and generic suggestions (eg., Vitamin C, ice, etc.) were removed from the coding. The resulting lists for each product category were then ranked by the number of recommendations, resulting in a winner for the category.

THANK YOU

INDEX OF MOSTRECOMMENDED BRANDS Acne treatment .................................... 52 Adult antihistamine ............................. 52 Adult toothache ................................... 53 Antibiotic eye & ear drops ................. 53 Antiflatulent ......................................... 54 Antinauseant ........................................ 54

2 0 17

To the staff at Rogers Media Audience Insights for producing and managing this year’s survey.

Baby teething ....................................... 55

NATIONAL

Blood glucose monitor........................ 55

ABOUT THE #1 OTC BRAND LOGO

Blood pressure monitor ...................... 56 DE

AR

M

D

OTC BRAND

PH

Only the OTC products voted #1 most-recommended brand by pharmacists in the Pharmacy Practice+ Survey on OTC Counselling & Recommendations may use this logo or claim to be “Pharmacists’ most recommended brand.”

AC

E

N

OTC Illustrations: Zigor Samaniego, colagene.com

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

IST

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M

Children’s antihistamine ..................... 56 Children’s oral analgesic..................... 57 Cold sore remedy ................................. 57 Common wart remedy ........................ 58 Condoms ................................................ 58

How to read the charts

Dermatological skin care ................... 59 Diaper rash treatment ........................ 59

Acne Treatment

Dry eye drops ........................................ 60 Emergency contraceptive ................. 60

Brands, ranked in order of the percentage of pharmacists who recommend them to patients.

Heat analgesic (patch/wrap/rub) .... 61

Benzagel 48%

Homeopathic medicines..................... 61

Spectro (NET) 16%

Intravaginal antifungal........................ 62

Cetaphil 10%

Iron supplement ................................... 62 Laxative .................................................. 63

Oxy (NET) 8%

Lip care ................................................... 63 Moisturizer/dry skin product ............ 64

Neutrogena 7%

Natural cold remedy............................ 64 Average number of times per month pharmacists make a recommendation on this category.

This section shows how often respondents recommend either a brand product only, a private label product only, or a choice between brand and private label products.

pharmacy practice+

Responses 5% or less are not shown; n=283; 81% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

4

PHARMACIST RECOMMENDS Brands only .......................................... 34% Private label only................................... 1% Both brand & private label................... 61% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Oral gynecological antifungal ........... 65 Pregnancy test kit ............................... 65 Probiotic ................................................. 66 Scar/stretch mark therapy ............... 66 Sunscreen .............................................. 67 Topical analgesic .................................. 67 Topical anti-infective ........................... 68 Vaginal lubricant .................................. 68

[Vol.4 No.3] April 2017

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COUNSELLING & RECOMMENDATIONS SURVEY

Acne Treatment Benzagel 48% Spectro (NET) 16% Cetaphil 10% Oxy (NET) 8% Neutrogena 7% Responses 5% or less are not shown; n=283; 81% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

4

PHARMACIST RECOMMENDS Brands only .......................................... 34% Private label only................................... 1% Both brand & private label................... 61% Not stated ............................................. 3%

Thanks to you, Benzagel® is the #1 pharmacist recommended acne treatment brand in Canada.* benzagel.ca

REACTINE ADULT ANTIHISTAMINE (1 of 2) *Pharmacy Practice+ 2017 Survey on OTC Counselling and Recommendations PP+and=Profession 4.4 xSanté 4.25; updates from 2015

BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

• 2869 OTC 2017 Thank You Program - ENG v1.indd 1

C R E AT I V E

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Reactine 55% Date

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March 8, 2017

Client Claritin 37% Docket Number

Columbia Labs - Benzagel Pharmacy Practice +

Insertion Date Benadryl 20% File Format

Thank4.5"w you xfor your 4.25"h continued support for Bleed Size 9 years running.

Trim Size

2869 (#1 OTC Acne Brand Thank You Ad)

Publication Aerius 34%

2017-03-09 6:08 PM

BLADE CREATIVE BRANDING INC.

Adult Antihistamine

Live Area

Colour

CMYK

April 2017 Notes

InDesign / PDF

Allegra 2% APPROVAL: PLEASE INITIAL Responses 1% or less are not shown; n=379; 99% recommend in category Results may total >100% due to multiple brand recommendations WITH

Art Director

CHANGES

WITH CHANGES

WITH CHANGES

This proof may be privileged and/or confidential, and Blade Creative Branding Inc. does not waive any related rights and obligations. Any distribution, use or copying of this pr other than an intended recipient is unauthorized. If you received this proof in error, please advise Blade Creative Branding Inc. (by return e-mail, fax or otherwise) immediately AVERAGE RECOMMENDATIONS/MONTH

21

PHARMACIST RECOMMENDS Brands only ............................................ 1% Private label only................................. 16% Both brand & private label................... 80% Not stated ............................................. 2% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

52

April 2017 [Vol.4 No.3]

#

1 Recommended Adult Antihistamine* 1-877-322-8463 www.reactine.ca

*Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

© JOHNSON & JOHNSON INC. 2017

pharmacy practice+

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Adult Toothache Orajel 37% Advil 36% Tylenol 13% Aleve 5%

THANK YOU

Amosan 5% Responses 4% or less are not shown; n=399; 85% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

5

FOR VOTING ORAJEL™ CANADA’S #1 ADULT TOOTHACHE BRAND.

PHARMACIST RECOMMENDS Brands only .......................................... 15% Private label only................................. 11% Both brand & private label................... 71% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling & Recommendations. © Church & Dwight Canada Corp. 2017.

Antibiotic Ear & Eye drops Polysporin 94% Eye & Ear Drops Other 2%

Thank you for your continued support.

Responses less than 1% are not shown; n=397; 97% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

10

PHARMACIST RECOMMENDS Brands only .......................................... 56% Private label only................................... 4% Both brand & private label................... 36% Not stated ............................................. 4% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

pharmacy practice+

Antibiotic treatments for Pink Eye and Swimmer’s Ear, conveniently available without a prescription. *Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

© JOHNSON & JOHNSON INC. 2017 To be sure this product is right for your patients, always read and follow the label.

[Vol.4 No.3] April 2017

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COUNSELLING & RECOMMENDATIONS SURVEY

Antiflatulent Ovol 45% Gas-X 32% Beano 6% Phazyme 5%

THANK YOU FOR VOTING OVOL™ THE #1 ANTIFLATULENT IN CANADA.

Responses 1% or less are not shown; n=383; 75% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

4

PHARMACIST RECOMMENDS Brands only .......................................... 17% Private label only................................... 6% Both brand & private label................... 75% Not stated ............................................. 2% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling & Recommendations. © Church & Dwight Canada Corp. 2017.

Antinauseant Gravol (NET) 83% Sea-Band 2% Transderm-v 2%

THANK YOU FOR VOTING GRAVOL THE #1 ANTINAUSEANT IN CANADA FOR 11 YEARS IN A ROW. TM

Responses less than 1% are not shown; n=386; 97% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

11

PHARMACIST RECOMMENDS Brands only ............................................ 2% Private label only................................. 14% Both brand & private label................... 82% Not stated ............................................. 2% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

54

Pharmacy Practice +, The Medical Post and Profession SantŽ 2017 Survey on OTC Counselling and Recommendations. © Church & Dwight Canada Corp. 2017.

pharmacy practice+

April 2017 [Vol.4 No.3] TK100119_CD_Gravol_PPP_ENG_R1.indd 1

2017-04-06 4:13 PM

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Baby Teething Orajel 34% Tylenol 25% Camilla/Boiron 16% Advil 14%

THANK YOU FOR VOTING ORAJEL™ CANADA’S #1 PHARMACIST RECOMMENDED BABY TEETHING BRAND.

Responses 5% or less are not shown; n=422; 78% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

3

PHARMACIST RECOMMENDS Brands only .......................................... 21% Private label only................................... 5% Both brand & private label................... 70% Not stated ............................................. 4% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations. © Church & Dwight Canada Corp. 2017.

Blood Glucose Monitor

Still the #1 Pharmacist Recommended Blood Glucose Monitor Brand* ➤ For the 3rd Year in a Row!†

Bayer Breeze/ 57% Contour (NET) One Touch (NET) 38% Accu-Chek (NET) 21% Freestyle/ 6% Freestyle Lite (NET) Responses 4% or less are not shown; n=344; 87% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

7

PHARMACIST RECOMMENDS Brands only .......................................... 74% Private label only................................... 1% Both brand & private label................... 18% Not stated ............................................. 7% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

pharmacy practice+

THANK YOU FOR YOUR ONGOING SUPPORT!

ascensiadiabetes.ca * Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations (re: pharmacists) † The survey relates to the brand, not specific blood glucose meter models. The CONTOUR® NEXT ONE and CONTOUR® NEXT LINK 2.4 meter models were launched in February 2017 and April 2017 respectively, and were not on the market during the time of the survey. ® TM see www.ascensiadiabetes.ca/tm-mc. All other trademarks are property of their respective owners.

Client: ADC - Melanie McAlister

Size: 4.5 X 4.25

NO of Pages: 2 [Vol.4 No.3] April 2017

Date: Feb 28, 2017 File: 6396 ADC Rogers#1 for 2017 Ad

+ bleed of.125 X No bleed

Proof #: 3A Approved:

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OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Blood Pressure Monitor

Thank You for Your Continued Confidence in Omron

Omron 47% LifeSource (NET) 37% Bios 5% A&D 2%

Among Canadian Pharmacists, Omron was chosen as the #1 recommended brand of home blood pressure monitors.

Responses less than 1% are not shown; n=290; 81% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

4

PHARMACIST RECOMMENDS Brands only .......................................... 45% Private label only................................... 3% Both brand & private label................... 47% Not stated ............................................. 5% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Pharmacy Practice+ and Professional Sante 2017 Survey on OTC Counselling and Recommendations.

The Medical Post and Professional Sante 2017 Survey on OTC Counselling and Recommendations. © 2017 Omron Healthcare, Inc.

OmronHealthcare.ca

Children’s Antihistamine Benadryl 43% Aerius 36% Claritin 30% Reactine 30%

Responses 1% and less are not shown; n=354; 93% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

11

PHARMACIST RECOMMENDS Brands only .......................................... 18% Private label only................................... 5% Both brand & private label................... 74% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

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April 2017 [Vol.4 No.3]

Thank you for your continued support for 5 years running.

#

1 Recommended Children’s Antihistamine* 1-800-661-4659 www.benadryl.ca

*Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

© JOHNSON & JOHNSON INC. 2017

pharmacy practice+

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Children’s Oral Analgesic Tylenol 66% Advil 44% Tempra 8%

Thank you for your continued support.

Motrin 5%

Responses 1% or less are not shown; n=371; 96% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

14

PHARMACIST RECOMMENDS Brands only ............................................ 7% Private label only................................... 9% Both brand & private label................... 82% Not stated ............................................. 2%

#1 Recommended Children’s Oral Analgesic 1-800-265-7323 B:4.5”

BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

*Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

www.tylenol.ca

© JOHNSON & JOHNSON INC. 2017

T:4.5”

Cold Sore Remedy Abreva 85% Lipactin 19% Orajel 2% Cold Sore FX 1%

Responses less than 1% are not shown; n=363; 96% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

6

PHARMACIST RECOMMENDS Brands only .......................................... 66% Private label only................................... 2% Both brand & private label................... 28% Not stated ............................................. 4% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

pharmacy practice+

Thank you for making abreva® the #1 recommended cold sore remedy.

Pharmacy Practice+ and Profession Santé 2016 Survey on OTC Counselling and Recommendations.

GlaxoSmithKline Consumer Healthcare Inc., Mississauga, Ontario L5N 6L4 ©2017 GSK group of companies. All rights reserved.

[Vol.4 No.3] April 2017

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COUNSELLING & RECOMMENDATIONS SURVEY

Common Wart Remedy Compound W/ 45% Freeze Off (NET) Dr. Scholl’s (NET) 31% Soluver 12%

Responses 1% and less are not shown; n=130; 25% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

4

PHARMACIST RECOMMENDS Brands only .......................................... 28% Private label only................................... 4% Both brand & private label................... 65% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Condoms Trojan 45% Durex 18% Lifestyles 7% Skyn 4%

THANK YOU

Ramses 2% Responses 1% and less are not shown; n=130; 25% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

1

FOR MAKING TROJAN™ THE #1 PHARMACIST RECOMMENDED CONDOM BRAND.

PHARMACIST RECOMMENDS Brands only .......................................... 52% Private label only................................... 3% Both brand & private label................... 41% Not stated ............................................. 4% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

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Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling & Recommendations. © Church & Dwight Canada Corp. 2017.

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COUNSELLING & RECOMMENDATIONS SURVEY

La Roche-Posay 25% CeraVe 18% Cetaphil 14% Aveeno 8% Avène 8% Responses 6% and less are not shown; n=274; 78% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

7

PHARMACIST RECOMMENDS Brands only .......................................... 31% Private label only................................... 3% Both brand & private label................... 61% Not stated ............................................. 5% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Diaper Rash Treatment Zincofax 40% Canesten 11%

CanadianHealthCareNetwork.ca, Pharmacy Practice+, Profession Santé, and The Medical Post 2017 Survey on OTC Counselling and Recommendations.

Dermatological Skin Care

Thank you for making La Roche-Posay the #1 brand in dermatological skincare.

LA ROCHE-POSAY. COMMITTED TO DERMATOLOGY. www.laroche-posay.ca

Thank you

Penaten 11%

for your vote of confidence.

Sudeocrem 11% Desitin 10% Responses 5% or less are not shown; n=417; 88% recommend in category Results may total >100% due to multiple brand recommendations

2 0 17 NATIONAL

4 D

DE

AR

BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

OTC BRAND

PH

PHARMACIST RECOMMENDS Brands only .......................................... 12% Private label only................................... 9% Both brand & private label................... 72% Not stated ............................................. 6%

M

AC

N

AVERAGE RECOMMENDATIONS/MONTH

IST

RECO M

M

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#1 Recommended Diaper Rash Treatment* * Pharmacy Practice+ and Profession SantŽ 2017 Survey on OTC Counselling and Recommendations. © 2017, Paladin Labs Inc., St-Laurent, QC

pharmacy practice+

www.zincofax.ca

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We Couldn’t Do Without Your Continued Support!

Dry Eye Drops

THANK YOU

Systane (NET) 72%

for Making

Refresh (NET) 35%

#

Tears Naturale 12% (NET) GenTeal 5% Visine 4% Responses 3% or less are not shown; n=642; 99% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

11

PHARMACIST RECOMMENDS Brands only .......................................... 56% Private label only................................... 1% Both brand & private label................... 40% Not stated ............................................. 3% Systane® is a registered trademark. © 2017 Novartis inc. PH16066

BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Emergency Contraceptive

Reference: Pharmacy Practice+, Medical Post and Profession Santé 2017 Survey on OTC Counselling and Recommandations

Systane_MVL_AN_201704-b.indd 9

17-03-30 14:33

Plan B 67%

Option 2 8%

Pharmacist Recommended Emergency Contraceptive*

Responses less than 1% are not shown; n=396; 83% recommend in category Results may total >100% due to multiple brand recommendations

NATIONAL

6

OTC BRAND D

PH AR

PHARMACIST RECOMMENDS Brands only .......................................... 33% Private label only................................. 11% Both brand & private label................... 50% Not stated ............................................. 6%

DE

AVERAGE RECOMMENDATIONS/MONTH

2 0 17

M

AC

N

Ella 2%

IST

RECO M

M

E

BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding ® 2017, Paladin Labs Inc., St-Laurent, QC

60

April 2017 [Vol.4 No.3]

pharmacy practice+

*Pharmacy Practice+ 2017 Survey on OTC Counselling and Recommendations.

Next Choice 27%

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Heat Analgesic (patch/wrap/rub) Rub A535/ Antiphlogistine 33% (NET) Voltaren (NET) 22% Myoflex 8% Thermacare 7%

THANK YOU FOR MAKING RUB A535™ THE #1 PHARMACIST RECOMMENDED HEAT RUB, WRAP AND PATCH.

Responses 5% and less are not shown; n=269; 68% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

5

PHARMACIST RECOMMENDS Brands only .......................................... 24% Private label only................................... 3% Both brand & private label................... 68% Not stated ............................................. 5% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

03.17 ADVERTISING OTC #1 2017.pdf 1 2017-03-07 10:52 AM Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling & Recommendations. © Church & Dwight Canada Corp. 2017.

Homeopathic Medicines Boiron (NET) 49%

Thank you for your continued support!

BOIRON® IS THE #1 OTC BRAND OF HOMEOPATHIC MEDICINES RECOMMENDED BY PHARMACISTS.

Homeocan 7% Helixia 4%

Responses 1% or less are not shown; n=207; 38% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

2

PHARMACIST RECOMMENDS Brands only .......................................... 50% Private label only................................... 3% Both brand & private label................... 44% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

pharmacy practice+

Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

These homeopathic medicines may not be right for everyone.

Always read and follow the label.

[Vol.4 No.3] April 2017

61

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Intravaginal Antifungal Canesten (NET) 80% Monistat 19% Diflucan 3%

Responses 3% or less are not shown; n=362; 93% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

7

PHARMACIST RECOMMENDS Brands only .......................................... 12% Private label only................................... 6% Both brand & private label................... 80% Not stated ............................................. 2%

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BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

/ &$ 0.7 &&

Iron Supplement FeraMAX 34% Palafer 18% Euro-Fer 13% Proferrin 6%

Responses 2% and less are not shown; n=187; 75% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

8

PHARMACIST RECOMMENDS Brands only ............................................ 6% Private label only................................. 20% Both brand & private label................... 71% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

62

April 2017 [Vol.4 No.3]

pharmacy practice+

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Laxative Lax-A-Day 37% Senokot (NET) 34% RestoraLAX 11% Dulcolax 10% Colace 8% Metamucil 8% Responses 3% and less are not shown; n=380; 98% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

16

PHARMACIST RECOMMENDS Brands only ............................................ 5% Private label only................................. 10% Both brand & private label................... 82% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Lip Care Blistex 26% La Roche Posay 14% Abreva 12% Nivea 12% Vaseline 11% Responses 6% or less are not shown; n=331; 73% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

4

PHARMACIST RECOMMENDS Brands only .......................................... 38% Private label only................................... 2% Both brand & private label................... 56% Not stated ............................................. 4% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

pharmacy practice+

[Vol.4 No.3] April 2017

63

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

©WellSpring Pharmaceutical Canada Corp. 2017

Moisturizer / Dry Skin Product Glaxal Base 28% CeraVe 27% Aveeno 21% Cetaphil 17% La Roche Posay 8% Responses 7% or less are not shown; n=363; 96% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

10

PHARMACIST RECOMMENDS Brands only .......................................... 40% Private label only................................... 1% Both brand & private label................... 57% Not stated ............................................. 2% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

We let the experts do the talking Thanks to you, Glaxal Base is the #1 pharmacist recommended Moisturizer/Dry Skin product.

Just the care your skin needs.

For further information call 1-866-337-4500.

Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

Natural Cold Remedy

WE’RE PRETTY PROUD OF THIS. NATURALLY.

Cold-FX 12%

D

M

ED

OTC BRAND

AR

Thank you for making Helixia® Cough Prospan® the #1 recommended natural cough remedy across Canada.

NATIONAL

PH

Stodal 13%

2 0 17

AC

N

Helixia 19%

IST

REC O M

M

E

Boiron (unspecified) 7%

Responses 3% and less are not shown; n=172; 48% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

5

PHARMACIST RECOMMENDS Brands only .......................................... 40% Private label only................................... 6% Both brand & private label................... 48% Not stated ............................................. 7% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

64

Available in 100 mL & 200 mL bottles and on-the-go sachets

HELIXIA.COM Pharmacy Practice+ & Profession Santé 2017 Survey on OTC Counselling & Recommendations.

pharmacy practice+

April 2017 [Vol.4 No.3] HEL_7966_Helixia_Pharmacist_ad_E05.indd 1

17-04-06 11:

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Oral Gynecologic Antifungal CanesOral (NET) 55% Diflucan One 27% Monistat-X 4%

Responses 2% or less are not shown; n=339; 90% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

6

PHARMACIST RECOMMENDS Brands only ............................................ 9% Private label only................................. 13% Both brand & private label................... 76% Not stated ............................................. 2% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

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Pregnancy Test Kits First Response 49% Clearblue/ 31% Clearblue Easy

THANK YOU Responses 1% and less are not shown; n=224; 66% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

FOR MAKING FIRST RESPONSEâ&#x201E;¢ THE #1 PREGNANCY TEST IN CANADA.

4

PHARMACIST RECOMMENDS Brands only .......................................... 18% Private label only................................. 10% Both brand & private label................... 71% Not stated ............................................. 2% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

pharmacy practice+

Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling & Recommendations. © Church & Dwight Canada Corp. 2017.

[Vol.4 No.3] April 2017

65

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Probiotic *

THANK YOU FOR MAKING

Bio-K+ 34%

THE

Probaclac 26%

PROBIOTIC IN CANADA

Align 22% Florastor 13% Jamieson 9% Responses 8% and less are not shown; n=448; 93% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

9

PHARMACIST RECOMMENDS Brands only .......................................... 31% Private label only................................... 4% Both brand & private label................... 62% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

50 Billion, THANK YOU! * Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

5191_BioOil_ThankYou_PP_Ad_E_hi.pdf biokplus.com

1

10:15 AM 1-800-593-2465

Mar-06-2017

Scar/stretch mark therapy

Thank you for making #1 for scars and stretch marks!

Bio-Oil 32% Mederma 16% Cicaplast (NET) 12% Dermatix/ 7% Dermatix C Webber 7% Responses 3% or less are not shown; n=188; 58% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

2

PHARMACIST RECOMMENDS Brands only .......................................... 44% Private label only................................... 2% Both brand & private label................... 49% Not stated ............................................. 5% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

66

April 2017 [Vol.4 No.3]

*The Medical Post, Profession Santé & Pharmacy Practice + 2017 Survey on OTC Counselling and Recommendations

pharmacy practice+

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Sunscreen Ombrelle 60% La Roche-Posay 21% (NET) Neutrogena 15%

Thank you for your continuous support that has made us the #1 recommended sunscreen

Aveeno 6%

since 1994.

Coppertone (NET) 5% Responses 4% or less are not shown; n=320; 88% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

7

PHARMACIST RECOMMENDS Brands only .......................................... 35% Private label only................................... 4% Both brand & private label................... 58% Not stated ............................................. 3% Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations.

BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

Topical Analgesic

Thank you for making Voltaren Emulgel the #1 recommended topical analgesic.

Voltaren (NET) 75%

®

Rub A535/ Antiphlogistine 12% (NET) Myoflex 7%

Responses 2% and less are not shown; n=341; 92% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

16

PHARMACIST RECOMMENDS Brands only .......................................... 43% Private label only................................... 2% Both brand & private label................... 52% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

pharmacy practice+

Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations.

GlaxoSmithKline Consumer Healthcare Inc., Mississauga, Ontario L5N 6L4 ©2017 GSK group of companies. All rights reserved.

[Vol.4 No.3] April 2017

67

OTC

COUNSELLING & RECOMMENDATIONS SURVEY

Topical Anti-infective Polysporin (NET) 82%

Thank you for your continued support.

Bactroban 4% Betadine x 2% Ozonol 1%

Responses less than 1% are not shown; n=368; 94% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

11

PHARMACIST RECOMMENDS Brands only ............................................ 6% Private label only................................... 9% Both brand & private label................... 81% Not stated ............................................. 4%

“Fast effective healing of minor cuts, scrapes and burns. + Pain relief” *Pharmacy Practice+ and Profession Santé 2017 Survey on OTC Counselling and Recommendations

© JOHNSON & JOHNSON INC. 2017

BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

To be sure this product is right for your patients, always read and follow the label.

Vaginal Lubricant Replens 61% K-Y (NET) 38% Vagisil 4% Astroglide 3%

THANK YOU Responses 1% or less are not shown; n=268; 64% recommend in category Results may total >100% due to multiple brand recommendations

AVERAGE RECOMMENDATIONS/MONTH

2

FOR MAKING REPLENS™ THE #1 VAGINAL LUBRICANT IN CANADA.

PHARMACIST RECOMMENDS Brands only .......................................... 46% Private label only................................... 3% Both brand & private label................... 48% Not stated ............................................. 3% BASE: Make at least 1 recommendation/month Column may not add to 100% due to rounding

68

April 2017 [Vol.4 No.3]

The Medical Post and Profession SantŽ 2017 Survey on OTC Counselling & Recommendations. © Church & Dwight Canada Corp. 2017.

pharmacy practice+

The Favourite OTC Brand

1-800-265-7323 www.tylenol.ca

*The Medical Post and Profession Santé 2017 Survey on OTC Counselling and Recommendations

© JOHNSON & JOHNSON INC. 2017

Classified

We are more than our name implies.

Check out our new website. www.oconnell.ca

a great place to work Advance your pharmacy career with Save-On-Foods. We are a Western Canadian company with over 115 pharmacies in over 50 communities across BC and Alberta, and now growing in Saskatchewan and Manitoba.

We’re looking for pharmacy professionals who share a passion for healthy living and for delivering quality patient-centred care to our customers.

Our pharmacists have opportunities to be involved with health screenings, vaccinations and travel health, medication management services, prescribing, and other clinical programs where possible in their province.

A career at Save-On-Foods is an opportunity to: • Work in a friendly, professional and supportive work environment • Enjoy flexibility, stability and great compensation packages • Develop your leadership skills, expand your scope of practice and advance your career!

For career opportunities, please forward your resume in confidence to: pharmacyemployment@owfg.com.

pharmacy

CLASSIFIED ADVERTISING

1 800 668-8151 70

April 2017 [Vol.4 No.3]

pharmacy practice+

When you’re thinking long term, Subaru makes the most sense.

425 L of cargo space SUBARU BOXER® engine

Rear-View Camera

EyeSight®

AWD Lineartronic® CVT

With a great model lineup to suit your business needs, it simply makes sense to add the safety, value and reliability of Subaru symmetrical full-time All-Wheel Drive vehicles to your fleet. Thanks to the Subaru symmetrical full-time All-Wheel Drive system, all Subaru vehicles are uniquely equipped to offer unsurpassed control and safety in all types of weather conditions and on all types of road surfaces. Affordable acquisition costs, high residual value and volume fleet incentives make Subaru vehicles an excellent value and a smart investment.

No matter how you look at it, Subaru makes the most sense. fleet.subaru.ca or call 1-877-293-7272

SafetyMatters

â&#x20AC;&#x2030;Introducing the Teva-Fentanyl Patch Return Program Help keep your community safer with this program from Teva Canada.

Protect your patients, your physician partners and yourself with this program. It gives you the tools and information you need to engage and collaborate with your community to ensure that Teva-Fentanyl patches are used correctly and disposed of safely.

TevaSafetyMatters.ca/Fentanyl