Pharmacy Practice+Business - July 2017 by ensembleiq

INSPIRING CANADIAN PHARMACISTS TO BE THEIR BEST

JULY/ AUGUST 2017

TACKLING

H.PYLORI WITH QUADRUPLE THERAPY

PHARMACISTS AND ANTIMICROBIAL STEWARDSHIP NEW COLUMN:

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Help them target the pain where it hurts. 1

The #1 Topical Analgesic recommended by physicians.*

*The Medical Post and Profession Santé 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.

JULY/AUGUST 2017

Contents 14

FEATURE 14 ON THE COVER QUADRUPLE THERAPY: NEW STANDARD FOR TREATING H. PYLORI

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OPINIONS

YOUR PRACTICE

Editorial

Drug News

Practice Experts

No excuse for not promoting naloxone

New launches, new indications, Health Canada advisories

Child and adolescent mental health; New column: Frontline Leadership

5 TIPS 20 Pearls for your practice Antimicrobial stewardship in community pharmacy

9 Clinical Notes

WHAT ARE YOUR PHYSICIAN COLLEAGUES TALKING ABOUT? If you are registered on Canadian HealthcareNetwork.ca, you can click on the “Physicians” tab on the top of any web page to check out the news, blogs and feature stories that doctors are reading.

New opioid guidelines; Assessing Diabetes MedsChecks; Antibiotics and spontaneous abortion

WATCH FOR OUR OTC COUNSELLING SURVEY!

YOUR CE SOURCE: Go to eCortex.ca to ﬁnd accredited Continuing Education lessons for both pharmacists and pharmacy technicians

+ Classified section: page 22 pharmacy practice+

You may soon receive an email invitation to participate in our annual survey on OTC Counselling & Recommendations. This important research tracks pharmacists' importance and inﬂuence as advisors on self-care and nonprescription products. Thank you for sharing your experiences and opinions.

[Vol.4 No.6] July/August 2017

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Recommend the OneTouch Verio Flex meter today! TM

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* Compared to a meter without a colour range indicator and a paper logbook Other trademarks and trade names are those of their respective owners. © 2017 LifeScan Canada. All rights reserved. NACO/VFX/0617/0461

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No excuse for not promoting naloxone

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Talk about a wake-up call. Actually, she wouldn’t wake up, that’s the thing. One February evening, after we had finished serving dinner at our youth drop-in, volunteers noticed one young woman apparently sleeping, her head on the table. Gentle words failed to stir her, so Jen, our youth worker, and a volunteer nurse were called over. They tried to shake her, and shouted into her ear, but she didn’t respond. They called 911 and continued to try to wake her. I tried to get some information, but (as so often happens) the friends who had accompanied her to the program had disappeared, so no one knew what she had taken. Her appearance didn’t seem consistent with an opioid overdose, but the possibility definitely crossed our minds. Thankfully, EMS responders were on site within three minutes or so, and after a couple of standard consciousness tests, determined that our young guest was extremely inebriated. She was not able to stand, or even fully wake up, so they took her to hospital to recover. As the initial adrenaline rush of the emergency passed, Jen and I looked at each other, realizing we’d been spared from a potential tragedy that we never wanted to come close to again, and said: “We have to get naloxone kits.” Thanks to local pharmacist Jim Snowdon, we had our kits and our training within two weeks. He booked a time to meet with us, went through the training very thoroughly and filled out the necessary forms. We left his pharmacy calmly reassured that, if faced with an actual overdose, we’d be prepared to take action. I knew that Snowdon, being what they used to call an “advanced practitioner,” would be eager to help us—and he was. Sadly, what I’ve since learned through attendance at a number of provincial and national pharmacy conferences this season, is that there are still many Canadian pharmacies that do not make naloxone available to the public. And even those that do, fail to alert the public that this crucial antidote is available free from their local pharmacy. I can’t count the number of times I heard presenters lament the fact that not enough community pharmacies take this crisis—and their crucial role as providers of naloxone, the life-saving antidote to opioid overdose—seriously. Seriously? Naloxone is fail-safe. It reverses the effects of opioid overdose quickly and without harm. If mistakenly administered to someone who has not ingested opioids, it has no effect at all. It can be given to someone who is unconscious, and acts in seconds. It can’t be abused. Most provincial government cover its distribution free of charge to anyone who wishes to have access. All pharmacies stock Epipens. Why don’t all pharmacies stock naloxone kits, which are equally crucial to saving lives in a timecritical emergency? What could the reason for this be? I’m not sure I even want to know the answer.

In the interest of the environment, Pharmacy Practice+ is printed on acid-free, oxygen-bleached paper.

vwood@ensembleiq.com @Ppr_plus pharmacy practice+

[Vol.4 No.6] July/August 2017

Your

CLINICAL AND PROFESSIONAL NEWS, ADVICE, EDUCATION

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

Lixiana: fourth direct-acting oral anticoagulant edoxaban 15 mg, 30 mg and 60 mg tablets, Servier.

INDICATIONS Prevention of

stroke and systemic embolic events in patients with atrial fibrillation (AF). Also approved for the treatment of venous thromboembolism (VTE) (i.e., deep vein thrombosis [DVT] and pulmonary embolism [PE]) and for the prevention of recurrent DVT and PE. ACTION A direct factor Xa inhibitor. Inhibition of factor Xa in the coagulation cascade reduces thrombin generation, prolongs clotting time and reduces the risk of thrombus formation. DOSAGE Stroke prevention in AF: Usual recommended dosage is 60 mg once daily. Treatment of VTE and prevention of recurrent DVT and PE: Recommended dosage is 60 mg once daily, after initial use of a parenteral anticoagulant (e.g., heparin) for five to 10 days. Can be taken with or without food. Duration of therapy should be individualized. Shorter duration (at least 3 months) should be considered in patients with transient risk factors (e.g., surgery, trauma, immobilization). More extended therapy should be considered in patients with permanent risk factors or idiopathic DVT or PE. Reduce dose to 30 mg once daily in patients with one or more of the following: moder6

July/August 2017 [Vol.4 No.6]

ate renal impairment (creatinine clearance [CrCl] 30–50 mL/ min); low body weight (≤ 60 kg); or concomitant use of a Pglycoprotein inhibitor/substrate (e.g., cyclosporine, dronedarone, erythromycin, but not amiodarone or verapamil). Not recommended in patients with severe renal impairment (CrCl < 30 mL/min) or in those on dialysis, due to lack of data. Usual dosage (60 mg once daily) can be used in patients with mild to moderate hepatic impairment; not recommended in patients with severe hepatic impairment as it has not yet been studied. No dose modification needed for patients who are also taking CYP3A4 inhibitors or inducers. ADVERSE EFFECTS Most common: As with other direct-acting oral anticoagulants (DOACs), bleeding is the most common adverse effect, particularly cutaneous soft tissue hemorrhage, epistaxis and vaginal hemorrhage, but can develop at any site. Anemia can occur. Most serious: Bleeding (e.g., gastrointestinal tract, intracranial, intraocular); may be severe and potentially fatal. COMMENTS Edoxaban joins three other DOACs currently marketed in Canada: apixaban, dabigatran and rivaroxaban.

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.

Tecentriq for urothelial carcinoma atezolizumab 60 mg/mL concentrate for solution for infusion, 1,200 mg/20 mL single-use vials, Hoffmann-La Roche.

INDICATIONS Treatment of locally advanced or meta-

static urothelial carcinoma in patients who have disease progression during or following platinum-containing chemotherapy, or have disease progression within 12 months of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy. Issued marketing authorization with conditions, pending the results of studies to verify the drug’s clinical benefit. ACTION A monoclonal antibody that directly binds to programmed death-ligand 1 (PD-L1) receptors. This disrupts the PD-L1 mediated inhibition of the immune response, leading to a reactivation of the antitumour immune response. DOSAGE 1,200 mg administered by intravenous (IV) infusion every three weeks. The first dose must be administered over 60 minutes; if the first dose is tolerated, subsequent infusions may be administered over 30 minutes. Treatment is continued until loss of clinical benefit or unmanageable toxicity occurs. Dose reductions are not recommended. Drug should be withheld if grade 3 rash develops and resumed when rash resolves and corticosteroids have been reduced to ≤ 10 mg oral prednisone equivalent per day. ADVERSE EFFECTS Most common (all ≥10%): Fatigue, decreased appetite, nausea, constipation, urinary tract infection, pyrexia, peripheral edema, diarrhea, vomiting, back pain, dyspnea, chills, arthralgia, anemia, cough, hematuria, pruritus, abdominal pain, rash, pain in extremities, headache. Most serious: Immune-related adverse reactions (pneumonitis, hepatitis, colitis, meningoencephalitis, neuropathies, pancreatitis, ocular inflammatory toxicity, endocrinopathies [hypothyroidism, hyperthyroidism, adrenal insufficiency, type 1 diabetes]), severe infections, infusion-related reactions. DRUG INTERACTIONS Not studied. COMMENTS Store vials in the refrigerator (2–8°C). Diluted solution for infusion should be used immediately, but can be stored for up to 24 hours at 2–8°C or for eight hours at room temperature (≤ 30°C). pharmacy practice+

Your Practice

New indications Blincyto

Metvix

(blinatumomab lyophilized powder for solution for infusion), Amgen.

(methyl aminolevulinate topical cream), Galderma.

Replagal

EXPANDED INDICATION Treatment

NEW INDICATION Treatment of thin or

agalsidase alfa for injection; 1 mg/mL concentrate for solution for IV infusion, 3.5 mL vials, Shire Pharma, Canadian distributor is Paladin Labs.

of children with Philadelphia chromosome-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL). (Originally approved for this indication only in adults). Issued marketing authorization with conditions for this use in both adults and children, pending the results of trials to verify the drug’s clinical benefit. DOSAGE Consult product monograph for details on dosage, administration, necessary premedication, and dosage interruptions, reductions and discontinuations required to manage adverse effects.

nonhyperkeratotic and nonpigmented actinic keratosis on the face and scalp when other therapies are considered less appropriate; used in combination with daylight (daylight photodynamic therapy). (Originally approved for this indication used only in combination with conventional photodynamic therapy [630 nm wavelength red light illumination using the Aktilite CL 128 lamp]. Also approved for use in combination with 630 nm wavelength red light illumination for the treatment of primary superficial basal cell carcinoma outside the H-zone of the face [e.g., ears, nose] when other therapies are considered less appropriate.) DOSAGE Consult product monograph for details.

Other new products

INDICATIONS Long-term enzyme replacement therapy in patients with a confirmed diagnosis of Fabry Disease (Į-galactosidase A deficiency). Issued marketing authorization with conditions, pending the results of studies to verify the drug’s clinical benefit. DOSAGE 0.2 mg/kg every other week, given by IV infusion over 40 minutes. Experience in children is limited. Some children seven to 18 years of age received 0.2 mg/kg every other week for one to four years in clinical studies, with no unexpected safety issues. Safety and efficacy not yet established in children < six years of age.

New generics • Olmesartan. Several manufacturers are launching generic olmesartan 20 mg and 40 mg tablets, including Pharmascience, Sandoz and Teva. Generic alternative to Olmetec.

• Olmesartan/hydrochlorothiazide. Several manufacturers are launching generic olmesartan/hydrochlorothiazide tablets (20/12.5 mg, 40/12.5 mg and 40/25), including Apotex and Teva. Generic alternative to Olmetec Plus. • Teva-Atazanavir (atazanavir 150 mg, 200 mg and 300 mg capsules), Teva. Generic alternative to Reyataz.

New dosage forms Ilaris (canakinumab injection), Novartis.

New 150 mg/1 mL solution for subcutaneous injection; 150 mg single-use vials. The original 150 mg powder for solution for subcutaneous injection (150 mg vial) format will be phased out. The new solution format is more patient friendly, as it does not require reconstitution. pharmacy practice+

Darzalex (daratumumab concentrate for solution for infusion), Janssen.

NEW INDICATION Treatment of multi-

ple myeloma in patients who have received at least one prior therapy; used in combination with lenalidomide and dexamethasone, or bortezomib and dexamethasone. (Originally approved only for use as a monotherapy for the treatment of multiple myeloma in patients who received at least three prior lines of therapy. Issued marketing authorization with conditions for use as a monotherapy, pending the results of studies to verify the drug’s clinical benefit.) DOSAGE Monotherapy or in combination therapy with lenalidomide/ dexamethasone: 16 mg/kg administered as an IV infusion weekly (weeks 1–8), every two weeks (weeks 9–24) and then every four weeks (week 25 onwards until disease progression). Combination therapy with bortezomib/dexamethasone: 16 mg/kg administered as an IV weekly (weeks 1–9), every three weeks (weeks 10–24) and then every four weeks (week 25 onwards until disease progression).

Orkambi (lumacaftor/ivacaftor tablets), Vertex Pharmaceuticals.

REVISED INDICATION Treatment of

cystic fibrosis in patients six years of age or older who are homozygous for the F508del mutation in the cystic fibrosis transmembrane conductance regulator gene. (Originally approved for this indication only in patients 12 years or older.) DOSAGE Children six–11 years: two lumacaftor 100 mg/ivacaftor 125 mg tablets every 12 hours with fat-containing food. Patients 12 years or older: two lumacaftor 200 mg/ivacaftor 125 mg tablets every 12 hours with fat-containing food. Meals and snacks containing adequate amounts of fat include those prepared with butter or oils or those containing eggs, cheeses, nuts, whole milk or meats. (NEW INDICATIONS CONT’D ON PAGE 12)

[Vol.4 No.6] July/August 2017

Inspiring business learning

BUILDING A SUSTAINABLE FUTURE

PharmacyU.ca

VANCOUVER

TORONTO

NOVEMBER 25, 2017

FEBRUARY 3, 2018

VANCOUVER CONVENTION CENTRE

THE INTERNATIONAL CENTRE

Your Practice

Clinical Notes Lu-Ann Murdoch RPh, BScPhm, ACPR ED DAT UP dian

a Can elines d Gui ***

Updated guidelines: opioid use in chronic noncancer pain

New Canadian guidelines for opioid use in chronic noncancer pain are now available, updating those published by the National Opioid Use Guideline Group in 2010. The 2017 guidelines strongly recommend optimizing nonopioid therapy (e.g., nonsteroidal antiinflammatory drugs, graduated exercise, cognitive behavioural therapy) before considering a trial of opioids. Guidance is provided for managing chronic noncancer pain in patients with a substance use or psychiatric disorder. Dose limits are recommended for patients starting opioid therapy (< 90 mg morphine equivalents daily [strong recommendation], or < 50 mg morphine equivalents daily [weak recommendation]). Switching to another opioid (rather than keeping the patient on the same opioid) is suggested for patients with persistent problematic noncancer pain and/or adverse effects. Opioid rotation may be done in conjunction with, and as a way of facilitating, dose reduction. Tapering to the lowest effective dose (and potential opioid discontinuation) is suggested for patients with chronic noncancer pain who are currently using ≥ 90 mg morphine equivalents of opioids per day, to reduce adverse effects and the likelihood of unintentional overdose. Tapering may be paused or potentially cancelled in patients who have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction. Practical information is provided in several tables: nonopioid treatments for managing chronic noncancer pain; opioid options that should/ should not be used for initiating opioid therapy; and an opioid conversion table. Guidance statements are provided on restricting the amount of opioid prescribed; immediate- versus controlledrelease opioids; opioid-induced sleep apnea/ hypogonadism; urine drug screening, treatment agreements, tamper-resistant formulations, fentanyl patch exchange, and co-prescribing with naloxone. Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain [abbreviated guidelines]. CMAJ 2017;189:E659-66. www.cmaj.ca/content/189/18/E659.full.pdf (accessed May 12, 2017). Michael G. DeGroote National Pain Centre. McMaster University. 2017 Canadian guideline for opioids for chronic pain. http://nationalpaincentre. mcmaster.ca/guidelines.html (accessed May 12, 2017).

pharmacy practice+

ONTARIO MEDSCHECK DIABETES PROGRAM EVALUATION A study of the ﬁrst 3.5 years of the MedsCheck Diabetes program in Ontario found extensive use of the program, with about half of Ontarians with diabetes receiving an assessment. However, only 4.1% of MedsCheck Diabetes recipients ≥ 66 years of age and 2.7% of those < 66 years of age received a follow-up assessment, indicating a signiﬁcant care gap. In addition, most MedsCheck Diabetes recipients (65.2%) received only one diabetes assessment during the 3.5-year study, although annual assessments were allowed. MacCallum L, Consiglio G, MacKeigan L, et al. Uptake of community pharmacist-delivered MedsCheck Diabetes medication review service in Ontario between 2010 and 2014. Can J Diabetes 2017; published online March 18, 2017.

SEVERAL ANTIBIOTICS MAY INCREASE RISK OF SPONTANEOUS ABORTION A new study using data from the Quebec Pregnancy Cohort has examined the association between antibiotic exposure during early pregnancy and the risk of spontaneous abortion. After adjusting for potential confounders, the following antibiotics/ antibiotic classes were associated with an increased risk of spontaneous abortion: azithromycin (adjusted odds ratio [OR] 1.65), clarithromycin (OR 2.35), tetracyclines (OR 2.59), doxycycline (OR 2.81), minocycline (OR 2.48), quinolones (OR 2.72), ciprofloxacin (OR 2.45), norfloxacin (OR 4.81), levofloxacin (OR 3.28), sulfonamides (OR 2.01) and metronidazole (OR 1.70). No increased risk of spontaneous abortion was seen with the use of nitrofurantoin (OR 0.70) or erythromycin (OR 0.70). Muanda FT, Sheehy O, Bérard A. Use of antibiotics during pregnancy and risk of spontaneous abortion. CMAJ 2017;189:E625-33. www.cmaj.ca/content/189/17/E625.full.pdf+html (accessed May 12, 2017).

Hepatitis C virus screening in Canadian adults The Canadian Task Force on Preventive Health Care strongly recommends against screening for hepatitis C virus (HCV) in adults who are not at elevated risk for HCV. No evidence indicates that screening for HCV in asymptomatic adults is effective, and it has potential harms (e.g., overdiagnosis, anxiety, stigma, medication side effects). HCV prevalence is low in most adults in the general Canadian population and many individuals detected through screening would never develop clinical disease even without treatment. In addition, drug plans could not afford to fund treatment for all asymptomatic HCV-positive individuals. The recommendation against HCV screening does not apply to pregnant women, or to adults who are at elevated risk for HCV infection. HCV testing should be discussed with people at elevated risk (see CMAJ reference below for list of high-risk adults). Canadian Task Force on Preventive Health Care. Recommendations on hepatitis C screening for adults. CMAJ 2017;189:E594-604. www.cmaj.ca/content/189/16/E594.full.pdf (accessed May 12, 2017).

[Vol.4 No.6] July/August 2017

NOW AVAILABLE WITHOUT A PRESCRIPTION!

FLONASE® Allergy Relief is the same intranasal corticosteroid (INS) that has been trusted by doctors and pharmacists for nearly 20 years.1 FLONASE® Allergy Relief is the ﬁrst and only over-the-counter (OTC) INS indicated to treat nasal and ocular symptoms of seasonal and perennial allergic rhinitis, without a prescription.1-3 It is available for OTC* use in adults 18 years of age and older.2

VISIT FLONASEPROFESSIONAL.CA FOR MORE INFORMATION. FLONASE® Allergy Relief (ﬂuticasone propionate aqueous nasal spray 50 mcg) is indicated for the treatment of the symptoms associated with seasonal allergic rhinitis including hay fever, and perennial rhinitis; and the management of sinus pain and pressure symptoms associated with allergic rhinitis.

References: 1. Data on ﬁle. GSK group of companies. 2016. 2. FLONASE® Allergy Relief Product Monograph. GlaxoSmithKline Consumer Healthcare Inc. August 23, 2016. 3. Nasacort Allergy 24HR/Nasacort AQ Product Monograph. Sanoﬁ-Aventis Canada Inc. December 11, 2013.

Please consult the product monograph at ﬂonaseprofessional.ca or by calling 1-866-994-7444 for information relating to adverse reactions, drug interactions, and dosing information.

* BTC in Quebec, Schedule II.

Your Practice

Practice Experts

Frontline Leadership Heather Foley BSc, BScPharm, RPh, ACPR Heather Foley is a pharmacist, Chatham Kent Family Health Team in Chatham, Ontario; regional clinical coordinator, University of Waterloo School of Pharmacy.

Potential to lead is within us all

NEW COLUMN In this column, Heather shares insights and inspirations that frontline pharmacists can use to build success in daily practice.

Making a commitment to practice self-improvement qualiﬁes you to start thinking of yourself as a leader.

Are you a leader? It can be difficult to know the correct response, as the answer depends on your own perception of the word. You may call yourself a leader because it’s in your job title, or because you have a particular academic credential that, for you, equates to leadership. On the flip side, perhaps you have the relevant certificates, but are not confident that you have what it takes to call yourself a leader. Many also discount their leadership qualities and would answer no, simply because their title or training does not formally reflect that of a “leader.” Or maybe being a leader means something completely different for you. From my perspective, being a leader doesn’t mean that you’ve guided a Fortune 500 company to record profits. It doesn’t mean that you have mastered all of the skills, or that you no longer make mistakes. Being a leader is much more modest; it’s simply a way of thinking, a way of acting and a way of living your life. Leading means making a personal commitment to improve and refine yourself through reflection, day pharmacy practice+

after day, in order to reach positive outcomes for those within your influence. Regardless of your background, it is my hope that, beginning today, every one of you who reads this article will be able to confidently declare that, yes… I am a leader! Just making a commitment to practise self-improvement qualifies you to start thinking of yourself as a leader. As a front-line pharmacist, I make my share of mistakes. I have failed and procrastinated. I sometimes lose my cool. At times when words were needed, I remained silent. These are not qualities associated with being a leader. Learning from such experiences, however, and employing an attitude of self-improvement, is. By practising self-reflection during negative occur-

rences, I am able to identify where I need to improve, and can then take steps towards bettering myself. The result of this reflection always takes me to the bookstore, online to motivational videos or to a conversation with my mentor in search of advice on how to improve in that area. Ever since I started to intentionally surround myself with “leadership noise,” and reflect when things go awry, I have been able to use the advice garnered from these sources to increase the number of positive outcomes within my control. I am by no means an expert on leadership—and that is exactly the point. Leadership is not limited to expertise, credentials or job titles. Anyone can lead. I have made an intentional decision to keep bettering myself, and it is [Vol.4 No.6] July/August 2017

(DRUG NEWS CONT’D FROM PAGE 7)

Your Practice

my hope that I can add a bit of value to your day by sharing some of these pearls and helpful advice. Hence, the evolution of this new column—Frontline Leadership— in which I will share lessons that have helped me in my career so far.

Lesson 1: Today matters

The influential John C. Maxwell said, “People create success in their lives by focusing on today. It may sound trite, but today is the only time you have. It’s too late for yesterday. And you can’t depend on tomorrow. Real, sustainable change doesn’t happen in a moment. It is a process. That’s why today matters.”(1) Day after day, patient after patient, your daily interactions, interventions and influences will eventually add up. By focusing on what you do each day, every day, you will change lives. You will save lives. You will shape health care. And you will be rewarded with a meaningful and successful career. The business and politics of health care are guaranteed to change tomorrow. As a frontline pharmacist, technician or student who cares very much about your profession, it’s easy to get caught up in the what-ifs and should-bes, which can be overwhelming. When this happens to me, I refocus by concentrating on what is within my control that day. I think to myself “today matters” and I get down to business, improving what is within my influence. The more I practise this approach, the easier it has become. Today matters. Each interaction you have with a patient today, matters. Make the commitment to start looking at life through the eyes of a leader today. People create success in their lives by focusing on today. Today is the only time you are guaranteed. That is why today matters. REFERENCE 1. Maxwell, John C. Today matters: 12 daily practices to guarantee tomorrow’s successes. New York: Warner Faith; 2004.

Ź Please send Frontline Leadership questions or comments to Heather at heather.foley@ckfht.ca.

New indications Revolade (eltrombopag tablets), Novartis.

REVISED INDICATION Treatment of chronic immune thrombocy-

topenia purpura (ITP) to increase platelet counts in adults and children one year of age or older who have had an insufficient response to corticosteroids or immunoglobulins. (This indication had been approved previously for children; in adults with ITP, the drug was formerly indicated to increase platelet counts in splenectomized patients who were refractory to first-line treatments [e.g., corticosteroids, immunoglobulins] and it was considered a second-line treatment for adult nonsplenectomized patients when surgery was contraindicated. Revolade also continues to be approved to increase platelet counts in thrombocytopenic patients with chronic hepatitis C virus infection to allow the initiation and maintenance of interferon-based therapy, as well as for the treatment of adults with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy.) DOSAGE Recommended starting dose in adults and children ≥ 6 years of age is 50 mg once daily. Recommended starting dose in children age one to < 6 years, or ITP patients aged ≥ 6 years of East Asian/Southeast Asian ancestry, is 25 mg once daily. Dosage regimens must then be individualized based on platelet counts.

Xolair (omalizumab subcutaneous injection), Novartis.

REVISED INDICATION For adults and children (≥ 6 years of age)

with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids. (Previously approved for this indication only in patients 12 years or older. Also indicated for the treatment of adults and adolescents [≥ 12 years of age] with chronic idiopathic urticaria who continue to be symptomatic despite antihistamine treatment.) DOSAGE Asthma: Dosage ranges from 75–375 mg administered by subcutaneous injection every two to four weeks. Consult product monograph for separate dosage tables for patients ≥ 12 years of age and for children six to < 12 years of age.

Yervoy (ipilimumab intravenous infusion), Bristol-Myers Squibb.

NEW INDICATION Treatment of unresectable or metastatic

melanoma in previously untreated adults, in combination with nivolumab. (Originally indicated only for the treatment of unresectable or metastatic melanoma, as a single agent.) DOSAGE Induction regimen is 3 mg/kg administered IV over 90 minutes every three weeks to a maximum of four doses, and within 16 weeks of the first dose. TO SEE HEALTH CANADA ADVISORIES, GO ONLINE Visit CanadianHealthcareNetwork.ca and click on the Pharmacy Practice+ logo.

July/August 2017 [Vol.4 No.6]

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July/August 2017 [Vol.4 No.6]

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Feature

Current management recommendations for Helicobacter pylori infections in adults

by Karen Jensen, MSc, BSP and Dorothy Sanderson, BSP

riple therapy with a proton pump inhibitor (PPI) and two antibiotics has been the gold standard for the treatment of Helicobacter pylori infections for many years. Recently, however, you may have been fielding more questions regarding alternate treatment regimens, because H. pylori treatment failure is increasing in North America, primarily due to antibiotic resistance. This article summarizes new treatment recommendations and outlines the pharmacist’s role in optimizing H. pylori therapy.

Epidemiology and pathophysiology H. pylori is a spiral-shaped, gramnegative bacterium found in the gastric mucosa or adherent to the gastric epithelial lining.(1-3) It can survive in acidic environments, making the human stomach the perfect breeding ground. Although H. pylori infection is asymptomatic in the majority of people, it is a proven risk factor for peptic ulcer disease and gastric cancer, and may contribute to dyspepsia, ulcer risk during low-dose acetylsalicylic acid (ASA) or nonsteroidal anti-inflammatory drug (NSAID) treatment, unexplained iron deficiency anemia and idiopathic thrombocytopenic purpura.(1-4) It continues to be one of the most common chronic bacterial infections affecting humans, with a worldwide prevalence of ≥ 50%.(1-4) Although H. pylori infections are more common in developing countries, western countries still report high rates of infection in pharmacy practice+

certain communities (e.g., 38%–75% in Alaskan or Canadian aboriginal populations).(3,4) For this reason, successful treatment of H. pylori infection continues to be a concern in Canada.

H. pylori resistance Traditionally, H. pylori infections have been treated with a three-medication regimen. The most commonly used medications were a PPI combined with two of the following: amoxicillin, clarithromycin or metronidazole. Levofloxacin has been used in place of amoxicillin for some penicillin-allergic patients and in combination with a PPI and amoxicillin for treatment failures.(1,4,5) As time has progressed, H. pylori–resistant strains have become more prevalent. Reasons include the increasing use of macrolide and fluoroquinolone (FQ) antibiotics for other indications, increasing treatment of H. pylori infections and noncompliance with H. pylori treatment regimens.(1-5) Resistance to clarithromycin has had the most impact on traditional triple therapy. Studies from the 1990s reported a low prevalence of clarithromycin resistance ranging from 1%–8%, but this has risen to 16%–24% based on more recent studies from around the world.(3,4) A 2010 meta-analysis reported a tripletherapy eradication rate of only 22% for clarithromycin-resistant H. pylori strains compared with 90% for clarithromycinsensitive strains.(3) Among alternate treatment options, FQ resistance is the most significant factor.(3,4) The limited data that exist suggest

that FQ resistance may be as high or perhaps even higher than clarithromycin resistance in North America.(3) Primary resistance to metronidazole appears to have remained relatively stable over time at 20%–40%.(3) Metronidazole resistance reduces H. pylori eradication rates by about 25% in triple therapies, but less so in quadruple therapies and when PPIs are included in the regimen.(3) Fortunately, H. pylori resistance to amoxicillin, tetracycline and rifabutin remains rare (< 5% for each).(3)

New H. pylori management guidelines The need for more effective treatment options and the development of new treatment regimens has led to the evolution of new guidelines for the management of H. pylori in adults. These guidelines were recently published by the Canadian Association of Gastroenterology, with the Canadian Helicobacter Study Group and the American College of Gastroenterology. These organizations systematically reviewed the literature relating to the management of H. pylori infection. Using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, they came to a consensus on the most appropriate management for H. pylori infection in North America.(4) Updated pediatric recommendations are currently being prepared by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. [Vol.4 No.6] July/August 2017

Feature

Table 1 H. PYLORI TESTING OPTIONS (2,3,6-9) Test

Description

Beneﬁt/Limitations

Medications Affecting Test

Urea breath test

Subject drinks a labelled carbon isotope; H. pylori urease degrades urea, producing ammonia and liberating tagged CO2 that can be detected in breath samples. An increase in the ratio of 13CO2 to CO2 between the pre- and post-ingestion samples indicates the presence of H pylori-associated urease.

• Noninvasive, easy to administer, highly sensitive • Test of choice pre- and posttreatment • Not suitable for pregnant females

Stop: • Antibiotics 4 wks prior to test • Bismuth ≥ 2 wks prior • PPI ≥ 2 wks prior • H2RA ≥ 1 wk prior

Endoscopic biopsy

Biopsy taken for culture & histology to determine presence of H. pylori

Invasive, generally only used if already doing endoscopy

Stop: • Antibiotics 4 wks prior to test • PPIs 2 wks prior • H2RAs 1 wk prior

Serology

A blood test (serology) detects speciﬁc antibodies to H. pylori, which the immune system develops in response to the bacterium. Shows whether someone has been exposed to H. pylori. Positive test indicates a current H. pylori infection or an H. pylori infection in the past.

• Noninvasive • Inexpensive • Cannot differentiate between past or current infection • False-positives limit use • Use only if urea breath test or biopsy not appropriate • Not suitable for eradication testing • May perform differently in different ethnic groups

Not affected by medications

Fecal stool antigen test

Detects H. pylori antigens in stool

• Noninvasive, easy • Not as accurate as others

Stop: • Antibiotics 4 wks prior to test • PPI & bismuth 2 wks prior

H2RA–histamine-2 receptor antagonist; PPI–proton pump inhibitor

Testing for H. pylori A “test and treat” strategy should be used (see summary of available tests in Table 1[2,3,6-9]). Testing for H. pylori can prevent unneeded treatment and patient cost, and possible development of antibiotic resistance. On the other hand, if treatment is not desired or indicated, it is a waste of time and expense to test. H. pylori testing is indicated in patients with the following conditions(1-4,6,8,9): • Active or history of peptic ulcer disease • Gastric cancer • History of endoscopic resection of early gastric cancer • Unexplained iron-deﬁciency anemia • Idiopathic thrombocytopenic purpura • Family history of or a member of an ethnic group with a high risk of gastric cancer

July/August 2017 [Vol.4 No.6]

H. pylori testing may be performed for other indications; if the test is positive, treatment should be initiated. If there is no intention to treat, then testing should be discouraged!

Treatment of H. pylori infection The recommended duration of treatment for H. pylori infections has been increased to 14 days (formerly 7–10 days), with the exception of rifabutin regimens which have a recommended duration of 10 days. Although the level of evidence is low, some studies have shown increased efficacy with lengthier treatment and the consensus guidelines now recommend the longer treatment duration.(3,4) In choosing which antibiotics to use for H. pylori eradication, the following factors should be considered: • Past history of macrolide use • Local resistance patterns • Medication allergies • Past treatment failure

Guidelines now recommend the following regimens as first-line treatments(3,4): • Concomitant nonbismuth quadruple therapy: PPI + amoxicillin + metronidazole + clarithromycin (PAMC) • Concomitant bismuth quadruple therapy: PPI + bismuth + metronidazole + tetracycline (PBMT). Table 2 provides details on drug dosing for these regimens. PPI triple therapy (Table 2) should only be used in areas where clarithromycin resistance is known to be low (< 15%) or where these regimens have high eradication success rates. The presence of clarithromycin resistance reduces the success of clarithromycin triple therapy by about 50%.(3) Recommended therapies for use after treatment failure include PBMT (if not pharmacy practice+

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Table 2 RECOMMENDED TREATMENT REGIMENS FOR H. PYLORI INFECTION IN ADULTS(4)

FIRST-LINE TREATMENTS

Regimen

Dosage

Duration

PAMC: PPI*+ amoxicillin + metronidazole + clarithromycin (quadruple therapy)

• PPI* bid • amoxicillin 1000 mg bid • metronidazole 500 mg bid • clarithromycin 500 mg bid

14 days

PBMT: PPI*+ bismuth + metronidazole + tetracycline (quadruple therapy)

• PPI* bid • bismuth subsalicylate 2 x 262 mg tablets or equivalent of liquid bid • metronidazole 500 mg tid or qid • tetracycline 500 mg qid

14 days

Only use triple-therapy regimens listed below if local clarithromycin resistance ≤ 15% PAC: PPI*+ amoxicillin + clarithromycin

• PPI* bid • amoxicillin 1000 mg bid • clarithromycin 500 mg bid

14 days

PMC: PPI*+ metronidazole + clarithromycin

• PPI* bid • metronidazole 500 mg bid • clarithromycin 500 mg bid

14 days

PBMT – as above (if not used as ﬁrst line)

• As above

14 days

Optimized PBMT

• Higher dose PPI ** • Higher dose metronidazole ***

14 days

PAL: PPI*+ amoxicillin + levoﬂoxacin

• PPI* bid • amoxicillin 1000 mg bid • levoﬂoxacin 500 mg once daily

14 days

PAR: PPI*+ amoxicillin + rifabutin

• PPI* bid • amoxicillin 1000 mg bid • rifabutin 150 mg bid

10 days

TREATMENT FAILURE

IF 3 OR MORE FAILURES

PPI–proton pump inhibitor. *PPI: esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg, rabeprazole 20 mg. ** Higher dose PPI: Double the above doses given bid. *** Higher dose metronidazole: 500 mg qid

used for initial treatment) or levofloxacincontaining therapy (PPI + amoxicillin + levofloxacin). Rifabutin regimens should be restricted to patients who have failed at least three prior treatment options. Rifabutin use is limited by its high cost, the rare risk of bone marrow suppression (almost always reversible) and the concern for inducing resistance among Mycobacterium tuberculosis strains.(3)

Pregnancy and lactation recommendations If peptic ulcer disease is diagnosed in a pregnant woman, the treatment is typically acid suppression alone.(1,6,8) Antacids, barrier agents (e.g., alginates), histamine H2 antagonists (H2RAs, e.g., ranitidine) and PPIs are considered to be generally safe during pregnancy.(1,8,10) If H. pylori testing is positive, treatment can be (and often is) deferred until after delivery. However, amoxicillin, clarithromycin, metronidazole and PPIs (omeprazole is the PPI of choice) are considered low risk in pregnancy.(1,8,10) Some evidence indicates that H. pylori may cause severe nausea and vomiting in pregnancy, 18

July/August 2017 [Vol.4 No.6]

including hyperemesis gravidarum.(1-3) Treatment of H. pylori may be preferable in these cases. Bismuth, tetracycline and levofloxacin should not be used during pregnancy or lactation.(8,10)

Other promising treatments The following treatments show promise in H. pylori treatment, but require more research: • Higher dose PPI regimens, such as esomeprazole 40 mg twice daily or rabeprazole 20 mg four times daily.(4) • High-dose dual PPI therapy (amoxicillin 750 mg qid plus rabeprazole 20 mg qid) for 14 days. This may be an option when both dual metronidazole/ clarithromycin resistance and levofloxacin resistance are suspected, such as in a patient with multiple previous treatment failures.(4) H. pylori resistance to amoxicillin is uncommon and amoxicillin efficacy increases with increasing gastric pH.(3) • Simvastatin. In one randomized controlled trial, the addition of simvastatin to the PAC regimen (see Table 2) significantly improved the H. pylori eradication rate.(11)

• Vonoprazan. This acid blocker with a novel mode of action is currently available only in Japan.(1,4,12,13) It is an oral potassium-competitive acid blocker (PCAB) with much more potent acid-inhibitory effects than PPIs. PCABs inhibit gastric H+/K+-ATPase in a K+ competitive, but reversible, mechanism; therefore, they do not require prior proton pump activation to achieve their antisecretory effect. PCABs exhibit an early onset of acidsecretion inhibition due to a rapid rise in peak plasma concentration.(12,14,15) • Probiotics. Some evidence indicates that Lactobacillus and Bifidobacterium have inhibitory effects on H. pylori and may reduce the side effects from treatment regimens.(16,17) However, evidence is not strong enough to recommend their use and the dose, timing and duration of treatment remain undetermined.(3,4) • H. pylori vaccine. A large phase 3 trial conducted in China reported 70% protection by an oral H. pylori vaccine (in children). More research is needed, however, as efficacy decreased after one year.(3) pharmacy practice+

Eradication testing

Acid suppression and PPI deprescribing after H. pylori eradication In the absence of other indications (e.g., ongoing ASA or NSAID use, gastroesophageal reflux disease, severe symptoms, bleeding ulcers), continued therapy with a PPI is not required after H. pylori eradication.(8,15) Although PPI use is considered relatively safe, longterm PPI therapy has been associated with gastrointestinal (GI) tract infections (e.g., Clostridium difficile), increased risk of pneumonia, increased risk of hip and vertebral fractures, hypomagnesemia and decreased vitamin B12 levels.(18) A systematic review evaluating the current evidence for deprescribing of PPIs found a substantial number (14%–64%) of people regularly using PPIs could discontinue them without symptom recurrence.(15) Rebound acid secretion may occur in some patients, but may be alleviated with PPI dosage tapering.(15,18,19) The following steps are suggested to taper PPI doses(18,20): • Decrease the PPI dose by 50% for a few weeks, or • Increase the interval between doses to every two or more days. This approach may be preferred for PPIs where a lower dose requires compounding. • Antacids or an H2RA (e.g., ranitipharmacy practice+

Pharmacist’s role Pharmacists can help optimize H. pylori management in four main ways: 1

Encourage adherence to the consensus guidelines.

• Local resistance rates to H. pylori antibiotic regimens are rarely known. If triple therapy is still being prescribed in your region, offer to provide educational workshops and/or consult with individual physicians to ensure they are familiar with the new recommendations for quadruple therapy. • Follow up with patients who have received H. pylori therapy to determine if dyspepsia symptoms have resolved. Pharmacists may be in the best position to identify treatment failure and provide advice on the most appropriate alternate regimen. Ensure clarithromycin regimens are not prescribed for treatment failure if clarithromycin was in the initial regimen. • Identify reasons for treatment failure. Cigarette smoking (1-3) and diabetes mellitus(3,21) have been associated with higher rates of treatment failure. If adherence is the problem, a simpler treatment regimen may be more suitable. • Suggest eradication testing when appropriate. Ensure patients understand which medications must to be stopped, and when, prior to the test (Table 1). 2

Encourage treatment adherence.

• Quadruple regimens are complex. It is important to educate patients that treatment success depends on taking the medications as directed and completing therapy. 3

Counsel patients on side effects and how to manage them if they occur:

• Black tongue with bismuth subsalicylate (warn patients to expect this and reassure them that it is not harmful)

• GI upset with all regimens (take with food if needed) • GI symptoms may worsen until treatment is completed (if patients know this is expected, it is more likely that they will continue to take the medication for the full duration) • Metallic taste in mouth with metronidazole and clarithromycin (reassure patient this is normal and will resolve on discontinuation) • Disulfiram-like reaction if alcohol is consumed with metronidazole (advise patient to avoid alcohol while taking metronidazole and for at least 1 day after the last dose) • Photosensitivity with tetracycline (advise patients to avoid sun and tanning beds, use sunscreen and wear protective clothing and eyewear.) 4

Feature

Although not routinely recommended, eradication testing can be useful in the following situations: • To ensure treatment success in serious conditions such as mucosaassociated lymphoid tissue (MALT) lymphoma, or ulcer with perforation or hemorrhage,(2-4,6) • To prevent treatment-failure complications, such as stomach ulceration or development of gastric cancer,(3,4,6) • To provide information on local resistance patterns,(3) • To prevent unnecessary retreatment if symptoms persist.(3) If indicated, eradication testing is performed four weeks after treatment cessation and one to two weeks after PPI cessation.(2-4,6,9) A urea breath test, biopsy or fecal stool antigen test can confirm eradication, but serology is not an appropriate test in this situation.(3,6,9)

dine) may be used during the taper for symptom control. Excellent PPI deprescribing tools have been developed for both patients and healthcare professionals (See rxfiles. ca/rxfiles/uploads/documents/Deprescribing-PPI-Patient-Tool.pdf and www. rxfiles.ca/rxfiles/uploads/documents/PPIDeprescribing-Newsletter.pdf).

Determine if there is a need for ongoing PPI use.

• Encourage deprescribing of PPIs, if applicable • Attempt to stop/reduce PPI use at least once yearly in most patients.(18)

Summary Resistance to H. pylori treatments is increasing. Because of this concern, gastroenterology associations have reviewed and updated H. pylori treatment recommendations. Pharmacists should be aware of the new treatment regimens and ensure their patients receive the recommended agents for the appropriate duration. They should also ensure that patients receive appropriate H. pylori diagnostic and eradication testing. In addition, pharmacists can monitor for adherence and treatment failure with H. pylori regimens and offer management strategies if problems arise. Karen Jensen (karen.jensen@usask.ca) is the manager and Dorothy Sanderson (med.sask@usask. ca) is a medication information consultant with medSask, Your Medication Information Service at the College of Pharmacy & Nutrition, University of Saskatchewan in Saskatoon.

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

[Vol.4 No.6] July/August 2017

Pearls you can use in your practice now Antimicrobial stewardship for community pharmacists by Matt Swankhuizen, BSc(Pharm), PharmD

Antibiotics have been described as the most significant healthcare innovation of our time, adding an estimated 20 years to our life expectancy.(1) Unfortunately, we are on the verge of an era where antibiotics will no longer be effective and once curable infections will again cause morbidity and mortality.(1) However, it does not have to be this way. Approximately 80% of antibiotics prescribed for human use come from prescribers in the community, and an estimated 50% of those prescriptions are inappropriate (Figure 1).(1,2) As the most accessible healthcare professional, community pharmacists are ideally placed to make significant interventions to combat inappropriate antibiotic use, thereby slowing the development of resistance and protecting this valuable resource. Below are five tips to improve your knowledge and confidence in being an antimicrobial steward. Common terms related to antimicrobial stewardship are defined in Box 1.

Screen for vaccines Prevention is the best strategy when it comes to curbing the development of antimicrobial resistance. It should be considered a priority by pharmacists to screen for patients at high risk for influenza- and pneumonia-related complications, and ensure that they receive both influenza and pneumococcal vaccines. Both vaccines are effective in preventing illness and, therefore, would prevent unnecessary antibiotic prescriptions.(2) Once patients have received the influenza vaccine, a reminder should be put on the patient’s profile to ensure they receive it yearly. 20

July/August 2017 [Vol.4 No.6]

Spend time in the OTC area A recent survey suggested that approximately 70% of general practitioners prescribe antibiotics when they are unsure whether they are treating a viral or bacterial infection.(3) Pharmacists can have a signiﬁcant impact in preventing some of these unnecessary antibiotic prescriptions by counselling patients in the over-the-counter (OTC) area. Suggest OTC products that will be effective for supportive care of viral infections. Consider having a conversation about the differences and similarities between viral and bacterial infections. Remember to tell your patients that most sore throats, ear infections, sinusitis and all cases of bronchitis are caused by viruses, which are not treatable with antibiotics. Provide patients with educational materials from Do Bugs Need Drugs?, the US Centers for Disease Control or MUMS Health (Box 2), to reinforce the message that viral infections are not treatable with antibiotics and we all have a responsibility to use antibiotics wisely. This may prevent patients from seeking a physician’s care for self-limiting viral infections, now and in the future.

Know your empiric therapy A key part of an antimicrobial stewardship program is prescription audit and feedback. Community pharmacists are in an ideal position to integrate this into their clinical practice. Pharmacists should familiarize themselves with empiric therapeutic options for common community-acquired infections. Ensure you pay attention to dose and duration of therapy, as they are linked to the development of resistant organisms such as methicillinresistant Staphylococcus aureus (MRSA) and Clostridium difficile.(1,2,4) Regional susceptibility patterns should be taken into account when choosing empiric therapy (see resources in Box 2); Canadian references should be consulted to ensure adequate treatment has been chosen. In general, 90% of bacterial isolates should be susceptible to the chosen empiric therapy. If the percentage is lower than this (based on regional susceptibility), a different agent should be chosen to ensure effective therapy. Pharmacists should interview patients presenting with a prescription for an antibiotic. Once information such as indication, patient comorbidities and signs and symptoms are known, the pharmacist can determine whether the agent is too broad spectrum, has resistance issues, is prescribed in a dose that is too low or too high or the duration of therapy is too short or too long. If any of these are present, the prescriber should be contacted and an alternate drug, dose, frequency and/or duration should be suggested. pharmacy practice+

Counsel your patients Once you have determined that the antibiotic is indicated, and the dose and duration are correct, you must ensure your patient takes it correctly. Studies suggest that 50% of Canadians prescribed an antibiotic do not ﬁnish the entire course.(4) Counselling every patient receiving an antibiotic can improve adherence, thereby helping to prevent the development of resistance.(5) All patients receiving an antibiotic should be counselled on key points using the following pneumonic: F Finish entire course, even if symptoms are gone and you feel better R Regular intervals A After, with or before food/vitamins I Interactions S Side effects

BOX 1 DEFINITIONS: TERMS RELATED TO ANTIMICROBIAL STEWARDSHIP Antimicrobial stewardship/ Antimicrobial steward

Ensuring the optimal selection, dose and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.

Empiric therapy

Treatment of an infection with an antimicrobial before knowing which organism is causing the infection.

Broad-spectrum antibiotic

An antibiotic that kills or prevents the growth of many different species of bacteria. Some examples of oral broad-spectrum antibiotics include ﬂuoroquinolones, amoxicillin/clavulanic acid, cefuroxime and ceﬁxime.

MRSA (methicillin-resistant Staphylococcus aureus)

An organism that causes several difficult-to-treat infections. It is resistant to all beta-lactam-based antibiotics, as well as various other antibiotics.

CRE (carbapenem-resistant Enterobacteriaceae)

Gram-negative bacteria (Escherichia coli, Klebsiella pneumoniae, Escherichia cloacae) that produce the carbapenemase enzyme. They have been referred to as the “nightmare bacteria” as they are resistant to most available antibiotics and cause death in up to 50% of patients.

Wash your hands While it seems like common sense, only 5% of healthcare workers wash their hands as often as they should.(1,4,6) Pharmacists come into contact with hundreds of patients every day. The single most important mode of transmission of antibiotic-resistant organisms is via the hands of healthcare workers after handling contaminated materials or equipment. In fact, 30%–40% of community-acquired infections are due to unclean hands.(7) One of the most important things you can do to prevent antibiotic usage is to wash your hands with soap and water or an alcoholbased rub frequently throughout the day.

Summary Community pharmacists can play a vital role in ensuring that antibiotics are viable treatment modalities in the future. By following the ﬁve tips in this article, you can help prevent unnecessary antibiotic use, ensure that appropriate antibiotics are being used and that nonadherence is not contributing to resistance. These small interventions, which you can make every day, can have a substantial and lasting effect to minimize the development of antibiotic resistance. Matt Swankhuizen (matthew.swankhuizen@ interiorhealth.ca) is a clinical pharmacy specialist– critical care with pharmacy services at Kootenay Boundary Regional Hospital in Trail, B.C.

pharmacy practice+

FIGURE 1 DOCTOR VISITS RESULTING IN ANTIBIOTIC PRESCRIPTION 2005-06

Sinusitis

Sore Throats

Bronchitis

Colds

Ear Infections

61.8%

46.5%

57.3%

37.3%

70.8%

Figure 1 is adapted from: Centers for Disease Control and Prevention. A decade's difference: doctor visits resulting in antibiotic prescription. https://www.cdc.gov/getsmart/community/images/materials/doctor-visits.jpg (accessed February 2, 2017).

BOX 2 ANTIMICROBIAL STEWARDSHIP RESOURCES Bugs and Drugs

www.bugsanddrugs.ca/ Do Bugs Need Drugs?

www.dobugsneeddrugs.org/ Canadian Antimicrobial Resistance Alliance (CARA)

www.can-r.ca/ MUMS Health

www.mumshealth.com/ CDC Get smart: Know when antibiotics work

www.cdc.gov/getsmart/ community/index.html

References 1. U.S. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/ pdf/ar-threats-2013-508.pdf (accessed November 20, 2016). 2. Sehatzadeh S. Inﬂuenza and pneumococcal vaccinations for patients with chronic obstructive pulmonary disease (COPD). Ont Health Technol Assess Ser 2012;12(3):1-64. 3. Leonard R. In the balance: GPs, patient care and antibiotics [Internet blog]. Longitude Prize. 2016 https:// longitudeprize.org/blog-post/balance-gps-patient-careand-antibiotics (accessed December 21, 2016]. 4. Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada 2013. Infectious disease – the never ending threat. Antimicrobial resistance – a shared responsibility. www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/ resistance-eng.php (accessed November 28, 2016). 5. Finney J, Friman P, Rapoff M, et al. Improving compliance with antibiotic regimens for otitis media. Am J Dis Child 1985;139:89-95. 6. Ashkenazi S. Beginning and possibly the end of the antibiotic era. J Paediatr Child Health 2013;49:E179-82. 7. Zanni GR. Good hand hygiene includes more than hands. Pharmacy Times 2006; June 1. www.pharmacytimes.com/publications/issue/2006/2006-06/2006-06-5623 (accessed December 21, 2016).

[Vol.4 No.6] July/August 2017

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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.

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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.

www.Asthma.ca

A career at Save-On-Foods is an opportunity to: t 8PSL JO B GSJFOEMZ QSPGFTTJPOBM BOE TVQQPSUJWF XPSL FOWJSPONFOU t &OKPZ n FYJCJMJUZ TUBCJMJUZ BOE HSFBU DPNQFOTBUJPO QBDLBHFT t %FWFMPQ ZPVS MFBEFSTIJQ TLJMMT FYQBOE ZPVS TDPQF PG QSBDUJDF BOE advance your career! For career opportunities, please forward your resume in conﬁdence to: pharmacyemployment@owfg.com.

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CLASSIFIED ADVERTISING 1 800 668-8151

July/August 2017 [Vol.4 No.6]

pharmacy practice+

ACCREDITED CE LESSONS AVAILABLE Subsequent Entry Biologics or Biosimilars: What Pharmacists Need to Know

Iron Deﬁciency Anemia Author(s): Victor Wong, Lucy Wang Sponsored by Aralez Pharmaceuticals Inc.

Author(s): Dr. Algis Jovaisas, Iris Krawchenko Sponsored by Merck

Approved for

1.25

1.0

CEUs

PCSK9 Inhibitors: A Primer for Pharmacists Author(s): Kori Leblanc Sponsored by Amgen

CEU

Caring for Geriatric Patients Author(s): Lisa Sever Sponsored by Teva

Approved for

1.0

CEU

TECH TALK FOR TECHNICIANS

CEU

eCortex.ca is Canada’s leading CE provider for pharmacists, owners and technicians. Join thousands of your colleagues on eCortex.ca for access to these and more CE lessons.

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